Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ELECTROLYTES PANEL

Facility

$105.00

Service Code	HCPCS 80051
Hospital Charge Code	4080051
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

ELECTROLYTES PANEL

Facility

$105.00

Service Code	HCPCS 80051
Hospital Charge Code	4080051
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

EMPAGLIFLOZIN 25 MG TABLET-NF

Facility

$80.00

Service Code	NDC 00597015337
Hospital Charge Code	3007396
Hospital Revenue Code	250
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

EMPAGLIFLOZIN 25 MG TABLET-NF

Facility

$80.00

Service Code	NDC 00597015337
Hospital Charge Code	3007396
Hospital Revenue Code	250
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

EMPAGLIFLOZIN (JARDIANCE) 10MG TAB NF

Facility

$77.00

Service Code	NDC 00597015237
Hospital Charge Code	3007122
Hospital Revenue Code	250
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

EMPAGLIFLOZIN (JARDIANCE) 10MG TAB NF

Facility

$77.00

Service Code	NDC 00597015237
Hospital Charge Code	3007122
Hospital Revenue Code	250
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

ENDOMYSIAL ANTIBODY, IGA (164996)

Facility

$79.00

Service Code	HCPCS 86231
Hospital Charge Code	4082784
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENDOMYSIAL ANTIBODY, IGA (164996)

Facility

$79.00

Service Code	HCPCS 86231
Hospital Charge Code	4082784
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENEMA BUCKET

Facility

$13.00

Hospital Charge Code	80030169
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

ENEMA BUCKET

Facility

$13.00

Hospital Charge Code	80030169
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

ENOXAPARIN INJ [100 MG/1 ML] - NONFORM

Facility

$79.00

Service Code	HCPCS J1650
Hospital Charge Code	3000139
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENOXAPARIN INJ [100 MG/1 ML] - NONFORM

Facility

$79.00

Service Code	HCPCS J1650
Hospital Charge Code	3000139
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENOXAPARIN INJ [30 MG/0.3 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000140
Hospital Revenue Code	259
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ENOXAPARIN INJ [30 MG/0.3 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000140
Hospital Revenue Code	259
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ENOXAPARIN INJ [30 MG/0.3 ML] PFS

Facility

$27.00

Service Code	HCPCS J1650
Hospital Charge Code	3000591
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

ENOXAPARIN INJ [30 MG/0.3 ML] PFS

Facility

$27.00

Service Code	HCPCS J1650
Hospital Charge Code	3000591
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

ENOXAPARIN INJ [40 MG/0.4 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000141
Hospital Revenue Code	259
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ENOXAPARIN INJ [40 MG/0.4 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000141
Hospital Revenue Code	259
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

.ENTEROVIRUS ANTIBODIES

Facility

$7.09

Service Code	HCPCS 86658
Hospital Charge Code	4086658
Hospital Revenue Code	306
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$7.09
Rate for Payer: Aetna Commercial	$6.74
Rate for Payer: Aetna Medicare	$6.38
Rate for Payer: BCBS MT CHIP	$6.38
Rate for Payer: BCBS MT Closed Plan Network	$6.74
Rate for Payer: BCBS MT HealthLink	$6.38
Rate for Payer: BCBS MT Medicare	$6.38
Rate for Payer: BCBS MT POS	$6.74
Rate for Payer: BCBS MT Traditional	$7.09
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cigna Commercial	$6.74
Rate for Payer: Cigna Medicare	$6.38
Rate for Payer: Medicaid All Medicaid	$6.52
Rate for Payer: Medicare All Medicare	$4.96
Rate for Payer: Monida Allegiance	$6.74
Rate for Payer: Monida First Choice Health	$6.88
Rate for Payer: Monida Montana Health Co-op	$6.74
Rate for Payer: Monida PacificSource	$6.74

.ENTEROVIRUS ANTIBODIES

Facility

$7.09

Service Code	HCPCS 86658
Hospital Charge Code	4086658
Hospital Revenue Code	306
Min. Negotiated Rate	$4.96
Max. Negotiated Rate	$7.09
Rate for Payer: Aetna Commercial	$6.74
Rate for Payer: Aetna Medicare	$6.38
Rate for Payer: BCBS MT CHIP	$6.38
Rate for Payer: BCBS MT Closed Plan Network	$6.74
Rate for Payer: BCBS MT HealthLink	$6.38
Rate for Payer: BCBS MT Medicare	$6.38
Rate for Payer: BCBS MT POS	$6.74
Rate for Payer: BCBS MT Traditional	$7.09
Rate for Payer: Cash Price	$6.38
Rate for Payer: Cigna Commercial	$6.74
Rate for Payer: Cigna Medicare	$6.38
Rate for Payer: Medicaid All Medicaid	$6.52
Rate for Payer: Medicare All Medicare	$4.96
Rate for Payer: Monida Allegiance	$6.74
Rate for Payer: Monida First Choice Health	$6.88
Rate for Payer: Monida Montana Health Co-op	$6.74
Rate for Payer: Monida PacificSource	$6.74

ePHEDrine INJ [50 MG/ML]

Facility

$112.00

Service Code	HCPCS J3490
Hospital Charge Code	3000143
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

ePHEDrine INJ [50 MG/ML]

Facility

$112.00

Service Code	HCPCS J3490
Hospital Charge Code	3000143
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

EPIFIX, 18 MM Q4186

Facility

$2,742.00

Service Code	HCPCS Q4186
Hospital Charge Code	8004200
Hospital Revenue Code	636
Min. Negotiated Rate	$1,919.40
Max. Negotiated Rate	$2,742.00
Rate for Payer: Aetna Commercial	$2,604.90
Rate for Payer: Aetna Medicare	$2,467.80
Rate for Payer: BCBS MT CHIP	$2,467.80
Rate for Payer: BCBS MT Closed Plan Network	$2,604.90
Rate for Payer: BCBS MT HealthLink	$2,467.80
Rate for Payer: BCBS MT Medicare	$2,467.80
Rate for Payer: BCBS MT POS	$2,604.90
Rate for Payer: BCBS MT Traditional	$2,742.00
Rate for Payer: Cash Price	$2,467.80
Rate for Payer: Cigna Commercial	$2,604.90
Rate for Payer: Cigna Medicare	$2,467.80
Rate for Payer: Medicaid All Medicaid	$2,522.64
Rate for Payer: Medicare All Medicare	$1,919.40
Rate for Payer: Monida Allegiance	$2,604.90
Rate for Payer: Monida First Choice Health	$2,659.74
Rate for Payer: Monida Montana Health Co-op	$2,604.90
Rate for Payer: Monida PacificSource	$2,604.90

EPIFIX, 18 MM Q4186

Facility

$2,742.00

Service Code	HCPCS Q4186
Hospital Charge Code	8004200
Hospital Revenue Code	636
Min. Negotiated Rate	$1,919.40
Max. Negotiated Rate	$2,742.00
Rate for Payer: Aetna Commercial	$2,604.90
Rate for Payer: Aetna Medicare	$2,467.80
Rate for Payer: BCBS MT CHIP	$2,467.80
Rate for Payer: BCBS MT Closed Plan Network	$2,604.90
Rate for Payer: BCBS MT HealthLink	$2,467.80
Rate for Payer: BCBS MT Medicare	$2,467.80
Rate for Payer: BCBS MT POS	$2,604.90
Rate for Payer: BCBS MT Traditional	$2,742.00
Rate for Payer: Cash Price	$2,467.80
Rate for Payer: Cigna Commercial	$2,604.90
Rate for Payer: Cigna Medicare	$2,467.80
Rate for Payer: Medicaid All Medicaid	$2,522.64
Rate for Payer: Medicare All Medicare	$1,919.40
Rate for Payer: Monida Allegiance	$2,604.90
Rate for Payer: Monida First Choice Health	$2,659.74
Rate for Payer: Monida Montana Health Co-op	$2,604.90
Rate for Payer: Monida PacificSource	$2,604.90

EPIFIX, 4X4.5 CM

Facility

$5,436.00

Service Code	HCPCS Q4186
Hospital Charge Code	8004201
Hospital Revenue Code	636
Min. Negotiated Rate	$3,805.20
Max. Negotiated Rate	$5,436.00
Rate for Payer: Aetna Commercial	$5,164.20
Rate for Payer: Aetna Medicare	$4,892.40
Rate for Payer: BCBS MT CHIP	$4,892.40
Rate for Payer: BCBS MT Closed Plan Network	$5,164.20
Rate for Payer: BCBS MT HealthLink	$4,892.40
Rate for Payer: BCBS MT Medicare	$4,892.40
Rate for Payer: BCBS MT POS	$5,164.20
Rate for Payer: BCBS MT Traditional	$5,436.00
Rate for Payer: Cash Price	$4,892.40
Rate for Payer: Cigna Commercial	$5,164.20
Rate for Payer: Cigna Medicare	$4,892.40
Rate for Payer: Medicaid All Medicaid	$5,001.12
Rate for Payer: Medicare All Medicare	$3,805.20
Rate for Payer: Monida Allegiance	$5,164.20
Rate for Payer: Monida First Choice Health	$5,272.92
Rate for Payer: Monida Montana Health Co-op	$5,164.20
Rate for Payer: Monida PacificSource	$5,164.20

Know your out-of-pocket cost for care.

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