Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

THUMB SPICA SPLINT RIGHT LG/X

Facility

$53.00

Hospital Charge Code	2893527
Hospital Revenue Code	290
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

THUMB SPICA SPLINT RIGHT SM/ME

Facility

$53.00

Hospital Charge Code	2893526
Hospital Revenue Code	290
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

THUMB SPICA SPLINT RIGHT SM/ME

Facility

$53.00

Hospital Charge Code	2893526
Hospital Revenue Code	290
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

THYROGLOBULIN ANTIBODY (006685)

Facility

$73.00

Service Code	HCPCS 86800
Hospital Charge Code	4086800
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

THYROGLOBULIN ANTIBODY (006685)

Facility

$73.00

Service Code	HCPCS 86800
Hospital Charge Code	4086800
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

THYROGLOBULIN ANTIBODY, REFLEX (042045)

Facility

$73.00

Service Code	HCPCS 86800
Hospital Charge Code	4068001
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

THYROGLOBULIN ANTIBODY, REFLEX (042045)

Facility

$73.00

Service Code	HCPCS 86800
Hospital Charge Code	4068001
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

THYROID AUTOANTIBODIES PROFILE

Facility

$43.00

Service Code	HCPCS 86376
Hospital Charge Code	4087939
Hospital Revenue Code	300
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

THYROID AUTOANTIBODIES PROFILE

Facility

$43.00

Service Code	HCPCS 86376
Hospital Charge Code	4087939
Hospital Revenue Code	300
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

THYROID PEROXIDASE ANTIBODIES (006676)

Facility

$71.00

Service Code	HCPCS 86376
Hospital Charge Code	4086376
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

THYROID PEROXIDASE ANTIBODIES (006676)

Facility

$71.00

Service Code	HCPCS 86376
Hospital Charge Code	4086376
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

THYROID STIMULATING IMMUNOGLOBULIN

Facility

$124.00

Service Code	HCPCS 84445
Hospital Charge Code	4087946
Hospital Revenue Code	300
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

THYROID STIMULATING IMMUNOGLOBULIN

Facility

$124.00

Service Code	HCPCS 84445
Hospital Charge Code	4087946
Hospital Revenue Code	300
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

THYROTROPIN RECEPTOR ANTIBODY

Facility

$95.85

Service Code	HCPCS 83520
Hospital Charge Code	4087912
Hospital Revenue Code	300
Min. Negotiated Rate	$67.09
Max. Negotiated Rate	$95.85
Rate for Payer: Aetna Commercial	$91.06
Rate for Payer: Aetna Medicare	$86.27
Rate for Payer: BCBS MT CHIP	$86.27
Rate for Payer: BCBS MT Closed Plan Network	$91.06
Rate for Payer: BCBS MT HealthLink	$86.27
Rate for Payer: BCBS MT Medicare	$86.27
Rate for Payer: BCBS MT POS	$91.06
Rate for Payer: BCBS MT Traditional	$95.85
Rate for Payer: Cash Price	$86.27
Rate for Payer: Cigna Commercial	$91.06
Rate for Payer: Cigna Medicare	$86.27
Rate for Payer: Medicaid All Medicaid	$88.18
Rate for Payer: Medicare All Medicare	$67.09
Rate for Payer: Monida Allegiance	$91.06
Rate for Payer: Monida First Choice Health	$92.97
Rate for Payer: Monida Montana Health Co-op	$91.06
Rate for Payer: Monida PacificSource	$91.06

THYROTROPIN RECEPTOR ANTIBODY

Facility

$95.85

Service Code	HCPCS 83520
Hospital Charge Code	4087912
Hospital Revenue Code	300
Min. Negotiated Rate	$67.09
Max. Negotiated Rate	$95.85
Rate for Payer: Aetna Commercial	$91.06
Rate for Payer: Aetna Medicare	$86.27
Rate for Payer: BCBS MT CHIP	$86.27
Rate for Payer: BCBS MT Closed Plan Network	$91.06
Rate for Payer: BCBS MT HealthLink	$86.27
Rate for Payer: BCBS MT Medicare	$86.27
Rate for Payer: BCBS MT POS	$91.06
Rate for Payer: BCBS MT Traditional	$95.85
Rate for Payer: Cash Price	$86.27
Rate for Payer: Cigna Commercial	$91.06
Rate for Payer: Cigna Medicare	$86.27
Rate for Payer: Medicaid All Medicaid	$88.18
Rate for Payer: Medicare All Medicare	$67.09
Rate for Payer: Monida Allegiance	$91.06
Rate for Payer: Monida First Choice Health	$92.97
Rate for Payer: Monida Montana Health Co-op	$91.06
Rate for Payer: Monida PacificSource	$91.06

TIBC ASSAY

Facility

$185.00

Hospital Charge Code	90197102
Hospital Revenue Code	270
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$185.00
Rate for Payer: Aetna Commercial	$175.75
Rate for Payer: Aetna Medicare	$166.50
Rate for Payer: BCBS MT CHIP	$166.50
Rate for Payer: BCBS MT Closed Plan Network	$175.75
Rate for Payer: BCBS MT HealthLink	$166.50
Rate for Payer: BCBS MT Medicare	$166.50
Rate for Payer: BCBS MT POS	$175.75
Rate for Payer: BCBS MT Traditional	$185.00
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cigna Commercial	$175.75
Rate for Payer: Cigna Medicare	$166.50
Rate for Payer: Medicaid All Medicaid	$170.20
Rate for Payer: Medicare All Medicare	$129.50
Rate for Payer: Monida Allegiance	$175.75
Rate for Payer: Monida First Choice Health	$179.45
Rate for Payer: Monida Montana Health Co-op	$175.75
Rate for Payer: Monida PacificSource	$175.75

TIBC ASSAY

Facility

$185.00

Hospital Charge Code	90197102
Hospital Revenue Code	270
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$185.00
Rate for Payer: Aetna Commercial	$175.75
Rate for Payer: Aetna Medicare	$166.50
Rate for Payer: BCBS MT CHIP	$166.50
Rate for Payer: BCBS MT Closed Plan Network	$175.75
Rate for Payer: BCBS MT HealthLink	$166.50
Rate for Payer: BCBS MT Medicare	$166.50
Rate for Payer: BCBS MT POS	$175.75
Rate for Payer: BCBS MT Traditional	$185.00
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cigna Commercial	$175.75
Rate for Payer: Cigna Medicare	$166.50
Rate for Payer: Medicaid All Medicaid	$170.20
Rate for Payer: Medicare All Medicare	$129.50
Rate for Payer: Monida Allegiance	$175.75
Rate for Payer: Monida First Choice Health	$179.45
Rate for Payer: Monida Montana Health Co-op	$175.75
Rate for Payer: Monida PacificSource	$175.75

TICAGRELOR TAB [90 MG]

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	3000450
Hospital Revenue Code	250
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

TICAGRELOR TAB [90 MG]

Facility

$29.00

Service Code	HCPCS J3490
Hospital Charge Code	3000450
Hospital Revenue Code	250
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

TIMOLOL MAL OPTH GTTS [0.5%] NF

Facility

$700.00

Service Code	HCPCS J3490
Hospital Charge Code	3000451
Hospital Revenue Code	250
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

TIMOLOL MAL OPTH GTTS [0.5%] NF

Facility

$700.00

Service Code	HCPCS J3490
Hospital Charge Code	3000451
Hospital Revenue Code	250
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

TIOTROPIUM BROMIDE INH [18 MCG] 30-DAY

Facility

$397.00

Service Code	HCPCS J3490
Hospital Charge Code	3000452
Hospital Revenue Code	259
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$397.00
Rate for Payer: Aetna Commercial	$377.15
Rate for Payer: Aetna Medicare	$357.30
Rate for Payer: BCBS MT CHIP	$357.30
Rate for Payer: BCBS MT Closed Plan Network	$377.15
Rate for Payer: BCBS MT HealthLink	$357.30
Rate for Payer: BCBS MT Medicare	$357.30
Rate for Payer: BCBS MT POS	$377.15
Rate for Payer: BCBS MT Traditional	$397.00
Rate for Payer: Cash Price	$357.30
Rate for Payer: Cigna Commercial	$377.15
Rate for Payer: Cigna Medicare	$357.30
Rate for Payer: Medicaid All Medicaid	$365.24
Rate for Payer: Medicare All Medicare	$277.90
Rate for Payer: Monida Allegiance	$377.15
Rate for Payer: Monida First Choice Health	$385.09
Rate for Payer: Monida Montana Health Co-op	$377.15
Rate for Payer: Monida PacificSource	$377.15

TIOTROPIUM BROMIDE INH [18 MCG] 30-DAY

Facility

$397.00

Service Code	HCPCS J3490
Hospital Charge Code	3000452
Hospital Revenue Code	259
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$397.00
Rate for Payer: Aetna Commercial	$377.15
Rate for Payer: Aetna Medicare	$357.30
Rate for Payer: BCBS MT CHIP	$357.30
Rate for Payer: BCBS MT Closed Plan Network	$377.15
Rate for Payer: BCBS MT HealthLink	$357.30
Rate for Payer: BCBS MT Medicare	$357.30
Rate for Payer: BCBS MT POS	$377.15
Rate for Payer: BCBS MT Traditional	$397.00
Rate for Payer: Cash Price	$357.30
Rate for Payer: Cigna Commercial	$377.15
Rate for Payer: Cigna Medicare	$357.30
Rate for Payer: Medicaid All Medicaid	$365.24
Rate for Payer: Medicare All Medicare	$277.90
Rate for Payer: Monida Allegiance	$377.15
Rate for Payer: Monida First Choice Health	$385.09
Rate for Payer: Monida Montana Health Co-op	$377.15
Rate for Payer: Monida PacificSource	$377.15

TIRZEPATIDE INJ [15 MG/0.5 ML] NF

Facility

$616.00

Service Code	HCPCS J3590
Hospital Charge Code	3000584
Hospital Revenue Code	250
Min. Negotiated Rate	$431.20
Max. Negotiated Rate	$616.00
Rate for Payer: Aetna Commercial	$585.20
Rate for Payer: Aetna Medicare	$554.40
Rate for Payer: BCBS MT CHIP	$554.40
Rate for Payer: BCBS MT Closed Plan Network	$585.20
Rate for Payer: BCBS MT HealthLink	$554.40
Rate for Payer: BCBS MT Medicare	$554.40
Rate for Payer: BCBS MT POS	$585.20
Rate for Payer: BCBS MT Traditional	$616.00
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cigna Commercial	$585.20
Rate for Payer: Cigna Medicare	$554.40
Rate for Payer: Medicaid All Medicaid	$566.72
Rate for Payer: Medicare All Medicare	$431.20
Rate for Payer: Monida Allegiance	$585.20
Rate for Payer: Monida First Choice Health	$597.52
Rate for Payer: Monida Montana Health Co-op	$585.20
Rate for Payer: Monida PacificSource	$585.20

TIRZEPATIDE INJ [15 MG/0.5 ML] NF

Facility

$616.00

Service Code	HCPCS J3590
Hospital Charge Code	3000584
Hospital Revenue Code	250
Min. Negotiated Rate	$431.20
Max. Negotiated Rate	$616.00
Rate for Payer: Aetna Commercial	$585.20
Rate for Payer: Aetna Medicare	$554.40
Rate for Payer: BCBS MT CHIP	$554.40
Rate for Payer: BCBS MT Closed Plan Network	$585.20
Rate for Payer: BCBS MT HealthLink	$554.40
Rate for Payer: BCBS MT Medicare	$554.40
Rate for Payer: BCBS MT POS	$585.20
Rate for Payer: BCBS MT Traditional	$616.00
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cigna Commercial	$585.20
Rate for Payer: Cigna Medicare	$554.40
Rate for Payer: Medicaid All Medicaid	$566.72
Rate for Payer: Medicare All Medicare	$431.20
Rate for Payer: Monida Allegiance	$585.20
Rate for Payer: Monida First Choice Health	$597.52
Rate for Payer: Monida Montana Health Co-op	$585.20
Rate for Payer: Monida PacificSource	$585.20

Know your out-of-pocket cost for care.

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