Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

BUDESONIDE FORMOTEROL 80/4.5 INH NF

Facility

$670.00

Hospital Charge Code	3007241
Hospital Revenue Code	250
Min. Negotiated Rate	$469.00
Max. Negotiated Rate	$670.00
Rate for Payer: Aetna Commercial	$636.50
Rate for Payer: Aetna Medicare	$603.00
Rate for Payer: BCBS MT CHIP	$603.00
Rate for Payer: BCBS MT Closed Plan Network	$636.50
Rate for Payer: BCBS MT HealthLink	$603.00
Rate for Payer: BCBS MT Medicare	$603.00
Rate for Payer: BCBS MT POS	$636.50
Rate for Payer: BCBS MT Traditional	$670.00
Rate for Payer: Cash Price	$603.00
Rate for Payer: Cigna Commercial	$636.50
Rate for Payer: Cigna Medicare	$603.00
Rate for Payer: Medicaid All Medicaid	$616.40
Rate for Payer: Medicare All Medicare	$469.00
Rate for Payer: Monida Allegiance	$636.50
Rate for Payer: Monida First Choice Health	$649.90
Rate for Payer: Monida Montana Health Co-op	$636.50
Rate for Payer: Monida PacificSource	$636.50

BUDESONIDE FORMOTEROL 80/4.5 INH NF

Facility

$670.00

Hospital Charge Code	3007241
Hospital Revenue Code	250
Min. Negotiated Rate	$469.00
Max. Negotiated Rate	$670.00
Rate for Payer: Aetna Commercial	$636.50
Rate for Payer: Aetna Medicare	$603.00
Rate for Payer: BCBS MT CHIP	$603.00
Rate for Payer: BCBS MT Closed Plan Network	$636.50
Rate for Payer: BCBS MT HealthLink	$603.00
Rate for Payer: BCBS MT Medicare	$603.00
Rate for Payer: BCBS MT POS	$636.50
Rate for Payer: BCBS MT Traditional	$670.00
Rate for Payer: Cash Price	$603.00
Rate for Payer: Cigna Commercial	$636.50
Rate for Payer: Cigna Medicare	$603.00
Rate for Payer: Medicaid All Medicaid	$616.40
Rate for Payer: Medicare All Medicare	$469.00
Rate for Payer: Monida Allegiance	$636.50
Rate for Payer: Monida First Choice Health	$649.90
Rate for Payer: Monida Montana Health Co-op	$636.50
Rate for Payer: Monida PacificSource	$636.50

BUDESONIDE INH [180MCG] MDI NF

Facility

$615.00

Service Code	HCPCS J7626
Hospital Charge Code	3000054
Hospital Revenue Code	250
Min. Negotiated Rate	$430.50
Max. Negotiated Rate	$615.00
Rate for Payer: Aetna Commercial	$584.25
Rate for Payer: Aetna Medicare	$553.50
Rate for Payer: BCBS MT CHIP	$553.50
Rate for Payer: BCBS MT Closed Plan Network	$584.25
Rate for Payer: BCBS MT HealthLink	$553.50
Rate for Payer: BCBS MT Medicare	$553.50
Rate for Payer: BCBS MT POS	$584.25
Rate for Payer: BCBS MT Traditional	$615.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Cigna Commercial	$584.25
Rate for Payer: Cigna Medicare	$553.50
Rate for Payer: Medicaid All Medicaid	$565.80
Rate for Payer: Medicare All Medicare	$430.50
Rate for Payer: Monida Allegiance	$584.25
Rate for Payer: Monida First Choice Health	$596.55
Rate for Payer: Monida Montana Health Co-op	$584.25
Rate for Payer: Monida PacificSource	$584.25

BUDESONIDE INH [180MCG] MDI NF

Facility

$615.00

Service Code	HCPCS J7626
Hospital Charge Code	3000054
Hospital Revenue Code	250
Min. Negotiated Rate	$430.50
Max. Negotiated Rate	$615.00
Rate for Payer: Aetna Commercial	$584.25
Rate for Payer: Aetna Medicare	$553.50
Rate for Payer: BCBS MT CHIP	$553.50
Rate for Payer: BCBS MT Closed Plan Network	$584.25
Rate for Payer: BCBS MT HealthLink	$553.50
Rate for Payer: BCBS MT Medicare	$553.50
Rate for Payer: BCBS MT POS	$584.25
Rate for Payer: BCBS MT Traditional	$615.00
Rate for Payer: Cash Price	$553.50
Rate for Payer: Cigna Commercial	$584.25
Rate for Payer: Cigna Medicare	$553.50
Rate for Payer: Medicaid All Medicaid	$565.80
Rate for Payer: Medicare All Medicare	$430.50
Rate for Payer: Monida Allegiance	$584.25
Rate for Payer: Monida First Choice Health	$596.55
Rate for Payer: Monida Montana Health Co-op	$584.25
Rate for Payer: Monida PacificSource	$584.25

BUDESONIDE NEB SOLN [0.5 MG/2 ML]

Facility

$36.00

Service Code	HCPCS J7626
Hospital Charge Code	3000055
Hospital Revenue Code	259
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

BUDESONIDE NEB SOLN [0.5 MG/2 ML]

Facility

$36.00

Service Code	HCPCS J7626
Hospital Charge Code	3000055
Hospital Revenue Code	259
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

BULB SYRINGE 3OZ

Facility

$12.00

Hospital Charge Code	80030303
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

BULB SYRINGE 3OZ

Facility

$12.00

Hospital Charge Code	80030303
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

BUMETANIDE INJ [0.25 MG/ML] 4ML SDV

Facility

$26.00

Service Code	HCPCS J1939
Hospital Charge Code	3000056
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

BUMETANIDE INJ [0.25 MG/ML] 4ML SDV

Facility

$26.00

Service Code	HCPCS J1939
Hospital Charge Code	3000056
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

BUMETANIDE TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000057
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

BUMETANIDE TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000057
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

BUPIVACAINE 0.25% INJ [10 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000058
Hospital Revenue Code	636
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

BUPIVACAINE 0.25% INJ [10 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000058
Hospital Revenue Code	636
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

BUPRENORPHINE INJ [300 MG/1.5 ML] SP ORD

Facility

$3,444.00

Service Code	HCPCS Q9992
Hospital Charge Code	300571
Hospital Revenue Code	250
Min. Negotiated Rate	$2,410.80
Max. Negotiated Rate	$3,444.00
Rate for Payer: Aetna Commercial	$3,271.80
Rate for Payer: Aetna Medicare	$3,099.60
Rate for Payer: BCBS MT CHIP	$3,099.60
Rate for Payer: BCBS MT Closed Plan Network	$3,271.80
Rate for Payer: BCBS MT HealthLink	$3,099.60
Rate for Payer: BCBS MT Medicare	$3,099.60
Rate for Payer: BCBS MT POS	$3,271.80
Rate for Payer: BCBS MT Traditional	$3,444.00
Rate for Payer: Cash Price	$3,099.60
Rate for Payer: Cigna Commercial	$3,271.80
Rate for Payer: Cigna Medicare	$3,099.60
Rate for Payer: Medicaid All Medicaid	$3,168.48
Rate for Payer: Medicare All Medicare	$2,410.80
Rate for Payer: Monida Allegiance	$3,271.80
Rate for Payer: Monida First Choice Health	$3,340.68
Rate for Payer: Monida Montana Health Co-op	$3,271.80
Rate for Payer: Monida PacificSource	$3,271.80

BUPRENORPHINE INJ [300 MG/1.5 ML] SP ORD

Facility

$3,444.00

Service Code	HCPCS Q9992
Hospital Charge Code	300571
Hospital Revenue Code	250
Min. Negotiated Rate	$2,410.80
Max. Negotiated Rate	$3,444.00
Rate for Payer: Aetna Commercial	$3,271.80
Rate for Payer: Aetna Medicare	$3,099.60
Rate for Payer: BCBS MT CHIP	$3,099.60
Rate for Payer: BCBS MT Closed Plan Network	$3,271.80
Rate for Payer: BCBS MT HealthLink	$3,099.60
Rate for Payer: BCBS MT Medicare	$3,099.60
Rate for Payer: BCBS MT POS	$3,271.80
Rate for Payer: BCBS MT Traditional	$3,444.00
Rate for Payer: Cash Price	$3,099.60
Rate for Payer: Cigna Commercial	$3,271.80
Rate for Payer: Cigna Medicare	$3,099.60
Rate for Payer: Medicaid All Medicaid	$3,168.48
Rate for Payer: Medicare All Medicare	$2,410.80
Rate for Payer: Monida Allegiance	$3,271.80
Rate for Payer: Monida First Choice Health	$3,340.68
Rate for Payer: Monida Montana Health Co-op	$3,271.80
Rate for Payer: Monida PacificSource	$3,271.80

BUPRENORPHINE SL TAB [2 MG] NF

Facility

$8.00

Service Code	HCPCS J0571
Hospital Charge Code	3000668
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

BUPRENORPHINE SL TAB [2 MG] NF

Facility

$8.00

Service Code	HCPCS J0571
Hospital Charge Code	3000668
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

BUPRENORPHINE SL TAB [8 MG] NF

Facility

$14.00

Service Code	HCPCS J0571
Hospital Charge Code	3007666
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

BUPRENORPHINE SL TAB [8 MG] NF

Facility

$14.00

Service Code	HCPCS J0571
Hospital Charge Code	3007666
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

BUPROPION SR TAB [150 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000541
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

BUPROPION SR TAB [150 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000541
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

BUPROPION XL TAB [150 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000060
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

BUPROPION XL TAB [150 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000060
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

BURN INITIAL TREATMENT LOCAL TX 1ST DEG

Facility

$290.00

Service Code	CPT 16000
Hospital Charge Code	8016000
Hospital Revenue Code	521
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

Know your out-of-pocket cost for care.

All Charges