Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TTG ANTIBODY, IGA (164640)

Facility

$79.00

Service Code	HCPCS 86364
Hospital Charge Code	4000071
Hospital Revenue Code	301
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

TTG ANTIBODY, IGA (164640)

Facility

$79.00

Service Code	HCPCS 86364
Hospital Charge Code	4000071
Hospital Revenue Code	301
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

TTG ANTIBODY, IGG (164988)

Facility

$84.00

Service Code	HCPCS 86364
Hospital Charge Code	4000072
Hospital Revenue Code	301
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

TTG ANTIBODY, IGG (164988)

Facility

$84.00

Service Code	HCPCS 86364
Hospital Charge Code	4000072
Hospital Revenue Code	301
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

TUBERCULOSIS TEST INTRADERMAL

Facility

$56.00

Service Code	HCPCS 86580
Hospital Charge Code	3000492
Hospital Revenue Code	302
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

TUBERCULOSIS TEST INTRADERMAL

Facility

$56.00

Service Code	HCPCS 86580
Hospital Charge Code	3000492
Hospital Revenue Code	302
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

TUBERSOL PPD INJ [5 TU/0.1 ML]

Facility

$38.00

Service Code	HCPCS 86580
Hospital Charge Code	3000463
Hospital Revenue Code	302
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

TUBERSOL PPD INJ [5 TU/0.1 ML]

Facility

$38.00

Service Code	HCPCS 86580
Hospital Charge Code	3000463
Hospital Revenue Code	302
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

TUBING FILTER

Facility

$59.00

Hospital Charge Code	80030208
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

TUBING FILTER

Facility

$59.00

Hospital Charge Code	80030208
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

TUBING PRIMARY HOSPIRA PLUM

Facility

$27.00

Hospital Charge Code	80030897
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

TUBING PRIMARY HOSPIRA PLUM

Facility

$27.00

Hospital Charge Code	80030897
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

TUBING SECONDARY HOSPIRA PLUM

Facility

$13.00

Hospital Charge Code	90030898
Hospital Revenue Code	270
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

TUBING SECONDARY HOSPIRA PLUM

Facility

$13.00

Hospital Charge Code	90030898
Hospital Revenue Code	270
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

TUCKS MEDICATED COOLING PADS

Facility

$12.45

Service Code	NDC 41388000732
Hospital Charge Code	3007354
Hospital Revenue Code	250
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$12.45
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Aetna Medicare	$11.21
Rate for Payer: BCBS MT CHIP	$11.21
Rate for Payer: BCBS MT Closed Plan Network	$11.83
Rate for Payer: BCBS MT HealthLink	$11.21
Rate for Payer: BCBS MT Medicare	$11.21
Rate for Payer: BCBS MT POS	$11.83
Rate for Payer: BCBS MT Traditional	$12.45
Rate for Payer: Cash Price	$11.21
Rate for Payer: Cigna Commercial	$11.83
Rate for Payer: Cigna Medicare	$11.21
Rate for Payer: Medicaid All Medicaid	$11.45
Rate for Payer: Medicare All Medicare	$8.71
Rate for Payer: Monida Allegiance	$11.83
Rate for Payer: Monida First Choice Health	$12.08
Rate for Payer: Monida Montana Health Co-op	$11.83
Rate for Payer: Monida PacificSource	$11.83

TUCKS MEDICATED COOLING PADS

Facility

$12.45

Service Code	NDC 41388000732
Hospital Charge Code	3007354
Hospital Revenue Code	250
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$12.45
Rate for Payer: Aetna Commercial	$11.83
Rate for Payer: Aetna Medicare	$11.21
Rate for Payer: BCBS MT CHIP	$11.21
Rate for Payer: BCBS MT Closed Plan Network	$11.83
Rate for Payer: BCBS MT HealthLink	$11.21
Rate for Payer: BCBS MT Medicare	$11.21
Rate for Payer: BCBS MT POS	$11.83
Rate for Payer: BCBS MT Traditional	$12.45
Rate for Payer: Cash Price	$11.21
Rate for Payer: Cigna Commercial	$11.83
Rate for Payer: Cigna Medicare	$11.21
Rate for Payer: Medicaid All Medicaid	$11.45
Rate for Payer: Medicare All Medicare	$8.71
Rate for Payer: Monida Allegiance	$11.83
Rate for Payer: Monida First Choice Health	$12.08
Rate for Payer: Monida Montana Health Co-op	$11.83
Rate for Payer: Monida PacificSource	$11.83

TX DISLOC JT W/O ANES W/MANIP CLO

Facility

$642.00

Hospital Charge Code	8126770
Hospital Revenue Code	520
Min. Negotiated Rate	$449.40
Max. Negotiated Rate	$642.00
Rate for Payer: Aetna Commercial	$609.90
Rate for Payer: Aetna Medicare	$577.80
Rate for Payer: BCBS MT CHIP	$577.80
Rate for Payer: BCBS MT Closed Plan Network	$609.90
Rate for Payer: BCBS MT HealthLink	$577.80
Rate for Payer: BCBS MT Medicare	$577.80
Rate for Payer: BCBS MT POS	$609.90
Rate for Payer: BCBS MT Traditional	$642.00
Rate for Payer: Cash Price	$577.80
Rate for Payer: Cigna Commercial	$609.90
Rate for Payer: Cigna Medicare	$577.80
Rate for Payer: Medicaid All Medicaid	$590.64
Rate for Payer: Medicare All Medicare	$449.40
Rate for Payer: Monida Allegiance	$609.90
Rate for Payer: Monida First Choice Health	$622.74
Rate for Payer: Monida Montana Health Co-op	$609.90
Rate for Payer: Monida PacificSource	$609.90

TX DISLOC JT W/O ANES W/MANIP CLO

Facility

$642.00

Hospital Charge Code	8126770
Hospital Revenue Code	520
Min. Negotiated Rate	$449.40
Max. Negotiated Rate	$642.00
Rate for Payer: Aetna Commercial	$609.90
Rate for Payer: Aetna Medicare	$577.80
Rate for Payer: BCBS MT CHIP	$577.80
Rate for Payer: BCBS MT Closed Plan Network	$609.90
Rate for Payer: BCBS MT HealthLink	$577.80
Rate for Payer: BCBS MT Medicare	$577.80
Rate for Payer: BCBS MT POS	$609.90
Rate for Payer: BCBS MT Traditional	$642.00
Rate for Payer: Cash Price	$577.80
Rate for Payer: Cigna Commercial	$609.90
Rate for Payer: Cigna Medicare	$577.80
Rate for Payer: Medicaid All Medicaid	$590.64
Rate for Payer: Medicare All Medicare	$449.40
Rate for Payer: Monida Allegiance	$609.90
Rate for Payer: Monida First Choice Health	$622.74
Rate for Payer: Monida Montana Health Co-op	$609.90
Rate for Payer: Monida PacificSource	$609.90

ULTRASENSITIVE PSA

Facility

$89.00

Service Code	HCPCS 84153
Hospital Charge Code	4087936
Hospital Revenue Code	301
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

ULTRASENSITIVE PSA

Facility

$89.00

Service Code	HCPCS 84153
Hospital Charge Code	4087936
Hospital Revenue Code	301
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

UMECLIDINIUM/VILANTEROL [62.5/25MCG] NF

Facility

$452.00

Service Code	NDC 00173086906
Hospital Charge Code	3007458
Hospital Revenue Code	250
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

UMECLIDINIUM/VILANTEROL [62.5/25MCG] NF

Facility

$452.00

Service Code	NDC 00173086906
Hospital Charge Code	3007458
Hospital Revenue Code	250
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

UNLISTED PROC, NERVOUS SYSTEM 64999

Facility

$1,588.00

Service Code	HCPCS 64999
Hospital Charge Code	1564999
Hospital Revenue Code	761
Min. Negotiated Rate	$1,111.60
Max. Negotiated Rate	$1,588.00
Rate for Payer: Aetna Commercial	$1,508.60
Rate for Payer: Aetna Medicare	$1,429.20
Rate for Payer: BCBS MT CHIP	$1,429.20
Rate for Payer: BCBS MT Closed Plan Network	$1,508.60
Rate for Payer: BCBS MT HealthLink	$1,429.20
Rate for Payer: BCBS MT Medicare	$1,429.20
Rate for Payer: BCBS MT POS	$1,508.60
Rate for Payer: BCBS MT Traditional	$1,588.00
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Cigna Commercial	$1,508.60
Rate for Payer: Cigna Medicare	$1,429.20
Rate for Payer: Medicaid All Medicaid	$1,460.96
Rate for Payer: Medicare All Medicare	$1,111.60
Rate for Payer: Monida Allegiance	$1,508.60
Rate for Payer: Monida First Choice Health	$1,540.36
Rate for Payer: Monida Montana Health Co-op	$1,508.60
Rate for Payer: Monida PacificSource	$1,508.60

UNLISTED PROC, NERVOUS SYSTEM 64999

Facility

$1,588.00

Service Code	HCPCS 64999
Hospital Charge Code	1564999
Hospital Revenue Code	761
Min. Negotiated Rate	$1,111.60
Max. Negotiated Rate	$1,588.00
Rate for Payer: Aetna Commercial	$1,508.60
Rate for Payer: Aetna Medicare	$1,429.20
Rate for Payer: BCBS MT CHIP	$1,429.20
Rate for Payer: BCBS MT Closed Plan Network	$1,508.60
Rate for Payer: BCBS MT HealthLink	$1,429.20
Rate for Payer: BCBS MT Medicare	$1,429.20
Rate for Payer: BCBS MT POS	$1,508.60
Rate for Payer: BCBS MT Traditional	$1,588.00
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Cigna Commercial	$1,508.60
Rate for Payer: Cigna Medicare	$1,429.20
Rate for Payer: Medicaid All Medicaid	$1,460.96
Rate for Payer: Medicare All Medicare	$1,111.60
Rate for Payer: Monida Allegiance	$1,508.60
Rate for Payer: Monida First Choice Health	$1,540.36
Rate for Payer: Monida Montana Health Co-op	$1,508.60
Rate for Payer: Monida PacificSource	$1,508.60

UNLISTED PSYCIATRIC PRO/THERAPY

Facility

$240.00

Service Code	HCPCS 90899
Hospital Charge Code	8090899
Hospital Revenue Code	900
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

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