Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

DAPTOMYCIN/NS 50ML [500 MG] SPECIAL ORDE

Facility

$231.00

Service Code	HCPCS J0878
Hospital Charge Code	3000549
Hospital Revenue Code	636
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

DAPTOMYCIN/NS 50ML [500 MG] SPECIAL ORDE

Facility

$231.00

Service Code	HCPCS J0878
Hospital Charge Code	3000549
Hospital Revenue Code	636
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

DARBEPOETIN ALFA [40 MCG/ ML] PFS SP ORD

Facility

$706.00

Service Code	HCPCS J0881
Hospital Charge Code	3007412
Hospital Revenue Code	250
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

DARBEPOETIN ALFA [40 MCG/ ML] PFS SP ORD

Facility

$706.00

Service Code	HCPCS J0881
Hospital Charge Code	3007412
Hospital Revenue Code	250
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

D/C ALTEPLASE INJ [100 MG]

Facility

$15,524.00

Service Code	HCPCS J2997
Hospital Charge Code	3000020
Hospital Revenue Code	636
Min. Negotiated Rate	$10,866.80
Max. Negotiated Rate	$15,524.00
Rate for Payer: Aetna Commercial	$14,747.80
Rate for Payer: Aetna Medicare	$13,971.60
Rate for Payer: BCBS MT CHIP	$13,971.60
Rate for Payer: BCBS MT Closed Plan Network	$14,747.80
Rate for Payer: BCBS MT HealthLink	$13,971.60
Rate for Payer: BCBS MT Medicare	$13,971.60
Rate for Payer: BCBS MT POS	$14,747.80
Rate for Payer: BCBS MT Traditional	$15,524.00
Rate for Payer: Cash Price	$13,971.60
Rate for Payer: Cigna Commercial	$14,747.80
Rate for Payer: Cigna Medicare	$13,971.60
Rate for Payer: Medicaid All Medicaid	$14,282.08
Rate for Payer: Medicare All Medicare	$10,866.80
Rate for Payer: Monida Allegiance	$14,747.80
Rate for Payer: Monida First Choice Health	$15,058.28
Rate for Payer: Monida Montana Health Co-op	$14,747.80
Rate for Payer: Monida PacificSource	$14,747.80

D/C ALTEPLASE INJ [100 MG]

Facility

$15,524.00

Service Code	HCPCS J2997
Hospital Charge Code	3000020
Hospital Revenue Code	636
Min. Negotiated Rate	$10,866.80
Max. Negotiated Rate	$15,524.00
Rate for Payer: Aetna Commercial	$14,747.80
Rate for Payer: Aetna Medicare	$13,971.60
Rate for Payer: BCBS MT CHIP	$13,971.60
Rate for Payer: BCBS MT Closed Plan Network	$14,747.80
Rate for Payer: BCBS MT HealthLink	$13,971.60
Rate for Payer: BCBS MT Medicare	$13,971.60
Rate for Payer: BCBS MT POS	$14,747.80
Rate for Payer: BCBS MT Traditional	$15,524.00
Rate for Payer: Cash Price	$13,971.60
Rate for Payer: Cigna Commercial	$14,747.80
Rate for Payer: Cigna Medicare	$13,971.60
Rate for Payer: Medicaid All Medicaid	$14,282.08
Rate for Payer: Medicare All Medicare	$10,866.80
Rate for Payer: Monida Allegiance	$14,747.80
Rate for Payer: Monida First Choice Health	$15,058.28
Rate for Payer: Monida Montana Health Co-op	$14,747.80
Rate for Payer: Monida PacificSource	$14,747.80

D/C AMOXICILLIN 875 MG TABLET

Facility

$8.00

Service Code	NDC 00781506120
Hospital Charge Code	3007198
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

D/C AMOXICILLIN 875 MG TABLET

Facility

$8.00

Service Code	NDC 00781506120
Hospital Charge Code	3007198
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

D/C AMPICILLIN 10GM VIAL NF

Facility

$230.00

Service Code	NDC 00781340995
Hospital Charge Code	3000524
Hospital Revenue Code	259
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

D/C AMPICILLIN 10GM VIAL NF

Facility

$230.00

Service Code	NDC 00781340995
Hospital Charge Code	3000524
Hospital Revenue Code	259
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

D/C Anoro Ellipta Inhalation Powder

Facility

$374.32

Service Code	NDC 00173086906
Hospital Charge Code	3007173
Hospital Revenue Code	250
Min. Negotiated Rate	$262.02
Max. Negotiated Rate	$374.32
Rate for Payer: Aetna Commercial	$355.60
Rate for Payer: Aetna Medicare	$336.89
Rate for Payer: BCBS MT CHIP	$336.89
Rate for Payer: BCBS MT Closed Plan Network	$355.60
Rate for Payer: BCBS MT HealthLink	$336.89
Rate for Payer: BCBS MT Medicare	$336.89
Rate for Payer: BCBS MT POS	$355.60
Rate for Payer: BCBS MT Traditional	$374.32
Rate for Payer: Cash Price	$336.89
Rate for Payer: Cigna Commercial	$355.60
Rate for Payer: Cigna Medicare	$336.89
Rate for Payer: Medicaid All Medicaid	$344.37
Rate for Payer: Medicare All Medicare	$262.02
Rate for Payer: Monida Allegiance	$355.60
Rate for Payer: Monida First Choice Health	$363.09
Rate for Payer: Monida Montana Health Co-op	$355.60
Rate for Payer: Monida PacificSource	$355.60

D/C Anoro Ellipta Inhalation Powder

Facility

$374.32

Service Code	NDC 00173086906
Hospital Charge Code	3007173
Hospital Revenue Code	250
Min. Negotiated Rate	$262.02
Max. Negotiated Rate	$374.32
Rate for Payer: Aetna Commercial	$355.60
Rate for Payer: Aetna Medicare	$336.89
Rate for Payer: BCBS MT CHIP	$336.89
Rate for Payer: BCBS MT Closed Plan Network	$355.60
Rate for Payer: BCBS MT HealthLink	$336.89
Rate for Payer: BCBS MT Medicare	$336.89
Rate for Payer: BCBS MT POS	$355.60
Rate for Payer: BCBS MT Traditional	$374.32
Rate for Payer: Cash Price	$336.89
Rate for Payer: Cigna Commercial	$355.60
Rate for Payer: Cigna Medicare	$336.89
Rate for Payer: Medicaid All Medicaid	$344.37
Rate for Payer: Medicare All Medicare	$262.02
Rate for Payer: Monida Allegiance	$355.60
Rate for Payer: Monida First Choice Health	$363.09
Rate for Payer: Monida Montana Health Co-op	$355.60
Rate for Payer: Monida PacificSource	$355.60

D/C APIXABAN TAB [5 MG] NF

Facility

$39.00

Service Code	HCPCS J3490
Hospital Charge Code	3000035
Hospital Revenue Code	250
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

D/C APIXABAN TAB [5 MG] NF

Facility

$39.00

Service Code	HCPCS J3490
Hospital Charge Code	3000035
Hospital Revenue Code	250
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

D/C AZELASTINE [0.1%] NASAL 30ML NF

Facility

$334.00

Service Code	NDC 60505083305
Hospital Charge Code	3007149
Hospital Revenue Code	250
Min. Negotiated Rate	$233.80
Max. Negotiated Rate	$334.00
Rate for Payer: Aetna Commercial	$317.30
Rate for Payer: Aetna Medicare	$300.60
Rate for Payer: BCBS MT CHIP	$300.60
Rate for Payer: BCBS MT Closed Plan Network	$317.30
Rate for Payer: BCBS MT HealthLink	$300.60
Rate for Payer: BCBS MT Medicare	$300.60
Rate for Payer: BCBS MT POS	$317.30
Rate for Payer: BCBS MT Traditional	$334.00
Rate for Payer: Cash Price	$300.60
Rate for Payer: Cigna Commercial	$317.30
Rate for Payer: Cigna Medicare	$300.60
Rate for Payer: Medicaid All Medicaid	$307.28
Rate for Payer: Medicare All Medicare	$233.80
Rate for Payer: Monida Allegiance	$317.30
Rate for Payer: Monida First Choice Health	$323.98
Rate for Payer: Monida Montana Health Co-op	$317.30
Rate for Payer: Monida PacificSource	$317.30

D/C AZELASTINE [0.1%] NASAL 30ML NF

Facility

$334.00

Service Code	NDC 60505083305
Hospital Charge Code	3007149
Hospital Revenue Code	250
Min. Negotiated Rate	$233.80
Max. Negotiated Rate	$334.00
Rate for Payer: Aetna Commercial	$317.30
Rate for Payer: Aetna Medicare	$300.60
Rate for Payer: BCBS MT CHIP	$300.60
Rate for Payer: BCBS MT Closed Plan Network	$317.30
Rate for Payer: BCBS MT HealthLink	$300.60
Rate for Payer: BCBS MT Medicare	$300.60
Rate for Payer: BCBS MT POS	$317.30
Rate for Payer: BCBS MT Traditional	$334.00
Rate for Payer: Cash Price	$300.60
Rate for Payer: Cigna Commercial	$317.30
Rate for Payer: Cigna Medicare	$300.60
Rate for Payer: Medicaid All Medicaid	$307.28
Rate for Payer: Medicare All Medicare	$233.80
Rate for Payer: Monida Allegiance	$317.30
Rate for Payer: Monida First Choice Health	$323.98
Rate for Payer: Monida Montana Health Co-op	$317.30
Rate for Payer: Monida PacificSource	$317.30

D/C BEBTELOVIMAB INJ &MONITORING

Facility

$368.00

Service Code	HCPCS M0222
Hospital Charge Code	3007174
Hospital Revenue Code	250
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

D/C BEBTELOVIMAB INJ &MONITORING

Facility

$368.00

Service Code	HCPCS M0222
Hospital Charge Code	3007174
Hospital Revenue Code	250
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

D/C BIKTARVY 50MG/200MG/25MG TABLET

Facility

$440.25

Service Code	NDC 61958250101
Hospital Charge Code	3007362
Hospital Revenue Code	250
Min. Negotiated Rate	$308.18
Max. Negotiated Rate	$440.25
Rate for Payer: Aetna Commercial	$418.24
Rate for Payer: Aetna Medicare	$396.23
Rate for Payer: BCBS MT CHIP	$396.23
Rate for Payer: BCBS MT Closed Plan Network	$418.24
Rate for Payer: BCBS MT HealthLink	$396.23
Rate for Payer: BCBS MT Medicare	$396.23
Rate for Payer: BCBS MT POS	$418.24
Rate for Payer: BCBS MT Traditional	$440.25
Rate for Payer: Cash Price	$396.23
Rate for Payer: Cigna Commercial	$418.24
Rate for Payer: Cigna Medicare	$396.23
Rate for Payer: Medicaid All Medicaid	$405.03
Rate for Payer: Medicare All Medicare	$308.18
Rate for Payer: Monida Allegiance	$418.24
Rate for Payer: Monida First Choice Health	$427.04
Rate for Payer: Monida Montana Health Co-op	$418.24
Rate for Payer: Monida PacificSource	$418.24

D/C BIKTARVY 50MG/200MG/25MG TABLET

Facility

$440.25

Service Code	NDC 61958250101
Hospital Charge Code	3007362
Hospital Revenue Code	250
Min. Negotiated Rate	$308.18
Max. Negotiated Rate	$440.25
Rate for Payer: Aetna Commercial	$418.24
Rate for Payer: Aetna Medicare	$396.23
Rate for Payer: BCBS MT CHIP	$396.23
Rate for Payer: BCBS MT Closed Plan Network	$418.24
Rate for Payer: BCBS MT HealthLink	$396.23
Rate for Payer: BCBS MT Medicare	$396.23
Rate for Payer: BCBS MT POS	$418.24
Rate for Payer: BCBS MT Traditional	$440.25
Rate for Payer: Cash Price	$396.23
Rate for Payer: Cigna Commercial	$418.24
Rate for Payer: Cigna Medicare	$396.23
Rate for Payer: Medicaid All Medicaid	$405.03
Rate for Payer: Medicare All Medicare	$308.18
Rate for Payer: Monida Allegiance	$418.24
Rate for Payer: Monida First Choice Health	$427.04
Rate for Payer: Monida Montana Health Co-op	$418.24
Rate for Payer: Monida PacificSource	$418.24

D/C Budesonide-Formoterol INH 80-4.5MCG

Facility

$756.20

Service Code	NDC 00186037220
Hospital Charge Code	3007191
Hospital Revenue Code	250
Min. Negotiated Rate	$529.34
Max. Negotiated Rate	$756.20
Rate for Payer: Aetna Commercial	$718.39
Rate for Payer: Aetna Medicare	$680.58
Rate for Payer: BCBS MT CHIP	$680.58
Rate for Payer: BCBS MT Closed Plan Network	$718.39
Rate for Payer: BCBS MT HealthLink	$680.58
Rate for Payer: BCBS MT Medicare	$680.58
Rate for Payer: BCBS MT POS	$718.39
Rate for Payer: BCBS MT Traditional	$756.20
Rate for Payer: Cash Price	$680.58
Rate for Payer: Cigna Commercial	$718.39
Rate for Payer: Cigna Medicare	$680.58
Rate for Payer: Medicaid All Medicaid	$695.70
Rate for Payer: Medicare All Medicare	$529.34
Rate for Payer: Monida Allegiance	$718.39
Rate for Payer: Monida First Choice Health	$733.51
Rate for Payer: Monida Montana Health Co-op	$718.39
Rate for Payer: Monida PacificSource	$718.39

D/C Budesonide-Formoterol INH 80-4.5MCG

Facility

$756.20

Service Code	NDC 00186037220
Hospital Charge Code	3007191
Hospital Revenue Code	250
Min. Negotiated Rate	$529.34
Max. Negotiated Rate	$756.20
Rate for Payer: Aetna Commercial	$718.39
Rate for Payer: Aetna Medicare	$680.58
Rate for Payer: BCBS MT CHIP	$680.58
Rate for Payer: BCBS MT Closed Plan Network	$718.39
Rate for Payer: BCBS MT HealthLink	$680.58
Rate for Payer: BCBS MT Medicare	$680.58
Rate for Payer: BCBS MT POS	$718.39
Rate for Payer: BCBS MT Traditional	$756.20
Rate for Payer: Cash Price	$680.58
Rate for Payer: Cigna Commercial	$718.39
Rate for Payer: Cigna Medicare	$680.58
Rate for Payer: Medicaid All Medicaid	$695.70
Rate for Payer: Medicare All Medicare	$529.34
Rate for Payer: Monida Allegiance	$718.39
Rate for Payer: Monida First Choice Health	$733.51
Rate for Payer: Monida Montana Health Co-op	$718.39
Rate for Payer: Monida PacificSource	$718.39

D/C BUTORPHANOL INJ [2 MG/ML]

Facility

$32.00

Service Code	HCPCS J0595
Hospital Charge Code	3000532
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

D/C BUTORPHANOL INJ [2 MG/ML]

Facility

$32.00

Service Code	HCPCS J0595
Hospital Charge Code	3000532
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

D/C CLONIDINE PATCH [0.2 MG/24 HR] NF

Facility

$187.00

Service Code	HCPCS J3490
Hospital Charge Code	3000100
Hospital Revenue Code	250
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

Know your out-of-pocket cost for care.

All Charges