Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

.B CELLS, TOTAL COUNT (506049)

Facility

$303.00

Service Code	HCPCS 86356
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

BD MICROTAINER LAVENDER K2 ED

Facility

$29.08

Hospital Charge Code	90195123
Hospital Revenue Code	270
Min. Negotiated Rate	$20.36
Max. Negotiated Rate	$29.08
Rate for Payer: Aetna Commercial	$27.63
Rate for Payer: Aetna Medicare	$26.17
Rate for Payer: BCBS MT CHIP	$26.17
Rate for Payer: BCBS MT Closed Plan Network	$27.63
Rate for Payer: BCBS MT HealthLink	$26.17
Rate for Payer: BCBS MT Medicare	$26.17
Rate for Payer: BCBS MT POS	$27.63
Rate for Payer: BCBS MT Traditional	$29.08
Rate for Payer: Cash Price	$26.17
Rate for Payer: Cigna Commercial	$27.63
Rate for Payer: Cigna Medicare	$26.17
Rate for Payer: Medicaid All Medicaid	$26.75
Rate for Payer: Medicare All Medicare	$20.36
Rate for Payer: Monida Allegiance	$27.63
Rate for Payer: Monida First Choice Health	$28.21
Rate for Payer: Monida Montana Health Co-op	$27.63
Rate for Payer: Monida PacificSource	$27.63

BD MICROTAINER LAVENDER K2 ED

Facility

$29.08

Hospital Charge Code	90195123
Hospital Revenue Code	270
Min. Negotiated Rate	$20.36
Max. Negotiated Rate	$29.08
Rate for Payer: Aetna Commercial	$27.63
Rate for Payer: Aetna Medicare	$26.17
Rate for Payer: BCBS MT CHIP	$26.17
Rate for Payer: BCBS MT Closed Plan Network	$27.63
Rate for Payer: BCBS MT HealthLink	$26.17
Rate for Payer: BCBS MT Medicare	$26.17
Rate for Payer: BCBS MT POS	$27.63
Rate for Payer: BCBS MT Traditional	$29.08
Rate for Payer: Cash Price	$26.17
Rate for Payer: Cigna Commercial	$27.63
Rate for Payer: Cigna Medicare	$26.17
Rate for Payer: Medicaid All Medicaid	$26.75
Rate for Payer: Medicare All Medicare	$20.36
Rate for Payer: Monida Allegiance	$27.63
Rate for Payer: Monida First Choice Health	$28.21
Rate for Payer: Monida Montana Health Co-op	$27.63
Rate for Payer: Monida PacificSource	$27.63

BD MICROTAINER MINT GREEN LI

Facility

$29.13

Hospital Charge Code	90195129
Hospital Revenue Code	270
Min. Negotiated Rate	$20.39
Max. Negotiated Rate	$29.13
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Aetna Medicare	$26.22
Rate for Payer: BCBS MT CHIP	$26.22
Rate for Payer: BCBS MT Closed Plan Network	$27.67
Rate for Payer: BCBS MT HealthLink	$26.22
Rate for Payer: BCBS MT Medicare	$26.22
Rate for Payer: BCBS MT POS	$27.67
Rate for Payer: BCBS MT Traditional	$29.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Cigna Commercial	$27.67
Rate for Payer: Cigna Medicare	$26.22
Rate for Payer: Medicaid All Medicaid	$26.80
Rate for Payer: Medicare All Medicare	$20.39
Rate for Payer: Monida Allegiance	$27.67
Rate for Payer: Monida First Choice Health	$28.26
Rate for Payer: Monida Montana Health Co-op	$27.67
Rate for Payer: Monida PacificSource	$27.67

BD MICROTAINER MINT GREEN LI

Facility

$29.13

Hospital Charge Code	90195129
Hospital Revenue Code	270
Min. Negotiated Rate	$20.39
Max. Negotiated Rate	$29.13
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Aetna Medicare	$26.22
Rate for Payer: BCBS MT CHIP	$26.22
Rate for Payer: BCBS MT Closed Plan Network	$27.67
Rate for Payer: BCBS MT HealthLink	$26.22
Rate for Payer: BCBS MT Medicare	$26.22
Rate for Payer: BCBS MT POS	$27.67
Rate for Payer: BCBS MT Traditional	$29.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Cigna Commercial	$27.67
Rate for Payer: Cigna Medicare	$26.22
Rate for Payer: Medicaid All Medicaid	$26.80
Rate for Payer: Medicare All Medicare	$20.39
Rate for Payer: Monida Allegiance	$27.67
Rate for Payer: Monida First Choice Health	$28.26
Rate for Payer: Monida Montana Health Co-op	$27.67
Rate for Payer: Monida PacificSource	$27.67

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

BENZOCAINE 14%/BUTAMBEN 2%/TETRACAINE 2%

Facility

$1,300.00

Service Code	HCPCS J3490
Hospital Charge Code	3000609
Hospital Revenue Code	250
Min. Negotiated Rate	$910.00
Max. Negotiated Rate	$1,300.00
Rate for Payer: Aetna Commercial	$1,235.00
Rate for Payer: Aetna Medicare	$1,170.00
Rate for Payer: BCBS MT CHIP	$1,170.00
Rate for Payer: BCBS MT Closed Plan Network	$1,235.00
Rate for Payer: BCBS MT HealthLink	$1,170.00
Rate for Payer: BCBS MT Medicare	$1,170.00
Rate for Payer: BCBS MT POS	$1,235.00
Rate for Payer: BCBS MT Traditional	$1,300.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cigna Commercial	$1,235.00
Rate for Payer: Cigna Medicare	$1,170.00
Rate for Payer: Medicaid All Medicaid	$1,196.00
Rate for Payer: Medicare All Medicare	$910.00
Rate for Payer: Monida Allegiance	$1,235.00
Rate for Payer: Monida First Choice Health	$1,261.00
Rate for Payer: Monida Montana Health Co-op	$1,235.00
Rate for Payer: Monida PacificSource	$1,235.00

BENZOCAINE 14%/BUTAMBEN 2%/TETRACAINE 2%

Facility

$1,300.00

Service Code	HCPCS J3490
Hospital Charge Code	3000609
Hospital Revenue Code	250
Min. Negotiated Rate	$910.00
Max. Negotiated Rate	$1,300.00
Rate for Payer: Aetna Commercial	$1,235.00
Rate for Payer: Aetna Medicare	$1,170.00
Rate for Payer: BCBS MT CHIP	$1,170.00
Rate for Payer: BCBS MT Closed Plan Network	$1,235.00
Rate for Payer: BCBS MT HealthLink	$1,170.00
Rate for Payer: BCBS MT Medicare	$1,170.00
Rate for Payer: BCBS MT POS	$1,235.00
Rate for Payer: BCBS MT Traditional	$1,300.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cigna Commercial	$1,235.00
Rate for Payer: Cigna Medicare	$1,170.00
Rate for Payer: Medicaid All Medicaid	$1,196.00
Rate for Payer: Medicare All Medicare	$910.00
Rate for Payer: Monida Allegiance	$1,235.00
Rate for Payer: Monida First Choice Health	$1,261.00
Rate for Payer: Monida Montana Health Co-op	$1,235.00
Rate for Payer: Monida PacificSource	$1,235.00

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

$87.00

Service Code	HCPCS 86146
Hospital Charge Code	4061461
Hospital Revenue Code	307
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

.BETA-2 GLYCOPROTEIN 1 AB, IGA

Facility

$87.00

Service Code	HCPCS 86146
Hospital Charge Code	4061461
Hospital Revenue Code	307
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

BETA-2 GLYCOPROTEIN 1 AB, IGG (163882)

Facility

$41.00

Service Code	HCPCS 86146
Hospital Charge Code	4086146
Hospital Revenue Code	307
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

BETA-2 GLYCOPROTEIN 1 AB, IGG (163882)

Facility

$41.00

Service Code	HCPCS 86146
Hospital Charge Code	4086146
Hospital Revenue Code	307
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

BETA-2 GLYCOPROTEIN 1 AB, IGM (163908)

Facility

$87.00

Service Code	HCPCS 86146
Hospital Charge Code	4000049
Hospital Revenue Code	307
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

BETA-2 GLYCOPROTEIN 1 AB, IGM (163908)

Facility

$87.00

Service Code	HCPCS 86146
Hospital Charge Code	4000049
Hospital Revenue Code	307
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

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

Know your out-of-pocket cost for care.

All Charges