Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OPO FIRST HOUR

Facility

$186.00

Service Code	HCPCS G0378
Hospital Charge Code	210051
Hospital Revenue Code	762
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

OPO PER HOUR 2 OR MORE

Facility

$52.00

Service Code	HCPCS G0378
Hospital Charge Code	210052
Hospital Revenue Code	762
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

OPO PER HOUR 2 OR MORE

Facility

$52.00

Service Code	HCPCS G0378
Hospital Charge Code	210052
Hospital Revenue Code	762
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

OP- PM MOD CONCSED >5 YR 1ST 15MIN 99152

Facility

$312.00

Service Code	HCPCS 99152
Hospital Charge Code	1599152
Hospital Revenue Code	370
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$312.00
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: BCBS MT CHIP	$280.80
Rate for Payer: BCBS MT Closed Plan Network	$296.40
Rate for Payer: BCBS MT HealthLink	$280.80
Rate for Payer: BCBS MT Medicare	$280.80
Rate for Payer: BCBS MT POS	$296.40
Rate for Payer: BCBS MT Traditional	$312.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cigna Commercial	$296.40
Rate for Payer: Cigna Medicare	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

OP- PM MOD CONCSED >5 YR 1ST 15MIN 99152

Facility

$312.00

Service Code	HCPCS 99152
Hospital Charge Code	1599152
Hospital Revenue Code	370
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$312.00
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: BCBS MT CHIP	$280.80
Rate for Payer: BCBS MT Closed Plan Network	$296.40
Rate for Payer: BCBS MT HealthLink	$280.80
Rate for Payer: BCBS MT Medicare	$280.80
Rate for Payer: BCBS MT POS	$296.40
Rate for Payer: BCBS MT Traditional	$312.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cigna Commercial	$296.40
Rate for Payer: Cigna Medicare	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

OP PRO FEE INJ ANE AGEN AXILLARY

Professional

Both

$331.00

Service Code	HCPCS 64417 GF
Hospital Charge Code	764417
Hospital Revenue Code	964
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$331.00
Rate for Payer: Aetna Commercial	$314.45
Rate for Payer: Aetna Medicare	$297.90
Rate for Payer: BCBS MT CHIP	$297.90
Rate for Payer: BCBS MT Closed Plan Network	$314.45
Rate for Payer: BCBS MT HealthLink	$297.90
Rate for Payer: BCBS MT Medicare	$297.90
Rate for Payer: BCBS MT POS	$314.45
Rate for Payer: BCBS MT Traditional	$331.00
Rate for Payer: Cash Price	$297.90
Rate for Payer: Cigna Commercial	$314.45
Rate for Payer: Cigna Medicare	$297.90
Rate for Payer: Medicaid All Medicaid	$304.52
Rate for Payer: Medicare All Medicare	$231.70
Rate for Payer: Monida Allegiance	$314.45
Rate for Payer: Monida First Choice Health	$321.07
Rate for Payer: Monida Montana Health Co-op	$314.45
Rate for Payer: Monida PacificSource	$314.45

OPSITE DRESSING 5.5X4

Facility

$13.00

Hospital Charge Code	80030139
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

OPSITE DRESSING 5.5X4

Facility

$13.00

Hospital Charge Code	80030139
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

OPTIFOAM 4X4 ADHESIVE

Facility

$36.00

Hospital Charge Code	80030700
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIFOAM 4X4 ADHESIVE

Facility

$36.00

Hospital Charge Code	80030700
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIFOAM GENTLE SILICONE FACE FOAM 8X8

Facility

$36.00

Hospital Charge Code	80030701
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIFOAM GENTLE SILICONE FACE FOAM 8X8

Facility

$36.00

Hospital Charge Code	80030701
Hospital Revenue Code	272
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

OPTIPORE SPONGE

Facility

$9.00

Hospital Charge Code	80041599
Hospital Revenue Code	270
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

OPTIPORE SPONGE

Facility

$9.00

Hospital Charge Code	80041599
Hospital Revenue Code	270
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

ORAL AIRWAY # 12 120MM

Facility

$4.00

Hospital Charge Code	80040161
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

ORAL AIRWAY # 12 120MM

Facility

$4.00

Hospital Charge Code	80040161
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

OSELTAMIVIR CAP [30 MG]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000367
Hospital Revenue Code	636
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

OSELTAMIVIR CAP [30 MG]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000367
Hospital Revenue Code	636
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

OSELTAMIVIR CAP [75 MG]

Facility

$52.00

Service Code	HCPCS J3490
Hospital Charge Code	3000366
Hospital Revenue Code	259
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

OSELTAMIVIR CAP [75 MG]

Facility

$52.00

Service Code	HCPCS J3490
Hospital Charge Code	3000366
Hospital Revenue Code	259
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

OSELTAMIVIR SUSPENSION [6 MG/ML]

Facility

$476.00

Service Code	HCPCS J3490
Hospital Charge Code	3000368
Hospital Revenue Code	259
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$476.00
Rate for Payer: Aetna Commercial	$452.20
Rate for Payer: Aetna Medicare	$428.40
Rate for Payer: BCBS MT CHIP	$428.40
Rate for Payer: BCBS MT Closed Plan Network	$452.20
Rate for Payer: BCBS MT HealthLink	$428.40
Rate for Payer: BCBS MT Medicare	$428.40
Rate for Payer: BCBS MT POS	$452.20
Rate for Payer: BCBS MT Traditional	$476.00
Rate for Payer: Cash Price	$428.40
Rate for Payer: Cigna Commercial	$452.20
Rate for Payer: Cigna Medicare	$428.40
Rate for Payer: Medicaid All Medicaid	$437.92
Rate for Payer: Medicare All Medicare	$333.20
Rate for Payer: Monida Allegiance	$452.20
Rate for Payer: Monida First Choice Health	$461.72
Rate for Payer: Monida Montana Health Co-op	$452.20
Rate for Payer: Monida PacificSource	$452.20

OSELTAMIVIR SUSPENSION [6 MG/ML]

Facility

$476.00

Service Code	HCPCS J3490
Hospital Charge Code	3000368
Hospital Revenue Code	259
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$476.00
Rate for Payer: Aetna Commercial	$452.20
Rate for Payer: Aetna Medicare	$428.40
Rate for Payer: BCBS MT CHIP	$428.40
Rate for Payer: BCBS MT Closed Plan Network	$452.20
Rate for Payer: BCBS MT HealthLink	$428.40
Rate for Payer: BCBS MT Medicare	$428.40
Rate for Payer: BCBS MT POS	$452.20
Rate for Payer: BCBS MT Traditional	$476.00
Rate for Payer: Cash Price	$428.40
Rate for Payer: Cigna Commercial	$452.20
Rate for Payer: Cigna Medicare	$428.40
Rate for Payer: Medicaid All Medicaid	$437.92
Rate for Payer: Medicare All Medicare	$333.20
Rate for Payer: Monida Allegiance	$452.20
Rate for Payer: Monida First Choice Health	$461.72
Rate for Payer: Monida Montana Health Co-op	$452.20
Rate for Payer: Monida PacificSource	$452.20

OSMOLALITY, SERUM (002071)

Facility

$60.00

Service Code	HCPCS 83930
Hospital Charge Code	4083930
Hospital Revenue Code	301
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

OSMOLALITY, SERUM (002071)

Facility

$60.00

Service Code	HCPCS 83930
Hospital Charge Code	4083930
Hospital Revenue Code	301
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

OSMOLALITY, URINE (003442)

Facility

$60.00

Service Code	HCPCS 83935
Hospital Charge Code	4083935
Hospital Revenue Code	301
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