Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

NEB TR CONTINUOUS EACH ADDITIONAL HR

Facility

$148.00

Service Code	CPT 94645
Hospital Charge Code	594645
Hospital Revenue Code	761
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna Commercial	$140.60
Rate for Payer: Aetna Medicare	$133.20
Rate for Payer: BCBS MT CHIP	$133.20
Rate for Payer: BCBS MT Closed Plan Network	$140.60
Rate for Payer: BCBS MT HealthLink	$133.20
Rate for Payer: BCBS MT Medicare	$133.20
Rate for Payer: BCBS MT POS	$140.60
Rate for Payer: BCBS MT Traditional	$148.00
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cigna Commercial	$140.60
Rate for Payer: Cigna Medicare	$133.20
Rate for Payer: Medicaid All Medicaid	$136.16
Rate for Payer: Medicare All Medicare	$103.60
Rate for Payer: Monida Allegiance	$140.60
Rate for Payer: Monida First Choice Health	$143.56
Rate for Payer: Monida Montana Health Co-op	$140.60
Rate for Payer: Monida PacificSource	$140.60

NEB TR CONTINUOUS EACH ADDITIONAL HR

Facility

$148.00

Service Code	CPT 94645
Hospital Charge Code	594645
Hospital Revenue Code	761
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna Commercial	$140.60
Rate for Payer: Aetna Medicare	$133.20
Rate for Payer: BCBS MT CHIP	$133.20
Rate for Payer: BCBS MT Closed Plan Network	$140.60
Rate for Payer: BCBS MT HealthLink	$133.20
Rate for Payer: BCBS MT Medicare	$133.20
Rate for Payer: BCBS MT POS	$140.60
Rate for Payer: BCBS MT Traditional	$148.00
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cigna Commercial	$140.60
Rate for Payer: Cigna Medicare	$133.20
Rate for Payer: Medicaid All Medicaid	$136.16
Rate for Payer: Medicare All Medicare	$103.60
Rate for Payer: Monida Allegiance	$140.60
Rate for Payer: Monida First Choice Health	$143.56
Rate for Payer: Monida Montana Health Co-op	$140.60
Rate for Payer: Monida PacificSource	$140.60

NEBULIZER PEDS MASK (FISH) VIXONE

Facility

$18.00

Hospital Charge Code	80030221
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

NEBULIZER PEDS MASK (FISH) VIXONE

Facility

$18.00

Hospital Charge Code	80030221
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

NEBULIZER PIPE 7'

Facility

$19.00

Hospital Charge Code	80030224
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

NEBULIZER PIPE 7'

Facility

$19.00

Hospital Charge Code	80030224
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

NEBULIZER TREATMENT-CLINIC

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	8094640
Hospital Revenue Code	521
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEBULIZER TREATMENT-CLINIC

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	8094640
Hospital Revenue Code	521
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEBULIZER TREATMENT-HOSPITAL

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEBULIZER TREATMENT-HOSPITAL

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEGATIVE PHQ9 SCORE OF 0

Facility

$0.01

Service Code	HCPCS G8510
Hospital Charge Code	8008510
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

NEGATIVE PHQ9 SCORE OF 0

Facility

$0.01

Service Code	HCPCS G8510
Hospital Charge Code	8008510
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

NEGATIVE SCREEN FOR DEPRESSIVE SYMPTOMS

Facility

$0.01

Service Code	CPT 3351F
Hospital Charge Code	8003351
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

NEGATIVE SCREEN FOR DEPRESSIVE SYMPTOMS

Facility

$0.01

Service Code	CPT 3351F
Hospital Charge Code	8003351
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

NEG PRESS WOUND TX </=50CM

Facility

$442.00

Service Code	CPT 97605
Hospital Charge Code	8097605
Hospital Revenue Code	521
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

NEG PRESS WOUND TX </=50CM

Facility

$442.00

Service Code	CPT 97605
Hospital Charge Code	8097605
Hospital Revenue Code	521
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$587.00

Service Code	CPT 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$410.90
Max. Negotiated Rate	$587.00
Rate for Payer: Aetna Commercial	$557.65
Rate for Payer: Aetna Medicare	$528.30
Rate for Payer: BCBS MT CHIP	$528.30
Rate for Payer: BCBS MT Closed Plan Network	$557.65
Rate for Payer: BCBS MT HealthLink	$528.30
Rate for Payer: BCBS MT Medicare	$528.30
Rate for Payer: BCBS MT POS	$557.65
Rate for Payer: BCBS MT Traditional	$587.00
Rate for Payer: Cash Price	$528.30
Rate for Payer: Cigna Commercial	$557.65
Rate for Payer: Cigna Medicare	$528.30
Rate for Payer: Medicaid All Medicaid	$540.04
Rate for Payer: Medicare All Medicare	$410.90
Rate for Payer: Monida Allegiance	$557.65
Rate for Payer: Monida First Choice Health	$569.39
Rate for Payer: Monida Montana Health Co-op	$557.65
Rate for Payer: Monida PacificSource	$557.65

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$587.00

Service Code	CPT 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$410.90
Max. Negotiated Rate	$587.00
Rate for Payer: Aetna Commercial	$557.65
Rate for Payer: Aetna Medicare	$528.30
Rate for Payer: BCBS MT CHIP	$528.30
Rate for Payer: BCBS MT Closed Plan Network	$557.65
Rate for Payer: BCBS MT HealthLink	$528.30
Rate for Payer: BCBS MT Medicare	$528.30
Rate for Payer: BCBS MT POS	$557.65
Rate for Payer: BCBS MT Traditional	$587.00
Rate for Payer: Cash Price	$528.30
Rate for Payer: Cigna Commercial	$557.65
Rate for Payer: Cigna Medicare	$528.30
Rate for Payer: Medicaid All Medicaid	$540.04
Rate for Payer: Medicare All Medicare	$410.90
Rate for Payer: Monida Allegiance	$557.65
Rate for Payer: Monida First Choice Health	$569.39
Rate for Payer: Monida Montana Health Co-op	$557.65
Rate for Payer: Monida PacificSource	$557.65

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$150.00

Service Code	CPT 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$150.00

Service Code	CPT 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

NEISSERI GONORRHOEAE AMP PROB TECH

Facility

$139.00

Service Code	CPT 87591
Hospital Charge Code	8087591
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

NEISSERI GONORRHOEAE AMP PROB TECH

Facility

$139.00

Service Code	CPT 87591
Hospital Charge Code	8087591
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

NETARSUDIL OPTH [0.02 %] 2.5ML NF

Facility

$677.40

Hospital Charge Code	3007247
Hospital Revenue Code	250
Min. Negotiated Rate	$474.18
Max. Negotiated Rate	$677.40
Rate for Payer: Aetna Commercial	$643.53
Rate for Payer: Aetna Medicare	$609.66
Rate for Payer: BCBS MT CHIP	$609.66
Rate for Payer: BCBS MT Closed Plan Network	$643.53
Rate for Payer: BCBS MT HealthLink	$609.66
Rate for Payer: BCBS MT Medicare	$609.66
Rate for Payer: BCBS MT POS	$643.53
Rate for Payer: BCBS MT Traditional	$677.40
Rate for Payer: Cash Price	$609.66
Rate for Payer: Cigna Commercial	$643.53
Rate for Payer: Cigna Medicare	$609.66
Rate for Payer: Medicaid All Medicaid	$623.21
Rate for Payer: Medicare All Medicare	$474.18
Rate for Payer: Monida Allegiance	$643.53
Rate for Payer: Monida First Choice Health	$657.08
Rate for Payer: Monida Montana Health Co-op	$643.53
Rate for Payer: Monida PacificSource	$643.53

NETARSUDIL OPTH [0.02 %] 2.5ML NF

Facility

$677.40

Hospital Charge Code	3007247
Hospital Revenue Code	250
Min. Negotiated Rate	$474.18
Max. Negotiated Rate	$677.40
Rate for Payer: Aetna Commercial	$643.53
Rate for Payer: Aetna Medicare	$609.66
Rate for Payer: BCBS MT CHIP	$609.66
Rate for Payer: BCBS MT Closed Plan Network	$643.53
Rate for Payer: BCBS MT HealthLink	$609.66
Rate for Payer: BCBS MT Medicare	$609.66
Rate for Payer: BCBS MT POS	$643.53
Rate for Payer: BCBS MT Traditional	$677.40
Rate for Payer: Cash Price	$609.66
Rate for Payer: Cigna Commercial	$643.53
Rate for Payer: Cigna Medicare	$609.66
Rate for Payer: Medicaid All Medicaid	$623.21
Rate for Payer: Medicare All Medicare	$474.18
Rate for Payer: Monida Allegiance	$643.53
Rate for Payer: Monida First Choice Health	$657.08
Rate for Payer: Monida Montana Health Co-op	$643.53
Rate for Payer: Monida PacificSource	$643.53

NEUROMUSCULAR REEDUCATION PER 15

Facility

$109.00

Service Code	CPT 97112
Hospital Charge Code	8197112
Hospital Revenue Code	521
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

Know your out-of-pocket cost for care.

All Charges