Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CMV ANTIBODIES, IGM (096727)

Facility

$75.00

Service Code	HCPCS 86645
Hospital Charge Code	4086645
Hospital Revenue Code	300
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

CMV ANTIBODIES, IGM (096727)

Facility

$75.00

Service Code	HCPCS 86645
Hospital Charge Code	4086645
Hospital Revenue Code	300
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

CO2 DETECTOR ADULT

Facility

$77.00

Hospital Charge Code	80040110
Hospital Revenue Code	270
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

CO2 DETECTOR ADULT

Facility

$77.00

Hospital Charge Code	80040110
Hospital Revenue Code	270
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

CO2 DETECTOR PED

Facility

$77.00

Hospital Charge Code	80040111
Hospital Revenue Code	270
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

CO2 DETECTOR PED

Facility

$77.00

Hospital Charge Code	80040111
Hospital Revenue Code	270
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

COAGUCHEK XS TEST STRIP (48/BX

Facility

$260.73

Hospital Charge Code	90195097
Hospital Revenue Code	270
Min. Negotiated Rate	$182.51
Max. Negotiated Rate	$260.73
Rate for Payer: Aetna Commercial	$247.69
Rate for Payer: Aetna Medicare	$234.66
Rate for Payer: BCBS MT CHIP	$234.66
Rate for Payer: BCBS MT Closed Plan Network	$247.69
Rate for Payer: BCBS MT HealthLink	$234.66
Rate for Payer: BCBS MT Medicare	$234.66
Rate for Payer: BCBS MT POS	$247.69
Rate for Payer: BCBS MT Traditional	$260.73
Rate for Payer: Cash Price	$234.66
Rate for Payer: Cigna Commercial	$247.69
Rate for Payer: Cigna Medicare	$234.66
Rate for Payer: Medicaid All Medicaid	$239.87
Rate for Payer: Medicare All Medicare	$182.51
Rate for Payer: Monida Allegiance	$247.69
Rate for Payer: Monida First Choice Health	$252.91
Rate for Payer: Monida Montana Health Co-op	$247.69
Rate for Payer: Monida PacificSource	$247.69

COAGUCHEK XS TEST STRIP (48/BX

Facility

$260.73

Hospital Charge Code	90195097
Hospital Revenue Code	270
Min. Negotiated Rate	$182.51
Max. Negotiated Rate	$260.73
Rate for Payer: Aetna Commercial	$247.69
Rate for Payer: Aetna Medicare	$234.66
Rate for Payer: BCBS MT CHIP	$234.66
Rate for Payer: BCBS MT Closed Plan Network	$247.69
Rate for Payer: BCBS MT HealthLink	$234.66
Rate for Payer: BCBS MT Medicare	$234.66
Rate for Payer: BCBS MT POS	$247.69
Rate for Payer: BCBS MT Traditional	$260.73
Rate for Payer: Cash Price	$234.66
Rate for Payer: Cigna Commercial	$247.69
Rate for Payer: Cigna Medicare	$234.66
Rate for Payer: Medicaid All Medicaid	$239.87
Rate for Payer: Medicare All Medicare	$182.51
Rate for Payer: Monida Allegiance	$247.69
Rate for Payer: Monida First Choice Health	$252.91
Rate for Payer: Monida Montana Health Co-op	$247.69
Rate for Payer: Monida PacificSource	$247.69

COAGULOPATHY SCREEN 85390

Facility

$72.00

Service Code	HCPCS 85390
Hospital Charge Code	4085390
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

COAGULOPATHY SCREEN 85390

Facility

$72.00

Service Code	HCPCS 85390
Hospital Charge Code	4085390
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

COBALT (071506)

Facility

$224.00

Service Code	HCPCS 83018
Hospital Charge Code	4083018
Hospital Revenue Code	300
Min. Negotiated Rate	$156.80
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial	$212.80
Rate for Payer: Aetna Medicare	$201.60
Rate for Payer: BCBS MT CHIP	$201.60
Rate for Payer: BCBS MT Closed Plan Network	$212.80
Rate for Payer: BCBS MT HealthLink	$201.60
Rate for Payer: BCBS MT Medicare	$201.60
Rate for Payer: BCBS MT POS	$212.80
Rate for Payer: BCBS MT Traditional	$224.00
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cigna Commercial	$212.80
Rate for Payer: Cigna Medicare	$201.60
Rate for Payer: Medicaid All Medicaid	$206.08
Rate for Payer: Medicare All Medicare	$156.80
Rate for Payer: Monida Allegiance	$212.80
Rate for Payer: Monida First Choice Health	$217.28
Rate for Payer: Monida Montana Health Co-op	$212.80
Rate for Payer: Monida PacificSource	$212.80

COBALT (071506)

Facility

$224.00

Service Code	HCPCS 83018
Hospital Charge Code	4083018
Hospital Revenue Code	300
Min. Negotiated Rate	$156.80
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial	$212.80
Rate for Payer: Aetna Medicare	$201.60
Rate for Payer: BCBS MT CHIP	$201.60
Rate for Payer: BCBS MT Closed Plan Network	$212.80
Rate for Payer: BCBS MT HealthLink	$201.60
Rate for Payer: BCBS MT Medicare	$201.60
Rate for Payer: BCBS MT POS	$212.80
Rate for Payer: BCBS MT Traditional	$224.00
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cigna Commercial	$212.80
Rate for Payer: Cigna Medicare	$201.60
Rate for Payer: Medicaid All Medicaid	$206.08
Rate for Payer: Medicare All Medicare	$156.80
Rate for Payer: Monida Allegiance	$212.80
Rate for Payer: Monida First Choice Health	$217.28
Rate for Payer: Monida Montana Health Co-op	$212.80
Rate for Payer: Monida PacificSource	$212.80

COFLEX 2'' COLORPAK

Facility

$21.00

Service Code	HCPCS A4590
Hospital Charge Code	80030090
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

COFLEX 2'' COLORPAK

Facility

$21.00

Service Code	HCPCS A4590
Hospital Charge Code	80030090
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

COFLEX 3'' COLORPAK

Facility

$13.00

Service Code	HCPCS A4590
Hospital Charge Code	80030091
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

COFLEX 3'' COLORPAK

Facility

$13.00

Service Code	HCPCS A4590
Hospital Charge Code	80030091
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

COFLEX 4'' COLORPAK

Facility

$17.00

Service Code	HCPCS A4590
Hospital Charge Code	80030092
Hospital Revenue Code	270
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

COFLEX 4'' COLORPAK

Facility

$17.00

Service Code	HCPCS A4590
Hospital Charge Code	80030092
Hospital Revenue Code	270
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

COLCHICINE TAB [0.6 MG]

Facility

$37.00

Service Code	HCPCS J3490
Hospital Charge Code	3000103
Hospital Revenue Code	250
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

COLCHICINE TAB [0.6 MG]

Facility

$37.00

Service Code	HCPCS J3490
Hospital Charge Code	3000103
Hospital Revenue Code	250
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

COL CHROMATOGRPY, NON-DRUG, EA SPC 82542

Facility

$166.00

Service Code	HCPCS 82542
Hospital Charge Code	4082542
Hospital Revenue Code	307
Min. Negotiated Rate	$116.20
Max. Negotiated Rate	$166.00
Rate for Payer: Aetna Commercial	$157.70
Rate for Payer: Aetna Medicare	$149.40
Rate for Payer: BCBS MT CHIP	$149.40
Rate for Payer: BCBS MT Closed Plan Network	$157.70
Rate for Payer: BCBS MT HealthLink	$149.40
Rate for Payer: BCBS MT Medicare	$149.40
Rate for Payer: BCBS MT POS	$157.70
Rate for Payer: BCBS MT Traditional	$166.00
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cigna Commercial	$157.70
Rate for Payer: Cigna Medicare	$149.40
Rate for Payer: Medicaid All Medicaid	$152.72
Rate for Payer: Medicare All Medicare	$116.20
Rate for Payer: Monida Allegiance	$157.70
Rate for Payer: Monida First Choice Health	$161.02
Rate for Payer: Monida Montana Health Co-op	$157.70
Rate for Payer: Monida PacificSource	$157.70

COL CHROMATOGRPY, NON-DRUG, EA SPC 82542

Facility

$166.00

Service Code	HCPCS 82542
Hospital Charge Code	4082542
Hospital Revenue Code	307
Min. Negotiated Rate	$116.20
Max. Negotiated Rate	$166.00
Rate for Payer: Aetna Commercial	$157.70
Rate for Payer: Aetna Medicare	$149.40
Rate for Payer: BCBS MT CHIP	$149.40
Rate for Payer: BCBS MT Closed Plan Network	$157.70
Rate for Payer: BCBS MT HealthLink	$149.40
Rate for Payer: BCBS MT Medicare	$149.40
Rate for Payer: BCBS MT POS	$157.70
Rate for Payer: BCBS MT Traditional	$166.00
Rate for Payer: Cash Price	$149.40
Rate for Payer: Cigna Commercial	$157.70
Rate for Payer: Cigna Medicare	$149.40
Rate for Payer: Medicaid All Medicaid	$152.72
Rate for Payer: Medicare All Medicare	$116.20
Rate for Payer: Monida Allegiance	$157.70
Rate for Payer: Monida First Choice Health	$161.02
Rate for Payer: Monida Montana Health Co-op	$157.70
Rate for Payer: Monida PacificSource	$157.70

COLLAGENASE OINT [250 IU/G] 30G SPEC ORD

Facility

$657.00

Service Code	HCPCS J3490
Hospital Charge Code	3000104
Hospital Revenue Code	250
Min. Negotiated Rate	$459.90
Max. Negotiated Rate	$657.00
Rate for Payer: Aetna Commercial	$624.15
Rate for Payer: Aetna Medicare	$591.30
Rate for Payer: BCBS MT CHIP	$591.30
Rate for Payer: BCBS MT Closed Plan Network	$624.15
Rate for Payer: BCBS MT HealthLink	$591.30
Rate for Payer: BCBS MT Medicare	$591.30
Rate for Payer: BCBS MT POS	$624.15
Rate for Payer: BCBS MT Traditional	$657.00
Rate for Payer: Cash Price	$591.30
Rate for Payer: Cigna Commercial	$624.15
Rate for Payer: Cigna Medicare	$591.30
Rate for Payer: Medicaid All Medicaid	$604.44
Rate for Payer: Medicare All Medicare	$459.90
Rate for Payer: Monida Allegiance	$624.15
Rate for Payer: Monida First Choice Health	$637.29
Rate for Payer: Monida Montana Health Co-op	$624.15
Rate for Payer: Monida PacificSource	$624.15

COLLAGENASE OINT [250 IU/G] 30G SPEC ORD

Facility

$657.00

Service Code	HCPCS J3490
Hospital Charge Code	3000104
Hospital Revenue Code	250
Min. Negotiated Rate	$459.90
Max. Negotiated Rate	$657.00
Rate for Payer: Aetna Commercial	$624.15
Rate for Payer: Aetna Medicare	$591.30
Rate for Payer: BCBS MT CHIP	$591.30
Rate for Payer: BCBS MT Closed Plan Network	$624.15
Rate for Payer: BCBS MT HealthLink	$591.30
Rate for Payer: BCBS MT Medicare	$591.30
Rate for Payer: BCBS MT POS	$624.15
Rate for Payer: BCBS MT Traditional	$657.00
Rate for Payer: Cash Price	$591.30
Rate for Payer: Cigna Commercial	$624.15
Rate for Payer: Cigna Medicare	$591.30
Rate for Payer: Medicaid All Medicaid	$604.44
Rate for Payer: Medicare All Medicare	$459.90
Rate for Payer: Monida Allegiance	$624.15
Rate for Payer: Monida First Choice Health	$637.29
Rate for Payer: Monida Montana Health Co-op	$624.15
Rate for Payer: Monida PacificSource	$624.15

COLLAR ADJ ADULT EXTRICAT

Facility

$40.00

Hospital Charge Code	80093320
Hospital Revenue Code	290
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

Know your out-of-pocket cost for care.

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