Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ID NOW INFLUENZA BUNDLE

Facility

$7,991.45

Hospital Charge Code	90197134
Hospital Revenue Code	270
Min. Negotiated Rate	$5,594.02
Max. Negotiated Rate	$7,991.45
Rate for Payer: Aetna Commercial	$7,591.88
Rate for Payer: Aetna Medicare	$7,192.31
Rate for Payer: BCBS MT CHIP	$7,192.31
Rate for Payer: BCBS MT Closed Plan Network	$7,591.88
Rate for Payer: BCBS MT HealthLink	$7,192.31
Rate for Payer: BCBS MT Medicare	$7,192.31
Rate for Payer: BCBS MT POS	$7,591.88
Rate for Payer: BCBS MT Traditional	$7,991.45
Rate for Payer: Cash Price	$7,192.31
Rate for Payer: Cigna Commercial	$7,591.88
Rate for Payer: Cigna Medicare	$7,192.31
Rate for Payer: Medicaid All Medicaid	$7,352.13
Rate for Payer: Medicare All Medicare	$5,594.02
Rate for Payer: Monida Allegiance	$7,591.88
Rate for Payer: Monida First Choice Health	$7,751.71
Rate for Payer: Monida Montana Health Co-op	$7,591.88
Rate for Payer: Monida PacificSource	$7,591.88

ID NOW INFLUENZA BUNDLE

Facility

$7,991.45

Hospital Charge Code	90197134
Hospital Revenue Code	270
Min. Negotiated Rate	$5,594.02
Max. Negotiated Rate	$7,991.45
Rate for Payer: Aetna Commercial	$7,591.88
Rate for Payer: Aetna Medicare	$7,192.31
Rate for Payer: BCBS MT CHIP	$7,192.31
Rate for Payer: BCBS MT Closed Plan Network	$7,591.88
Rate for Payer: BCBS MT HealthLink	$7,192.31
Rate for Payer: BCBS MT Medicare	$7,192.31
Rate for Payer: BCBS MT POS	$7,591.88
Rate for Payer: BCBS MT Traditional	$7,991.45
Rate for Payer: Cash Price	$7,192.31
Rate for Payer: Cigna Commercial	$7,591.88
Rate for Payer: Cigna Medicare	$7,192.31
Rate for Payer: Medicaid All Medicaid	$7,352.13
Rate for Payer: Medicare All Medicare	$5,594.02
Rate for Payer: Monida Allegiance	$7,591.88
Rate for Payer: Monida First Choice Health	$7,751.71
Rate for Payer: Monida Montana Health Co-op	$7,591.88
Rate for Payer: Monida PacificSource	$7,591.88

ID NOW STREP BUNDLE

Facility

$5,934.55

Hospital Charge Code	90197114
Hospital Revenue Code	270
Min. Negotiated Rate	$4,154.19
Max. Negotiated Rate	$5,934.55
Rate for Payer: Aetna Commercial	$5,637.82
Rate for Payer: Aetna Medicare	$5,341.10
Rate for Payer: BCBS MT CHIP	$5,341.10
Rate for Payer: BCBS MT Closed Plan Network	$5,637.82
Rate for Payer: BCBS MT HealthLink	$5,341.10
Rate for Payer: BCBS MT Medicare	$5,341.10
Rate for Payer: BCBS MT POS	$5,637.82
Rate for Payer: BCBS MT Traditional	$5,934.55
Rate for Payer: Cash Price	$5,341.10
Rate for Payer: Cigna Commercial	$5,637.82
Rate for Payer: Cigna Medicare	$5,341.10
Rate for Payer: Medicaid All Medicaid	$5,459.79
Rate for Payer: Medicare All Medicare	$4,154.19
Rate for Payer: Monida Allegiance	$5,637.82
Rate for Payer: Monida First Choice Health	$5,756.51
Rate for Payer: Monida Montana Health Co-op	$5,637.82
Rate for Payer: Monida PacificSource	$5,637.82

ID NOW STREP BUNDLE

Facility

$5,934.55

Hospital Charge Code	90197114
Hospital Revenue Code	270
Min. Negotiated Rate	$4,154.19
Max. Negotiated Rate	$5,934.55
Rate for Payer: Aetna Commercial	$5,637.82
Rate for Payer: Aetna Medicare	$5,341.10
Rate for Payer: BCBS MT CHIP	$5,341.10
Rate for Payer: BCBS MT Closed Plan Network	$5,637.82
Rate for Payer: BCBS MT HealthLink	$5,341.10
Rate for Payer: BCBS MT Medicare	$5,341.10
Rate for Payer: BCBS MT POS	$5,637.82
Rate for Payer: BCBS MT Traditional	$5,934.55
Rate for Payer: Cash Price	$5,341.10
Rate for Payer: Cigna Commercial	$5,637.82
Rate for Payer: Cigna Medicare	$5,341.10
Rate for Payer: Medicaid All Medicaid	$5,459.79
Rate for Payer: Medicare All Medicare	$4,154.19
Rate for Payer: Monida Allegiance	$5,637.82
Rate for Payer: Monida First Choice Health	$5,756.51
Rate for Payer: Monida Montana Health Co-op	$5,637.82
Rate for Payer: Monida PacificSource	$5,637.82

.IMMUNASSY ANALYTE NOT INF AB/AG 83516

Facility

$100.00

Service Code	HCPCS 83516
Hospital Charge Code	4035161
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: BCBS MT CHIP	$90.00
Rate for Payer: BCBS MT Closed Plan Network	$95.00
Rate for Payer: BCBS MT HealthLink	$90.00
Rate for Payer: BCBS MT Medicare	$90.00
Rate for Payer: BCBS MT POS	$95.00
Rate for Payer: BCBS MT Traditional	$100.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Cigna Medicare	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

.IMMUNASSY ANALYTE NOT INF AB/AG 83516

Facility

$100.00

Service Code	HCPCS 83516
Hospital Charge Code	4035161
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: BCBS MT CHIP	$90.00
Rate for Payer: BCBS MT Closed Plan Network	$95.00
Rate for Payer: BCBS MT HealthLink	$90.00
Rate for Payer: BCBS MT Medicare	$90.00
Rate for Payer: BCBS MT POS	$95.00
Rate for Payer: BCBS MT Traditional	$100.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Cigna Medicare	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

.IMMUNASSY ANLYT NOT INF AB/AG QUA 83520

Facility

$157.00

Service Code	HCPCS 83520
Hospital Charge Code	4083520
Hospital Revenue Code	301
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$157.00
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: BCBS MT CHIP	$141.30
Rate for Payer: BCBS MT Closed Plan Network	$149.15
Rate for Payer: BCBS MT HealthLink	$141.30
Rate for Payer: BCBS MT Medicare	$141.30
Rate for Payer: BCBS MT POS	$149.15
Rate for Payer: BCBS MT Traditional	$157.00
Rate for Payer: Cash Price	$141.30
Rate for Payer: Cigna Commercial	$149.15
Rate for Payer: Cigna Medicare	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

.IMMUNASSY ANLYT NOT INF AB/AG QUA 83520

Facility

$157.00

Service Code	HCPCS 83520
Hospital Charge Code	4083520
Hospital Revenue Code	301
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$157.00
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: BCBS MT CHIP	$141.30
Rate for Payer: BCBS MT Closed Plan Network	$149.15
Rate for Payer: BCBS MT HealthLink	$141.30
Rate for Payer: BCBS MT Medicare	$141.30
Rate for Payer: BCBS MT POS	$149.15
Rate for Payer: BCBS MT Traditional	$157.00
Rate for Payer: Cash Price	$141.30
Rate for Payer: Cigna Commercial	$149.15
Rate for Payer: Cigna Medicare	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

IMMUNE GLOBULIN [20 G] 10% 200ML SDV

Facility

$5,116.00

Service Code	HCPCS J1459
Hospital Charge Code	3000229
Hospital Revenue Code	636
Min. Negotiated Rate	$3,581.20
Max. Negotiated Rate	$5,116.00
Rate for Payer: Aetna Commercial	$4,860.20
Rate for Payer: Aetna Medicare	$4,604.40
Rate for Payer: BCBS MT CHIP	$4,604.40
Rate for Payer: BCBS MT Closed Plan Network	$4,860.20
Rate for Payer: BCBS MT HealthLink	$4,604.40
Rate for Payer: BCBS MT Medicare	$4,604.40
Rate for Payer: BCBS MT POS	$4,860.20
Rate for Payer: BCBS MT Traditional	$5,116.00
Rate for Payer: Cash Price	$4,604.40
Rate for Payer: Cigna Commercial	$4,860.20
Rate for Payer: Cigna Medicare	$4,604.40
Rate for Payer: Medicaid All Medicaid	$4,706.72
Rate for Payer: Medicare All Medicare	$3,581.20
Rate for Payer: Monida Allegiance	$4,860.20
Rate for Payer: Monida First Choice Health	$4,962.52
Rate for Payer: Monida Montana Health Co-op	$4,860.20
Rate for Payer: Monida PacificSource	$4,860.20

IMMUNE GLOBULIN [20 G] 10% 200ML SDV

Facility

$5,116.00

Service Code	HCPCS J1459
Hospital Charge Code	3000229
Hospital Revenue Code	636
Min. Negotiated Rate	$3,581.20
Max. Negotiated Rate	$5,116.00
Rate for Payer: Aetna Commercial	$4,860.20
Rate for Payer: Aetna Medicare	$4,604.40
Rate for Payer: BCBS MT CHIP	$4,604.40
Rate for Payer: BCBS MT Closed Plan Network	$4,860.20
Rate for Payer: BCBS MT HealthLink	$4,604.40
Rate for Payer: BCBS MT Medicare	$4,604.40
Rate for Payer: BCBS MT POS	$4,860.20
Rate for Payer: BCBS MT Traditional	$5,116.00
Rate for Payer: Cash Price	$4,604.40
Rate for Payer: Cigna Commercial	$4,860.20
Rate for Payer: Cigna Medicare	$4,604.40
Rate for Payer: Medicaid All Medicaid	$4,706.72
Rate for Payer: Medicare All Medicare	$3,581.20
Rate for Payer: Monida Allegiance	$4,860.20
Rate for Payer: Monida First Choice Health	$4,962.52
Rate for Payer: Monida Montana Health Co-op	$4,860.20
Rate for Payer: Monida PacificSource	$4,860.20

IMMUNOASAY-TUMOR ANT CA15-3(27.29)-86300

Facility

$32.00

Service Code	HCPCS 86300
Hospital Charge Code	4086300
Hospital Revenue Code	300
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

IMMUNOASAY-TUMOR ANT CA15-3(27.29)-86300

Facility

$32.00

Service Code	HCPCS 86300
Hospital Charge Code	4086300
Hospital Revenue Code	300
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

IMMUNOCHEMICAL FIT OCCULT BLOOD (IFOBT)

Facility

$150.00

Service Code	HCPCS 82274
Hospital Charge Code	4087961
Hospital Revenue Code	300
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

IMMUNOCHEMICAL FIT OCCULT BLOOD (IFOBT)

Facility

$150.00

Service Code	HCPCS 82274
Hospital Charge Code	4087961
Hospital Revenue Code	300
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

IMMUNOFIXATION, SERUM (001685)

Facility

$83.00

Service Code	HCPCS 86334
Hospital Charge Code	4086334
Hospital Revenue Code	300
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

IMMUNOFIXATION, SERUM (001685)

Facility

$83.00

Service Code	HCPCS 86334
Hospital Charge Code	4086334
Hospital Revenue Code	300
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

.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

$68.00

Service Code	HCPCS 82784
Hospital Charge Code	4000060
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

IMMUNOGLOBULIN A (001784)

Facility

$68.00

Service Code	HCPCS 82784
Hospital Charge Code	4000060
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

IMMUNOGLOBULIN E TOTAL (002170)

Facility

$54.00

Service Code	HCPCS 82785
Hospital Charge Code	4082785
Hospital Revenue Code	300
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

IMMUNOGLOBULIN E TOTAL (002170)

Facility

$54.00

Service Code	HCPCS 82785
Hospital Charge Code	4082785
Hospital Revenue Code	300
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

IMMUNOGLOBULIN G (001776)

Facility

$68.00

Service Code	HCPCS 82784
Hospital Charge Code	4000058
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

IMMUNOGLOBULIN G (001776)

Facility

$68.00

Service Code	HCPCS 82784
Hospital Charge Code	4000058
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

.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

Know your out-of-pocket cost for care.

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