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

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

$504.00

Service Code	HCPCS 51705
Hospital Charge Code	551705
Hospital Revenue Code	761
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$478.80
Rate for Payer: Aetna Medicare	$453.60
Rate for Payer: BCBS MT CHIP	$453.60
Rate for Payer: BCBS MT Closed Plan Network	$478.80
Rate for Payer: BCBS MT HealthLink	$453.60
Rate for Payer: BCBS MT Medicare	$453.60
Rate for Payer: BCBS MT POS	$478.80
Rate for Payer: BCBS MT Traditional	$504.00
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna Commercial	$478.80
Rate for Payer: Cigna Medicare	$453.60
Rate for Payer: Medicaid All Medicaid	$463.68
Rate for Payer: Medicare All Medicare	$352.80
Rate for Payer: Monida Allegiance	$478.80
Rate for Payer: Monida First Choice Health	$488.88
Rate for Payer: Monida Montana Health Co-op	$478.80
Rate for Payer: Monida PacificSource	$478.80

CHANGE OF CYCTOSTOMY TUBE; SIMPLE

Facility

$504.00

Service Code	HCPCS 51705
Hospital Charge Code	551705
Hospital Revenue Code	761
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$478.80
Rate for Payer: Aetna Medicare	$453.60
Rate for Payer: BCBS MT CHIP	$453.60
Rate for Payer: BCBS MT Closed Plan Network	$478.80
Rate for Payer: BCBS MT HealthLink	$453.60
Rate for Payer: BCBS MT Medicare	$453.60
Rate for Payer: BCBS MT POS	$478.80
Rate for Payer: BCBS MT Traditional	$504.00
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna Commercial	$478.80
Rate for Payer: Cigna Medicare	$453.60
Rate for Payer: Medicaid All Medicaid	$463.68
Rate for Payer: Medicare All Medicare	$352.80
Rate for Payer: Monida Allegiance	$478.80
Rate for Payer: Monida First Choice Health	$488.88
Rate for Payer: Monida Montana Health Co-op	$478.80
Rate for Payer: Monida PacificSource	$478.80

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

CHART RECORDER REFRIGERATOR

Facility

$208.20

Hospital Charge Code	90196616
Hospital Revenue Code	270
Min. Negotiated Rate	$145.74
Max. Negotiated Rate	$208.20
Rate for Payer: Aetna Commercial	$197.79
Rate for Payer: Aetna Medicare	$187.38
Rate for Payer: BCBS MT CHIP	$187.38
Rate for Payer: BCBS MT Closed Plan Network	$197.79
Rate for Payer: BCBS MT HealthLink	$187.38
Rate for Payer: BCBS MT Medicare	$187.38
Rate for Payer: BCBS MT POS	$197.79
Rate for Payer: BCBS MT Traditional	$208.20
Rate for Payer: Cash Price	$187.38
Rate for Payer: Cigna Commercial	$197.79
Rate for Payer: Cigna Medicare	$187.38
Rate for Payer: Medicaid All Medicaid	$191.54
Rate for Payer: Medicare All Medicare	$145.74
Rate for Payer: Monida Allegiance	$197.79
Rate for Payer: Monida First Choice Health	$201.95
Rate for Payer: Monida Montana Health Co-op	$197.79
Rate for Payer: Monida PacificSource	$197.79

CHART RECORDER REFRIGERATOR

Facility

$208.20

Hospital Charge Code	90196616
Hospital Revenue Code	270
Min. Negotiated Rate	$145.74
Max. Negotiated Rate	$208.20
Rate for Payer: Aetna Commercial	$197.79
Rate for Payer: Aetna Medicare	$187.38
Rate for Payer: BCBS MT CHIP	$187.38
Rate for Payer: BCBS MT Closed Plan Network	$197.79
Rate for Payer: BCBS MT HealthLink	$187.38
Rate for Payer: BCBS MT Medicare	$187.38
Rate for Payer: BCBS MT POS	$197.79
Rate for Payer: BCBS MT Traditional	$208.20
Rate for Payer: Cash Price	$187.38
Rate for Payer: Cigna Commercial	$197.79
Rate for Payer: Cigna Medicare	$187.38
Rate for Payer: Medicaid All Medicaid	$191.54
Rate for Payer: Medicare All Medicare	$145.74
Rate for Payer: Monida Allegiance	$197.79
Rate for Payer: Monida First Choice Health	$201.95
Rate for Payer: Monida Montana Health Co-op	$197.79
Rate for Payer: Monida PacificSource	$197.79

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/GONORRHEA RVMC

Facility

$300.00

Service Code	HCPCS 87591
Hospital Charge Code	4087917
Hospital Revenue Code	300
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

CHLAMYDIA/GONORRHEA RVMC

Facility

$300.00

Service Code	HCPCS 87591
Hospital Charge Code	4087917
Hospital Revenue Code	300
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

CHLAMYDIA TRACHOMATIS, NAA (188078)

Facility

$101.00

Service Code	HCPCS 87491
Hospital Charge Code	4087491
Hospital Revenue Code	300
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

CHLAMYDIA TRACHOMATIS, NAA (188078)

Facility

$101.00

Service Code	HCPCS 87491
Hospital Charge Code	4087491
Hospital Revenue Code	300
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

CHLORASEPTIC SORE THROAT LOZENGE

Facility

$5.00

Service Code	NDC 00904625549
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

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