Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SIMETHICONE CAP [125 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000425
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

SIMPLY SALINE 12/CS

Facility

$5.00

Hospital Charge Code	80062609
Hospital Revenue Code	270
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

SIMPLY SALINE 12/CS

Facility

$5.00

Hospital Charge Code	80062609
Hospital Revenue Code	270
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

SIMVASTATIN TAB [20 MG]

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	3000426
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

SIMVASTATIN TAB [20 MG]

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	3000426
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

SIROLIMUS (716712)

Facility

$158.00

Service Code	HCPCS 80195
Hospital Charge Code	4080195
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

SIROLIMUS (716712)

Facility

$158.00

Service Code	HCPCS 80195
Hospital Charge Code	4080195
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

SKIN MARKERS

Facility

$4.00

Hospital Charge Code	80040170
Hospital Revenue Code	259
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

SKIN MARKERS

Facility

$4.00

Hospital Charge Code	80040170
Hospital Revenue Code	259
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

SKIN PROTECTANT BOA VIDA

Facility

$21.00

Hospital Charge Code	2840186
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

SKIN PROTECTANT BOA VIDA

Facility

$21.00

Hospital Charge Code	2840186
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

SKIN STAPLER

Facility

$39.00

Hospital Charge Code	80040149
Hospital Revenue Code	270
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

SKIN STAPLER

Facility

$39.00

Hospital Charge Code	80040149
Hospital Revenue Code	270
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

SKIN STAPLER REMOVER

Facility

$25.00

Hospital Charge Code	80030261
Hospital Revenue Code	270
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

SKIN STAPLER REMOVER

Facility

$25.00

Hospital Charge Code	80030261
Hospital Revenue Code	270
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

SKIN SUB APPLIC H,FT,FC 1ST100SQCM 15277

Facility

$1,849.00

Service Code	HCPCS 15277
Hospital Charge Code	8015277
Hospital Revenue Code	761
Min. Negotiated Rate	$1,294.30
Max. Negotiated Rate	$1,849.00
Rate for Payer: Aetna Commercial	$1,756.55
Rate for Payer: Aetna Medicare	$1,664.10
Rate for Payer: BCBS MT CHIP	$1,664.10
Rate for Payer: BCBS MT Closed Plan Network	$1,756.55
Rate for Payer: BCBS MT HealthLink	$1,664.10
Rate for Payer: BCBS MT Medicare	$1,664.10
Rate for Payer: BCBS MT POS	$1,756.55
Rate for Payer: BCBS MT Traditional	$1,849.00
Rate for Payer: Cash Price	$1,664.10
Rate for Payer: Cigna Commercial	$1,756.55
Rate for Payer: Cigna Medicare	$1,664.10
Rate for Payer: Medicaid All Medicaid	$1,701.08
Rate for Payer: Medicare All Medicare	$1,294.30
Rate for Payer: Monida Allegiance	$1,756.55
Rate for Payer: Monida First Choice Health	$1,793.53
Rate for Payer: Monida Montana Health Co-op	$1,756.55
Rate for Payer: Monida PacificSource	$1,756.55

SKIN SUB APPLIC H,FT,FC 1ST100SQCM 15277

Facility

$1,849.00

Service Code	HCPCS 15277
Hospital Charge Code	8015277
Hospital Revenue Code	761
Min. Negotiated Rate	$1,294.30
Max. Negotiated Rate	$1,849.00
Rate for Payer: Aetna Commercial	$1,756.55
Rate for Payer: Aetna Medicare	$1,664.10
Rate for Payer: BCBS MT CHIP	$1,664.10
Rate for Payer: BCBS MT Closed Plan Network	$1,756.55
Rate for Payer: BCBS MT HealthLink	$1,664.10
Rate for Payer: BCBS MT Medicare	$1,664.10
Rate for Payer: BCBS MT POS	$1,756.55
Rate for Payer: BCBS MT Traditional	$1,849.00
Rate for Payer: Cash Price	$1,664.10
Rate for Payer: Cigna Commercial	$1,756.55
Rate for Payer: Cigna Medicare	$1,664.10
Rate for Payer: Medicaid All Medicaid	$1,701.08
Rate for Payer: Medicare All Medicare	$1,294.30
Rate for Payer: Monida Allegiance	$1,756.55
Rate for Payer: Monida First Choice Health	$1,793.53
Rate for Payer: Monida Montana Health Co-op	$1,756.55
Rate for Payer: Monida PacificSource	$1,756.55

SKIN SUBS APP H,FT,FC EA 100+ SQCM 15278

Facility

$1,241.00

Service Code	HCPCS 15278
Hospital Charge Code	8015278
Hospital Revenue Code	761
Min. Negotiated Rate	$868.70
Max. Negotiated Rate	$1,241.00
Rate for Payer: Aetna Commercial	$1,178.95
Rate for Payer: Aetna Medicare	$1,116.90
Rate for Payer: BCBS MT CHIP	$1,116.90
Rate for Payer: BCBS MT Closed Plan Network	$1,178.95
Rate for Payer: BCBS MT HealthLink	$1,116.90
Rate for Payer: BCBS MT Medicare	$1,116.90
Rate for Payer: BCBS MT POS	$1,178.95
Rate for Payer: BCBS MT Traditional	$1,241.00
Rate for Payer: Cash Price	$1,116.90
Rate for Payer: Cigna Commercial	$1,178.95
Rate for Payer: Cigna Medicare	$1,116.90
Rate for Payer: Medicaid All Medicaid	$1,141.72
Rate for Payer: Medicare All Medicare	$868.70
Rate for Payer: Monida Allegiance	$1,178.95
Rate for Payer: Monida First Choice Health	$1,203.77
Rate for Payer: Monida Montana Health Co-op	$1,178.95
Rate for Payer: Monida PacificSource	$1,178.95

SKIN SUBS APP H,FT,FC EA 100+ SQCM 15278

Facility

$1,241.00

Service Code	HCPCS 15278
Hospital Charge Code	8015278
Hospital Revenue Code	761
Min. Negotiated Rate	$868.70
Max. Negotiated Rate	$1,241.00
Rate for Payer: Aetna Commercial	$1,178.95
Rate for Payer: Aetna Medicare	$1,116.90
Rate for Payer: BCBS MT CHIP	$1,116.90
Rate for Payer: BCBS MT Closed Plan Network	$1,178.95
Rate for Payer: BCBS MT HealthLink	$1,116.90
Rate for Payer: BCBS MT Medicare	$1,116.90
Rate for Payer: BCBS MT POS	$1,178.95
Rate for Payer: BCBS MT Traditional	$1,241.00
Rate for Payer: Cash Price	$1,116.90
Rate for Payer: Cigna Commercial	$1,178.95
Rate for Payer: Cigna Medicare	$1,116.90
Rate for Payer: Medicaid All Medicaid	$1,141.72
Rate for Payer: Medicare All Medicare	$868.70
Rate for Payer: Monida Allegiance	$1,178.95
Rate for Payer: Monida First Choice Health	$1,203.77
Rate for Payer: Monida Montana Health Co-op	$1,178.95
Rate for Payer: Monida PacificSource	$1,178.95

SKIN SUBS APPLIC H,FT,FC, 1-25SQCM 15275

Facility

$1,750.00

Service Code	HCPCS 15275
Hospital Charge Code	8015275
Hospital Revenue Code	761
Min. Negotiated Rate	$1,225.00
Max. Negotiated Rate	$1,750.00
Rate for Payer: Aetna Commercial	$1,662.50
Rate for Payer: Aetna Medicare	$1,575.00
Rate for Payer: BCBS MT CHIP	$1,575.00
Rate for Payer: BCBS MT Closed Plan Network	$1,662.50
Rate for Payer: BCBS MT HealthLink	$1,575.00
Rate for Payer: BCBS MT Medicare	$1,575.00
Rate for Payer: BCBS MT POS	$1,662.50
Rate for Payer: BCBS MT Traditional	$1,750.00
Rate for Payer: Cash Price	$1,575.00
Rate for Payer: Cigna Commercial	$1,662.50
Rate for Payer: Cigna Medicare	$1,575.00
Rate for Payer: Medicaid All Medicaid	$1,610.00
Rate for Payer: Medicare All Medicare	$1,225.00
Rate for Payer: Monida Allegiance	$1,662.50
Rate for Payer: Monida First Choice Health	$1,697.50
Rate for Payer: Monida Montana Health Co-op	$1,662.50
Rate for Payer: Monida PacificSource	$1,662.50

SKIN SUBS APPLIC H,FT,FC, 1-25SQCM 15275

Facility

$1,750.00

Service Code	HCPCS 15275
Hospital Charge Code	8015275
Hospital Revenue Code	761
Min. Negotiated Rate	$1,225.00
Max. Negotiated Rate	$1,750.00
Rate for Payer: Aetna Commercial	$1,662.50
Rate for Payer: Aetna Medicare	$1,575.00
Rate for Payer: BCBS MT CHIP	$1,575.00
Rate for Payer: BCBS MT Closed Plan Network	$1,662.50
Rate for Payer: BCBS MT HealthLink	$1,575.00
Rate for Payer: BCBS MT Medicare	$1,575.00
Rate for Payer: BCBS MT POS	$1,662.50
Rate for Payer: BCBS MT Traditional	$1,750.00
Rate for Payer: Cash Price	$1,575.00
Rate for Payer: Cigna Commercial	$1,662.50
Rate for Payer: Cigna Medicare	$1,575.00
Rate for Payer: Medicaid All Medicaid	$1,610.00
Rate for Payer: Medicare All Medicare	$1,225.00
Rate for Payer: Monida Allegiance	$1,662.50
Rate for Payer: Monida First Choice Health	$1,697.50
Rate for Payer: Monida Montana Health Co-op	$1,662.50
Rate for Payer: Monida PacificSource	$1,662.50

SKIN SUBS APPLIC H,FT,FC EA 25SQCM 15276

Facility

$555.00

Service Code	HCPCS 15276
Hospital Charge Code	8015276
Hospital Revenue Code	761
Min. Negotiated Rate	$388.50
Max. Negotiated Rate	$555.00
Rate for Payer: Aetna Commercial	$527.25
Rate for Payer: Aetna Medicare	$499.50
Rate for Payer: BCBS MT CHIP	$499.50
Rate for Payer: BCBS MT Closed Plan Network	$527.25
Rate for Payer: BCBS MT HealthLink	$499.50
Rate for Payer: BCBS MT Medicare	$499.50
Rate for Payer: BCBS MT POS	$527.25
Rate for Payer: BCBS MT Traditional	$555.00
Rate for Payer: Cash Price	$499.50
Rate for Payer: Cigna Commercial	$527.25
Rate for Payer: Cigna Medicare	$499.50
Rate for Payer: Medicaid All Medicaid	$510.60
Rate for Payer: Medicare All Medicare	$388.50
Rate for Payer: Monida Allegiance	$527.25
Rate for Payer: Monida First Choice Health	$538.35
Rate for Payer: Monida Montana Health Co-op	$527.25
Rate for Payer: Monida PacificSource	$527.25

SKIN SUBS APPLIC H,FT,FC EA 25SQCM 15276

Facility

$555.00

Service Code	HCPCS 15276
Hospital Charge Code	8015276
Hospital Revenue Code	761
Min. Negotiated Rate	$388.50
Max. Negotiated Rate	$555.00
Rate for Payer: Aetna Commercial	$527.25
Rate for Payer: Aetna Medicare	$499.50
Rate for Payer: BCBS MT CHIP	$499.50
Rate for Payer: BCBS MT Closed Plan Network	$527.25
Rate for Payer: BCBS MT HealthLink	$499.50
Rate for Payer: BCBS MT Medicare	$499.50
Rate for Payer: BCBS MT POS	$527.25
Rate for Payer: BCBS MT Traditional	$555.00
Rate for Payer: Cash Price	$499.50
Rate for Payer: Cigna Commercial	$527.25
Rate for Payer: Cigna Medicare	$499.50
Rate for Payer: Medicaid All Medicaid	$510.60
Rate for Payer: Medicare All Medicare	$388.50
Rate for Payer: Monida Allegiance	$527.25
Rate for Payer: Monida First Choice Health	$538.35
Rate for Payer: Monida Montana Health Co-op	$527.25
Rate for Payer: Monida PacificSource	$527.25

SKIN SUBS APPLIC T,A,L 1-25 SQCM 15271

Facility

$1,653.00

Service Code	HCPCS 15271
Hospital Charge Code	8015271
Hospital Revenue Code	761
Min. Negotiated Rate	$1,157.10
Max. Negotiated Rate	$1,653.00
Rate for Payer: Aetna Commercial	$1,570.35
Rate for Payer: Aetna Medicare	$1,487.70
Rate for Payer: BCBS MT CHIP	$1,487.70
Rate for Payer: BCBS MT Closed Plan Network	$1,570.35
Rate for Payer: BCBS MT HealthLink	$1,487.70
Rate for Payer: BCBS MT Medicare	$1,487.70
Rate for Payer: BCBS MT POS	$1,570.35
Rate for Payer: BCBS MT Traditional	$1,653.00
Rate for Payer: Cash Price	$1,487.70
Rate for Payer: Cigna Commercial	$1,570.35
Rate for Payer: Cigna Medicare	$1,487.70
Rate for Payer: Medicaid All Medicaid	$1,520.76
Rate for Payer: Medicare All Medicare	$1,157.10
Rate for Payer: Monida Allegiance	$1,570.35
Rate for Payer: Monida First Choice Health	$1,603.41
Rate for Payer: Monida Montana Health Co-op	$1,570.35
Rate for Payer: Monida PacificSource	$1,570.35

SKIN SUBS APPLIC T,A,L 1-25 SQCM 15271

Facility

$1,653.00

Service Code	HCPCS 15271
Hospital Charge Code	8015271
Hospital Revenue Code	761
Min. Negotiated Rate	$1,157.10
Max. Negotiated Rate	$1,653.00
Rate for Payer: Aetna Commercial	$1,570.35
Rate for Payer: Aetna Medicare	$1,487.70
Rate for Payer: BCBS MT CHIP	$1,487.70
Rate for Payer: BCBS MT Closed Plan Network	$1,570.35
Rate for Payer: BCBS MT HealthLink	$1,487.70
Rate for Payer: BCBS MT Medicare	$1,487.70
Rate for Payer: BCBS MT POS	$1,570.35
Rate for Payer: BCBS MT Traditional	$1,653.00
Rate for Payer: Cash Price	$1,487.70
Rate for Payer: Cigna Commercial	$1,570.35
Rate for Payer: Cigna Medicare	$1,487.70
Rate for Payer: Medicaid All Medicaid	$1,520.76
Rate for Payer: Medicare All Medicare	$1,157.10
Rate for Payer: Monida Allegiance	$1,570.35
Rate for Payer: Monida First Choice Health	$1,603.41
Rate for Payer: Monida Montana Health Co-op	$1,570.35
Rate for Payer: Monida PacificSource	$1,570.35

Know your out-of-pocket cost for care.

All Charges