Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CT THORACIC SPINE W CONTRAST

Facility

$2,003.00

Service Code	HCPCS 72129 TC
Hospital Charge Code	5200047
Hospital Revenue Code	350
Min. Negotiated Rate	$1,402.10
Max. Negotiated Rate	$2,003.00
Rate for Payer: Aetna Commercial	$1,902.85
Rate for Payer: Aetna Medicare	$1,802.70
Rate for Payer: BCBS MT CHIP	$1,802.70
Rate for Payer: BCBS MT Closed Plan Network	$1,902.85
Rate for Payer: BCBS MT HealthLink	$1,802.70
Rate for Payer: BCBS MT Medicare	$1,802.70
Rate for Payer: BCBS MT POS	$1,902.85
Rate for Payer: BCBS MT Traditional	$2,003.00
Rate for Payer: Cash Price	$1,802.70
Rate for Payer: Cigna Commercial	$1,902.85
Rate for Payer: Cigna Medicare	$1,802.70
Rate for Payer: Medicaid All Medicaid	$1,842.76
Rate for Payer: Medicare All Medicare	$1,402.10
Rate for Payer: Monida Allegiance	$1,902.85
Rate for Payer: Monida First Choice Health	$1,942.91
Rate for Payer: Monida Montana Health Co-op	$1,902.85
Rate for Payer: Monida PacificSource	$1,902.85

CT THORACIC SPINE W CONTRAST

Facility

$2,003.00

Service Code	HCPCS 72129 TC
Hospital Charge Code	5200047
Hospital Revenue Code	350
Min. Negotiated Rate	$1,402.10
Max. Negotiated Rate	$2,003.00
Rate for Payer: Aetna Commercial	$1,902.85
Rate for Payer: Aetna Medicare	$1,802.70
Rate for Payer: BCBS MT CHIP	$1,802.70
Rate for Payer: BCBS MT Closed Plan Network	$1,902.85
Rate for Payer: BCBS MT HealthLink	$1,802.70
Rate for Payer: BCBS MT Medicare	$1,802.70
Rate for Payer: BCBS MT POS	$1,902.85
Rate for Payer: BCBS MT Traditional	$2,003.00
Rate for Payer: Cash Price	$1,802.70
Rate for Payer: Cigna Commercial	$1,902.85
Rate for Payer: Cigna Medicare	$1,802.70
Rate for Payer: Medicaid All Medicaid	$1,842.76
Rate for Payer: Medicare All Medicare	$1,402.10
Rate for Payer: Monida Allegiance	$1,902.85
Rate for Payer: Monida First Choice Health	$1,942.91
Rate for Payer: Monida Montana Health Co-op	$1,902.85
Rate for Payer: Monida PacificSource	$1,902.85

CT THORACIC SPINE WO CONTRAST

Facility

$1,611.00

Service Code	HCPCS 72128 TC
Hospital Charge Code	5200045
Hospital Revenue Code	350
Min. Negotiated Rate	$1,127.70
Max. Negotiated Rate	$1,611.00
Rate for Payer: Aetna Commercial	$1,530.45
Rate for Payer: Aetna Medicare	$1,449.90
Rate for Payer: BCBS MT CHIP	$1,449.90
Rate for Payer: BCBS MT Closed Plan Network	$1,530.45
Rate for Payer: BCBS MT HealthLink	$1,449.90
Rate for Payer: BCBS MT Medicare	$1,449.90
Rate for Payer: BCBS MT POS	$1,530.45
Rate for Payer: BCBS MT Traditional	$1,611.00
Rate for Payer: Cash Price	$1,449.90
Rate for Payer: Cigna Commercial	$1,530.45
Rate for Payer: Cigna Medicare	$1,449.90
Rate for Payer: Medicaid All Medicaid	$1,482.12
Rate for Payer: Medicare All Medicare	$1,127.70
Rate for Payer: Monida Allegiance	$1,530.45
Rate for Payer: Monida First Choice Health	$1,562.67
Rate for Payer: Monida Montana Health Co-op	$1,530.45
Rate for Payer: Monida PacificSource	$1,530.45

CT THORACIC SPINE WO CONTRAST

Facility

$1,611.00

Service Code	HCPCS 72128 TC
Hospital Charge Code	5200045
Hospital Revenue Code	350
Min. Negotiated Rate	$1,127.70
Max. Negotiated Rate	$1,611.00
Rate for Payer: Aetna Commercial	$1,530.45
Rate for Payer: Aetna Medicare	$1,449.90
Rate for Payer: BCBS MT CHIP	$1,449.90
Rate for Payer: BCBS MT Closed Plan Network	$1,530.45
Rate for Payer: BCBS MT HealthLink	$1,449.90
Rate for Payer: BCBS MT Medicare	$1,449.90
Rate for Payer: BCBS MT POS	$1,530.45
Rate for Payer: BCBS MT Traditional	$1,611.00
Rate for Payer: Cash Price	$1,449.90
Rate for Payer: Cigna Commercial	$1,530.45
Rate for Payer: Cigna Medicare	$1,449.90
Rate for Payer: Medicaid All Medicaid	$1,482.12
Rate for Payer: Medicare All Medicare	$1,127.70
Rate for Payer: Monida Allegiance	$1,530.45
Rate for Payer: Monida First Choice Health	$1,562.67
Rate for Payer: Monida Montana Health Co-op	$1,530.45
Rate for Payer: Monida PacificSource	$1,530.45

CT THORACIC SPINE W WO CONTRAST

Facility

$2,288.00

Service Code	HCPCS 72130 TC
Hospital Charge Code	5200046
Hospital Revenue Code	350
Min. Negotiated Rate	$1,601.60
Max. Negotiated Rate	$2,288.00
Rate for Payer: Aetna Commercial	$2,173.60
Rate for Payer: Aetna Medicare	$2,059.20
Rate for Payer: BCBS MT CHIP	$2,059.20
Rate for Payer: BCBS MT Closed Plan Network	$2,173.60
Rate for Payer: BCBS MT HealthLink	$2,059.20
Rate for Payer: BCBS MT Medicare	$2,059.20
Rate for Payer: BCBS MT POS	$2,173.60
Rate for Payer: BCBS MT Traditional	$2,288.00
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Cigna Commercial	$2,173.60
Rate for Payer: Cigna Medicare	$2,059.20
Rate for Payer: Medicaid All Medicaid	$2,104.96
Rate for Payer: Medicare All Medicare	$1,601.60
Rate for Payer: Monida Allegiance	$2,173.60
Rate for Payer: Monida First Choice Health	$2,219.36
Rate for Payer: Monida Montana Health Co-op	$2,173.60
Rate for Payer: Monida PacificSource	$2,173.60

CT THORACIC SPINE W WO CONTRAST

Facility

$2,288.00

Service Code	HCPCS 72130 TC
Hospital Charge Code	5200046
Hospital Revenue Code	350
Min. Negotiated Rate	$1,601.60
Max. Negotiated Rate	$2,288.00
Rate for Payer: Aetna Commercial	$2,173.60
Rate for Payer: Aetna Medicare	$2,059.20
Rate for Payer: BCBS MT CHIP	$2,059.20
Rate for Payer: BCBS MT Closed Plan Network	$2,173.60
Rate for Payer: BCBS MT HealthLink	$2,059.20
Rate for Payer: BCBS MT Medicare	$2,059.20
Rate for Payer: BCBS MT POS	$2,173.60
Rate for Payer: BCBS MT Traditional	$2,288.00
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Cigna Commercial	$2,173.60
Rate for Payer: Cigna Medicare	$2,059.20
Rate for Payer: Medicaid All Medicaid	$2,104.96
Rate for Payer: Medicare All Medicare	$1,601.60
Rate for Payer: Monida Allegiance	$2,173.60
Rate for Payer: Monida First Choice Health	$2,219.36
Rate for Payer: Monida Montana Health Co-op	$2,173.60
Rate for Payer: Monida PacificSource	$2,173.60

CT UPPER EXTREMITY LT W CONTRAST

Facility

$1,737.00

Service Code	HCPCS 73201 TC,LT
Hospital Charge Code	5200048
Hospital Revenue Code	350
Min. Negotiated Rate	$1,215.90
Max. Negotiated Rate	$1,737.00
Rate for Payer: Aetna Commercial	$1,650.15
Rate for Payer: Aetna Medicare	$1,563.30
Rate for Payer: BCBS MT CHIP	$1,563.30
Rate for Payer: BCBS MT Closed Plan Network	$1,650.15
Rate for Payer: BCBS MT HealthLink	$1,563.30
Rate for Payer: BCBS MT Medicare	$1,563.30
Rate for Payer: BCBS MT POS	$1,650.15
Rate for Payer: BCBS MT Traditional	$1,737.00
Rate for Payer: Cash Price	$1,563.30
Rate for Payer: Cigna Commercial	$1,650.15
Rate for Payer: Cigna Medicare	$1,563.30
Rate for Payer: Medicaid All Medicaid	$1,598.04
Rate for Payer: Medicare All Medicare	$1,215.90
Rate for Payer: Monida Allegiance	$1,650.15
Rate for Payer: Monida First Choice Health	$1,684.89
Rate for Payer: Monida Montana Health Co-op	$1,650.15
Rate for Payer: Monida PacificSource	$1,650.15

CT UPPER EXTREMITY LT W CONTRAST

Facility

$1,737.00

Service Code	HCPCS 73201 TC,LT
Hospital Charge Code	5200048
Hospital Revenue Code	350
Min. Negotiated Rate	$1,215.90
Max. Negotiated Rate	$1,737.00
Rate for Payer: Aetna Commercial	$1,650.15
Rate for Payer: Aetna Medicare	$1,563.30
Rate for Payer: BCBS MT CHIP	$1,563.30
Rate for Payer: BCBS MT Closed Plan Network	$1,650.15
Rate for Payer: BCBS MT HealthLink	$1,563.30
Rate for Payer: BCBS MT Medicare	$1,563.30
Rate for Payer: BCBS MT POS	$1,650.15
Rate for Payer: BCBS MT Traditional	$1,737.00
Rate for Payer: Cash Price	$1,563.30
Rate for Payer: Cigna Commercial	$1,650.15
Rate for Payer: Cigna Medicare	$1,563.30
Rate for Payer: Medicaid All Medicaid	$1,598.04
Rate for Payer: Medicare All Medicare	$1,215.90
Rate for Payer: Monida Allegiance	$1,650.15
Rate for Payer: Monida First Choice Health	$1,684.89
Rate for Payer: Monida Montana Health Co-op	$1,650.15
Rate for Payer: Monida PacificSource	$1,650.15

CT UPPER EXTREMITY LT WO CONTRAST

Facility

$1,447.00

Service Code	HCPCS 73200 TC,LT
Hospital Charge Code	5200049
Hospital Revenue Code	350
Min. Negotiated Rate	$1,012.90
Max. Negotiated Rate	$1,447.00
Rate for Payer: Aetna Commercial	$1,374.65
Rate for Payer: Aetna Medicare	$1,302.30
Rate for Payer: BCBS MT CHIP	$1,302.30
Rate for Payer: BCBS MT Closed Plan Network	$1,374.65
Rate for Payer: BCBS MT HealthLink	$1,302.30
Rate for Payer: BCBS MT Medicare	$1,302.30
Rate for Payer: BCBS MT POS	$1,374.65
Rate for Payer: BCBS MT Traditional	$1,447.00
Rate for Payer: Cash Price	$1,302.30
Rate for Payer: Cigna Commercial	$1,374.65
Rate for Payer: Cigna Medicare	$1,302.30
Rate for Payer: Medicaid All Medicaid	$1,331.24
Rate for Payer: Medicare All Medicare	$1,012.90
Rate for Payer: Monida Allegiance	$1,374.65
Rate for Payer: Monida First Choice Health	$1,403.59
Rate for Payer: Monida Montana Health Co-op	$1,374.65
Rate for Payer: Monida PacificSource	$1,374.65

CT UPPER EXTREMITY LT WO CONTRAST

Facility

$1,447.00

Service Code	HCPCS 73200 TC,LT
Hospital Charge Code	5200049
Hospital Revenue Code	350
Min. Negotiated Rate	$1,012.90
Max. Negotiated Rate	$1,447.00
Rate for Payer: Aetna Commercial	$1,374.65
Rate for Payer: Aetna Medicare	$1,302.30
Rate for Payer: BCBS MT CHIP	$1,302.30
Rate for Payer: BCBS MT Closed Plan Network	$1,374.65
Rate for Payer: BCBS MT HealthLink	$1,302.30
Rate for Payer: BCBS MT Medicare	$1,302.30
Rate for Payer: BCBS MT POS	$1,374.65
Rate for Payer: BCBS MT Traditional	$1,447.00
Rate for Payer: Cash Price	$1,302.30
Rate for Payer: Cigna Commercial	$1,374.65
Rate for Payer: Cigna Medicare	$1,302.30
Rate for Payer: Medicaid All Medicaid	$1,331.24
Rate for Payer: Medicare All Medicare	$1,012.90
Rate for Payer: Monida Allegiance	$1,374.65
Rate for Payer: Monida First Choice Health	$1,403.59
Rate for Payer: Monida Montana Health Co-op	$1,374.65
Rate for Payer: Monida PacificSource	$1,374.65

CT UPPER EXTREMITY LT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,LT
Hospital Charge Code	5200050
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CT UPPER EXTREMITY LT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,LT
Hospital Charge Code	5200050
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CT UPPER EXTREMITY RT W CONTRAST

Facility

$1,737.00

Service Code	HCPCS 73201 TC,RT
Hospital Charge Code	5200051
Hospital Revenue Code	350
Min. Negotiated Rate	$1,215.90
Max. Negotiated Rate	$1,737.00
Rate for Payer: Aetna Commercial	$1,650.15
Rate for Payer: Aetna Medicare	$1,563.30
Rate for Payer: BCBS MT CHIP	$1,563.30
Rate for Payer: BCBS MT Closed Plan Network	$1,650.15
Rate for Payer: BCBS MT HealthLink	$1,563.30
Rate for Payer: BCBS MT Medicare	$1,563.30
Rate for Payer: BCBS MT POS	$1,650.15
Rate for Payer: BCBS MT Traditional	$1,737.00
Rate for Payer: Cash Price	$1,563.30
Rate for Payer: Cigna Commercial	$1,650.15
Rate for Payer: Cigna Medicare	$1,563.30
Rate for Payer: Medicaid All Medicaid	$1,598.04
Rate for Payer: Medicare All Medicare	$1,215.90
Rate for Payer: Monida Allegiance	$1,650.15
Rate for Payer: Monida First Choice Health	$1,684.89
Rate for Payer: Monida Montana Health Co-op	$1,650.15
Rate for Payer: Monida PacificSource	$1,650.15

CT UPPER EXTREMITY RT W CONTRAST

Facility

$1,737.00

Service Code	HCPCS 73201 TC,RT
Hospital Charge Code	5200051
Hospital Revenue Code	350
Min. Negotiated Rate	$1,215.90
Max. Negotiated Rate	$1,737.00
Rate for Payer: Aetna Commercial	$1,650.15
Rate for Payer: Aetna Medicare	$1,563.30
Rate for Payer: BCBS MT CHIP	$1,563.30
Rate for Payer: BCBS MT Closed Plan Network	$1,650.15
Rate for Payer: BCBS MT HealthLink	$1,563.30
Rate for Payer: BCBS MT Medicare	$1,563.30
Rate for Payer: BCBS MT POS	$1,650.15
Rate for Payer: BCBS MT Traditional	$1,737.00
Rate for Payer: Cash Price	$1,563.30
Rate for Payer: Cigna Commercial	$1,650.15
Rate for Payer: Cigna Medicare	$1,563.30
Rate for Payer: Medicaid All Medicaid	$1,598.04
Rate for Payer: Medicare All Medicare	$1,215.90
Rate for Payer: Monida Allegiance	$1,650.15
Rate for Payer: Monida First Choice Health	$1,684.89
Rate for Payer: Monida Montana Health Co-op	$1,650.15
Rate for Payer: Monida PacificSource	$1,650.15

CT UPPER EXTREMITY RT WO CONTRAST

Facility

$1,447.00

Service Code	HCPCS 73200 TC,RT
Hospital Charge Code	5200004
Hospital Revenue Code	350
Min. Negotiated Rate	$1,012.90
Max. Negotiated Rate	$1,447.00
Rate for Payer: Aetna Commercial	$1,374.65
Rate for Payer: Aetna Medicare	$1,302.30
Rate for Payer: BCBS MT CHIP	$1,302.30
Rate for Payer: BCBS MT Closed Plan Network	$1,374.65
Rate for Payer: BCBS MT HealthLink	$1,302.30
Rate for Payer: BCBS MT Medicare	$1,302.30
Rate for Payer: BCBS MT POS	$1,374.65
Rate for Payer: BCBS MT Traditional	$1,447.00
Rate for Payer: Cash Price	$1,302.30
Rate for Payer: Cigna Commercial	$1,374.65
Rate for Payer: Cigna Medicare	$1,302.30
Rate for Payer: Medicaid All Medicaid	$1,331.24
Rate for Payer: Medicare All Medicare	$1,012.90
Rate for Payer: Monida Allegiance	$1,374.65
Rate for Payer: Monida First Choice Health	$1,403.59
Rate for Payer: Monida Montana Health Co-op	$1,374.65
Rate for Payer: Monida PacificSource	$1,374.65

CT UPPER EXTREMITY RT WO CONTRAST

Facility

$1,447.00

Service Code	HCPCS 73200 TC,RT
Hospital Charge Code	5200004
Hospital Revenue Code	350
Min. Negotiated Rate	$1,012.90
Max. Negotiated Rate	$1,447.00
Rate for Payer: Aetna Commercial	$1,374.65
Rate for Payer: Aetna Medicare	$1,302.30
Rate for Payer: BCBS MT CHIP	$1,302.30
Rate for Payer: BCBS MT Closed Plan Network	$1,374.65
Rate for Payer: BCBS MT HealthLink	$1,302.30
Rate for Payer: BCBS MT Medicare	$1,302.30
Rate for Payer: BCBS MT POS	$1,374.65
Rate for Payer: BCBS MT Traditional	$1,447.00
Rate for Payer: Cash Price	$1,302.30
Rate for Payer: Cigna Commercial	$1,374.65
Rate for Payer: Cigna Medicare	$1,302.30
Rate for Payer: Medicaid All Medicaid	$1,331.24
Rate for Payer: Medicare All Medicare	$1,012.90
Rate for Payer: Monida Allegiance	$1,374.65
Rate for Payer: Monida First Choice Health	$1,403.59
Rate for Payer: Monida Montana Health Co-op	$1,374.65
Rate for Payer: Monida PacificSource	$1,374.65

CT UPPER EXTREMITY RT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,RT
Hospital Charge Code	5200052
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CT UPPER EXTREMITY RT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,RT
Hospital Charge Code	5200052
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CYANOCOBALAMIN INJ [1000 MCG/ML]

Facility

$29.00

Service Code	HCPCS J3420
Hospital Charge Code	3000105
Hospital Revenue Code	259
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

CYANOCOBALAMIN INJ [1000 MCG/ML]

Facility

$29.00

Service Code	HCPCS J3420
Hospital Charge Code	3000105
Hospital Revenue Code	259
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

CYCLOBENZAPRINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000106
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

CYCLOBENZAPRINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000106
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

CYCLOSPORINE

Facility

$168.00

Service Code	HCPCS 80158
Hospital Charge Code	4087888
Hospital Revenue Code	301
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$168.00
Rate for Payer: Aetna Commercial	$159.60
Rate for Payer: Aetna Medicare	$151.20
Rate for Payer: BCBS MT CHIP	$151.20
Rate for Payer: BCBS MT Closed Plan Network	$159.60
Rate for Payer: BCBS MT HealthLink	$151.20
Rate for Payer: BCBS MT Medicare	$151.20
Rate for Payer: BCBS MT POS	$159.60
Rate for Payer: BCBS MT Traditional	$168.00
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cigna Commercial	$159.60
Rate for Payer: Cigna Medicare	$151.20
Rate for Payer: Medicaid All Medicaid	$154.56
Rate for Payer: Medicare All Medicare	$117.60
Rate for Payer: Monida Allegiance	$159.60
Rate for Payer: Monida First Choice Health	$162.96
Rate for Payer: Monida Montana Health Co-op	$159.60
Rate for Payer: Monida PacificSource	$159.60

CYCLOSPORINE

Facility

$168.00

Service Code	HCPCS 80158
Hospital Charge Code	4087888
Hospital Revenue Code	301
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$168.00
Rate for Payer: Aetna Commercial	$159.60
Rate for Payer: Aetna Medicare	$151.20
Rate for Payer: BCBS MT CHIP	$151.20
Rate for Payer: BCBS MT Closed Plan Network	$159.60
Rate for Payer: BCBS MT HealthLink	$151.20
Rate for Payer: BCBS MT Medicare	$151.20
Rate for Payer: BCBS MT POS	$159.60
Rate for Payer: BCBS MT Traditional	$168.00
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cigna Commercial	$159.60
Rate for Payer: Cigna Medicare	$151.20
Rate for Payer: Medicaid All Medicaid	$154.56
Rate for Payer: Medicare All Medicare	$117.60
Rate for Payer: Monida Allegiance	$159.60
Rate for Payer: Monida First Choice Health	$162.96
Rate for Payer: Monida Montana Health Co-op	$159.60
Rate for Payer: Monida PacificSource	$159.60

CYGNUS DUAL- 2X3 SQ CENTIMETER

Facility

$15,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004192
Hospital Revenue Code	636
Min. Negotiated Rate	$10,500.00
Max. Negotiated Rate	$15,000.00
Rate for Payer: Aetna Commercial	$14,250.00
Rate for Payer: Aetna Medicare	$13,500.00
Rate for Payer: BCBS MT CHIP	$13,500.00
Rate for Payer: BCBS MT Closed Plan Network	$14,250.00
Rate for Payer: BCBS MT HealthLink	$13,500.00
Rate for Payer: BCBS MT Medicare	$13,500.00
Rate for Payer: BCBS MT POS	$14,250.00
Rate for Payer: BCBS MT Traditional	$15,000.00
Rate for Payer: Cash Price	$13,500.00
Rate for Payer: Cigna Commercial	$14,250.00
Rate for Payer: Cigna Medicare	$13,500.00
Rate for Payer: Medicaid All Medicaid	$13,800.00
Rate for Payer: Medicare All Medicare	$10,500.00
Rate for Payer: Monida Allegiance	$14,250.00
Rate for Payer: Monida First Choice Health	$14,550.00
Rate for Payer: Monida Montana Health Co-op	$14,250.00
Rate for Payer: Monida PacificSource	$14,250.00

Know your out-of-pocket cost for care.

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