Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INTREPID VISIT

Facility

$94.00

Service Code	HCPCS G0151
Hospital Charge Code	611005
Hospital Revenue Code	421
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

INTREPID VISIT

Facility

$94.00

Service Code	HCPCS G0151
Hospital Charge Code	611005
Hospital Revenue Code	421
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

INVALID RING

Facility

$9.00

Hospital Charge Code	2830195
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

INVALID RING

Facility

$9.00

Hospital Charge Code	2830195
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

IODOFORM PACKING 1/4 "

Facility

$4.00

Hospital Charge Code	80030179
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

IODOFORM PACKING 1/4 "

Facility

$4.00

Hospital Charge Code	80030179
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

IPRATROP/ALBUTEROL MDI [20/100MCG] NF

Facility

$999.00

Service Code	HCPCS J7620
Hospital Charge Code	3000237
Hospital Revenue Code	250
Min. Negotiated Rate	$699.30
Max. Negotiated Rate	$999.00
Rate for Payer: Aetna Commercial	$949.05
Rate for Payer: Aetna Medicare	$899.10
Rate for Payer: BCBS MT CHIP	$899.10
Rate for Payer: BCBS MT Closed Plan Network	$949.05
Rate for Payer: BCBS MT HealthLink	$899.10
Rate for Payer: BCBS MT Medicare	$899.10
Rate for Payer: BCBS MT POS	$949.05
Rate for Payer: BCBS MT Traditional	$999.00
Rate for Payer: Cash Price	$899.10
Rate for Payer: Cigna Commercial	$949.05
Rate for Payer: Cigna Medicare	$899.10
Rate for Payer: Medicaid All Medicaid	$919.08
Rate for Payer: Medicare All Medicare	$699.30
Rate for Payer: Monida Allegiance	$949.05
Rate for Payer: Monida First Choice Health	$969.03
Rate for Payer: Monida Montana Health Co-op	$949.05
Rate for Payer: Monida PacificSource	$949.05

IPRATROP/ALBUTEROL MDI [20/100MCG] NF

Facility

$999.00

Service Code	HCPCS J7620
Hospital Charge Code	3000237
Hospital Revenue Code	250
Min. Negotiated Rate	$699.30
Max. Negotiated Rate	$999.00
Rate for Payer: Aetna Commercial	$949.05
Rate for Payer: Aetna Medicare	$899.10
Rate for Payer: BCBS MT CHIP	$899.10
Rate for Payer: BCBS MT Closed Plan Network	$949.05
Rate for Payer: BCBS MT HealthLink	$899.10
Rate for Payer: BCBS MT Medicare	$899.10
Rate for Payer: BCBS MT POS	$949.05
Rate for Payer: BCBS MT Traditional	$999.00
Rate for Payer: Cash Price	$899.10
Rate for Payer: Cigna Commercial	$949.05
Rate for Payer: Cigna Medicare	$899.10
Rate for Payer: Medicaid All Medicaid	$919.08
Rate for Payer: Medicare All Medicare	$699.30
Rate for Payer: Monida Allegiance	$949.05
Rate for Payer: Monida First Choice Health	$969.03
Rate for Payer: Monida Montana Health Co-op	$949.05
Rate for Payer: Monida PacificSource	$949.05

IPRATROPIUM HFA INH (17 MCG) NF

Facility

$700.00

Service Code	NDC 00597008717
Hospital Charge Code	3007298
Hospital Revenue Code	250
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

IPRATROPIUM HFA INH (17 MCG) NF

Facility

$700.00

Service Code	NDC 00597008717
Hospital Charge Code	3007298
Hospital Revenue Code	250
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

IPRATROPIUM NEB [0.02 %] SLN

Facility

$8.00

Service Code	HCPCS J7644
Hospital Charge Code	3000238
Hospital Revenue Code	259
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

IPRATROPIUM NEB [0.02 %] SLN

Facility

$8.00

Service Code	HCPCS J7644
Hospital Charge Code	3000238
Hospital Revenue Code	259
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

IRBESARTAN [75MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000503
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

IRBESARTAN [75MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000503
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

IRON ASSAY

Facility

$90.00

Hospital Charge Code	90197101
Hospital Revenue Code	270
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

IRON ASSAY

Facility

$90.00

Hospital Charge Code	90197101
Hospital Revenue Code	270
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

IRON DEXTRAN INJ [100 MG/2 ML]

Facility

$144.00

Service Code	HCPCS J1750
Hospital Charge Code	3000587
Hospital Revenue Code	636
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

IRON DEXTRAN INJ [100 MG/2 ML]

Facility

$144.00

Service Code	HCPCS J1750
Hospital Charge Code	3000587
Hospital Revenue Code	636
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

IRON SUCROSE INJ 20MG/ML (10ML VIAL)

Facility

$443.60

Service Code	HCPCS J1756
Hospital Charge Code	3007258
Hospital Revenue Code	250
Min. Negotiated Rate	$310.52
Max. Negotiated Rate	$443.60
Rate for Payer: Aetna Commercial	$421.42
Rate for Payer: Aetna Medicare	$399.24
Rate for Payer: BCBS MT CHIP	$399.24
Rate for Payer: BCBS MT Closed Plan Network	$421.42
Rate for Payer: BCBS MT HealthLink	$399.24
Rate for Payer: BCBS MT Medicare	$399.24
Rate for Payer: BCBS MT POS	$421.42
Rate for Payer: BCBS MT Traditional	$443.60
Rate for Payer: Cash Price	$399.24
Rate for Payer: Cigna Commercial	$421.42
Rate for Payer: Cigna Medicare	$399.24
Rate for Payer: Medicaid All Medicaid	$408.11
Rate for Payer: Medicare All Medicare	$310.52
Rate for Payer: Monida Allegiance	$421.42
Rate for Payer: Monida First Choice Health	$430.29
Rate for Payer: Monida Montana Health Co-op	$421.42
Rate for Payer: Monida PacificSource	$421.42

IRON SUCROSE INJ 20MG/ML (10ML VIAL)

Facility

$443.60

Service Code	HCPCS J1756
Hospital Charge Code	3007258
Hospital Revenue Code	250
Min. Negotiated Rate	$310.52
Max. Negotiated Rate	$443.60
Rate for Payer: Aetna Commercial	$421.42
Rate for Payer: Aetna Medicare	$399.24
Rate for Payer: BCBS MT CHIP	$399.24
Rate for Payer: BCBS MT Closed Plan Network	$421.42
Rate for Payer: BCBS MT HealthLink	$399.24
Rate for Payer: BCBS MT Medicare	$399.24
Rate for Payer: BCBS MT POS	$421.42
Rate for Payer: BCBS MT Traditional	$443.60
Rate for Payer: Cash Price	$399.24
Rate for Payer: Cigna Commercial	$421.42
Rate for Payer: Cigna Medicare	$399.24
Rate for Payer: Medicaid All Medicaid	$408.11
Rate for Payer: Medicare All Medicare	$310.52
Rate for Payer: Monida Allegiance	$421.42
Rate for Payer: Monida First Choice Health	$430.29
Rate for Payer: Monida Montana Health Co-op	$421.42
Rate for Payer: Monida PacificSource	$421.42

.IRON, TOTAL

Facility

$56.00

Service Code	HCPCS 83540
Hospital Charge Code	4035401
Hospital Revenue Code	300
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

.IRON, TOTAL

Facility

$56.00

Service Code	HCPCS 83540
Hospital Charge Code	4035401
Hospital Revenue Code	300
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

IRON, TOTAL (001339)

Facility

$56.00

Service Code	HCPCS 83540
Hospital Charge Code	4083540
Hospital Revenue Code	300
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

IRON, TOTAL (001339)

Facility

$56.00

Service Code	HCPCS 83540
Hospital Charge Code	4083540
Hospital Revenue Code	300
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

IRRIGATION OF IMPLANTED VENOUS ACCESS TR

Facility

$143.00

Service Code	HCPCS 96523
Hospital Charge Code	1096523
Hospital Revenue Code	761
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$135.85
Rate for Payer: Aetna Medicare	$128.70
Rate for Payer: BCBS MT CHIP	$128.70
Rate for Payer: BCBS MT Closed Plan Network	$135.85
Rate for Payer: BCBS MT HealthLink	$128.70
Rate for Payer: BCBS MT Medicare	$128.70
Rate for Payer: BCBS MT POS	$135.85
Rate for Payer: BCBS MT Traditional	$143.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cigna Commercial	$135.85
Rate for Payer: Cigna Medicare	$128.70
Rate for Payer: Medicaid All Medicaid	$131.56
Rate for Payer: Medicare All Medicare	$100.10
Rate for Payer: Monida Allegiance	$135.85
Rate for Payer: Monida First Choice Health	$138.71
Rate for Payer: Monida Montana Health Co-op	$135.85
Rate for Payer: Monida PacificSource	$135.85

Know your out-of-pocket cost for care.

All Charges