Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

BENZONATATE CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000050
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

BENZONATATE CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000050
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

.BETA-2 GLYCOPROTEIN 1 AB, IGA

Facility

$39.00

Service Code	HCPCS 86146
Hospital Charge Code	4061461
Hospital Revenue Code	307
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

.BETA-2 GLYCOPROTEIN 1 AB, IGA

Facility

$39.00

Service Code	HCPCS 86146
Hospital Charge Code	4061461
Hospital Revenue Code	307
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

BETA-2 GLYCOPROTEIN 1 AB, IGG (163882)

Facility

$39.00

Service Code	HCPCS 86146
Hospital Charge Code	4086146
Hospital Revenue Code	307
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

BETA-2 GLYCOPROTEIN 1 AB, IGG (163882)

Facility

$39.00

Service Code	HCPCS 86146
Hospital Charge Code	4086146
Hospital Revenue Code	307
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

BETA-2 GLYCOPROTEIN 1 AB, IGM (163908)

Facility

$39.00

Service Code	HCPCS 86146
Hospital Charge Code	4000049
Hospital Revenue Code	307
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

BETA-2 GLYCOPROTEIN 1 AB, IGM (163908)

Facility

$39.00

Service Code	HCPCS 86146
Hospital Charge Code	4000049
Hospital Revenue Code	307
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

BETA 2 MICROGLOBULIN (010181)

Facility

$45.00

Service Code	HCPCS 82232
Hospital Charge Code	4082232
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

BETA 2 MICROGLOBULIN (010181)

Facility

$45.00

Service Code	HCPCS 82232
Hospital Charge Code	4082232
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

BETA-2 TRANSFERRIN (829030)

Facility

$361.00

Service Code	HCPCS 86335
Hospital Charge Code	4086335
Hospital Revenue Code	307
Min. Negotiated Rate	$252.70
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.95
Rate for Payer: Aetna Medicare	$324.90
Rate for Payer: BCBS MT CHIP	$324.90
Rate for Payer: BCBS MT Closed Plan Network	$342.95
Rate for Payer: BCBS MT HealthLink	$324.90
Rate for Payer: BCBS MT Medicare	$324.90
Rate for Payer: BCBS MT POS	$342.95
Rate for Payer: BCBS MT Traditional	$361.00
Rate for Payer: Cash Price	$324.90
Rate for Payer: Cigna Commercial	$342.95
Rate for Payer: Cigna Medicare	$324.90
Rate for Payer: Medicaid All Medicaid	$332.12
Rate for Payer: Medicare All Medicare	$252.70
Rate for Payer: Monida Allegiance	$342.95
Rate for Payer: Monida First Choice Health	$350.17
Rate for Payer: Monida Montana Health Co-op	$342.95
Rate for Payer: Monida PacificSource	$342.95

BETA-2 TRANSFERRIN (829030)

Facility

$361.00

Service Code	HCPCS 86335
Hospital Charge Code	4086335
Hospital Revenue Code	307
Min. Negotiated Rate	$252.70
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.95
Rate for Payer: Aetna Medicare	$324.90
Rate for Payer: BCBS MT CHIP	$324.90
Rate for Payer: BCBS MT Closed Plan Network	$342.95
Rate for Payer: BCBS MT HealthLink	$324.90
Rate for Payer: BCBS MT Medicare	$324.90
Rate for Payer: BCBS MT POS	$342.95
Rate for Payer: BCBS MT Traditional	$361.00
Rate for Payer: Cash Price	$324.90
Rate for Payer: Cigna Commercial	$342.95
Rate for Payer: Cigna Medicare	$324.90
Rate for Payer: Medicaid All Medicaid	$332.12
Rate for Payer: Medicare All Medicare	$252.70
Rate for Payer: Monida Allegiance	$342.95
Rate for Payer: Monida First Choice Health	$350.17
Rate for Payer: Monida Montana Health Co-op	$342.95
Rate for Payer: Monida PacificSource	$342.95

BETA-HYDROXYBUTYRATE (503610)

Facility

$215.00

Service Code	HCPCS 82010
Hospital Charge Code	4082010
Hospital Revenue Code	300
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

BETA-HYDROXYBUTYRATE (503610)

Facility

$215.00

Service Code	HCPCS 82010
Hospital Charge Code	4082010
Hospital Revenue Code	300
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

BETAMETHASONE INJ [6 MG/ML]

Facility

$135.00

Service Code	HCPCS J0702
Hospital Charge Code	3000051
Hospital Revenue Code	259
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

BETAMETHASONE INJ [6 MG/ML]

Facility

$135.00

Service Code	HCPCS J0702
Hospital Charge Code	3000051
Hospital Revenue Code	259
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

BIKTARVY 50MG/200MG/25MG TABLET

Facility

$440.25

Service Code	NDC 61958250101
Hospital Charge Code	3007362
Hospital Revenue Code	250
Min. Negotiated Rate	$308.18
Max. Negotiated Rate	$440.25
Rate for Payer: Aetna Commercial	$418.24
Rate for Payer: Aetna Medicare	$396.22
Rate for Payer: BCBS MT CHIP	$396.22
Rate for Payer: BCBS MT Closed Plan Network	$418.24
Rate for Payer: BCBS MT HealthLink	$396.22
Rate for Payer: BCBS MT Medicare	$396.22
Rate for Payer: BCBS MT POS	$418.24
Rate for Payer: BCBS MT Traditional	$440.25
Rate for Payer: Cash Price	$396.23
Rate for Payer: Cigna Commercial	$418.24
Rate for Payer: Cigna Medicare	$396.22
Rate for Payer: Medicaid All Medicaid	$405.03
Rate for Payer: Medicare All Medicare	$308.18
Rate for Payer: Monida Allegiance	$418.24
Rate for Payer: Monida First Choice Health	$427.04
Rate for Payer: Monida Montana Health Co-op	$418.24
Rate for Payer: Monida PacificSource	$418.24

BIKTARVY 50MG/200MG/25MG TABLET

Facility

$440.25

Service Code	NDC 61958250101
Hospital Charge Code	3007362
Hospital Revenue Code	250
Min. Negotiated Rate	$308.18
Max. Negotiated Rate	$440.25
Rate for Payer: Aetna Commercial	$418.24
Rate for Payer: Aetna Medicare	$396.22
Rate for Payer: BCBS MT CHIP	$396.22
Rate for Payer: BCBS MT Closed Plan Network	$418.24
Rate for Payer: BCBS MT HealthLink	$396.22
Rate for Payer: BCBS MT Medicare	$396.22
Rate for Payer: BCBS MT POS	$418.24
Rate for Payer: BCBS MT Traditional	$440.25
Rate for Payer: Cash Price	$396.23
Rate for Payer: Cigna Commercial	$418.24
Rate for Payer: Cigna Medicare	$396.22
Rate for Payer: Medicaid All Medicaid	$405.03
Rate for Payer: Medicare All Medicare	$308.18
Rate for Payer: Monida Allegiance	$418.24
Rate for Payer: Monida First Choice Health	$427.04
Rate for Payer: Monida Montana Health Co-op	$418.24
Rate for Payer: Monida PacificSource	$418.24

BILIRUBIN, TOTAL

Facility

$61.00

Service Code	HCPCS 82247
Hospital Charge Code	4082247
Hospital Revenue Code	301
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

BILIRUBIN, TOTAL

Facility

$61.00

Service Code	HCPCS 82247
Hospital Charge Code	4082247
Hospital Revenue Code	301
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

BIOPSY-SKIN SINGLE LESION- ER

Facility

$175.00

Service Code	HCPCS 11102
Hospital Charge Code	1011100
Hospital Revenue Code	450
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

BIOPSY-SKIN SINGLE LESION- ER

Facility

$175.00

Service Code	HCPCS 11102
Hospital Charge Code	1011100
Hospital Revenue Code	450
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

BIOTENE DRY MOUTH LOZENGE NF

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000564
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

BIOTENE DRY MOUTH LOZENGE NF

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000564
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

BIOTENE DRY MOUTH RINSE 118ML

Facility

$5.00

Service Code	NDC 48582000330
Hospital Charge Code	3007209
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

Know your out-of-pocket cost for care.

All Charges