Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CALCIUM/VITAMIN D3 TAB [600 MG/400 IU]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000067
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

CALPROTECTIN (123255)

Facility

$394.00

Service Code	HCPCS 83993
Hospital Charge Code	4083993
Hospital Revenue Code	300
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

CALPROTECTIN (123255)

Facility

$394.00

Service Code	HCPCS 83993
Hospital Charge Code	4083993
Hospital Revenue Code	300
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

CAMPHOR/MENTHOL LOTION [0.5 %/0.5 %] BTL

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	3000068
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

CAMPHOR/MENTHOL LOTION [0.5 %/0.5 %] BTL

Facility

$22.00

Service Code	HCPCS J3490
Hospital Charge Code	3000068
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

CANDIDA SPECIES

Facility

$125.00

Service Code	HCPCS 87480
Hospital Charge Code	4080056
Hospital Revenue Code	300
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

CANDIDA SPECIES

Facility

$125.00

Service Code	HCPCS 87480
Hospital Charge Code	4080056
Hospital Revenue Code	300
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

CANISTER SUCTION 1000 ML (TRA

Facility

$20.00

Hospital Charge Code	80040289
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

CANISTER SUCTION 1000 ML (TRA

Facility

$20.00

Hospital Charge Code	80040289
Hospital Revenue Code	270
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

.CAPILLARY SAMPLE COLLECTION

Facility

$27.00

Service Code	HCPCS 36416
Hospital Charge Code	4036416
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

.CAPILLARY SAMPLE COLLECTION

Facility

$27.00

Service Code	HCPCS 36416
Hospital Charge Code	4036416
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARBAMAZEPINE (007419)

Facility

$37.00

Service Code	HCPCS 80156
Hospital Charge Code	4080156
Hospital Revenue Code	300
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

CARBAMAZEPINE (007419)

Facility

$37.00

Service Code	HCPCS 80156
Hospital Charge Code	4080156
Hospital Revenue Code	300
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

CARBIDOPA/ LEVO ER TAB [23.75-95MG] NF

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	3000513
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

CARBIDOPA/ LEVO ER TAB [23.75-95MG] NF

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	3000513
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

CARBIDOPA/ LEVO TAB [25-100 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000069
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

CARBIDOPA/ LEVO TAB [25-100 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000069
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

CARBON DIOXIDE

Facility

$50.00

Service Code	HCPCS 82374
Hospital Charge Code	4082374
Hospital Revenue Code	300
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

CARBON DIOXIDE

Facility

$50.00

Service Code	HCPCS 82374
Hospital Charge Code	4082374
Hospital Revenue Code	300
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

CARBOPROST TROMETHAMINE 250MCG/ML

Facility

$515.10

Service Code	NDC 81298501005
Hospital Charge Code	3007378
Hospital Revenue Code	250
Min. Negotiated Rate	$360.57
Max. Negotiated Rate	$515.10
Rate for Payer: Aetna Commercial	$489.34
Rate for Payer: Aetna Medicare	$463.59
Rate for Payer: BCBS MT CHIP	$463.59
Rate for Payer: BCBS MT Closed Plan Network	$489.34
Rate for Payer: BCBS MT HealthLink	$463.59
Rate for Payer: BCBS MT Medicare	$463.59
Rate for Payer: BCBS MT POS	$489.34
Rate for Payer: BCBS MT Traditional	$515.10
Rate for Payer: Cash Price	$463.59
Rate for Payer: Cigna Commercial	$489.34
Rate for Payer: Cigna Medicare	$463.59
Rate for Payer: Medicaid All Medicaid	$473.89
Rate for Payer: Medicare All Medicare	$360.57
Rate for Payer: Monida Allegiance	$489.34
Rate for Payer: Monida First Choice Health	$499.65
Rate for Payer: Monida Montana Health Co-op	$489.34
Rate for Payer: Monida PacificSource	$489.34

CARBOPROST TROMETHAMINE 250MCG/ML

Facility

$515.10

Service Code	NDC 81298501005
Hospital Charge Code	3007378
Hospital Revenue Code	250
Min. Negotiated Rate	$360.57
Max. Negotiated Rate	$515.10
Rate for Payer: Aetna Commercial	$489.34
Rate for Payer: Aetna Medicare	$463.59
Rate for Payer: BCBS MT CHIP	$463.59
Rate for Payer: BCBS MT Closed Plan Network	$489.34
Rate for Payer: BCBS MT HealthLink	$463.59
Rate for Payer: BCBS MT Medicare	$463.59
Rate for Payer: BCBS MT POS	$489.34
Rate for Payer: BCBS MT Traditional	$515.10
Rate for Payer: Cash Price	$463.59
Rate for Payer: Cigna Commercial	$489.34
Rate for Payer: Cigna Medicare	$463.59
Rate for Payer: Medicaid All Medicaid	$473.89
Rate for Payer: Medicare All Medicare	$360.57
Rate for Payer: Monida Allegiance	$489.34
Rate for Payer: Monida First Choice Health	$499.65
Rate for Payer: Monida Montana Health Co-op	$489.34
Rate for Payer: Monida PacificSource	$489.34

CARBOPROST TROMETHAMINE 250 MCG SDV

Facility

$515.10

Service Code	NDC 81298501005
Hospital Charge Code	3007341
Hospital Revenue Code	250
Min. Negotiated Rate	$360.57
Max. Negotiated Rate	$515.10
Rate for Payer: Aetna Commercial	$489.34
Rate for Payer: Aetna Medicare	$463.59
Rate for Payer: BCBS MT CHIP	$463.59
Rate for Payer: BCBS MT Closed Plan Network	$489.34
Rate for Payer: BCBS MT HealthLink	$463.59
Rate for Payer: BCBS MT Medicare	$463.59
Rate for Payer: BCBS MT POS	$489.34
Rate for Payer: BCBS MT Traditional	$515.10
Rate for Payer: Cash Price	$463.59
Rate for Payer: Cigna Commercial	$489.34
Rate for Payer: Cigna Medicare	$463.59
Rate for Payer: Medicaid All Medicaid	$473.89
Rate for Payer: Medicare All Medicare	$360.57
Rate for Payer: Monida Allegiance	$489.34
Rate for Payer: Monida First Choice Health	$499.65
Rate for Payer: Monida Montana Health Co-op	$489.34
Rate for Payer: Monida PacificSource	$489.34

CARBOPROST TROMETHAMINE 250 MCG SDV

Facility

$515.10

Service Code	NDC 81298501005
Hospital Charge Code	3007341
Hospital Revenue Code	250
Min. Negotiated Rate	$360.57
Max. Negotiated Rate	$515.10
Rate for Payer: Aetna Commercial	$489.34
Rate for Payer: Aetna Medicare	$463.59
Rate for Payer: BCBS MT CHIP	$463.59
Rate for Payer: BCBS MT Closed Plan Network	$489.34
Rate for Payer: BCBS MT HealthLink	$463.59
Rate for Payer: BCBS MT Medicare	$463.59
Rate for Payer: BCBS MT POS	$489.34
Rate for Payer: BCBS MT Traditional	$515.10
Rate for Payer: Cash Price	$463.59
Rate for Payer: Cigna Commercial	$489.34
Rate for Payer: Cigna Medicare	$463.59
Rate for Payer: Medicaid All Medicaid	$473.89
Rate for Payer: Medicare All Medicare	$360.57
Rate for Payer: Monida Allegiance	$489.34
Rate for Payer: Monida First Choice Health	$499.65
Rate for Payer: Monida Montana Health Co-op	$489.34
Rate for Payer: Monida PacificSource	$489.34

CARCINOEMBRYONIC ANTIGEN (002139)

Facility

$32.00

Service Code	HCPCS 82378
Hospital Charge Code	4082378
Hospital Revenue Code	301
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

CARCINOEMBRYONIC ANTIGEN (002139)

Facility

$32.00

Service Code	HCPCS 82378
Hospital Charge Code	4082378
Hospital Revenue Code	301
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

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