Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR WRIST RT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300024
Hospital Revenue Code	614
Min. Negotiated Rate	$1,789.20
Max. Negotiated Rate	$2,556.00
Rate for Payer: Aetna Commercial	$2,428.20
Rate for Payer: Aetna Medicare	$2,300.40
Rate for Payer: BCBS MT CHIP	$2,300.40
Rate for Payer: BCBS MT Closed Plan Network	$2,428.20
Rate for Payer: BCBS MT HealthLink	$2,300.40
Rate for Payer: BCBS MT Medicare	$2,300.40
Rate for Payer: BCBS MT POS	$2,428.20
Rate for Payer: BCBS MT Traditional	$2,556.00
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Cigna Commercial	$2,428.20
Rate for Payer: Cigna Medicare	$2,300.40
Rate for Payer: Medicaid All Medicaid	$2,351.52
Rate for Payer: Medicare All Medicare	$1,789.20
Rate for Payer: Monida Allegiance	$2,428.20
Rate for Payer: Monida First Choice Health	$2,479.32
Rate for Payer: Monida Montana Health Co-op	$2,428.20
Rate for Payer: Monida PacificSource	$2,428.20

MR WRIST RT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300024
Hospital Revenue Code	614
Min. Negotiated Rate	$1,789.20
Max. Negotiated Rate	$2,556.00
Rate for Payer: Aetna Commercial	$2,428.20
Rate for Payer: Aetna Medicare	$2,300.40
Rate for Payer: BCBS MT CHIP	$2,300.40
Rate for Payer: BCBS MT Closed Plan Network	$2,428.20
Rate for Payer: BCBS MT HealthLink	$2,300.40
Rate for Payer: BCBS MT Medicare	$2,300.40
Rate for Payer: BCBS MT POS	$2,428.20
Rate for Payer: BCBS MT Traditional	$2,556.00
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Cigna Commercial	$2,428.20
Rate for Payer: Cigna Medicare	$2,300.40
Rate for Payer: Medicaid All Medicaid	$2,351.52
Rate for Payer: Medicare All Medicare	$1,789.20
Rate for Payer: Monida Allegiance	$2,428.20
Rate for Payer: Monida First Choice Health	$2,479.32
Rate for Payer: Monida Montana Health Co-op	$2,428.20
Rate for Payer: Monida PacificSource	$2,428.20

MR WRIST RT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300030
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR WRIST RT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300030
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR WRIST RT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300036
Hospital Revenue Code	614
Min. Negotiated Rate	$2,243.50
Max. Negotiated Rate	$3,205.00
Rate for Payer: Aetna Commercial	$3,044.75
Rate for Payer: Aetna Medicare	$2,884.50
Rate for Payer: BCBS MT CHIP	$2,884.50
Rate for Payer: BCBS MT Closed Plan Network	$3,044.75
Rate for Payer: BCBS MT HealthLink	$2,884.50
Rate for Payer: BCBS MT Medicare	$2,884.50
Rate for Payer: BCBS MT POS	$3,044.75
Rate for Payer: BCBS MT Traditional	$3,205.00
Rate for Payer: Cash Price	$2,884.50
Rate for Payer: Cigna Commercial	$3,044.75
Rate for Payer: Cigna Medicare	$2,884.50
Rate for Payer: Medicaid All Medicaid	$2,948.60
Rate for Payer: Medicare All Medicare	$2,243.50
Rate for Payer: Monida Allegiance	$3,044.75
Rate for Payer: Monida First Choice Health	$3,108.85
Rate for Payer: Monida Montana Health Co-op	$3,044.75
Rate for Payer: Monida PacificSource	$3,044.75

MR WRIST RT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300036
Hospital Revenue Code	614
Min. Negotiated Rate	$2,243.50
Max. Negotiated Rate	$3,205.00
Rate for Payer: Aetna Commercial	$3,044.75
Rate for Payer: Aetna Medicare	$2,884.50
Rate for Payer: BCBS MT CHIP	$2,884.50
Rate for Payer: BCBS MT Closed Plan Network	$3,044.75
Rate for Payer: BCBS MT HealthLink	$2,884.50
Rate for Payer: BCBS MT Medicare	$2,884.50
Rate for Payer: BCBS MT POS	$3,044.75
Rate for Payer: BCBS MT Traditional	$3,205.00
Rate for Payer: Cash Price	$2,884.50
Rate for Payer: Cigna Commercial	$3,044.75
Rate for Payer: Cigna Medicare	$2,884.50
Rate for Payer: Medicaid All Medicaid	$2,948.60
Rate for Payer: Medicare All Medicare	$2,243.50
Rate for Payer: Monida Allegiance	$3,044.75
Rate for Payer: Monida First Choice Health	$3,108.85
Rate for Payer: Monida Montana Health Co-op	$3,044.75
Rate for Payer: Monida PacificSource	$3,044.75

MS CONTIN TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000336
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

MS CONTIN TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000336
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

MTHFR (511238)

Facility

$219.00

Service Code	HCPCS 81291
Hospital Charge Code	4081291
Hospital Revenue Code	300
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

MTHFR (511238)

Facility

$219.00

Service Code	HCPCS 81291
Hospital Charge Code	4081291
Hospital Revenue Code	300
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

MULTI VITAMIN TAB ADULT

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000340
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

MULTI VITAMIN TAB ADULT

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000340
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

MUMPS AB, IGG (096552)

Facility

$26.00

Service Code	HCPCS 86735
Hospital Charge Code	4086735
Hospital Revenue Code	300
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

MUMPS AB, IGG (096552)

Facility

$26.00

Service Code	HCPCS 86735
Hospital Charge Code	4086735
Hospital Revenue Code	300
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

MUMPS AB, IGM (160499)

Facility

$84.00

Service Code	HCPCS 86735
Hospital Charge Code	4067351
Hospital Revenue Code	300
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

MUMPS AB, IGM (160499)

Facility

$84.00

Service Code	HCPCS 86735
Hospital Charge Code	4067351
Hospital Revenue Code	300
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

MUMPS VIRAL CULTURE (186150)

Facility

$507.00

Service Code	HCPCS 87254
Hospital Charge Code	4087254
Hospital Revenue Code	306
Min. Negotiated Rate	$354.90
Max. Negotiated Rate	$507.00
Rate for Payer: Aetna Commercial	$481.65
Rate for Payer: Aetna Medicare	$456.30
Rate for Payer: BCBS MT CHIP	$456.30
Rate for Payer: BCBS MT Closed Plan Network	$481.65
Rate for Payer: BCBS MT HealthLink	$456.30
Rate for Payer: BCBS MT Medicare	$456.30
Rate for Payer: BCBS MT POS	$481.65
Rate for Payer: BCBS MT Traditional	$507.00
Rate for Payer: Cash Price	$456.30
Rate for Payer: Cigna Commercial	$481.65
Rate for Payer: Cigna Medicare	$456.30
Rate for Payer: Medicaid All Medicaid	$466.44
Rate for Payer: Medicare All Medicare	$354.90
Rate for Payer: Monida Allegiance	$481.65
Rate for Payer: Monida First Choice Health	$491.79
Rate for Payer: Monida Montana Health Co-op	$481.65
Rate for Payer: Monida PacificSource	$481.65

MUMPS VIRAL CULTURE (186150)

Facility

$507.00

Service Code	HCPCS 87254
Hospital Charge Code	4087254
Hospital Revenue Code	306
Min. Negotiated Rate	$354.90
Max. Negotiated Rate	$507.00
Rate for Payer: Aetna Commercial	$481.65
Rate for Payer: Aetna Medicare	$456.30
Rate for Payer: BCBS MT CHIP	$456.30
Rate for Payer: BCBS MT Closed Plan Network	$481.65
Rate for Payer: BCBS MT HealthLink	$456.30
Rate for Payer: BCBS MT Medicare	$456.30
Rate for Payer: BCBS MT POS	$481.65
Rate for Payer: BCBS MT Traditional	$507.00
Rate for Payer: Cash Price	$456.30
Rate for Payer: Cigna Commercial	$481.65
Rate for Payer: Cigna Medicare	$456.30
Rate for Payer: Medicaid All Medicaid	$466.44
Rate for Payer: Medicare All Medicare	$354.90
Rate for Payer: Monida Allegiance	$481.65
Rate for Payer: Monida First Choice Health	$491.79
Rate for Payer: Monida Montana Health Co-op	$481.65
Rate for Payer: Monida PacificSource	$481.65

MUPIROCIN (BACTROBAN) OINT 2% 22GM

Facility

$144.00

Service Code	NDC 68462018022
Hospital Charge Code	3007066
Hospital Revenue Code	250
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

MUPIROCIN (BACTROBAN) OINT 2% 22GM

Facility

$144.00

Service Code	NDC 68462018022
Hospital Charge Code	3007066
Hospital Revenue Code	250
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

MUSCLE TEST, 2 LIMBS

Facility

$372.00

Service Code	HCPCS 95861
Hospital Charge Code	595861
Hospital Revenue Code	761
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$372.00
Rate for Payer: Aetna Commercial	$353.40
Rate for Payer: Aetna Medicare	$334.80
Rate for Payer: BCBS MT CHIP	$334.80
Rate for Payer: BCBS MT Closed Plan Network	$353.40
Rate for Payer: BCBS MT HealthLink	$334.80
Rate for Payer: BCBS MT Medicare	$334.80
Rate for Payer: BCBS MT POS	$353.40
Rate for Payer: BCBS MT Traditional	$372.00
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cigna Commercial	$353.40
Rate for Payer: Cigna Medicare	$334.80
Rate for Payer: Medicaid All Medicaid	$342.24
Rate for Payer: Medicare All Medicare	$260.40
Rate for Payer: Monida Allegiance	$353.40
Rate for Payer: Monida First Choice Health	$360.84
Rate for Payer: Monida Montana Health Co-op	$353.40
Rate for Payer: Monida PacificSource	$353.40

MUSCLE TEST, 2 LIMBS

Facility

$372.00

Service Code	HCPCS 95861
Hospital Charge Code	595861
Hospital Revenue Code	761
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$372.00
Rate for Payer: Aetna Commercial	$353.40
Rate for Payer: Aetna Medicare	$334.80
Rate for Payer: BCBS MT CHIP	$334.80
Rate for Payer: BCBS MT Closed Plan Network	$353.40
Rate for Payer: BCBS MT HealthLink	$334.80
Rate for Payer: BCBS MT Medicare	$334.80
Rate for Payer: BCBS MT POS	$353.40
Rate for Payer: BCBS MT Traditional	$372.00
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cigna Commercial	$353.40
Rate for Payer: Cigna Medicare	$334.80
Rate for Payer: Medicaid All Medicaid	$342.24
Rate for Payer: Medicare All Medicare	$260.40
Rate for Payer: Monida Allegiance	$353.40
Rate for Payer: Monida First Choice Health	$360.84
Rate for Payer: Monida Montana Health Co-op	$353.40
Rate for Payer: Monida PacificSource	$353.40

MVI ADULT VITS FOR INFUSION

Facility

$1,182.00

Service Code	HCPCS J3490
Hospital Charge Code	3000341
Hospital Revenue Code	258
Min. Negotiated Rate	$827.40
Max. Negotiated Rate	$1,182.00
Rate for Payer: Aetna Commercial	$1,122.90
Rate for Payer: Aetna Medicare	$1,063.80
Rate for Payer: BCBS MT CHIP	$1,063.80
Rate for Payer: BCBS MT Closed Plan Network	$1,122.90
Rate for Payer: BCBS MT HealthLink	$1,063.80
Rate for Payer: BCBS MT Medicare	$1,063.80
Rate for Payer: BCBS MT POS	$1,122.90
Rate for Payer: BCBS MT Traditional	$1,182.00
Rate for Payer: Cash Price	$1,063.80
Rate for Payer: Cigna Commercial	$1,122.90
Rate for Payer: Cigna Medicare	$1,063.80
Rate for Payer: Medicaid All Medicaid	$1,087.44
Rate for Payer: Medicare All Medicare	$827.40
Rate for Payer: Monida Allegiance	$1,122.90
Rate for Payer: Monida First Choice Health	$1,146.54
Rate for Payer: Monida Montana Health Co-op	$1,122.90
Rate for Payer: Monida PacificSource	$1,122.90

MVI ADULT VITS FOR INFUSION

Facility

$1,182.00

Service Code	HCPCS J3490
Hospital Charge Code	3000341
Hospital Revenue Code	258
Min. Negotiated Rate	$827.40
Max. Negotiated Rate	$1,182.00
Rate for Payer: Aetna Commercial	$1,122.90
Rate for Payer: Aetna Medicare	$1,063.80
Rate for Payer: BCBS MT CHIP	$1,063.80
Rate for Payer: BCBS MT Closed Plan Network	$1,122.90
Rate for Payer: BCBS MT HealthLink	$1,063.80
Rate for Payer: BCBS MT Medicare	$1,063.80
Rate for Payer: BCBS MT POS	$1,122.90
Rate for Payer: BCBS MT Traditional	$1,182.00
Rate for Payer: Cash Price	$1,063.80
Rate for Payer: Cigna Commercial	$1,122.90
Rate for Payer: Cigna Medicare	$1,063.80
Rate for Payer: Medicaid All Medicaid	$1,087.44
Rate for Payer: Medicare All Medicare	$827.40
Rate for Payer: Monida Allegiance	$1,122.90
Rate for Payer: Monida First Choice Health	$1,146.54
Rate for Payer: Monida Montana Health Co-op	$1,122.90
Rate for Payer: Monida PacificSource	$1,122.90

MYCOPHENOLIC ACID (716795)

Facility

$258.00

Service Code	HCPCS 80180
Hospital Charge Code	4080180
Hospital Revenue Code	300
Min. Negotiated Rate	$180.60
Max. Negotiated Rate	$258.00
Rate for Payer: Aetna Commercial	$245.10
Rate for Payer: Aetna Medicare	$232.20
Rate for Payer: BCBS MT CHIP	$232.20
Rate for Payer: BCBS MT Closed Plan Network	$245.10
Rate for Payer: BCBS MT HealthLink	$232.20
Rate for Payer: BCBS MT Medicare	$232.20
Rate for Payer: BCBS MT POS	$245.10
Rate for Payer: BCBS MT Traditional	$258.00
Rate for Payer: Cash Price	$232.20
Rate for Payer: Cigna Commercial	$245.10
Rate for Payer: Cigna Medicare	$232.20
Rate for Payer: Medicaid All Medicaid	$237.36
Rate for Payer: Medicare All Medicare	$180.60
Rate for Payer: Monida Allegiance	$245.10
Rate for Payer: Monida First Choice Health	$250.26
Rate for Payer: Monida Montana Health Co-op	$245.10
Rate for Payer: Monida PacificSource	$245.10

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