Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OBSV CARE SUBSEQUENT CARE HIGH COMPLE

Professional

Both

$329.00

Service Code	CPT 99233
Hospital Charge Code	799226
Hospital Revenue Code	982
Min. Negotiated Rate	$230.30
Max. Negotiated Rate	$319.13
Rate for Payer: Aetna Commercial	$312.55
Rate for Payer: Aetna Medicare	$296.10
Rate for Payer: Cash Price	$296.10
Rate for Payer: Medicaid All Medicaid	$302.68
Rate for Payer: Medicare All Medicare	$230.30
Rate for Payer: Monida Allegiance	$312.55
Rate for Payer: Monida First Choice Health	$319.13
Rate for Payer: Monida Montana Health Co-op	$312.55
Rate for Payer: Monida PacificSource	$312.55

OBSV CARE SUBSEQUENT CARE LOW COMPLEX

Professional

Both

$136.00

Service Code	CPT 99231
Hospital Charge Code	799224
Hospital Revenue Code	982
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$131.92
Rate for Payer: Aetna Commercial	$129.20
Rate for Payer: Aetna Medicare	$122.40
Rate for Payer: Cash Price	$122.40
Rate for Payer: Medicaid All Medicaid	$125.12
Rate for Payer: Medicare All Medicare	$95.20
Rate for Payer: Monida Allegiance	$129.20
Rate for Payer: Monida First Choice Health	$131.92
Rate for Payer: Monida Montana Health Co-op	$129.20
Rate for Payer: Monida PacificSource	$129.20

OBSV CARE SUBSEQUENT CARE MOD COMPLEX

Professional

Both

$221.00

Service Code	CPT 99232
Hospital Charge Code	799225
Hospital Revenue Code	982
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$214.37
Rate for Payer: Aetna Commercial	$209.95
Rate for Payer: Aetna Medicare	$198.90
Rate for Payer: Cash Price	$198.90
Rate for Payer: Medicaid All Medicaid	$203.32
Rate for Payer: Medicare All Medicare	$154.70
Rate for Payer: Monida Allegiance	$209.95
Rate for Payer: Monida First Choice Health	$214.37
Rate for Payer: Monida Montana Health Co-op	$209.95
Rate for Payer: Monida PacificSource	$209.95

OBTAINING SCREEN PAP SMEAR

Facility

$94.00

Service Code	HCPCS Q0091
Hospital Charge Code	800091
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

OBTAINING SCREEN PAP SMEAR

Facility

$94.00

Service Code	HCPCS Q0091
Hospital Charge Code	800091
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

OCCULT BLOOD, FECAL X 1

Facility

$47.00

Service Code	CPT 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	CPT 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 3

Facility

$44.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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 J2359
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 J2359
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 ODT TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000590
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

OLANZAPINE ODT TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000590
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

OLANZAPINE TAB [2.5 MG] NF

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] NF

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

OLMESARTAN MEDOXOMIL TAB [40 MG] NF

Facility

$31.00

Service Code	HCPCS J8499
Hospital Charge Code	3000607
Hospital Revenue Code	250
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$31.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: BCBS MT CHIP	$27.90
Rate for Payer: BCBS MT Closed Plan Network	$29.45
Rate for Payer: BCBS MT HealthLink	$27.90
Rate for Payer: BCBS MT Medicare	$27.90
Rate for Payer: BCBS MT POS	$29.45
Rate for Payer: BCBS MT Traditional	$31.00
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cigna Commercial	$29.45
Rate for Payer: Cigna Medicare	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

OLMESARTAN MEDOXOMIL TAB [40 MG] NF

Facility

$31.00

Service Code	HCPCS J8499
Hospital Charge Code	3000607
Hospital Revenue Code	250
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$31.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: BCBS MT CHIP	$27.90
Rate for Payer: BCBS MT Closed Plan Network	$29.45
Rate for Payer: BCBS MT HealthLink	$27.90
Rate for Payer: BCBS MT Medicare	$27.90
Rate for Payer: BCBS MT POS	$29.45
Rate for Payer: BCBS MT Traditional	$31.00
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cigna Commercial	$29.45
Rate for Payer: Cigna Medicare	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

OMEPRAZOLE DR CAP [20 MG]

Facility

$8.00

Service Code	HCPCS J8499
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 J8499
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 [300 MG/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 [300 MG/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

Know your out-of-pocket cost for care.

All Charges