Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

EASYDROP FLOW CONTROLLER

Facility

$64.00

Hospital Charge Code	80040122
Hospital Revenue Code	270
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

EASYDROP FLOW CONTROLLER

Facility

$64.00

Hospital Charge Code	80040122
Hospital Revenue Code	270
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

EBV AB TO VCA, IGG (096230)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4086665
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV AB TO VCA, IGG (096230)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4086665
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV AB TO VCA, IGM (096735)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4000054
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV AB TO VCA, IGM (096735)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4000054
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV ANTIBODY PROFILE (240610)

Facility

$124.00

Service Code	HCPCS 86664
Hospital Charge Code	4066641
Hospital Revenue Code	302
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

EBV ANTIBODY PROFILE (240610)

Facility

$124.00

Service Code	HCPCS 86664
Hospital Charge Code	4066641
Hospital Revenue Code	302
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

EBV NUCLEAR ANTIGEN AB, IGG (010272)

Facility

$42.00

Service Code	HCPCS 86664
Hospital Charge Code	4086664
Hospital Revenue Code	302
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

EBV NUCLEAR ANTIGEN AB, IGG (010272)

Facility

$42.00

Service Code	HCPCS 86664
Hospital Charge Code	4086664
Hospital Revenue Code	302
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

EBV, QUALITATIVE, PCR (138289)

Facility

$659.00

Service Code	HCPCS 87798
Hospital Charge Code	4087799
Hospital Revenue Code	300
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

EBV, QUALITATIVE, PCR (138289)

Facility

$659.00

Service Code	HCPCS 87798
Hospital Charge Code	4087799
Hospital Revenue Code	300
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

EBV, QUANTITATIVE, PCR (138230)

Facility

$630.00

Service Code	HCPCS 87799
Hospital Charge Code	4077991
Hospital Revenue Code	300
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

EBV, QUANTITATIVE, PCR (138230)

Facility

$630.00

Service Code	HCPCS 87799
Hospital Charge Code	4077991
Hospital Revenue Code	300
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

ED MODERATE CONCIOUS SEDATION ADD ON 15M

Facility

$127.00

Service Code	HCPCS 99153
Hospital Charge Code	1099153
Hospital Revenue Code	450
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$127.00
Rate for Payer: Aetna Commercial	$120.65
Rate for Payer: Aetna Medicare	$114.30
Rate for Payer: BCBS MT CHIP	$114.30
Rate for Payer: BCBS MT Closed Plan Network	$120.65
Rate for Payer: BCBS MT HealthLink	$114.30
Rate for Payer: BCBS MT Medicare	$114.30
Rate for Payer: BCBS MT POS	$120.65
Rate for Payer: BCBS MT Traditional	$127.00
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cigna Commercial	$120.65
Rate for Payer: Cigna Medicare	$114.30
Rate for Payer: Medicaid All Medicaid	$116.84
Rate for Payer: Medicare All Medicare	$88.90
Rate for Payer: Monida Allegiance	$120.65
Rate for Payer: Monida First Choice Health	$123.19
Rate for Payer: Monida Montana Health Co-op	$120.65
Rate for Payer: Monida PacificSource	$120.65

ED MODERATE CONCIOUS SEDATION ADD ON 15M

Facility

$127.00

Service Code	HCPCS 99153
Hospital Charge Code	1099153
Hospital Revenue Code	450
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$127.00
Rate for Payer: Aetna Commercial	$120.65
Rate for Payer: Aetna Medicare	$114.30
Rate for Payer: BCBS MT CHIP	$114.30
Rate for Payer: BCBS MT Closed Plan Network	$120.65
Rate for Payer: BCBS MT HealthLink	$114.30
Rate for Payer: BCBS MT Medicare	$114.30
Rate for Payer: BCBS MT POS	$120.65
Rate for Payer: BCBS MT Traditional	$127.00
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cigna Commercial	$120.65
Rate for Payer: Cigna Medicare	$114.30
Rate for Payer: Medicaid All Medicaid	$116.84
Rate for Payer: Medicare All Medicare	$88.90
Rate for Payer: Monida Allegiance	$120.65
Rate for Payer: Monida First Choice Health	$123.19
Rate for Payer: Monida Montana Health Co-op	$120.65
Rate for Payer: Monida PacificSource	$120.65

EGD 43235

Facility

$2,682.00

Service Code	HCPCS 43235
Hospital Charge Code	5843235
Hospital Revenue Code	750
Min. Negotiated Rate	$1,877.40
Max. Negotiated Rate	$2,682.00
Rate for Payer: Aetna Commercial	$2,547.90
Rate for Payer: Aetna Medicare	$2,413.80
Rate for Payer: BCBS MT CHIP	$2,413.80
Rate for Payer: BCBS MT Closed Plan Network	$2,547.90
Rate for Payer: BCBS MT HealthLink	$2,413.80
Rate for Payer: BCBS MT Medicare	$2,413.80
Rate for Payer: BCBS MT POS	$2,547.90
Rate for Payer: BCBS MT Traditional	$2,682.00
Rate for Payer: Cash Price	$2,413.80
Rate for Payer: Cigna Commercial	$2,547.90
Rate for Payer: Cigna Medicare	$2,413.80
Rate for Payer: Medicaid All Medicaid	$2,467.44
Rate for Payer: Medicare All Medicare	$1,877.40
Rate for Payer: Monida Allegiance	$2,547.90
Rate for Payer: Monida First Choice Health	$2,601.54
Rate for Payer: Monida Montana Health Co-op	$2,547.90
Rate for Payer: Monida PacificSource	$2,547.90

EGD 43235

Facility

$2,682.00

Service Code	HCPCS 43235
Hospital Charge Code	5843235
Hospital Revenue Code	750
Min. Negotiated Rate	$1,877.40
Max. Negotiated Rate	$2,682.00
Rate for Payer: Aetna Commercial	$2,547.90
Rate for Payer: Aetna Medicare	$2,413.80
Rate for Payer: BCBS MT CHIP	$2,413.80
Rate for Payer: BCBS MT Closed Plan Network	$2,547.90
Rate for Payer: BCBS MT HealthLink	$2,413.80
Rate for Payer: BCBS MT Medicare	$2,413.80
Rate for Payer: BCBS MT POS	$2,547.90
Rate for Payer: BCBS MT Traditional	$2,682.00
Rate for Payer: Cash Price	$2,413.80
Rate for Payer: Cigna Commercial	$2,547.90
Rate for Payer: Cigna Medicare	$2,413.80
Rate for Payer: Medicaid All Medicaid	$2,467.44
Rate for Payer: Medicare All Medicare	$1,877.40
Rate for Payer: Monida Allegiance	$2,547.90
Rate for Payer: Monida First Choice Health	$2,601.54
Rate for Payer: Monida Montana Health Co-op	$2,547.90
Rate for Payer: Monida PacificSource	$2,547.90

EGD W/ BIOPSY 43239

Facility

$2,756.00

Service Code	HCPCS 43239
Hospital Charge Code	5843239
Hospital Revenue Code	750
Min. Negotiated Rate	$1,929.20
Max. Negotiated Rate	$2,756.00
Rate for Payer: Aetna Commercial	$2,618.20
Rate for Payer: Aetna Medicare	$2,480.40
Rate for Payer: BCBS MT CHIP	$2,480.40
Rate for Payer: BCBS MT Closed Plan Network	$2,618.20
Rate for Payer: BCBS MT HealthLink	$2,480.40
Rate for Payer: BCBS MT Medicare	$2,480.40
Rate for Payer: BCBS MT POS	$2,618.20
Rate for Payer: BCBS MT Traditional	$2,756.00
Rate for Payer: Cash Price	$2,480.40
Rate for Payer: Cigna Commercial	$2,618.20
Rate for Payer: Cigna Medicare	$2,480.40
Rate for Payer: Medicaid All Medicaid	$2,535.52
Rate for Payer: Medicare All Medicare	$1,929.20
Rate for Payer: Monida Allegiance	$2,618.20
Rate for Payer: Monida First Choice Health	$2,673.32
Rate for Payer: Monida Montana Health Co-op	$2,618.20
Rate for Payer: Monida PacificSource	$2,618.20

EGD W/ BIOPSY 43239

Facility

$2,756.00

Service Code	HCPCS 43239
Hospital Charge Code	5843239
Hospital Revenue Code	750
Min. Negotiated Rate	$1,929.20
Max. Negotiated Rate	$2,756.00
Rate for Payer: Aetna Commercial	$2,618.20
Rate for Payer: Aetna Medicare	$2,480.40
Rate for Payer: BCBS MT CHIP	$2,480.40
Rate for Payer: BCBS MT Closed Plan Network	$2,618.20
Rate for Payer: BCBS MT HealthLink	$2,480.40
Rate for Payer: BCBS MT Medicare	$2,480.40
Rate for Payer: BCBS MT POS	$2,618.20
Rate for Payer: BCBS MT Traditional	$2,756.00
Rate for Payer: Cash Price	$2,480.40
Rate for Payer: Cigna Commercial	$2,618.20
Rate for Payer: Cigna Medicare	$2,480.40
Rate for Payer: Medicaid All Medicaid	$2,535.52
Rate for Payer: Medicare All Medicare	$1,929.20
Rate for Payer: Monida Allegiance	$2,618.20
Rate for Payer: Monida First Choice Health	$2,673.32
Rate for Payer: Monida Montana Health Co-op	$2,618.20
Rate for Payer: Monida PacificSource	$2,618.20

EGD W/ DILITATION 43248

Facility

$2,600.00

Service Code	HCPCS 43248
Hospital Charge Code	5843248
Hospital Revenue Code	750
Min. Negotiated Rate	$1,820.00
Max. Negotiated Rate	$2,600.00
Rate for Payer: Aetna Commercial	$2,470.00
Rate for Payer: Aetna Medicare	$2,340.00
Rate for Payer: BCBS MT CHIP	$2,340.00
Rate for Payer: BCBS MT Closed Plan Network	$2,470.00
Rate for Payer: BCBS MT HealthLink	$2,340.00
Rate for Payer: BCBS MT Medicare	$2,340.00
Rate for Payer: BCBS MT POS	$2,470.00
Rate for Payer: BCBS MT Traditional	$2,600.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Cigna Commercial	$2,470.00
Rate for Payer: Cigna Medicare	$2,340.00
Rate for Payer: Medicaid All Medicaid	$2,392.00
Rate for Payer: Medicare All Medicare	$1,820.00
Rate for Payer: Monida Allegiance	$2,470.00
Rate for Payer: Monida First Choice Health	$2,522.00
Rate for Payer: Monida Montana Health Co-op	$2,470.00
Rate for Payer: Monida PacificSource	$2,470.00

EGD W/ DILITATION 43248

Facility

$2,600.00

Service Code	HCPCS 43248
Hospital Charge Code	5843248
Hospital Revenue Code	750
Min. Negotiated Rate	$1,820.00
Max. Negotiated Rate	$2,600.00
Rate for Payer: Aetna Commercial	$2,470.00
Rate for Payer: Aetna Medicare	$2,340.00
Rate for Payer: BCBS MT CHIP	$2,340.00
Rate for Payer: BCBS MT Closed Plan Network	$2,470.00
Rate for Payer: BCBS MT HealthLink	$2,340.00
Rate for Payer: BCBS MT Medicare	$2,340.00
Rate for Payer: BCBS MT POS	$2,470.00
Rate for Payer: BCBS MT Traditional	$2,600.00
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Cigna Commercial	$2,470.00
Rate for Payer: Cigna Medicare	$2,340.00
Rate for Payer: Medicaid All Medicaid	$2,392.00
Rate for Payer: Medicare All Medicare	$1,820.00
Rate for Payer: Monida Allegiance	$2,470.00
Rate for Payer: Monida First Choice Health	$2,522.00
Rate for Payer: Monida Montana Health Co-op	$2,470.00
Rate for Payer: Monida PacificSource	$2,470.00

EKG - AMBULANCE

Facility

$179.00

Service Code	HCPCS 93005 QN
Hospital Charge Code	693005
Hospital Revenue Code	730
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

EKG - AMBULANCE

Facility

$179.00

Service Code	HCPCS 93005 QN
Hospital Charge Code	693005
Hospital Revenue Code	730
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

EKG - OP/HOSPITAL

Facility

$186.00

Service Code	HCPCS 93005
Hospital Charge Code	114001
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

Know your out-of-pocket cost for care.

All Charges