Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

AZITHROMYCIN SUSP [100 MG/5 ML]

Facility

$112.00

Service Code	HCPCS J3490
Hospital Charge Code	3000045
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

AZITHROMYCIN TAB [250 MG]

Facility

$8.00

Service Code	HCPCS Q0144
Hospital Charge Code	3000046
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

AZITHROMYCIN TAB [250 MG]

Facility

$8.00

Service Code	HCPCS Q0144
Hospital Charge Code	3000046
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

AZITHROMYCIN Z-PACK TAB [250 MG] 6 TABS

Facility

$150.00

Service Code	HCPCS Q0144
Hospital Charge Code	3000047
Hospital Revenue Code	250
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

AZITHROMYCIN Z-PACK TAB [250 MG] 6 TABS

Facility

$150.00

Service Code	HCPCS Q0144
Hospital Charge Code	3000047
Hospital Revenue Code	250
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

AZTREONAM 1 GM VIAL

Facility

$138.60

Service Code	HCPCS J0457
Hospital Charge Code	3007406
Hospital Revenue Code	250
Min. Negotiated Rate	$97.02
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna Commercial	$131.67
Rate for Payer: Aetna Medicare	$124.74
Rate for Payer: BCBS MT CHIP	$124.74
Rate for Payer: BCBS MT Closed Plan Network	$131.67
Rate for Payer: BCBS MT HealthLink	$124.74
Rate for Payer: BCBS MT Medicare	$124.74
Rate for Payer: BCBS MT POS	$131.67
Rate for Payer: BCBS MT Traditional	$138.60
Rate for Payer: Cash Price	$124.74
Rate for Payer: Cigna Commercial	$131.67
Rate for Payer: Cigna Medicare	$124.74
Rate for Payer: Medicaid All Medicaid	$127.51
Rate for Payer: Medicare All Medicare	$97.02
Rate for Payer: Monida Allegiance	$131.67
Rate for Payer: Monida First Choice Health	$134.44
Rate for Payer: Monida Montana Health Co-op	$131.67
Rate for Payer: Monida PacificSource	$131.67

AZTREONAM 1 GM VIAL

Facility

$138.60

Service Code	HCPCS J0457
Hospital Charge Code	3007406
Hospital Revenue Code	250
Min. Negotiated Rate	$97.02
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna Commercial	$131.67
Rate for Payer: Aetna Medicare	$124.74
Rate for Payer: BCBS MT CHIP	$124.74
Rate for Payer: BCBS MT Closed Plan Network	$131.67
Rate for Payer: BCBS MT HealthLink	$124.74
Rate for Payer: BCBS MT Medicare	$124.74
Rate for Payer: BCBS MT POS	$131.67
Rate for Payer: BCBS MT Traditional	$138.60
Rate for Payer: Cash Price	$124.74
Rate for Payer: Cigna Commercial	$131.67
Rate for Payer: Cigna Medicare	$124.74
Rate for Payer: Medicaid All Medicaid	$127.51
Rate for Payer: Medicare All Medicare	$97.02
Rate for Payer: Monida Allegiance	$131.67
Rate for Payer: Monida First Choice Health	$134.44
Rate for Payer: Monida Montana Health Co-op	$131.67
Rate for Payer: Monida PacificSource	$131.67

BACLOFEN TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000048
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

BACLOFEN TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000048
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

BAIR HUGGER BLANKET

Facility

$32.00

Hospital Charge Code	80040159
Hospital Revenue Code	270
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

BAIR HUGGER BLANKET

Facility

$32.00

Hospital Charge Code	80040159
Hospital Revenue Code	270
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

BASIC METABOLIC PANEL

Facility

$158.00

Service Code	HCPCS 80048
Hospital Charge Code	4080048
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

BASIC METABOLIC PANEL

Facility

$158.00

Service Code	HCPCS 80048
Hospital Charge Code	4080048
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

BB ADMINISTRATION BLOOD/DAY

Facility

$630.00

Service Code	HCPCS 36430
Hospital Charge Code	4330041
Hospital Revenue Code	391
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

BB ADMINISTRATION BLOOD/DAY

Facility

$630.00

Service Code	HCPCS 36430
Hospital Charge Code	4330041
Hospital Revenue Code	391
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

BB BLOOD PACKED CELLS

Facility

$659.00

Service Code	HCPCS P9016
Hospital Charge Code	4330040
Hospital Revenue Code	381
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

BB BLOOD PACKED CELLS

Facility

$659.00

Service Code	HCPCS P9016
Hospital Charge Code	4330040
Hospital Revenue Code	381
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

.B CELLS, TOTAL COUNT

Facility

$125.00

Service Code	HCPCS 86355
Hospital Charge Code	4086355
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

.B CELLS, TOTAL COUNT

Facility

$125.00

Service Code	HCPCS 86355
Hospital Charge Code	4086355
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

.B CELLS, TOTAL COUNT (506049)

Facility

$303.00

Service Code	HCPCS 86355
Hospital Charge Code	4063552
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

.B CELLS, TOTAL COUNT (506049)

Facility

$303.00

Service Code	HCPCS 86355
Hospital Charge Code	4063552
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

BEBTELOVIMAB INTRAVENOUS INJ &MONITORING

Facility

$368.00

Service Code	HCPCS M0222
Hospital Charge Code	3007174
Hospital Revenue Code	250
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

BEBTELOVIMAB INTRAVENOUS INJ &MONITORING

Facility

$368.00

Service Code	HCPCS M0222
Hospital Charge Code	3007174
Hospital Revenue Code	250
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

BENZION SWAB

Facility

$4.00

Hospital Charge Code	80040107
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

BENZION SWAB

Facility

$4.00

Hospital Charge Code	80040107
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

Know your out-of-pocket cost for care.

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