Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

BLOOD TRANSFER DEVICE (NURSING ONLY)

Facility

$3.00

Hospital Charge Code	80040231
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.85
Rate for Payer: Aetna Medicare	$2.70
Rate for Payer: BCBS MT CHIP	$2.70
Rate for Payer: BCBS MT Closed Plan Network	$2.85
Rate for Payer: BCBS MT HealthLink	$2.70
Rate for Payer: BCBS MT Medicare	$2.70
Rate for Payer: BCBS MT POS	$2.85
Rate for Payer: BCBS MT Traditional	$3.00
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna Commercial	$2.85
Rate for Payer: Cigna Medicare	$2.70
Rate for Payer: Medicaid All Medicaid	$2.76
Rate for Payer: Medicare All Medicare	$2.10
Rate for Payer: Monida Allegiance	$2.85
Rate for Payer: Monida First Choice Health	$2.91
Rate for Payer: Monida Montana Health Co-op	$2.85
Rate for Payer: Monida PacificSource	$2.85

BLOOD TRANSFER DEVICE (NURSING ONLY)

Facility

$3.00

Hospital Charge Code	80040231
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.85
Rate for Payer: Aetna Medicare	$2.70
Rate for Payer: BCBS MT CHIP	$2.70
Rate for Payer: BCBS MT Closed Plan Network	$2.85
Rate for Payer: BCBS MT HealthLink	$2.70
Rate for Payer: BCBS MT Medicare	$2.70
Rate for Payer: BCBS MT POS	$2.85
Rate for Payer: BCBS MT Traditional	$3.00
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna Commercial	$2.85
Rate for Payer: Cigna Medicare	$2.70
Rate for Payer: Medicaid All Medicaid	$2.76
Rate for Payer: Medicare All Medicare	$2.10
Rate for Payer: Monida Allegiance	$2.85
Rate for Payer: Monida First Choice Health	$2.91
Rate for Payer: Monida Montana Health Co-op	$2.85
Rate for Payer: Monida PacificSource	$2.85

BLOOD TRANSFER PACK BAG

Facility

$26.00

Hospital Charge Code	80040141
Hospital Revenue Code	270
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

BLOOD TRANSFER PACK BAG

Facility

$26.00

Hospital Charge Code	80040141
Hospital Revenue Code	270
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

BLOOD UREA NITROGEN (BUN)

Facility

$58.00

Service Code	HCPCS 84520
Hospital Charge Code	4084520
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

BLOOD UREA NITROGEN (BUN)

Facility

$58.00

Service Code	HCPCS 84520
Hospital Charge Code	4084520
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

BOTULINUM TOXIN 100UN VIAL

Facility

$1,065.20

Service Code	HCPCS J0585
Hospital Charge Code	3007394
Hospital Revenue Code	250
Min. Negotiated Rate	$745.64
Max. Negotiated Rate	$1,065.20
Rate for Payer: Aetna Commercial	$1,011.94
Rate for Payer: Aetna Medicare	$958.68
Rate for Payer: BCBS MT CHIP	$958.68
Rate for Payer: BCBS MT Closed Plan Network	$1,011.94
Rate for Payer: BCBS MT HealthLink	$958.68
Rate for Payer: BCBS MT Medicare	$958.68
Rate for Payer: BCBS MT POS	$1,011.94
Rate for Payer: BCBS MT Traditional	$1,065.20
Rate for Payer: Cash Price	$958.68
Rate for Payer: Cigna Commercial	$1,011.94
Rate for Payer: Cigna Medicare	$958.68
Rate for Payer: Medicaid All Medicaid	$979.98
Rate for Payer: Medicare All Medicare	$745.64
Rate for Payer: Monida Allegiance	$1,011.94
Rate for Payer: Monida First Choice Health	$1,033.24
Rate for Payer: Monida Montana Health Co-op	$1,011.94
Rate for Payer: Monida PacificSource	$1,011.94

BOTULINUM TOXIN 100UN VIAL

Facility

$1,065.20

Service Code	HCPCS J0585
Hospital Charge Code	3007394
Hospital Revenue Code	250
Min. Negotiated Rate	$745.64
Max. Negotiated Rate	$1,065.20
Rate for Payer: Aetna Commercial	$1,011.94
Rate for Payer: Aetna Medicare	$958.68
Rate for Payer: BCBS MT CHIP	$958.68
Rate for Payer: BCBS MT Closed Plan Network	$1,011.94
Rate for Payer: BCBS MT HealthLink	$958.68
Rate for Payer: BCBS MT Medicare	$958.68
Rate for Payer: BCBS MT POS	$1,011.94
Rate for Payer: BCBS MT Traditional	$1,065.20
Rate for Payer: Cash Price	$958.68
Rate for Payer: Cigna Commercial	$1,011.94
Rate for Payer: Cigna Medicare	$958.68
Rate for Payer: Medicaid All Medicaid	$979.98
Rate for Payer: Medicare All Medicare	$745.64
Rate for Payer: Monida Allegiance	$1,011.94
Rate for Payer: Monida First Choice Health	$1,033.24
Rate for Payer: Monida Montana Health Co-op	$1,011.94
Rate for Payer: Monida PacificSource	$1,011.94

BRIMONIDINE 0.2% (5ML) OPTH DROPS

Facility

$42.00

Service Code	NDC 70069023101
Hospital Charge Code	3007072
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

BRIMONIDINE 0.2% (5ML) OPTH DROPS

Facility

$42.00

Service Code	NDC 70069023101
Hospital Charge Code	3007072
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

BRIMONIDINE/TIMOLOL [0.2%/0.5%] 5ML NF

Facility

$617.00

Service Code	NDC 00832142505
Hospital Charge Code	3007262
Hospital Revenue Code	250
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

BRIMONIDINE/TIMOLOL [0.2%/0.5%] 5ML NF

Facility

$617.00

Service Code	NDC 00832142505
Hospital Charge Code	3007262
Hospital Revenue Code	250
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

B-TYPE NATRIURETIC PEPTIDE

Facility

$268.00

Service Code	HCPCS 83880
Hospital Charge Code	4083880
Hospital Revenue Code	300
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

B-TYPE NATRIURETIC PEPTIDE

Facility

$268.00

Service Code	HCPCS 83880
Hospital Charge Code	4083880
Hospital Revenue Code	300
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

BUDESONIDE/FORMOTEROL 160/4.5MCG-NF

Facility

$719.00

Service Code	HCPCS J3490
Hospital Charge Code	3007107
Hospital Revenue Code	250
Min. Negotiated Rate	$503.30
Max. Negotiated Rate	$719.00
Rate for Payer: Aetna Commercial	$683.05
Rate for Payer: Aetna Medicare	$647.10
Rate for Payer: BCBS MT CHIP	$647.10
Rate for Payer: BCBS MT Closed Plan Network	$683.05
Rate for Payer: BCBS MT HealthLink	$647.10
Rate for Payer: BCBS MT Medicare	$647.10
Rate for Payer: BCBS MT POS	$683.05
Rate for Payer: BCBS MT Traditional	$719.00
Rate for Payer: Cash Price	$647.10
Rate for Payer: Cigna Commercial	$683.05
Rate for Payer: Cigna Medicare	$647.10
Rate for Payer: Medicaid All Medicaid	$661.48
Rate for Payer: Medicare All Medicare	$503.30
Rate for Payer: Monida Allegiance	$683.05
Rate for Payer: Monida First Choice Health	$697.43
Rate for Payer: Monida Montana Health Co-op	$683.05
Rate for Payer: Monida PacificSource	$683.05

BUDESONIDE/FORMOTEROL 160/4.5MCG-NF

Facility

$719.00

Service Code	HCPCS J3490
Hospital Charge Code	3007107
Hospital Revenue Code	250
Min. Negotiated Rate	$503.30
Max. Negotiated Rate	$719.00
Rate for Payer: Aetna Commercial	$683.05
Rate for Payer: Aetna Medicare	$647.10
Rate for Payer: BCBS MT CHIP	$647.10
Rate for Payer: BCBS MT Closed Plan Network	$683.05
Rate for Payer: BCBS MT HealthLink	$647.10
Rate for Payer: BCBS MT Medicare	$647.10
Rate for Payer: BCBS MT POS	$683.05
Rate for Payer: BCBS MT Traditional	$719.00
Rate for Payer: Cash Price	$647.10
Rate for Payer: Cigna Commercial	$683.05
Rate for Payer: Cigna Medicare	$647.10
Rate for Payer: Medicaid All Medicaid	$661.48
Rate for Payer: Medicare All Medicare	$503.30
Rate for Payer: Monida Allegiance	$683.05
Rate for Payer: Monida First Choice Health	$697.43
Rate for Payer: Monida Montana Health Co-op	$683.05
Rate for Payer: Monida PacificSource	$683.05

BUDESONIDE FORMOTEROL 80/4.5 INH-NF

Facility

$703.00

Service Code	NDC 00310737220
Hospital Charge Code	3007241
Hospital Revenue Code	250
Min. Negotiated Rate	$492.10
Max. Negotiated Rate	$703.00
Rate for Payer: Aetna Commercial	$667.85
Rate for Payer: Aetna Medicare	$632.70
Rate for Payer: BCBS MT CHIP	$632.70
Rate for Payer: BCBS MT Closed Plan Network	$667.85
Rate for Payer: BCBS MT HealthLink	$632.70
Rate for Payer: BCBS MT Medicare	$632.70
Rate for Payer: BCBS MT POS	$667.85
Rate for Payer: BCBS MT Traditional	$703.00
Rate for Payer: Cash Price	$632.70
Rate for Payer: Cigna Commercial	$667.85
Rate for Payer: Cigna Medicare	$632.70
Rate for Payer: Medicaid All Medicaid	$646.76
Rate for Payer: Medicare All Medicare	$492.10
Rate for Payer: Monida Allegiance	$667.85
Rate for Payer: Monida First Choice Health	$681.91
Rate for Payer: Monida Montana Health Co-op	$667.85
Rate for Payer: Monida PacificSource	$667.85

BUDESONIDE FORMOTEROL 80/4.5 INH-NF

Facility

$703.00

Service Code	NDC 00310737220
Hospital Charge Code	3007241
Hospital Revenue Code	250
Min. Negotiated Rate	$492.10
Max. Negotiated Rate	$703.00
Rate for Payer: Aetna Commercial	$667.85
Rate for Payer: Aetna Medicare	$632.70
Rate for Payer: BCBS MT CHIP	$632.70
Rate for Payer: BCBS MT Closed Plan Network	$667.85
Rate for Payer: BCBS MT HealthLink	$632.70
Rate for Payer: BCBS MT Medicare	$632.70
Rate for Payer: BCBS MT POS	$667.85
Rate for Payer: BCBS MT Traditional	$703.00
Rate for Payer: Cash Price	$632.70
Rate for Payer: Cigna Commercial	$667.85
Rate for Payer: Cigna Medicare	$632.70
Rate for Payer: Medicaid All Medicaid	$646.76
Rate for Payer: Medicare All Medicare	$492.10
Rate for Payer: Monida Allegiance	$667.85
Rate for Payer: Monida First Choice Health	$681.91
Rate for Payer: Monida Montana Health Co-op	$667.85
Rate for Payer: Monida PacificSource	$667.85

BUDESONIDE INH [180MCG] 120 DOSES

Facility

$615.00

Service Code	HCPCS J7626
Hospital Charge Code	3000054
Hospital Revenue Code	250
Min. Negotiated Rate	$430.50
Max. Negotiated Rate	$615.00
Rate for Payer: Aetna Commercial	$584.25
Rate for Payer: Aetna Medicare	$553.50
Rate for Payer: BCBS MT CHIP	$553.50
Rate for Payer: BCBS MT Closed Plan Network	$584.25
Rate for Payer: BCBS MT HealthLink	$553.50
Rate for Payer: BCBS MT Medicare	$553.50
Rate for Payer: BCBS MT POS	$584.25
Rate for Payer: BCBS MT Traditional	$615.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Cigna Commercial	$584.25
Rate for Payer: Cigna Medicare	$553.50
Rate for Payer: Medicaid All Medicaid	$565.80
Rate for Payer: Medicare All Medicare	$430.50
Rate for Payer: Monida Allegiance	$584.25
Rate for Payer: Monida First Choice Health	$596.55
Rate for Payer: Monida Montana Health Co-op	$584.25
Rate for Payer: Monida PacificSource	$584.25

BUDESONIDE INH [180MCG] 120 DOSES

Facility

$615.00

Service Code	HCPCS J7626
Hospital Charge Code	3000054
Hospital Revenue Code	250
Min. Negotiated Rate	$430.50
Max. Negotiated Rate	$615.00
Rate for Payer: Aetna Commercial	$584.25
Rate for Payer: Aetna Medicare	$553.50
Rate for Payer: BCBS MT CHIP	$553.50
Rate for Payer: BCBS MT Closed Plan Network	$584.25
Rate for Payer: BCBS MT HealthLink	$553.50
Rate for Payer: BCBS MT Medicare	$553.50
Rate for Payer: BCBS MT POS	$584.25
Rate for Payer: BCBS MT Traditional	$615.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Cigna Commercial	$584.25
Rate for Payer: Cigna Medicare	$553.50
Rate for Payer: Medicaid All Medicaid	$565.80
Rate for Payer: Medicare All Medicare	$430.50
Rate for Payer: Monida Allegiance	$584.25
Rate for Payer: Monida First Choice Health	$596.55
Rate for Payer: Monida Montana Health Co-op	$584.25
Rate for Payer: Monida PacificSource	$584.25

BUDESONIDE NEB SOLN [0.5 MG/2 ML]

Facility

$36.00

Service Code	HCPCS J7626
Hospital Charge Code	3000055
Hospital Revenue Code	259
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

BUDESONIDE NEB SOLN [0.5 MG/2 ML]

Facility

$36.00

Service Code	HCPCS J7626
Hospital Charge Code	3000055
Hospital Revenue Code	259
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

BULB SYRINGE 3OZ

Facility

$12.00

Hospital Charge Code	80030303
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

BULB SYRINGE 3OZ

Facility

$12.00

Hospital Charge Code	80030303
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

BUMETANIDE INJ [0.25 MG/ML] 4ML SDV

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000056
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges