Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OXYCODONE TAB IR [10 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000373
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

OXYCODONE TAB IR [10 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000373
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

OXYCODONE TAB IR [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000372
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

OXYCODONE TAB IR [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000372
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

OXYCONTIN ER TAB [10 MG] NF

Facility

$19.30

Service Code	HCPCS J8499
Hospital Charge Code	3007300
Hospital Revenue Code	250
Min. Negotiated Rate	$13.51
Max. Negotiated Rate	$19.30
Rate for Payer: Aetna Commercial	$18.34
Rate for Payer: Aetna Medicare	$17.37
Rate for Payer: BCBS MT CHIP	$17.37
Rate for Payer: BCBS MT Closed Plan Network	$18.34
Rate for Payer: BCBS MT HealthLink	$17.37
Rate for Payer: BCBS MT Medicare	$17.37
Rate for Payer: BCBS MT POS	$18.34
Rate for Payer: BCBS MT Traditional	$19.30
Rate for Payer: Cash Price	$17.37
Rate for Payer: Cigna Commercial	$18.34
Rate for Payer: Cigna Medicare	$17.37
Rate for Payer: Medicaid All Medicaid	$17.76
Rate for Payer: Medicare All Medicare	$13.51
Rate for Payer: Monida Allegiance	$18.34
Rate for Payer: Monida First Choice Health	$18.72
Rate for Payer: Monida Montana Health Co-op	$18.34
Rate for Payer: Monida PacificSource	$18.34

OXYCONTIN ER TAB [10 MG] NF

Facility

$19.30

Service Code	HCPCS J8499
Hospital Charge Code	3007300
Hospital Revenue Code	250
Min. Negotiated Rate	$13.51
Max. Negotiated Rate	$19.30
Rate for Payer: Aetna Commercial	$18.34
Rate for Payer: Aetna Medicare	$17.37
Rate for Payer: BCBS MT CHIP	$17.37
Rate for Payer: BCBS MT Closed Plan Network	$18.34
Rate for Payer: BCBS MT HealthLink	$17.37
Rate for Payer: BCBS MT Medicare	$17.37
Rate for Payer: BCBS MT POS	$18.34
Rate for Payer: BCBS MT Traditional	$19.30
Rate for Payer: Cash Price	$17.37
Rate for Payer: Cigna Commercial	$18.34
Rate for Payer: Cigna Medicare	$17.37
Rate for Payer: Medicaid All Medicaid	$17.76
Rate for Payer: Medicare All Medicare	$13.51
Rate for Payer: Monida Allegiance	$18.34
Rate for Payer: Monida First Choice Health	$18.72
Rate for Payer: Monida Montana Health Co-op	$18.34
Rate for Payer: Monida PacificSource	$18.34

OXYGEN CANNULA 25' 25/CS

Facility

$45.00

Hospital Charge Code	80020243
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

OXYGEN CANNULA 25' 25/CS

Facility

$45.00

Hospital Charge Code	80020243
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

OXYGEN CANNULA PEDS.

Facility

$19.00

Hospital Charge Code	80030229
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

OXYGEN CANNULA PEDS.

Facility

$19.00

Hospital Charge Code	80030229
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

OXYGEN MASK NON-REBREATHER

Facility

$21.00

Hospital Charge Code	80030346
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

OXYGEN MASK NON-REBREATHER

Facility

$21.00

Hospital Charge Code	80030346
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

OXYGEN PER DAY

Facility

$126.00

Hospital Charge Code	6630147
Hospital Revenue Code	270
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: BCBS MT CHIP	$113.40
Rate for Payer: BCBS MT Closed Plan Network	$119.70
Rate for Payer: BCBS MT HealthLink	$113.40
Rate for Payer: BCBS MT Medicare	$113.40
Rate for Payer: BCBS MT POS	$119.70
Rate for Payer: BCBS MT Traditional	$126.00
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial	$119.70
Rate for Payer: Cigna Medicare	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

OXYGEN PER DAY

Facility

$126.00

Hospital Charge Code	6630147
Hospital Revenue Code	270
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: BCBS MT CHIP	$113.40
Rate for Payer: BCBS MT Closed Plan Network	$119.70
Rate for Payer: BCBS MT HealthLink	$113.40
Rate for Payer: BCBS MT Medicare	$113.40
Rate for Payer: BCBS MT POS	$119.70
Rate for Payer: BCBS MT Traditional	$126.00
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial	$119.70
Rate for Payer: Cigna Medicare	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

OXYMETAZOLINE NASAL [0.05%] 12HR

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000374
Hospital Revenue Code	250
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

OXYMETAZOLINE NASAL [0.05%] 12HR

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000374
Hospital Revenue Code	250
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

OXYTOCIN INJ [10 U/ML]

Facility

$26.00

Service Code	HCPCS J2590
Hospital Charge Code	3000375
Hospital Revenue Code	259
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

OXYTOCIN INJ [10 U/ML]

Facility

$26.00

Service Code	HCPCS J2590
Hospital Charge Code	3000375
Hospital Revenue Code	259
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

PAIN MGT DRUG PROFILE SCREEN

Facility

$130.00

Service Code	CPT 80307
Hospital Charge Code	4088121
Hospital Revenue Code	302
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

PAIN MGT DRUG PROFILE SCREEN

Facility

$130.00

Service Code	CPT 80307
Hospital Charge Code	4088121
Hospital Revenue Code	302
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

PAIN ROOM FACILITY LEVEL 2

Facility

$3,557.00

Hospital Charge Code	1500212
Hospital Revenue Code	761
Min. Negotiated Rate	$2,489.90
Max. Negotiated Rate	$3,557.00
Rate for Payer: Aetna Commercial	$3,379.15
Rate for Payer: Aetna Medicare	$3,201.30
Rate for Payer: BCBS MT CHIP	$3,201.30
Rate for Payer: BCBS MT Closed Plan Network	$3,379.15
Rate for Payer: BCBS MT HealthLink	$3,201.30
Rate for Payer: BCBS MT Medicare	$3,201.30
Rate for Payer: BCBS MT POS	$3,379.15
Rate for Payer: BCBS MT Traditional	$3,557.00
Rate for Payer: Cash Price	$3,201.30
Rate for Payer: Cigna Commercial	$3,379.15
Rate for Payer: Cigna Medicare	$3,201.30
Rate for Payer: Medicaid All Medicaid	$3,272.44
Rate for Payer: Medicare All Medicare	$2,489.90
Rate for Payer: Monida Allegiance	$3,379.15
Rate for Payer: Monida First Choice Health	$3,450.29
Rate for Payer: Monida Montana Health Co-op	$3,379.15
Rate for Payer: Monida PacificSource	$3,379.15

PAIN ROOM FACILITY LEVEL 2

Facility

$3,557.00

Hospital Charge Code	1500212
Hospital Revenue Code	761
Min. Negotiated Rate	$2,489.90
Max. Negotiated Rate	$3,557.00
Rate for Payer: Aetna Commercial	$3,379.15
Rate for Payer: Aetna Medicare	$3,201.30
Rate for Payer: BCBS MT CHIP	$3,201.30
Rate for Payer: BCBS MT Closed Plan Network	$3,379.15
Rate for Payer: BCBS MT HealthLink	$3,201.30
Rate for Payer: BCBS MT Medicare	$3,201.30
Rate for Payer: BCBS MT POS	$3,379.15
Rate for Payer: BCBS MT Traditional	$3,557.00
Rate for Payer: Cash Price	$3,201.30
Rate for Payer: Cigna Commercial	$3,379.15
Rate for Payer: Cigna Medicare	$3,201.30
Rate for Payer: Medicaid All Medicaid	$3,272.44
Rate for Payer: Medicare All Medicare	$2,489.90
Rate for Payer: Monida Allegiance	$3,379.15
Rate for Payer: Monida First Choice Health	$3,450.29
Rate for Payer: Monida Montana Health Co-op	$3,379.15
Rate for Payer: Monida PacificSource	$3,379.15

PAIN ROOM FACILITY LEVEL 3

Facility

$4,509.00

Hospital Charge Code	1500213
Hospital Revenue Code	761
Min. Negotiated Rate	$3,156.30
Max. Negotiated Rate	$4,509.00
Rate for Payer: Aetna Commercial	$4,283.55
Rate for Payer: Aetna Medicare	$4,058.10
Rate for Payer: BCBS MT CHIP	$4,058.10
Rate for Payer: BCBS MT Closed Plan Network	$4,283.55
Rate for Payer: BCBS MT HealthLink	$4,058.10
Rate for Payer: BCBS MT Medicare	$4,058.10
Rate for Payer: BCBS MT POS	$4,283.55
Rate for Payer: BCBS MT Traditional	$4,509.00
Rate for Payer: Cash Price	$4,058.10
Rate for Payer: Cigna Commercial	$4,283.55
Rate for Payer: Cigna Medicare	$4,058.10
Rate for Payer: Medicaid All Medicaid	$4,148.28
Rate for Payer: Medicare All Medicare	$3,156.30
Rate for Payer: Monida Allegiance	$4,283.55
Rate for Payer: Monida First Choice Health	$4,373.73
Rate for Payer: Monida Montana Health Co-op	$4,283.55
Rate for Payer: Monida PacificSource	$4,283.55

PAIN ROOM FACILITY LEVEL 3

Facility

$4,509.00

Hospital Charge Code	1500213
Hospital Revenue Code	761
Min. Negotiated Rate	$3,156.30
Max. Negotiated Rate	$4,509.00
Rate for Payer: Aetna Commercial	$4,283.55
Rate for Payer: Aetna Medicare	$4,058.10
Rate for Payer: BCBS MT CHIP	$4,058.10
Rate for Payer: BCBS MT Closed Plan Network	$4,283.55
Rate for Payer: BCBS MT HealthLink	$4,058.10
Rate for Payer: BCBS MT Medicare	$4,058.10
Rate for Payer: BCBS MT POS	$4,283.55
Rate for Payer: BCBS MT Traditional	$4,509.00
Rate for Payer: Cash Price	$4,058.10
Rate for Payer: Cigna Commercial	$4,283.55
Rate for Payer: Cigna Medicare	$4,058.10
Rate for Payer: Medicaid All Medicaid	$4,148.28
Rate for Payer: Medicare All Medicare	$3,156.30
Rate for Payer: Monida Allegiance	$4,283.55
Rate for Payer: Monida First Choice Health	$4,373.73
Rate for Payer: Monida Montana Health Co-op	$4,283.55
Rate for Payer: Monida PacificSource	$4,283.55

PAIN SEVERITY QUANTIFIED; NO PAIN PRESEN

Facility

$0.01

Service Code	CPT 1126F
Hospital Charge Code	8001126
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

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