Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CEPHEID CTNG COLLECTION KIT

Facility

$115.00

Hospital Charge Code	90197108
Hospital Revenue Code	270
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$115.00
Rate for Payer: Aetna Commercial	$109.25
Rate for Payer: Aetna Medicare	$103.50
Rate for Payer: BCBS MT CHIP	$103.50
Rate for Payer: BCBS MT Closed Plan Network	$109.25
Rate for Payer: BCBS MT HealthLink	$103.50
Rate for Payer: BCBS MT Medicare	$103.50
Rate for Payer: BCBS MT POS	$109.25
Rate for Payer: BCBS MT Traditional	$115.00
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cigna Commercial	$109.25
Rate for Payer: Cigna Medicare	$103.50
Rate for Payer: Medicaid All Medicaid	$105.80
Rate for Payer: Medicare All Medicare	$80.50
Rate for Payer: Monida Allegiance	$109.25
Rate for Payer: Monida First Choice Health	$111.55
Rate for Payer: Monida Montana Health Co-op	$109.25
Rate for Payer: Monida PacificSource	$109.25

CEPHEID CTNG COLLECTION KIT

Facility

$115.00

Hospital Charge Code	90197108
Hospital Revenue Code	270
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$115.00
Rate for Payer: Aetna Commercial	$109.25
Rate for Payer: Aetna Medicare	$103.50
Rate for Payer: BCBS MT CHIP	$103.50
Rate for Payer: BCBS MT Closed Plan Network	$109.25
Rate for Payer: BCBS MT HealthLink	$103.50
Rate for Payer: BCBS MT Medicare	$103.50
Rate for Payer: BCBS MT POS	$109.25
Rate for Payer: BCBS MT Traditional	$115.00
Rate for Payer: Cash Price	$103.50
Rate for Payer: Cigna Commercial	$109.25
Rate for Payer: Cigna Medicare	$103.50
Rate for Payer: Medicaid All Medicaid	$105.80
Rate for Payer: Medicare All Medicare	$80.50
Rate for Payer: Monida Allegiance	$109.25
Rate for Payer: Monida First Choice Health	$111.55
Rate for Payer: Monida Montana Health Co-op	$109.25
Rate for Payer: Monida PacificSource	$109.25

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 MRSAMSSA KIT

Facility

$730.81

Hospital Charge Code	90197159
Hospital Revenue Code	270
Min. Negotiated Rate	$511.57
Max. Negotiated Rate	$730.81
Rate for Payer: Aetna Commercial	$694.27
Rate for Payer: Aetna Medicare	$657.73
Rate for Payer: BCBS MT CHIP	$657.73
Rate for Payer: BCBS MT Closed Plan Network	$694.27
Rate for Payer: BCBS MT HealthLink	$657.73
Rate for Payer: BCBS MT Medicare	$657.73
Rate for Payer: BCBS MT POS	$694.27
Rate for Payer: BCBS MT Traditional	$730.81
Rate for Payer: Cash Price	$657.73
Rate for Payer: Cigna Commercial	$694.27
Rate for Payer: Cigna Medicare	$657.73
Rate for Payer: Medicaid All Medicaid	$672.35
Rate for Payer: Medicare All Medicare	$511.57
Rate for Payer: Monida Allegiance	$694.27
Rate for Payer: Monida First Choice Health	$708.89
Rate for Payer: Monida Montana Health Co-op	$694.27
Rate for Payer: Monida PacificSource	$694.27

CEPHEID MRSAMSSA KIT

Facility

$730.81

Hospital Charge Code	90197159
Hospital Revenue Code	270
Min. Negotiated Rate	$511.57
Max. Negotiated Rate	$730.81
Rate for Payer: Aetna Commercial	$694.27
Rate for Payer: Aetna Medicare	$657.73
Rate for Payer: BCBS MT CHIP	$657.73
Rate for Payer: BCBS MT Closed Plan Network	$694.27
Rate for Payer: BCBS MT HealthLink	$657.73
Rate for Payer: BCBS MT Medicare	$657.73
Rate for Payer: BCBS MT POS	$694.27
Rate for Payer: BCBS MT Traditional	$730.81
Rate for Payer: Cash Price	$657.73
Rate for Payer: Cigna Commercial	$694.27
Rate for Payer: Cigna Medicare	$657.73
Rate for Payer: Medicaid All Medicaid	$672.35
Rate for Payer: Medicare All Medicare	$511.57
Rate for Payer: Monida Allegiance	$694.27
Rate for Payer: Monida First Choice Health	$708.89
Rate for Payer: Monida Montana Health Co-op	$694.27
Rate for Payer: Monida PacificSource	$694.27

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	CPT 81515
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	CPT 81515
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	CPT 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	CPT 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

CERVICAL CANCER SCREENING RESULTS DOCUME

Facility

$0.01

Service Code	CPT 3015F
Hospital Charge Code	8003015
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

CERVICAL CANCER SCREENING RESULTS DOCUME

Facility

$0.01

Service Code	CPT 3015F
Hospital Charge Code	8003015
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

CETIRIZINE SOL [1 MG/ML] 118ML

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

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 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 J8499
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 J8499
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	CPT 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	CPT 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

Know your out-of-pocket cost for care.

All Charges