Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TIRZEPATIDE SQ INJ [5 MG/0.5 ML] PEN

Facility

$1,027.00

Service Code	HCPCS J3490
Hospital Charge Code	3000538
Hospital Revenue Code	250
Min. Negotiated Rate	$718.90
Max. Negotiated Rate	$1,027.00
Rate for Payer: Aetna Commercial	$975.65
Rate for Payer: Aetna Medicare	$924.30
Rate for Payer: BCBS MT CHIP	$924.30
Rate for Payer: BCBS MT Closed Plan Network	$975.65
Rate for Payer: BCBS MT HealthLink	$924.30
Rate for Payer: BCBS MT Medicare	$924.30
Rate for Payer: BCBS MT POS	$975.65
Rate for Payer: BCBS MT Traditional	$1,027.00
Rate for Payer: Cash Price	$924.30
Rate for Payer: Cigna Commercial	$975.65
Rate for Payer: Cigna Medicare	$924.30
Rate for Payer: Medicaid All Medicaid	$944.84
Rate for Payer: Medicare All Medicare	$718.90
Rate for Payer: Monida Allegiance	$975.65
Rate for Payer: Monida First Choice Health	$996.19
Rate for Payer: Monida Montana Health Co-op	$975.65
Rate for Payer: Monida PacificSource	$975.65

TIRZEPATIDE SQ INJ [5 MG/0.5 ML] PEN

Facility

$1,027.00

Service Code	HCPCS J3490
Hospital Charge Code	3000538
Hospital Revenue Code	250
Min. Negotiated Rate	$718.90
Max. Negotiated Rate	$1,027.00
Rate for Payer: Aetna Commercial	$975.65
Rate for Payer: Aetna Medicare	$924.30
Rate for Payer: BCBS MT CHIP	$924.30
Rate for Payer: BCBS MT Closed Plan Network	$975.65
Rate for Payer: BCBS MT HealthLink	$924.30
Rate for Payer: BCBS MT Medicare	$924.30
Rate for Payer: BCBS MT POS	$975.65
Rate for Payer: BCBS MT Traditional	$1,027.00
Rate for Payer: Cash Price	$924.30
Rate for Payer: Cigna Commercial	$975.65
Rate for Payer: Cigna Medicare	$924.30
Rate for Payer: Medicaid All Medicaid	$944.84
Rate for Payer: Medicare All Medicare	$718.90
Rate for Payer: Monida Allegiance	$975.65
Rate for Payer: Monida First Choice Health	$996.19
Rate for Payer: Monida Montana Health Co-op	$975.65
Rate for Payer: Monida PacificSource	$975.65

TIZANIDINE TAB [4 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000453
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

TIZANIDINE TAB [4 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000453
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

TNIH CALIBRATOR RC627 2 X 5

Facility

$69.51

Hospital Charge Code	90196552
Hospital Revenue Code	270
Min. Negotiated Rate	$48.66
Max. Negotiated Rate	$69.51
Rate for Payer: Aetna Commercial	$66.03
Rate for Payer: Aetna Medicare	$62.56
Rate for Payer: BCBS MT CHIP	$62.56
Rate for Payer: BCBS MT Closed Plan Network	$66.03
Rate for Payer: BCBS MT HealthLink	$62.56
Rate for Payer: BCBS MT Medicare	$62.56
Rate for Payer: BCBS MT POS	$66.03
Rate for Payer: BCBS MT Traditional	$69.51
Rate for Payer: Cash Price	$62.56
Rate for Payer: Cigna Commercial	$66.03
Rate for Payer: Cigna Medicare	$62.56
Rate for Payer: Medicaid All Medicaid	$63.95
Rate for Payer: Medicare All Medicare	$48.66
Rate for Payer: Monida Allegiance	$66.03
Rate for Payer: Monida First Choice Health	$67.42
Rate for Payer: Monida Montana Health Co-op	$66.03
Rate for Payer: Monida PacificSource	$66.03

TNIH CALIBRATOR RC627 2 X 5

Facility

$69.51

Hospital Charge Code	90196552
Hospital Revenue Code	270
Min. Negotiated Rate	$48.66
Max. Negotiated Rate	$69.51
Rate for Payer: Aetna Commercial	$66.03
Rate for Payer: Aetna Medicare	$62.56
Rate for Payer: BCBS MT CHIP	$62.56
Rate for Payer: BCBS MT Closed Plan Network	$66.03
Rate for Payer: BCBS MT HealthLink	$62.56
Rate for Payer: BCBS MT Medicare	$62.56
Rate for Payer: BCBS MT POS	$66.03
Rate for Payer: BCBS MT Traditional	$69.51
Rate for Payer: Cash Price	$62.56
Rate for Payer: Cigna Commercial	$66.03
Rate for Payer: Cigna Medicare	$62.56
Rate for Payer: Medicaid All Medicaid	$63.95
Rate for Payer: Medicare All Medicare	$48.66
Rate for Payer: Monida Allegiance	$66.03
Rate for Payer: Monida First Choice Health	$67.42
Rate for Payer: Monida Montana Health Co-op	$66.03
Rate for Payer: Monida PacificSource	$66.03

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

$58.00

Service Code	HCPCS 83550
Hospital Charge Code	4083550
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

.TOTAL IRON-BINDING CAPACITY

Facility

$58.00

Service Code	HCPCS 83550
Hospital Charge Code	4083550
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

.TOTAL PROTEIN, URINE

Facility

$55.00

Service Code	HCPCS 84156
Hospital Charge Code	4084156
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

.TOTAL PROTEIN, URINE

Facility

$55.00

Service Code	HCPCS 84156
Hospital Charge Code	4084156
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

TOURNIQUET (LAB ONLY)

Facility

$30.44

Hospital Charge Code	90195381
Hospital Revenue Code	270
Min. Negotiated Rate	$21.31
Max. Negotiated Rate	$30.44
Rate for Payer: Aetna Commercial	$28.92
Rate for Payer: Aetna Medicare	$27.40
Rate for Payer: BCBS MT CHIP	$27.40
Rate for Payer: BCBS MT Closed Plan Network	$28.92
Rate for Payer: BCBS MT HealthLink	$27.40
Rate for Payer: BCBS MT Medicare	$27.40
Rate for Payer: BCBS MT POS	$28.92
Rate for Payer: BCBS MT Traditional	$30.44
Rate for Payer: Cash Price	$27.40
Rate for Payer: Cigna Commercial	$28.92
Rate for Payer: Cigna Medicare	$27.40
Rate for Payer: Medicaid All Medicaid	$28.00
Rate for Payer: Medicare All Medicare	$21.31
Rate for Payer: Monida Allegiance	$28.92
Rate for Payer: Monida First Choice Health	$29.53
Rate for Payer: Monida Montana Health Co-op	$28.92
Rate for Payer: Monida PacificSource	$28.92

TOURNIQUET (LAB ONLY)

Facility

$30.44

Hospital Charge Code	90195381
Hospital Revenue Code	270
Min. Negotiated Rate	$21.31
Max. Negotiated Rate	$30.44
Rate for Payer: Aetna Commercial	$28.92
Rate for Payer: Aetna Medicare	$27.40
Rate for Payer: BCBS MT CHIP	$27.40
Rate for Payer: BCBS MT Closed Plan Network	$28.92
Rate for Payer: BCBS MT HealthLink	$27.40
Rate for Payer: BCBS MT Medicare	$27.40
Rate for Payer: BCBS MT POS	$28.92
Rate for Payer: BCBS MT Traditional	$30.44
Rate for Payer: Cash Price	$27.40
Rate for Payer: Cigna Commercial	$28.92
Rate for Payer: Cigna Medicare	$27.40
Rate for Payer: Medicaid All Medicaid	$28.00
Rate for Payer: Medicare All Medicare	$21.31
Rate for Payer: Monida Allegiance	$28.92
Rate for Payer: Monida First Choice Health	$29.53
Rate for Payer: Monida Montana Health Co-op	$28.92
Rate for Payer: Monida PacificSource	$28.92

T PALLIDUM SCREENING CASCADE (082345)

Facility

$69.00

Service Code	HCPCS 86780
Hospital Charge Code	4086780
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

T PALLIDUM SCREENING CASCADE (082345)

Facility

$69.00

Service Code	HCPCS 86780
Hospital Charge Code	4086780
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

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

Know your out-of-pocket cost for care.

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