Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR WRIST LT W WO CONTRAST

Facility

$3,397.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300033
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR WRIST LT W WO CONTRAST

Facility

$3,397.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300033
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR WRIST RT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300024
Hospital Revenue Code	614
Min. Negotiated Rate	$1,896.30
Max. Negotiated Rate	$2,709.00
Rate for Payer: Aetna Commercial	$2,573.55
Rate for Payer: Aetna Medicare	$2,438.10
Rate for Payer: BCBS MT CHIP	$2,438.10
Rate for Payer: BCBS MT Closed Plan Network	$2,573.55
Rate for Payer: BCBS MT HealthLink	$2,438.10
Rate for Payer: BCBS MT Medicare	$2,438.10
Rate for Payer: BCBS MT POS	$2,573.55
Rate for Payer: BCBS MT Traditional	$2,709.00
Rate for Payer: Cash Price	$2,438.10
Rate for Payer: Cigna Commercial	$2,573.55
Rate for Payer: Cigna Medicare	$2,438.10
Rate for Payer: Medicaid All Medicaid	$2,492.28
Rate for Payer: Medicare All Medicare	$1,896.30
Rate for Payer: Monida Allegiance	$2,573.55
Rate for Payer: Monida First Choice Health	$2,627.73
Rate for Payer: Monida Montana Health Co-op	$2,573.55
Rate for Payer: Monida PacificSource	$2,573.55

MR WRIST RT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300024
Hospital Revenue Code	614
Min. Negotiated Rate	$1,896.30
Max. Negotiated Rate	$2,709.00
Rate for Payer: Aetna Commercial	$2,573.55
Rate for Payer: Aetna Medicare	$2,438.10
Rate for Payer: BCBS MT CHIP	$2,438.10
Rate for Payer: BCBS MT Closed Plan Network	$2,573.55
Rate for Payer: BCBS MT HealthLink	$2,438.10
Rate for Payer: BCBS MT Medicare	$2,438.10
Rate for Payer: BCBS MT POS	$2,573.55
Rate for Payer: BCBS MT Traditional	$2,709.00
Rate for Payer: Cash Price	$2,438.10
Rate for Payer: Cigna Commercial	$2,573.55
Rate for Payer: Cigna Medicare	$2,438.10
Rate for Payer: Medicaid All Medicaid	$2,492.28
Rate for Payer: Medicare All Medicare	$1,896.30
Rate for Payer: Monida Allegiance	$2,573.55
Rate for Payer: Monida First Choice Health	$2,627.73
Rate for Payer: Monida Montana Health Co-op	$2,573.55
Rate for Payer: Monida PacificSource	$2,573.55

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 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

$3,397.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300036
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR WRIST RT W WO CONTRAST

Facility

$3,397.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300036
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

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

$69.00

Service Code	HCPCS 86735
Hospital Charge Code	4086735
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

MUMPS AB, IGG (096552)

Facility

$69.00

Service Code	HCPCS 86735
Hospital Charge Code	4086735
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

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 OINT [2 %] 22GM

Facility

$144.00

Service Code	HCPCS J3490
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 OINT [2 %] 22GM

Facility

$144.00

Service Code	HCPCS J3490
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

$394.00

Service Code	HCPCS 95861
Hospital Charge Code	595861
Hospital Revenue Code	761
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

MUSCLE TEST, 2 LIMBS

Facility

$394.00

Service Code	HCPCS 95861
Hospital Charge Code	595861
Hospital Revenue Code	761
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

MVI ADULT VITS FOR INFUSION

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	3000341
Hospital Revenue Code	258
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

Know your out-of-pocket cost for care.

All Charges