Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OCCULT BLOOD, FECAL X 3

Facility

$44.00

Service Code	HCPCS 82270
Hospital Charge Code	4082270
Hospital Revenue Code	300
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

OCCULT BLOOD, FECAL X 3

Facility

$44.00

Service Code	HCPCS 82270
Hospital Charge Code	4082270
Hospital Revenue Code	300
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$44.00
Rate for Payer: Aetna Commercial	$41.80
Rate for Payer: Aetna Medicare	$39.60
Rate for Payer: BCBS MT CHIP	$39.60
Rate for Payer: BCBS MT Closed Plan Network	$41.80
Rate for Payer: BCBS MT HealthLink	$39.60
Rate for Payer: BCBS MT Medicare	$39.60
Rate for Payer: BCBS MT POS	$41.80
Rate for Payer: BCBS MT Traditional	$44.00
Rate for Payer: Cash Price	$39.60
Rate for Payer: Cigna Commercial	$41.80
Rate for Payer: Cigna Medicare	$39.60
Rate for Payer: Medicaid All Medicaid	$40.48
Rate for Payer: Medicare All Medicare	$30.80
Rate for Payer: Monida Allegiance	$41.80
Rate for Payer: Monida First Choice Health	$42.68
Rate for Payer: Monida Montana Health Co-op	$41.80
Rate for Payer: Monida PacificSource	$41.80

OCCULT BLOOD, GASTRIC

Facility

$54.00

Service Code	HCPCS 82271
Hospital Charge Code	4082271
Hospital Revenue Code	300
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

OCCULT BLOOD, GASTRIC

Facility

$54.00

Service Code	HCPCS 82271
Hospital Charge Code	4082271
Hospital Revenue Code	300
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

OFLOXACIN 0.3% OPTH DRP [5 ML]

Facility

$82.00

Service Code	HCPCS J3490
Hospital Charge Code	3000359
Hospital Revenue Code	259
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

OFLOXACIN 0.3% OPTH DRP [5 ML]

Facility

$82.00

Service Code	HCPCS J3490
Hospital Charge Code	3000359
Hospital Revenue Code	259
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

OLANZAPINE INJ [10 MG]

Facility

$133.00

Service Code	HCPCS J3490
Hospital Charge Code	3000360
Hospital Revenue Code	636
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

OLANZAPINE INJ [10 MG]

Facility

$133.00

Service Code	HCPCS J3490
Hospital Charge Code	3000360
Hospital Revenue Code	636
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

OLANZAPINE TAB [2.5 MG] - NONFORMULARY

Facility

$38.00

Service Code	HCPCS J3490
Hospital Charge Code	3000361
Hospital Revenue Code	250
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

OLANZAPINE TAB [2.5 MG] - NONFORMULARY

Facility

$38.00

Service Code	HCPCS J3490
Hospital Charge Code	3000361
Hospital Revenue Code	250
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

OMEPRAZOLE DR CAP [20 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000362
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

OMEPRAZOLE DR CAP [20 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000362
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

OMNIPAQUE 300mg/ml (PAIN INJ)

Facility

$177.60

Service Code	HCPCS Q9967
Hospital Charge Code	3000363
Hospital Revenue Code	255
Min. Negotiated Rate	$124.32
Max. Negotiated Rate	$177.60
Rate for Payer: Aetna Commercial	$168.72
Rate for Payer: Aetna Medicare	$159.84
Rate for Payer: BCBS MT CHIP	$159.84
Rate for Payer: BCBS MT Closed Plan Network	$168.72
Rate for Payer: BCBS MT HealthLink	$159.84
Rate for Payer: BCBS MT Medicare	$159.84
Rate for Payer: BCBS MT POS	$168.72
Rate for Payer: BCBS MT Traditional	$177.60
Rate for Payer: Cash Price	$159.84
Rate for Payer: Cigna Commercial	$168.72
Rate for Payer: Cigna Medicare	$159.84
Rate for Payer: Medicaid All Medicaid	$163.39
Rate for Payer: Medicare All Medicare	$124.32
Rate for Payer: Monida Allegiance	$168.72
Rate for Payer: Monida First Choice Health	$172.27
Rate for Payer: Monida Montana Health Co-op	$168.72
Rate for Payer: Monida PacificSource	$168.72

OMNIPAQUE 300mg/ml (PAIN INJ)

Facility

$177.60

Service Code	HCPCS Q9967
Hospital Charge Code	3000363
Hospital Revenue Code	255
Min. Negotiated Rate	$124.32
Max. Negotiated Rate	$177.60
Rate for Payer: Aetna Commercial	$168.72
Rate for Payer: Aetna Medicare	$159.84
Rate for Payer: BCBS MT CHIP	$159.84
Rate for Payer: BCBS MT Closed Plan Network	$168.72
Rate for Payer: BCBS MT HealthLink	$159.84
Rate for Payer: BCBS MT Medicare	$159.84
Rate for Payer: BCBS MT POS	$168.72
Rate for Payer: BCBS MT Traditional	$177.60
Rate for Payer: Cash Price	$159.84
Rate for Payer: Cigna Commercial	$168.72
Rate for Payer: Cigna Medicare	$159.84
Rate for Payer: Medicaid All Medicaid	$163.39
Rate for Payer: Medicare All Medicare	$124.32
Rate for Payer: Monida Allegiance	$168.72
Rate for Payer: Monida First Choice Health	$172.27
Rate for Payer: Monida Montana Health Co-op	$168.72
Rate for Payer: Monida PacificSource	$168.72

ONDANSETRON INJ [2 MG/ML]

Facility

$26.00

Service Code	HCPCS J2405
Hospital Charge Code	3000364
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

ONDANSETRON INJ [2 MG/ML]

Facility

$26.00

Service Code	HCPCS J2405
Hospital Charge Code	3000364
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

ONDANSETRON ODT TAB [4 MG]

Facility

$8.00

Service Code	HCPCS Q0162
Hospital Charge Code	3000365
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

ONDANSETRON ODT TAB [4 MG]

Facility

$8.00

Service Code	HCPCS Q0162
Hospital Charge Code	3000365
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

.ONE ALLELE OR ALLELE GRP EA (MOLC PATH)

Facility

$469.00

Service Code	HCPCS 81383
Hospital Charge Code	4081383
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

.ONE ALLELE OR ALLELE GRP EA (MOLC PATH)

Facility

$469.00

Service Code	HCPCS 81383
Hospital Charge Code	4081383
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

.ONE ANTIGEN EQUIVALENT EACH (MOLC PATH)

Facility

$469.00

Service Code	HCPCS 81377
Hospital Charge Code	4081377
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

.ONE ANTIGEN EQUIVALENT EACH (MOLC PATH)

Facility

$469.00

Service Code	HCPCS 81377
Hospital Charge Code	4081377
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

OP IJ INTERCOSTAL NRVE BLK EA ADD 64421

Facility

$2,129.00

Service Code	HCPCS 64421
Hospital Charge Code	564421
Hospital Revenue Code	760
Min. Negotiated Rate	$1,490.30
Max. Negotiated Rate	$2,129.00
Rate for Payer: Aetna Commercial	$2,022.55
Rate for Payer: Aetna Medicare	$1,916.10
Rate for Payer: BCBS MT CHIP	$1,916.10
Rate for Payer: BCBS MT Closed Plan Network	$2,022.55
Rate for Payer: BCBS MT HealthLink	$1,916.10
Rate for Payer: BCBS MT Medicare	$1,916.10
Rate for Payer: BCBS MT POS	$2,022.55
Rate for Payer: BCBS MT Traditional	$2,129.00
Rate for Payer: Cash Price	$1,916.10
Rate for Payer: Cigna Commercial	$2,022.55
Rate for Payer: Cigna Medicare	$1,916.10
Rate for Payer: Medicaid All Medicaid	$1,958.68
Rate for Payer: Medicare All Medicare	$1,490.30
Rate for Payer: Monida Allegiance	$2,022.55
Rate for Payer: Monida First Choice Health	$2,065.13
Rate for Payer: Monida Montana Health Co-op	$2,022.55
Rate for Payer: Monida PacificSource	$2,022.55

OP IJ INTERCOSTAL NRVE BLK EA ADD 64421

Facility

$2,129.00

Service Code	HCPCS 64421
Hospital Charge Code	564421
Hospital Revenue Code	760
Min. Negotiated Rate	$1,490.30
Max. Negotiated Rate	$2,129.00
Rate for Payer: Aetna Commercial	$2,022.55
Rate for Payer: Aetna Medicare	$1,916.10
Rate for Payer: BCBS MT CHIP	$1,916.10
Rate for Payer: BCBS MT Closed Plan Network	$2,022.55
Rate for Payer: BCBS MT HealthLink	$1,916.10
Rate for Payer: BCBS MT Medicare	$1,916.10
Rate for Payer: BCBS MT POS	$2,022.55
Rate for Payer: BCBS MT Traditional	$2,129.00
Rate for Payer: Cash Price	$1,916.10
Rate for Payer: Cigna Commercial	$2,022.55
Rate for Payer: Cigna Medicare	$1,916.10
Rate for Payer: Medicaid All Medicaid	$1,958.68
Rate for Payer: Medicare All Medicare	$1,490.30
Rate for Payer: Monida Allegiance	$2,022.55
Rate for Payer: Monida First Choice Health	$2,065.13
Rate for Payer: Monida Montana Health Co-op	$2,022.55
Rate for Payer: Monida PacificSource	$2,022.55

OP IJ PERIPH NV BLOCK/LESSER OCC 64450

Facility

$1,393.00

Service Code	HCPCS 64450
Hospital Charge Code	1564450
Hospital Revenue Code	761
Min. Negotiated Rate	$975.10
Max. Negotiated Rate	$1,393.00
Rate for Payer: Aetna Commercial	$1,323.35
Rate for Payer: Aetna Medicare	$1,253.70
Rate for Payer: BCBS MT CHIP	$1,253.70
Rate for Payer: BCBS MT Closed Plan Network	$1,323.35
Rate for Payer: BCBS MT HealthLink	$1,253.70
Rate for Payer: BCBS MT Medicare	$1,253.70
Rate for Payer: BCBS MT POS	$1,323.35
Rate for Payer: BCBS MT Traditional	$1,393.00
Rate for Payer: Cash Price	$1,253.70
Rate for Payer: Cigna Commercial	$1,323.35
Rate for Payer: Cigna Medicare	$1,253.70
Rate for Payer: Medicaid All Medicaid	$1,281.56
Rate for Payer: Medicare All Medicare	$975.10
Rate for Payer: Monida Allegiance	$1,323.35
Rate for Payer: Monida First Choice Health	$1,351.21
Rate for Payer: Monida Montana Health Co-op	$1,323.35
Rate for Payer: Monida PacificSource	$1,323.35

Know your out-of-pocket cost for care.

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