Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

BB ADMINISTRATION BLOOD/DAY

Facility

$668.00

Service Code	CPT 36430
Hospital Charge Code	4330041
Hospital Revenue Code	391
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$668.00
Rate for Payer: Aetna Commercial	$634.60
Rate for Payer: Aetna Medicare	$601.20
Rate for Payer: BCBS MT CHIP	$601.20
Rate for Payer: BCBS MT Closed Plan Network	$634.60
Rate for Payer: BCBS MT HealthLink	$601.20
Rate for Payer: BCBS MT Medicare	$601.20
Rate for Payer: BCBS MT POS	$634.60
Rate for Payer: BCBS MT Traditional	$668.00
Rate for Payer: Cash Price	$601.20
Rate for Payer: Cigna Commercial	$634.60
Rate for Payer: Cigna Medicare	$601.20
Rate for Payer: Medicaid All Medicaid	$614.56
Rate for Payer: Medicare All Medicare	$467.60
Rate for Payer: Monida Allegiance	$634.60
Rate for Payer: Monida First Choice Health	$647.96
Rate for Payer: Monida Montana Health Co-op	$634.60
Rate for Payer: Monida PacificSource	$634.60

BB ADMINISTRATION BLOOD/DAY

Facility

$668.00

Service Code	CPT 36430
Hospital Charge Code	4330041
Hospital Revenue Code	391
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$668.00
Rate for Payer: Aetna Commercial	$634.60
Rate for Payer: Aetna Medicare	$601.20
Rate for Payer: BCBS MT CHIP	$601.20
Rate for Payer: BCBS MT Closed Plan Network	$634.60
Rate for Payer: BCBS MT HealthLink	$601.20
Rate for Payer: BCBS MT Medicare	$601.20
Rate for Payer: BCBS MT POS	$634.60
Rate for Payer: BCBS MT Traditional	$668.00
Rate for Payer: Cash Price	$601.20
Rate for Payer: Cigna Commercial	$634.60
Rate for Payer: Cigna Medicare	$601.20
Rate for Payer: Medicaid All Medicaid	$614.56
Rate for Payer: Medicare All Medicare	$467.60
Rate for Payer: Monida Allegiance	$634.60
Rate for Payer: Monida First Choice Health	$647.96
Rate for Payer: Monida Montana Health Co-op	$634.60
Rate for Payer: Monida PacificSource	$634.60

BB BLOOD PACKED CELLS

Facility

$699.00

Service Code	HCPCS P9016
Hospital Charge Code	4330040
Hospital Revenue Code	381
Min. Negotiated Rate	$489.30
Max. Negotiated Rate	$699.00
Rate for Payer: Aetna Commercial	$664.05
Rate for Payer: Aetna Medicare	$629.10
Rate for Payer: BCBS MT CHIP	$629.10
Rate for Payer: BCBS MT Closed Plan Network	$664.05
Rate for Payer: BCBS MT HealthLink	$629.10
Rate for Payer: BCBS MT Medicare	$629.10
Rate for Payer: BCBS MT POS	$664.05
Rate for Payer: BCBS MT Traditional	$699.00
Rate for Payer: Cash Price	$629.10
Rate for Payer: Cigna Commercial	$664.05
Rate for Payer: Cigna Medicare	$629.10
Rate for Payer: Medicaid All Medicaid	$643.08
Rate for Payer: Medicare All Medicare	$489.30
Rate for Payer: Monida Allegiance	$664.05
Rate for Payer: Monida First Choice Health	$678.03
Rate for Payer: Monida Montana Health Co-op	$664.05
Rate for Payer: Monida PacificSource	$664.05

BB BLOOD PACKED CELLS

Facility

$699.00

Service Code	HCPCS P9016
Hospital Charge Code	4330040
Hospital Revenue Code	381
Min. Negotiated Rate	$489.30
Max. Negotiated Rate	$699.00
Rate for Payer: Aetna Commercial	$664.05
Rate for Payer: Aetna Medicare	$629.10
Rate for Payer: BCBS MT CHIP	$629.10
Rate for Payer: BCBS MT Closed Plan Network	$664.05
Rate for Payer: BCBS MT HealthLink	$629.10
Rate for Payer: BCBS MT Medicare	$629.10
Rate for Payer: BCBS MT POS	$664.05
Rate for Payer: BCBS MT Traditional	$699.00
Rate for Payer: Cash Price	$629.10
Rate for Payer: Cigna Commercial	$664.05
Rate for Payer: Cigna Medicare	$629.10
Rate for Payer: Medicaid All Medicaid	$643.08
Rate for Payer: Medicare All Medicare	$489.30
Rate for Payer: Monida Allegiance	$664.05
Rate for Payer: Monida First Choice Health	$678.03
Rate for Payer: Monida Montana Health Co-op	$664.05
Rate for Payer: Monida PacificSource	$664.05

.B CELLS, TOTAL COUNT

Facility

$133.00

Service Code	CPT 86355
Hospital Charge Code	4086355
Hospital Revenue Code	302
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

.B CELLS, TOTAL COUNT

Facility

$133.00

Service Code	CPT 86355
Hospital Charge Code	4086355
Hospital Revenue Code	302
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

.B CELLS, TOTAL COUNT (506049)

Facility

$303.00

Service Code	CPT 86356
Hospital Charge Code	4063552
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

.B CELLS, TOTAL COUNT (506049)

Facility

$303.00

Service Code	CPT 86356
Hospital Charge Code	4063552
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

BD ECLIPSE SAFETY NEEDLE 21 G

Facility

$14.32

Hospital Charge Code	90195590
Hospital Revenue Code	270
Min. Negotiated Rate	$10.02
Max. Negotiated Rate	$14.32
Rate for Payer: Aetna Commercial	$13.60
Rate for Payer: Aetna Medicare	$12.89
Rate for Payer: BCBS MT CHIP	$12.89
Rate for Payer: BCBS MT Closed Plan Network	$13.60
Rate for Payer: BCBS MT HealthLink	$12.89
Rate for Payer: BCBS MT Medicare	$12.89
Rate for Payer: BCBS MT POS	$13.60
Rate for Payer: BCBS MT Traditional	$14.32
Rate for Payer: Cash Price	$12.89
Rate for Payer: Cigna Commercial	$13.60
Rate for Payer: Cigna Medicare	$12.89
Rate for Payer: Medicaid All Medicaid	$13.17
Rate for Payer: Medicare All Medicare	$10.02
Rate for Payer: Monida Allegiance	$13.60
Rate for Payer: Monida First Choice Health	$13.89
Rate for Payer: Monida Montana Health Co-op	$13.60
Rate for Payer: Monida PacificSource	$13.60

BD ECLIPSE SAFETY NEEDLE 21 G

Facility

$14.32

Hospital Charge Code	90195590
Hospital Revenue Code	270
Min. Negotiated Rate	$10.02
Max. Negotiated Rate	$14.32
Rate for Payer: Aetna Commercial	$13.60
Rate for Payer: Aetna Medicare	$12.89
Rate for Payer: BCBS MT CHIP	$12.89
Rate for Payer: BCBS MT Closed Plan Network	$13.60
Rate for Payer: BCBS MT HealthLink	$12.89
Rate for Payer: BCBS MT Medicare	$12.89
Rate for Payer: BCBS MT POS	$13.60
Rate for Payer: BCBS MT Traditional	$14.32
Rate for Payer: Cash Price	$12.89
Rate for Payer: Cigna Commercial	$13.60
Rate for Payer: Cigna Medicare	$12.89
Rate for Payer: Medicaid All Medicaid	$13.17
Rate for Payer: Medicare All Medicare	$10.02
Rate for Payer: Monida Allegiance	$13.60
Rate for Payer: Monida First Choice Health	$13.89
Rate for Payer: Monida Montana Health Co-op	$13.60
Rate for Payer: Monida PacificSource	$13.60

BD MICROTAINER LAVENDER K2 ED

Facility

$29.08

Hospital Charge Code	90195123
Hospital Revenue Code	270
Min. Negotiated Rate	$20.36
Max. Negotiated Rate	$29.08
Rate for Payer: Aetna Commercial	$27.63
Rate for Payer: Aetna Medicare	$26.17
Rate for Payer: BCBS MT CHIP	$26.17
Rate for Payer: BCBS MT Closed Plan Network	$27.63
Rate for Payer: BCBS MT HealthLink	$26.17
Rate for Payer: BCBS MT Medicare	$26.17
Rate for Payer: BCBS MT POS	$27.63
Rate for Payer: BCBS MT Traditional	$29.08
Rate for Payer: Cash Price	$26.17
Rate for Payer: Cigna Commercial	$27.63
Rate for Payer: Cigna Medicare	$26.17
Rate for Payer: Medicaid All Medicaid	$26.75
Rate for Payer: Medicare All Medicare	$20.36
Rate for Payer: Monida Allegiance	$27.63
Rate for Payer: Monida First Choice Health	$28.21
Rate for Payer: Monida Montana Health Co-op	$27.63
Rate for Payer: Monida PacificSource	$27.63

BD MICROTAINER LAVENDER K2 ED

Facility

$29.08

Hospital Charge Code	90195123
Hospital Revenue Code	270
Min. Negotiated Rate	$20.36
Max. Negotiated Rate	$29.08
Rate for Payer: Aetna Commercial	$27.63
Rate for Payer: Aetna Medicare	$26.17
Rate for Payer: BCBS MT CHIP	$26.17
Rate for Payer: BCBS MT Closed Plan Network	$27.63
Rate for Payer: BCBS MT HealthLink	$26.17
Rate for Payer: BCBS MT Medicare	$26.17
Rate for Payer: BCBS MT POS	$27.63
Rate for Payer: BCBS MT Traditional	$29.08
Rate for Payer: Cash Price	$26.17
Rate for Payer: Cigna Commercial	$27.63
Rate for Payer: Cigna Medicare	$26.17
Rate for Payer: Medicaid All Medicaid	$26.75
Rate for Payer: Medicare All Medicare	$20.36
Rate for Payer: Monida Allegiance	$27.63
Rate for Payer: Monida First Choice Health	$28.21
Rate for Payer: Monida Montana Health Co-op	$27.63
Rate for Payer: Monida PacificSource	$27.63

BD MICROTAINER MINT GREEN LI

Facility

$29.13

Hospital Charge Code	90195129
Hospital Revenue Code	270
Min. Negotiated Rate	$20.39
Max. Negotiated Rate	$29.13
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Aetna Medicare	$26.22
Rate for Payer: BCBS MT CHIP	$26.22
Rate for Payer: BCBS MT Closed Plan Network	$27.67
Rate for Payer: BCBS MT HealthLink	$26.22
Rate for Payer: BCBS MT Medicare	$26.22
Rate for Payer: BCBS MT POS	$27.67
Rate for Payer: BCBS MT Traditional	$29.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Cigna Commercial	$27.67
Rate for Payer: Cigna Medicare	$26.22
Rate for Payer: Medicaid All Medicaid	$26.80
Rate for Payer: Medicare All Medicare	$20.39
Rate for Payer: Monida Allegiance	$27.67
Rate for Payer: Monida First Choice Health	$28.26
Rate for Payer: Monida Montana Health Co-op	$27.67
Rate for Payer: Monida PacificSource	$27.67

BD MICROTAINER MINT GREEN LI

Facility

$29.13

Hospital Charge Code	90195129
Hospital Revenue Code	270
Min. Negotiated Rate	$20.39
Max. Negotiated Rate	$29.13
Rate for Payer: Aetna Commercial	$27.67
Rate for Payer: Aetna Medicare	$26.22
Rate for Payer: BCBS MT CHIP	$26.22
Rate for Payer: BCBS MT Closed Plan Network	$27.67
Rate for Payer: BCBS MT HealthLink	$26.22
Rate for Payer: BCBS MT Medicare	$26.22
Rate for Payer: BCBS MT POS	$27.67
Rate for Payer: BCBS MT Traditional	$29.13
Rate for Payer: Cash Price	$26.22
Rate for Payer: Cigna Commercial	$27.67
Rate for Payer: Cigna Medicare	$26.22
Rate for Payer: Medicaid All Medicaid	$26.80
Rate for Payer: Medicare All Medicare	$20.39
Rate for Payer: Monida Allegiance	$27.67
Rate for Payer: Monida First Choice Health	$28.26
Rate for Payer: Monida Montana Health Co-op	$27.67
Rate for Payer: Monida PacificSource	$27.67

BD VACUTAINER GRAY NAFL/KOX

Facility

$12.60

Hospital Charge Code	90195131
Hospital Revenue Code	270
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna Commercial	$11.97
Rate for Payer: Aetna Medicare	$11.34
Rate for Payer: BCBS MT CHIP	$11.34
Rate for Payer: BCBS MT Closed Plan Network	$11.97
Rate for Payer: BCBS MT HealthLink	$11.34
Rate for Payer: BCBS MT Medicare	$11.34
Rate for Payer: BCBS MT POS	$11.97
Rate for Payer: BCBS MT Traditional	$12.60
Rate for Payer: Cash Price	$11.34
Rate for Payer: Cigna Commercial	$11.97
Rate for Payer: Cigna Medicare	$11.34
Rate for Payer: Medicaid All Medicaid	$11.59
Rate for Payer: Medicare All Medicare	$8.82
Rate for Payer: Monida Allegiance	$11.97
Rate for Payer: Monida First Choice Health	$12.22
Rate for Payer: Monida Montana Health Co-op	$11.97
Rate for Payer: Monida PacificSource	$11.97

BD VACUTAINER GRAY NAFL/KOX

Facility

$12.60

Hospital Charge Code	90195131
Hospital Revenue Code	270
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna Commercial	$11.97
Rate for Payer: Aetna Medicare	$11.34
Rate for Payer: BCBS MT CHIP	$11.34
Rate for Payer: BCBS MT Closed Plan Network	$11.97
Rate for Payer: BCBS MT HealthLink	$11.34
Rate for Payer: BCBS MT Medicare	$11.34
Rate for Payer: BCBS MT POS	$11.97
Rate for Payer: BCBS MT Traditional	$12.60
Rate for Payer: Cash Price	$11.34
Rate for Payer: Cigna Commercial	$11.97
Rate for Payer: Cigna Medicare	$11.34
Rate for Payer: Medicaid All Medicaid	$11.59
Rate for Payer: Medicare All Medicare	$8.82
Rate for Payer: Monida Allegiance	$11.97
Rate for Payer: Monida First Choice Health	$12.22
Rate for Payer: Monida Montana Health Co-op	$11.97
Rate for Payer: Monida PacificSource	$11.97

BENZION SWAB

Facility

$4.00

Hospital Charge Code	80040107
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

BENZION SWAB

Facility

$4.00

Hospital Charge Code	80040107
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

BENZOCAINE 14%/BUTAMBEN 2%/TETRACAINE 2%

Facility

$1,300.00

Service Code	HCPCS J3490
Hospital Charge Code	3000609
Hospital Revenue Code	250
Min. Negotiated Rate	$910.00
Max. Negotiated Rate	$1,300.00
Rate for Payer: Aetna Commercial	$1,235.00
Rate for Payer: Aetna Medicare	$1,170.00
Rate for Payer: BCBS MT CHIP	$1,170.00
Rate for Payer: BCBS MT Closed Plan Network	$1,235.00
Rate for Payer: BCBS MT HealthLink	$1,170.00
Rate for Payer: BCBS MT Medicare	$1,170.00
Rate for Payer: BCBS MT POS	$1,235.00
Rate for Payer: BCBS MT Traditional	$1,300.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cigna Commercial	$1,235.00
Rate for Payer: Cigna Medicare	$1,170.00
Rate for Payer: Medicaid All Medicaid	$1,196.00
Rate for Payer: Medicare All Medicare	$910.00
Rate for Payer: Monida Allegiance	$1,235.00
Rate for Payer: Monida First Choice Health	$1,261.00
Rate for Payer: Monida Montana Health Co-op	$1,235.00
Rate for Payer: Monida PacificSource	$1,235.00

BENZOCAINE 14%/BUTAMBEN 2%/TETRACAINE 2%

Facility

$1,300.00

Service Code	HCPCS J3490
Hospital Charge Code	3000609
Hospital Revenue Code	250
Min. Negotiated Rate	$910.00
Max. Negotiated Rate	$1,300.00
Rate for Payer: Aetna Commercial	$1,235.00
Rate for Payer: Aetna Medicare	$1,170.00
Rate for Payer: BCBS MT CHIP	$1,170.00
Rate for Payer: BCBS MT Closed Plan Network	$1,235.00
Rate for Payer: BCBS MT HealthLink	$1,170.00
Rate for Payer: BCBS MT Medicare	$1,170.00
Rate for Payer: BCBS MT POS	$1,235.00
Rate for Payer: BCBS MT Traditional	$1,300.00
Rate for Payer: Cash Price	$1,170.00
Rate for Payer: Cigna Commercial	$1,235.00
Rate for Payer: Cigna Medicare	$1,170.00
Rate for Payer: Medicaid All Medicaid	$1,196.00
Rate for Payer: Medicare All Medicare	$910.00
Rate for Payer: Monida Allegiance	$1,235.00
Rate for Payer: Monida First Choice Health	$1,261.00
Rate for Payer: Monida Montana Health Co-op	$1,235.00
Rate for Payer: Monida PacificSource	$1,235.00

BENZONATATE CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000050
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

BENZONATATE CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000050
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

.BETA-2 GLYCOPROTEIN 1 AB, IGA

Facility

$87.00

Service Code	CPT 86146
Hospital Charge Code	4061461
Hospital Revenue Code	307
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

.BETA-2 GLYCOPROTEIN 1 AB, IGA

Facility

$87.00

Service Code	CPT 86146
Hospital Charge Code	4061461
Hospital Revenue Code	307
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

Know your out-of-pocket cost for care.

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