Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

BODY MASS INDEX (BMI) DOCUMENTED

Facility

$0.01

Service Code	CPT 3008F
Hospital Charge Code	8003008
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

BODY MASS INDEX (BMI) DOCUMENTED

Facility

$0.01

Service Code	CPT 3008F
Hospital Charge Code	8003008
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

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

BORRELIA BURGDORFERI VLSE1 PEPC10 AB REF

Facility

$150.00

Service Code	CPT 86618
Hospital Charge Code	4088123
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

BORRELIA BURGDORFERI VLSE1 PEPC10 AB REF

Facility

$150.00

Service Code	CPT 86618
Hospital Charge Code	4088123
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

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

BRIEF EMOTION/BEHAVIOR ASSESSMENT-PHQ-9

Facility

$5.00

Service Code	CPT 96127
Hospital Charge Code	8096127
Hospital Revenue Code	521
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

BRIEF EMOTION/BEHAVIOR ASSESSMENT-PHQ-9

Facility

$5.00

Service Code	CPT 96127
Hospital Charge Code	8096127
Hospital Revenue Code	521
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

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

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

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

Know your out-of-pocket cost for care.

All Charges