Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CHIRO ADJ EXTR

Facility

$37.00

Service Code	CPT 98943
Hospital Charge Code	8198943
Hospital Revenue Code	521
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

CHIRO ADJ EXTR

Facility

$37.00

Service Code	CPT 98943
Hospital Charge Code	8198943
Hospital Revenue Code	521
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

CHLAMYDIA GONORRHEA RECTAL NAAT

Facility

$250.00

Service Code	CPT 87491
Hospital Charge Code	4088073
Hospital Revenue Code	302
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

CHLAMYDIA GONORRHEA RECTAL NAAT

Facility

$250.00

Service Code	CPT 87491
Hospital Charge Code	4088073
Hospital Revenue Code	302
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

CHLAMYDIA/GONORRHEA RVMC

Facility

$300.00

Service Code	CPT 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	CPT 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 THROAT NAAT

Facility

$250.00

Service Code	CPT 87491
Hospital Charge Code	4088074
Hospital Revenue Code	302
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

CHLAMYDIA GONORRHEA THROAT NAAT

Facility

$250.00

Service Code	CPT 87491
Hospital Charge Code	4088074
Hospital Revenue Code	302
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

CHLAMYDIA TRACHOMATIS AMP. PROBE TECH

Facility

$139.00

Service Code	CPT 87491
Hospital Charge Code	8087491
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

CHLAMYDIA TRACHOMATIS AMP. PROBE TECH

Facility

$139.00

Service Code	CPT 87491
Hospital Charge Code	8087491
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

CHLAMYDIA TRACHOMATIS, NAA (188078)

Facility

$155.00

Service Code	CPT 87491
Hospital Charge Code	4087491
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

CHLAMYDIA TRACHOMATIS, NAA (188078)

Facility

$155.00

Service Code	CPT 87491
Hospital Charge Code	4087491
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

CHLORAPREP 1.5 ML

Facility

$51.49

Hospital Charge Code	90196565
Hospital Revenue Code	270
Min. Negotiated Rate	$36.04
Max. Negotiated Rate	$51.49
Rate for Payer: Aetna Commercial	$48.92
Rate for Payer: Aetna Medicare	$46.34
Rate for Payer: BCBS MT CHIP	$46.34
Rate for Payer: BCBS MT Closed Plan Network	$48.92
Rate for Payer: BCBS MT HealthLink	$46.34
Rate for Payer: BCBS MT Medicare	$46.34
Rate for Payer: BCBS MT POS	$48.92
Rate for Payer: BCBS MT Traditional	$51.49
Rate for Payer: Cash Price	$46.34
Rate for Payer: Cigna Commercial	$48.92
Rate for Payer: Cigna Medicare	$46.34
Rate for Payer: Medicaid All Medicaid	$47.37
Rate for Payer: Medicare All Medicare	$36.04
Rate for Payer: Monida Allegiance	$48.92
Rate for Payer: Monida First Choice Health	$49.95
Rate for Payer: Monida Montana Health Co-op	$48.92
Rate for Payer: Monida PacificSource	$48.92

CHLORAPREP 1.5 ML

Facility

$51.49

Hospital Charge Code	90196565
Hospital Revenue Code	270
Min. Negotiated Rate	$36.04
Max. Negotiated Rate	$51.49
Rate for Payer: Aetna Commercial	$48.92
Rate for Payer: Aetna Medicare	$46.34
Rate for Payer: BCBS MT CHIP	$46.34
Rate for Payer: BCBS MT Closed Plan Network	$48.92
Rate for Payer: BCBS MT HealthLink	$46.34
Rate for Payer: BCBS MT Medicare	$46.34
Rate for Payer: BCBS MT POS	$48.92
Rate for Payer: BCBS MT Traditional	$51.49
Rate for Payer: Cash Price	$46.34
Rate for Payer: Cigna Commercial	$48.92
Rate for Payer: Cigna Medicare	$46.34
Rate for Payer: Medicaid All Medicaid	$47.37
Rate for Payer: Medicare All Medicare	$36.04
Rate for Payer: Monida Allegiance	$48.92
Rate for Payer: Monida First Choice Health	$49.95
Rate for Payer: Monida Montana Health Co-op	$48.92
Rate for Payer: Monida PacificSource	$48.92

CHLORASEPTIC SORE THROAT SPRAY

Facility

$23.20

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

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

CHLORHEXIDINE SLN [4 %] 118ML BTL

Facility

$21.00

Service Code	HCPCS A4248
Hospital Charge Code	3007623
Hospital Revenue Code	250
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

CHLORHEXIDINE SLN [4 %] 118ML BTL

Facility

$21.00

Service Code	HCPCS A4248
Hospital Charge Code	3007623
Hospital Revenue Code	250
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

CHLORIDE

Facility

$55.00

Service Code	CPT 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	CPT 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

CHLOROX BLEACH 1 GAL

Facility

$8.54

Hospital Charge Code	90197180
Hospital Revenue Code	270
Min. Negotiated Rate	$5.98
Max. Negotiated Rate	$8.54
Rate for Payer: Aetna Commercial	$8.11
Rate for Payer: Aetna Medicare	$7.69
Rate for Payer: BCBS MT CHIP	$7.69
Rate for Payer: BCBS MT Closed Plan Network	$8.11
Rate for Payer: BCBS MT HealthLink	$7.69
Rate for Payer: BCBS MT Medicare	$7.69
Rate for Payer: BCBS MT POS	$8.11
Rate for Payer: BCBS MT Traditional	$8.54
Rate for Payer: Cash Price	$7.69
Rate for Payer: Cigna Commercial	$8.11
Rate for Payer: Cigna Medicare	$7.69
Rate for Payer: Medicaid All Medicaid	$7.86
Rate for Payer: Medicare All Medicare	$5.98
Rate for Payer: Monida Allegiance	$8.11
Rate for Payer: Monida First Choice Health	$8.28
Rate for Payer: Monida Montana Health Co-op	$8.11
Rate for Payer: Monida PacificSource	$8.11

CHLOROX BLEACH 1 GAL

Facility

$8.54

Hospital Charge Code	90197180
Hospital Revenue Code	270
Min. Negotiated Rate	$5.98
Max. Negotiated Rate	$8.54
Rate for Payer: Aetna Commercial	$8.11
Rate for Payer: Aetna Medicare	$7.69
Rate for Payer: BCBS MT CHIP	$7.69
Rate for Payer: BCBS MT Closed Plan Network	$8.11
Rate for Payer: BCBS MT HealthLink	$7.69
Rate for Payer: BCBS MT Medicare	$7.69
Rate for Payer: BCBS MT POS	$8.11
Rate for Payer: BCBS MT Traditional	$8.54
Rate for Payer: Cash Price	$7.69
Rate for Payer: Cigna Commercial	$8.11
Rate for Payer: Cigna Medicare	$7.69
Rate for Payer: Medicaid All Medicaid	$7.86
Rate for Payer: Medicare All Medicare	$5.98
Rate for Payer: Monida Allegiance	$8.11
Rate for Payer: Monida First Choice Health	$8.28
Rate for Payer: Monida Montana Health Co-op	$8.11
Rate for Payer: Monida PacificSource	$8.11

CHLORTHALIDONE TABS [25MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000086
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

CHLORTHALIDONE TABS [25MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000086
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

CHOLESTEROL, HDL

Facility

$77.00

Service Code	CPT 83718
Hospital Charge Code	4083718
Hospital Revenue Code	301
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

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