Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CULTURETTE LIQ STUART DUAL

Facility

$32.31

Hospital Charge Code	90197183
Hospital Revenue Code	270
Min. Negotiated Rate	$22.62
Max. Negotiated Rate	$32.31
Rate for Payer: Aetna Commercial	$30.69
Rate for Payer: Aetna Medicare	$29.08
Rate for Payer: BCBS MT CHIP	$29.08
Rate for Payer: BCBS MT Closed Plan Network	$30.69
Rate for Payer: BCBS MT HealthLink	$29.08
Rate for Payer: BCBS MT Medicare	$29.08
Rate for Payer: BCBS MT POS	$30.69
Rate for Payer: BCBS MT Traditional	$32.31
Rate for Payer: Cash Price	$29.08
Rate for Payer: Cigna Commercial	$30.69
Rate for Payer: Cigna Medicare	$29.08
Rate for Payer: Medicaid All Medicaid	$29.73
Rate for Payer: Medicare All Medicare	$22.62
Rate for Payer: Monida Allegiance	$30.69
Rate for Payer: Monida First Choice Health	$31.34
Rate for Payer: Monida Montana Health Co-op	$30.69
Rate for Payer: Monida PacificSource	$30.69

CULTURETTE LIQ STUART DUAL

Facility

$32.31

Hospital Charge Code	90197183
Hospital Revenue Code	270
Min. Negotiated Rate	$22.62
Max. Negotiated Rate	$32.31
Rate for Payer: Aetna Commercial	$30.69
Rate for Payer: Aetna Medicare	$29.08
Rate for Payer: BCBS MT CHIP	$29.08
Rate for Payer: BCBS MT Closed Plan Network	$30.69
Rate for Payer: BCBS MT HealthLink	$29.08
Rate for Payer: BCBS MT Medicare	$29.08
Rate for Payer: BCBS MT POS	$30.69
Rate for Payer: BCBS MT Traditional	$32.31
Rate for Payer: Cash Price	$29.08
Rate for Payer: Cigna Commercial	$30.69
Rate for Payer: Cigna Medicare	$29.08
Rate for Payer: Medicaid All Medicaid	$29.73
Rate for Payer: Medicare All Medicare	$22.62
Rate for Payer: Monida Allegiance	$30.69
Rate for Payer: Monida First Choice Health	$31.34
Rate for Payer: Monida Montana Health Co-op	$30.69
Rate for Payer: Monida PacificSource	$30.69

CURRENT SMOKELESS TOBACCO USER

Facility

$0.01

Service Code	CPT 1035F
Hospital Charge Code	8001035
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

CURRENT SMOKELESS TOBACCO USER

Facility

$0.01

Service Code	CPT 1035F
Hospital Charge Code	8001035
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

CURRENT TOBACCO NON-USER

Facility

$0.01

Service Code	CPT 1036F
Hospital Charge Code	8001036
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

CURRENT TOBACCO NON-USER

Facility

$0.01

Service Code	CPT 1036F
Hospital Charge Code	8001036
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

CURRENT TOBACCO SMOKER

Facility

$0.01

Service Code	CPT 1034F
Hospital Charge Code	8001034
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

CURRENT TOBACCO SMOKER

Facility

$0.01

Service Code	CPT 1034F
Hospital Charge Code	8001034
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

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

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

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

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

CYGNUS DUAL - 4X4 SQ CENTIMETER

Facility

$40,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004193
Hospital Revenue Code	636
Min. Negotiated Rate	$28,000.00
Max. Negotiated Rate	$40,000.00
Rate for Payer: Aetna Commercial	$38,000.00
Rate for Payer: Aetna Medicare	$36,000.00
Rate for Payer: BCBS MT CHIP	$36,000.00
Rate for Payer: BCBS MT Closed Plan Network	$38,000.00
Rate for Payer: BCBS MT HealthLink	$36,000.00
Rate for Payer: BCBS MT Medicare	$36,000.00
Rate for Payer: BCBS MT POS	$38,000.00
Rate for Payer: BCBS MT Traditional	$40,000.00
Rate for Payer: Cash Price	$36,000.00
Rate for Payer: Cigna Commercial	$38,000.00
Rate for Payer: Cigna Medicare	$36,000.00
Rate for Payer: Medicaid All Medicaid	$36,800.00
Rate for Payer: Medicare All Medicare	$28,000.00
Rate for Payer: Monida Allegiance	$38,000.00
Rate for Payer: Monida First Choice Health	$38,800.00
Rate for Payer: Monida Montana Health Co-op	$38,000.00
Rate for Payer: Monida PacificSource	$38,000.00

CYGNUS DUAL - 4X4 SQ CENTIMETER

Facility

$40,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004193
Hospital Revenue Code	636
Min. Negotiated Rate	$28,000.00
Max. Negotiated Rate	$40,000.00
Rate for Payer: Aetna Commercial	$38,000.00
Rate for Payer: Aetna Medicare	$36,000.00
Rate for Payer: BCBS MT CHIP	$36,000.00
Rate for Payer: BCBS MT Closed Plan Network	$38,000.00
Rate for Payer: BCBS MT HealthLink	$36,000.00
Rate for Payer: BCBS MT Medicare	$36,000.00
Rate for Payer: BCBS MT POS	$38,000.00
Rate for Payer: BCBS MT Traditional	$40,000.00
Rate for Payer: Cash Price	$36,000.00
Rate for Payer: Cigna Commercial	$38,000.00
Rate for Payer: Cigna Medicare	$36,000.00
Rate for Payer: Medicaid All Medicaid	$36,800.00
Rate for Payer: Medicare All Medicare	$28,000.00
Rate for Payer: Monida Allegiance	$38,000.00
Rate for Payer: Monida First Choice Health	$38,800.00
Rate for Payer: Monida Montana Health Co-op	$38,000.00
Rate for Payer: Monida PacificSource	$38,000.00

CYGNUS DUAL - 4X6 SQ CENTIMETER

Facility

$60,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004194
Hospital Revenue Code	636
Min. Negotiated Rate	$42,000.00
Max. Negotiated Rate	$60,000.00
Rate for Payer: Aetna Commercial	$57,000.00
Rate for Payer: Aetna Medicare	$54,000.00
Rate for Payer: BCBS MT CHIP	$54,000.00
Rate for Payer: BCBS MT Closed Plan Network	$57,000.00
Rate for Payer: BCBS MT HealthLink	$54,000.00
Rate for Payer: BCBS MT Medicare	$54,000.00
Rate for Payer: BCBS MT POS	$57,000.00
Rate for Payer: BCBS MT Traditional	$60,000.00
Rate for Payer: Cash Price	$54,000.00
Rate for Payer: Cigna Commercial	$57,000.00
Rate for Payer: Cigna Medicare	$54,000.00
Rate for Payer: Medicaid All Medicaid	$55,200.00
Rate for Payer: Medicare All Medicare	$42,000.00
Rate for Payer: Monida Allegiance	$57,000.00
Rate for Payer: Monida First Choice Health	$58,200.00
Rate for Payer: Monida Montana Health Co-op	$57,000.00
Rate for Payer: Monida PacificSource	$57,000.00

CYGNUS DUAL - 4X6 SQ CENTIMETER

Facility

$60,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004194
Hospital Revenue Code	636
Min. Negotiated Rate	$42,000.00
Max. Negotiated Rate	$60,000.00
Rate for Payer: Aetna Commercial	$57,000.00
Rate for Payer: Aetna Medicare	$54,000.00
Rate for Payer: BCBS MT CHIP	$54,000.00
Rate for Payer: BCBS MT Closed Plan Network	$57,000.00
Rate for Payer: BCBS MT HealthLink	$54,000.00
Rate for Payer: BCBS MT Medicare	$54,000.00
Rate for Payer: BCBS MT POS	$57,000.00
Rate for Payer: BCBS MT Traditional	$60,000.00
Rate for Payer: Cash Price	$54,000.00
Rate for Payer: Cigna Commercial	$57,000.00
Rate for Payer: Cigna Medicare	$54,000.00
Rate for Payer: Medicaid All Medicaid	$55,200.00
Rate for Payer: Medicare All Medicare	$42,000.00
Rate for Payer: Monida Allegiance	$57,000.00
Rate for Payer: Monida First Choice Health	$58,200.00
Rate for Payer: Monida Montana Health Co-op	$57,000.00
Rate for Payer: Monida PacificSource	$57,000.00

CYGNUS DUAL - 7X15 SQ CENTIMETER

Facility

$262,500.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004195
Hospital Revenue Code	636
Min. Negotiated Rate	$183,750.00
Max. Negotiated Rate	$262,500.00
Rate for Payer: Aetna Commercial	$249,375.00
Rate for Payer: Aetna Medicare	$236,250.00
Rate for Payer: BCBS MT CHIP	$236,250.00
Rate for Payer: BCBS MT Closed Plan Network	$249,375.00
Rate for Payer: BCBS MT HealthLink	$236,250.00
Rate for Payer: BCBS MT Medicare	$236,250.00
Rate for Payer: BCBS MT POS	$249,375.00
Rate for Payer: BCBS MT Traditional	$262,500.00
Rate for Payer: Cash Price	$236,250.00
Rate for Payer: Cigna Commercial	$249,375.00
Rate for Payer: Cigna Medicare	$236,250.00
Rate for Payer: Medicaid All Medicaid	$241,500.00
Rate for Payer: Medicare All Medicare	$183,750.00
Rate for Payer: Monida Allegiance	$249,375.00
Rate for Payer: Monida First Choice Health	$254,625.00
Rate for Payer: Monida Montana Health Co-op	$249,375.00
Rate for Payer: Monida PacificSource	$249,375.00

CYGNUS DUAL - 7X15 SQ CENTIMETER

Facility

$262,500.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004195
Hospital Revenue Code	636
Min. Negotiated Rate	$183,750.00
Max. Negotiated Rate	$262,500.00
Rate for Payer: Aetna Commercial	$249,375.00
Rate for Payer: Aetna Medicare	$236,250.00
Rate for Payer: BCBS MT CHIP	$236,250.00
Rate for Payer: BCBS MT Closed Plan Network	$249,375.00
Rate for Payer: BCBS MT HealthLink	$236,250.00
Rate for Payer: BCBS MT Medicare	$236,250.00
Rate for Payer: BCBS MT POS	$249,375.00
Rate for Payer: BCBS MT Traditional	$262,500.00
Rate for Payer: Cash Price	$236,250.00
Rate for Payer: Cigna Commercial	$249,375.00
Rate for Payer: Cigna Medicare	$236,250.00
Rate for Payer: Medicaid All Medicaid	$241,500.00
Rate for Payer: Medicare All Medicare	$183,750.00
Rate for Payer: Monida Allegiance	$249,375.00
Rate for Payer: Monida First Choice Health	$254,625.00
Rate for Payer: Monida Montana Health Co-op	$249,375.00
Rate for Payer: Monida PacificSource	$249,375.00

CYGNUS MATRIX-PER SQ CENTIMETER

Facility

$592.00

Service Code	HCPCS Q4199
Hospital Charge Code	8004199
Hospital Revenue Code	636
Min. Negotiated Rate	$414.40
Max. Negotiated Rate	$592.00
Rate for Payer: Aetna Commercial	$562.40
Rate for Payer: Aetna Medicare	$532.80
Rate for Payer: BCBS MT CHIP	$532.80
Rate for Payer: BCBS MT Closed Plan Network	$562.40
Rate for Payer: BCBS MT HealthLink	$532.80
Rate for Payer: BCBS MT Medicare	$532.80
Rate for Payer: BCBS MT POS	$562.40
Rate for Payer: BCBS MT Traditional	$592.00
Rate for Payer: Cash Price	$532.80
Rate for Payer: Cigna Commercial	$562.40
Rate for Payer: Cigna Medicare	$532.80
Rate for Payer: Medicaid All Medicaid	$544.64
Rate for Payer: Medicare All Medicare	$414.40
Rate for Payer: Monida Allegiance	$562.40
Rate for Payer: Monida First Choice Health	$574.24
Rate for Payer: Monida Montana Health Co-op	$562.40
Rate for Payer: Monida PacificSource	$562.40

CYGNUS MATRIX-PER SQ CENTIMETER

Facility

$592.00

Service Code	HCPCS Q4199
Hospital Charge Code	8004199
Hospital Revenue Code	636
Min. Negotiated Rate	$414.40
Max. Negotiated Rate	$592.00
Rate for Payer: Aetna Commercial	$562.40
Rate for Payer: Aetna Medicare	$532.80
Rate for Payer: BCBS MT CHIP	$532.80
Rate for Payer: BCBS MT Closed Plan Network	$562.40
Rate for Payer: BCBS MT HealthLink	$532.80
Rate for Payer: BCBS MT Medicare	$532.80
Rate for Payer: BCBS MT POS	$562.40
Rate for Payer: BCBS MT Traditional	$592.00
Rate for Payer: Cash Price	$532.80
Rate for Payer: Cigna Commercial	$562.40
Rate for Payer: Cigna Medicare	$532.80
Rate for Payer: Medicaid All Medicaid	$544.64
Rate for Payer: Medicare All Medicare	$414.40
Rate for Payer: Monida Allegiance	$562.40
Rate for Payer: Monida First Choice Health	$574.24
Rate for Payer: Monida Montana Health Co-op	$562.40
Rate for Payer: Monida PacificSource	$562.40

CYSTATIN C W/ EGFR (121265)

Facility

$355.00

Service Code	CPT 82610
Hospital Charge Code	4082610
Hospital Revenue Code	301
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

Know your out-of-pocket cost for care.

All Charges