Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

TR DRAINAGE OF FINGER ABCESS

Facility

$266.00

Service Code	HCPCS 26010
Hospital Charge Code	1026010
Hospital Revenue Code	761
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

TR DRAINAGE OF FINGER ABCESS

Facility

$266.00

Service Code	HCPCS 26010
Hospital Charge Code	1026010
Hospital Revenue Code	761
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

TR DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$495.00

Service Code	HCPCS 16030
Hospital Charge Code	1046030
Hospital Revenue Code	761
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna Commercial	$470.25
Rate for Payer: Aetna Medicare	$445.50
Rate for Payer: BCBS MT CHIP	$445.50
Rate for Payer: BCBS MT Closed Plan Network	$470.25
Rate for Payer: BCBS MT HealthLink	$445.50
Rate for Payer: BCBS MT Medicare	$445.50
Rate for Payer: BCBS MT POS	$470.25
Rate for Payer: BCBS MT Traditional	$495.00
Rate for Payer: Cash Price	$445.50
Rate for Payer: Cigna Commercial	$470.25
Rate for Payer: Cigna Medicare	$445.50
Rate for Payer: Medicaid All Medicaid	$455.40
Rate for Payer: Medicare All Medicare	$346.50
Rate for Payer: Monida Allegiance	$470.25
Rate for Payer: Monida First Choice Health	$480.15
Rate for Payer: Monida Montana Health Co-op	$470.25
Rate for Payer: Monida PacificSource	$470.25

TR DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$495.00

Service Code	HCPCS 16030
Hospital Charge Code	1046030
Hospital Revenue Code	761
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$495.00
Rate for Payer: Aetna Commercial	$470.25
Rate for Payer: Aetna Medicare	$445.50
Rate for Payer: BCBS MT CHIP	$445.50
Rate for Payer: BCBS MT Closed Plan Network	$470.25
Rate for Payer: BCBS MT HealthLink	$445.50
Rate for Payer: BCBS MT Medicare	$445.50
Rate for Payer: BCBS MT POS	$470.25
Rate for Payer: BCBS MT Traditional	$495.00
Rate for Payer: Cash Price	$445.50
Rate for Payer: Cigna Commercial	$470.25
Rate for Payer: Cigna Medicare	$445.50
Rate for Payer: Medicaid All Medicaid	$455.40
Rate for Payer: Medicare All Medicare	$346.50
Rate for Payer: Monida Allegiance	$470.25
Rate for Payer: Monida First Choice Health	$480.15
Rate for Payer: Monida Montana Health Co-op	$470.25
Rate for Payer: Monida PacificSource	$470.25

TREAT FRACTURE RADIUS & ULNA W/MANI

Facility

$729.00

Service Code	HCPCS 25565
Hospital Charge Code	1025565
Hospital Revenue Code	450
Min. Negotiated Rate	$510.30
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna Commercial	$692.55
Rate for Payer: Aetna Medicare	$656.10
Rate for Payer: BCBS MT CHIP	$656.10
Rate for Payer: BCBS MT Closed Plan Network	$692.55
Rate for Payer: BCBS MT HealthLink	$656.10
Rate for Payer: BCBS MT Medicare	$656.10
Rate for Payer: BCBS MT POS	$692.55
Rate for Payer: BCBS MT Traditional	$729.00
Rate for Payer: Cash Price	$656.10
Rate for Payer: Cigna Commercial	$692.55
Rate for Payer: Cigna Medicare	$656.10
Rate for Payer: Medicaid All Medicaid	$670.68
Rate for Payer: Medicare All Medicare	$510.30
Rate for Payer: Monida Allegiance	$692.55
Rate for Payer: Monida First Choice Health	$707.13
Rate for Payer: Monida Montana Health Co-op	$692.55
Rate for Payer: Monida PacificSource	$692.55

TREAT FRACTURE RADIUS & ULNA W/MANI

Facility

$729.00

Service Code	HCPCS 25565
Hospital Charge Code	1025565
Hospital Revenue Code	450
Min. Negotiated Rate	$510.30
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna Commercial	$692.55
Rate for Payer: Aetna Medicare	$656.10
Rate for Payer: BCBS MT CHIP	$656.10
Rate for Payer: BCBS MT Closed Plan Network	$692.55
Rate for Payer: BCBS MT HealthLink	$656.10
Rate for Payer: BCBS MT Medicare	$656.10
Rate for Payer: BCBS MT POS	$692.55
Rate for Payer: BCBS MT Traditional	$729.00
Rate for Payer: Cash Price	$656.10
Rate for Payer: Cigna Commercial	$692.55
Rate for Payer: Cigna Medicare	$656.10
Rate for Payer: Medicaid All Medicaid	$670.68
Rate for Payer: Medicare All Medicare	$510.30
Rate for Payer: Monida Allegiance	$692.55
Rate for Payer: Monida First Choice Health	$707.13
Rate for Payer: Monida Montana Health Co-op	$692.55
Rate for Payer: Monida PacificSource	$692.55

TREATMENT RM

Facility

$1,556.00

Service Code	HCPCS 36556
Hospital Charge Code	1036556
Hospital Revenue Code	761
Min. Negotiated Rate	$1,089.20
Max. Negotiated Rate	$1,556.00
Rate for Payer: Aetna Commercial	$1,478.20
Rate for Payer: Aetna Medicare	$1,400.40
Rate for Payer: BCBS MT CHIP	$1,400.40
Rate for Payer: BCBS MT Closed Plan Network	$1,478.20
Rate for Payer: BCBS MT HealthLink	$1,400.40
Rate for Payer: BCBS MT Medicare	$1,400.40
Rate for Payer: BCBS MT POS	$1,478.20
Rate for Payer: BCBS MT Traditional	$1,556.00
Rate for Payer: Cash Price	$1,400.40
Rate for Payer: Cigna Commercial	$1,478.20
Rate for Payer: Cigna Medicare	$1,400.40
Rate for Payer: Medicaid All Medicaid	$1,431.52
Rate for Payer: Medicare All Medicare	$1,089.20
Rate for Payer: Monida Allegiance	$1,478.20
Rate for Payer: Monida First Choice Health	$1,509.32
Rate for Payer: Monida Montana Health Co-op	$1,478.20
Rate for Payer: Monida PacificSource	$1,478.20

TREATMENT RM

Facility

$1,556.00

Service Code	HCPCS 36556
Hospital Charge Code	1036556
Hospital Revenue Code	761
Min. Negotiated Rate	$1,089.20
Max. Negotiated Rate	$1,556.00
Rate for Payer: Aetna Commercial	$1,478.20
Rate for Payer: Aetna Medicare	$1,400.40
Rate for Payer: BCBS MT CHIP	$1,400.40
Rate for Payer: BCBS MT Closed Plan Network	$1,478.20
Rate for Payer: BCBS MT HealthLink	$1,400.40
Rate for Payer: BCBS MT Medicare	$1,400.40
Rate for Payer: BCBS MT POS	$1,478.20
Rate for Payer: BCBS MT Traditional	$1,556.00
Rate for Payer: Cash Price	$1,400.40
Rate for Payer: Cigna Commercial	$1,478.20
Rate for Payer: Cigna Medicare	$1,400.40
Rate for Payer: Medicaid All Medicaid	$1,431.52
Rate for Payer: Medicare All Medicare	$1,089.20
Rate for Payer: Monida Allegiance	$1,478.20
Rate for Payer: Monida First Choice Health	$1,509.32
Rate for Payer: Monida Montana Health Co-op	$1,478.20
Rate for Payer: Monida PacificSource	$1,478.20

TREATMENT RM CHG TUBE GASTROSTOMY

Facility

$552.00

Service Code	HCPCS 43760
Hospital Charge Code	1043760
Hospital Revenue Code	761
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$552.00
Rate for Payer: Aetna Commercial	$524.40
Rate for Payer: Aetna Medicare	$496.80
Rate for Payer: BCBS MT CHIP	$496.80
Rate for Payer: BCBS MT Closed Plan Network	$524.40
Rate for Payer: BCBS MT HealthLink	$496.80
Rate for Payer: BCBS MT Medicare	$496.80
Rate for Payer: BCBS MT POS	$524.40
Rate for Payer: BCBS MT Traditional	$552.00
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cigna Commercial	$524.40
Rate for Payer: Cigna Medicare	$496.80
Rate for Payer: Medicaid All Medicaid	$507.84
Rate for Payer: Medicare All Medicare	$386.40
Rate for Payer: Monida Allegiance	$524.40
Rate for Payer: Monida First Choice Health	$535.44
Rate for Payer: Monida Montana Health Co-op	$524.40
Rate for Payer: Monida PacificSource	$524.40

TREATMENT RM CHG TUBE GASTROSTOMY

Facility

$552.00

Service Code	HCPCS 43760
Hospital Charge Code	1043760
Hospital Revenue Code	761
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$552.00
Rate for Payer: Aetna Commercial	$524.40
Rate for Payer: Aetna Medicare	$496.80
Rate for Payer: BCBS MT CHIP	$496.80
Rate for Payer: BCBS MT Closed Plan Network	$524.40
Rate for Payer: BCBS MT HealthLink	$496.80
Rate for Payer: BCBS MT Medicare	$496.80
Rate for Payer: BCBS MT POS	$524.40
Rate for Payer: BCBS MT Traditional	$552.00
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cigna Commercial	$524.40
Rate for Payer: Cigna Medicare	$496.80
Rate for Payer: Medicaid All Medicaid	$507.84
Rate for Payer: Medicare All Medicare	$386.40
Rate for Payer: Monida Allegiance	$524.40
Rate for Payer: Monida First Choice Health	$535.44
Rate for Payer: Monida Montana Health Co-op	$524.40
Rate for Payer: Monida PacificSource	$524.40

TREATMENT RN NURSE ONLY

Facility

$89.00

Service Code	HCPCS 99211
Hospital Charge Code	530204
Hospital Revenue Code	761
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

TREATMENT RN NURSE ONLY

Facility

$89.00

Service Code	HCPCS 99211
Hospital Charge Code	530204
Hospital Revenue Code	761
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

TR EXCISION MALIGNANT LESION INC MARGINS

Facility

$530.00

Service Code	HCPCS 11602
Hospital Charge Code	1011602
Hospital Revenue Code	761
Min. Negotiated Rate	$371.00
Max. Negotiated Rate	$530.00
Rate for Payer: Aetna Commercial	$503.50
Rate for Payer: Aetna Medicare	$477.00
Rate for Payer: BCBS MT CHIP	$477.00
Rate for Payer: BCBS MT Closed Plan Network	$503.50
Rate for Payer: BCBS MT HealthLink	$477.00
Rate for Payer: BCBS MT Medicare	$477.00
Rate for Payer: BCBS MT POS	$503.50
Rate for Payer: BCBS MT Traditional	$530.00
Rate for Payer: Cash Price	$477.00
Rate for Payer: Cigna Commercial	$503.50
Rate for Payer: Cigna Medicare	$477.00
Rate for Payer: Medicaid All Medicaid	$487.60
Rate for Payer: Medicare All Medicare	$371.00
Rate for Payer: Monida Allegiance	$503.50
Rate for Payer: Monida First Choice Health	$514.10
Rate for Payer: Monida Montana Health Co-op	$503.50
Rate for Payer: Monida PacificSource	$503.50

TR EXCISION MALIGNANT LESION INC MARGINS

Facility

$530.00

Service Code	HCPCS 11602
Hospital Charge Code	1011602
Hospital Revenue Code	761
Min. Negotiated Rate	$371.00
Max. Negotiated Rate	$530.00
Rate for Payer: Aetna Commercial	$503.50
Rate for Payer: Aetna Medicare	$477.00
Rate for Payer: BCBS MT CHIP	$477.00
Rate for Payer: BCBS MT Closed Plan Network	$503.50
Rate for Payer: BCBS MT HealthLink	$477.00
Rate for Payer: BCBS MT Medicare	$477.00
Rate for Payer: BCBS MT POS	$503.50
Rate for Payer: BCBS MT Traditional	$530.00
Rate for Payer: Cash Price	$477.00
Rate for Payer: Cigna Commercial	$503.50
Rate for Payer: Cigna Medicare	$477.00
Rate for Payer: Medicaid All Medicaid	$487.60
Rate for Payer: Medicare All Medicare	$371.00
Rate for Payer: Monida Allegiance	$503.50
Rate for Payer: Monida First Choice Health	$514.10
Rate for Payer: Monida Montana Health Co-op	$503.50
Rate for Payer: Monida PacificSource	$503.50

TR GI SERVICES GENERAL

Facility

$2,358.00

Service Code	HCPCS 43246
Hospital Charge Code	1043246
Hospital Revenue Code	761
Min. Negotiated Rate	$1,650.60
Max. Negotiated Rate	$2,358.00
Rate for Payer: Aetna Commercial	$2,240.10
Rate for Payer: Aetna Medicare	$2,122.20
Rate for Payer: BCBS MT CHIP	$2,122.20
Rate for Payer: BCBS MT Closed Plan Network	$2,240.10
Rate for Payer: BCBS MT HealthLink	$2,122.20
Rate for Payer: BCBS MT Medicare	$2,122.20
Rate for Payer: BCBS MT POS	$2,240.10
Rate for Payer: BCBS MT Traditional	$2,358.00
Rate for Payer: Cash Price	$2,122.20
Rate for Payer: Cigna Commercial	$2,240.10
Rate for Payer: Cigna Medicare	$2,122.20
Rate for Payer: Medicaid All Medicaid	$2,169.36
Rate for Payer: Medicare All Medicare	$1,650.60
Rate for Payer: Monida Allegiance	$2,240.10
Rate for Payer: Monida First Choice Health	$2,287.26
Rate for Payer: Monida Montana Health Co-op	$2,240.10
Rate for Payer: Monida PacificSource	$2,240.10

TR GI SERVICES GENERAL

Facility

$2,358.00

Service Code	HCPCS 43246
Hospital Charge Code	1043246
Hospital Revenue Code	761
Min. Negotiated Rate	$1,650.60
Max. Negotiated Rate	$2,358.00
Rate for Payer: Aetna Commercial	$2,240.10
Rate for Payer: Aetna Medicare	$2,122.20
Rate for Payer: BCBS MT CHIP	$2,122.20
Rate for Payer: BCBS MT Closed Plan Network	$2,240.10
Rate for Payer: BCBS MT HealthLink	$2,122.20
Rate for Payer: BCBS MT Medicare	$2,122.20
Rate for Payer: BCBS MT POS	$2,240.10
Rate for Payer: BCBS MT Traditional	$2,358.00
Rate for Payer: Cash Price	$2,122.20
Rate for Payer: Cigna Commercial	$2,240.10
Rate for Payer: Cigna Medicare	$2,122.20
Rate for Payer: Medicaid All Medicaid	$2,169.36
Rate for Payer: Medicare All Medicare	$1,650.60
Rate for Payer: Monida Allegiance	$2,240.10
Rate for Payer: Monida First Choice Health	$2,287.26
Rate for Payer: Monida Montana Health Co-op	$2,240.10
Rate for Payer: Monida PacificSource	$2,240.10

TRIAMCINOLONE 0.1% CREAM [15 GM]

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000460
Hospital Revenue Code	259
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

TRIAMCINOLONE 0.1% CREAM [15 GM]

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000460
Hospital Revenue Code	259
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

TRIAMCINOLONE INJ [40 MG/ML]

Facility

$35.00

Service Code	HCPCS J3301
Hospital Charge Code	3000461
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

TRIAMCINOLONE INJ [40 MG/ML]

Facility

$35.00

Service Code	HCPCS J3301
Hospital Charge Code	3000461
Hospital Revenue Code	250
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

TRIAMTER/ HCTZ CAP [37.5-25 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000462
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

TRIAMTER/ HCTZ CAP [37.5-25 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000462
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

TR I & D PILONIDAL CYST SIMPLE

Facility

$354.00

Service Code	HCPCS 10080
Hospital Charge Code	1010080
Hospital Revenue Code	761
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

TR I & D PILONIDAL CYST SIMPLE

Facility

$354.00

Service Code	HCPCS 10080
Hospital Charge Code	1010080
Hospital Revenue Code	761
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

Know your out-of-pocket cost for care.

All Charges