Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

BLOOD TRANSFER DEVICE (NURSING ONLY)

Facility

$3.00

Hospital Charge Code	80040231
Hospital Revenue Code	270
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.00
Rate for Payer: Aetna Commercial	$2.85
Rate for Payer: Aetna Medicare	$2.70
Rate for Payer: BCBS MT CHIP	$2.70
Rate for Payer: BCBS MT Closed Plan Network	$2.85
Rate for Payer: BCBS MT HealthLink	$2.70
Rate for Payer: BCBS MT Medicare	$2.70
Rate for Payer: BCBS MT POS	$2.85
Rate for Payer: BCBS MT Traditional	$3.00
Rate for Payer: Cash Price	$2.70
Rate for Payer: Cigna Commercial	$2.85
Rate for Payer: Cigna Medicare	$2.70
Rate for Payer: Medicaid All Medicaid	$2.76
Rate for Payer: Medicare All Medicare	$2.10
Rate for Payer: Monida Allegiance	$2.85
Rate for Payer: Monida First Choice Health	$2.91
Rate for Payer: Monida Montana Health Co-op	$2.85
Rate for Payer: Monida PacificSource	$2.85

BLOOD TRANSFER PACK BAG

Facility

$26.00

Hospital Charge Code	80040141
Hospital Revenue Code	270
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

BLOOD TRANSFER PACK BAG

Facility

$26.00

Hospital Charge Code	80040141
Hospital Revenue Code	270
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

BLOOD UREA NITROGEN (BUN)

Facility

$58.00

Service Code	CPT 84520
Hospital Charge Code	4084520
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

BLOOD UREA NITROGEN (BUN)

Facility

$58.00

Service Code	CPT 84520
Hospital Charge Code	4084520
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

BODY FLUID CELL COUNT AND DIFF

Facility

$95.00

Service Code	CPT 89051
Hospital Charge Code	4088076
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

BODY FLUID CELL COUNT AND DIFF

Facility

$95.00

Service Code	CPT 89051
Hospital Charge Code	4088076
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

BONE SPECIFIC ALK PHOS

Facility

$125.00

Service Code	CPT 84080
Hospital Charge Code	4088085
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

BONE SPECIFIC ALK PHOS

Facility

$125.00

Service Code	CPT 84080
Hospital Charge Code	4088085
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

BOTULINUM TOXIN 100UN VIAL

Facility

$1,065.20

Service Code	HCPCS J0585
Hospital Charge Code	3007394
Hospital Revenue Code	250
Min. Negotiated Rate	$745.64
Max. Negotiated Rate	$1,065.20
Rate for Payer: Aetna Commercial	$1,011.94
Rate for Payer: Aetna Medicare	$958.68
Rate for Payer: BCBS MT CHIP	$958.68
Rate for Payer: BCBS MT Closed Plan Network	$1,011.94
Rate for Payer: BCBS MT HealthLink	$958.68
Rate for Payer: BCBS MT Medicare	$958.68
Rate for Payer: BCBS MT POS	$1,011.94
Rate for Payer: BCBS MT Traditional	$1,065.20
Rate for Payer: Cash Price	$958.68
Rate for Payer: Cigna Commercial	$1,011.94
Rate for Payer: Cigna Medicare	$958.68
Rate for Payer: Medicaid All Medicaid	$979.98
Rate for Payer: Medicare All Medicare	$745.64
Rate for Payer: Monida Allegiance	$1,011.94
Rate for Payer: Monida First Choice Health	$1,033.24
Rate for Payer: Monida Montana Health Co-op	$1,011.94
Rate for Payer: Monida PacificSource	$1,011.94

BOTULINUM TOXIN 100UN VIAL

Facility

$1,065.20

Service Code	HCPCS J0585
Hospital Charge Code	3007394
Hospital Revenue Code	250
Min. Negotiated Rate	$745.64
Max. Negotiated Rate	$1,065.20
Rate for Payer: Aetna Commercial	$1,011.94
Rate for Payer: Aetna Medicare	$958.68
Rate for Payer: BCBS MT CHIP	$958.68
Rate for Payer: BCBS MT Closed Plan Network	$1,011.94
Rate for Payer: BCBS MT HealthLink	$958.68
Rate for Payer: BCBS MT Medicare	$958.68
Rate for Payer: BCBS MT POS	$1,011.94
Rate for Payer: BCBS MT Traditional	$1,065.20
Rate for Payer: Cash Price	$958.68
Rate for Payer: Cigna Commercial	$1,011.94
Rate for Payer: Cigna Medicare	$958.68
Rate for Payer: Medicaid All Medicaid	$979.98
Rate for Payer: Medicare All Medicare	$745.64
Rate for Payer: Monida Allegiance	$1,011.94
Rate for Payer: Monida First Choice Health	$1,033.24
Rate for Payer: Monida Montana Health Co-op	$1,011.94
Rate for Payer: Monida PacificSource	$1,011.94

BREAST CARCINOMA ASSOCIATED ANTIGEN

Facility

$94.00

Service Code	CPT 86300
Hospital Charge Code	4088005
Hospital Revenue Code	302
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

BREAST CARCINOMA ASSOCIATED ANTIGEN

Facility

$94.00

Service Code	CPT 86300
Hospital Charge Code	4088005
Hospital Revenue Code	302
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

BRIEF COMUNICAJ TECH-BSD SVC

Facility

$30.00

Service Code	CPT 98016
Hospital Charge Code	8098016
Hospital Revenue Code	521
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

BRIEF COMUNICAJ TECH-BSD SVC

Facility

$30.00

Service Code	CPT 98016
Hospital Charge Code	8098016
Hospital Revenue Code	521
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

BRIMONIDINE 0.2% (10 ML) OPTH DROPS

Facility

$208.00

Hospital Charge Code	3007072
Hospital Revenue Code	250
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

BRIMONIDINE 0.2% (10 ML) OPTH DROPS

Facility

$208.00

Hospital Charge Code	3007072
Hospital Revenue Code	250
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

BRIMONIDINE OPTH SLN [0.1 %] NF

Facility

$564.00

Service Code	HCPCS J3490
Hospital Charge Code	3007643
Hospital Revenue Code	250
Min. Negotiated Rate	$394.80
Max. Negotiated Rate	$564.00
Rate for Payer: Aetna Commercial	$535.80
Rate for Payer: Aetna Medicare	$507.60
Rate for Payer: BCBS MT CHIP	$507.60
Rate for Payer: BCBS MT Closed Plan Network	$535.80
Rate for Payer: BCBS MT HealthLink	$507.60
Rate for Payer: BCBS MT Medicare	$507.60
Rate for Payer: BCBS MT POS	$535.80
Rate for Payer: BCBS MT Traditional	$564.00
Rate for Payer: Cash Price	$507.60
Rate for Payer: Cigna Commercial	$535.80
Rate for Payer: Cigna Medicare	$507.60
Rate for Payer: Medicaid All Medicaid	$518.88
Rate for Payer: Medicare All Medicare	$394.80
Rate for Payer: Monida Allegiance	$535.80
Rate for Payer: Monida First Choice Health	$547.08
Rate for Payer: Monida Montana Health Co-op	$535.80
Rate for Payer: Monida PacificSource	$535.80

BRIMONIDINE OPTH SLN [0.1 %] NF

Facility

$564.00

Service Code	HCPCS J3490
Hospital Charge Code	3007643
Hospital Revenue Code	250
Min. Negotiated Rate	$394.80
Max. Negotiated Rate	$564.00
Rate for Payer: Aetna Commercial	$535.80
Rate for Payer: Aetna Medicare	$507.60
Rate for Payer: BCBS MT CHIP	$507.60
Rate for Payer: BCBS MT Closed Plan Network	$535.80
Rate for Payer: BCBS MT HealthLink	$507.60
Rate for Payer: BCBS MT Medicare	$507.60
Rate for Payer: BCBS MT POS	$535.80
Rate for Payer: BCBS MT Traditional	$564.00
Rate for Payer: Cash Price	$507.60
Rate for Payer: Cigna Commercial	$535.80
Rate for Payer: Cigna Medicare	$507.60
Rate for Payer: Medicaid All Medicaid	$518.88
Rate for Payer: Medicare All Medicare	$394.80
Rate for Payer: Monida Allegiance	$535.80
Rate for Payer: Monida First Choice Health	$547.08
Rate for Payer: Monida Montana Health Co-op	$535.80
Rate for Payer: Monida PacificSource	$535.80

BRIMONIDINE/TIMOLOL [0.2%/0.5%] 5ML NF

Facility

$617.00

Hospital Charge Code	3007262
Hospital Revenue Code	250
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

BRIMONIDINE/TIMOLOL [0.2%/0.5%] 5ML NF

Facility

$617.00

Hospital Charge Code	3007262
Hospital Revenue Code	250
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

B-TYPE NATRIURETIC PEPTIDE RVMC

Facility

$341.00

Service Code	CPT 83880
Hospital Charge Code	4083880
Hospital Revenue Code	300
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

B-TYPE NATRIURETIC PEPTIDE RVMC

Facility

$341.00

Service Code	CPT 83880
Hospital Charge Code	4083880
Hospital Revenue Code	300
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

BUDESONIDE/FORMOTEROL 160/4.5MCG-NF

Facility

$719.00

Service Code	HCPCS J3490
Hospital Charge Code	3007107
Hospital Revenue Code	250
Min. Negotiated Rate	$503.30
Max. Negotiated Rate	$719.00
Rate for Payer: Aetna Commercial	$683.05
Rate for Payer: Aetna Medicare	$647.10
Rate for Payer: BCBS MT CHIP	$647.10
Rate for Payer: BCBS MT Closed Plan Network	$683.05
Rate for Payer: BCBS MT HealthLink	$647.10
Rate for Payer: BCBS MT Medicare	$647.10
Rate for Payer: BCBS MT POS	$683.05
Rate for Payer: BCBS MT Traditional	$719.00
Rate for Payer: Cash Price	$647.10
Rate for Payer: Cigna Commercial	$683.05
Rate for Payer: Cigna Medicare	$647.10
Rate for Payer: Medicaid All Medicaid	$661.48
Rate for Payer: Medicare All Medicare	$503.30
Rate for Payer: Monida Allegiance	$683.05
Rate for Payer: Monida First Choice Health	$697.43
Rate for Payer: Monida Montana Health Co-op	$683.05
Rate for Payer: Monida PacificSource	$683.05

BUDESONIDE/FORMOTEROL 160/4.5MCG-NF

Facility

$719.00

Service Code	HCPCS J3490
Hospital Charge Code	3007107
Hospital Revenue Code	250
Min. Negotiated Rate	$503.30
Max. Negotiated Rate	$719.00
Rate for Payer: Aetna Commercial	$683.05
Rate for Payer: Aetna Medicare	$647.10
Rate for Payer: BCBS MT CHIP	$647.10
Rate for Payer: BCBS MT Closed Plan Network	$683.05
Rate for Payer: BCBS MT HealthLink	$647.10
Rate for Payer: BCBS MT Medicare	$647.10
Rate for Payer: BCBS MT POS	$683.05
Rate for Payer: BCBS MT Traditional	$719.00
Rate for Payer: Cash Price	$647.10
Rate for Payer: Cigna Commercial	$683.05
Rate for Payer: Cigna Medicare	$647.10
Rate for Payer: Medicaid All Medicaid	$661.48
Rate for Payer: Medicare All Medicare	$503.30
Rate for Payer: Monida Allegiance	$683.05
Rate for Payer: Monida First Choice Health	$697.43
Rate for Payer: Monida Montana Health Co-op	$683.05
Rate for Payer: Monida PacificSource	$683.05

Know your out-of-pocket cost for care.

All Charges