Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

AVULSION NAIL PLATE SIMPLE ADDITIONAL

Facility

$196.00

Service Code	CPT 11732
Hospital Charge Code	8011732
Hospital Revenue Code	521
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

AVULSION NAIL PLATE SIMPLE ADDITIONAL

Facility

$196.00

Service Code	CPT 11732
Hospital Charge Code	8011732
Hospital Revenue Code	521
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

AVULSION NAIL PLATE SIMPLE SINGLE

Facility

$301.00

Service Code	CPT 11730
Hospital Charge Code	8011730
Hospital Revenue Code	521
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

AVULSION NAIL PLATE SIMPLE SINGLE

Facility

$301.00

Service Code	CPT 11730
Hospital Charge Code	8011730
Hospital Revenue Code	521
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

AYR SALINE NASAL GEL

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

AYR SALINE NASAL GEL

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

AZITHROMYCIN 500MG INJ

Facility

$36.00

Service Code	HCPCS J0456
Hospital Charge Code	3000044
Hospital Revenue Code	250
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

AZITHROMYCIN 500MG INJ

Facility

$36.00

Service Code	HCPCS J0456
Hospital Charge Code	3000044
Hospital Revenue Code	250
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

AZITHROMYCIN SUSP [100 MG/5 ML]

Facility

$112.00

Service Code	HCPCS J8499
Hospital Charge Code	3000045
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

AZITHROMYCIN SUSP [100 MG/5 ML]

Facility

$112.00

Service Code	HCPCS J8499
Hospital Charge Code	3000045
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

AZITHROMYCIN TAB [250 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000046
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

AZITHROMYCIN TAB [250 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000046
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

AZITHROMYCIN Z-PACK TAB [250 MG] 6 TABS

Facility

$150.00

Service Code	HCPCS J8499
Hospital Charge Code	3000047
Hospital Revenue Code	250
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

AZITHROMYCIN Z-PACK TAB [250 MG] 6 TABS

Facility

$150.00

Service Code	HCPCS J8499
Hospital Charge Code	3000047
Hospital Revenue Code	250
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

AZTREONAM 1 GM VIAL

Facility

$138.60

Service Code	HCPCS J0457
Hospital Charge Code	3007406
Hospital Revenue Code	250
Min. Negotiated Rate	$97.02
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna Commercial	$131.67
Rate for Payer: Aetna Medicare	$124.74
Rate for Payer: BCBS MT CHIP	$124.74
Rate for Payer: BCBS MT Closed Plan Network	$131.67
Rate for Payer: BCBS MT HealthLink	$124.74
Rate for Payer: BCBS MT Medicare	$124.74
Rate for Payer: BCBS MT POS	$131.67
Rate for Payer: BCBS MT Traditional	$138.60
Rate for Payer: Cash Price	$124.74
Rate for Payer: Cigna Commercial	$131.67
Rate for Payer: Cigna Medicare	$124.74
Rate for Payer: Medicaid All Medicaid	$127.51
Rate for Payer: Medicare All Medicare	$97.02
Rate for Payer: Monida Allegiance	$131.67
Rate for Payer: Monida First Choice Health	$134.44
Rate for Payer: Monida Montana Health Co-op	$131.67
Rate for Payer: Monida PacificSource	$131.67

AZTREONAM 1 GM VIAL

Facility

$138.60

Service Code	HCPCS J0457
Hospital Charge Code	3007406
Hospital Revenue Code	250
Min. Negotiated Rate	$97.02
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna Commercial	$131.67
Rate for Payer: Aetna Medicare	$124.74
Rate for Payer: BCBS MT CHIP	$124.74
Rate for Payer: BCBS MT Closed Plan Network	$131.67
Rate for Payer: BCBS MT HealthLink	$124.74
Rate for Payer: BCBS MT Medicare	$124.74
Rate for Payer: BCBS MT POS	$131.67
Rate for Payer: BCBS MT Traditional	$138.60
Rate for Payer: Cash Price	$124.74
Rate for Payer: Cigna Commercial	$131.67
Rate for Payer: Cigna Medicare	$124.74
Rate for Payer: Medicaid All Medicaid	$127.51
Rate for Payer: Medicare All Medicare	$97.02
Rate for Payer: Monida Allegiance	$131.67
Rate for Payer: Monida First Choice Health	$134.44
Rate for Payer: Monida Montana Health Co-op	$131.67
Rate for Payer: Monida PacificSource	$131.67

B2 GLYCOPROTEIN I AB IGG IGM

Facility

$95.00

Service Code	CPT 86146
Hospital Charge Code	4088083
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

B2 GLYCOPROTEIN I AB IGG IGM

Facility

$95.00

Service Code	CPT 86146
Hospital Charge Code	4088083
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

BACITRACIN OINT [500 UNITS/ GM] NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3007578
Hospital Revenue Code	250
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

BACITRACIN OINT [500 UNITS/ GM] NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3007578
Hospital Revenue Code	250
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

BACLOFEN TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000048
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

BACLOFEN TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000048
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

BAIR HUGGER BLANKET

Facility

$32.00

Hospital Charge Code	80040159
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

BAIR HUGGER BLANKET

Facility

$32.00

Hospital Charge Code	80040159
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

BASIC METABOLIC PANEL

Facility

$158.00

Service Code	CPT 80048
Hospital Charge Code	4080048
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

Know your out-of-pocket cost for care.

All Charges