Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FX CLOSED PHALAN/PROX/MIDDLE W/O MANIPUL

Facility

$534.00

Service Code	CPT 26720
Hospital Charge Code	8026720
Hospital Revenue Code	521
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

FX CLOSED RADIAL SHAFT W/O MANIPUL

Facility

$549.00

Service Code	CPT 25500
Hospital Charge Code	8025500
Hospital Revenue Code	521
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$549.00
Rate for Payer: Aetna Commercial	$521.55
Rate for Payer: Aetna Medicare	$494.10
Rate for Payer: BCBS MT CHIP	$494.10
Rate for Payer: BCBS MT Closed Plan Network	$521.55
Rate for Payer: BCBS MT HealthLink	$494.10
Rate for Payer: BCBS MT Medicare	$494.10
Rate for Payer: BCBS MT POS	$521.55
Rate for Payer: BCBS MT Traditional	$549.00
Rate for Payer: Cash Price	$494.10
Rate for Payer: Cigna Commercial	$521.55
Rate for Payer: Cigna Medicare	$494.10
Rate for Payer: Medicaid All Medicaid	$505.08
Rate for Payer: Medicare All Medicare	$384.30
Rate for Payer: Monida Allegiance	$521.55
Rate for Payer: Monida First Choice Health	$532.53
Rate for Payer: Monida Montana Health Co-op	$521.55
Rate for Payer: Monida PacificSource	$521.55

FX CLOSED RADIAL SHAFT W/O MANIPUL

Facility

$549.00

Service Code	CPT 25500
Hospital Charge Code	8025500
Hospital Revenue Code	521
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$549.00
Rate for Payer: Aetna Commercial	$521.55
Rate for Payer: Aetna Medicare	$494.10
Rate for Payer: BCBS MT CHIP	$494.10
Rate for Payer: BCBS MT Closed Plan Network	$521.55
Rate for Payer: BCBS MT HealthLink	$494.10
Rate for Payer: BCBS MT Medicare	$494.10
Rate for Payer: BCBS MT POS	$521.55
Rate for Payer: BCBS MT Traditional	$549.00
Rate for Payer: Cash Price	$494.10
Rate for Payer: Cigna Commercial	$521.55
Rate for Payer: Cigna Medicare	$494.10
Rate for Payer: Medicaid All Medicaid	$505.08
Rate for Payer: Medicare All Medicare	$384.30
Rate for Payer: Monida Allegiance	$521.55
Rate for Payer: Monida First Choice Health	$532.53
Rate for Payer: Monida Montana Health Co-op	$521.55
Rate for Payer: Monida PacificSource	$521.55

FX CLOSED TARSAL W/O MANIPULATION

Facility

$617.00

Service Code	CPT 28450
Hospital Charge Code	8028450
Hospital Revenue Code	521
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

FX CLOSED TARSAL W/O MANIPULATION

Facility

$617.00

Service Code	CPT 28450
Hospital Charge Code	8028450
Hospital Revenue Code	521
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

FX CLOSED TIBIAL PROXIMAL PLATEAU

Facility

$869.00

Service Code	CPT 27530
Hospital Charge Code	8027530
Hospital Revenue Code	521
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$869.00
Rate for Payer: Aetna Commercial	$825.55
Rate for Payer: Aetna Medicare	$782.10
Rate for Payer: BCBS MT CHIP	$782.10
Rate for Payer: BCBS MT Closed Plan Network	$825.55
Rate for Payer: BCBS MT HealthLink	$782.10
Rate for Payer: BCBS MT Medicare	$782.10
Rate for Payer: BCBS MT POS	$825.55
Rate for Payer: BCBS MT Traditional	$869.00
Rate for Payer: Cash Price	$782.10
Rate for Payer: Cigna Commercial	$825.55
Rate for Payer: Cigna Medicare	$782.10
Rate for Payer: Medicaid All Medicaid	$799.48
Rate for Payer: Medicare All Medicare	$608.30
Rate for Payer: Monida Allegiance	$825.55
Rate for Payer: Monida First Choice Health	$842.93
Rate for Payer: Monida Montana Health Co-op	$825.55
Rate for Payer: Monida PacificSource	$825.55

FX CLOSED TIBIAL PROXIMAL PLATEAU

Facility

$869.00

Service Code	CPT 27530
Hospital Charge Code	8027530
Hospital Revenue Code	521
Min. Negotiated Rate	$608.30
Max. Negotiated Rate	$869.00
Rate for Payer: Aetna Commercial	$825.55
Rate for Payer: Aetna Medicare	$782.10
Rate for Payer: BCBS MT CHIP	$782.10
Rate for Payer: BCBS MT Closed Plan Network	$825.55
Rate for Payer: BCBS MT HealthLink	$782.10
Rate for Payer: BCBS MT Medicare	$782.10
Rate for Payer: BCBS MT POS	$825.55
Rate for Payer: BCBS MT Traditional	$869.00
Rate for Payer: Cash Price	$782.10
Rate for Payer: Cigna Commercial	$825.55
Rate for Payer: Cigna Medicare	$782.10
Rate for Payer: Medicaid All Medicaid	$799.48
Rate for Payer: Medicare All Medicare	$608.30
Rate for Payer: Monida Allegiance	$825.55
Rate for Payer: Monida First Choice Health	$842.93
Rate for Payer: Monida Montana Health Co-op	$825.55
Rate for Payer: Monida PacificSource	$825.55

FX CLOSED TIBIA SHAFT W MANIPULATION

Facility

$930.00

Service Code	CPT 27752
Hospital Charge Code	1027752
Hospital Revenue Code	450
Min. Negotiated Rate	$651.00
Max. Negotiated Rate	$930.00
Rate for Payer: Aetna Commercial	$883.50
Rate for Payer: Aetna Medicare	$837.00
Rate for Payer: BCBS MT CHIP	$837.00
Rate for Payer: BCBS MT Closed Plan Network	$883.50
Rate for Payer: BCBS MT HealthLink	$837.00
Rate for Payer: BCBS MT Medicare	$837.00
Rate for Payer: BCBS MT POS	$883.50
Rate for Payer: BCBS MT Traditional	$930.00
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cigna Commercial	$883.50
Rate for Payer: Cigna Medicare	$837.00
Rate for Payer: Medicaid All Medicaid	$855.60
Rate for Payer: Medicare All Medicare	$651.00
Rate for Payer: Monida Allegiance	$883.50
Rate for Payer: Monida First Choice Health	$902.10
Rate for Payer: Monida Montana Health Co-op	$883.50
Rate for Payer: Monida PacificSource	$883.50

FX CLOSED TIBIA SHAFT W MANIPULATION

Facility

$930.00

Service Code	CPT 27752
Hospital Charge Code	1027752
Hospital Revenue Code	450
Min. Negotiated Rate	$651.00
Max. Negotiated Rate	$930.00
Rate for Payer: Aetna Commercial	$883.50
Rate for Payer: Aetna Medicare	$837.00
Rate for Payer: BCBS MT CHIP	$837.00
Rate for Payer: BCBS MT Closed Plan Network	$883.50
Rate for Payer: BCBS MT HealthLink	$837.00
Rate for Payer: BCBS MT Medicare	$837.00
Rate for Payer: BCBS MT POS	$883.50
Rate for Payer: BCBS MT Traditional	$930.00
Rate for Payer: Cash Price	$837.00
Rate for Payer: Cigna Commercial	$883.50
Rate for Payer: Cigna Medicare	$837.00
Rate for Payer: Medicaid All Medicaid	$855.60
Rate for Payer: Medicare All Medicare	$651.00
Rate for Payer: Monida Allegiance	$883.50
Rate for Payer: Monida First Choice Health	$902.10
Rate for Payer: Monida Montana Health Co-op	$883.50
Rate for Payer: Monida PacificSource	$883.50

FX CLOSED TIBIA SHAFT W/O MANIPULA

Facility

$872.00

Service Code	CPT 27750
Hospital Charge Code	8027750
Hospital Revenue Code	521
Min. Negotiated Rate	$610.40
Max. Negotiated Rate	$872.00
Rate for Payer: Aetna Commercial	$828.40
Rate for Payer: Aetna Medicare	$784.80
Rate for Payer: BCBS MT CHIP	$784.80
Rate for Payer: BCBS MT Closed Plan Network	$828.40
Rate for Payer: BCBS MT HealthLink	$784.80
Rate for Payer: BCBS MT Medicare	$784.80
Rate for Payer: BCBS MT POS	$828.40
Rate for Payer: BCBS MT Traditional	$872.00
Rate for Payer: Cash Price	$784.80
Rate for Payer: Cigna Commercial	$828.40
Rate for Payer: Cigna Medicare	$784.80
Rate for Payer: Medicaid All Medicaid	$802.24
Rate for Payer: Medicare All Medicare	$610.40
Rate for Payer: Monida Allegiance	$828.40
Rate for Payer: Monida First Choice Health	$845.84
Rate for Payer: Monida Montana Health Co-op	$828.40
Rate for Payer: Monida PacificSource	$828.40

FX CLOSED TIBIA SHAFT W/O MANIPULA

Facility

$872.00

Service Code	CPT 27750
Hospital Charge Code	8027750
Hospital Revenue Code	521
Min. Negotiated Rate	$610.40
Max. Negotiated Rate	$872.00
Rate for Payer: Aetna Commercial	$828.40
Rate for Payer: Aetna Medicare	$784.80
Rate for Payer: BCBS MT CHIP	$784.80
Rate for Payer: BCBS MT Closed Plan Network	$828.40
Rate for Payer: BCBS MT HealthLink	$784.80
Rate for Payer: BCBS MT Medicare	$784.80
Rate for Payer: BCBS MT POS	$828.40
Rate for Payer: BCBS MT Traditional	$872.00
Rate for Payer: Cash Price	$784.80
Rate for Payer: Cigna Commercial	$828.40
Rate for Payer: Cigna Medicare	$784.80
Rate for Payer: Medicaid All Medicaid	$802.24
Rate for Payer: Medicare All Medicare	$610.40
Rate for Payer: Monida Allegiance	$828.40
Rate for Payer: Monida First Choice Health	$845.84
Rate for Payer: Monida Montana Health Co-op	$828.40
Rate for Payer: Monida PacificSource	$828.40

G6PD ENZYME ACTIVITY (121003)

Facility

$82.00

Service Code	CPT 82955
Hospital Charge Code	4082955
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

G6PD ENZYME ACTIVITY (121003)

Facility

$82.00

Service Code	CPT 82955
Hospital Charge Code	4082955
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

GABAPENTIN CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000195
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

GABAPENTIN CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000195
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

GABAPENTIN CAP [300 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000196
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

GABAPENTIN CAP [300 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000196
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

GASTRIN (004390)

Facility

$142.00

Service Code	CPT 82941
Hospital Charge Code	4082941
Hospital Revenue Code	301
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

GASTRIN (004390)

Facility

$142.00

Service Code	CPT 82941
Hospital Charge Code	4082941
Hospital Revenue Code	301
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

GASTROCCULT OCCULT BLOOD & PH

Facility

$155.70

Hospital Charge Code	90195110
Hospital Revenue Code	270
Min. Negotiated Rate	$108.99
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna Commercial	$147.91
Rate for Payer: Aetna Medicare	$140.13
Rate for Payer: BCBS MT CHIP	$140.13
Rate for Payer: BCBS MT Closed Plan Network	$147.91
Rate for Payer: BCBS MT HealthLink	$140.13
Rate for Payer: BCBS MT Medicare	$140.13
Rate for Payer: BCBS MT POS	$147.91
Rate for Payer: BCBS MT Traditional	$155.70
Rate for Payer: Cash Price	$140.13
Rate for Payer: Cigna Commercial	$147.91
Rate for Payer: Cigna Medicare	$140.13
Rate for Payer: Medicaid All Medicaid	$143.24
Rate for Payer: Medicare All Medicare	$108.99
Rate for Payer: Monida Allegiance	$147.91
Rate for Payer: Monida First Choice Health	$151.03
Rate for Payer: Monida Montana Health Co-op	$147.91
Rate for Payer: Monida PacificSource	$147.91

GASTROCCULT OCCULT BLOOD & PH

Facility

$155.70

Hospital Charge Code	90195110
Hospital Revenue Code	270
Min. Negotiated Rate	$108.99
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna Commercial	$147.91
Rate for Payer: Aetna Medicare	$140.13
Rate for Payer: BCBS MT CHIP	$140.13
Rate for Payer: BCBS MT Closed Plan Network	$147.91
Rate for Payer: BCBS MT HealthLink	$140.13
Rate for Payer: BCBS MT Medicare	$140.13
Rate for Payer: BCBS MT POS	$147.91
Rate for Payer: BCBS MT Traditional	$155.70
Rate for Payer: Cash Price	$140.13
Rate for Payer: Cigna Commercial	$147.91
Rate for Payer: Cigna Medicare	$140.13
Rate for Payer: Medicaid All Medicaid	$143.24
Rate for Payer: Medicare All Medicare	$108.99
Rate for Payer: Monida Allegiance	$147.91
Rate for Payer: Monida First Choice Health	$151.03
Rate for Payer: Monida Montana Health Co-op	$147.91
Rate for Payer: Monida PacificSource	$147.91

GASTROGRAFIN [37%] 30ML SLN

Facility

$93.00

Service Code	HCPCS J8499
Hospital Charge Code	3000522
Hospital Revenue Code	250
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

GASTROGRAFIN [37%] 30ML SLN

Facility

$93.00

Service Code	HCPCS J8499
Hospital Charge Code	3000522
Hospital Revenue Code	250
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

GASTROINTESTINAL PROFILE, PCR (183480)

Facility

$792.00

Service Code	CPT 87507
Hospital Charge Code	4087507
Hospital Revenue Code	300
Min. Negotiated Rate	$554.40
Max. Negotiated Rate	$792.00
Rate for Payer: Aetna Commercial	$752.40
Rate for Payer: Aetna Medicare	$712.80
Rate for Payer: BCBS MT CHIP	$712.80
Rate for Payer: BCBS MT Closed Plan Network	$752.40
Rate for Payer: BCBS MT HealthLink	$712.80
Rate for Payer: BCBS MT Medicare	$712.80
Rate for Payer: BCBS MT POS	$752.40
Rate for Payer: BCBS MT Traditional	$792.00
Rate for Payer: Cash Price	$712.80
Rate for Payer: Cigna Commercial	$752.40
Rate for Payer: Cigna Medicare	$712.80
Rate for Payer: Medicaid All Medicaid	$728.64
Rate for Payer: Medicare All Medicare	$554.40
Rate for Payer: Monida Allegiance	$752.40
Rate for Payer: Monida First Choice Health	$768.24
Rate for Payer: Monida Montana Health Co-op	$752.40
Rate for Payer: Monida PacificSource	$752.40

GASTROINTESTINAL PROFILE, PCR (183480)

Facility

$792.00

Service Code	CPT 87507
Hospital Charge Code	4087507
Hospital Revenue Code	300
Min. Negotiated Rate	$554.40
Max. Negotiated Rate	$792.00
Rate for Payer: Aetna Commercial	$752.40
Rate for Payer: Aetna Medicare	$712.80
Rate for Payer: BCBS MT CHIP	$712.80
Rate for Payer: BCBS MT Closed Plan Network	$752.40
Rate for Payer: BCBS MT HealthLink	$712.80
Rate for Payer: BCBS MT Medicare	$712.80
Rate for Payer: BCBS MT POS	$752.40
Rate for Payer: BCBS MT Traditional	$792.00
Rate for Payer: Cash Price	$712.80
Rate for Payer: Cigna Commercial	$752.40
Rate for Payer: Cigna Medicare	$712.80
Rate for Payer: Medicaid All Medicaid	$728.64
Rate for Payer: Medicare All Medicare	$554.40
Rate for Payer: Monida Allegiance	$752.40
Rate for Payer: Monida First Choice Health	$768.24
Rate for Payer: Monida Montana Health Co-op	$752.40
Rate for Payer: Monida PacificSource	$752.40

Know your out-of-pocket cost for care.

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