Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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

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

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

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

D/C DEXAMETHASONE INJ [20 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J1100
Hospital Charge Code	3000110
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

D/C DEXAMETHASONE INJ [20 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J1100
Hospital Charge Code	3000110
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

D/C DIAZEPAM INJ SYR [10 MG/2 ML]

Facility

$62.00

Service Code	HCPCS J3360
Hospital Charge Code	3000113
Hospital Revenue Code	259
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

D/C DIAZEPAM INJ SYR [10 MG/2 ML]

Facility

$62.00

Service Code	HCPCS J3360
Hospital Charge Code	3000113
Hospital Revenue Code	259
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

D/C DORZOLAMIDE-TIMOLOL 22.3 -6.8MG NF

Facility

$390.40

Hospital Charge Code	3007246
Hospital Revenue Code	250
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$390.40
Rate for Payer: Aetna Commercial	$370.88
Rate for Payer: Aetna Medicare	$351.36
Rate for Payer: BCBS MT CHIP	$351.36
Rate for Payer: BCBS MT Closed Plan Network	$370.88
Rate for Payer: BCBS MT HealthLink	$351.36
Rate for Payer: BCBS MT Medicare	$351.36
Rate for Payer: BCBS MT POS	$370.88
Rate for Payer: BCBS MT Traditional	$390.40
Rate for Payer: Cash Price	$351.36
Rate for Payer: Cigna Commercial	$370.88
Rate for Payer: Cigna Medicare	$351.36
Rate for Payer: Medicaid All Medicaid	$359.17
Rate for Payer: Medicare All Medicare	$273.28
Rate for Payer: Monida Allegiance	$370.88
Rate for Payer: Monida First Choice Health	$378.69
Rate for Payer: Monida Montana Health Co-op	$370.88
Rate for Payer: Monida PacificSource	$370.88

D/C DORZOLAMIDE-TIMOLOL 22.3 -6.8MG NF

Facility

$390.40

Hospital Charge Code	3007246
Hospital Revenue Code	250
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$390.40
Rate for Payer: Aetna Commercial	$370.88
Rate for Payer: Aetna Medicare	$351.36
Rate for Payer: BCBS MT CHIP	$351.36
Rate for Payer: BCBS MT Closed Plan Network	$370.88
Rate for Payer: BCBS MT HealthLink	$351.36
Rate for Payer: BCBS MT Medicare	$351.36
Rate for Payer: BCBS MT POS	$370.88
Rate for Payer: BCBS MT Traditional	$390.40
Rate for Payer: Cash Price	$351.36
Rate for Payer: Cigna Commercial	$370.88
Rate for Payer: Cigna Medicare	$351.36
Rate for Payer: Medicaid All Medicaid	$359.17
Rate for Payer: Medicare All Medicare	$273.28
Rate for Payer: Monida Allegiance	$370.88
Rate for Payer: Monida First Choice Health	$378.69
Rate for Payer: Monida Montana Health Co-op	$370.88
Rate for Payer: Monida PacificSource	$370.88

D/C ENOXAPARIN INJ [60 MG/0.6M

Facility

$48.00

Service Code	HCPCS J1650
Hospital Charge Code	3000142
Hospital Revenue Code	259
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

D/C ENOXAPARIN INJ [60 MG/0.6M

Facility

$48.00

Service Code	HCPCS J1650
Hospital Charge Code	3000142
Hospital Revenue Code	259
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

D/C EPINEPHRINE 1MG/ML 10ML VIAL

Facility

$59.00

Service Code	HCPCS J0171
Hospital Charge Code	3000144
Hospital Revenue Code	636
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

D/C EPINEPHRINE 1MG/ML 10ML VIAL

Facility

$59.00

Service Code	HCPCS J0171
Hospital Charge Code	3000144
Hospital Revenue Code	636
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

D/C ERPAK ACETAMINOPHEN TAB [325 MG] #6

Facility

$11.00

Service Code	HCPCS J3490
Hospital Charge Code	3000150
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

D/C ERPAK ACETAMINOPHEN TAB [325 MG] #6

Facility

$11.00

Service Code	HCPCS J3490
Hospital Charge Code	3000150
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

D/C ERPAK AMLODOPINE TAB [5 MG] 4 TAB

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000151
Hospital Revenue Code	250
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

D/C ERPAK AMLODOPINE TAB [5 MG] 4 TAB

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000151
Hospital Revenue Code	250
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

D/C ERPAK AMOX/CLAV TAB [875/125 MG] #6

Facility

$69.00

Service Code	HCPCS J3490
Hospital Charge Code	3000152
Hospital Revenue Code	250
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

D/C ERPAK AMOX/CLAV TAB [875/125 MG] #6

Facility

$69.00

Service Code	HCPCS J3490
Hospital Charge Code	3000152
Hospital Revenue Code	250
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

Know your out-of-pocket cost for care.

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