Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

NEBULIZER 7'' 50/CS

Facility

$19.00

Hospital Charge Code	80030224
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

NEBULIZER 7'' 50/CS

Facility

$19.00

Hospital Charge Code	80030224
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

NEBULIZER PEDS MASK ( FISH)

Facility

$18.00

Hospital Charge Code	80030221
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

NEBULIZER PEDS MASK ( FISH)

Facility

$18.00

Hospital Charge Code	80030221
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

NEBULIZER TREATMENT-CLINIC

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	8094640
Hospital Revenue Code	521
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEBULIZER TREATMENT-CLINIC

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	8094640
Hospital Revenue Code	521
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEBULIZER TREATMENT-HOSPITAL

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEBULIZER TREATMENT-HOSPITAL

Facility

$94.00

Service Code	CPT 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEG PRESS WOUND TX </=50CM

Facility

$442.00

Service Code	CPT 97605
Hospital Charge Code	8097605
Hospital Revenue Code	521
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

NEG PRESS WOUND TX </=50CM

Facility

$442.00

Service Code	CPT 97605
Hospital Charge Code	8097605
Hospital Revenue Code	521
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$587.00

Service Code	CPT 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$410.90
Max. Negotiated Rate	$587.00
Rate for Payer: Aetna Commercial	$557.65
Rate for Payer: Aetna Medicare	$528.30
Rate for Payer: BCBS MT CHIP	$528.30
Rate for Payer: BCBS MT Closed Plan Network	$557.65
Rate for Payer: BCBS MT HealthLink	$528.30
Rate for Payer: BCBS MT Medicare	$528.30
Rate for Payer: BCBS MT POS	$557.65
Rate for Payer: BCBS MT Traditional	$587.00
Rate for Payer: Cash Price	$528.30
Rate for Payer: Cigna Commercial	$557.65
Rate for Payer: Cigna Medicare	$528.30
Rate for Payer: Medicaid All Medicaid	$540.04
Rate for Payer: Medicare All Medicare	$410.90
Rate for Payer: Monida Allegiance	$557.65
Rate for Payer: Monida First Choice Health	$569.39
Rate for Payer: Monida Montana Health Co-op	$557.65
Rate for Payer: Monida PacificSource	$557.65

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$587.00

Service Code	CPT 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$410.90
Max. Negotiated Rate	$587.00
Rate for Payer: Aetna Commercial	$557.65
Rate for Payer: Aetna Medicare	$528.30
Rate for Payer: BCBS MT CHIP	$528.30
Rate for Payer: BCBS MT Closed Plan Network	$557.65
Rate for Payer: BCBS MT HealthLink	$528.30
Rate for Payer: BCBS MT Medicare	$528.30
Rate for Payer: BCBS MT POS	$557.65
Rate for Payer: BCBS MT Traditional	$587.00
Rate for Payer: Cash Price	$528.30
Rate for Payer: Cigna Commercial	$557.65
Rate for Payer: Cigna Medicare	$528.30
Rate for Payer: Medicaid All Medicaid	$540.04
Rate for Payer: Medicare All Medicare	$410.90
Rate for Payer: Monida Allegiance	$557.65
Rate for Payer: Monida First Choice Health	$569.39
Rate for Payer: Monida Montana Health Co-op	$557.65
Rate for Payer: Monida PacificSource	$557.65

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$101.00

Service Code	CPT 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$101.00

Service Code	CPT 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

NEISSERI GONORRHOEAE AMP PROB TECH

Facility

$139.00

Service Code	CPT 87591
Hospital Charge Code	8087591
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

NEISSERI GONORRHOEAE AMP PROB TECH

Facility

$139.00

Service Code	CPT 87591
Hospital Charge Code	8087591
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

NETARSUDIL OPTH [0.02 %] 2.5ML NF

Facility

$677.40

Hospital Charge Code	3007247
Hospital Revenue Code	250
Min. Negotiated Rate	$474.18
Max. Negotiated Rate	$677.40
Rate for Payer: Aetna Commercial	$643.53
Rate for Payer: Aetna Medicare	$609.66
Rate for Payer: BCBS MT CHIP	$609.66
Rate for Payer: BCBS MT Closed Plan Network	$643.53
Rate for Payer: BCBS MT HealthLink	$609.66
Rate for Payer: BCBS MT Medicare	$609.66
Rate for Payer: BCBS MT POS	$643.53
Rate for Payer: BCBS MT Traditional	$677.40
Rate for Payer: Cash Price	$609.66
Rate for Payer: Cigna Commercial	$643.53
Rate for Payer: Cigna Medicare	$609.66
Rate for Payer: Medicaid All Medicaid	$623.21
Rate for Payer: Medicare All Medicare	$474.18
Rate for Payer: Monida Allegiance	$643.53
Rate for Payer: Monida First Choice Health	$657.08
Rate for Payer: Monida Montana Health Co-op	$643.53
Rate for Payer: Monida PacificSource	$643.53

NETARSUDIL OPTH [0.02 %] 2.5ML NF

Facility

$677.40

Hospital Charge Code	3007247
Hospital Revenue Code	250
Min. Negotiated Rate	$474.18
Max. Negotiated Rate	$677.40
Rate for Payer: Aetna Commercial	$643.53
Rate for Payer: Aetna Medicare	$609.66
Rate for Payer: BCBS MT CHIP	$609.66
Rate for Payer: BCBS MT Closed Plan Network	$643.53
Rate for Payer: BCBS MT HealthLink	$609.66
Rate for Payer: BCBS MT Medicare	$609.66
Rate for Payer: BCBS MT POS	$643.53
Rate for Payer: BCBS MT Traditional	$677.40
Rate for Payer: Cash Price	$609.66
Rate for Payer: Cigna Commercial	$643.53
Rate for Payer: Cigna Medicare	$609.66
Rate for Payer: Medicaid All Medicaid	$623.21
Rate for Payer: Medicare All Medicare	$474.18
Rate for Payer: Monida Allegiance	$643.53
Rate for Payer: Monida First Choice Health	$657.08
Rate for Payer: Monida Montana Health Co-op	$643.53
Rate for Payer: Monida PacificSource	$643.53

NEUROMUSCULAR REEDUCATION PER 15

Facility

$109.00

Service Code	CPT 97112
Hospital Charge Code	8197112
Hospital Revenue Code	521
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

NEUROMUSCULAR REEDUCATION PER 15

Facility

$109.00

Service Code	CPT 97112
Hospital Charge Code	8197112
Hospital Revenue Code	521
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

NEWBORN SCREENING PANEL

Facility

$158.00

Service Code	CPT 84030
Hospital Charge Code	4002017
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

NEWBORN SCREENING PANEL

Facility

$158.00

Service Code	CPT 84030
Hospital Charge Code	4002017
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

NEXPLANON ETONOGESTREL IMPLANT

Facility

$5.00

Service Code	HCPCS J7307
Hospital Charge Code	3000567
Hospital Revenue Code	521
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

NEXPLANON ETONOGESTREL IMPLANT

Facility

$5.00

Service Code	HCPCS J7307
Hospital Charge Code	3000567
Hospital Revenue Code	521
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

nf-ACETYL-L-CARNITINE [500 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000515
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.

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