Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

AUDITMICRO LINR IMMUNOASSAY

Facility

$369.21

Hospital Charge Code	90197120
Hospital Revenue Code	270
Min. Negotiated Rate	$258.45
Max. Negotiated Rate	$369.21
Rate for Payer: Aetna Commercial	$350.75
Rate for Payer: Aetna Medicare	$332.29
Rate for Payer: BCBS MT CHIP	$332.29
Rate for Payer: BCBS MT Closed Plan Network	$350.75
Rate for Payer: BCBS MT HealthLink	$332.29
Rate for Payer: BCBS MT Medicare	$332.29
Rate for Payer: BCBS MT POS	$350.75
Rate for Payer: BCBS MT Traditional	$369.21
Rate for Payer: Cash Price	$332.29
Rate for Payer: Cigna Commercial	$350.75
Rate for Payer: Cigna Medicare	$332.29
Rate for Payer: Medicaid All Medicaid	$339.67
Rate for Payer: Medicare All Medicare	$258.45
Rate for Payer: Monida Allegiance	$350.75
Rate for Payer: Monida First Choice Health	$358.13
Rate for Payer: Monida Montana Health Co-op	$350.75
Rate for Payer: Monida PacificSource	$350.75

AUDITMICRO LINR IMMUNOASSAY

Facility

$369.21

Hospital Charge Code	90197120
Hospital Revenue Code	270
Min. Negotiated Rate	$258.45
Max. Negotiated Rate	$369.21
Rate for Payer: Aetna Commercial	$350.75
Rate for Payer: Aetna Medicare	$332.29
Rate for Payer: BCBS MT CHIP	$332.29
Rate for Payer: BCBS MT Closed Plan Network	$350.75
Rate for Payer: BCBS MT HealthLink	$332.29
Rate for Payer: BCBS MT Medicare	$332.29
Rate for Payer: BCBS MT POS	$350.75
Rate for Payer: BCBS MT Traditional	$369.21
Rate for Payer: Cash Price	$332.29
Rate for Payer: Cigna Commercial	$350.75
Rate for Payer: Cigna Medicare	$332.29
Rate for Payer: Medicaid All Medicaid	$339.67
Rate for Payer: Medicare All Medicare	$258.45
Rate for Payer: Monida Allegiance	$350.75
Rate for Payer: Monida First Choice Health	$358.13
Rate for Payer: Monida Montana Health Co-op	$350.75
Rate for Payer: Monida PacificSource	$350.75

AUDITMICRO LINR LIPIDS

Facility

$380.00

Hospital Charge Code	90197119
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

AUDITMICRO LINR LIPIDS

Facility

$380.00

Hospital Charge Code	90197119
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

AUDITMICRO LINR PATHFAST NTBNP

Facility

$201.69

Hospital Charge Code	90197079
Hospital Revenue Code	270
Min. Negotiated Rate	$141.18
Max. Negotiated Rate	$201.69
Rate for Payer: Aetna Commercial	$191.61
Rate for Payer: Aetna Medicare	$181.52
Rate for Payer: BCBS MT CHIP	$181.52
Rate for Payer: BCBS MT Closed Plan Network	$191.61
Rate for Payer: BCBS MT HealthLink	$181.52
Rate for Payer: BCBS MT Medicare	$181.52
Rate for Payer: BCBS MT POS	$191.61
Rate for Payer: BCBS MT Traditional	$201.69
Rate for Payer: Cash Price	$181.52
Rate for Payer: Cigna Commercial	$191.61
Rate for Payer: Cigna Medicare	$181.52
Rate for Payer: Medicaid All Medicaid	$185.55
Rate for Payer: Medicare All Medicare	$141.18
Rate for Payer: Monida Allegiance	$191.61
Rate for Payer: Monida First Choice Health	$195.64
Rate for Payer: Monida Montana Health Co-op	$191.61
Rate for Payer: Monida PacificSource	$191.61

AUDITMICRO LINR PATHFAST NTBNP

Facility

$201.69

Hospital Charge Code	90197079
Hospital Revenue Code	270
Min. Negotiated Rate	$141.18
Max. Negotiated Rate	$201.69
Rate for Payer: Aetna Commercial	$191.61
Rate for Payer: Aetna Medicare	$181.52
Rate for Payer: BCBS MT CHIP	$181.52
Rate for Payer: BCBS MT Closed Plan Network	$191.61
Rate for Payer: BCBS MT HealthLink	$181.52
Rate for Payer: BCBS MT Medicare	$181.52
Rate for Payer: BCBS MT POS	$191.61
Rate for Payer: BCBS MT Traditional	$201.69
Rate for Payer: Cash Price	$181.52
Rate for Payer: Cigna Commercial	$191.61
Rate for Payer: Cigna Medicare	$181.52
Rate for Payer: Medicaid All Medicaid	$185.55
Rate for Payer: Medicare All Medicare	$141.18
Rate for Payer: Monida Allegiance	$191.61
Rate for Payer: Monida First Choice Health	$195.64
Rate for Payer: Monida Montana Health Co-op	$191.61
Rate for Payer: Monida PacificSource	$191.61

AUDITMICRO LINR PROCALCITONIN

Facility

$337.38

Hospital Charge Code	90197155
Hospital Revenue Code	270
Min. Negotiated Rate	$236.17
Max. Negotiated Rate	$337.38
Rate for Payer: Aetna Commercial	$320.51
Rate for Payer: Aetna Medicare	$303.64
Rate for Payer: BCBS MT CHIP	$303.64
Rate for Payer: BCBS MT Closed Plan Network	$320.51
Rate for Payer: BCBS MT HealthLink	$303.64
Rate for Payer: BCBS MT Medicare	$303.64
Rate for Payer: BCBS MT POS	$320.51
Rate for Payer: BCBS MT Traditional	$337.38
Rate for Payer: Cash Price	$303.64
Rate for Payer: Cigna Commercial	$320.51
Rate for Payer: Cigna Medicare	$303.64
Rate for Payer: Medicaid All Medicaid	$310.39
Rate for Payer: Medicare All Medicare	$236.17
Rate for Payer: Monida Allegiance	$320.51
Rate for Payer: Monida First Choice Health	$327.26
Rate for Payer: Monida Montana Health Co-op	$320.51
Rate for Payer: Monida PacificSource	$320.51

AUDITMICRO LINR PROCALCITONIN

Facility

$337.38

Hospital Charge Code	90197155
Hospital Revenue Code	270
Min. Negotiated Rate	$236.17
Max. Negotiated Rate	$337.38
Rate for Payer: Aetna Commercial	$320.51
Rate for Payer: Aetna Medicare	$303.64
Rate for Payer: BCBS MT CHIP	$303.64
Rate for Payer: BCBS MT Closed Plan Network	$320.51
Rate for Payer: BCBS MT HealthLink	$303.64
Rate for Payer: BCBS MT Medicare	$303.64
Rate for Payer: BCBS MT POS	$320.51
Rate for Payer: BCBS MT Traditional	$337.38
Rate for Payer: Cash Price	$303.64
Rate for Payer: Cigna Commercial	$320.51
Rate for Payer: Cigna Medicare	$303.64
Rate for Payer: Medicaid All Medicaid	$310.39
Rate for Payer: Medicare All Medicare	$236.17
Rate for Payer: Monida Allegiance	$320.51
Rate for Payer: Monida First Choice Health	$327.26
Rate for Payer: Monida Montana Health Co-op	$320.51
Rate for Payer: Monida PacificSource	$320.51

AUDITMICRO LINR TDM

Facility

$355.38

Hospital Charge Code	90197178
Hospital Revenue Code	270
Min. Negotiated Rate	$248.77
Max. Negotiated Rate	$355.38
Rate for Payer: Aetna Commercial	$337.61
Rate for Payer: Aetna Medicare	$319.84
Rate for Payer: BCBS MT CHIP	$319.84
Rate for Payer: BCBS MT Closed Plan Network	$337.61
Rate for Payer: BCBS MT HealthLink	$319.84
Rate for Payer: BCBS MT Medicare	$319.84
Rate for Payer: BCBS MT POS	$337.61
Rate for Payer: BCBS MT Traditional	$355.38
Rate for Payer: Cash Price	$319.84
Rate for Payer: Cigna Commercial	$337.61
Rate for Payer: Cigna Medicare	$319.84
Rate for Payer: Medicaid All Medicaid	$326.95
Rate for Payer: Medicare All Medicare	$248.77
Rate for Payer: Monida Allegiance	$337.61
Rate for Payer: Monida First Choice Health	$344.72
Rate for Payer: Monida Montana Health Co-op	$337.61
Rate for Payer: Monida PacificSource	$337.61

AUDITMICRO LINR TDM

Facility

$355.38

Hospital Charge Code	90197178
Hospital Revenue Code	270
Min. Negotiated Rate	$248.77
Max. Negotiated Rate	$355.38
Rate for Payer: Aetna Commercial	$337.61
Rate for Payer: Aetna Medicare	$319.84
Rate for Payer: BCBS MT CHIP	$319.84
Rate for Payer: BCBS MT Closed Plan Network	$337.61
Rate for Payer: BCBS MT HealthLink	$319.84
Rate for Payer: BCBS MT Medicare	$319.84
Rate for Payer: BCBS MT POS	$337.61
Rate for Payer: BCBS MT Traditional	$355.38
Rate for Payer: Cash Price	$319.84
Rate for Payer: Cigna Commercial	$337.61
Rate for Payer: Cigna Medicare	$319.84
Rate for Payer: Medicaid All Medicaid	$326.95
Rate for Payer: Medicare All Medicare	$248.77
Rate for Payer: Monida Allegiance	$337.61
Rate for Payer: Monida First Choice Health	$344.72
Rate for Payer: Monida Montana Health Co-op	$337.61
Rate for Payer: Monida PacificSource	$337.61

AUDITMICRO LINR VITAMIN D

Facility

$201.89

Hospital Charge Code	90197124
Hospital Revenue Code	270
Min. Negotiated Rate	$141.32
Max. Negotiated Rate	$201.89
Rate for Payer: Aetna Commercial	$191.80
Rate for Payer: Aetna Medicare	$181.70
Rate for Payer: BCBS MT CHIP	$181.70
Rate for Payer: BCBS MT Closed Plan Network	$191.80
Rate for Payer: BCBS MT HealthLink	$181.70
Rate for Payer: BCBS MT Medicare	$181.70
Rate for Payer: BCBS MT POS	$191.80
Rate for Payer: BCBS MT Traditional	$201.89
Rate for Payer: Cash Price	$181.70
Rate for Payer: Cigna Commercial	$191.80
Rate for Payer: Cigna Medicare	$181.70
Rate for Payer: Medicaid All Medicaid	$185.74
Rate for Payer: Medicare All Medicare	$141.32
Rate for Payer: Monida Allegiance	$191.80
Rate for Payer: Monida First Choice Health	$195.83
Rate for Payer: Monida Montana Health Co-op	$191.80
Rate for Payer: Monida PacificSource	$191.80

AUDITMICRO LINR VITAMIN D

Facility

$201.89

Hospital Charge Code	90197124
Hospital Revenue Code	270
Min. Negotiated Rate	$141.32
Max. Negotiated Rate	$201.89
Rate for Payer: Aetna Commercial	$191.80
Rate for Payer: Aetna Medicare	$181.70
Rate for Payer: BCBS MT CHIP	$181.70
Rate for Payer: BCBS MT Closed Plan Network	$191.80
Rate for Payer: BCBS MT HealthLink	$181.70
Rate for Payer: BCBS MT Medicare	$181.70
Rate for Payer: BCBS MT POS	$191.80
Rate for Payer: BCBS MT Traditional	$201.89
Rate for Payer: Cash Price	$181.70
Rate for Payer: Cigna Commercial	$191.80
Rate for Payer: Cigna Medicare	$181.70
Rate for Payer: Medicaid All Medicaid	$185.74
Rate for Payer: Medicare All Medicare	$141.32
Rate for Payer: Monida Allegiance	$191.80
Rate for Payer: Monida First Choice Health	$195.83
Rate for Payer: Monida Montana Health Co-op	$191.80
Rate for Payer: Monida PacificSource	$191.80

AVULSION NAIL PLATE SIMPLE ADDITIONAL

Facility

$196.00

Service Code	CPT 11732
Hospital Charge Code	8011732
Hospital Revenue Code	521
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

AVULSION NAIL PLATE SIMPLE ADDITIONAL

Facility

$196.00

Service Code	CPT 11732
Hospital Charge Code	8011732
Hospital Revenue Code	521
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

AVULSION NAIL PLATE SIMPLE SINGLE

Facility

$301.00

Service Code	CPT 11730
Hospital Charge Code	8011730
Hospital Revenue Code	521
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

AVULSION NAIL PLATE SIMPLE SINGLE

Facility

$301.00

Service Code	CPT 11730
Hospital Charge Code	8011730
Hospital Revenue Code	521
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

AYR SALINE NASAL GEL

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

AYR SALINE NASAL GEL

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	3000043
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

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 J8499
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

AZITHROMYCIN SUSP [100 MG/5 ML]

Facility

$112.00

Service Code	HCPCS J8499
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

AZITHROMYCIN TAB [250 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000046
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

AZITHROMYCIN TAB [250 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000046
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

AZITHROMYCIN Z-PACK TAB [250 MG] 6 TABS

Facility

$150.00

Service Code	HCPCS J8499
Hospital Charge Code	3000047
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges