Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

BIOPSY-PUNCH SINGLE LESION-11104

Facility

$208.00

Service Code	CPT 11104
Hospital Charge Code	8011104
Hospital Revenue Code	521
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

BIOPSY-SHAVE/SCOOP SNGL LESION-11102

Facility

$186.00

Service Code	CPT 11102
Hospital Charge Code	8011102
Hospital Revenue Code	521
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

BIOPSY-SHAVE/SCOOP SNGL LESION-11102

Facility

$186.00

Service Code	CPT 11102
Hospital Charge Code	8011102
Hospital Revenue Code	521
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

BIOPSY-SKIN SINGLE LESION- ER

Facility

$186.00

Service Code	CPT 11102
Hospital Charge Code	1011100
Hospital Revenue Code	450
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

BIOPSY-SKIN SINGLE LESION- ER

Facility

$186.00

Service Code	CPT 11102
Hospital Charge Code	1011100
Hospital Revenue Code	450
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

BIOPSY SUPERFICIAL FOREARM/WRIST

Facility

$648.00

Service Code	CPT 25065
Hospital Charge Code	8025065
Hospital Revenue Code	521
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna Commercial	$615.60
Rate for Payer: Aetna Medicare	$583.20
Rate for Payer: BCBS MT CHIP	$583.20
Rate for Payer: BCBS MT Closed Plan Network	$615.60
Rate for Payer: BCBS MT HealthLink	$583.20
Rate for Payer: BCBS MT Medicare	$583.20
Rate for Payer: BCBS MT POS	$615.60
Rate for Payer: BCBS MT Traditional	$648.00
Rate for Payer: Cash Price	$583.20
Rate for Payer: Cigna Commercial	$615.60
Rate for Payer: Cigna Medicare	$583.20
Rate for Payer: Medicaid All Medicaid	$596.16
Rate for Payer: Medicare All Medicare	$453.60
Rate for Payer: Monida Allegiance	$615.60
Rate for Payer: Monida First Choice Health	$628.56
Rate for Payer: Monida Montana Health Co-op	$615.60
Rate for Payer: Monida PacificSource	$615.60

BIOPSY SUPERFICIAL FOREARM/WRIST

Facility

$648.00

Service Code	CPT 25065
Hospital Charge Code	8025065
Hospital Revenue Code	521
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$648.00
Rate for Payer: Aetna Commercial	$615.60
Rate for Payer: Aetna Medicare	$583.20
Rate for Payer: BCBS MT CHIP	$583.20
Rate for Payer: BCBS MT Closed Plan Network	$615.60
Rate for Payer: BCBS MT HealthLink	$583.20
Rate for Payer: BCBS MT Medicare	$583.20
Rate for Payer: BCBS MT POS	$615.60
Rate for Payer: BCBS MT Traditional	$648.00
Rate for Payer: Cash Price	$583.20
Rate for Payer: Cigna Commercial	$615.60
Rate for Payer: Cigna Medicare	$583.20
Rate for Payer: Medicaid All Medicaid	$596.16
Rate for Payer: Medicare All Medicare	$453.60
Rate for Payer: Monida Allegiance	$615.60
Rate for Payer: Monida First Choice Health	$628.56
Rate for Payer: Monida Montana Health Co-op	$615.60
Rate for Payer: Monida PacificSource	$615.60

BIOPSY VULVA OR PERI-EA ADD LESION 56606

Facility

$254.00

Service Code	CPT 56606
Hospital Charge Code	8056606
Hospital Revenue Code	521
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

BIOPSY VULVA OR PERI-EA ADD LESION 56606

Facility

$254.00

Service Code	CPT 56606
Hospital Charge Code	8056606
Hospital Revenue Code	521
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

BIOPSY VULVA OR PERINEUM-1 LESION 56605

Facility

$594.00

Service Code	CPT 56605
Hospital Charge Code	8056605
Hospital Revenue Code	521
Min. Negotiated Rate	$415.80
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: Aetna Medicare	$534.60
Rate for Payer: BCBS MT CHIP	$534.60
Rate for Payer: BCBS MT Closed Plan Network	$564.30
Rate for Payer: BCBS MT HealthLink	$534.60
Rate for Payer: BCBS MT Medicare	$534.60
Rate for Payer: BCBS MT POS	$564.30
Rate for Payer: BCBS MT Traditional	$594.00
Rate for Payer: Cash Price	$534.60
Rate for Payer: Cigna Commercial	$564.30
Rate for Payer: Cigna Medicare	$534.60
Rate for Payer: Medicaid All Medicaid	$546.48
Rate for Payer: Medicare All Medicare	$415.80
Rate for Payer: Monida Allegiance	$564.30
Rate for Payer: Monida First Choice Health	$576.18
Rate for Payer: Monida Montana Health Co-op	$564.30
Rate for Payer: Monida PacificSource	$564.30

BIOPSY VULVA OR PERINEUM-1 LESION 56605

Facility

$594.00

Service Code	CPT 56605
Hospital Charge Code	8056605
Hospital Revenue Code	521
Min. Negotiated Rate	$415.80
Max. Negotiated Rate	$594.00
Rate for Payer: Aetna Commercial	$564.30
Rate for Payer: Aetna Medicare	$534.60
Rate for Payer: BCBS MT CHIP	$534.60
Rate for Payer: BCBS MT Closed Plan Network	$564.30
Rate for Payer: BCBS MT HealthLink	$534.60
Rate for Payer: BCBS MT Medicare	$534.60
Rate for Payer: BCBS MT POS	$564.30
Rate for Payer: BCBS MT Traditional	$594.00
Rate for Payer: Cash Price	$534.60
Rate for Payer: Cigna Commercial	$564.30
Rate for Payer: Cigna Medicare	$534.60
Rate for Payer: Medicaid All Medicaid	$546.48
Rate for Payer: Medicare All Medicare	$415.80
Rate for Payer: Monida Allegiance	$564.30
Rate for Payer: Monida First Choice Health	$576.18
Rate for Payer: Monida Montana Health Co-op	$564.30
Rate for Payer: Monida PacificSource	$564.30

BIO RAD QUANTIFY URINE QC

Facility

$209.13

Hospital Charge Code	90197057
Hospital Revenue Code	270
Min. Negotiated Rate	$146.39
Max. Negotiated Rate	$209.13
Rate for Payer: Aetna Commercial	$198.67
Rate for Payer: Aetna Medicare	$188.22
Rate for Payer: BCBS MT CHIP	$188.22
Rate for Payer: BCBS MT Closed Plan Network	$198.67
Rate for Payer: BCBS MT HealthLink	$188.22
Rate for Payer: BCBS MT Medicare	$188.22
Rate for Payer: BCBS MT POS	$198.67
Rate for Payer: BCBS MT Traditional	$209.13
Rate for Payer: Cash Price	$188.22
Rate for Payer: Cigna Commercial	$198.67
Rate for Payer: Cigna Medicare	$188.22
Rate for Payer: Medicaid All Medicaid	$192.40
Rate for Payer: Medicare All Medicare	$146.39
Rate for Payer: Monida Allegiance	$198.67
Rate for Payer: Monida First Choice Health	$202.86
Rate for Payer: Monida Montana Health Co-op	$198.67
Rate for Payer: Monida PacificSource	$198.67

BIO RAD QUANTIFY URINE QC

Facility

$209.13

Hospital Charge Code	90197057
Hospital Revenue Code	270
Min. Negotiated Rate	$146.39
Max. Negotiated Rate	$209.13
Rate for Payer: Aetna Commercial	$198.67
Rate for Payer: Aetna Medicare	$188.22
Rate for Payer: BCBS MT CHIP	$188.22
Rate for Payer: BCBS MT Closed Plan Network	$198.67
Rate for Payer: BCBS MT HealthLink	$188.22
Rate for Payer: BCBS MT Medicare	$188.22
Rate for Payer: BCBS MT POS	$198.67
Rate for Payer: BCBS MT Traditional	$209.13
Rate for Payer: Cash Price	$188.22
Rate for Payer: Cigna Commercial	$198.67
Rate for Payer: Cigna Medicare	$188.22
Rate for Payer: Medicaid All Medicaid	$192.40
Rate for Payer: Medicare All Medicare	$146.39
Rate for Payer: Monida Allegiance	$198.67
Rate for Payer: Monida First Choice Health	$202.86
Rate for Payer: Monida Montana Health Co-op	$198.67
Rate for Payer: Monida PacificSource	$198.67

BIOTENE DRY MOUTH LOZENGE NF

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000564
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

BIOTENE DRY MOUTH LOZENGE NF

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000564
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

BIOTENE DRY MOUTH RINSE 118ML

Facility

$5.00

Hospital Charge Code	3007209
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

BIOTENE DRY MOUTH RINSE 118ML

Facility

$5.00

Hospital Charge Code	3007209
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

BISACODYL SUPP [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000052
Hospital Revenue Code	259
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

BISACODYL SUPP [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000052
Hospital Revenue Code	259
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

BISACODYL TAB [5 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000053
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

BISACODYL TAB [5 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000053
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

BISOPROLOL/HCTZ TAB [2.5 MG/6.25 MG] NF

Facility

$11.00

Service Code	HCPCS J8499
Hospital Charge Code	3007573
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

BISOPROLOL/HCTZ TAB [2.5 MG/6.25 MG] NF

Facility

$11.00

Service Code	HCPCS J8499
Hospital Charge Code	3007573
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

BK VIRUS QUANTITATIVE NAAT

Facility

$220.00

Service Code	CPT 87799
Hospital Charge Code	4088084
Hospital Revenue Code	302
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$220.00
Rate for Payer: Aetna Commercial	$209.00
Rate for Payer: Aetna Medicare	$198.00
Rate for Payer: BCBS MT CHIP	$198.00
Rate for Payer: BCBS MT Closed Plan Network	$209.00
Rate for Payer: BCBS MT HealthLink	$198.00
Rate for Payer: BCBS MT Medicare	$198.00
Rate for Payer: BCBS MT POS	$209.00
Rate for Payer: BCBS MT Traditional	$220.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial	$209.00
Rate for Payer: Cigna Medicare	$198.00
Rate for Payer: Medicaid All Medicaid	$202.40
Rate for Payer: Medicare All Medicare	$154.00
Rate for Payer: Monida Allegiance	$209.00
Rate for Payer: Monida First Choice Health	$213.40
Rate for Payer: Monida Montana Health Co-op	$209.00
Rate for Payer: Monida PacificSource	$209.00

BK VIRUS QUANTITATIVE NAAT

Facility

$220.00

Service Code	CPT 87799
Hospital Charge Code	4088084
Hospital Revenue Code	302
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$220.00
Rate for Payer: Aetna Commercial	$209.00
Rate for Payer: Aetna Medicare	$198.00
Rate for Payer: BCBS MT CHIP	$198.00
Rate for Payer: BCBS MT Closed Plan Network	$209.00
Rate for Payer: BCBS MT HealthLink	$198.00
Rate for Payer: BCBS MT Medicare	$198.00
Rate for Payer: BCBS MT POS	$209.00
Rate for Payer: BCBS MT Traditional	$220.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial	$209.00
Rate for Payer: Cigna Medicare	$198.00
Rate for Payer: Medicaid All Medicaid	$202.40
Rate for Payer: Medicare All Medicare	$154.00
Rate for Payer: Monida Allegiance	$209.00
Rate for Payer: Monida First Choice Health	$213.40
Rate for Payer: Monida Montana Health Co-op	$209.00
Rate for Payer: Monida PacificSource	$209.00

Know your out-of-pocket cost for care.

All Charges