Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER GASTRIC INTUBATION

Facility

$374.00

Service Code	HCPCS 43753
Hospital Charge Code	1043753
Hospital Revenue Code	450
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

ER GASTRIC INTUBATION

Facility

$374.00

Service Code	HCPCS 43753
Hospital Charge Code	1043753
Hospital Revenue Code	450
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

ER INCISION OF RECTAL ABSCESS

Facility

$1,042.00

Service Code	HCPCS 46040
Hospital Charge Code	1046040
Hospital Revenue Code	450
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

ER INCISION OF RECTAL ABSCESS

Facility

$1,042.00

Service Code	HCPCS 46040
Hospital Charge Code	1046040
Hospital Revenue Code	450
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

ER INFUSION ADD PUMP SET UP

Facility

$94.00

Service Code	HCPCS 96371
Hospital Charge Code	1030203
Hospital Revenue Code	450
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

ER INFUSION ADD PUMP SET UP

Facility

$94.00

Service Code	HCPCS 96371
Hospital Charge Code	1030203
Hospital Revenue Code	450
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

ER INJ AND/OR ASPIRATION JOINT INTERM

Facility

$672.00

Service Code	HCPCS 20605
Hospital Charge Code	1020605
Hospital Revenue Code	450
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

ER INJ AND/OR ASPIRATION JOINT INTERM

Facility

$672.00

Service Code	HCPCS 20605
Hospital Charge Code	1020605
Hospital Revenue Code	450
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

ER INJECT/ASPIR JOINT LG

Facility

$984.00

Service Code	HCPCS 20610
Hospital Charge Code	1020610
Hospital Revenue Code	450
Min. Negotiated Rate	$688.80
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$934.80
Rate for Payer: Aetna Medicare	$885.60
Rate for Payer: BCBS MT CHIP	$885.60
Rate for Payer: BCBS MT Closed Plan Network	$934.80
Rate for Payer: BCBS MT HealthLink	$885.60
Rate for Payer: BCBS MT Medicare	$885.60
Rate for Payer: BCBS MT POS	$934.80
Rate for Payer: BCBS MT Traditional	$984.00
Rate for Payer: Cash Price	$885.60
Rate for Payer: Cigna Commercial	$934.80
Rate for Payer: Cigna Medicare	$885.60
Rate for Payer: Medicaid All Medicaid	$905.28
Rate for Payer: Medicare All Medicare	$688.80
Rate for Payer: Monida Allegiance	$934.80
Rate for Payer: Monida First Choice Health	$954.48
Rate for Payer: Monida Montana Health Co-op	$934.80
Rate for Payer: Monida PacificSource	$934.80

ER INJECT/ASPIR JOINT LG

Facility

$984.00

Service Code	HCPCS 20610
Hospital Charge Code	1020610
Hospital Revenue Code	450
Min. Negotiated Rate	$688.80
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$934.80
Rate for Payer: Aetna Medicare	$885.60
Rate for Payer: BCBS MT CHIP	$885.60
Rate for Payer: BCBS MT Closed Plan Network	$934.80
Rate for Payer: BCBS MT HealthLink	$885.60
Rate for Payer: BCBS MT Medicare	$885.60
Rate for Payer: BCBS MT POS	$934.80
Rate for Payer: BCBS MT Traditional	$984.00
Rate for Payer: Cash Price	$885.60
Rate for Payer: Cigna Commercial	$934.80
Rate for Payer: Cigna Medicare	$885.60
Rate for Payer: Medicaid All Medicaid	$905.28
Rate for Payer: Medicare All Medicare	$688.80
Rate for Payer: Monida Allegiance	$934.80
Rate for Payer: Monida First Choice Health	$954.48
Rate for Payer: Monida Montana Health Co-op	$934.80
Rate for Payer: Monida PacificSource	$934.80

ER INJ SQ/IM

Facility

$98.00

Service Code	HCPCS 96372
Hospital Charge Code	1030202
Hospital Revenue Code	450
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

ER INJ SQ/IM

Facility

$98.00

Service Code	HCPCS 96372
Hospital Charge Code	1030202
Hospital Revenue Code	450
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

ER INSERTION OF CHEST TUBE

Facility

$1,253.00

Service Code	HCPCS 32551
Hospital Charge Code	1032551
Hospital Revenue Code	450
Min. Negotiated Rate	$877.10
Max. Negotiated Rate	$1,253.00
Rate for Payer: Aetna Commercial	$1,190.35
Rate for Payer: Aetna Medicare	$1,127.70
Rate for Payer: BCBS MT CHIP	$1,127.70
Rate for Payer: BCBS MT Closed Plan Network	$1,190.35
Rate for Payer: BCBS MT HealthLink	$1,127.70
Rate for Payer: BCBS MT Medicare	$1,127.70
Rate for Payer: BCBS MT POS	$1,190.35
Rate for Payer: BCBS MT Traditional	$1,253.00
Rate for Payer: Cash Price	$1,127.70
Rate for Payer: Cigna Commercial	$1,190.35
Rate for Payer: Cigna Medicare	$1,127.70
Rate for Payer: Medicaid All Medicaid	$1,152.76
Rate for Payer: Medicare All Medicare	$877.10
Rate for Payer: Monida Allegiance	$1,190.35
Rate for Payer: Monida First Choice Health	$1,215.41
Rate for Payer: Monida Montana Health Co-op	$1,190.35
Rate for Payer: Monida PacificSource	$1,190.35

ER INSERTION OF CHEST TUBE

Facility

$1,253.00

Service Code	HCPCS 32551
Hospital Charge Code	1032551
Hospital Revenue Code	450
Min. Negotiated Rate	$877.10
Max. Negotiated Rate	$1,253.00
Rate for Payer: Aetna Commercial	$1,190.35
Rate for Payer: Aetna Medicare	$1,127.70
Rate for Payer: BCBS MT CHIP	$1,127.70
Rate for Payer: BCBS MT Closed Plan Network	$1,190.35
Rate for Payer: BCBS MT HealthLink	$1,127.70
Rate for Payer: BCBS MT Medicare	$1,127.70
Rate for Payer: BCBS MT POS	$1,190.35
Rate for Payer: BCBS MT Traditional	$1,253.00
Rate for Payer: Cash Price	$1,127.70
Rate for Payer: Cigna Commercial	$1,190.35
Rate for Payer: Cigna Medicare	$1,127.70
Rate for Payer: Medicaid All Medicaid	$1,152.76
Rate for Payer: Medicare All Medicare	$877.10
Rate for Payer: Monida Allegiance	$1,190.35
Rate for Payer: Monida First Choice Health	$1,215.41
Rate for Payer: Monida Montana Health Co-op	$1,190.35
Rate for Payer: Monida PacificSource	$1,190.35

ER INTUBATION, ENDOTRACHEAL 31500

Facility

$641.00

Service Code	HCPCS 31500
Hospital Charge Code	1031500
Hospital Revenue Code	450
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

ER INTUBATION, ENDOTRACHEAL 31500

Facility

$641.00

Service Code	HCPCS 31500
Hospital Charge Code	1031500
Hospital Revenue Code	450
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

ER MISCELLANEOUS

Facility

$914.00

Hospital Charge Code	1099999
Hospital Revenue Code	450
Min. Negotiated Rate	$639.80
Max. Negotiated Rate	$914.00
Rate for Payer: Aetna Commercial	$868.30
Rate for Payer: Aetna Medicare	$822.60
Rate for Payer: BCBS MT CHIP	$822.60
Rate for Payer: BCBS MT Closed Plan Network	$868.30
Rate for Payer: BCBS MT HealthLink	$822.60
Rate for Payer: BCBS MT Medicare	$822.60
Rate for Payer: BCBS MT POS	$868.30
Rate for Payer: BCBS MT Traditional	$914.00
Rate for Payer: Cash Price	$822.60
Rate for Payer: Cigna Commercial	$868.30
Rate for Payer: Cigna Medicare	$822.60
Rate for Payer: Medicaid All Medicaid	$840.88
Rate for Payer: Medicare All Medicare	$639.80
Rate for Payer: Monida Allegiance	$868.30
Rate for Payer: Monida First Choice Health	$886.58
Rate for Payer: Monida Montana Health Co-op	$868.30
Rate for Payer: Monida PacificSource	$868.30

ER MISCELLANEOUS

Facility

$914.00

Hospital Charge Code	1099999
Hospital Revenue Code	450
Min. Negotiated Rate	$639.80
Max. Negotiated Rate	$914.00
Rate for Payer: Aetna Commercial	$868.30
Rate for Payer: Aetna Medicare	$822.60
Rate for Payer: BCBS MT CHIP	$822.60
Rate for Payer: BCBS MT Closed Plan Network	$868.30
Rate for Payer: BCBS MT HealthLink	$822.60
Rate for Payer: BCBS MT Medicare	$822.60
Rate for Payer: BCBS MT POS	$868.30
Rate for Payer: BCBS MT Traditional	$914.00
Rate for Payer: Cash Price	$822.60
Rate for Payer: Cigna Commercial	$868.30
Rate for Payer: Cigna Medicare	$822.60
Rate for Payer: Medicaid All Medicaid	$840.88
Rate for Payer: Medicare All Medicare	$639.80
Rate for Payer: Monida Allegiance	$868.30
Rate for Payer: Monida First Choice Health	$886.58
Rate for Payer: Monida Montana Health Co-op	$868.30
Rate for Payer: Monida PacificSource	$868.30

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

$904.00

Service Code	HCPCS 64450
Hospital Charge Code	1064450
Hospital Revenue Code	450
Min. Negotiated Rate	$632.80
Max. Negotiated Rate	$904.00
Rate for Payer: Aetna Commercial	$858.80
Rate for Payer: Aetna Medicare	$813.60
Rate for Payer: BCBS MT CHIP	$813.60
Rate for Payer: BCBS MT Closed Plan Network	$858.80
Rate for Payer: BCBS MT HealthLink	$813.60
Rate for Payer: BCBS MT Medicare	$813.60
Rate for Payer: BCBS MT POS	$858.80
Rate for Payer: BCBS MT Traditional	$904.00
Rate for Payer: Cash Price	$813.60
Rate for Payer: Cigna Commercial	$858.80
Rate for Payer: Cigna Medicare	$813.60
Rate for Payer: Medicaid All Medicaid	$831.68
Rate for Payer: Medicare All Medicare	$632.80
Rate for Payer: Monida Allegiance	$858.80
Rate for Payer: Monida First Choice Health	$876.88
Rate for Payer: Monida Montana Health Co-op	$858.80
Rate for Payer: Monida PacificSource	$858.80

ER N BLOCK OF PERIPHERAL BRANCH

Facility

$904.00

Service Code	HCPCS 64450
Hospital Charge Code	1064450
Hospital Revenue Code	450
Min. Negotiated Rate	$632.80
Max. Negotiated Rate	$904.00
Rate for Payer: Aetna Commercial	$858.80
Rate for Payer: Aetna Medicare	$813.60
Rate for Payer: BCBS MT CHIP	$813.60
Rate for Payer: BCBS MT Closed Plan Network	$858.80
Rate for Payer: BCBS MT HealthLink	$813.60
Rate for Payer: BCBS MT Medicare	$813.60
Rate for Payer: BCBS MT POS	$858.80
Rate for Payer: BCBS MT Traditional	$904.00
Rate for Payer: Cash Price	$813.60
Rate for Payer: Cigna Commercial	$858.80
Rate for Payer: Cigna Medicare	$813.60
Rate for Payer: Medicaid All Medicaid	$831.68
Rate for Payer: Medicare All Medicare	$632.80
Rate for Payer: Monida Allegiance	$858.80
Rate for Payer: Monida First Choice Health	$876.88
Rate for Payer: Monida Montana Health Co-op	$858.80
Rate for Payer: Monida PacificSource	$858.80

ERPAK HYDROCODONE/APAP [5/325 MG]4 TAB

Facility

$32.00

Service Code	HCPCS J3490
Hospital Charge Code	3000157
Hospital Revenue Code	250
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

ERPAK HYDROCODONE/APAP [5/325 MG]4 TAB

Facility

$32.00

Service Code	HCPCS J3490
Hospital Charge Code	3000157
Hospital Revenue Code	250
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

ERPAK ONDANSETRON ODT [4 MG] 6 TAB PACKS

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000162
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