Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

RACEPINEPHRINE NEB SLN [2.25%]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000412
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

RACEPINEPHRINE NEB SLN [2.25%]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000412
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

RALOXIFENE HCL TAB [60 MG] NF

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000413
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

RALOXIFENE HCL TAB [60 MG] NF

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000413
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

RED BLOOD CELL COUNT, BLOOD

Facility

$54.00

Service Code	HCPCS 85041
Hospital Charge Code	4085041
Hospital Revenue Code	305
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

RED BLOOD CELL COUNT, BLOOD

Facility

$54.00

Service Code	HCPCS 85041
Hospital Charge Code	4085041
Hospital Revenue Code	305
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

REMDESIVIR INJ [100 MG]

Facility

$918.00

Service Code	HCPCS J3490
Hospital Charge Code	3000414
Hospital Revenue Code	250
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$918.00
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: Aetna Medicare	$826.20
Rate for Payer: BCBS MT CHIP	$826.20
Rate for Payer: BCBS MT Closed Plan Network	$872.10
Rate for Payer: BCBS MT HealthLink	$826.20
Rate for Payer: BCBS MT Medicare	$826.20
Rate for Payer: BCBS MT POS	$872.10
Rate for Payer: BCBS MT Traditional	$918.00
Rate for Payer: Cash Price	$826.20
Rate for Payer: Cigna Commercial	$872.10
Rate for Payer: Cigna Medicare	$826.20
Rate for Payer: Medicaid All Medicaid	$844.56
Rate for Payer: Medicare All Medicare	$642.60
Rate for Payer: Monida Allegiance	$872.10
Rate for Payer: Monida First Choice Health	$890.46
Rate for Payer: Monida Montana Health Co-op	$872.10
Rate for Payer: Monida PacificSource	$872.10

REMDESIVIR INJ [100 MG]

Facility

$918.00

Service Code	HCPCS J3490
Hospital Charge Code	3000414
Hospital Revenue Code	250
Min. Negotiated Rate	$642.60
Max. Negotiated Rate	$918.00
Rate for Payer: Aetna Commercial	$872.10
Rate for Payer: Aetna Medicare	$826.20
Rate for Payer: BCBS MT CHIP	$826.20
Rate for Payer: BCBS MT Closed Plan Network	$872.10
Rate for Payer: BCBS MT HealthLink	$826.20
Rate for Payer: BCBS MT Medicare	$826.20
Rate for Payer: BCBS MT POS	$872.10
Rate for Payer: BCBS MT Traditional	$918.00
Rate for Payer: Cash Price	$826.20
Rate for Payer: Cigna Commercial	$872.10
Rate for Payer: Cigna Medicare	$826.20
Rate for Payer: Medicaid All Medicaid	$844.56
Rate for Payer: Medicare All Medicare	$642.60
Rate for Payer: Monida Allegiance	$872.10
Rate for Payer: Monida First Choice Health	$890.46
Rate for Payer: Monida Montana Health Co-op	$872.10
Rate for Payer: Monida PacificSource	$872.10

REMOTE 30 DAY ECG REV/REPORT CON, REC, R

Facility

$360.00

Service Code	HCPCS 93270
Hospital Charge Code	193270
Hospital Revenue Code	731
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

REMOTE 30 DAY ECG REV/REPORT CON, REC, R

Facility

$360.00

Service Code	HCPCS 93270
Hospital Charge Code	193270
Hospital Revenue Code	731
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

RENAL FUNCTION PANEL

Facility

$159.00

Service Code	HCPCS 80069
Hospital Charge Code	4080069
Hospital Revenue Code	300
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

RENAL FUNCTION PANEL

Facility

$159.00

Service Code	HCPCS 80069
Hospital Charge Code	4080069
Hospital Revenue Code	300
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

RENIN ACTIVITY (002006)

Facility

$68.00

Service Code	HCPCS 84244
Hospital Charge Code	4084244
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

RENIN ACTIVITY (002006)

Facility

$68.00

Service Code	HCPCS 84244
Hospital Charge Code	4084244
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

RESPIRATORY PANEL, NAD RVMC

Facility

$613.00

Service Code	HCPCS 0202U
Hospital Charge Code	4050202
Hospital Revenue Code	300
Min. Negotiated Rate	$429.10
Max. Negotiated Rate	$613.00
Rate for Payer: Aetna Commercial	$582.35
Rate for Payer: Aetna Medicare	$551.70
Rate for Payer: BCBS MT CHIP	$551.70
Rate for Payer: BCBS MT Closed Plan Network	$582.35
Rate for Payer: BCBS MT HealthLink	$551.70
Rate for Payer: BCBS MT Medicare	$551.70
Rate for Payer: BCBS MT POS	$582.35
Rate for Payer: BCBS MT Traditional	$613.00
Rate for Payer: Cash Price	$551.70
Rate for Payer: Cigna Commercial	$582.35
Rate for Payer: Cigna Medicare	$551.70
Rate for Payer: Medicaid All Medicaid	$563.96
Rate for Payer: Medicare All Medicare	$429.10
Rate for Payer: Monida Allegiance	$582.35
Rate for Payer: Monida First Choice Health	$594.61
Rate for Payer: Monida Montana Health Co-op	$582.35
Rate for Payer: Monida PacificSource	$582.35

RESPIRATORY PANEL, NAD RVMC

Facility

$613.00

Service Code	HCPCS 0202U
Hospital Charge Code	4050202
Hospital Revenue Code	300
Min. Negotiated Rate	$429.10
Max. Negotiated Rate	$613.00
Rate for Payer: Aetna Commercial	$582.35
Rate for Payer: Aetna Medicare	$551.70
Rate for Payer: BCBS MT CHIP	$551.70
Rate for Payer: BCBS MT Closed Plan Network	$582.35
Rate for Payer: BCBS MT HealthLink	$551.70
Rate for Payer: BCBS MT Medicare	$551.70
Rate for Payer: BCBS MT POS	$582.35
Rate for Payer: BCBS MT Traditional	$613.00
Rate for Payer: Cash Price	$551.70
Rate for Payer: Cigna Commercial	$582.35
Rate for Payer: Cigna Medicare	$551.70
Rate for Payer: Medicaid All Medicaid	$563.96
Rate for Payer: Medicare All Medicare	$429.10
Rate for Payer: Monida Allegiance	$582.35
Rate for Payer: Monida First Choice Health	$594.61
Rate for Payer: Monida Montana Health Co-op	$582.35
Rate for Payer: Monida PacificSource	$582.35

RESPITE CARE

Facility

$445.00

Hospital Charge Code	800001
Hospital Revenue Code	120
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

RESUSCITATOR INFANT

Facility

$152.00

Hospital Charge Code	80030011
Hospital Revenue Code	270
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

RESUSCITATOR INFANT

Facility

$152.00

Hospital Charge Code	80030011
Hospital Revenue Code	270
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

RETICULOCYTE COUNT (005280)

Facility

$13.00

Service Code	HCPCS 85045
Hospital Charge Code	4085046
Hospital Revenue Code	300
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

RETICULOCYTE COUNT (005280)

Facility

$13.00

Service Code	HCPCS 85045
Hospital Charge Code	4085046
Hospital Revenue Code	300
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

RF ABLTJ NRV NRVTG SI JT W/I 64625

Facility

$5,053.00

Service Code	HCPCS 64625
Hospital Charge Code	1564625
Hospital Revenue Code	761
Min. Negotiated Rate	$3,537.10
Max. Negotiated Rate	$5,053.00
Rate for Payer: Aetna Commercial	$4,800.35
Rate for Payer: Aetna Medicare	$4,547.70
Rate for Payer: BCBS MT CHIP	$4,547.70
Rate for Payer: BCBS MT Closed Plan Network	$4,800.35
Rate for Payer: BCBS MT HealthLink	$4,547.70
Rate for Payer: BCBS MT Medicare	$4,547.70
Rate for Payer: BCBS MT POS	$4,800.35
Rate for Payer: BCBS MT Traditional	$5,053.00
Rate for Payer: Cash Price	$4,547.70
Rate for Payer: Cigna Commercial	$4,800.35
Rate for Payer: Cigna Medicare	$4,547.70
Rate for Payer: Medicaid All Medicaid	$4,648.76
Rate for Payer: Medicare All Medicare	$3,537.10
Rate for Payer: Monida Allegiance	$4,800.35
Rate for Payer: Monida First Choice Health	$4,901.41
Rate for Payer: Monida Montana Health Co-op	$4,800.35
Rate for Payer: Monida PacificSource	$4,800.35

RF ABLTJ NRV NRVTG SI JT W/I 64625

Facility

$5,053.00

Service Code	HCPCS 64625
Hospital Charge Code	1564625
Hospital Revenue Code	761
Min. Negotiated Rate	$3,537.10
Max. Negotiated Rate	$5,053.00
Rate for Payer: Aetna Commercial	$4,800.35
Rate for Payer: Aetna Medicare	$4,547.70
Rate for Payer: BCBS MT CHIP	$4,547.70
Rate for Payer: BCBS MT Closed Plan Network	$4,800.35
Rate for Payer: BCBS MT HealthLink	$4,547.70
Rate for Payer: BCBS MT Medicare	$4,547.70
Rate for Payer: BCBS MT POS	$4,800.35
Rate for Payer: BCBS MT Traditional	$5,053.00
Rate for Payer: Cash Price	$4,547.70
Rate for Payer: Cigna Commercial	$4,800.35
Rate for Payer: Cigna Medicare	$4,547.70
Rate for Payer: Medicaid All Medicaid	$4,648.76
Rate for Payer: Medicare All Medicare	$3,537.10
Rate for Payer: Monida Allegiance	$4,800.35
Rate for Payer: Monida First Choice Health	$4,901.41
Rate for Payer: Monida Montana Health Co-op	$4,800.35
Rate for Payer: Monida PacificSource	$4,800.35

RHEUMATOID FACTOR (006502)

Facility

$60.00

Service Code	HCPCS 86431
Hospital Charge Code	4086431
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

RHEUMATOID FACTOR (006502)

Facility

$60.00

Service Code	HCPCS 86431
Hospital Charge Code	4086431
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

Know your out-of-pocket cost for care.

All Charges