Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

GAUZE 2 X 2 (200/BX) (LAB ONLY)

Facility

$2.56

Hospital Charge Code	90196556
Hospital Revenue Code	270
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna Commercial	$2.43
Rate for Payer: Aetna Medicare	$2.30
Rate for Payer: BCBS MT CHIP	$2.30
Rate for Payer: BCBS MT Closed Plan Network	$2.43
Rate for Payer: BCBS MT HealthLink	$2.30
Rate for Payer: BCBS MT Medicare	$2.30
Rate for Payer: BCBS MT POS	$2.43
Rate for Payer: BCBS MT Traditional	$2.56
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cigna Commercial	$2.43
Rate for Payer: Cigna Medicare	$2.30
Rate for Payer: Medicaid All Medicaid	$2.36
Rate for Payer: Medicare All Medicare	$1.79
Rate for Payer: Monida Allegiance	$2.43
Rate for Payer: Monida First Choice Health	$2.48
Rate for Payer: Monida Montana Health Co-op	$2.43
Rate for Payer: Monida PacificSource	$2.43

GAUZE 2 X 2 (200/BX) (LAB ONLY)

Facility

$2.56

Hospital Charge Code	90196556
Hospital Revenue Code	270
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna Commercial	$2.43
Rate for Payer: Aetna Medicare	$2.30
Rate for Payer: BCBS MT CHIP	$2.30
Rate for Payer: BCBS MT Closed Plan Network	$2.43
Rate for Payer: BCBS MT HealthLink	$2.30
Rate for Payer: BCBS MT Medicare	$2.30
Rate for Payer: BCBS MT POS	$2.43
Rate for Payer: BCBS MT Traditional	$2.56
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cigna Commercial	$2.43
Rate for Payer: Cigna Medicare	$2.30
Rate for Payer: Medicaid All Medicaid	$2.36
Rate for Payer: Medicare All Medicare	$1.79
Rate for Payer: Monida Allegiance	$2.43
Rate for Payer: Monida First Choice Health	$2.48
Rate for Payer: Monida Montana Health Co-op	$2.43
Rate for Payer: Monida PacificSource	$2.43

GAUZE 2 X 2 STERILE

Facility

$4.00

Hospital Charge Code	80032745
Hospital Revenue Code	270
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

GAUZE 2 X 2 STERILE

Facility

$4.00

Hospital Charge Code	80032745
Hospital Revenue Code	270
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

GAUZE 3 X 3 STERILE

Facility

$4.00

Hospital Charge Code	80030277
Hospital Revenue Code	270
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

GAUZE 3 X 3 STERILE

Facility

$4.00

Hospital Charge Code	80030277
Hospital Revenue Code	270
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

GAUZE 4 X 4 IN PEEL BACK TRAY

Facility

$30.00

Hospital Charge Code	80040172
Hospital Revenue Code	270
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

GAUZE 4 X 4 IN PEEL BACK TRAY

Facility

$30.00

Hospital Charge Code	80040172
Hospital Revenue Code	270
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

GAUZE 4 X 4 STERILE

Facility

$4.00

Hospital Charge Code	80030278
Hospital Revenue Code	270
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

GAUZE 4 X 4 STERILE

Facility

$4.00

Hospital Charge Code	80030278
Hospital Revenue Code	270
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

GENITAL CULTURE (008334)

Facility

$64.00

Service Code	CPT 87070
Hospital Charge Code	4070703
Hospital Revenue Code	306
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

GENITAL CULTURE (008334)

Facility

$64.00

Service Code	CPT 87070
Hospital Charge Code	4070703
Hospital Revenue Code	306
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

GENTAMICIN [0.3 %] OPTH DROPS NF

Facility

$65.00

Service Code	HCPCS J3490
Hospital Charge Code	3000197
Hospital Revenue Code	259
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

GENTAMICIN [0.3 %] OPTH DROPS NF

Facility

$65.00

Service Code	HCPCS J3490
Hospital Charge Code	3000197
Hospital Revenue Code	259
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

GENTAMICIN INJ [80 MG/2 ML]

Facility

$25.00

Service Code	HCPCS J1580
Hospital Charge Code	3000198
Hospital Revenue Code	636
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

GENTAMICIN INJ [80 MG/2 ML]

Facility

$25.00

Service Code	HCPCS J1580
Hospital Charge Code	3000198
Hospital Revenue Code	636
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

GENTAMICIN OINT [0.1 %] 15 GM NF

Facility

$159.00

Service Code	HCPCS J8499
Hospital Charge Code	3007695
Hospital Revenue Code	250
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

GENTAMICIN OINT [0.1 %] 15 GM NF

Facility

$159.00

Service Code	HCPCS J8499
Hospital Charge Code	3007695
Hospital Revenue Code	250
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

GENTAMICIN, PEAK (007162)

Facility

$197.00

Service Code	CPT 80170
Hospital Charge Code	4000074
Hospital Revenue Code	301
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

GENTAMICIN, PEAK (007162)

Facility

$197.00

Service Code	CPT 80170
Hospital Charge Code	4000074
Hospital Revenue Code	301
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

GENTAMICIN PEDIATRIC 10MG/ML 2ML VIAL

Facility

$26.00

Service Code	HCPCS J1580
Hospital Charge Code	3007407
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

GENTAMICIN PEDIATRIC 10MG/ML 2ML VIAL

Facility

$26.00

Service Code	HCPCS J1580
Hospital Charge Code	3007407
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

GENTAMICIN, TROUGH (007163)

Facility

$197.00

Service Code	CPT 80170
Hospital Charge Code	4000075
Hospital Revenue Code	301
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

GENTAMICIN, TROUGH (007163)

Facility

$197.00

Service Code	CPT 80170
Hospital Charge Code	4000075
Hospital Revenue Code	301
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

GENTEAL OPTH GTTS

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000199
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

Know your out-of-pocket cost for care.

All Charges