Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CENTRAL LINE DRESSING

Facility

$5.00

Hospital Charge Code	80040164
Hospital Revenue Code	270
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

CEPHALEXIN CAP [250 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000078
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

CEPHALEXIN CAP [250 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000078
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

CEPHALEXIN CAP [500 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000079
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

CEPHALEXIN CAP [500 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000079
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

CEPHALEXIN SUSP [125 MG/5 ML] 100 ML

Facility

$76.00

Service Code	HCPCS J3490
Hospital Charge Code	3000080
Hospital Revenue Code	250
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

CEPHALEXIN SUSP [125 MG/5 ML] 100 ML

Facility

$76.00

Service Code	HCPCS J3490
Hospital Charge Code	3000080
Hospital Revenue Code	250
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

CEPHALEXIN SUSP [250 MG/5 ML] 100 ML

Facility

$92.00

Service Code	HCPCS J3490
Hospital Charge Code	3000081
Hospital Revenue Code	250
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

CEPHALEXIN SUSP [250 MG/5 ML] 100 ML

Facility

$92.00

Service Code	HCPCS J3490
Hospital Charge Code	3000081
Hospital Revenue Code	250
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

CEPHEID CT/NG

Facility

$408.00

Hospital Charge Code	90197106
Hospital Revenue Code	270
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$408.00
Rate for Payer: Aetna Commercial	$387.60
Rate for Payer: Aetna Medicare	$367.20
Rate for Payer: BCBS MT CHIP	$367.20
Rate for Payer: BCBS MT Closed Plan Network	$387.60
Rate for Payer: BCBS MT HealthLink	$367.20
Rate for Payer: BCBS MT Medicare	$367.20
Rate for Payer: BCBS MT POS	$387.60
Rate for Payer: BCBS MT Traditional	$408.00
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna Commercial	$387.60
Rate for Payer: Cigna Medicare	$367.20
Rate for Payer: Medicaid All Medicaid	$375.36
Rate for Payer: Medicare All Medicare	$285.60
Rate for Payer: Monida Allegiance	$387.60
Rate for Payer: Monida First Choice Health	$395.76
Rate for Payer: Monida Montana Health Co-op	$387.60
Rate for Payer: Monida PacificSource	$387.60

CEPHEID CT/NG

Facility

$408.00

Hospital Charge Code	90197106
Hospital Revenue Code	270
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$408.00
Rate for Payer: Aetna Commercial	$387.60
Rate for Payer: Aetna Medicare	$367.20
Rate for Payer: BCBS MT CHIP	$367.20
Rate for Payer: BCBS MT Closed Plan Network	$387.60
Rate for Payer: BCBS MT HealthLink	$367.20
Rate for Payer: BCBS MT Medicare	$367.20
Rate for Payer: BCBS MT POS	$387.60
Rate for Payer: BCBS MT Traditional	$408.00
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna Commercial	$387.60
Rate for Payer: Cigna Medicare	$367.20
Rate for Payer: Medicaid All Medicaid	$375.36
Rate for Payer: Medicare All Medicare	$285.60
Rate for Payer: Monida Allegiance	$387.60
Rate for Payer: Monida First Choice Health	$395.76
Rate for Payer: Monida Montana Health Co-op	$387.60
Rate for Payer: Monida PacificSource	$387.60

CEPHEID CTNG STARTPAK

Facility

$4,300.00

Hospital Charge Code	90197108
Hospital Revenue Code	270
Min. Negotiated Rate	$3,010.00
Max. Negotiated Rate	$4,300.00
Rate for Payer: Aetna Commercial	$4,085.00
Rate for Payer: Aetna Medicare	$3,870.00
Rate for Payer: BCBS MT CHIP	$3,870.00
Rate for Payer: BCBS MT Closed Plan Network	$4,085.00
Rate for Payer: BCBS MT HealthLink	$3,870.00
Rate for Payer: BCBS MT Medicare	$3,870.00
Rate for Payer: BCBS MT POS	$4,085.00
Rate for Payer: BCBS MT Traditional	$4,300.00
Rate for Payer: Cash Price	$3,870.00
Rate for Payer: Cigna Commercial	$4,085.00
Rate for Payer: Cigna Medicare	$3,870.00
Rate for Payer: Medicaid All Medicaid	$3,956.00
Rate for Payer: Medicare All Medicare	$3,010.00
Rate for Payer: Monida Allegiance	$4,085.00
Rate for Payer: Monida First Choice Health	$4,171.00
Rate for Payer: Monida Montana Health Co-op	$4,085.00
Rate for Payer: Monida PacificSource	$4,085.00

CEPHEID CTNG STARTPAK

Facility

$4,300.00

Hospital Charge Code	90197108
Hospital Revenue Code	270
Min. Negotiated Rate	$3,010.00
Max. Negotiated Rate	$4,300.00
Rate for Payer: Aetna Commercial	$4,085.00
Rate for Payer: Aetna Medicare	$3,870.00
Rate for Payer: BCBS MT CHIP	$3,870.00
Rate for Payer: BCBS MT Closed Plan Network	$4,085.00
Rate for Payer: BCBS MT HealthLink	$3,870.00
Rate for Payer: BCBS MT Medicare	$3,870.00
Rate for Payer: BCBS MT POS	$4,085.00
Rate for Payer: BCBS MT Traditional	$4,300.00
Rate for Payer: Cash Price	$3,870.00
Rate for Payer: Cigna Commercial	$4,085.00
Rate for Payer: Cigna Medicare	$3,870.00
Rate for Payer: Medicaid All Medicaid	$3,956.00
Rate for Payer: Medicare All Medicare	$3,010.00
Rate for Payer: Monida Allegiance	$4,085.00
Rate for Payer: Monida First Choice Health	$4,171.00
Rate for Payer: Monida Montana Health Co-op	$4,085.00
Rate for Payer: Monida PacificSource	$4,085.00

CEPHEID GENEXPERT SERVICE AGREEMENT

Facility

$5,571.00

Hospital Charge Code	90197016
Hospital Revenue Code	270
Min. Negotiated Rate	$3,899.70
Max. Negotiated Rate	$5,571.00
Rate for Payer: Aetna Commercial	$5,292.45
Rate for Payer: Aetna Medicare	$5,013.90
Rate for Payer: BCBS MT CHIP	$5,013.90
Rate for Payer: BCBS MT Closed Plan Network	$5,292.45
Rate for Payer: BCBS MT HealthLink	$5,013.90
Rate for Payer: BCBS MT Medicare	$5,013.90
Rate for Payer: BCBS MT POS	$5,292.45
Rate for Payer: BCBS MT Traditional	$5,571.00
Rate for Payer: Cash Price	$5,013.90
Rate for Payer: Cigna Commercial	$5,292.45
Rate for Payer: Cigna Medicare	$5,013.90
Rate for Payer: Medicaid All Medicaid	$5,125.32
Rate for Payer: Medicare All Medicare	$3,899.70
Rate for Payer: Monida Allegiance	$5,292.45
Rate for Payer: Monida First Choice Health	$5,403.87
Rate for Payer: Monida Montana Health Co-op	$5,292.45
Rate for Payer: Monida PacificSource	$5,292.45

CEPHEID GENEXPERT SERVICE AGREEMENT

Facility

$5,571.00

Hospital Charge Code	90197016
Hospital Revenue Code	270
Min. Negotiated Rate	$3,899.70
Max. Negotiated Rate	$5,571.00
Rate for Payer: Aetna Commercial	$5,292.45
Rate for Payer: Aetna Medicare	$5,013.90
Rate for Payer: BCBS MT CHIP	$5,013.90
Rate for Payer: BCBS MT Closed Plan Network	$5,292.45
Rate for Payer: BCBS MT HealthLink	$5,013.90
Rate for Payer: BCBS MT Medicare	$5,013.90
Rate for Payer: BCBS MT POS	$5,292.45
Rate for Payer: BCBS MT Traditional	$5,571.00
Rate for Payer: Cash Price	$5,013.90
Rate for Payer: Cigna Commercial	$5,292.45
Rate for Payer: Cigna Medicare	$5,013.90
Rate for Payer: Medicaid All Medicaid	$5,125.32
Rate for Payer: Medicare All Medicare	$3,899.70
Rate for Payer: Monida Allegiance	$5,292.45
Rate for Payer: Monida First Choice Health	$5,403.87
Rate for Payer: Monida Montana Health Co-op	$5,292.45
Rate for Payer: Monida PacificSource	$5,292.45

CEPHEID VAGINAL G SWAB

Facility

$115.01

Hospital Charge Code	90197082
Hospital Revenue Code	270
Min. Negotiated Rate	$80.51
Max. Negotiated Rate	$115.01
Rate for Payer: Aetna Commercial	$109.26
Rate for Payer: Aetna Medicare	$103.51
Rate for Payer: BCBS MT CHIP	$103.51
Rate for Payer: BCBS MT Closed Plan Network	$109.26
Rate for Payer: BCBS MT HealthLink	$103.51
Rate for Payer: BCBS MT Medicare	$103.51
Rate for Payer: BCBS MT POS	$109.26
Rate for Payer: BCBS MT Traditional	$115.01
Rate for Payer: Cash Price	$103.51
Rate for Payer: Cigna Commercial	$109.26
Rate for Payer: Cigna Medicare	$103.51
Rate for Payer: Medicaid All Medicaid	$105.81
Rate for Payer: Medicare All Medicare	$80.51
Rate for Payer: Monida Allegiance	$109.26
Rate for Payer: Monida First Choice Health	$111.56
Rate for Payer: Monida Montana Health Co-op	$109.26
Rate for Payer: Monida PacificSource	$109.26

CEPHEID VAGINAL G SWAB

Facility

$115.01

Hospital Charge Code	90197082
Hospital Revenue Code	270
Min. Negotiated Rate	$80.51
Max. Negotiated Rate	$115.01
Rate for Payer: Aetna Commercial	$109.26
Rate for Payer: Aetna Medicare	$103.51
Rate for Payer: BCBS MT CHIP	$103.51
Rate for Payer: BCBS MT Closed Plan Network	$109.26
Rate for Payer: BCBS MT HealthLink	$103.51
Rate for Payer: BCBS MT Medicare	$103.51
Rate for Payer: BCBS MT POS	$109.26
Rate for Payer: BCBS MT Traditional	$115.01
Rate for Payer: Cash Price	$103.51
Rate for Payer: Cigna Commercial	$109.26
Rate for Payer: Cigna Medicare	$103.51
Rate for Payer: Medicaid All Medicaid	$105.81
Rate for Payer: Medicare All Medicare	$80.51
Rate for Payer: Monida Allegiance	$109.26
Rate for Payer: Monida First Choice Health	$111.56
Rate for Payer: Monida Montana Health Co-op	$109.26
Rate for Payer: Monida PacificSource	$109.26

CEPHEID VAGINAL MVP PANEL

Facility

$1,104.41

Hospital Charge Code	90197081
Hospital Revenue Code	270
Min. Negotiated Rate	$773.09
Max. Negotiated Rate	$1,104.41
Rate for Payer: Aetna Commercial	$1,049.19
Rate for Payer: Aetna Medicare	$993.97
Rate for Payer: BCBS MT CHIP	$993.97
Rate for Payer: BCBS MT Closed Plan Network	$1,049.19
Rate for Payer: BCBS MT HealthLink	$993.97
Rate for Payer: BCBS MT Medicare	$993.97
Rate for Payer: BCBS MT POS	$1,049.19
Rate for Payer: BCBS MT Traditional	$1,104.41
Rate for Payer: Cash Price	$993.97
Rate for Payer: Cigna Commercial	$1,049.19
Rate for Payer: Cigna Medicare	$993.97
Rate for Payer: Medicaid All Medicaid	$1,016.06
Rate for Payer: Medicare All Medicare	$773.09
Rate for Payer: Monida Allegiance	$1,049.19
Rate for Payer: Monida First Choice Health	$1,071.28
Rate for Payer: Monida Montana Health Co-op	$1,049.19
Rate for Payer: Monida PacificSource	$1,049.19

CEPHEID VAGINAL MVP PANEL

Facility

$1,104.41

Hospital Charge Code	90197081
Hospital Revenue Code	270
Min. Negotiated Rate	$773.09
Max. Negotiated Rate	$1,104.41
Rate for Payer: Aetna Commercial	$1,049.19
Rate for Payer: Aetna Medicare	$993.97
Rate for Payer: BCBS MT CHIP	$993.97
Rate for Payer: BCBS MT Closed Plan Network	$1,049.19
Rate for Payer: BCBS MT HealthLink	$993.97
Rate for Payer: BCBS MT Medicare	$993.97
Rate for Payer: BCBS MT POS	$1,049.19
Rate for Payer: BCBS MT Traditional	$1,104.41
Rate for Payer: Cash Price	$993.97
Rate for Payer: Cigna Commercial	$1,049.19
Rate for Payer: Cigna Medicare	$993.97
Rate for Payer: Medicaid All Medicaid	$1,016.06
Rate for Payer: Medicare All Medicare	$773.09
Rate for Payer: Monida Allegiance	$1,049.19
Rate for Payer: Monida First Choice Health	$1,071.28
Rate for Payer: Monida Montana Health Co-op	$1,049.19
Rate for Payer: Monida PacificSource	$1,049.19

CEPHEID VAGINITIS PANEL RVMC

Facility

$460.00

Service Code	HCPCS 0352U -Q,
Hospital Charge Code	4087894
Hospital Revenue Code	300
Min. Negotiated Rate	$322.00
Max. Negotiated Rate	$460.00
Rate for Payer: Aetna Commercial	$437.00
Rate for Payer: Aetna Medicare	$414.00
Rate for Payer: BCBS MT CHIP	$414.00
Rate for Payer: BCBS MT Closed Plan Network	$437.00
Rate for Payer: BCBS MT HealthLink	$414.00
Rate for Payer: BCBS MT Medicare	$414.00
Rate for Payer: BCBS MT POS	$437.00
Rate for Payer: BCBS MT Traditional	$460.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cigna Commercial	$437.00
Rate for Payer: Cigna Medicare	$414.00
Rate for Payer: Medicaid All Medicaid	$423.20
Rate for Payer: Medicare All Medicare	$322.00
Rate for Payer: Monida Allegiance	$437.00
Rate for Payer: Monida First Choice Health	$446.20
Rate for Payer: Monida Montana Health Co-op	$437.00
Rate for Payer: Monida PacificSource	$437.00

CEPHEID VAGINITIS PANEL RVMC

Facility

$460.00

Service Code	HCPCS 0352U -Q,
Hospital Charge Code	4087894
Hospital Revenue Code	300
Min. Negotiated Rate	$322.00
Max. Negotiated Rate	$460.00
Rate for Payer: Aetna Commercial	$437.00
Rate for Payer: Aetna Medicare	$414.00
Rate for Payer: BCBS MT CHIP	$414.00
Rate for Payer: BCBS MT Closed Plan Network	$437.00
Rate for Payer: BCBS MT HealthLink	$414.00
Rate for Payer: BCBS MT Medicare	$414.00
Rate for Payer: BCBS MT POS	$437.00
Rate for Payer: BCBS MT Traditional	$460.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cigna Commercial	$437.00
Rate for Payer: Cigna Medicare	$414.00
Rate for Payer: Medicaid All Medicaid	$423.20
Rate for Payer: Medicare All Medicare	$322.00
Rate for Payer: Monida Allegiance	$437.00
Rate for Payer: Monida First Choice Health	$446.20
Rate for Payer: Monida Montana Health Co-op	$437.00
Rate for Payer: Monida PacificSource	$437.00

CERULOPLASMIN (001560)

Facility

$25.00

Service Code	HCPCS 82390
Hospital Charge Code	4082390
Hospital Revenue Code	301
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

CERULOPLASMIN (001560)

Facility

$25.00

Service Code	HCPCS 82390
Hospital Charge Code	4082390
Hospital Revenue Code	301
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

CETIRIZINE SOL [1 MG/ML] 118ML NF

Facility

$117.00

Service Code	HCPCS J3490
Hospital Charge Code	3000082
Hospital Revenue Code	250
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare	$105.30
Rate for Payer: BCBS MT CHIP	$105.30
Rate for Payer: BCBS MT Closed Plan Network	$111.15
Rate for Payer: BCBS MT HealthLink	$105.30
Rate for Payer: BCBS MT Medicare	$105.30
Rate for Payer: BCBS MT POS	$111.15
Rate for Payer: BCBS MT Traditional	$117.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cigna Commercial	$111.15
Rate for Payer: Cigna Medicare	$105.30
Rate for Payer: Medicaid All Medicaid	$107.64
Rate for Payer: Medicare All Medicare	$81.90
Rate for Payer: Monida Allegiance	$111.15
Rate for Payer: Monida First Choice Health	$113.49
Rate for Payer: Monida Montana Health Co-op	$111.15
Rate for Payer: Monida PacificSource	$111.15

CETIRIZINE SOL [1 MG/ML] 118ML NF

Facility

$117.00

Service Code	HCPCS J3490
Hospital Charge Code	3000082
Hospital Revenue Code	250
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare	$105.30
Rate for Payer: BCBS MT CHIP	$105.30
Rate for Payer: BCBS MT Closed Plan Network	$111.15
Rate for Payer: BCBS MT HealthLink	$105.30
Rate for Payer: BCBS MT Medicare	$105.30
Rate for Payer: BCBS MT POS	$111.15
Rate for Payer: BCBS MT Traditional	$117.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cigna Commercial	$111.15
Rate for Payer: Cigna Medicare	$105.30
Rate for Payer: Medicaid All Medicaid	$107.64
Rate for Payer: Medicare All Medicare	$81.90
Rate for Payer: Monida Allegiance	$111.15
Rate for Payer: Monida First Choice Health	$113.49
Rate for Payer: Monida Montana Health Co-op	$111.15
Rate for Payer: Monida PacificSource	$111.15

Know your out-of-pocket cost for care.

All Charges