Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

RISPERIDONE TAB [1 MG]

Facility

$16.00

Service Code	HCPCS J8499
Hospital Charge Code	3000415
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

RIVAROXABAN TAB [10 MG] NF

Facility

$73.00

Service Code	HCPCS J8499
Hospital Charge Code	3000416
Hospital Revenue Code	250
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

RIVAROXABAN TAB [10 MG] NF

Facility

$73.00

Service Code	HCPCS J8499
Hospital Charge Code	3000416
Hospital Revenue Code	250
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

RIVAROXABAN TAB [20 MG] NF

Facility

$77.00

Service Code	HCPCS J8499
Hospital Charge Code	3007506
Hospital Revenue Code	250
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

RIVAROXABAN TAB [20 MG] NF

Facility

$77.00

Service Code	HCPCS J8499
Hospital Charge Code	3007506
Hospital Revenue Code	250
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

RIVAROXABAN TAB [2.5 MG] NF

Facility

$33.00

Service Code	HCPCS J8499
Hospital Charge Code	3000417
Hospital Revenue Code	250
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

RIVAROXABAN TAB [2.5 MG] NF

Facility

$33.00

Service Code	HCPCS J8499
Hospital Charge Code	3000417
Hospital Revenue Code	250
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

RN/INS PHYSICAL

Facility

$283.00

Hospital Charge Code	610110
Hospital Revenue Code	230
Min. Negotiated Rate	$198.10
Max. Negotiated Rate	$283.00
Rate for Payer: Aetna Commercial	$268.85
Rate for Payer: Aetna Medicare	$254.70
Rate for Payer: BCBS MT CHIP	$254.70
Rate for Payer: BCBS MT Closed Plan Network	$268.85
Rate for Payer: BCBS MT HealthLink	$254.70
Rate for Payer: BCBS MT Medicare	$254.70
Rate for Payer: BCBS MT POS	$268.85
Rate for Payer: BCBS MT Traditional	$283.00
Rate for Payer: Cash Price	$254.70
Rate for Payer: Cigna Commercial	$268.85
Rate for Payer: Cigna Medicare	$254.70
Rate for Payer: Medicaid All Medicaid	$260.36
Rate for Payer: Medicare All Medicare	$198.10
Rate for Payer: Monida Allegiance	$268.85
Rate for Payer: Monida First Choice Health	$274.51
Rate for Payer: Monida Montana Health Co-op	$268.85
Rate for Payer: Monida PacificSource	$268.85

RN/INS PHYSICAL

Facility

$283.00

Hospital Charge Code	610110
Hospital Revenue Code	230
Min. Negotiated Rate	$198.10
Max. Negotiated Rate	$283.00
Rate for Payer: Aetna Commercial	$268.85
Rate for Payer: Aetna Medicare	$254.70
Rate for Payer: BCBS MT CHIP	$254.70
Rate for Payer: BCBS MT Closed Plan Network	$268.85
Rate for Payer: BCBS MT HealthLink	$254.70
Rate for Payer: BCBS MT Medicare	$254.70
Rate for Payer: BCBS MT POS	$268.85
Rate for Payer: BCBS MT Traditional	$283.00
Rate for Payer: Cash Price	$254.70
Rate for Payer: Cigna Commercial	$268.85
Rate for Payer: Cigna Medicare	$254.70
Rate for Payer: Medicaid All Medicaid	$260.36
Rate for Payer: Medicare All Medicare	$198.10
Rate for Payer: Monida Allegiance	$268.85
Rate for Payer: Monida First Choice Health	$274.51
Rate for Payer: Monida Montana Health Co-op	$268.85
Rate for Payer: Monida PacificSource	$268.85

RNP ANTIBODIES (016353)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4000063
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

RNP ANTIBODIES (016353)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4000063
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

ROCURONIUM BROMIDE INJ [10 MG/ML] 5ML VL

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000418
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

ROCURONIUM BROMIDE INJ [10 MG/ML] 5ML VL

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000418
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

ROFLUMILAST TAB [250 MCG] NF

Facility

$56.00

Service Code	HCPCS J8499
Hospital Charge Code	3007236
Hospital Revenue Code	250
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

ROFLUMILAST TAB [250 MCG] NF

Facility

$56.00

Service Code	HCPCS J8499
Hospital Charge Code	3007236
Hospital Revenue Code	250
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

ROMOSOZUMAB-AQQG SQ INJ [105 MG] PFS

Facility

$2,209.00

Service Code	HCPCS J3111
Hospital Charge Code	3000615
Hospital Revenue Code	636
Min. Negotiated Rate	$1,546.30
Max. Negotiated Rate	$2,209.00
Rate for Payer: Aetna Commercial	$2,098.55
Rate for Payer: Aetna Medicare	$1,988.10
Rate for Payer: BCBS MT CHIP	$1,988.10
Rate for Payer: BCBS MT Closed Plan Network	$2,098.55
Rate for Payer: BCBS MT HealthLink	$1,988.10
Rate for Payer: BCBS MT Medicare	$1,988.10
Rate for Payer: BCBS MT POS	$2,098.55
Rate for Payer: BCBS MT Traditional	$2,209.00
Rate for Payer: Cash Price	$1,988.10
Rate for Payer: Cigna Commercial	$2,098.55
Rate for Payer: Cigna Medicare	$1,988.10
Rate for Payer: Medicaid All Medicaid	$2,032.28
Rate for Payer: Medicare All Medicare	$1,546.30
Rate for Payer: Monida Allegiance	$2,098.55
Rate for Payer: Monida First Choice Health	$2,142.73
Rate for Payer: Monida Montana Health Co-op	$2,098.55
Rate for Payer: Monida PacificSource	$2,098.55

ROMOSOZUMAB-AQQG SQ INJ [105 MG] PFS

Facility

$2,209.00

Service Code	HCPCS J3111
Hospital Charge Code	3000615
Hospital Revenue Code	636
Min. Negotiated Rate	$1,546.30
Max. Negotiated Rate	$2,209.00
Rate for Payer: Aetna Commercial	$2,098.55
Rate for Payer: Aetna Medicare	$1,988.10
Rate for Payer: BCBS MT CHIP	$1,988.10
Rate for Payer: BCBS MT Closed Plan Network	$2,098.55
Rate for Payer: BCBS MT HealthLink	$1,988.10
Rate for Payer: BCBS MT Medicare	$1,988.10
Rate for Payer: BCBS MT POS	$2,098.55
Rate for Payer: BCBS MT Traditional	$2,209.00
Rate for Payer: Cash Price	$1,988.10
Rate for Payer: Cigna Commercial	$2,098.55
Rate for Payer: Cigna Medicare	$1,988.10
Rate for Payer: Medicaid All Medicaid	$2,032.28
Rate for Payer: Medicare All Medicare	$1,546.30
Rate for Payer: Monida Allegiance	$2,098.55
Rate for Payer: Monida First Choice Health	$2,142.73
Rate for Payer: Monida Montana Health Co-op	$2,098.55
Rate for Payer: Monida PacificSource	$2,098.55

ROPINIROLE TAB [0.25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000419
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

ROPINIROLE TAB [0.25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000419
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

ROSUVASTATIN TAB [20 MG]

Facility

$29.00

Service Code	HCPCS J8499
Hospital Charge Code	3007073
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

ROSUVASTATIN TAB [20 MG]

Facility

$29.00

Service Code	HCPCS J8499
Hospital Charge Code	3007073
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

ROSUVASTATIN TAB [5 MG] NF

Facility

$30.00

Service Code	HCPCS J8499
Hospital Charge Code	3007214
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

ROSUVASTATIN TAB [5 MG] NF

Facility

$30.00

Service Code	HCPCS J8499
Hospital Charge Code	3007214
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

ROTAVIRUS ORAL -ROTARIX (2DOSE)

Facility

$553.00

Service Code	CPT 90681
Hospital Charge Code	8090681
Hospital Revenue Code	521
Min. Negotiated Rate	$387.10
Max. Negotiated Rate	$553.00
Rate for Payer: Aetna Commercial	$525.35
Rate for Payer: Aetna Medicare	$497.70
Rate for Payer: BCBS MT CHIP	$497.70
Rate for Payer: BCBS MT Closed Plan Network	$525.35
Rate for Payer: BCBS MT HealthLink	$497.70
Rate for Payer: BCBS MT Medicare	$497.70
Rate for Payer: BCBS MT POS	$525.35
Rate for Payer: BCBS MT Traditional	$553.00
Rate for Payer: Cash Price	$497.70
Rate for Payer: Cigna Commercial	$525.35
Rate for Payer: Cigna Medicare	$497.70
Rate for Payer: Medicaid All Medicaid	$508.76
Rate for Payer: Medicare All Medicare	$387.10
Rate for Payer: Monida Allegiance	$525.35
Rate for Payer: Monida First Choice Health	$536.41
Rate for Payer: Monida Montana Health Co-op	$525.35
Rate for Payer: Monida PacificSource	$525.35

ROTAVIRUS ORAL -ROTARIX (2DOSE)

Facility

$553.00

Service Code	CPT 90681
Hospital Charge Code	8090681
Hospital Revenue Code	521
Min. Negotiated Rate	$387.10
Max. Negotiated Rate	$553.00
Rate for Payer: Aetna Commercial	$525.35
Rate for Payer: Aetna Medicare	$497.70
Rate for Payer: BCBS MT CHIP	$497.70
Rate for Payer: BCBS MT Closed Plan Network	$525.35
Rate for Payer: BCBS MT HealthLink	$497.70
Rate for Payer: BCBS MT Medicare	$497.70
Rate for Payer: BCBS MT POS	$525.35
Rate for Payer: BCBS MT Traditional	$553.00
Rate for Payer: Cash Price	$497.70
Rate for Payer: Cigna Commercial	$525.35
Rate for Payer: Cigna Medicare	$497.70
Rate for Payer: Medicaid All Medicaid	$508.76
Rate for Payer: Medicare All Medicare	$387.10
Rate for Payer: Monida Allegiance	$525.35
Rate for Payer: Monida First Choice Health	$536.41
Rate for Payer: Monida Montana Health Co-op	$525.35
Rate for Payer: Monida PacificSource	$525.35

Know your out-of-pocket cost for care.

All Charges