Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

METOLAZONE TAB [5 MG] NF

Facility

$13.50

Service Code	HCPCS J8499
Hospital Charge Code	3000320
Hospital Revenue Code	250
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.82
Rate for Payer: Aetna Medicare	$12.15
Rate for Payer: BCBS MT CHIP	$12.15
Rate for Payer: BCBS MT Closed Plan Network	$12.82
Rate for Payer: BCBS MT HealthLink	$12.15
Rate for Payer: BCBS MT Medicare	$12.15
Rate for Payer: BCBS MT POS	$12.82
Rate for Payer: BCBS MT Traditional	$13.50
Rate for Payer: Cash Price	$12.15
Rate for Payer: Cigna Commercial	$12.82
Rate for Payer: Cigna Medicare	$12.15
Rate for Payer: Medicaid All Medicaid	$12.42
Rate for Payer: Medicare All Medicare	$9.45
Rate for Payer: Monida Allegiance	$12.82
Rate for Payer: Monida First Choice Health	$13.10
Rate for Payer: Monida Montana Health Co-op	$12.82
Rate for Payer: Monida PacificSource	$12.82

METOPROLOL INJ [5 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J0616
Hospital Charge Code	3000321
Hospital Revenue Code	258
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

METOPROLOL INJ [5 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J0616
Hospital Charge Code	3000321
Hospital Revenue Code	258
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

METOPROLOL SUCC ER TAB [25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000322
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

METOPROLOL SUCC ER TAB [25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000322
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

METOPROLOL SUCC ER TAB [50 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000323
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

METOPROLOL SUCC ER TAB [50 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000323
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

METOPROLOL TART [25 MG] TAB

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000324
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

METOPROLOL TART [25 MG] TAB

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000324
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

METOPROLOL TART [50 MG] TAB NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000325
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

METOPROLOL TART [50 MG] TAB NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000325
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

METRONIDAZOLE/NACL [500MG/100ML] PREMIX

Facility

$8.00

Service Code	HCPCS J1836
Hospital Charge Code	3000327
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

METRONIDAZOLE/NACL [500MG/100ML] PREMIX

Facility

$8.00

Service Code	HCPCS J1836
Hospital Charge Code	3000327
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

METRONIDAZOLE TAB [500 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000326
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

METRONIDAZOLE TAB [500 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000326
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

MG REAGENT DF57 30 TESTS/FLE

Facility

$35.10

Hospital Charge Code	90195060
Hospital Revenue Code	270
Min. Negotiated Rate	$24.57
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna Commercial	$33.34
Rate for Payer: Aetna Medicare	$31.59
Rate for Payer: BCBS MT CHIP	$31.59
Rate for Payer: BCBS MT Closed Plan Network	$33.34
Rate for Payer: BCBS MT HealthLink	$31.59
Rate for Payer: BCBS MT Medicare	$31.59
Rate for Payer: BCBS MT POS	$33.34
Rate for Payer: BCBS MT Traditional	$35.10
Rate for Payer: Cash Price	$31.59
Rate for Payer: Cigna Commercial	$33.34
Rate for Payer: Cigna Medicare	$31.59
Rate for Payer: Medicaid All Medicaid	$32.29
Rate for Payer: Medicare All Medicare	$24.57
Rate for Payer: Monida Allegiance	$33.34
Rate for Payer: Monida First Choice Health	$34.05
Rate for Payer: Monida Montana Health Co-op	$33.34
Rate for Payer: Monida PacificSource	$33.34

MG REAGENT DF57 30 TESTS/FLE

Facility

$35.10

Hospital Charge Code	90195060
Hospital Revenue Code	270
Min. Negotiated Rate	$24.57
Max. Negotiated Rate	$35.10
Rate for Payer: Aetna Commercial	$33.34
Rate for Payer: Aetna Medicare	$31.59
Rate for Payer: BCBS MT CHIP	$31.59
Rate for Payer: BCBS MT Closed Plan Network	$33.34
Rate for Payer: BCBS MT HealthLink	$31.59
Rate for Payer: BCBS MT Medicare	$31.59
Rate for Payer: BCBS MT POS	$33.34
Rate for Payer: BCBS MT Traditional	$35.10
Rate for Payer: Cash Price	$31.59
Rate for Payer: Cigna Commercial	$33.34
Rate for Payer: Cigna Medicare	$31.59
Rate for Payer: Medicaid All Medicaid	$32.29
Rate for Payer: Medicare All Medicare	$24.57
Rate for Payer: Monida Allegiance	$33.34
Rate for Payer: Monida First Choice Health	$34.05
Rate for Payer: Monida Montana Health Co-op	$33.34
Rate for Payer: Monida PacificSource	$33.34

MICONAZOLE CRM [2%] 14.2GM NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000545
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

MICONAZOLE CRM [2%] 14.2GM NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000545
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

MICONAZOLE OINT [2 %] NF

Facility

$14.00

Service Code	HCPCS A9150
Hospital Charge Code	3007781
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

MICONAZOLE OINT [2 %] NF

Facility

$14.00

Service Code	HCPCS A9150
Hospital Charge Code	3007781
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

MICROALBUMIN CONTROL LEVEL 1

Facility

$124.60

Hospital Charge Code	90196625
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

MICROALBUMIN CONTROL LEVEL 1

Facility

$124.60

Hospital Charge Code	90196625
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

MICROALBUMIN CONTROL LEVEL 2

Facility

$124.60

Hospital Charge Code	90196626
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

MICROALBUMIN CONTROL LEVEL 2

Facility

$124.60

Hospital Charge Code	90196626
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

Know your out-of-pocket cost for care.

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