Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

VITAMIN K1 (121200)

Facility

$289.00

Service Code	CPT 84597
Hospital Charge Code	4084597
Hospital Revenue Code	300
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

VITAMIN K1 (121200)

Facility

$289.00

Service Code	CPT 84597
Hospital Charge Code	4084597
Hospital Revenue Code	300
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

VIT B12 ASSAY

Facility

$119.48

Hospital Charge Code	90197100
Hospital Revenue Code	270
Min. Negotiated Rate	$83.64
Max. Negotiated Rate	$119.48
Rate for Payer: Aetna Commercial	$113.51
Rate for Payer: Aetna Medicare	$107.53
Rate for Payer: BCBS MT CHIP	$107.53
Rate for Payer: BCBS MT Closed Plan Network	$113.51
Rate for Payer: BCBS MT HealthLink	$107.53
Rate for Payer: BCBS MT Medicare	$107.53
Rate for Payer: BCBS MT POS	$113.51
Rate for Payer: BCBS MT Traditional	$119.48
Rate for Payer: Cash Price	$107.53
Rate for Payer: Cigna Commercial	$113.51
Rate for Payer: Cigna Medicare	$107.53
Rate for Payer: Medicaid All Medicaid	$109.92
Rate for Payer: Medicare All Medicare	$83.64
Rate for Payer: Monida Allegiance	$113.51
Rate for Payer: Monida First Choice Health	$115.90
Rate for Payer: Monida Montana Health Co-op	$113.51
Rate for Payer: Monida PacificSource	$113.51

VIT B12 ASSAY

Facility

$119.48

Hospital Charge Code	90197100
Hospital Revenue Code	270
Min. Negotiated Rate	$83.64
Max. Negotiated Rate	$119.48
Rate for Payer: Aetna Commercial	$113.51
Rate for Payer: Aetna Medicare	$107.53
Rate for Payer: BCBS MT CHIP	$107.53
Rate for Payer: BCBS MT Closed Plan Network	$113.51
Rate for Payer: BCBS MT HealthLink	$107.53
Rate for Payer: BCBS MT Medicare	$107.53
Rate for Payer: BCBS MT POS	$113.51
Rate for Payer: BCBS MT Traditional	$119.48
Rate for Payer: Cash Price	$107.53
Rate for Payer: Cigna Commercial	$113.51
Rate for Payer: Cigna Medicare	$107.53
Rate for Payer: Medicaid All Medicaid	$109.92
Rate for Payer: Medicare All Medicare	$83.64
Rate for Payer: Monida Allegiance	$113.51
Rate for Payer: Monida First Choice Health	$115.90
Rate for Payer: Monida Montana Health Co-op	$113.51
Rate for Payer: Monida PacificSource	$113.51

VIT B12 + FOLATE

Facility

$150.00

Service Code	CPT 82607
Hospital Charge Code	4087979
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

VIT B12 + FOLATE

Facility

$150.00

Service Code	CPT 82607
Hospital Charge Code	4087979
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

VOLDYNE VOLUME EXERCISER

Facility

$19.00

Hospital Charge Code	2840349
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

VOLDYNE VOLUME EXERCISER

Facility

$19.00

Hospital Charge Code	2840349
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

.VOLUME MEASUREMENT, TIMED COLLECTION

Facility

$30.00

Service Code	CPT 81050
Hospital Charge Code	4081050
Hospital Revenue Code	307
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

.VOLUME MEASUREMENT, TIMED COLLECTION

Facility

$30.00

Service Code	CPT 81050
Hospital Charge Code	4081050
Hospital Revenue Code	307
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

VON WILLEBRAND FACTOR ACTIVITY (164509)

Facility

$158.00

Service Code	CPT 85245
Hospital Charge Code	4085245
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

VON WILLEBRAND FACTOR ACTIVITY (164509)

Facility

$158.00

Service Code	CPT 85245
Hospital Charge Code	4085245
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

VON WILLEBRAND FACTOR ANTIGEN (086280)

Facility

$197.00

Service Code	CPT 85246
Hospital Charge Code	4085246
Hospital Revenue Code	300
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

VON WILLEBRAND FACTOR ANTIGEN (086280)

Facility

$197.00

Service Code	CPT 85246
Hospital Charge Code	4085246
Hospital Revenue Code	300
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

VORICONAZOLE TAB [200 MG] NF

Facility

$267.00

Service Code	HCPCS J8499
Hospital Charge Code	3000483
Hospital Revenue Code	250
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$267.00
Rate for Payer: Aetna Commercial	$253.65
Rate for Payer: Aetna Medicare	$240.30
Rate for Payer: BCBS MT CHIP	$240.30
Rate for Payer: BCBS MT Closed Plan Network	$253.65
Rate for Payer: BCBS MT HealthLink	$240.30
Rate for Payer: BCBS MT Medicare	$240.30
Rate for Payer: BCBS MT POS	$253.65
Rate for Payer: BCBS MT Traditional	$267.00
Rate for Payer: Cash Price	$240.30
Rate for Payer: Cigna Commercial	$253.65
Rate for Payer: Cigna Medicare	$240.30
Rate for Payer: Medicaid All Medicaid	$245.64
Rate for Payer: Medicare All Medicare	$186.90
Rate for Payer: Monida Allegiance	$253.65
Rate for Payer: Monida First Choice Health	$258.99
Rate for Payer: Monida Montana Health Co-op	$253.65
Rate for Payer: Monida PacificSource	$253.65

VORICONAZOLE TAB [200 MG] NF

Facility

$267.00

Service Code	HCPCS J8499
Hospital Charge Code	3000483
Hospital Revenue Code	250
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$267.00
Rate for Payer: Aetna Commercial	$253.65
Rate for Payer: Aetna Medicare	$240.30
Rate for Payer: BCBS MT CHIP	$240.30
Rate for Payer: BCBS MT Closed Plan Network	$253.65
Rate for Payer: BCBS MT HealthLink	$240.30
Rate for Payer: BCBS MT Medicare	$240.30
Rate for Payer: BCBS MT POS	$253.65
Rate for Payer: BCBS MT Traditional	$267.00
Rate for Payer: Cash Price	$240.30
Rate for Payer: Cigna Commercial	$253.65
Rate for Payer: Cigna Medicare	$240.30
Rate for Payer: Medicaid All Medicaid	$245.64
Rate for Payer: Medicare All Medicare	$186.90
Rate for Payer: Monida Allegiance	$253.65
Rate for Payer: Monida First Choice Health	$258.99
Rate for Payer: Monida Montana Health Co-op	$253.65
Rate for Payer: Monida PacificSource	$253.65

WARFARIN TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000484
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

WARFARIN TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000484
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

WARFARIN TAB [2 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000485
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

WARFARIN TAB [2 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000485
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

WARFARIN TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000486
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

WARFARIN TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000486
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

WELCOME TO MEDICARE EXAM

Facility

$382.00

Service Code	HCPCS G0402
Hospital Charge Code	8000402
Hospital Revenue Code	521
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$382.00
Rate for Payer: Aetna Commercial	$362.90
Rate for Payer: Aetna Medicare	$343.80
Rate for Payer: BCBS MT CHIP	$343.80
Rate for Payer: BCBS MT Closed Plan Network	$362.90
Rate for Payer: BCBS MT HealthLink	$343.80
Rate for Payer: BCBS MT Medicare	$343.80
Rate for Payer: BCBS MT POS	$362.90
Rate for Payer: BCBS MT Traditional	$382.00
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cigna Commercial	$362.90
Rate for Payer: Cigna Medicare	$343.80
Rate for Payer: Medicaid All Medicaid	$351.44
Rate for Payer: Medicare All Medicare	$267.40
Rate for Payer: Monida Allegiance	$362.90
Rate for Payer: Monida First Choice Health	$370.54
Rate for Payer: Monida Montana Health Co-op	$362.90
Rate for Payer: Monida PacificSource	$362.90

WELCOME TO MEDICARE EXAM

Facility

$382.00

Service Code	HCPCS G0402
Hospital Charge Code	8000402
Hospital Revenue Code	521
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$382.00
Rate for Payer: Aetna Commercial	$362.90
Rate for Payer: Aetna Medicare	$343.80
Rate for Payer: BCBS MT CHIP	$343.80
Rate for Payer: BCBS MT Closed Plan Network	$362.90
Rate for Payer: BCBS MT HealthLink	$343.80
Rate for Payer: BCBS MT Medicare	$343.80
Rate for Payer: BCBS MT POS	$362.90
Rate for Payer: BCBS MT Traditional	$382.00
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cigna Commercial	$362.90
Rate for Payer: Cigna Medicare	$343.80
Rate for Payer: Medicaid All Medicaid	$351.44
Rate for Payer: Medicare All Medicare	$267.40
Rate for Payer: Monida Allegiance	$362.90
Rate for Payer: Monida First Choice Health	$370.54
Rate for Payer: Monida Montana Health Co-op	$362.90
Rate for Payer: Monida PacificSource	$362.90

WET MOUNT, VAGINAL

Facility

$78.00

Service Code	CPT 87210
Hospital Charge Code	4087210
Hospital Revenue Code	306
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

Know your out-of-pocket cost for care.

All Charges