Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SCREENING HEARING

Facility

$45.00

Service Code	CPT 92551
Hospital Charge Code	8092551
Hospital Revenue Code	521
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

SCREENING MAMMOGRAPHY RESULTS DOCUMENTED

Facility

$0.01

Service Code	CPT 3014F
Hospital Charge Code	8003014
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

SCREENING MAMMOGRAPHY RESULTS DOCUMENTED

Facility

$0.01

Service Code	CPT 3014F
Hospital Charge Code	8003014
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

SCREENING VISUAL

Facility

$18.00

Service Code	CPT 99173
Hospital Charge Code	8099173
Hospital Revenue Code	521
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

SCREENING VISUAL

Facility

$18.00

Service Code	CPT 99173
Hospital Charge Code	8099173
Hospital Revenue Code	521
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

SEASONAL ALLERGENS

Facility

$188.00

Service Code	CPT 86003
Hospital Charge Code	4088027
Hospital Revenue Code	302
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$188.00
Rate for Payer: Aetna Commercial	$178.60
Rate for Payer: Aetna Medicare	$169.20
Rate for Payer: BCBS MT CHIP	$169.20
Rate for Payer: BCBS MT Closed Plan Network	$178.60
Rate for Payer: BCBS MT HealthLink	$169.20
Rate for Payer: BCBS MT Medicare	$169.20
Rate for Payer: BCBS MT POS	$178.60
Rate for Payer: BCBS MT Traditional	$188.00
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cigna Commercial	$178.60
Rate for Payer: Cigna Medicare	$169.20
Rate for Payer: Medicaid All Medicaid	$172.96
Rate for Payer: Medicare All Medicare	$131.60
Rate for Payer: Monida Allegiance	$178.60
Rate for Payer: Monida First Choice Health	$182.36
Rate for Payer: Monida Montana Health Co-op	$178.60
Rate for Payer: Monida PacificSource	$178.60

SEASONAL ALLERGENS

Facility

$188.00

Service Code	CPT 86003
Hospital Charge Code	4088027
Hospital Revenue Code	302
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$188.00
Rate for Payer: Aetna Commercial	$178.60
Rate for Payer: Aetna Medicare	$169.20
Rate for Payer: BCBS MT CHIP	$169.20
Rate for Payer: BCBS MT Closed Plan Network	$178.60
Rate for Payer: BCBS MT HealthLink	$169.20
Rate for Payer: BCBS MT Medicare	$169.20
Rate for Payer: BCBS MT POS	$178.60
Rate for Payer: BCBS MT Traditional	$188.00
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cigna Commercial	$178.60
Rate for Payer: Cigna Medicare	$169.20
Rate for Payer: Medicaid All Medicaid	$172.96
Rate for Payer: Medicare All Medicare	$131.60
Rate for Payer: Monida Allegiance	$178.60
Rate for Payer: Monida First Choice Health	$182.36
Rate for Payer: Monida Montana Health Co-op	$178.60
Rate for Payer: Monida PacificSource	$178.60

SEDI-RATE ESR TEST KIT (100/BX

Facility

$92.79

Hospital Charge Code	90196611
Hospital Revenue Code	270
Min. Negotiated Rate	$64.95
Max. Negotiated Rate	$92.79
Rate for Payer: Aetna Commercial	$88.15
Rate for Payer: Aetna Medicare	$83.51
Rate for Payer: BCBS MT CHIP	$83.51
Rate for Payer: BCBS MT Closed Plan Network	$88.15
Rate for Payer: BCBS MT HealthLink	$83.51
Rate for Payer: BCBS MT Medicare	$83.51
Rate for Payer: BCBS MT POS	$88.15
Rate for Payer: BCBS MT Traditional	$92.79
Rate for Payer: Cash Price	$83.51
Rate for Payer: Cigna Commercial	$88.15
Rate for Payer: Cigna Medicare	$83.51
Rate for Payer: Medicaid All Medicaid	$85.37
Rate for Payer: Medicare All Medicare	$64.95
Rate for Payer: Monida Allegiance	$88.15
Rate for Payer: Monida First Choice Health	$90.01
Rate for Payer: Monida Montana Health Co-op	$88.15
Rate for Payer: Monida PacificSource	$88.15

SEDI-RATE ESR TEST KIT (100/BX

Facility

$92.79

Hospital Charge Code	90196611
Hospital Revenue Code	270
Min. Negotiated Rate	$64.95
Max. Negotiated Rate	$92.79
Rate for Payer: Aetna Commercial	$88.15
Rate for Payer: Aetna Medicare	$83.51
Rate for Payer: BCBS MT CHIP	$83.51
Rate for Payer: BCBS MT Closed Plan Network	$88.15
Rate for Payer: BCBS MT HealthLink	$83.51
Rate for Payer: BCBS MT Medicare	$83.51
Rate for Payer: BCBS MT POS	$88.15
Rate for Payer: BCBS MT Traditional	$92.79
Rate for Payer: Cash Price	$83.51
Rate for Payer: Cigna Commercial	$88.15
Rate for Payer: Cigna Medicare	$83.51
Rate for Payer: Medicaid All Medicaid	$85.37
Rate for Payer: Medicare All Medicare	$64.95
Rate for Payer: Monida Allegiance	$88.15
Rate for Payer: Monida First Choice Health	$90.01
Rate for Payer: Monida Montana Health Co-op	$88.15
Rate for Payer: Monida PacificSource	$88.15

SELENIUM (716910)

Facility

$180.00

Service Code	CPT 84255
Hospital Charge Code	4084255
Hospital Revenue Code	300
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

SELENIUM (716910)

Facility

$180.00

Service Code	CPT 84255
Hospital Charge Code	4084255
Hospital Revenue Code	300
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

SEMAGLUTIDE SQ INJ [1 MG/0.75 ML] SP ORD

Facility

$1,676.00

Service Code	HCPCS J3590
Hospital Charge Code	3000605
Hospital Revenue Code	250
Min. Negotiated Rate	$1,173.20
Max. Negotiated Rate	$1,676.00
Rate for Payer: Aetna Commercial	$1,592.20
Rate for Payer: Aetna Medicare	$1,508.40
Rate for Payer: BCBS MT CHIP	$1,508.40
Rate for Payer: BCBS MT Closed Plan Network	$1,592.20
Rate for Payer: BCBS MT HealthLink	$1,508.40
Rate for Payer: BCBS MT Medicare	$1,508.40
Rate for Payer: BCBS MT POS	$1,592.20
Rate for Payer: BCBS MT Traditional	$1,676.00
Rate for Payer: Cash Price	$1,508.40
Rate for Payer: Cigna Commercial	$1,592.20
Rate for Payer: Cigna Medicare	$1,508.40
Rate for Payer: Medicaid All Medicaid	$1,541.92
Rate for Payer: Medicare All Medicare	$1,173.20
Rate for Payer: Monida Allegiance	$1,592.20
Rate for Payer: Monida First Choice Health	$1,625.72
Rate for Payer: Monida Montana Health Co-op	$1,592.20
Rate for Payer: Monida PacificSource	$1,592.20

SEMAGLUTIDE SQ INJ [1 MG/0.75 ML] SP ORD

Facility

$1,676.00

Service Code	HCPCS J3590
Hospital Charge Code	3000605
Hospital Revenue Code	250
Min. Negotiated Rate	$1,173.20
Max. Negotiated Rate	$1,676.00
Rate for Payer: Aetna Commercial	$1,592.20
Rate for Payer: Aetna Medicare	$1,508.40
Rate for Payer: BCBS MT CHIP	$1,508.40
Rate for Payer: BCBS MT Closed Plan Network	$1,592.20
Rate for Payer: BCBS MT HealthLink	$1,508.40
Rate for Payer: BCBS MT Medicare	$1,508.40
Rate for Payer: BCBS MT POS	$1,592.20
Rate for Payer: BCBS MT Traditional	$1,676.00
Rate for Payer: Cash Price	$1,508.40
Rate for Payer: Cigna Commercial	$1,592.20
Rate for Payer: Cigna Medicare	$1,508.40
Rate for Payer: Medicaid All Medicaid	$1,541.92
Rate for Payer: Medicare All Medicare	$1,173.20
Rate for Payer: Monida Allegiance	$1,592.20
Rate for Payer: Monida First Choice Health	$1,625.72
Rate for Payer: Monida Montana Health Co-op	$1,592.20
Rate for Payer: Monida PacificSource	$1,592.20

SENNA TAB [8.6 MG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000512
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

SENNA TAB [8.6 MG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000512
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

.SENSITIVITY, EACH ORGANISM

Facility

$95.00

Service Code	CPT 87186
Hospital Charge Code	4087186
Hospital Revenue Code	300
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

.SENSITIVITY, EACH ORGANISM

Facility

$95.00

Service Code	CPT 87186
Hospital Charge Code	4087186
Hospital Revenue Code	300
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

SERINE PROTEASE 3 IGG

Facility

$78.00

Service Code	CPT 83516
Hospital Charge Code	4088081
Hospital Revenue Code	302
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

SERINE PROTEASE 3 IGG

Facility

$78.00

Service Code	CPT 83516
Hospital Charge Code	4088081
Hospital Revenue Code	302
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

SERTRALINE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000422
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

SERTRALINE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000422
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

SEVELAMER TAB [800 MG] NF

Facility

$26.00

Service Code	HCPCS J8499
Hospital Charge Code	3000557
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

SEVELAMER TAB [800 MG] NF

Facility

$26.00

Service Code	HCPCS J8499
Hospital Charge Code	3000557
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

SEX HORMONE-BINDING GLOBULIN (082016)

Facility

$79.00

Service Code	CPT 84270
Hospital Charge Code	4084270
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

SEX HORMONE-BINDING GLOBULIN (082016)

Facility

$79.00

Service Code	CPT 84270
Hospital Charge Code	4084270
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

Know your out-of-pocket cost for care.

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