Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CETIRIZINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000083
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

CEVIMELINE [30 MG] CAP NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3000500
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

CEVIMELINE [30 MG] CAP NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3000500
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

CHANGE OF CYCTOSTOMY TUBE; SIMPLE

Facility

$475.00

Service Code	HCPCS 51705
Hospital Charge Code	551705
Hospital Revenue Code	761
Min. Negotiated Rate	$332.50
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna Commercial	$451.25
Rate for Payer: Aetna Medicare	$427.50
Rate for Payer: BCBS MT CHIP	$427.50
Rate for Payer: BCBS MT Closed Plan Network	$451.25
Rate for Payer: BCBS MT HealthLink	$427.50
Rate for Payer: BCBS MT Medicare	$427.50
Rate for Payer: BCBS MT POS	$451.25
Rate for Payer: BCBS MT Traditional	$475.00
Rate for Payer: Cash Price	$427.50
Rate for Payer: Cigna Commercial	$451.25
Rate for Payer: Cigna Medicare	$427.50
Rate for Payer: Medicaid All Medicaid	$437.00
Rate for Payer: Medicare All Medicare	$332.50
Rate for Payer: Monida Allegiance	$451.25
Rate for Payer: Monida First Choice Health	$460.75
Rate for Payer: Monida Montana Health Co-op	$451.25
Rate for Payer: Monida PacificSource	$451.25

CHANGE OF CYCTOSTOMY TUBE; SIMPLE

Facility

$475.00

Service Code	HCPCS 51705
Hospital Charge Code	551705
Hospital Revenue Code	761
Min. Negotiated Rate	$332.50
Max. Negotiated Rate	$475.00
Rate for Payer: Aetna Commercial	$451.25
Rate for Payer: Aetna Medicare	$427.50
Rate for Payer: BCBS MT CHIP	$427.50
Rate for Payer: BCBS MT Closed Plan Network	$451.25
Rate for Payer: BCBS MT HealthLink	$427.50
Rate for Payer: BCBS MT Medicare	$427.50
Rate for Payer: BCBS MT POS	$451.25
Rate for Payer: BCBS MT Traditional	$475.00
Rate for Payer: Cash Price	$427.50
Rate for Payer: Cigna Commercial	$451.25
Rate for Payer: Cigna Medicare	$427.50
Rate for Payer: Medicaid All Medicaid	$437.00
Rate for Payer: Medicare All Medicare	$332.50
Rate for Payer: Monida Allegiance	$451.25
Rate for Payer: Monida First Choice Health	$460.75
Rate for Payer: Monida Montana Health Co-op	$451.25
Rate for Payer: Monida PacificSource	$451.25

CHarge Only (DICYCLOMINE HCL) 10mg/5ml

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000084
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

CHarge Only (DICYCLOMINE HCL) 10mg/5ml

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000084
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

Charge Only (LIDOCAINE VISCOUS 2%)

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000085
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

Charge Only (LIDOCAINE VISCOUS 2%)

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000085
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

CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO

Facility

$268.00

Service Code	HCPCS 96402
Hospital Charge Code	596402
Hospital Revenue Code	280
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

CHEMOTX ADMN SUBQ/IM HORMONAL ANTI-NEO

Facility

$268.00

Service Code	HCPCS 96402
Hospital Charge Code	596402
Hospital Revenue Code	280
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-N

Facility

$330.00

Service Code	HCPCS 96401
Hospital Charge Code	596401
Hospital Revenue Code	280
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

CHEMOTX ADMN SUBQ/IM NON-HORMONAL ANTI-N

Facility

$330.00

Service Code	HCPCS 96401
Hospital Charge Code	596401
Hospital Revenue Code	280
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

CHEST SEAL

Facility

$28.00

Hospital Charge Code	80040209
Hospital Revenue Code	270
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

CHEST SEAL

Facility

$28.00

Hospital Charge Code	80040209
Hospital Revenue Code	270
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

CHEST TUBE INSERTION TRAY

Facility

$248.00

Hospital Charge Code	80030356
Hospital Revenue Code	270
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$248.00
Rate for Payer: Aetna Commercial	$235.60
Rate for Payer: Aetna Medicare	$223.20
Rate for Payer: BCBS MT CHIP	$223.20
Rate for Payer: BCBS MT Closed Plan Network	$235.60
Rate for Payer: BCBS MT HealthLink	$223.20
Rate for Payer: BCBS MT Medicare	$223.20
Rate for Payer: BCBS MT POS	$235.60
Rate for Payer: BCBS MT Traditional	$248.00
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cigna Commercial	$235.60
Rate for Payer: Cigna Medicare	$223.20
Rate for Payer: Medicaid All Medicaid	$228.16
Rate for Payer: Medicare All Medicare	$173.60
Rate for Payer: Monida Allegiance	$235.60
Rate for Payer: Monida First Choice Health	$240.56
Rate for Payer: Monida Montana Health Co-op	$235.60
Rate for Payer: Monida PacificSource	$235.60

CHEST TUBE INSERTION TRAY

Facility

$248.00

Hospital Charge Code	80030356
Hospital Revenue Code	270
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$248.00
Rate for Payer: Aetna Commercial	$235.60
Rate for Payer: Aetna Medicare	$223.20
Rate for Payer: BCBS MT CHIP	$223.20
Rate for Payer: BCBS MT Closed Plan Network	$235.60
Rate for Payer: BCBS MT HealthLink	$223.20
Rate for Payer: BCBS MT Medicare	$223.20
Rate for Payer: BCBS MT POS	$235.60
Rate for Payer: BCBS MT Traditional	$248.00
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cigna Commercial	$235.60
Rate for Payer: Cigna Medicare	$223.20
Rate for Payer: Medicaid All Medicaid	$228.16
Rate for Payer: Medicare All Medicare	$173.60
Rate for Payer: Monida Allegiance	$235.60
Rate for Payer: Monida First Choice Health	$240.56
Rate for Payer: Monida Montana Health Co-op	$235.60
Rate for Payer: Monida PacificSource	$235.60

CHLAMYDIA TRACHOMATIS, NAA (188078)

Facility

$55.00

Service Code	HCPCS 87491
Hospital Charge Code	4087491
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

CHLAMYDIA TRACHOMATIS, NAA (188078)

Facility

$55.00

Service Code	HCPCS 87491
Hospital Charge Code	4087491
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

CHLORASEPTIC SORE THROAT LOZENGE

Facility

$5.00

Service Code	NDC 78112080122
Hospital Charge Code	3007303
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

CHLORASEPTIC SORE THROAT LOZENGE

Facility

$5.00

Service Code	NDC 78112080122
Hospital Charge Code	3007303
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

CHLORASEPTIC SORE THROAT SPRAY

Facility

$23.20

Service Code	NDC 78112069480
Hospital Charge Code	3007302
Hospital Revenue Code	250
Min. Negotiated Rate	$16.24
Max. Negotiated Rate	$23.20
Rate for Payer: Aetna Commercial	$22.04
Rate for Payer: Aetna Medicare	$20.88
Rate for Payer: BCBS MT CHIP	$20.88
Rate for Payer: BCBS MT Closed Plan Network	$22.04
Rate for Payer: BCBS MT HealthLink	$20.88
Rate for Payer: BCBS MT Medicare	$20.88
Rate for Payer: BCBS MT POS	$22.04
Rate for Payer: BCBS MT Traditional	$23.20
Rate for Payer: Cash Price	$20.88
Rate for Payer: Cigna Commercial	$22.04
Rate for Payer: Cigna Medicare	$20.88
Rate for Payer: Medicaid All Medicaid	$21.34
Rate for Payer: Medicare All Medicare	$16.24
Rate for Payer: Monida Allegiance	$22.04
Rate for Payer: Monida First Choice Health	$22.50
Rate for Payer: Monida Montana Health Co-op	$22.04
Rate for Payer: Monida PacificSource	$22.04

CHLORASEPTIC SORE THROAT SPRAY

Facility

$23.20

Service Code	NDC 78112069480
Hospital Charge Code	3007302
Hospital Revenue Code	250
Min. Negotiated Rate	$16.24
Max. Negotiated Rate	$23.20
Rate for Payer: Aetna Commercial	$22.04
Rate for Payer: Aetna Medicare	$20.88
Rate for Payer: BCBS MT CHIP	$20.88
Rate for Payer: BCBS MT Closed Plan Network	$22.04
Rate for Payer: BCBS MT HealthLink	$20.88
Rate for Payer: BCBS MT Medicare	$20.88
Rate for Payer: BCBS MT POS	$22.04
Rate for Payer: BCBS MT Traditional	$23.20
Rate for Payer: Cash Price	$20.88
Rate for Payer: Cigna Commercial	$22.04
Rate for Payer: Cigna Medicare	$20.88
Rate for Payer: Medicaid All Medicaid	$21.34
Rate for Payer: Medicare All Medicare	$16.24
Rate for Payer: Monida Allegiance	$22.04
Rate for Payer: Monida First Choice Health	$22.50
Rate for Payer: Monida Montana Health Co-op	$22.04
Rate for Payer: Monida PacificSource	$22.04

CHLORIDE

Facility

$55.00

Service Code	HCPCS 82435
Hospital Charge Code	4082435
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

CHLORIDE

Facility

$55.00

Service Code	HCPCS 82435
Hospital Charge Code	4082435
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

Know your out-of-pocket cost for care.

All Charges