Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CT UPPER EXTREMITY RT W CONTRAST

Facility

$1,841.00

Service Code	CPT 73201
Hospital Charge Code	5200051
Hospital Revenue Code	350
Min. Negotiated Rate	$1,288.70
Max. Negotiated Rate	$1,841.00
Rate for Payer: Aetna Commercial	$1,748.95
Rate for Payer: Aetna Medicare	$1,656.90
Rate for Payer: BCBS MT CHIP	$1,656.90
Rate for Payer: BCBS MT Closed Plan Network	$1,748.95
Rate for Payer: BCBS MT HealthLink	$1,656.90
Rate for Payer: BCBS MT Medicare	$1,656.90
Rate for Payer: BCBS MT POS	$1,748.95
Rate for Payer: BCBS MT Traditional	$1,841.00
Rate for Payer: Cash Price	$1,656.90
Rate for Payer: Cigna Commercial	$1,748.95
Rate for Payer: Cigna Medicare	$1,656.90
Rate for Payer: Medicaid All Medicaid	$1,693.72
Rate for Payer: Medicare All Medicare	$1,288.70
Rate for Payer: Monida Allegiance	$1,748.95
Rate for Payer: Monida First Choice Health	$1,785.77
Rate for Payer: Monida Montana Health Co-op	$1,748.95
Rate for Payer: Monida PacificSource	$1,748.95

CT UPPER EXTREMITY RT W CONTRAST

Facility

$1,841.00

Service Code	CPT 73201
Hospital Charge Code	5200051
Hospital Revenue Code	350
Min. Negotiated Rate	$1,288.70
Max. Negotiated Rate	$1,841.00
Rate for Payer: Aetna Commercial	$1,748.95
Rate for Payer: Aetna Medicare	$1,656.90
Rate for Payer: BCBS MT CHIP	$1,656.90
Rate for Payer: BCBS MT Closed Plan Network	$1,748.95
Rate for Payer: BCBS MT HealthLink	$1,656.90
Rate for Payer: BCBS MT Medicare	$1,656.90
Rate for Payer: BCBS MT POS	$1,748.95
Rate for Payer: BCBS MT Traditional	$1,841.00
Rate for Payer: Cash Price	$1,656.90
Rate for Payer: Cigna Commercial	$1,748.95
Rate for Payer: Cigna Medicare	$1,656.90
Rate for Payer: Medicaid All Medicaid	$1,693.72
Rate for Payer: Medicare All Medicare	$1,288.70
Rate for Payer: Monida Allegiance	$1,748.95
Rate for Payer: Monida First Choice Health	$1,785.77
Rate for Payer: Monida Montana Health Co-op	$1,748.95
Rate for Payer: Monida PacificSource	$1,748.95

CT UPPER EXTREMITY RT WO CONTRAST

Facility

$1,534.00

Service Code	CPT 73200
Hospital Charge Code	5200004
Hospital Revenue Code	350
Min. Negotiated Rate	$1,073.80
Max. Negotiated Rate	$1,534.00
Rate for Payer: Aetna Commercial	$1,457.30
Rate for Payer: Aetna Medicare	$1,380.60
Rate for Payer: BCBS MT CHIP	$1,380.60
Rate for Payer: BCBS MT Closed Plan Network	$1,457.30
Rate for Payer: BCBS MT HealthLink	$1,380.60
Rate for Payer: BCBS MT Medicare	$1,380.60
Rate for Payer: BCBS MT POS	$1,457.30
Rate for Payer: BCBS MT Traditional	$1,534.00
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Cigna Commercial	$1,457.30
Rate for Payer: Cigna Medicare	$1,380.60
Rate for Payer: Medicaid All Medicaid	$1,411.28
Rate for Payer: Medicare All Medicare	$1,073.80
Rate for Payer: Monida Allegiance	$1,457.30
Rate for Payer: Monida First Choice Health	$1,487.98
Rate for Payer: Monida Montana Health Co-op	$1,457.30
Rate for Payer: Monida PacificSource	$1,457.30

CT UPPER EXTREMITY RT WO CONTRAST

Facility

$1,534.00

Service Code	CPT 73200
Hospital Charge Code	5200004
Hospital Revenue Code	350
Min. Negotiated Rate	$1,073.80
Max. Negotiated Rate	$1,534.00
Rate for Payer: Aetna Commercial	$1,457.30
Rate for Payer: Aetna Medicare	$1,380.60
Rate for Payer: BCBS MT CHIP	$1,380.60
Rate for Payer: BCBS MT Closed Plan Network	$1,457.30
Rate for Payer: BCBS MT HealthLink	$1,380.60
Rate for Payer: BCBS MT Medicare	$1,380.60
Rate for Payer: BCBS MT POS	$1,457.30
Rate for Payer: BCBS MT Traditional	$1,534.00
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Cigna Commercial	$1,457.30
Rate for Payer: Cigna Medicare	$1,380.60
Rate for Payer: Medicaid All Medicaid	$1,411.28
Rate for Payer: Medicare All Medicare	$1,073.80
Rate for Payer: Monida Allegiance	$1,457.30
Rate for Payer: Monida First Choice Health	$1,487.98
Rate for Payer: Monida Montana Health Co-op	$1,457.30
Rate for Payer: Monida PacificSource	$1,457.30

CT UPPER EXTREMITY RT W WO CONTRAST

Facility

$1,878.00

Service Code	CPT 73202
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	CPT 73202
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 UROGRAM -ABD/PELV W WO CONTRAST

Facility

$3,559.00

Service Code	CPT 74178
Hospital Charge Code	5200080
Hospital Revenue Code	350
Min. Negotiated Rate	$2,491.30
Max. Negotiated Rate	$3,559.00
Rate for Payer: Aetna Commercial	$3,381.05
Rate for Payer: Aetna Medicare	$3,203.10
Rate for Payer: BCBS MT CHIP	$3,203.10
Rate for Payer: BCBS MT Closed Plan Network	$3,381.05
Rate for Payer: BCBS MT HealthLink	$3,203.10
Rate for Payer: BCBS MT Medicare	$3,203.10
Rate for Payer: BCBS MT POS	$3,381.05
Rate for Payer: BCBS MT Traditional	$3,559.00
Rate for Payer: Cash Price	$3,203.10
Rate for Payer: Cigna Commercial	$3,381.05
Rate for Payer: Cigna Medicare	$3,203.10
Rate for Payer: Medicaid All Medicaid	$3,274.28
Rate for Payer: Medicare All Medicare	$2,491.30
Rate for Payer: Monida Allegiance	$3,381.05
Rate for Payer: Monida First Choice Health	$3,452.23
Rate for Payer: Monida Montana Health Co-op	$3,381.05
Rate for Payer: Monida PacificSource	$3,381.05

CT UROGRAM -ABD/PELV W WO CONTRAST

Facility

$3,559.00

Service Code	CPT 74178
Hospital Charge Code	5200080
Hospital Revenue Code	350
Min. Negotiated Rate	$2,491.30
Max. Negotiated Rate	$3,559.00
Rate for Payer: Aetna Commercial	$3,381.05
Rate for Payer: Aetna Medicare	$3,203.10
Rate for Payer: BCBS MT CHIP	$3,203.10
Rate for Payer: BCBS MT Closed Plan Network	$3,381.05
Rate for Payer: BCBS MT HealthLink	$3,203.10
Rate for Payer: BCBS MT Medicare	$3,203.10
Rate for Payer: BCBS MT POS	$3,381.05
Rate for Payer: BCBS MT Traditional	$3,559.00
Rate for Payer: Cash Price	$3,203.10
Rate for Payer: Cigna Commercial	$3,381.05
Rate for Payer: Cigna Medicare	$3,203.10
Rate for Payer: Medicaid All Medicaid	$3,274.28
Rate for Payer: Medicare All Medicare	$2,491.30
Rate for Payer: Monida Allegiance	$3,381.05
Rate for Payer: Monida First Choice Health	$3,452.23
Rate for Payer: Monida Montana Health Co-op	$3,381.05
Rate for Payer: Monida PacificSource	$3,381.05

CT VENOGRAM LOWER EXT BILATERAL

Facility

$2,092.00

Service Code	CPT 73706
Hospital Charge Code	5200353
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CT VENOGRAM LOWER EXT BILATERAL

Facility

$2,092.00

Service Code	CPT 73706
Hospital Charge Code	5200353
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CULTURE EAR

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088068
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

CULTURE EAR

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088068
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

CULTURE EYE

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088067
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

CULTURE EYE

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088067
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

CULTURE GENITAL

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088069
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

CULTURE GENITAL

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088069
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

CULTURE RECTAL VRE

Facility

$150.00

Service Code	CPT 87046
Hospital Charge Code	4088072
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

CULTURE RECTAL VRE

Facility

$150.00

Service Code	CPT 87046
Hospital Charge Code	4088072
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

CULTURE THROAT COMPLETE

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088071
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

CULTURE THROAT COMPLETE

Facility

$120.00

Service Code	CPT 87070
Hospital Charge Code	4088071
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

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 J8499
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 J8499
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	CPT 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

Know your out-of-pocket cost for care.

All Charges