Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$1,960.00

Service Code	HCPCS 15277
Hospital Charge Code	8015277
Hospital Revenue Code	761
Min. Negotiated Rate	$1,372.00
Max. Negotiated Rate	$1,960.00
Rate for Payer: Aetna Commercial	$1,862.00
Rate for Payer: Aetna Medicare	$1,764.00
Rate for Payer: BCBS MT CHIP	$1,764.00
Rate for Payer: BCBS MT Closed Plan Network	$1,862.00
Rate for Payer: BCBS MT HealthLink	$1,764.00
Rate for Payer: BCBS MT Medicare	$1,764.00
Rate for Payer: BCBS MT POS	$1,862.00
Rate for Payer: BCBS MT Traditional	$1,960.00
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Cigna Commercial	$1,862.00
Rate for Payer: Cigna Medicare	$1,764.00
Rate for Payer: Medicaid All Medicaid	$1,803.20
Rate for Payer: Medicare All Medicare	$1,372.00
Rate for Payer: Monida Allegiance	$1,862.00
Rate for Payer: Monida First Choice Health	$1,901.20
Rate for Payer: Monida Montana Health Co-op	$1,862.00
Rate for Payer: Monida PacificSource	$1,862.00

SKIN SUB APPLIC H,FT,FC 1ST100SQCM 15277

Facility

$1,960.00

Service Code	HCPCS 15277
Hospital Charge Code	8015277
Hospital Revenue Code	761
Min. Negotiated Rate	$1,372.00
Max. Negotiated Rate	$1,960.00
Rate for Payer: Aetna Commercial	$1,862.00
Rate for Payer: Aetna Medicare	$1,764.00
Rate for Payer: BCBS MT CHIP	$1,764.00
Rate for Payer: BCBS MT Closed Plan Network	$1,862.00
Rate for Payer: BCBS MT HealthLink	$1,764.00
Rate for Payer: BCBS MT Medicare	$1,764.00
Rate for Payer: BCBS MT POS	$1,862.00
Rate for Payer: BCBS MT Traditional	$1,960.00
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Cigna Commercial	$1,862.00
Rate for Payer: Cigna Medicare	$1,764.00
Rate for Payer: Medicaid All Medicaid	$1,803.20
Rate for Payer: Medicare All Medicare	$1,372.00
Rate for Payer: Monida Allegiance	$1,862.00
Rate for Payer: Monida First Choice Health	$1,901.20
Rate for Payer: Monida Montana Health Co-op	$1,862.00
Rate for Payer: Monida PacificSource	$1,862.00

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

Facility

$1,315.00

Service Code	HCPCS 15278
Hospital Charge Code	8015278
Hospital Revenue Code	761
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$1,315.00
Rate for Payer: Aetna Commercial	$1,249.25
Rate for Payer: Aetna Medicare	$1,183.50
Rate for Payer: BCBS MT CHIP	$1,183.50
Rate for Payer: BCBS MT Closed Plan Network	$1,249.25
Rate for Payer: BCBS MT HealthLink	$1,183.50
Rate for Payer: BCBS MT Medicare	$1,183.50
Rate for Payer: BCBS MT POS	$1,249.25
Rate for Payer: BCBS MT Traditional	$1,315.00
Rate for Payer: Cash Price	$1,183.50
Rate for Payer: Cigna Commercial	$1,249.25
Rate for Payer: Cigna Medicare	$1,183.50
Rate for Payer: Medicaid All Medicaid	$1,209.80
Rate for Payer: Medicare All Medicare	$920.50
Rate for Payer: Monida Allegiance	$1,249.25
Rate for Payer: Monida First Choice Health	$1,275.55
Rate for Payer: Monida Montana Health Co-op	$1,249.25
Rate for Payer: Monida PacificSource	$1,249.25

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

Facility

$1,315.00

Service Code	HCPCS 15278
Hospital Charge Code	8015278
Hospital Revenue Code	761
Min. Negotiated Rate	$920.50
Max. Negotiated Rate	$1,315.00
Rate for Payer: Aetna Commercial	$1,249.25
Rate for Payer: Aetna Medicare	$1,183.50
Rate for Payer: BCBS MT CHIP	$1,183.50
Rate for Payer: BCBS MT Closed Plan Network	$1,249.25
Rate for Payer: BCBS MT HealthLink	$1,183.50
Rate for Payer: BCBS MT Medicare	$1,183.50
Rate for Payer: BCBS MT POS	$1,249.25
Rate for Payer: BCBS MT Traditional	$1,315.00
Rate for Payer: Cash Price	$1,183.50
Rate for Payer: Cigna Commercial	$1,249.25
Rate for Payer: Cigna Medicare	$1,183.50
Rate for Payer: Medicaid All Medicaid	$1,209.80
Rate for Payer: Medicare All Medicare	$920.50
Rate for Payer: Monida Allegiance	$1,249.25
Rate for Payer: Monida First Choice Health	$1,275.55
Rate for Payer: Monida Montana Health Co-op	$1,249.25
Rate for Payer: Monida PacificSource	$1,249.25

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

Facility

$1,855.00

Service Code	HCPCS 15275
Hospital Charge Code	8015275
Hospital Revenue Code	761
Min. Negotiated Rate	$1,298.50
Max. Negotiated Rate	$1,855.00
Rate for Payer: Aetna Commercial	$1,762.25
Rate for Payer: Aetna Medicare	$1,669.50
Rate for Payer: BCBS MT CHIP	$1,669.50
Rate for Payer: BCBS MT Closed Plan Network	$1,762.25
Rate for Payer: BCBS MT HealthLink	$1,669.50
Rate for Payer: BCBS MT Medicare	$1,669.50
Rate for Payer: BCBS MT POS	$1,762.25
Rate for Payer: BCBS MT Traditional	$1,855.00
Rate for Payer: Cash Price	$1,669.50
Rate for Payer: Cigna Commercial	$1,762.25
Rate for Payer: Cigna Medicare	$1,669.50
Rate for Payer: Medicaid All Medicaid	$1,706.60
Rate for Payer: Medicare All Medicare	$1,298.50
Rate for Payer: Monida Allegiance	$1,762.25
Rate for Payer: Monida First Choice Health	$1,799.35
Rate for Payer: Monida Montana Health Co-op	$1,762.25
Rate for Payer: Monida PacificSource	$1,762.25

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

Facility

$1,855.00

Service Code	HCPCS 15275
Hospital Charge Code	8015275
Hospital Revenue Code	761
Min. Negotiated Rate	$1,298.50
Max. Negotiated Rate	$1,855.00
Rate for Payer: Aetna Commercial	$1,762.25
Rate for Payer: Aetna Medicare	$1,669.50
Rate for Payer: BCBS MT CHIP	$1,669.50
Rate for Payer: BCBS MT Closed Plan Network	$1,762.25
Rate for Payer: BCBS MT HealthLink	$1,669.50
Rate for Payer: BCBS MT Medicare	$1,669.50
Rate for Payer: BCBS MT POS	$1,762.25
Rate for Payer: BCBS MT Traditional	$1,855.00
Rate for Payer: Cash Price	$1,669.50
Rate for Payer: Cigna Commercial	$1,762.25
Rate for Payer: Cigna Medicare	$1,669.50
Rate for Payer: Medicaid All Medicaid	$1,706.60
Rate for Payer: Medicare All Medicare	$1,298.50
Rate for Payer: Monida Allegiance	$1,762.25
Rate for Payer: Monida First Choice Health	$1,799.35
Rate for Payer: Monida Montana Health Co-op	$1,762.25
Rate for Payer: Monida PacificSource	$1,762.25

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

Facility

$588.00

Service Code	HCPCS 15276
Hospital Charge Code	8015276
Hospital Revenue Code	761
Min. Negotiated Rate	$411.60
Max. Negotiated Rate	$588.00
Rate for Payer: Aetna Commercial	$558.60
Rate for Payer: Aetna Medicare	$529.20
Rate for Payer: BCBS MT CHIP	$529.20
Rate for Payer: BCBS MT Closed Plan Network	$558.60
Rate for Payer: BCBS MT HealthLink	$529.20
Rate for Payer: BCBS MT Medicare	$529.20
Rate for Payer: BCBS MT POS	$558.60
Rate for Payer: BCBS MT Traditional	$588.00
Rate for Payer: Cash Price	$529.20
Rate for Payer: Cigna Commercial	$558.60
Rate for Payer: Cigna Medicare	$529.20
Rate for Payer: Medicaid All Medicaid	$540.96
Rate for Payer: Medicare All Medicare	$411.60
Rate for Payer: Monida Allegiance	$558.60
Rate for Payer: Monida First Choice Health	$570.36
Rate for Payer: Monida Montana Health Co-op	$558.60
Rate for Payer: Monida PacificSource	$558.60

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

Facility

$588.00

Service Code	HCPCS 15276
Hospital Charge Code	8015276
Hospital Revenue Code	761
Min. Negotiated Rate	$411.60
Max. Negotiated Rate	$588.00
Rate for Payer: Aetna Commercial	$558.60
Rate for Payer: Aetna Medicare	$529.20
Rate for Payer: BCBS MT CHIP	$529.20
Rate for Payer: BCBS MT Closed Plan Network	$558.60
Rate for Payer: BCBS MT HealthLink	$529.20
Rate for Payer: BCBS MT Medicare	$529.20
Rate for Payer: BCBS MT POS	$558.60
Rate for Payer: BCBS MT Traditional	$588.00
Rate for Payer: Cash Price	$529.20
Rate for Payer: Cigna Commercial	$558.60
Rate for Payer: Cigna Medicare	$529.20
Rate for Payer: Medicaid All Medicaid	$540.96
Rate for Payer: Medicare All Medicare	$411.60
Rate for Payer: Monida Allegiance	$558.60
Rate for Payer: Monida First Choice Health	$570.36
Rate for Payer: Monida Montana Health Co-op	$558.60
Rate for Payer: Monida PacificSource	$558.60

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

Facility

$1,752.00

Service Code	HCPCS 15271
Hospital Charge Code	8015271
Hospital Revenue Code	761
Min. Negotiated Rate	$1,226.40
Max. Negotiated Rate	$1,752.00
Rate for Payer: Aetna Commercial	$1,664.40
Rate for Payer: Aetna Medicare	$1,576.80
Rate for Payer: BCBS MT CHIP	$1,576.80
Rate for Payer: BCBS MT Closed Plan Network	$1,664.40
Rate for Payer: BCBS MT HealthLink	$1,576.80
Rate for Payer: BCBS MT Medicare	$1,576.80
Rate for Payer: BCBS MT POS	$1,664.40
Rate for Payer: BCBS MT Traditional	$1,752.00
Rate for Payer: Cash Price	$1,576.80
Rate for Payer: Cigna Commercial	$1,664.40
Rate for Payer: Cigna Medicare	$1,576.80
Rate for Payer: Medicaid All Medicaid	$1,611.84
Rate for Payer: Medicare All Medicare	$1,226.40
Rate for Payer: Monida Allegiance	$1,664.40
Rate for Payer: Monida First Choice Health	$1,699.44
Rate for Payer: Monida Montana Health Co-op	$1,664.40
Rate for Payer: Monida PacificSource	$1,664.40

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

Facility

$1,752.00

Service Code	HCPCS 15271
Hospital Charge Code	8015271
Hospital Revenue Code	761
Min. Negotiated Rate	$1,226.40
Max. Negotiated Rate	$1,752.00
Rate for Payer: Aetna Commercial	$1,664.40
Rate for Payer: Aetna Medicare	$1,576.80
Rate for Payer: BCBS MT CHIP	$1,576.80
Rate for Payer: BCBS MT Closed Plan Network	$1,664.40
Rate for Payer: BCBS MT HealthLink	$1,576.80
Rate for Payer: BCBS MT Medicare	$1,576.80
Rate for Payer: BCBS MT POS	$1,664.40
Rate for Payer: BCBS MT Traditional	$1,752.00
Rate for Payer: Cash Price	$1,576.80
Rate for Payer: Cigna Commercial	$1,664.40
Rate for Payer: Cigna Medicare	$1,576.80
Rate for Payer: Medicaid All Medicaid	$1,611.84
Rate for Payer: Medicare All Medicare	$1,226.40
Rate for Payer: Monida Allegiance	$1,664.40
Rate for Payer: Monida First Choice Health	$1,699.44
Rate for Payer: Monida Montana Health Co-op	$1,664.40
Rate for Payer: Monida PacificSource	$1,664.40

SKIN SUBS APPLIC T,A,L 1ST100 SQCM 15273

Facility

$1,914.00

Service Code	HCPCS 15273
Hospital Charge Code	8015273
Hospital Revenue Code	761
Min. Negotiated Rate	$1,339.80
Max. Negotiated Rate	$1,914.00
Rate for Payer: Aetna Commercial	$1,818.30
Rate for Payer: Aetna Medicare	$1,722.60
Rate for Payer: BCBS MT CHIP	$1,722.60
Rate for Payer: BCBS MT Closed Plan Network	$1,818.30
Rate for Payer: BCBS MT HealthLink	$1,722.60
Rate for Payer: BCBS MT Medicare	$1,722.60
Rate for Payer: BCBS MT POS	$1,818.30
Rate for Payer: BCBS MT Traditional	$1,914.00
Rate for Payer: Cash Price	$1,722.60
Rate for Payer: Cigna Commercial	$1,818.30
Rate for Payer: Cigna Medicare	$1,722.60
Rate for Payer: Medicaid All Medicaid	$1,760.88
Rate for Payer: Medicare All Medicare	$1,339.80
Rate for Payer: Monida Allegiance	$1,818.30
Rate for Payer: Monida First Choice Health	$1,856.58
Rate for Payer: Monida Montana Health Co-op	$1,818.30
Rate for Payer: Monida PacificSource	$1,818.30

SKIN SUBS APPLIC T,A,L 1ST100 SQCM 15273

Facility

$1,914.00

Service Code	HCPCS 15273
Hospital Charge Code	8015273
Hospital Revenue Code	761
Min. Negotiated Rate	$1,339.80
Max. Negotiated Rate	$1,914.00
Rate for Payer: Aetna Commercial	$1,818.30
Rate for Payer: Aetna Medicare	$1,722.60
Rate for Payer: BCBS MT CHIP	$1,722.60
Rate for Payer: BCBS MT Closed Plan Network	$1,818.30
Rate for Payer: BCBS MT HealthLink	$1,722.60
Rate for Payer: BCBS MT Medicare	$1,722.60
Rate for Payer: BCBS MT POS	$1,818.30
Rate for Payer: BCBS MT Traditional	$1,914.00
Rate for Payer: Cash Price	$1,722.60
Rate for Payer: Cigna Commercial	$1,818.30
Rate for Payer: Cigna Medicare	$1,722.60
Rate for Payer: Medicaid All Medicaid	$1,760.88
Rate for Payer: Medicare All Medicare	$1,339.80
Rate for Payer: Monida Allegiance	$1,818.30
Rate for Payer: Monida First Choice Health	$1,856.58
Rate for Payer: Monida Montana Health Co-op	$1,818.30
Rate for Payer: Monida PacificSource	$1,818.30

SKIN SUBS APPLIC T,A,L EA100+ SQCM 15274

Facility

$815.00

Service Code	HCPCS 15274
Hospital Charge Code	8015274
Hospital Revenue Code	761
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$815.00
Rate for Payer: Aetna Commercial	$774.25
Rate for Payer: Aetna Medicare	$733.50
Rate for Payer: BCBS MT CHIP	$733.50
Rate for Payer: BCBS MT Closed Plan Network	$774.25
Rate for Payer: BCBS MT HealthLink	$733.50
Rate for Payer: BCBS MT Medicare	$733.50
Rate for Payer: BCBS MT POS	$774.25
Rate for Payer: BCBS MT Traditional	$815.00
Rate for Payer: Cash Price	$733.50
Rate for Payer: Cigna Commercial	$774.25
Rate for Payer: Cigna Medicare	$733.50
Rate for Payer: Medicaid All Medicaid	$749.80
Rate for Payer: Medicare All Medicare	$570.50
Rate for Payer: Monida Allegiance	$774.25
Rate for Payer: Monida First Choice Health	$790.55
Rate for Payer: Monida Montana Health Co-op	$774.25
Rate for Payer: Monida PacificSource	$774.25

SKIN SUBS APPLIC T,A,L EA100+ SQCM 15274

Facility

$815.00

Service Code	HCPCS 15274
Hospital Charge Code	8015274
Hospital Revenue Code	761
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$815.00
Rate for Payer: Aetna Commercial	$774.25
Rate for Payer: Aetna Medicare	$733.50
Rate for Payer: BCBS MT CHIP	$733.50
Rate for Payer: BCBS MT Closed Plan Network	$774.25
Rate for Payer: BCBS MT HealthLink	$733.50
Rate for Payer: BCBS MT Medicare	$733.50
Rate for Payer: BCBS MT POS	$774.25
Rate for Payer: BCBS MT Traditional	$815.00
Rate for Payer: Cash Price	$733.50
Rate for Payer: Cigna Commercial	$774.25
Rate for Payer: Cigna Medicare	$733.50
Rate for Payer: Medicaid All Medicaid	$749.80
Rate for Payer: Medicare All Medicare	$570.50
Rate for Payer: Monida Allegiance	$774.25
Rate for Payer: Monida First Choice Health	$790.55
Rate for Payer: Monida Montana Health Co-op	$774.25
Rate for Payer: Monida PacificSource	$774.25

Know your out-of-pocket cost for care.

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