Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ACE BANDAGE 6'' W/ VELCRO

Facility

$6.00

Service Code	HCPCS A4590
Hospital Charge Code	2830449
Hospital Revenue Code	270
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

ACETAMINOPHEN

Facility

$174.00

Service Code	HCPCS 80143
Hospital Charge Code	4080307
Hospital Revenue Code	300
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

ACETAMINOPHEN

Facility

$174.00

Service Code	HCPCS 80143
Hospital Charge Code	4080307
Hospital Revenue Code	300
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

ACETAMINOPHEN [160 MG/5 ML] 5ML CUP

Facility

$7.00

Service Code	HCPCS J3490
Hospital Charge Code	3000005
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.65
Rate for Payer: Aetna Medicare	$6.30
Rate for Payer: BCBS MT CHIP	$6.30
Rate for Payer: BCBS MT Closed Plan Network	$6.65
Rate for Payer: BCBS MT HealthLink	$6.30
Rate for Payer: BCBS MT Medicare	$6.30
Rate for Payer: BCBS MT POS	$6.65
Rate for Payer: BCBS MT Traditional	$7.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna Commercial	$6.65
Rate for Payer: Cigna Medicare	$6.30
Rate for Payer: Medicaid All Medicaid	$6.44
Rate for Payer: Medicare All Medicare	$4.90
Rate for Payer: Monida Allegiance	$6.65
Rate for Payer: Monida First Choice Health	$6.79
Rate for Payer: Monida Montana Health Co-op	$6.65
Rate for Payer: Monida PacificSource	$6.65

ACETAMINOPHEN [160 MG/5 ML] 5ML CUP

Facility

$7.00

Service Code	HCPCS J3490
Hospital Charge Code	3000005
Hospital Revenue Code	250
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.65
Rate for Payer: Aetna Medicare	$6.30
Rate for Payer: BCBS MT CHIP	$6.30
Rate for Payer: BCBS MT Closed Plan Network	$6.65
Rate for Payer: BCBS MT HealthLink	$6.30
Rate for Payer: BCBS MT Medicare	$6.30
Rate for Payer: BCBS MT POS	$6.65
Rate for Payer: BCBS MT Traditional	$7.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna Commercial	$6.65
Rate for Payer: Cigna Medicare	$6.30
Rate for Payer: Medicaid All Medicaid	$6.44
Rate for Payer: Medicare All Medicare	$4.90
Rate for Payer: Monida Allegiance	$6.65
Rate for Payer: Monida First Choice Health	$6.79
Rate for Payer: Monida Montana Health Co-op	$6.65
Rate for Payer: Monida PacificSource	$6.65

ACETAMINOPHEN BTL [160 MG/5 ML] 118 ML

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000001
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

ACETAMINOPHEN BTL [160 MG/5 ML] 118 ML

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000001
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

ACETAMINOPHEN/CODEINE TAB [300 MG/30 MG]

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	3000006
Hospital Revenue Code	250
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

ACETAMINOPHEN/CODEINE TAB [300 MG/30 MG]

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	3000006
Hospital Revenue Code	250
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

ACETAMINOPHEN SUPP 3-6YRS [120 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000003
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

ACETAMINOPHEN SUPP 3-6YRS [120 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000003
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

ACETAMINOPHEN SUPP ADULT [650 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000002
Hospital Revenue Code	259
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

ACETAMINOPHEN SUPP ADULT [650 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000002
Hospital Revenue Code	259
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

ACETAMINOPHEN TAB [325 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000004
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

ACETAMINOPHEN TAB [325 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000004
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

ACETAMINOPHEN TAB [500 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3007044
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

ACETAMINOPHEN TAB [500 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3007044
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

ACETYLCYSTEINE INH [20%] 30 ML

Facility

$8.00

Service Code	HCPCS J7608
Hospital Charge Code	3000007
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

ACETYLCYSTEINE INH [20%] 30 ML

Facility

$8.00

Service Code	HCPCS J7608
Hospital Charge Code	3000007
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

ACETYLCYSTEINE INJ (200MG/ML) 30ML

Facility

$665.00

Service Code	HCPCS J0132
Hospital Charge Code	3007141
Hospital Revenue Code	250
Min. Negotiated Rate	$465.50
Max. Negotiated Rate	$665.00
Rate for Payer: Aetna Commercial	$631.75
Rate for Payer: Aetna Medicare	$598.50
Rate for Payer: BCBS MT CHIP	$598.50
Rate for Payer: BCBS MT Closed Plan Network	$631.75
Rate for Payer: BCBS MT HealthLink	$598.50
Rate for Payer: BCBS MT Medicare	$598.50
Rate for Payer: BCBS MT POS	$631.75
Rate for Payer: BCBS MT Traditional	$665.00
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cigna Commercial	$631.75
Rate for Payer: Cigna Medicare	$598.50
Rate for Payer: Medicaid All Medicaid	$611.80
Rate for Payer: Medicare All Medicare	$465.50
Rate for Payer: Monida Allegiance	$631.75
Rate for Payer: Monida First Choice Health	$645.05
Rate for Payer: Monida Montana Health Co-op	$631.75
Rate for Payer: Monida PacificSource	$631.75

ACETYLCYSTEINE INJ (200MG/ML) 30ML

Facility

$665.00

Service Code	HCPCS J0132
Hospital Charge Code	3007141
Hospital Revenue Code	250
Min. Negotiated Rate	$465.50
Max. Negotiated Rate	$665.00
Rate for Payer: Aetna Commercial	$631.75
Rate for Payer: Aetna Medicare	$598.50
Rate for Payer: BCBS MT CHIP	$598.50
Rate for Payer: BCBS MT Closed Plan Network	$631.75
Rate for Payer: BCBS MT HealthLink	$598.50
Rate for Payer: BCBS MT Medicare	$598.50
Rate for Payer: BCBS MT POS	$631.75
Rate for Payer: BCBS MT Traditional	$665.00
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cigna Commercial	$631.75
Rate for Payer: Cigna Medicare	$598.50
Rate for Payer: Medicaid All Medicaid	$611.80
Rate for Payer: Medicare All Medicare	$465.50
Rate for Payer: Monida Allegiance	$631.75
Rate for Payer: Monida First Choice Health	$645.05
Rate for Payer: Monida Montana Health Co-op	$631.75
Rate for Payer: Monida PacificSource	$631.75

ACETYL-L-CARNITINE [500 MG] NF

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

ACETYL-L-CARNITINE [500 MG] NF

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

.ACID FAST STAIN

Facility

$55.00

Service Code	HCPCS 87206
Hospital Charge Code	4087206
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

.ACID FAST STAIN

Facility

$55.00

Service Code	HCPCS 87206
Hospital Charge Code	4087206
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

Know your out-of-pocket cost for care.

All Charges