Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

EPICORD PER SQ CM, 3X5 CM Q4187

Facility

$857.00

Service Code	HCPCS Q4187
Hospital Charge Code	8004202
Hospital Revenue Code	636
Min. Negotiated Rate	$599.90
Max. Negotiated Rate	$857.00
Rate for Payer: Aetna Commercial	$814.15
Rate for Payer: Aetna Medicare	$771.30
Rate for Payer: BCBS MT CHIP	$771.30
Rate for Payer: BCBS MT Closed Plan Network	$814.15
Rate for Payer: BCBS MT HealthLink	$771.30
Rate for Payer: BCBS MT Medicare	$771.30
Rate for Payer: BCBS MT POS	$814.15
Rate for Payer: BCBS MT Traditional	$857.00
Rate for Payer: Cash Price	$771.30
Rate for Payer: Cigna Commercial	$814.15
Rate for Payer: Cigna Medicare	$771.30
Rate for Payer: Medicaid All Medicaid	$788.44
Rate for Payer: Medicare All Medicare	$599.90
Rate for Payer: Monida Allegiance	$814.15
Rate for Payer: Monida First Choice Health	$831.29
Rate for Payer: Monida Montana Health Co-op	$814.15
Rate for Payer: Monida PacificSource	$814.15

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

$11,982.00

Service Code	HCPCS Q4186
Hospital Charge Code	8004201
Hospital Revenue Code	636
Min. Negotiated Rate	$8,387.40
Max. Negotiated Rate	$11,982.00
Rate for Payer: Aetna Commercial	$11,382.90
Rate for Payer: Aetna Medicare	$10,783.80
Rate for Payer: BCBS MT CHIP	$10,783.80
Rate for Payer: BCBS MT Closed Plan Network	$11,382.90
Rate for Payer: BCBS MT HealthLink	$10,783.80
Rate for Payer: BCBS MT Medicare	$10,783.80
Rate for Payer: BCBS MT POS	$11,382.90
Rate for Payer: BCBS MT Traditional	$11,982.00
Rate for Payer: Cash Price	$10,783.80
Rate for Payer: Cigna Commercial	$11,382.90
Rate for Payer: Cigna Medicare	$10,783.80
Rate for Payer: Medicaid All Medicaid	$11,023.44
Rate for Payer: Medicare All Medicare	$8,387.40
Rate for Payer: Monida Allegiance	$11,382.90
Rate for Payer: Monida First Choice Health	$11,622.54
Rate for Payer: Monida Montana Health Co-op	$11,382.90
Rate for Payer: Monida PacificSource	$11,382.90

EPIFIX, 4X4.5 CM

Facility

$11,982.00

Service Code	HCPCS Q4186
Hospital Charge Code	8004201
Hospital Revenue Code	636
Min. Negotiated Rate	$8,387.40
Max. Negotiated Rate	$11,982.00
Rate for Payer: Aetna Commercial	$11,382.90
Rate for Payer: Aetna Medicare	$10,783.80
Rate for Payer: BCBS MT CHIP	$10,783.80
Rate for Payer: BCBS MT Closed Plan Network	$11,382.90
Rate for Payer: BCBS MT HealthLink	$10,783.80
Rate for Payer: BCBS MT Medicare	$10,783.80
Rate for Payer: BCBS MT POS	$11,382.90
Rate for Payer: BCBS MT Traditional	$11,982.00
Rate for Payer: Cash Price	$10,783.80
Rate for Payer: Cigna Commercial	$11,382.90
Rate for Payer: Cigna Medicare	$10,783.80
Rate for Payer: Medicaid All Medicaid	$11,023.44
Rate for Payer: Medicare All Medicare	$8,387.40
Rate for Payer: Monida Allegiance	$11,382.90
Rate for Payer: Monida First Choice Health	$11,622.54
Rate for Payer: Monida Montana Health Co-op	$11,382.90
Rate for Payer: Monida PacificSource	$11,382.90

EPINEPHRINE HCL INJ PEN [0.15 MG]

Facility

$571.00

Service Code	HCPCS J0165
Hospital Charge Code	3000145
Hospital Revenue Code	250
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.15 MG]

Facility

$571.00

Service Code	HCPCS J0165
Hospital Charge Code	3000145
Hospital Revenue Code	250
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.3 MG]

Facility

$571.00

Service Code	HCPCS J0165
Hospital Charge Code	3000146
Hospital Revenue Code	259
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE HCL INJ PEN [0.3 MG]

Facility

$571.00

Service Code	HCPCS J0165
Hospital Charge Code	3000146
Hospital Revenue Code	259
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

EPINEPHRINE INJ [1 MG/ML] SDV

Facility

$56.00

Service Code	HCPCS J0162
Hospital Charge Code	3000147
Hospital Revenue Code	259
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

EPINEPHRINE INJ [1 MG/ML] SDV

Facility

$56.00

Service Code	HCPCS J0162
Hospital Charge Code	3000147
Hospital Revenue Code	259
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

EPINEPHRINE INJ SYR [1 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J0168
Hospital Charge Code	3000148
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

EPINEPHRINE INJ SYR [1 MG/10 ML]

Facility

$26.00

Service Code	HCPCS J0168
Hospital Charge Code	3000148
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

EPISTAXIS COMPLEX- ER

Facility

$489.00

Service Code	CPT 30903
Hospital Charge Code	1030903
Hospital Revenue Code	450
Min. Negotiated Rate	$342.30
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna Commercial	$464.55
Rate for Payer: Aetna Medicare	$440.10
Rate for Payer: BCBS MT CHIP	$440.10
Rate for Payer: BCBS MT Closed Plan Network	$464.55
Rate for Payer: BCBS MT HealthLink	$440.10
Rate for Payer: BCBS MT Medicare	$440.10
Rate for Payer: BCBS MT POS	$464.55
Rate for Payer: BCBS MT Traditional	$489.00
Rate for Payer: Cash Price	$440.10
Rate for Payer: Cigna Commercial	$464.55
Rate for Payer: Cigna Medicare	$440.10
Rate for Payer: Medicaid All Medicaid	$449.88
Rate for Payer: Medicare All Medicare	$342.30
Rate for Payer: Monida Allegiance	$464.55
Rate for Payer: Monida First Choice Health	$474.33
Rate for Payer: Monida Montana Health Co-op	$464.55
Rate for Payer: Monida PacificSource	$464.55

EPISTAXIS COMPLEX- ER

Facility

$489.00

Service Code	CPT 30903
Hospital Charge Code	1030903
Hospital Revenue Code	450
Min. Negotiated Rate	$342.30
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna Commercial	$464.55
Rate for Payer: Aetna Medicare	$440.10
Rate for Payer: BCBS MT CHIP	$440.10
Rate for Payer: BCBS MT Closed Plan Network	$464.55
Rate for Payer: BCBS MT HealthLink	$440.10
Rate for Payer: BCBS MT Medicare	$440.10
Rate for Payer: BCBS MT POS	$464.55
Rate for Payer: BCBS MT Traditional	$489.00
Rate for Payer: Cash Price	$440.10
Rate for Payer: Cigna Commercial	$464.55
Rate for Payer: Cigna Medicare	$440.10
Rate for Payer: Medicaid All Medicaid	$449.88
Rate for Payer: Medicare All Medicare	$342.30
Rate for Payer: Monida Allegiance	$464.55
Rate for Payer: Monida First Choice Health	$474.33
Rate for Payer: Monida Montana Health Co-op	$464.55
Rate for Payer: Monida PacificSource	$464.55

EPISTAXIS INITIAL- ER

Facility

$357.00

Service Code	CPT 30905
Hospital Charge Code	1030905
Hospital Revenue Code	450
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$357.00
Rate for Payer: Aetna Commercial	$339.15
Rate for Payer: Aetna Medicare	$321.30
Rate for Payer: BCBS MT CHIP	$321.30
Rate for Payer: BCBS MT Closed Plan Network	$339.15
Rate for Payer: BCBS MT HealthLink	$321.30
Rate for Payer: BCBS MT Medicare	$321.30
Rate for Payer: BCBS MT POS	$339.15
Rate for Payer: BCBS MT Traditional	$357.00
Rate for Payer: Cash Price	$321.30
Rate for Payer: Cigna Commercial	$339.15
Rate for Payer: Cigna Medicare	$321.30
Rate for Payer: Medicaid All Medicaid	$328.44
Rate for Payer: Medicare All Medicare	$249.90
Rate for Payer: Monida Allegiance	$339.15
Rate for Payer: Monida First Choice Health	$346.29
Rate for Payer: Monida Montana Health Co-op	$339.15
Rate for Payer: Monida PacificSource	$339.15

EPISTAXIS INITIAL- ER

Facility

$357.00

Service Code	CPT 30905
Hospital Charge Code	1030905
Hospital Revenue Code	450
Min. Negotiated Rate	$249.90
Max. Negotiated Rate	$357.00
Rate for Payer: Aetna Commercial	$339.15
Rate for Payer: Aetna Medicare	$321.30
Rate for Payer: BCBS MT CHIP	$321.30
Rate for Payer: BCBS MT Closed Plan Network	$339.15
Rate for Payer: BCBS MT HealthLink	$321.30
Rate for Payer: BCBS MT Medicare	$321.30
Rate for Payer: BCBS MT POS	$339.15
Rate for Payer: BCBS MT Traditional	$357.00
Rate for Payer: Cash Price	$321.30
Rate for Payer: Cigna Commercial	$339.15
Rate for Payer: Cigna Medicare	$321.30
Rate for Payer: Medicaid All Medicaid	$328.44
Rate for Payer: Medicare All Medicare	$249.90
Rate for Payer: Monida Allegiance	$339.15
Rate for Payer: Monida First Choice Health	$346.29
Rate for Payer: Monida Montana Health Co-op	$339.15
Rate for Payer: Monida PacificSource	$339.15

EPISTAXIS SIMPLE- ER

Facility

$326.00

Service Code	CPT 30901
Hospital Charge Code	1030901
Hospital Revenue Code	450
Min. Negotiated Rate	$228.20
Max. Negotiated Rate	$326.00
Rate for Payer: Aetna Commercial	$309.70
Rate for Payer: Aetna Medicare	$293.40
Rate for Payer: BCBS MT CHIP	$293.40
Rate for Payer: BCBS MT Closed Plan Network	$309.70
Rate for Payer: BCBS MT HealthLink	$293.40
Rate for Payer: BCBS MT Medicare	$293.40
Rate for Payer: BCBS MT POS	$309.70
Rate for Payer: BCBS MT Traditional	$326.00
Rate for Payer: Cash Price	$293.40
Rate for Payer: Cigna Commercial	$309.70
Rate for Payer: Cigna Medicare	$293.40
Rate for Payer: Medicaid All Medicaid	$299.92
Rate for Payer: Medicare All Medicare	$228.20
Rate for Payer: Monida Allegiance	$309.70
Rate for Payer: Monida First Choice Health	$316.22
Rate for Payer: Monida Montana Health Co-op	$309.70
Rate for Payer: Monida PacificSource	$309.70

EPISTAXIS SIMPLE- ER

Facility

$326.00

Service Code	CPT 30901
Hospital Charge Code	1030901
Hospital Revenue Code	450
Min. Negotiated Rate	$228.20
Max. Negotiated Rate	$326.00
Rate for Payer: Aetna Commercial	$309.70
Rate for Payer: Aetna Medicare	$293.40
Rate for Payer: BCBS MT CHIP	$293.40
Rate for Payer: BCBS MT Closed Plan Network	$309.70
Rate for Payer: BCBS MT HealthLink	$293.40
Rate for Payer: BCBS MT Medicare	$293.40
Rate for Payer: BCBS MT POS	$309.70
Rate for Payer: BCBS MT Traditional	$326.00
Rate for Payer: Cash Price	$293.40
Rate for Payer: Cigna Commercial	$309.70
Rate for Payer: Cigna Medicare	$293.40
Rate for Payer: Medicaid All Medicaid	$299.92
Rate for Payer: Medicare All Medicare	$228.20
Rate for Payer: Monida Allegiance	$309.70
Rate for Payer: Monida First Choice Health	$316.22
Rate for Payer: Monida Montana Health Co-op	$309.70
Rate for Payer: Monida PacificSource	$309.70

EPLEY MANEUVER / CANALITH REPOSITIONING

Facility

$137.00

Service Code	CPT 95992
Hospital Charge Code	8095992
Hospital Revenue Code	521
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$137.00
Rate for Payer: Aetna Commercial	$130.15
Rate for Payer: Aetna Medicare	$123.30
Rate for Payer: BCBS MT CHIP	$123.30
Rate for Payer: BCBS MT Closed Plan Network	$130.15
Rate for Payer: BCBS MT HealthLink	$123.30
Rate for Payer: BCBS MT Medicare	$123.30
Rate for Payer: BCBS MT POS	$130.15
Rate for Payer: BCBS MT Traditional	$137.00
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial	$130.15
Rate for Payer: Cigna Medicare	$123.30
Rate for Payer: Medicaid All Medicaid	$126.04
Rate for Payer: Medicare All Medicare	$95.90
Rate for Payer: Monida Allegiance	$130.15
Rate for Payer: Monida First Choice Health	$132.89
Rate for Payer: Monida Montana Health Co-op	$130.15
Rate for Payer: Monida PacificSource	$130.15

EPLEY MANEUVER / CANALITH REPOSITIONING

Facility

$137.00

Service Code	CPT 95992
Hospital Charge Code	8095992
Hospital Revenue Code	521
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$137.00
Rate for Payer: Aetna Commercial	$130.15
Rate for Payer: Aetna Medicare	$123.30
Rate for Payer: BCBS MT CHIP	$123.30
Rate for Payer: BCBS MT Closed Plan Network	$130.15
Rate for Payer: BCBS MT HealthLink	$123.30
Rate for Payer: BCBS MT Medicare	$123.30
Rate for Payer: BCBS MT POS	$130.15
Rate for Payer: BCBS MT Traditional	$137.00
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial	$130.15
Rate for Payer: Cigna Medicare	$123.30
Rate for Payer: Medicaid All Medicaid	$126.04
Rate for Payer: Medicare All Medicare	$95.90
Rate for Payer: Monida Allegiance	$130.15
Rate for Payer: Monida First Choice Health	$132.89
Rate for Payer: Monida Montana Health Co-op	$130.15
Rate for Payer: Monida PacificSource	$130.15

EPOETIN ALFA INJ [10,000 U/ML] SPEC ORD

Facility

$640.00

Service Code	HCPCS J0885
Hospital Charge Code	3000149
Hospital Revenue Code	259
Min. Negotiated Rate	$448.00
Max. Negotiated Rate	$640.00
Rate for Payer: Aetna Commercial	$608.00
Rate for Payer: Aetna Medicare	$576.00
Rate for Payer: BCBS MT CHIP	$576.00
Rate for Payer: BCBS MT Closed Plan Network	$608.00
Rate for Payer: BCBS MT HealthLink	$576.00
Rate for Payer: BCBS MT Medicare	$576.00
Rate for Payer: BCBS MT POS	$608.00
Rate for Payer: BCBS MT Traditional	$640.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna Commercial	$608.00
Rate for Payer: Cigna Medicare	$576.00
Rate for Payer: Medicaid All Medicaid	$588.80
Rate for Payer: Medicare All Medicare	$448.00
Rate for Payer: Monida Allegiance	$608.00
Rate for Payer: Monida First Choice Health	$620.80
Rate for Payer: Monida Montana Health Co-op	$608.00
Rate for Payer: Monida PacificSource	$608.00

EPOETIN ALFA INJ [10,000 U/ML] SPEC ORD

Facility

$640.00

Service Code	HCPCS J0885
Hospital Charge Code	3000149
Hospital Revenue Code	259
Min. Negotiated Rate	$448.00
Max. Negotiated Rate	$640.00
Rate for Payer: Aetna Commercial	$608.00
Rate for Payer: Aetna Medicare	$576.00
Rate for Payer: BCBS MT CHIP	$576.00
Rate for Payer: BCBS MT Closed Plan Network	$608.00
Rate for Payer: BCBS MT HealthLink	$576.00
Rate for Payer: BCBS MT Medicare	$576.00
Rate for Payer: BCBS MT POS	$608.00
Rate for Payer: BCBS MT Traditional	$640.00
Rate for Payer: Cash Price	$576.00
Rate for Payer: Cigna Commercial	$608.00
Rate for Payer: Cigna Medicare	$576.00
Rate for Payer: Medicaid All Medicaid	$588.80
Rate for Payer: Medicare All Medicare	$448.00
Rate for Payer: Monida Allegiance	$608.00
Rate for Payer: Monida First Choice Health	$620.80
Rate for Payer: Monida Montana Health Co-op	$608.00
Rate for Payer: Monida PacificSource	$608.00

EPPSTEIN BARR AB NUCLEAR ANTIGEN

Facility

$75.00

Service Code	CPT 86664
Hospital Charge Code	4088091
Hospital Revenue Code	302
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

EPPSTEIN BARR AB NUCLEAR ANTIGEN

Facility

$75.00

Service Code	CPT 86664
Hospital Charge Code	4088091
Hospital Revenue Code	302
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

Know your out-of-pocket cost for care.

All Charges