Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

AST

Facility

$65.00

Service Code	HCPCS 84450
Hospital Charge Code	4000042
Hospital Revenue Code	301
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

AST

Facility

$65.00

Service Code	HCPCS 84450
Hospital Charge Code	4000042
Hospital Revenue Code	301
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

ATENOLOL TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000039
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

ATENOLOL TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000039
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

ATORVASTATIN TAB [10 MG]

Facility

$8.00

Service Code	NDC 00904629006
Hospital Charge Code	3007245
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

ATORVASTATIN TAB [10 MG]

Facility

$8.00

Service Code	NDC 00904629006
Hospital Charge Code	3007245
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

ATORVASTATIN TAB [40 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000040
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

ATORVASTATIN TAB [40 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000040
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

ATROPINE INJ SYR [0.1 MG/ML - 10 ML]

Facility

$26.00

Service Code	HCPCS J0461
Hospital Charge Code	3000041
Hospital Revenue Code	259
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

ATROPINE INJ SYR [0.1 MG/ML - 10 ML]

Facility

$26.00

Service Code	HCPCS J0461
Hospital Charge Code	3000041
Hospital Revenue Code	259
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

ATROPINE OPTH [1%] 5 ML

Facility

$196.00

Service Code	HCPCS J3490
Hospital Charge Code	3000042
Hospital Revenue Code	259
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

ATROPINE OPTH [1%] 5 ML

Facility

$196.00

Service Code	HCPCS J3490
Hospital Charge Code	3000042
Hospital Revenue Code	259
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

ATROPINE SULFATE 0.4 MG/ML VIAL SDV

Facility

$32.00

Service Code	HCPCS J0461
Hospital Charge Code	3007068
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

ATROPINE SULFATE 0.4 MG/ML VIAL SDV

Facility

$32.00

Service Code	HCPCS J0461
Hospital Charge Code	3007068
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

ATROVENT HFA INH (17MCG)-NF

Facility

$934.95

Service Code	NDC 00597008717
Hospital Charge Code	3007298
Hospital Revenue Code	250
Min. Negotiated Rate	$654.46
Max. Negotiated Rate	$934.95
Rate for Payer: Aetna Commercial	$888.20
Rate for Payer: Aetna Medicare	$841.46
Rate for Payer: BCBS MT CHIP	$841.46
Rate for Payer: BCBS MT Closed Plan Network	$888.20
Rate for Payer: BCBS MT HealthLink	$841.46
Rate for Payer: BCBS MT Medicare	$841.46
Rate for Payer: BCBS MT POS	$888.20
Rate for Payer: BCBS MT Traditional	$934.95
Rate for Payer: Cash Price	$841.46
Rate for Payer: Cigna Commercial	$888.20
Rate for Payer: Cigna Medicare	$841.46
Rate for Payer: Medicaid All Medicaid	$860.15
Rate for Payer: Medicare All Medicare	$654.46
Rate for Payer: Monida Allegiance	$888.20
Rate for Payer: Monida First Choice Health	$906.90
Rate for Payer: Monida Montana Health Co-op	$888.20
Rate for Payer: Monida PacificSource	$888.20

ATROVENT HFA INH (17MCG)-NF

Facility

$934.95

Service Code	NDC 00597008717
Hospital Charge Code	3007298
Hospital Revenue Code	250
Min. Negotiated Rate	$654.46
Max. Negotiated Rate	$934.95
Rate for Payer: Aetna Commercial	$888.20
Rate for Payer: Aetna Medicare	$841.46
Rate for Payer: BCBS MT CHIP	$841.46
Rate for Payer: BCBS MT Closed Plan Network	$888.20
Rate for Payer: BCBS MT HealthLink	$841.46
Rate for Payer: BCBS MT Medicare	$841.46
Rate for Payer: BCBS MT POS	$888.20
Rate for Payer: BCBS MT Traditional	$934.95
Rate for Payer: Cash Price	$841.46
Rate for Payer: Cigna Commercial	$888.20
Rate for Payer: Cigna Medicare	$841.46
Rate for Payer: Medicaid All Medicaid	$860.15
Rate for Payer: Medicare All Medicare	$654.46
Rate for Payer: Monida Allegiance	$888.20
Rate for Payer: Monida First Choice Health	$906.90
Rate for Payer: Monida Montana Health Co-op	$888.20
Rate for Payer: Monida PacificSource	$888.20

ATTENDS YOUTH XSMALL

Facility

$43.00

Hospital Charge Code	80030413
Hospital Revenue Code	270
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

ATTENDS YOUTH XSMALL

Facility

$43.00

Hospital Charge Code	80030413
Hospital Revenue Code	270
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

AYR SALINE NASAL GEL

Facility

$11.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
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

AYR SALINE NASAL GEL

Facility

$11.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
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

AZELASTINE HCL 0.1% NASAL SPRAY 30ML

Facility

$354.00

Service Code	NDC 60505083305
Hospital Charge Code	3007149
Hospital Revenue Code	250
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

AZELASTINE HCL 0.1% NASAL SPRAY 30ML

Facility

$354.00

Service Code	NDC 60505083305
Hospital Charge Code	3007149
Hospital Revenue Code	250
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

AZITHROMYCIN 500MG INJ

Facility

$36.00

Service Code	HCPCS J0456
Hospital Charge Code	3000044
Hospital Revenue Code	250
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

AZITHROMYCIN 500MG INJ

Facility

$36.00

Service Code	HCPCS J0456
Hospital Charge Code	3000044
Hospital Revenue Code	250
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

AZITHROMYCIN SUSP [100 MG/5 ML]

Facility

$112.00

Service Code	HCPCS J3490
Hospital Charge Code	3000045
Hospital Revenue Code	250
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

Know your out-of-pocket cost for care.

All Charges