Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

ATROPINE INJ SYR [0.1 MG/ML] 10 ML

Facility

$26.00

Service Code	HCPCS J0461
Hospital Charge Code	3000041
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

ATROPINE INJ SYR [0.1 MG/ML] 10 ML

Facility

$26.00

Service Code	HCPCS J0461
Hospital Charge Code	3000041
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

ATROPINE OPTH [1 %] 5 ML

Facility

$146.00

Service Code	HCPCS J3490
Hospital Charge Code	3000042
Hospital Revenue Code	259
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$146.00
Rate for Payer: Aetna Commercial	$138.70
Rate for Payer: Aetna Medicare	$131.40
Rate for Payer: BCBS MT CHIP	$131.40
Rate for Payer: BCBS MT Closed Plan Network	$138.70
Rate for Payer: BCBS MT HealthLink	$131.40
Rate for Payer: BCBS MT Medicare	$131.40
Rate for Payer: BCBS MT POS	$138.70
Rate for Payer: BCBS MT Traditional	$146.00
Rate for Payer: Cash Price	$131.40
Rate for Payer: Cigna Commercial	$138.70
Rate for Payer: Cigna Medicare	$131.40
Rate for Payer: Medicaid All Medicaid	$134.32
Rate for Payer: Medicare All Medicare	$102.20
Rate for Payer: Monida Allegiance	$138.70
Rate for Payer: Monida First Choice Health	$141.62
Rate for Payer: Monida Montana Health Co-op	$138.70
Rate for Payer: Monida PacificSource	$138.70

ATROPINE OPTH [1 %] 5 ML

Facility

$146.00

Service Code	HCPCS J3490
Hospital Charge Code	3000042
Hospital Revenue Code	259
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$146.00
Rate for Payer: Aetna Commercial	$138.70
Rate for Payer: Aetna Medicare	$131.40
Rate for Payer: BCBS MT CHIP	$131.40
Rate for Payer: BCBS MT Closed Plan Network	$138.70
Rate for Payer: BCBS MT HealthLink	$131.40
Rate for Payer: BCBS MT Medicare	$131.40
Rate for Payer: BCBS MT POS	$138.70
Rate for Payer: BCBS MT Traditional	$146.00
Rate for Payer: Cash Price	$131.40
Rate for Payer: Cigna Commercial	$138.70
Rate for Payer: Cigna Medicare	$131.40
Rate for Payer: Medicaid All Medicaid	$134.32
Rate for Payer: Medicare All Medicare	$102.20
Rate for Payer: Monida Allegiance	$138.70
Rate for Payer: Monida First Choice Health	$141.62
Rate for Payer: Monida Montana Health Co-op	$138.70
Rate for Payer: Monida PacificSource	$138.70

ATROPINE SULFATE 0.4 MG/ML VIAL SDV

Facility

$32.00

Service Code	HCPCS J0461
Hospital Charge Code	3007068
Hospital Revenue Code	250
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

ATROPINE SULFATE 0.4 MG/ML VIAL SDV

Facility

$32.00

Service Code	HCPCS J0461
Hospital Charge Code	3007068
Hospital Revenue Code	250
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

ATTENDS YOUTH XSMALL

Facility

$43.00

Hospital Charge Code	80030413
Hospital Revenue Code	270
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

ATTENDS YOUTH XSMALL

Facility

$43.00

Hospital Charge Code	80030413
Hospital Revenue Code	270
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

AUDITMICRO LINR AMMONIA

Facility

$375.00

Hospital Charge Code	90197125
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

AUDITMICRO LINR AMMONIA

Facility

$375.00

Hospital Charge Code	90197125
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

AUDITMICRO LINR CARDIAC TNIH

Facility

$375.00

Hospital Charge Code	90197122
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

AUDITMICRO LINR CARDIAC TNIH

Facility

$375.00

Hospital Charge Code	90197122
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

AUDITMICRO LINR GEN CHEM

Facility

$395.00

Hospital Charge Code	90197121
Hospital Revenue Code	270
Min. Negotiated Rate	$276.50
Max. Negotiated Rate	$395.00
Rate for Payer: Aetna Commercial	$375.25
Rate for Payer: Aetna Medicare	$355.50
Rate for Payer: BCBS MT CHIP	$355.50
Rate for Payer: BCBS MT Closed Plan Network	$375.25
Rate for Payer: BCBS MT HealthLink	$355.50
Rate for Payer: BCBS MT Medicare	$355.50
Rate for Payer: BCBS MT POS	$375.25
Rate for Payer: BCBS MT Traditional	$395.00
Rate for Payer: Cash Price	$355.50
Rate for Payer: Cigna Commercial	$375.25
Rate for Payer: Cigna Medicare	$355.50
Rate for Payer: Medicaid All Medicaid	$363.40
Rate for Payer: Medicare All Medicare	$276.50
Rate for Payer: Monida Allegiance	$375.25
Rate for Payer: Monida First Choice Health	$383.15
Rate for Payer: Monida Montana Health Co-op	$375.25
Rate for Payer: Monida PacificSource	$375.25

AUDITMICRO LINR GEN CHEM

Facility

$395.00

Hospital Charge Code	90197121
Hospital Revenue Code	270
Min. Negotiated Rate	$276.50
Max. Negotiated Rate	$395.00
Rate for Payer: Aetna Commercial	$375.25
Rate for Payer: Aetna Medicare	$355.50
Rate for Payer: BCBS MT CHIP	$355.50
Rate for Payer: BCBS MT Closed Plan Network	$375.25
Rate for Payer: BCBS MT HealthLink	$355.50
Rate for Payer: BCBS MT Medicare	$355.50
Rate for Payer: BCBS MT POS	$375.25
Rate for Payer: BCBS MT Traditional	$395.00
Rate for Payer: Cash Price	$355.50
Rate for Payer: Cigna Commercial	$375.25
Rate for Payer: Cigna Medicare	$355.50
Rate for Payer: Medicaid All Medicaid	$363.40
Rate for Payer: Medicare All Medicare	$276.50
Rate for Payer: Monida Allegiance	$375.25
Rate for Payer: Monida First Choice Health	$383.15
Rate for Payer: Monida Montana Health Co-op	$375.25
Rate for Payer: Monida PacificSource	$375.25

AUDITMICRO LINR HBA1C

Facility

$350.00

Hospital Charge Code	90197123
Hospital Revenue Code	270
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

AUDITMICRO LINR HBA1C

Facility

$350.00

Hospital Charge Code	90197123
Hospital Revenue Code	270
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

AUDITMICRO LINR IMMUNOASSAY

Facility

$425.00

Hospital Charge Code	90197120
Hospital Revenue Code	270
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: BCBS MT CHIP	$382.50
Rate for Payer: BCBS MT Closed Plan Network	$403.75
Rate for Payer: BCBS MT HealthLink	$382.50
Rate for Payer: BCBS MT Medicare	$382.50
Rate for Payer: BCBS MT POS	$403.75
Rate for Payer: BCBS MT Traditional	$425.00
Rate for Payer: Cash Price	$382.50
Rate for Payer: Cigna Commercial	$403.75
Rate for Payer: Cigna Medicare	$382.50
Rate for Payer: Medicaid All Medicaid	$391.00
Rate for Payer: Medicare All Medicare	$297.50
Rate for Payer: Monida Allegiance	$403.75
Rate for Payer: Monida First Choice Health	$412.25
Rate for Payer: Monida Montana Health Co-op	$403.75
Rate for Payer: Monida PacificSource	$403.75

AUDITMICRO LINR IMMUNOASSAY

Facility

$425.00

Hospital Charge Code	90197120
Hospital Revenue Code	270
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: BCBS MT CHIP	$382.50
Rate for Payer: BCBS MT Closed Plan Network	$403.75
Rate for Payer: BCBS MT HealthLink	$382.50
Rate for Payer: BCBS MT Medicare	$382.50
Rate for Payer: BCBS MT POS	$403.75
Rate for Payer: BCBS MT Traditional	$425.00
Rate for Payer: Cash Price	$382.50
Rate for Payer: Cigna Commercial	$403.75
Rate for Payer: Cigna Medicare	$382.50
Rate for Payer: Medicaid All Medicaid	$391.00
Rate for Payer: Medicare All Medicare	$297.50
Rate for Payer: Monida Allegiance	$403.75
Rate for Payer: Monida First Choice Health	$412.25
Rate for Payer: Monida Montana Health Co-op	$403.75
Rate for Payer: Monida PacificSource	$403.75

AUDITMICRO LINR LIPIDS

Facility

$380.00

Hospital Charge Code	90197119
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

AUDITMICRO LINR LIPIDS

Facility

$380.00

Hospital Charge Code	90197119
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

AUDITMICRO LINR VITAMIN D

Facility

$200.00

Hospital Charge Code	90197124
Hospital Revenue Code	270
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: BCBS MT CHIP	$180.00
Rate for Payer: BCBS MT Closed Plan Network	$190.00
Rate for Payer: BCBS MT HealthLink	$180.00
Rate for Payer: BCBS MT Medicare	$180.00
Rate for Payer: BCBS MT POS	$190.00
Rate for Payer: BCBS MT Traditional	$200.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna Commercial	$190.00
Rate for Payer: Cigna Medicare	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

AUDITMICRO LINR VITAMIN D

Facility

$200.00

Hospital Charge Code	90197124
Hospital Revenue Code	270
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: BCBS MT CHIP	$180.00
Rate for Payer: BCBS MT Closed Plan Network	$190.00
Rate for Payer: BCBS MT HealthLink	$180.00
Rate for Payer: BCBS MT Medicare	$180.00
Rate for Payer: BCBS MT POS	$190.00
Rate for Payer: BCBS MT Traditional	$200.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna Commercial	$190.00
Rate for Payer: Cigna Medicare	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

AYR SALINE NASAL GEL

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

AYR SALINE NASAL GEL

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

Know your out-of-pocket cost for care.

All Charges