Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

IMMUNOFIXATION, SERUM (001685)

Facility

$81.00

Service Code	HCPCS 86334
Hospital Charge Code	4086334
Hospital Revenue Code	300
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

IMMUNOFIXATION, SERUM (001685)

Facility

$81.00

Service Code	HCPCS 86334
Hospital Charge Code	4086334
Hospital Revenue Code	300
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

.IMMUNOFIXATION, URINE

Facility

$189.00

Service Code	HCPCS 86335
Hospital Charge Code	4063351
Hospital Revenue Code	300
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: BCBS MT CHIP	$170.10
Rate for Payer: BCBS MT Closed Plan Network	$179.55
Rate for Payer: BCBS MT HealthLink	$170.10
Rate for Payer: BCBS MT Medicare	$170.10
Rate for Payer: BCBS MT POS	$179.55
Rate for Payer: BCBS MT Traditional	$189.00
Rate for Payer: Cash Price	$170.10
Rate for Payer: Cigna Commercial	$179.55
Rate for Payer: Cigna Medicare	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

.IMMUNOFIXATION, URINE

Facility

$189.00

Service Code	HCPCS 86335
Hospital Charge Code	4063351
Hospital Revenue Code	300
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: BCBS MT CHIP	$170.10
Rate for Payer: BCBS MT Closed Plan Network	$179.55
Rate for Payer: BCBS MT HealthLink	$170.10
Rate for Payer: BCBS MT Medicare	$170.10
Rate for Payer: BCBS MT POS	$179.55
Rate for Payer: BCBS MT Traditional	$189.00
Rate for Payer: Cash Price	$170.10
Rate for Payer: Cigna Commercial	$179.55
Rate for Payer: Cigna Medicare	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

IMMUNOGLOBULIN A (001784)

Facility

$13.00

Service Code	HCPCS 82784
Hospital Charge Code	4000060
Hospital Revenue Code	300
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

IMMUNOGLOBULIN A (001784)

Facility

$13.00

Service Code	HCPCS 82784
Hospital Charge Code	4000060
Hospital Revenue Code	300
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

IMMUNOGLOBULIN E TOTAL (002170)

Facility

$22.00

Service Code	HCPCS 82785
Hospital Charge Code	4082785
Hospital Revenue Code	300
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

IMMUNOGLOBULIN E TOTAL (002170)

Facility

$22.00

Service Code	HCPCS 82785
Hospital Charge Code	4082785
Hospital Revenue Code	300
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

IMMUNOGLOBULIN G (001776)

Facility

$13.00

Service Code	HCPCS 82784
Hospital Charge Code	4000058
Hospital Revenue Code	300
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

IMMUNOGLOBULIN G (001776)

Facility

$13.00

Service Code	HCPCS 82784
Hospital Charge Code	4000058
Hospital Revenue Code	300
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

.IMMUNOGLOBULIN LIGHT CHAINS

Facility

$108.00

Service Code	HCPCS 83521
Hospital Charge Code	4083521
Hospital Revenue Code	300
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: BCBS MT CHIP	$97.20
Rate for Payer: BCBS MT Closed Plan Network	$102.60
Rate for Payer: BCBS MT HealthLink	$97.20
Rate for Payer: BCBS MT Medicare	$97.20
Rate for Payer: BCBS MT POS	$102.60
Rate for Payer: BCBS MT Traditional	$108.00
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial	$102.60
Rate for Payer: Cigna Medicare	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

.IMMUNOGLOBULIN LIGHT CHAINS

Facility

$108.00

Service Code	HCPCS 83521
Hospital Charge Code	4083521
Hospital Revenue Code	300
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: BCBS MT CHIP	$97.20
Rate for Payer: BCBS MT Closed Plan Network	$102.60
Rate for Payer: BCBS MT HealthLink	$97.20
Rate for Payer: BCBS MT Medicare	$97.20
Rate for Payer: BCBS MT POS	$102.60
Rate for Payer: BCBS MT Traditional	$108.00
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial	$102.60
Rate for Payer: Cigna Medicare	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

IMMUNOGLOBULIN M (001792)

Facility

$13.00

Service Code	HCPCS 82784
Hospital Charge Code	4000059
Hospital Revenue Code	300
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

IMMUNOGLOBULIN M (001792)

Facility

$13.00

Service Code	HCPCS 82784
Hospital Charge Code	4000059
Hospital Revenue Code	300
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

.IMMUNOGLOBULIN SUBCLASS

Facility

$38.00

Service Code	HCPCS 82787
Hospital Charge Code	4082787
Hospital Revenue Code	300
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

.IMMUNOGLOBULIN SUBCLASS

Facility

$38.00

Service Code	HCPCS 82787
Hospital Charge Code	4082787
Hospital Revenue Code	300
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

.IMMUNOGLOBULIN SUBCLASS (209601 ONLY)

Facility

$62.00

Service Code	HCPCS 82787
Hospital Charge Code	4027870
Hospital Revenue Code	300
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

.IMMUNOGLOBULIN SUBCLASS (209601 ONLY)

Facility

$62.00

Service Code	HCPCS 82787
Hospital Charge Code	4027870
Hospital Revenue Code	300
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

INCISION OF THROMBOSED HEMORRHOID, EXTER

Facility

$382.00

Service Code	HCPCS 46083
Hospital Charge Code	1046083
Hospital Revenue Code	450
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$382.00
Rate for Payer: Aetna Commercial	$362.90
Rate for Payer: Aetna Medicare	$343.80
Rate for Payer: BCBS MT CHIP	$343.80
Rate for Payer: BCBS MT Closed Plan Network	$362.90
Rate for Payer: BCBS MT HealthLink	$343.80
Rate for Payer: BCBS MT Medicare	$343.80
Rate for Payer: BCBS MT POS	$362.90
Rate for Payer: BCBS MT Traditional	$382.00
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cigna Commercial	$362.90
Rate for Payer: Cigna Medicare	$343.80
Rate for Payer: Medicaid All Medicaid	$351.44
Rate for Payer: Medicare All Medicare	$267.40
Rate for Payer: Monida Allegiance	$362.90
Rate for Payer: Monida First Choice Health	$370.54
Rate for Payer: Monida Montana Health Co-op	$362.90
Rate for Payer: Monida PacificSource	$362.90

INCISION OF THROMBOSED HEMORRHOID, EXTER

Facility

$382.00

Service Code	HCPCS 46083
Hospital Charge Code	1046083
Hospital Revenue Code	450
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$382.00
Rate for Payer: Aetna Commercial	$362.90
Rate for Payer: Aetna Medicare	$343.80
Rate for Payer: BCBS MT CHIP	$343.80
Rate for Payer: BCBS MT Closed Plan Network	$362.90
Rate for Payer: BCBS MT HealthLink	$343.80
Rate for Payer: BCBS MT Medicare	$343.80
Rate for Payer: BCBS MT POS	$362.90
Rate for Payer: BCBS MT Traditional	$382.00
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cigna Commercial	$362.90
Rate for Payer: Cigna Medicare	$343.80
Rate for Payer: Medicaid All Medicaid	$351.44
Rate for Payer: Medicare All Medicare	$267.40
Rate for Payer: Monida Allegiance	$362.90
Rate for Payer: Monida First Choice Health	$370.54
Rate for Payer: Monida Montana Health Co-op	$362.90
Rate for Payer: Monida PacificSource	$362.90

INDOMETHACIN CAP[25 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000230
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

INDOMETHACIN CAP[25 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000230
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

INFANT CATH KIT

Facility

$18.00

Hospital Charge Code	80040206
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

INFANT CATH KIT

Facility

$18.00

Hospital Charge Code	80040206
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

INFECTIOUS MONONUCLEOSIS, RAPID TEST

Facility

$90.00

Service Code	HCPCS 86308
Hospital Charge Code	4086308
Hospital Revenue Code	302
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

Know your out-of-pocket cost for care.

All Charges