Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER GASTRIC INTUBATION

Facility

$353.00

Service Code	HCPCS 43753
Hospital Charge Code	1043753
Hospital Revenue Code	450
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

ER INCISION OF RECTAL ABSCESS

Facility

$983.00

Service Code	HCPCS 46040
Hospital Charge Code	1046040
Hospital Revenue Code	450
Min. Negotiated Rate	$688.10
Max. Negotiated Rate	$983.00
Rate for Payer: Aetna Commercial	$933.85
Rate for Payer: Aetna Medicare	$884.70
Rate for Payer: BCBS MT CHIP	$884.70
Rate for Payer: BCBS MT Closed Plan Network	$933.85
Rate for Payer: BCBS MT HealthLink	$884.70
Rate for Payer: BCBS MT Medicare	$884.70
Rate for Payer: BCBS MT POS	$933.85
Rate for Payer: BCBS MT Traditional	$983.00
Rate for Payer: Cash Price	$884.70
Rate for Payer: Cigna Commercial	$933.85
Rate for Payer: Cigna Medicare	$884.70
Rate for Payer: Medicaid All Medicaid	$904.36
Rate for Payer: Medicare All Medicare	$688.10
Rate for Payer: Monida Allegiance	$933.85
Rate for Payer: Monida First Choice Health	$953.51
Rate for Payer: Monida Montana Health Co-op	$933.85
Rate for Payer: Monida PacificSource	$933.85

ER INCISION OF RECTAL ABSCESS

Facility

$983.00

Service Code	HCPCS 46040
Hospital Charge Code	1046040
Hospital Revenue Code	450
Min. Negotiated Rate	$688.10
Max. Negotiated Rate	$983.00
Rate for Payer: Aetna Commercial	$933.85
Rate for Payer: Aetna Medicare	$884.70
Rate for Payer: BCBS MT CHIP	$884.70
Rate for Payer: BCBS MT Closed Plan Network	$933.85
Rate for Payer: BCBS MT HealthLink	$884.70
Rate for Payer: BCBS MT Medicare	$884.70
Rate for Payer: BCBS MT POS	$933.85
Rate for Payer: BCBS MT Traditional	$983.00
Rate for Payer: Cash Price	$884.70
Rate for Payer: Cigna Commercial	$933.85
Rate for Payer: Cigna Medicare	$884.70
Rate for Payer: Medicaid All Medicaid	$904.36
Rate for Payer: Medicare All Medicare	$688.10
Rate for Payer: Monida Allegiance	$933.85
Rate for Payer: Monida First Choice Health	$953.51
Rate for Payer: Monida Montana Health Co-op	$933.85
Rate for Payer: Monida PacificSource	$933.85

ER INFUSION ADD PUMP SET UP

Facility

$89.00

Service Code	HCPCS 96371
Hospital Charge Code	1030203
Hospital Revenue Code	450
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

ER INFUSION ADD PUMP SET UP

Facility

$89.00

Service Code	HCPCS 96371
Hospital Charge Code	1030203
Hospital Revenue Code	450
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

ER INJ AND/OR ASPIRATION JOINT INTERM

Facility

$421.00

Service Code	HCPCS 20605
Hospital Charge Code	1020605
Hospital Revenue Code	450
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

ER INJ AND/OR ASPIRATION JOINT INTERM

Facility

$421.00

Service Code	HCPCS 20605
Hospital Charge Code	1020605
Hospital Revenue Code	450
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

ER INJECT/ASPIR JOINT LG

Facility

$599.00

Service Code	HCPCS 20610
Hospital Charge Code	1020610
Hospital Revenue Code	450
Min. Negotiated Rate	$419.30
Max. Negotiated Rate	$599.00
Rate for Payer: Aetna Commercial	$569.05
Rate for Payer: Aetna Medicare	$539.10
Rate for Payer: BCBS MT CHIP	$539.10
Rate for Payer: BCBS MT Closed Plan Network	$569.05
Rate for Payer: BCBS MT HealthLink	$539.10
Rate for Payer: BCBS MT Medicare	$539.10
Rate for Payer: BCBS MT POS	$569.05
Rate for Payer: BCBS MT Traditional	$599.00
Rate for Payer: Cash Price	$539.10
Rate for Payer: Cigna Commercial	$569.05
Rate for Payer: Cigna Medicare	$539.10
Rate for Payer: Medicaid All Medicaid	$551.08
Rate for Payer: Medicare All Medicare	$419.30
Rate for Payer: Monida Allegiance	$569.05
Rate for Payer: Monida First Choice Health	$581.03
Rate for Payer: Monida Montana Health Co-op	$569.05
Rate for Payer: Monida PacificSource	$569.05

ER INJECT/ASPIR JOINT LG

Facility

$599.00

Service Code	HCPCS 20610
Hospital Charge Code	1020610
Hospital Revenue Code	450
Min. Negotiated Rate	$419.30
Max. Negotiated Rate	$599.00
Rate for Payer: Aetna Commercial	$569.05
Rate for Payer: Aetna Medicare	$539.10
Rate for Payer: BCBS MT CHIP	$539.10
Rate for Payer: BCBS MT Closed Plan Network	$569.05
Rate for Payer: BCBS MT HealthLink	$539.10
Rate for Payer: BCBS MT Medicare	$539.10
Rate for Payer: BCBS MT POS	$569.05
Rate for Payer: BCBS MT Traditional	$599.00
Rate for Payer: Cash Price	$539.10
Rate for Payer: Cigna Commercial	$569.05
Rate for Payer: Cigna Medicare	$539.10
Rate for Payer: Medicaid All Medicaid	$551.08
Rate for Payer: Medicare All Medicare	$419.30
Rate for Payer: Monida Allegiance	$569.05
Rate for Payer: Monida First Choice Health	$581.03
Rate for Payer: Monida Montana Health Co-op	$569.05
Rate for Payer: Monida PacificSource	$569.05

ER INJ SQ/IM

Facility

$92.00

Service Code	HCPCS 96372
Hospital Charge Code	1030202
Hospital Revenue Code	450
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

ER INJ SQ/IM

Facility

$92.00

Service Code	HCPCS 96372
Hospital Charge Code	1030202
Hospital Revenue Code	450
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

ER INSERT EMERGENCY AIRWAY

Facility

$605.00

Service Code	HCPCS 31500
Hospital Charge Code	1031500
Hospital Revenue Code	450
Min. Negotiated Rate	$423.50
Max. Negotiated Rate	$605.00
Rate for Payer: Aetna Commercial	$574.75
Rate for Payer: Aetna Medicare	$544.50
Rate for Payer: BCBS MT CHIP	$544.50
Rate for Payer: BCBS MT Closed Plan Network	$574.75
Rate for Payer: BCBS MT HealthLink	$544.50
Rate for Payer: BCBS MT Medicare	$544.50
Rate for Payer: BCBS MT POS	$574.75
Rate for Payer: BCBS MT Traditional	$605.00
Rate for Payer: Cash Price	$544.50
Rate for Payer: Cigna Commercial	$574.75
Rate for Payer: Cigna Medicare	$544.50
Rate for Payer: Medicaid All Medicaid	$556.60
Rate for Payer: Medicare All Medicare	$423.50
Rate for Payer: Monida Allegiance	$574.75
Rate for Payer: Monida First Choice Health	$586.85
Rate for Payer: Monida Montana Health Co-op	$574.75
Rate for Payer: Monida PacificSource	$574.75

ER INSERT EMERGENCY AIRWAY

Facility

$605.00

Service Code	HCPCS 31500
Hospital Charge Code	1031500
Hospital Revenue Code	450
Min. Negotiated Rate	$423.50
Max. Negotiated Rate	$605.00
Rate for Payer: Aetna Commercial	$574.75
Rate for Payer: Aetna Medicare	$544.50
Rate for Payer: BCBS MT CHIP	$544.50
Rate for Payer: BCBS MT Closed Plan Network	$574.75
Rate for Payer: BCBS MT HealthLink	$544.50
Rate for Payer: BCBS MT Medicare	$544.50
Rate for Payer: BCBS MT POS	$574.75
Rate for Payer: BCBS MT Traditional	$605.00
Rate for Payer: Cash Price	$544.50
Rate for Payer: Cigna Commercial	$574.75
Rate for Payer: Cigna Medicare	$544.50
Rate for Payer: Medicaid All Medicaid	$556.60
Rate for Payer: Medicare All Medicare	$423.50
Rate for Payer: Monida Allegiance	$574.75
Rate for Payer: Monida First Choice Health	$586.85
Rate for Payer: Monida Montana Health Co-op	$574.75
Rate for Payer: Monida PacificSource	$574.75

ER INSERTION OF CHEST TUBE

Facility

$1,182.00

Service Code	HCPCS 32551
Hospital Charge Code	1032551
Hospital Revenue Code	450
Min. Negotiated Rate	$827.40
Max. Negotiated Rate	$1,182.00
Rate for Payer: Aetna Commercial	$1,122.90
Rate for Payer: Aetna Medicare	$1,063.80
Rate for Payer: BCBS MT CHIP	$1,063.80
Rate for Payer: BCBS MT Closed Plan Network	$1,122.90
Rate for Payer: BCBS MT HealthLink	$1,063.80
Rate for Payer: BCBS MT Medicare	$1,063.80
Rate for Payer: BCBS MT POS	$1,122.90
Rate for Payer: BCBS MT Traditional	$1,182.00
Rate for Payer: Cash Price	$1,063.80
Rate for Payer: Cigna Commercial	$1,122.90
Rate for Payer: Cigna Medicare	$1,063.80
Rate for Payer: Medicaid All Medicaid	$1,087.44
Rate for Payer: Medicare All Medicare	$827.40
Rate for Payer: Monida Allegiance	$1,122.90
Rate for Payer: Monida First Choice Health	$1,146.54
Rate for Payer: Monida Montana Health Co-op	$1,122.90
Rate for Payer: Monida PacificSource	$1,122.90

ER INSERTION OF CHEST TUBE

Facility

$1,182.00

Service Code	HCPCS 32551
Hospital Charge Code	1032551
Hospital Revenue Code	450
Min. Negotiated Rate	$827.40
Max. Negotiated Rate	$1,182.00
Rate for Payer: Aetna Commercial	$1,122.90
Rate for Payer: Aetna Medicare	$1,063.80
Rate for Payer: BCBS MT CHIP	$1,063.80
Rate for Payer: BCBS MT Closed Plan Network	$1,122.90
Rate for Payer: BCBS MT HealthLink	$1,063.80
Rate for Payer: BCBS MT Medicare	$1,063.80
Rate for Payer: BCBS MT POS	$1,122.90
Rate for Payer: BCBS MT Traditional	$1,182.00
Rate for Payer: Cash Price	$1,063.80
Rate for Payer: Cigna Commercial	$1,122.90
Rate for Payer: Cigna Medicare	$1,063.80
Rate for Payer: Medicaid All Medicaid	$1,087.44
Rate for Payer: Medicare All Medicare	$827.40
Rate for Payer: Monida Allegiance	$1,122.90
Rate for Payer: Monida First Choice Health	$1,146.54
Rate for Payer: Monida Montana Health Co-op	$1,122.90
Rate for Payer: Monida PacificSource	$1,122.90

ER MISCELLANEOUS

Facility

$862.00

Hospital Charge Code	1099999
Hospital Revenue Code	450
Min. Negotiated Rate	$603.40
Max. Negotiated Rate	$862.00
Rate for Payer: Aetna Commercial	$818.90
Rate for Payer: Aetna Medicare	$775.80
Rate for Payer: BCBS MT CHIP	$775.80
Rate for Payer: BCBS MT Closed Plan Network	$818.90
Rate for Payer: BCBS MT HealthLink	$775.80
Rate for Payer: BCBS MT Medicare	$775.80
Rate for Payer: BCBS MT POS	$818.90
Rate for Payer: BCBS MT Traditional	$862.00
Rate for Payer: Cash Price	$775.80
Rate for Payer: Cigna Commercial	$818.90
Rate for Payer: Cigna Medicare	$775.80
Rate for Payer: Medicaid All Medicaid	$793.04
Rate for Payer: Medicare All Medicare	$603.40
Rate for Payer: Monida Allegiance	$818.90
Rate for Payer: Monida First Choice Health	$836.14
Rate for Payer: Monida Montana Health Co-op	$818.90
Rate for Payer: Monida PacificSource	$818.90

ER MISCELLANEOUS

Facility

$862.00

Hospital Charge Code	1099999
Hospital Revenue Code	450
Min. Negotiated Rate	$603.40
Max. Negotiated Rate	$862.00
Rate for Payer: Aetna Commercial	$818.90
Rate for Payer: Aetna Medicare	$775.80
Rate for Payer: BCBS MT CHIP	$775.80
Rate for Payer: BCBS MT Closed Plan Network	$818.90
Rate for Payer: BCBS MT HealthLink	$775.80
Rate for Payer: BCBS MT Medicare	$775.80
Rate for Payer: BCBS MT POS	$818.90
Rate for Payer: BCBS MT Traditional	$862.00
Rate for Payer: Cash Price	$775.80
Rate for Payer: Cigna Commercial	$818.90
Rate for Payer: Cigna Medicare	$775.80
Rate for Payer: Medicaid All Medicaid	$793.04
Rate for Payer: Medicare All Medicare	$603.40
Rate for Payer: Monida Allegiance	$818.90
Rate for Payer: Monida First Choice Health	$836.14
Rate for Payer: Monida Montana Health Co-op	$818.90
Rate for Payer: Monida PacificSource	$818.90

ER MODERATE SEDATION SERVICES

Facility

$324.00

Service Code	HCPCS 99152
Hospital Charge Code	1099152
Hospital Revenue Code	450
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

ER MODERATE SEDATION SERVICES

Facility

$324.00

Service Code	HCPCS 99152
Hospital Charge Code	1099152
Hospital Revenue Code	450
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

ER N BLOCK OF PERIPHERAL BRANCH

Facility

$853.00

Service Code	HCPCS 64450
Hospital Charge Code	1064450
Hospital Revenue Code	450
Min. Negotiated Rate	$597.10
Max. Negotiated Rate	$853.00
Rate for Payer: Aetna Commercial	$810.35
Rate for Payer: Aetna Medicare	$767.70
Rate for Payer: BCBS MT CHIP	$767.70
Rate for Payer: BCBS MT Closed Plan Network	$810.35
Rate for Payer: BCBS MT HealthLink	$767.70
Rate for Payer: BCBS MT Medicare	$767.70
Rate for Payer: BCBS MT POS	$810.35
Rate for Payer: BCBS MT Traditional	$853.00
Rate for Payer: Cash Price	$767.70
Rate for Payer: Cigna Commercial	$810.35
Rate for Payer: Cigna Medicare	$767.70
Rate for Payer: Medicaid All Medicaid	$784.76
Rate for Payer: Medicare All Medicare	$597.10
Rate for Payer: Monida Allegiance	$810.35
Rate for Payer: Monida First Choice Health	$827.41
Rate for Payer: Monida Montana Health Co-op	$810.35
Rate for Payer: Monida PacificSource	$810.35

ER N BLOCK OF PERIPHERAL BRANCH

Facility

$853.00

Service Code	HCPCS 64450
Hospital Charge Code	1064450
Hospital Revenue Code	450
Min. Negotiated Rate	$597.10
Max. Negotiated Rate	$853.00
Rate for Payer: Aetna Commercial	$810.35
Rate for Payer: Aetna Medicare	$767.70
Rate for Payer: BCBS MT CHIP	$767.70
Rate for Payer: BCBS MT Closed Plan Network	$810.35
Rate for Payer: BCBS MT HealthLink	$767.70
Rate for Payer: BCBS MT Medicare	$767.70
Rate for Payer: BCBS MT POS	$810.35
Rate for Payer: BCBS MT Traditional	$853.00
Rate for Payer: Cash Price	$767.70
Rate for Payer: Cigna Commercial	$810.35
Rate for Payer: Cigna Medicare	$767.70
Rate for Payer: Medicaid All Medicaid	$784.76
Rate for Payer: Medicare All Medicare	$597.10
Rate for Payer: Monida Allegiance	$810.35
Rate for Payer: Monida First Choice Health	$827.41
Rate for Payer: Monida Montana Health Co-op	$810.35
Rate for Payer: Monida PacificSource	$810.35

ERPAK ACETAMINOPHEN TAB [325 MG] 6 TAB

Facility

$11.00

Service Code	HCPCS J3490
Hospital Charge Code	3000150
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

ERPAK ACETAMINOPHEN TAB [325 MG] 6 TAB

Facility

$11.00

Service Code	HCPCS J3490
Hospital Charge Code	3000150
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

ERPAK AMLODOPINE TAB [5 MG] 4 TAB PACK

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000151
Hospital Revenue Code	250
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

ERPAK AMLODOPINE TAB [5 MG] 4 TAB PACK

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000151
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges