Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PYRIDOSTIGMINE BROMIDE TAB [60 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000556
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

PYRIDOSTIGMINE BROMIDE TAB [60 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000556
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

QUANTIFERON-TB GOLD PLUS (182893)

Facility

$131.00

Service Code	HCPCS 86480
Hospital Charge Code	4086480
Hospital Revenue Code	300
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$131.00
Rate for Payer: Aetna Commercial	$124.45
Rate for Payer: Aetna Medicare	$117.90
Rate for Payer: BCBS MT CHIP	$117.90
Rate for Payer: BCBS MT Closed Plan Network	$124.45
Rate for Payer: BCBS MT HealthLink	$117.90
Rate for Payer: BCBS MT Medicare	$117.90
Rate for Payer: BCBS MT POS	$124.45
Rate for Payer: BCBS MT Traditional	$131.00
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial	$124.45
Rate for Payer: Cigna Medicare	$117.90
Rate for Payer: Medicaid All Medicaid	$120.52
Rate for Payer: Medicare All Medicare	$91.70
Rate for Payer: Monida Allegiance	$124.45
Rate for Payer: Monida First Choice Health	$127.07
Rate for Payer: Monida Montana Health Co-op	$124.45
Rate for Payer: Monida PacificSource	$124.45

QUANTIFERON-TB GOLD PLUS (182893)

Facility

$131.00

Service Code	HCPCS 86480
Hospital Charge Code	4086480
Hospital Revenue Code	300
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$131.00
Rate for Payer: Aetna Commercial	$124.45
Rate for Payer: Aetna Medicare	$117.90
Rate for Payer: BCBS MT CHIP	$117.90
Rate for Payer: BCBS MT Closed Plan Network	$124.45
Rate for Payer: BCBS MT HealthLink	$117.90
Rate for Payer: BCBS MT Medicare	$117.90
Rate for Payer: BCBS MT POS	$124.45
Rate for Payer: BCBS MT Traditional	$131.00
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial	$124.45
Rate for Payer: Cigna Medicare	$117.90
Rate for Payer: Medicaid All Medicaid	$120.52
Rate for Payer: Medicare All Medicare	$91.70
Rate for Payer: Monida Allegiance	$124.45
Rate for Payer: Monida First Choice Health	$127.07
Rate for Payer: Monida Montana Health Co-op	$124.45
Rate for Payer: Monida PacificSource	$124.45

QUETIAPINE TAB [100 MG]

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	3000410
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

QUETIAPINE TAB [100 MG]

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	3000410
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

QUETIAPINE TAB [25 MG]

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000411
Hospital Revenue Code	250
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

QUETIAPINE TAB [25 MG]

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000411
Hospital Revenue Code	250
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

RABIES IMMUNE GLOBULIN [150IU/ML] 2ML

Facility

$1,253.00

Service Code	HCPCS 90375
Hospital Charge Code	3000566
Hospital Revenue Code	250
Min. Negotiated Rate	$877.10
Max. Negotiated Rate	$1,253.00
Rate for Payer: Aetna Commercial	$1,190.35
Rate for Payer: Aetna Medicare	$1,127.70
Rate for Payer: BCBS MT CHIP	$1,127.70
Rate for Payer: BCBS MT Closed Plan Network	$1,190.35
Rate for Payer: BCBS MT HealthLink	$1,127.70
Rate for Payer: BCBS MT Medicare	$1,127.70
Rate for Payer: BCBS MT POS	$1,190.35
Rate for Payer: BCBS MT Traditional	$1,253.00
Rate for Payer: Cash Price	$1,127.70
Rate for Payer: Cigna Commercial	$1,190.35
Rate for Payer: Cigna Medicare	$1,127.70
Rate for Payer: Medicaid All Medicaid	$1,152.76
Rate for Payer: Medicare All Medicare	$877.10
Rate for Payer: Monida Allegiance	$1,190.35
Rate for Payer: Monida First Choice Health	$1,215.41
Rate for Payer: Monida Montana Health Co-op	$1,190.35
Rate for Payer: Monida PacificSource	$1,190.35

RABIES IMMUNE GLOBULIN [150IU/ML] 2ML

Facility

$1,253.00

Service Code	HCPCS 90375
Hospital Charge Code	3000566
Hospital Revenue Code	250
Min. Negotiated Rate	$877.10
Max. Negotiated Rate	$1,253.00
Rate for Payer: Aetna Commercial	$1,190.35
Rate for Payer: Aetna Medicare	$1,127.70
Rate for Payer: BCBS MT CHIP	$1,127.70
Rate for Payer: BCBS MT Closed Plan Network	$1,190.35
Rate for Payer: BCBS MT HealthLink	$1,127.70
Rate for Payer: BCBS MT Medicare	$1,127.70
Rate for Payer: BCBS MT POS	$1,190.35
Rate for Payer: BCBS MT Traditional	$1,253.00
Rate for Payer: Cash Price	$1,127.70
Rate for Payer: Cigna Commercial	$1,190.35
Rate for Payer: Cigna Medicare	$1,127.70
Rate for Payer: Medicaid All Medicaid	$1,152.76
Rate for Payer: Medicare All Medicare	$877.10
Rate for Payer: Monida Allegiance	$1,190.35
Rate for Payer: Monida First Choice Health	$1,215.41
Rate for Payer: Monida Montana Health Co-op	$1,190.35
Rate for Payer: Monida PacificSource	$1,190.35

RACEPINEPHRINE NEB SLN [2.25%]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000412
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

RACEPINEPHRINE NEB SLN [2.25%]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000412
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

RALOXIFENE HCL TAB [60 MG] NON FORMULARY

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000413
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

RALOXIFENE HCL TAB [60 MG] NON FORMULARY

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000413
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

RED BLOOD CELL COUNT, BLOOD

Facility

$23.00

Service Code	HCPCS 85041
Hospital Charge Code	4085041
Hospital Revenue Code	305
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

RED BLOOD CELL COUNT, BLOOD

Facility

$23.00

Service Code	HCPCS 85041
Hospital Charge Code	4085041
Hospital Revenue Code	305
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

REMDESIVIR INJ [100 MG]

Facility

$918.00

Service Code	HCPCS J3490
Hospital Charge Code	3000414
Hospital Revenue Code	250
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$918.00
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: Aetna Medicare	$826.20
Rate for Payer: BCBS MT CHIP	$826.20
Rate for Payer: BCBS MT Closed Plan Network	$872.10
Rate for Payer: BCBS MT HealthLink	$826.20
Rate for Payer: BCBS MT Medicare	$826.20
Rate for Payer: BCBS MT POS	$872.10
Rate for Payer: BCBS MT Traditional	$918.00
Rate for Payer: Cash Price	$826.20
Rate for Payer: Cigna Commercial	$872.10
Rate for Payer: Cigna Medicare	$826.20
Rate for Payer: Medicaid All Medicaid	$844.56
Rate for Payer: Medicare All Medicare	$642.60
Rate for Payer: Monida Allegiance	$872.10
Rate for Payer: Monida First Choice Health	$890.46
Rate for Payer: Monida Montana Health Co-op	$872.10
Rate for Payer: Monida PacificSource	$872.10

REMDESIVIR INJ [100 MG]

Facility

$918.00

Service Code	HCPCS J3490
Hospital Charge Code	3000414
Hospital Revenue Code	250
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$918.00
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: Aetna Medicare	$826.20
Rate for Payer: BCBS MT CHIP	$826.20
Rate for Payer: BCBS MT Closed Plan Network	$872.10
Rate for Payer: BCBS MT HealthLink	$826.20
Rate for Payer: BCBS MT Medicare	$826.20
Rate for Payer: BCBS MT POS	$872.10
Rate for Payer: BCBS MT Traditional	$918.00
Rate for Payer: Cash Price	$826.20
Rate for Payer: Cigna Commercial	$872.10
Rate for Payer: Cigna Medicare	$826.20
Rate for Payer: Medicaid All Medicaid	$844.56
Rate for Payer: Medicare All Medicare	$642.60
Rate for Payer: Monida Allegiance	$872.10
Rate for Payer: Monida First Choice Health	$890.46
Rate for Payer: Monida Montana Health Co-op	$872.10
Rate for Payer: Monida PacificSource	$872.10

REMOTE 30 DAY ECG REV/REPORT CON, REC, R

Facility

$360.00

Service Code	HCPCS 93270
Hospital Charge Code	193270
Hospital Revenue Code	731
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

REMOTE 30 DAY ECG REV/REPORT CON, REC, R

Facility

$360.00

Service Code	HCPCS 93270
Hospital Charge Code	193270
Hospital Revenue Code	731
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

RENAL FUNCTION PANEL

Facility

$159.00

Service Code	HCPCS 80069
Hospital Charge Code	4080069
Hospital Revenue Code	300
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

RENAL FUNCTION PANEL

Facility

$159.00

Service Code	HCPCS 80069
Hospital Charge Code	4080069
Hospital Revenue Code	300
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

RENIN ACTIVITY (002006)

Facility

$68.00

Service Code	HCPCS 84244
Hospital Charge Code	4084244
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

RENIN ACTIVITY (002006)

Facility

$68.00

Service Code	HCPCS 84244
Hospital Charge Code	4084244
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

RESPIRATORY PANEL, NAD

Facility

$578.00

Service Code	HCPCS 0202U
Hospital Charge Code	4050202
Hospital Revenue Code	300
Min. Negotiated Rate	$404.60
Max. Negotiated Rate	$578.00
Rate for Payer: Aetna Commercial	$549.10
Rate for Payer: Aetna Medicare	$520.20
Rate for Payer: BCBS MT CHIP	$520.20
Rate for Payer: BCBS MT Closed Plan Network	$549.10
Rate for Payer: BCBS MT HealthLink	$520.20
Rate for Payer: BCBS MT Medicare	$520.20
Rate for Payer: BCBS MT POS	$549.10
Rate for Payer: BCBS MT Traditional	$578.00
Rate for Payer: Cash Price	$520.20
Rate for Payer: Cigna Commercial	$549.10
Rate for Payer: Cigna Medicare	$520.20
Rate for Payer: Medicaid All Medicaid	$531.76
Rate for Payer: Medicare All Medicare	$404.60
Rate for Payer: Monida Allegiance	$549.10
Rate for Payer: Monida First Choice Health	$560.66
Rate for Payer: Monida Montana Health Co-op	$549.10
Rate for Payer: Monida PacificSource	$549.10

Know your out-of-pocket cost for care.

All Charges