Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

DOPAMINE PREMIX [800 MG/500ML]

Facility

$53.00

Service Code	HCPCS J1265
Hospital Charge Code	3000134
Hospital Revenue Code	636
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

DOPAMINE PREMIX [800 MG/500ML]

Facility

$53.00

Service Code	HCPCS J1265
Hospital Charge Code	3000134
Hospital Revenue Code	636
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

DORZOLAMIDE/TIMOLOL 2% / 0.5% OPTH NF

Facility

$216.00

Service Code	HCPCS J3490
Hospital Charge Code	3007392
Hospital Revenue Code	250
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Aetna Medicare	$194.40
Rate for Payer: BCBS MT CHIP	$194.40
Rate for Payer: BCBS MT Closed Plan Network	$205.20
Rate for Payer: BCBS MT HealthLink	$194.40
Rate for Payer: BCBS MT Medicare	$194.40
Rate for Payer: BCBS MT POS	$205.20
Rate for Payer: BCBS MT Traditional	$216.00
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna Commercial	$205.20
Rate for Payer: Cigna Medicare	$194.40
Rate for Payer: Medicaid All Medicaid	$198.72
Rate for Payer: Medicare All Medicare	$151.20
Rate for Payer: Monida Allegiance	$205.20
Rate for Payer: Monida First Choice Health	$209.52
Rate for Payer: Monida Montana Health Co-op	$205.20
Rate for Payer: Monida PacificSource	$205.20

DORZOLAMIDE/TIMOLOL 2% / 0.5% OPTH NF

Facility

$216.00

Service Code	HCPCS J3490
Hospital Charge Code	3007392
Hospital Revenue Code	250
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Aetna Medicare	$194.40
Rate for Payer: BCBS MT CHIP	$194.40
Rate for Payer: BCBS MT Closed Plan Network	$205.20
Rate for Payer: BCBS MT HealthLink	$194.40
Rate for Payer: BCBS MT Medicare	$194.40
Rate for Payer: BCBS MT POS	$205.20
Rate for Payer: BCBS MT Traditional	$216.00
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna Commercial	$205.20
Rate for Payer: Cigna Medicare	$194.40
Rate for Payer: Medicaid All Medicaid	$198.72
Rate for Payer: Medicare All Medicare	$151.20
Rate for Payer: Monida Allegiance	$205.20
Rate for Payer: Monida First Choice Health	$209.52
Rate for Payer: Monida Montana Health Co-op	$205.20
Rate for Payer: Monida PacificSource	$205.20

DOXAZOSIN TAB [4 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000614
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

DOXAZOSIN TAB [4 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000135
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

DOXAZOSIN TAB [4 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000135
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

DOXAZOSIN TAB [4 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000614
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

DOXEPIN CAP [50 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000136
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

DOXEPIN CAP [50 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000136
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

DOXYCYCLINE CAP [100 MG]

Facility

$19.00

Service Code	HCPCS J8499
Hospital Charge Code	3000137
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

DOXYCYCLINE CAP [100 MG]

Facility

$19.00

Service Code	HCPCS J8499
Hospital Charge Code	3000137
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

DOXYLAMINE SUCC TAB [25 MG] NF

Facility

$5.00

Service Code	HCPCS J8499
Hospital Charge Code	3000623
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

DOXYLAMINE SUCC TAB [25 MG] NF

Facility

$5.00

Service Code	HCPCS J8499
Hospital Charge Code	3000623
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

DRAIN BLOOD FROM UNDER NAIL

Facility

$175.00

Service Code	CPT 11740
Hospital Charge Code	8011740
Hospital Revenue Code	521
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

DRAIN BLOOD FROM UNDER NAIL

Facility

$175.00

Service Code	CPT 11740
Hospital Charge Code	8011740
Hospital Revenue Code	521
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

DRAIN/INJ JOINT/BURSA W/US 20604

Facility

$365.00

Service Code	CPT 20604
Hospital Charge Code	1520604
Hospital Revenue Code	760
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

DRAIN/INJ JOINT/BURSA W/US 20604

Facility

$365.00

Service Code	CPT 20604
Hospital Charge Code	1520604
Hospital Revenue Code	760
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

DRAIN SPONGE

Facility

$4.00

Hospital Charge Code	80030468
Hospital Revenue Code	272
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

DRAIN SPONGE

Facility

$4.00

Hospital Charge Code	80030468
Hospital Revenue Code	272
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

DRONABINOL CAP [2.5 MG] NF

Facility

$17.00

Service Code	HCPCS Q0167
Hospital Charge Code	3007251
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

DRONABINOL CAP [2.5 MG] NF

Facility

$17.00

Service Code	HCPCS Q0167
Hospital Charge Code	3007251
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

DROPERIDOL INJ [2.5 MG/ML] SDV

Facility

$36.00

Service Code	HCPCS J1790
Hospital Charge Code	3000533
Hospital Revenue Code	250
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

DROPERIDOL INJ [2.5 MG/ML] SDV

Facility

$36.00

Service Code	HCPCS J1790
Hospital Charge Code	3000533
Hospital Revenue Code	250
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

DRUG BUSTER 64OZ

Facility

$9.00

Hospital Charge Code	80040142
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

Know your out-of-pocket cost for care.

All Charges