Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PT VASOPNEUMATIC DEVICE

Facility

$86.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	6197016
Hospital Revenue Code	420
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$86.00
Rate for Payer: Aetna Commercial	$81.70
Rate for Payer: Aetna Medicare	$77.40
Rate for Payer: BCBS MT CHIP	$77.40
Rate for Payer: BCBS MT Closed Plan Network	$81.70
Rate for Payer: BCBS MT HealthLink	$77.40
Rate for Payer: BCBS MT Medicare	$77.40
Rate for Payer: BCBS MT POS	$81.70
Rate for Payer: BCBS MT Traditional	$86.00
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cigna Commercial	$81.70
Rate for Payer: Cigna Medicare	$77.40
Rate for Payer: Medicaid All Medicaid	$79.12
Rate for Payer: Medicare All Medicare	$60.20
Rate for Payer: Monida Allegiance	$81.70
Rate for Payer: Monida First Choice Health	$83.42
Rate for Payer: Monida Montana Health Co-op	$81.70
Rate for Payer: Monida PacificSource	$81.70

PT WHEELCHAIR MGMT

Facility

$108.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	6197542
Hospital Revenue Code	420
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: BCBS MT CHIP	$97.20
Rate for Payer: BCBS MT Closed Plan Network	$102.60
Rate for Payer: BCBS MT HealthLink	$97.20
Rate for Payer: BCBS MT Medicare	$97.20
Rate for Payer: BCBS MT POS	$102.60
Rate for Payer: BCBS MT Traditional	$108.00
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial	$102.60
Rate for Payer: Cigna Medicare	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

PT WHEELCHAIR MGMT

Facility

$108.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	6197542
Hospital Revenue Code	420
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: BCBS MT CHIP	$97.20
Rate for Payer: BCBS MT Closed Plan Network	$102.60
Rate for Payer: BCBS MT HealthLink	$97.20
Rate for Payer: BCBS MT Medicare	$97.20
Rate for Payer: BCBS MT POS	$102.60
Rate for Payer: BCBS MT Traditional	$108.00
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial	$102.60
Rate for Payer: Cigna Medicare	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

PT WHIRLPOOL

Facility

$116.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	6197022
Hospital Revenue Code	420
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

PT WHIRLPOOL

Facility

$116.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	6197022
Hospital Revenue Code	420
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

PT WORK HARDENING EA ADD HR

Facility

$88.00

Service Code	HCPCS 97546
Hospital Charge Code	6197546
Hospital Revenue Code	420
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

PT WORK HARDENING EA ADD HR

Facility

$88.00

Service Code	HCPCS 97546
Hospital Charge Code	6197546
Hospital Revenue Code	420
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

PT WORK HARDENING INITIAL 2 HRS

Facility

$350.00

Service Code	HCPCS 97545 GP
Hospital Charge Code	6197545
Hospital Revenue Code	420
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

PT WORK HARDENING INITIAL 2 HRS

Facility

$350.00

Service Code	HCPCS 97545 GP
Hospital Charge Code	6197545
Hospital Revenue Code	420
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

PURE PAK NASAL TAMPON SM 8/BX

Facility

$32.00

Hospital Charge Code	80040287
Hospital Revenue Code	270
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

PURE PAK NASAL TAMPON SM 8/BX

Facility

$32.00

Hospital Charge Code	80040287
Hospital Revenue Code	270
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

PVB THORACIC SECOND AND ANY ADD ON

Facility

$975.00

Service Code	HCPCS 64462
Hospital Charge Code	1564462
Hospital Revenue Code	760
Min. Negotiated Rate	$682.50
Max. Negotiated Rate	$975.00
Rate for Payer: Aetna Commercial	$926.25
Rate for Payer: Aetna Medicare	$877.50
Rate for Payer: BCBS MT CHIP	$877.50
Rate for Payer: BCBS MT Closed Plan Network	$926.25
Rate for Payer: BCBS MT HealthLink	$877.50
Rate for Payer: BCBS MT Medicare	$877.50
Rate for Payer: BCBS MT POS	$926.25
Rate for Payer: BCBS MT Traditional	$975.00
Rate for Payer: Cash Price	$877.50
Rate for Payer: Cigna Commercial	$926.25
Rate for Payer: Cigna Medicare	$877.50
Rate for Payer: Medicaid All Medicaid	$897.00
Rate for Payer: Medicare All Medicare	$682.50
Rate for Payer: Monida Allegiance	$926.25
Rate for Payer: Monida First Choice Health	$945.75
Rate for Payer: Monida Montana Health Co-op	$926.25
Rate for Payer: Monida PacificSource	$926.25

PVB THORACIC SECOND AND ANY ADD ON

Facility

$975.00

Service Code	HCPCS 64462
Hospital Charge Code	1564462
Hospital Revenue Code	760
Min. Negotiated Rate	$682.50
Max. Negotiated Rate	$975.00
Rate for Payer: Aetna Commercial	$926.25
Rate for Payer: Aetna Medicare	$877.50
Rate for Payer: BCBS MT CHIP	$877.50
Rate for Payer: BCBS MT Closed Plan Network	$926.25
Rate for Payer: BCBS MT HealthLink	$877.50
Rate for Payer: BCBS MT Medicare	$877.50
Rate for Payer: BCBS MT POS	$926.25
Rate for Payer: BCBS MT Traditional	$975.00
Rate for Payer: Cash Price	$877.50
Rate for Payer: Cigna Commercial	$926.25
Rate for Payer: Cigna Medicare	$877.50
Rate for Payer: Medicaid All Medicaid	$897.00
Rate for Payer: Medicare All Medicare	$682.50
Rate for Payer: Monida Allegiance	$926.25
Rate for Payer: Monida First Choice Health	$945.75
Rate for Payer: Monida Montana Health Co-op	$926.25
Rate for Payer: Monida PacificSource	$926.25

PVB THORACIC SINGLE

Facility

$1,852.00

Service Code	HCPCS 64461
Hospital Charge Code	1564461
Hospital Revenue Code	760
Min. Negotiated Rate	$1,296.40
Max. Negotiated Rate	$1,852.00
Rate for Payer: Aetna Commercial	$1,759.40
Rate for Payer: Aetna Medicare	$1,666.80
Rate for Payer: BCBS MT CHIP	$1,666.80
Rate for Payer: BCBS MT Closed Plan Network	$1,759.40
Rate for Payer: BCBS MT HealthLink	$1,666.80
Rate for Payer: BCBS MT Medicare	$1,666.80
Rate for Payer: BCBS MT POS	$1,759.40
Rate for Payer: BCBS MT Traditional	$1,852.00
Rate for Payer: Cash Price	$1,666.80
Rate for Payer: Cigna Commercial	$1,759.40
Rate for Payer: Cigna Medicare	$1,666.80
Rate for Payer: Medicaid All Medicaid	$1,703.84
Rate for Payer: Medicare All Medicare	$1,296.40
Rate for Payer: Monida Allegiance	$1,759.40
Rate for Payer: Monida First Choice Health	$1,796.44
Rate for Payer: Monida Montana Health Co-op	$1,759.40
Rate for Payer: Monida PacificSource	$1,759.40

PVB THORACIC SINGLE

Facility

$1,852.00

Service Code	HCPCS 64461
Hospital Charge Code	1564461
Hospital Revenue Code	760
Min. Negotiated Rate	$1,296.40
Max. Negotiated Rate	$1,852.00
Rate for Payer: Aetna Commercial	$1,759.40
Rate for Payer: Aetna Medicare	$1,666.80
Rate for Payer: BCBS MT CHIP	$1,666.80
Rate for Payer: BCBS MT Closed Plan Network	$1,759.40
Rate for Payer: BCBS MT HealthLink	$1,666.80
Rate for Payer: BCBS MT Medicare	$1,666.80
Rate for Payer: BCBS MT POS	$1,759.40
Rate for Payer: BCBS MT Traditional	$1,852.00
Rate for Payer: Cash Price	$1,666.80
Rate for Payer: Cigna Commercial	$1,759.40
Rate for Payer: Cigna Medicare	$1,666.80
Rate for Payer: Medicaid All Medicaid	$1,703.84
Rate for Payer: Medicare All Medicare	$1,296.40
Rate for Payer: Monida Allegiance	$1,759.40
Rate for Payer: Monida First Choice Health	$1,796.44
Rate for Payer: Monida Montana Health Co-op	$1,759.40
Rate for Payer: Monida PacificSource	$1,759.40

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

$140.00

Service Code	HCPCS 86480
Hospital Charge Code	4086480
Hospital Revenue Code	300
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS MT CHIP	$126.00
Rate for Payer: BCBS MT Closed Plan Network	$133.00
Rate for Payer: BCBS MT HealthLink	$126.00
Rate for Payer: BCBS MT Medicare	$126.00
Rate for Payer: BCBS MT POS	$133.00
Rate for Payer: BCBS MT Traditional	$140.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial	$133.00
Rate for Payer: Cigna Medicare	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

QUANTIFERON-TB GOLD PLUS (182893)

Facility

$140.00

Service Code	HCPCS 86480
Hospital Charge Code	4086480
Hospital Revenue Code	300
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS MT CHIP	$126.00
Rate for Payer: BCBS MT Closed Plan Network	$133.00
Rate for Payer: BCBS MT HealthLink	$126.00
Rate for Payer: BCBS MT Medicare	$126.00
Rate for Payer: BCBS MT POS	$133.00
Rate for Payer: BCBS MT Traditional	$140.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial	$133.00
Rate for Payer: Cigna Medicare	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

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

Know your out-of-pocket cost for care.

All Charges