Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TOBRAMYCIN 0.3% OPTH SOL

Facility

$49.00

Service Code	HCPCS J3490
Hospital Charge Code	3000454
Hospital Revenue Code	259
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: BCBS MT CHIP	$44.10
Rate for Payer: BCBS MT Closed Plan Network	$46.55
Rate for Payer: BCBS MT HealthLink	$44.10
Rate for Payer: BCBS MT Medicare	$44.10
Rate for Payer: BCBS MT POS	$46.55
Rate for Payer: BCBS MT Traditional	$49.00
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna Commercial	$46.55
Rate for Payer: Cigna Medicare	$44.10
Rate for Payer: Medicaid All Medicaid	$45.08
Rate for Payer: Medicare All Medicare	$34.30
Rate for Payer: Monida Allegiance	$46.55
Rate for Payer: Monida First Choice Health	$47.53
Rate for Payer: Monida Montana Health Co-op	$46.55
Rate for Payer: Monida PacificSource	$46.55

TOBRAMYCIN 0.3% OPTH SOL

Facility

$49.00

Service Code	HCPCS J3490
Hospital Charge Code	3000454
Hospital Revenue Code	259
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: BCBS MT CHIP	$44.10
Rate for Payer: BCBS MT Closed Plan Network	$46.55
Rate for Payer: BCBS MT HealthLink	$44.10
Rate for Payer: BCBS MT Medicare	$44.10
Rate for Payer: BCBS MT POS	$46.55
Rate for Payer: BCBS MT Traditional	$49.00
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna Commercial	$46.55
Rate for Payer: Cigna Medicare	$44.10
Rate for Payer: Medicaid All Medicaid	$45.08
Rate for Payer: Medicare All Medicare	$34.30
Rate for Payer: Monida Allegiance	$46.55
Rate for Payer: Monida First Choice Health	$47.53
Rate for Payer: Monida Montana Health Co-op	$46.55
Rate for Payer: Monida PacificSource	$46.55

TOPIRAMATE (716285)

Facility

$131.00

Service Code	HCPCS 80201
Hospital Charge Code	4080201
Hospital Revenue Code	300
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$131.00
Rate for Payer: Aetna Commercial	$124.45
Rate for Payer: Aetna Medicare	$117.90
Rate for Payer: BCBS MT CHIP	$117.90
Rate for Payer: BCBS MT Closed Plan Network	$124.45
Rate for Payer: BCBS MT HealthLink	$117.90
Rate for Payer: BCBS MT Medicare	$117.90
Rate for Payer: BCBS MT POS	$124.45
Rate for Payer: BCBS MT Traditional	$131.00
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial	$124.45
Rate for Payer: Cigna Medicare	$117.90
Rate for Payer: Medicaid All Medicaid	$120.52
Rate for Payer: Medicare All Medicare	$91.70
Rate for Payer: Monida Allegiance	$124.45
Rate for Payer: Monida First Choice Health	$127.07
Rate for Payer: Monida Montana Health Co-op	$124.45
Rate for Payer: Monida PacificSource	$124.45

TOPIRAMATE (716285)

Facility

$131.00

Service Code	HCPCS 80201
Hospital Charge Code	4080201
Hospital Revenue Code	300
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$131.00
Rate for Payer: Aetna Commercial	$124.45
Rate for Payer: Aetna Medicare	$117.90
Rate for Payer: BCBS MT CHIP	$117.90
Rate for Payer: BCBS MT Closed Plan Network	$124.45
Rate for Payer: BCBS MT HealthLink	$117.90
Rate for Payer: BCBS MT Medicare	$117.90
Rate for Payer: BCBS MT POS	$124.45
Rate for Payer: BCBS MT Traditional	$131.00
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial	$124.45
Rate for Payer: Cigna Medicare	$117.90
Rate for Payer: Medicaid All Medicaid	$120.52
Rate for Payer: Medicare All Medicare	$91.70
Rate for Payer: Monida Allegiance	$124.45
Rate for Payer: Monida First Choice Health	$127.07
Rate for Payer: Monida Montana Health Co-op	$124.45
Rate for Payer: Monida PacificSource	$124.45

TOPIRAMATE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000455
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

TOPIRAMATE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000455
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

TORSEMIDE TAB [20 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000456
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

TORSEMIDE TAB [20 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000456
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

.TOTAL IRON-BINDING CAPACITY

Facility

$9.00

Service Code	HCPCS 83550
Hospital Charge Code	4083550
Hospital Revenue Code	301
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

.TOTAL IRON-BINDING CAPACITY

Facility

$9.00

Service Code	HCPCS 83550
Hospital Charge Code	4083550
Hospital Revenue Code	301
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

.TOTAL PROTEIN, URINE

Facility

$12.00

Service Code	HCPCS 84156
Hospital Charge Code	4084156
Hospital Revenue Code	300
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

.TOTAL PROTEIN, URINE

Facility

$12.00

Service Code	HCPCS 84156
Hospital Charge Code	4084156
Hospital Revenue Code	300
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

T PALLIDUM SCREENING CASCADE (082345)

Facility

$65.00

Service Code	HCPCS 86780
Hospital Charge Code	4086780
Hospital Revenue Code	300
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

T PALLIDUM SCREENING CASCADE (082345)

Facility

$65.00

Service Code	HCPCS 86780
Hospital Charge Code	4086780
Hospital Revenue Code	300
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

TRAMADOL TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000457
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

TRAMADOL TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000457
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

TRANEXAMIC ACID 100MG/ML 10ML VIAL

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000458
Hospital Revenue Code	636
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

TRANEXAMIC ACID 100MG/ML 10ML VIAL

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000458
Hospital Revenue Code	636
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

TRANSFERRIN (004937)

Facility

$91.00

Service Code	HCPCS 84466
Hospital Charge Code	4084466
Hospital Revenue Code	300
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

TRANSFERRIN (004937)

Facility

$91.00

Service Code	HCPCS 84466
Hospital Charge Code	4084466
Hospital Revenue Code	300
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

TRAUMA ACTIVATION

Facility

$3,713.00

Service Code	HCPCS G0390
Hospital Charge Code	1010110
Hospital Revenue Code	681
Min. Negotiated Rate	$2,599.10
Max. Negotiated Rate	$3,713.00
Rate for Payer: Aetna Commercial	$3,527.35
Rate for Payer: Aetna Medicare	$3,341.70
Rate for Payer: BCBS MT CHIP	$3,341.70
Rate for Payer: BCBS MT Closed Plan Network	$3,527.35
Rate for Payer: BCBS MT HealthLink	$3,341.70
Rate for Payer: BCBS MT Medicare	$3,341.70
Rate for Payer: BCBS MT POS	$3,527.35
Rate for Payer: BCBS MT Traditional	$3,713.00
Rate for Payer: Cash Price	$3,341.70
Rate for Payer: Cigna Commercial	$3,527.35
Rate for Payer: Cigna Medicare	$3,341.70
Rate for Payer: Medicaid All Medicaid	$3,415.96
Rate for Payer: Medicare All Medicare	$2,599.10
Rate for Payer: Monida Allegiance	$3,527.35
Rate for Payer: Monida First Choice Health	$3,601.61
Rate for Payer: Monida Montana Health Co-op	$3,527.35
Rate for Payer: Monida PacificSource	$3,527.35

TRAUMA ACTIVATION

Facility

$3,713.00

Service Code	HCPCS G0390
Hospital Charge Code	1010110
Hospital Revenue Code	681
Min. Negotiated Rate	$2,599.10
Max. Negotiated Rate	$3,713.00
Rate for Payer: Aetna Commercial	$3,527.35
Rate for Payer: Aetna Medicare	$3,341.70
Rate for Payer: BCBS MT CHIP	$3,341.70
Rate for Payer: BCBS MT Closed Plan Network	$3,527.35
Rate for Payer: BCBS MT HealthLink	$3,341.70
Rate for Payer: BCBS MT Medicare	$3,341.70
Rate for Payer: BCBS MT POS	$3,527.35
Rate for Payer: BCBS MT Traditional	$3,713.00
Rate for Payer: Cash Price	$3,341.70
Rate for Payer: Cigna Commercial	$3,527.35
Rate for Payer: Cigna Medicare	$3,341.70
Rate for Payer: Medicaid All Medicaid	$3,415.96
Rate for Payer: Medicare All Medicare	$2,599.10
Rate for Payer: Monida Allegiance	$3,527.35
Rate for Payer: Monida First Choice Health	$3,601.61
Rate for Payer: Monida Montana Health Co-op	$3,527.35
Rate for Payer: Monida PacificSource	$3,527.35

TRAVOPROST 0.004% SOLUTION 2.5 ML -NF

Facility

$525.65

Service Code	NDC 00378965132
Hospital Charge Code	3007248
Hospital Revenue Code	250
Min. Negotiated Rate	$367.96
Max. Negotiated Rate	$525.65
Rate for Payer: Aetna Commercial	$499.37
Rate for Payer: Aetna Medicare	$473.08
Rate for Payer: BCBS MT CHIP	$473.08
Rate for Payer: BCBS MT Closed Plan Network	$499.37
Rate for Payer: BCBS MT HealthLink	$473.08
Rate for Payer: BCBS MT Medicare	$473.08
Rate for Payer: BCBS MT POS	$499.37
Rate for Payer: BCBS MT Traditional	$525.65
Rate for Payer: Cash Price	$473.09
Rate for Payer: Cigna Commercial	$499.37
Rate for Payer: Cigna Medicare	$473.08
Rate for Payer: Medicaid All Medicaid	$483.60
Rate for Payer: Medicare All Medicare	$367.96
Rate for Payer: Monida Allegiance	$499.37
Rate for Payer: Monida First Choice Health	$509.88
Rate for Payer: Monida Montana Health Co-op	$499.37
Rate for Payer: Monida PacificSource	$499.37

TRAVOPROST 0.004% SOLUTION 2.5 ML -NF

Facility

$525.65

Service Code	NDC 00378965132
Hospital Charge Code	3007248
Hospital Revenue Code	250
Min. Negotiated Rate	$367.96
Max. Negotiated Rate	$525.65
Rate for Payer: Aetna Commercial	$499.37
Rate for Payer: Aetna Medicare	$473.08
Rate for Payer: BCBS MT CHIP	$473.08
Rate for Payer: BCBS MT Closed Plan Network	$499.37
Rate for Payer: BCBS MT HealthLink	$473.08
Rate for Payer: BCBS MT Medicare	$473.08
Rate for Payer: BCBS MT POS	$499.37
Rate for Payer: BCBS MT Traditional	$525.65
Rate for Payer: Cash Price	$473.09
Rate for Payer: Cigna Commercial	$499.37
Rate for Payer: Cigna Medicare	$473.08
Rate for Payer: Medicaid All Medicaid	$483.60
Rate for Payer: Medicare All Medicare	$367.96
Rate for Payer: Monida Allegiance	$499.37
Rate for Payer: Monida First Choice Health	$509.88
Rate for Payer: Monida Montana Health Co-op	$499.37
Rate for Payer: Monida PacificSource	$499.37

TRAZODONE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000459
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

Know your out-of-pocket cost for care.

All Charges