Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

GLYCOPYRROLATE INJ [0.2 MG/ML]

Facility

$26.00

Service Code	HCPCS J1596
Hospital Charge Code	3000205
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

GMA AUDIOMETRY PURE TONE

Facility

$62.00

Service Code	CPT 92552
Hospital Charge Code	9092552
Hospital Revenue Code	521
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

GMA AUDIOMETRY PURE TONE

Facility

$62.00

Service Code	CPT 92552
Hospital Charge Code	9092552
Hospital Revenue Code	521
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

GMA SCREENING VISUAL ACUITY

Facility

$6.00

Service Code	CPT 99173
Hospital Charge Code	9099173
Hospital Revenue Code	521
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

GMA SCREENING VISUAL ACUITY

Facility

$6.00

Service Code	CPT 99173
Hospital Charge Code	9099173
Hospital Revenue Code	521
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

GMA SPIROMETRY BRONCHODILATION RESPONSIV

Facility

$121.00

Service Code	CPT 94060
Hospital Charge Code	9094060
Hospital Revenue Code	521
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

GMA SPIROMETRY BRONCHODILATION RESPONSIV

Facility

$121.00

Service Code	CPT 94060
Hospital Charge Code	9094060
Hospital Revenue Code	521
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

GMA URINALYSIS, DIPSTICK

Facility

$16.00

Service Code	CPT 81003
Hospital Charge Code	9081003
Hospital Revenue Code	307
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

GMA URINALYSIS, DIPSTICK

Facility

$16.00

Service Code	CPT 81003
Hospital Charge Code	9081003
Hospital Revenue Code	307
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

GMA WORK/DISABILITY EXAM

Facility

$250.00

Service Code	CPT 99455
Hospital Charge Code	9099455
Hospital Revenue Code	521
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

GMA WORK/DISABILITY EXAM

Facility

$250.00

Service Code	CPT 99455
Hospital Charge Code	9099455
Hospital Revenue Code	521
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

GMA XR CHEST 1 VIEW

Facility

$300.00

Service Code	CPT 71045
Hospital Charge Code	5000253
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

GMA XR CHEST 1 VIEW

Facility

$300.00

Service Code	CPT 71045
Hospital Charge Code	5000253
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

GRAM STAIN (008540)

Facility

$56.00

Service Code	CPT 87205
Hospital Charge Code	4087205
Hospital Revenue Code	306
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

GRAM STAIN (008540)

Facility

$56.00

Service Code	CPT 87205
Hospital Charge Code	4087205
Hospital Revenue Code	306
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

GRAM STAIN EVAL W/ SPUTUM CULT (BCL6066)

Facility

$110.00

Service Code	CPT 87205
Hospital Charge Code	4072051
Hospital Revenue Code	306
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

GRAM STAIN EVAL W/ SPUTUM CULT (BCL6066)

Facility

$110.00

Service Code	CPT 87205
Hospital Charge Code	4072051
Hospital Revenue Code	306
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

GREINER CITRATED TUBE 4ML (50TUBES)

Facility

$6.59

Hospital Charge Code	90197028
Hospital Revenue Code	270
Min. Negotiated Rate	$4.61
Max. Negotiated Rate	$6.59
Rate for Payer: Aetna Commercial	$6.26
Rate for Payer: Aetna Medicare	$5.93
Rate for Payer: BCBS MT CHIP	$5.93
Rate for Payer: BCBS MT Closed Plan Network	$6.26
Rate for Payer: BCBS MT HealthLink	$5.93
Rate for Payer: BCBS MT Medicare	$5.93
Rate for Payer: BCBS MT POS	$6.26
Rate for Payer: BCBS MT Traditional	$6.59
Rate for Payer: Cash Price	$5.93
Rate for Payer: Cigna Commercial	$6.26
Rate for Payer: Cigna Medicare	$5.93
Rate for Payer: Medicaid All Medicaid	$6.06
Rate for Payer: Medicare All Medicare	$4.61
Rate for Payer: Monida Allegiance	$6.26
Rate for Payer: Monida First Choice Health	$6.39
Rate for Payer: Monida Montana Health Co-op	$6.26
Rate for Payer: Monida PacificSource	$6.26

GREINER CITRATED TUBE 4ML (50TUBES)

Facility

$6.59

Hospital Charge Code	90197028
Hospital Revenue Code	270
Min. Negotiated Rate	$4.61
Max. Negotiated Rate	$6.59
Rate for Payer: Aetna Commercial	$6.26
Rate for Payer: Aetna Medicare	$5.93
Rate for Payer: BCBS MT CHIP	$5.93
Rate for Payer: BCBS MT Closed Plan Network	$6.26
Rate for Payer: BCBS MT HealthLink	$5.93
Rate for Payer: BCBS MT Medicare	$5.93
Rate for Payer: BCBS MT POS	$6.26
Rate for Payer: BCBS MT Traditional	$6.59
Rate for Payer: Cash Price	$5.93
Rate for Payer: Cigna Commercial	$6.26
Rate for Payer: Cigna Medicare	$5.93
Rate for Payer: Medicaid All Medicaid	$6.06
Rate for Payer: Medicare All Medicare	$4.61
Rate for Payer: Monida Allegiance	$6.26
Rate for Payer: Monida First Choice Health	$6.39
Rate for Payer: Monida Montana Health Co-op	$6.26
Rate for Payer: Monida PacificSource	$6.26

GRIPPER PLUS 19 X .75' (NOT CT SAFE)

Facility

$32.00

Hospital Charge Code	80030231
Hospital Revenue Code	270
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

GRIPPER PLUS 19 X .75' (NOT CT SAFE)

Facility

$32.00

Hospital Charge Code	80030231
Hospital Revenue Code	270
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

GROSS EXAM PATHOLOGY

Facility

$76.25

Service Code	CPT 88300
Hospital Charge Code	4087928
Hospital Revenue Code	310
Min. Negotiated Rate	$53.38
Max. Negotiated Rate	$76.25
Rate for Payer: Aetna Commercial	$72.44
Rate for Payer: Aetna Medicare	$68.62
Rate for Payer: BCBS MT CHIP	$68.62
Rate for Payer: BCBS MT Closed Plan Network	$72.44
Rate for Payer: BCBS MT HealthLink	$68.62
Rate for Payer: BCBS MT Medicare	$68.62
Rate for Payer: BCBS MT POS	$72.44
Rate for Payer: BCBS MT Traditional	$76.25
Rate for Payer: Cash Price	$68.63
Rate for Payer: Cigna Commercial	$72.44
Rate for Payer: Cigna Medicare	$68.62
Rate for Payer: Medicaid All Medicaid	$70.15
Rate for Payer: Medicare All Medicare	$53.38
Rate for Payer: Monida Allegiance	$72.44
Rate for Payer: Monida First Choice Health	$73.96
Rate for Payer: Monida Montana Health Co-op	$72.44
Rate for Payer: Monida PacificSource	$72.44

GROSS EXAM PATHOLOGY

Facility

$76.25

Service Code	CPT 88300
Hospital Charge Code	4087928
Hospital Revenue Code	310
Min. Negotiated Rate	$53.38
Max. Negotiated Rate	$76.25
Rate for Payer: Aetna Commercial	$72.44
Rate for Payer: Aetna Medicare	$68.62
Rate for Payer: BCBS MT CHIP	$68.62
Rate for Payer: BCBS MT Closed Plan Network	$72.44
Rate for Payer: BCBS MT HealthLink	$68.62
Rate for Payer: BCBS MT Medicare	$68.62
Rate for Payer: BCBS MT POS	$72.44
Rate for Payer: BCBS MT Traditional	$76.25
Rate for Payer: Cash Price	$68.63
Rate for Payer: Cigna Commercial	$72.44
Rate for Payer: Cigna Medicare	$68.62
Rate for Payer: Medicaid All Medicaid	$70.15
Rate for Payer: Medicare All Medicare	$53.38
Rate for Payer: Monida Allegiance	$72.44
Rate for Payer: Monida First Choice Health	$73.96
Rate for Payer: Monida Montana Health Co-op	$72.44
Rate for Payer: Monida PacificSource	$72.44

GROUP A STREP CULTURE (008169)

Facility

$58.00

Service Code	CPT 87081
Hospital Charge Code	4087081
Hospital Revenue Code	306
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

GROUP A STREP CULTURE (008169)

Facility

$58.00

Service Code	CPT 87081
Hospital Charge Code	4087081
Hospital Revenue Code	306
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

Know your out-of-pocket cost for care.

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