Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HPV GENOTYPES 16 AND 18

Facility

$136.00

Service Code	HCPCS 87625
Hospital Charge Code	4087957
Hospital Revenue Code	310
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna Commercial	$129.20
Rate for Payer: Aetna Medicare	$122.40
Rate for Payer: BCBS MT CHIP	$122.40
Rate for Payer: BCBS MT Closed Plan Network	$129.20
Rate for Payer: BCBS MT HealthLink	$122.40
Rate for Payer: BCBS MT Medicare	$122.40
Rate for Payer: BCBS MT POS	$129.20
Rate for Payer: BCBS MT Traditional	$136.00
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna Commercial	$129.20
Rate for Payer: Cigna Medicare	$122.40
Rate for Payer: Medicaid All Medicaid	$125.12
Rate for Payer: Medicare All Medicare	$95.20
Rate for Payer: Monida Allegiance	$129.20
Rate for Payer: Monida First Choice Health	$131.92
Rate for Payer: Monida Montana Health Co-op	$129.20
Rate for Payer: Monida PacificSource	$129.20

H PYLORI ANTIGEN, STOOL (180764)

Facility

$171.00

Service Code	HCPCS 87338
Hospital Charge Code	4087338
Hospital Revenue Code	301
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

H PYLORI ANTIGEN, STOOL (180764)

Facility

$171.00

Service Code	HCPCS 87338
Hospital Charge Code	4087338
Hospital Revenue Code	301
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

H PYLORI BREATH TEST (180836)

Facility

$236.00

Service Code	HCPCS 83013
Hospital Charge Code	4083013
Hospital Revenue Code	301
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$236.00
Rate for Payer: Aetna Commercial	$224.20
Rate for Payer: Aetna Medicare	$212.40
Rate for Payer: BCBS MT CHIP	$212.40
Rate for Payer: BCBS MT Closed Plan Network	$224.20
Rate for Payer: BCBS MT HealthLink	$212.40
Rate for Payer: BCBS MT Medicare	$212.40
Rate for Payer: BCBS MT POS	$224.20
Rate for Payer: BCBS MT Traditional	$236.00
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$224.20
Rate for Payer: Cigna Medicare	$212.40
Rate for Payer: Medicaid All Medicaid	$217.12
Rate for Payer: Medicare All Medicare	$165.20
Rate for Payer: Monida Allegiance	$224.20
Rate for Payer: Monida First Choice Health	$228.92
Rate for Payer: Monida Montana Health Co-op	$224.20
Rate for Payer: Monida PacificSource	$224.20

H PYLORI BREATH TEST (180836)

Facility

$236.00

Service Code	HCPCS 83013
Hospital Charge Code	4083013
Hospital Revenue Code	301
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$236.00
Rate for Payer: Aetna Commercial	$224.20
Rate for Payer: Aetna Medicare	$212.40
Rate for Payer: BCBS MT CHIP	$212.40
Rate for Payer: BCBS MT Closed Plan Network	$224.20
Rate for Payer: BCBS MT HealthLink	$212.40
Rate for Payer: BCBS MT Medicare	$212.40
Rate for Payer: BCBS MT POS	$224.20
Rate for Payer: BCBS MT Traditional	$236.00
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$224.20
Rate for Payer: Cigna Medicare	$212.40
Rate for Payer: Medicaid All Medicaid	$217.12
Rate for Payer: Medicare All Medicare	$165.20
Rate for Payer: Monida Allegiance	$224.20
Rate for Payer: Monida First Choice Health	$228.92
Rate for Payer: Monida Montana Health Co-op	$224.20
Rate for Payer: Monida PacificSource	$224.20

H PYLORI STOOL AG EIA

Facility

$171.00

Service Code	HCPCS 87338
Hospital Charge Code	4087881
Hospital Revenue Code	300
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

H PYLORI STOOL AG EIA

Facility

$171.00

Service Code	HCPCS 87338
Hospital Charge Code	4087881
Hospital Revenue Code	300
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

HSV TYPE 1 ANTIBODIES, IGG (164897)

Facility

$47.00

Service Code	HCPCS 86695
Hospital Charge Code	4086695
Hospital Revenue Code	300
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

HSV TYPE 1 ANTIBODIES, IGG (164897)

Facility

$47.00

Service Code	HCPCS 86695
Hospital Charge Code	4086695
Hospital Revenue Code	300
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

HSV TYPE 2 ANTIBODIES, IGG (163033)

Facility

$67.00

Service Code	HCPCS 86696
Hospital Charge Code	4086696
Hospital Revenue Code	300
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

HSV TYPE 2 ANTIBODIES, IGG (163033)

Facility

$67.00

Service Code	HCPCS 86696
Hospital Charge Code	4086696
Hospital Revenue Code	300
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

HSV TYPES 1/2, DNA PCR (138651)

Facility

$433.00

Service Code	HCPCS 87529
Hospital Charge Code	4087529
Hospital Revenue Code	300
Min. Negotiated Rate	$303.10
Max. Negotiated Rate	$433.00
Rate for Payer: Aetna Commercial	$411.35
Rate for Payer: Aetna Medicare	$389.70
Rate for Payer: BCBS MT CHIP	$389.70
Rate for Payer: BCBS MT Closed Plan Network	$411.35
Rate for Payer: BCBS MT HealthLink	$389.70
Rate for Payer: BCBS MT Medicare	$389.70
Rate for Payer: BCBS MT POS	$411.35
Rate for Payer: BCBS MT Traditional	$433.00
Rate for Payer: Cash Price	$389.70
Rate for Payer: Cigna Commercial	$411.35
Rate for Payer: Cigna Medicare	$389.70
Rate for Payer: Medicaid All Medicaid	$398.36
Rate for Payer: Medicare All Medicare	$303.10
Rate for Payer: Monida Allegiance	$411.35
Rate for Payer: Monida First Choice Health	$420.01
Rate for Payer: Monida Montana Health Co-op	$411.35
Rate for Payer: Monida PacificSource	$411.35

HSV TYPES 1/2, DNA PCR (138651)

Facility

$433.00

Service Code	HCPCS 87529
Hospital Charge Code	4087529
Hospital Revenue Code	300
Min. Negotiated Rate	$303.10
Max. Negotiated Rate	$433.00
Rate for Payer: Aetna Commercial	$411.35
Rate for Payer: Aetna Medicare	$389.70
Rate for Payer: BCBS MT CHIP	$389.70
Rate for Payer: BCBS MT Closed Plan Network	$411.35
Rate for Payer: BCBS MT HealthLink	$389.70
Rate for Payer: BCBS MT Medicare	$389.70
Rate for Payer: BCBS MT POS	$411.35
Rate for Payer: BCBS MT Traditional	$433.00
Rate for Payer: Cash Price	$389.70
Rate for Payer: Cigna Commercial	$411.35
Rate for Payer: Cigna Medicare	$389.70
Rate for Payer: Medicaid All Medicaid	$398.36
Rate for Payer: Medicare All Medicare	$303.10
Rate for Payer: Monida Allegiance	$411.35
Rate for Payer: Monida First Choice Health	$420.01
Rate for Payer: Monida Montana Health Co-op	$411.35
Rate for Payer: Monida PacificSource	$411.35

hydrALAZINE INJ [20 MG/ML] SDV

Facility

$55.00

Service Code	HCPCS J0360
Hospital Charge Code	3000603
Hospital Revenue Code	250
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

hydrALAZINE INJ [20 MG/ML] SDV

Facility

$55.00

Service Code	HCPCS J0360
Hospital Charge Code	3000603
Hospital Revenue Code	250
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

HYDRALAZINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3007148
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

HYDRALAZINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3007148
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

HYDRALAZINE TAB [50 MG] NF

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	3000215
Hospital Revenue Code	250
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

HYDRALAZINE TAB [50 MG] NF

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	3000215
Hospital Revenue Code	250
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

HYDRATION IV INFUSION, ADD-ON

Facility

$114.00

Service Code	HCPCS 96361
Hospital Charge Code	530196
Hospital Revenue Code	260
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

HYDRATION IV INFUSION, ADD-ON

Facility

$114.00

Service Code	HCPCS 96361
Hospital Charge Code	530196
Hospital Revenue Code	260
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

HYDRATION IV INFUSION INIT UP TO 1.5HRS

Facility

$355.00

Service Code	HCPCS 96360
Hospital Charge Code	530197
Hospital Revenue Code	260
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

HYDRATION IV INFUSION INIT UP TO 1.5HRS

Facility

$355.00

Service Code	HCPCS 96360
Hospital Charge Code	530197
Hospital Revenue Code	260
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

HYDROCHLOROTHIAZIDE 12.5MG CAP NON FORM

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000216
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

HYDROCHLOROTHIAZIDE 12.5MG CAP NON FORM

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000216
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

Know your out-of-pocket cost for care.

All Charges