Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ARM SLING XL

Facility

$15.00

Hospital Charge Code	2893187
Hospital Revenue Code	290
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

ARM SLING XL

Facility

$15.00

Hospital Charge Code	2893187
Hospital Revenue Code	290
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

.ARTERIAL PUNCTURE

Facility

$188.00

Service Code	HCPCS 36600
Hospital Charge Code	4000078
Hospital Revenue Code	300
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$188.00
Rate for Payer: Aetna Commercial	$178.60
Rate for Payer: Aetna Medicare	$169.20
Rate for Payer: BCBS MT CHIP	$169.20
Rate for Payer: BCBS MT Closed Plan Network	$178.60
Rate for Payer: BCBS MT HealthLink	$169.20
Rate for Payer: BCBS MT Medicare	$169.20
Rate for Payer: BCBS MT POS	$178.60
Rate for Payer: BCBS MT Traditional	$188.00
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cigna Commercial	$178.60
Rate for Payer: Cigna Medicare	$169.20
Rate for Payer: Medicaid All Medicaid	$172.96
Rate for Payer: Medicare All Medicare	$131.60
Rate for Payer: Monida Allegiance	$178.60
Rate for Payer: Monida First Choice Health	$182.36
Rate for Payer: Monida Montana Health Co-op	$178.60
Rate for Payer: Monida PacificSource	$178.60

.ARTERIAL PUNCTURE

Facility

$188.00

Service Code	HCPCS 36600
Hospital Charge Code	4000078
Hospital Revenue Code	300
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$188.00
Rate for Payer: Aetna Commercial	$178.60
Rate for Payer: Aetna Medicare	$169.20
Rate for Payer: BCBS MT CHIP	$169.20
Rate for Payer: BCBS MT Closed Plan Network	$178.60
Rate for Payer: BCBS MT HealthLink	$169.20
Rate for Payer: BCBS MT Medicare	$169.20
Rate for Payer: BCBS MT POS	$178.60
Rate for Payer: BCBS MT Traditional	$188.00
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cigna Commercial	$178.60
Rate for Payer: Cigna Medicare	$169.20
Rate for Payer: Medicaid All Medicaid	$172.96
Rate for Payer: Medicare All Medicare	$131.60
Rate for Payer: Monida Allegiance	$178.60
Rate for Payer: Monida First Choice Health	$182.36
Rate for Payer: Monida Montana Health Co-op	$178.60
Rate for Payer: Monida PacificSource	$178.60

ASO ANTIBODIES (006031)

Facility

$61.00

Service Code	HCPCS 86060
Hospital Charge Code	4086060
Hospital Revenue Code	302
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$61.00
Rate for Payer: Aetna Commercial	$57.95
Rate for Payer: Aetna Medicare	$54.90
Rate for Payer: BCBS MT CHIP	$54.90
Rate for Payer: BCBS MT Closed Plan Network	$57.95
Rate for Payer: BCBS MT HealthLink	$54.90
Rate for Payer: BCBS MT Medicare	$54.90
Rate for Payer: BCBS MT POS	$57.95
Rate for Payer: BCBS MT Traditional	$61.00
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cigna Commercial	$57.95
Rate for Payer: Cigna Medicare	$54.90
Rate for Payer: Medicaid All Medicaid	$56.12
Rate for Payer: Medicare All Medicare	$42.70
Rate for Payer: Monida Allegiance	$57.95
Rate for Payer: Monida First Choice Health	$59.17
Rate for Payer: Monida Montana Health Co-op	$57.95
Rate for Payer: Monida PacificSource	$57.95

ASO ANTIBODIES (006031)

Facility

$61.00

Service Code	HCPCS 86060
Hospital Charge Code	4086060
Hospital Revenue Code	302
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$61.00
Rate for Payer: Aetna Commercial	$57.95
Rate for Payer: Aetna Medicare	$54.90
Rate for Payer: BCBS MT CHIP	$54.90
Rate for Payer: BCBS MT Closed Plan Network	$57.95
Rate for Payer: BCBS MT HealthLink	$54.90
Rate for Payer: BCBS MT Medicare	$54.90
Rate for Payer: BCBS MT POS	$57.95
Rate for Payer: BCBS MT Traditional	$61.00
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cigna Commercial	$57.95
Rate for Payer: Cigna Medicare	$54.90
Rate for Payer: Medicaid All Medicaid	$56.12
Rate for Payer: Medicare All Medicare	$42.70
Rate for Payer: Monida Allegiance	$57.95
Rate for Payer: Monida First Choice Health	$59.17
Rate for Payer: Monida Montana Health Co-op	$57.95
Rate for Payer: Monida PacificSource	$57.95

ASPERGILLUS ANTIGEN

Facility

$165.00

Service Code	HCPCS 87305
Hospital Charge Code	4087900
Hospital Revenue Code	300
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

ASPERGILLUS ANTIGEN

Facility

$165.00

Service Code	HCPCS 87305
Hospital Charge Code	4087900
Hospital Revenue Code	300
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

ASPERGILLUS FUMIGATUS AB IGG

Facility

$135.00

Service Code	HCPCS 86606
Hospital Charge Code	4087899
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

ASPERGILLUS FUMIGATUS AB IGG

Facility

$135.00

Service Code	HCPCS 86606
Hospital Charge Code	4087899
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

ASPIRIN CHEW TAB [81 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000036
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

ASPIRIN CHEW TAB [81 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000036
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

ASPIRIN EC TAB [81 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000037
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

ASPIRIN EC TAB [81 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000037
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

ASPIRIN TAB [325 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000038
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

ASPIRIN TAB [325 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000038
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

ASSAY OF URINE SULFATE

Facility

$135.00

Service Code	HCPCS 84392
Hospital Charge Code	4084392
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

ASSAY OF URINE SULFATE

Facility

$135.00

Service Code	HCPCS 84392
Hospital Charge Code	4084392
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

AST

Facility

$65.00

Service Code	HCPCS 84450
Hospital Charge Code	4000042
Hospital Revenue Code	301
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

AST

Facility

$65.00

Service Code	HCPCS 84450
Hospital Charge Code	4000042
Hospital Revenue Code	301
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

ATENOLOL TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000039
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

ATENOLOL TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000039
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

ATORVASTATIN TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3007245
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

ATORVASTATIN TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3007245
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

ATORVASTATIN TAB [40 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000040
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