Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CLIN ONDANSETRON ODT [4 MG]

Facility

$78.00

Service Code	HCPCS Q0162
Hospital Charge Code	8007018
Hospital Revenue Code	521
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

CLIN ONDANSETRON ODT [4 MG]

Facility

$78.00

Service Code	HCPCS Q0162
Hospital Charge Code	8007018
Hospital Revenue Code	521
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

CLIN TETRACAINE OPTH 0.5% 4ML

Facility

$43.00

Service Code	HCPCS J3490
Hospital Charge Code	8007019
Hospital Revenue Code	521
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

CLIN TETRACAINE OPTH 0.5% 4ML

Facility

$43.00

Service Code	HCPCS J3490
Hospital Charge Code	8007019
Hospital Revenue Code	521
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

CLIN TRIAMCINOLONE INJ [40 MG/ML]

Facility

$38.00

Service Code	HCPCS J3301
Hospital Charge Code	8007020
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

CLIN TRIAMCINOLONE INJ [40 MG/ML]

Facility

$38.00

Service Code	HCPCS J3301
Hospital Charge Code	8007020
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

CLOBETASOL CREAM [0.05%] NF

Facility

$431.00

Service Code	HCPCS J3490
Hospital Charge Code	3000097
Hospital Revenue Code	250
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

CLOBETASOL CREAM [0.05%] NF

Facility

$431.00

Service Code	HCPCS J3490
Hospital Charge Code	3000097
Hospital Revenue Code	250
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

CLONAZEPAM ODT [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000595
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

CLONAZEPAM ODT [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000595
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

CLONAZEPAM TAB [0.5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007751
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

CLONAZEPAM TAB [0.5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007751
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

CLONAZEPAM TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000098
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

CLONAZEPAM TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000098
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

CLONIDINE TAB [0.1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000101
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

CLONIDINE TAB [0.1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000101
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

CLOPIDOGREL TAB [75 MG]

Facility

$22.00

Service Code	HCPCS J8499
Hospital Charge Code	3000102
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

CLOPIDOGREL TAB [75 MG]

Facility

$22.00

Service Code	HCPCS J8499
Hospital Charge Code	3000102
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

CLOSED TREAT ANKLE W MANIPULATION

Facility

$1,648.00

Service Code	CPT 27818
Hospital Charge Code	1027818
Hospital Revenue Code	450
Min. Negotiated Rate	$1,153.60
Max. Negotiated Rate	$1,648.00
Rate for Payer: Aetna Commercial	$1,565.60
Rate for Payer: Aetna Medicare	$1,483.20
Rate for Payer: BCBS MT CHIP	$1,483.20
Rate for Payer: BCBS MT Closed Plan Network	$1,565.60
Rate for Payer: BCBS MT HealthLink	$1,483.20
Rate for Payer: BCBS MT Medicare	$1,483.20
Rate for Payer: BCBS MT POS	$1,565.60
Rate for Payer: BCBS MT Traditional	$1,648.00
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cigna Commercial	$1,565.60
Rate for Payer: Cigna Medicare	$1,483.20
Rate for Payer: Medicaid All Medicaid	$1,516.16
Rate for Payer: Medicare All Medicare	$1,153.60
Rate for Payer: Monida Allegiance	$1,565.60
Rate for Payer: Monida First Choice Health	$1,598.56
Rate for Payer: Monida Montana Health Co-op	$1,565.60
Rate for Payer: Monida PacificSource	$1,565.60

CLOSED TREAT ANKLE W MANIPULATION

Facility

$1,648.00

Service Code	CPT 27818
Hospital Charge Code	1027818
Hospital Revenue Code	450
Min. Negotiated Rate	$1,153.60
Max. Negotiated Rate	$1,648.00
Rate for Payer: Aetna Commercial	$1,565.60
Rate for Payer: Aetna Medicare	$1,483.20
Rate for Payer: BCBS MT CHIP	$1,483.20
Rate for Payer: BCBS MT Closed Plan Network	$1,565.60
Rate for Payer: BCBS MT HealthLink	$1,483.20
Rate for Payer: BCBS MT Medicare	$1,483.20
Rate for Payer: BCBS MT POS	$1,565.60
Rate for Payer: BCBS MT Traditional	$1,648.00
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cigna Commercial	$1,565.60
Rate for Payer: Cigna Medicare	$1,483.20
Rate for Payer: Medicaid All Medicaid	$1,516.16
Rate for Payer: Medicare All Medicare	$1,153.60
Rate for Payer: Monida Allegiance	$1,565.60
Rate for Payer: Monida First Choice Health	$1,598.56
Rate for Payer: Monida Montana Health Co-op	$1,565.60
Rate for Payer: Monida PacificSource	$1,565.60

CLOSED TREAT RADIAL HEAD W/O MANI

Facility

$652.00

Service Code	CPT 24650
Hospital Charge Code	1024650
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$652.00
Rate for Payer: Aetna Commercial	$619.40
Rate for Payer: Aetna Medicare	$586.80
Rate for Payer: BCBS MT CHIP	$586.80
Rate for Payer: BCBS MT Closed Plan Network	$619.40
Rate for Payer: BCBS MT HealthLink	$586.80
Rate for Payer: BCBS MT Medicare	$586.80
Rate for Payer: BCBS MT POS	$619.40
Rate for Payer: BCBS MT Traditional	$652.00
Rate for Payer: Cash Price	$586.80
Rate for Payer: Cigna Commercial	$619.40
Rate for Payer: Cigna Medicare	$586.80
Rate for Payer: Medicaid All Medicaid	$599.84
Rate for Payer: Medicare All Medicare	$456.40
Rate for Payer: Monida Allegiance	$619.40
Rate for Payer: Monida First Choice Health	$632.44
Rate for Payer: Monida Montana Health Co-op	$619.40
Rate for Payer: Monida PacificSource	$619.40

CLOSED TREAT RADIAL HEAD W/O MANI

Facility

$652.00

Service Code	CPT 24650
Hospital Charge Code	1024650
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$652.00
Rate for Payer: Aetna Commercial	$619.40
Rate for Payer: Aetna Medicare	$586.80
Rate for Payer: BCBS MT CHIP	$586.80
Rate for Payer: BCBS MT Closed Plan Network	$619.40
Rate for Payer: BCBS MT HealthLink	$586.80
Rate for Payer: BCBS MT Medicare	$586.80
Rate for Payer: BCBS MT POS	$619.40
Rate for Payer: BCBS MT Traditional	$652.00
Rate for Payer: Cash Price	$586.80
Rate for Payer: Cigna Commercial	$619.40
Rate for Payer: Cigna Medicare	$586.80
Rate for Payer: Medicaid All Medicaid	$599.84
Rate for Payer: Medicare All Medicare	$456.40
Rate for Payer: Monida Allegiance	$619.40
Rate for Payer: Monida First Choice Health	$632.44
Rate for Payer: Monida Montana Health Co-op	$619.40
Rate for Payer: Monida PacificSource	$619.40

CLOTRIMAZOLE CREAM [1 %] NF

Facility

$64.00

Service Code	HCPCS A9150
Hospital Charge Code	3007760
Hospital Revenue Code	250
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

CLOTRIMAZOLE CREAM [1 %] NF

Facility

$64.00

Service Code	HCPCS A9150
Hospital Charge Code	3007760
Hospital Revenue Code	250
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

CLOZAPINE AND METABOLITES

Facility

$92.00

Service Code	CPT 80159
Hospital Charge Code	4088095
Hospital Revenue Code	302
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

Know your out-of-pocket cost for care.

All Charges