Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

NORTRIPYLINE 10 MG TAB- NF

Facility

$8.00

Service Code	NDC 50268060315
Hospital Charge Code	3007313
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

NORTRIPYLINE 10 MG TAB- NF

Facility

$8.00

Service Code	NDC 50268060315
Hospital Charge Code	3007313
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

NPA 12F

Facility

$45.00

Hospital Charge Code	80030234
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

NPA 12F

Facility

$45.00

Hospital Charge Code	80030234
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

NP THYROID 60MG TABLET-NF

Facility

$8.00

Service Code	NDC 42192033001
Hospital Charge Code	3007204
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

NP THYROID 60MG TABLET-NF

Facility

$8.00

Service Code	NDC 42192033001
Hospital Charge Code	3007204
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

NS 100mL Charge only

Facility

$9.00

Service Code	HCPCS J7050
Hospital Charge Code	3000355
Hospital Revenue Code	258
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

NS 100mL Charge only

Facility

$9.00

Service Code	HCPCS J7050
Hospital Charge Code	3000355
Hospital Revenue Code	258
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

NT-PROBNP (143000)

Facility

$341.00

Service Code	HCPCS 83880
Hospital Charge Code	4000050
Hospital Revenue Code	300
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

NT-PROBNP (143000)

Facility

$341.00

Service Code	HCPCS 83880
Hospital Charge Code	4000050
Hospital Revenue Code	300
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

NYSTATIN OINT [100000 UNITS] 15GM NF

Facility

$84.00

Service Code	HCPCS J3490
Hospital Charge Code	3000551
Hospital Revenue Code	259
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

NYSTATIN OINT [100000 UNITS] 15GM NF

Facility

$84.00

Service Code	HCPCS J3490
Hospital Charge Code	3000551
Hospital Revenue Code	259
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

NYSTATIN POWDER [100000U/1GM] 15GM

Facility

$88.00

Service Code	NDC 00574200815
Hospital Charge Code	3000523
Hospital Revenue Code	250
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

NYSTATIN POWDER [100000U/1GM] 15GM

Facility

$88.00

Service Code	NDC 00574200815
Hospital Charge Code	3000523
Hospital Revenue Code	250
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

NYSTATIN POWDER [100 MU/GM]

Facility

$90.00

Service Code	HCPCS J3490
Hospital Charge Code	3000356
Hospital Revenue Code	250
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

NYSTATIN POWDER [100 MU/GM]

Facility

$90.00

Service Code	HCPCS J3490
Hospital Charge Code	3000356
Hospital Revenue Code	250
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

NYSTATIN SUSP [100,000 U/ML] 60 ML BTL

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000357
Hospital Revenue Code	250
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

NYSTATIN SUSP [100,000 U/ML] 60 ML BTL

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000357
Hospital Revenue Code	250
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

NYSTATIN-TRIAMCINOLONE CRM [15 GM]

Facility

$376.00

Service Code	HCPCS J3490
Hospital Charge Code	3000358
Hospital Revenue Code	259
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

NYSTATIN-TRIAMCINOLONE CRM [15 GM]

Facility

$376.00

Service Code	HCPCS J3490
Hospital Charge Code	3000358
Hospital Revenue Code	259
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

OBSV CARE SUBSEQUENT CARE HIGH COMPLE

Professional

Both

$227.00

Service Code	HCPCS 99233 AQ
Hospital Charge Code	799226
Hospital Revenue Code	982
Min. Negotiated Rate	$158.90
Max. Negotiated Rate	$220.19
Rate for Payer: Aetna Commercial	$215.65
Rate for Payer: Aetna Medicare	$204.30
Rate for Payer: Cash Price	$204.30
Rate for Payer: Medicaid All Medicaid	$208.84
Rate for Payer: Medicare All Medicare	$158.90
Rate for Payer: Monida Allegiance	$215.65
Rate for Payer: Monida First Choice Health	$220.19
Rate for Payer: Monida Montana Health Co-op	$215.65
Rate for Payer: Monida PacificSource	$215.65

OBSV CARE SUBSEQUENT CARE LOW COMPLEX

Professional

Both

$100.00

Service Code	HCPCS 99231 AQ
Hospital Charge Code	799224
Hospital Revenue Code	982
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

OBSV CARE SUBSEQUENT CARE MOD COMPLEX

Professional

Both

$163.00

Service Code	HCPCS 99232 AQ
Hospital Charge Code	799225
Hospital Revenue Code	982
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$158.11
Rate for Payer: Aetna Commercial	$154.85
Rate for Payer: Aetna Medicare	$146.70
Rate for Payer: Cash Price	$146.70
Rate for Payer: Medicaid All Medicaid	$149.96
Rate for Payer: Medicare All Medicare	$114.10
Rate for Payer: Monida Allegiance	$154.85
Rate for Payer: Monida First Choice Health	$158.11
Rate for Payer: Monida Montana Health Co-op	$154.85
Rate for Payer: Monida PacificSource	$154.85

OCCULT BLOOD, FECAL X 1

Facility

$47.00

Service Code	HCPCS 82272
Hospital Charge Code	4082272
Hospital Revenue Code	301
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

OCCULT BLOOD, FECAL X 1

Facility

$47.00

Service Code	HCPCS 82272
Hospital Charge Code	4082272
Hospital Revenue Code	301
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

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