Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$3,936.00

Service Code	HCPCS G0390
Hospital Charge Code	1010110
Hospital Revenue Code	681
Min. Negotiated Rate	$2,755.20
Max. Negotiated Rate	$3,936.00
Rate for Payer: Aetna Commercial	$3,739.20
Rate for Payer: Aetna Medicare	$3,542.40
Rate for Payer: BCBS MT CHIP	$3,542.40
Rate for Payer: BCBS MT Closed Plan Network	$3,739.20
Rate for Payer: BCBS MT HealthLink	$3,542.40
Rate for Payer: BCBS MT Medicare	$3,542.40
Rate for Payer: BCBS MT POS	$3,739.20
Rate for Payer: BCBS MT Traditional	$3,936.00
Rate for Payer: Cash Price	$3,542.40
Rate for Payer: Cigna Commercial	$3,739.20
Rate for Payer: Cigna Medicare	$3,542.40
Rate for Payer: Medicaid All Medicaid	$3,621.12
Rate for Payer: Medicare All Medicare	$2,755.20
Rate for Payer: Monida Allegiance	$3,739.20
Rate for Payer: Monida First Choice Health	$3,817.92
Rate for Payer: Monida Montana Health Co-op	$3,739.20
Rate for Payer: Monida PacificSource	$3,739.20

TRAUMA ACTIVATION

Facility

$3,936.00

Service Code	HCPCS G0390
Hospital Charge Code	1010110
Hospital Revenue Code	681
Min. Negotiated Rate	$2,755.20
Max. Negotiated Rate	$3,936.00
Rate for Payer: Aetna Commercial	$3,739.20
Rate for Payer: Aetna Medicare	$3,542.40
Rate for Payer: BCBS MT CHIP	$3,542.40
Rate for Payer: BCBS MT Closed Plan Network	$3,739.20
Rate for Payer: BCBS MT HealthLink	$3,542.40
Rate for Payer: BCBS MT Medicare	$3,542.40
Rate for Payer: BCBS MT POS	$3,739.20
Rate for Payer: BCBS MT Traditional	$3,936.00
Rate for Payer: Cash Price	$3,542.40
Rate for Payer: Cigna Commercial	$3,739.20
Rate for Payer: Cigna Medicare	$3,542.40
Rate for Payer: Medicaid All Medicaid	$3,621.12
Rate for Payer: Medicare All Medicare	$2,755.20
Rate for Payer: Monida Allegiance	$3,739.20
Rate for Payer: Monida First Choice Health	$3,817.92
Rate for Payer: Monida Montana Health Co-op	$3,739.20
Rate for Payer: Monida PacificSource	$3,739.20

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	$367.95
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	$367.95
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	$367.95
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	$367.95
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

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 COVID-19 VAC ADMIN SINGLE DOSE- 90480

Facility

$69.00

Service Code	HCPCS 90480
Hospital Charge Code	590480
Hospital Revenue Code	771
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

TR COVID-19 VAC ADMIN SINGLE DOSE- 90480

Facility

$69.00

Service Code	HCPCS 90480
Hospital Charge Code	590480
Hospital Revenue Code	771
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

TR DRAINAGE OF FINGER ABCESS

Facility

$282.00

Service Code	HCPCS 26010
Hospital Charge Code	1026010
Hospital Revenue Code	761
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

TR DRAINAGE OF FINGER ABCESS

Facility

$282.00

Service Code	HCPCS 26010
Hospital Charge Code	1026010
Hospital Revenue Code	761
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

TR DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$525.00

Service Code	HCPCS 16030
Hospital Charge Code	1046030
Hospital Revenue Code	761
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

TR DRESS/DEBRIDE BURN >10%TOTAL LARGE

Facility

$525.00

Service Code	HCPCS 16030
Hospital Charge Code	1046030
Hospital Revenue Code	761
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

TREAT FRACTURE RADIUS & ULNA W/MANI

Facility

$773.00

Service Code	HCPCS 25565
Hospital Charge Code	1025565
Hospital Revenue Code	450
Min. Negotiated Rate	$541.10
Max. Negotiated Rate	$773.00
Rate for Payer: Aetna Commercial	$734.35
Rate for Payer: Aetna Medicare	$695.70
Rate for Payer: BCBS MT CHIP	$695.70
Rate for Payer: BCBS MT Closed Plan Network	$734.35
Rate for Payer: BCBS MT HealthLink	$695.70
Rate for Payer: BCBS MT Medicare	$695.70
Rate for Payer: BCBS MT POS	$734.35
Rate for Payer: BCBS MT Traditional	$773.00
Rate for Payer: Cash Price	$695.70
Rate for Payer: Cigna Commercial	$734.35
Rate for Payer: Cigna Medicare	$695.70
Rate for Payer: Medicaid All Medicaid	$711.16
Rate for Payer: Medicare All Medicare	$541.10
Rate for Payer: Monida Allegiance	$734.35
Rate for Payer: Monida First Choice Health	$749.81
Rate for Payer: Monida Montana Health Co-op	$734.35
Rate for Payer: Monida PacificSource	$734.35

TREAT FRACTURE RADIUS & ULNA W/MANI

Facility

$773.00

Service Code	HCPCS 25565
Hospital Charge Code	1025565
Hospital Revenue Code	450
Min. Negotiated Rate	$541.10
Max. Negotiated Rate	$773.00
Rate for Payer: Aetna Commercial	$734.35
Rate for Payer: Aetna Medicare	$695.70
Rate for Payer: BCBS MT CHIP	$695.70
Rate for Payer: BCBS MT Closed Plan Network	$734.35
Rate for Payer: BCBS MT HealthLink	$695.70
Rate for Payer: BCBS MT Medicare	$695.70
Rate for Payer: BCBS MT POS	$734.35
Rate for Payer: BCBS MT Traditional	$773.00
Rate for Payer: Cash Price	$695.70
Rate for Payer: Cigna Commercial	$734.35
Rate for Payer: Cigna Medicare	$695.70
Rate for Payer: Medicaid All Medicaid	$711.16
Rate for Payer: Medicare All Medicare	$541.10
Rate for Payer: Monida Allegiance	$734.35
Rate for Payer: Monida First Choice Health	$749.81
Rate for Payer: Monida Montana Health Co-op	$734.35
Rate for Payer: Monida PacificSource	$734.35

TREATMENT RM

Facility

$1,649.00

Service Code	HCPCS 36556
Hospital Charge Code	1036556
Hospital Revenue Code	761
Min. Negotiated Rate	$1,154.30
Max. Negotiated Rate	$1,649.00
Rate for Payer: Aetna Commercial	$1,566.55
Rate for Payer: Aetna Medicare	$1,484.10
Rate for Payer: BCBS MT CHIP	$1,484.10
Rate for Payer: BCBS MT Closed Plan Network	$1,566.55
Rate for Payer: BCBS MT HealthLink	$1,484.10
Rate for Payer: BCBS MT Medicare	$1,484.10
Rate for Payer: BCBS MT POS	$1,566.55
Rate for Payer: BCBS MT Traditional	$1,649.00
Rate for Payer: Cash Price	$1,484.10
Rate for Payer: Cigna Commercial	$1,566.55
Rate for Payer: Cigna Medicare	$1,484.10
Rate for Payer: Medicaid All Medicaid	$1,517.08
Rate for Payer: Medicare All Medicare	$1,154.30
Rate for Payer: Monida Allegiance	$1,566.55
Rate for Payer: Monida First Choice Health	$1,599.53
Rate for Payer: Monida Montana Health Co-op	$1,566.55
Rate for Payer: Monida PacificSource	$1,566.55

TREATMENT RM

Facility

$1,649.00

Service Code	HCPCS 36556
Hospital Charge Code	1036556
Hospital Revenue Code	761
Min. Negotiated Rate	$1,154.30
Max. Negotiated Rate	$1,649.00
Rate for Payer: Aetna Commercial	$1,566.55
Rate for Payer: Aetna Medicare	$1,484.10
Rate for Payer: BCBS MT CHIP	$1,484.10
Rate for Payer: BCBS MT Closed Plan Network	$1,566.55
Rate for Payer: BCBS MT HealthLink	$1,484.10
Rate for Payer: BCBS MT Medicare	$1,484.10
Rate for Payer: BCBS MT POS	$1,566.55
Rate for Payer: BCBS MT Traditional	$1,649.00
Rate for Payer: Cash Price	$1,484.10
Rate for Payer: Cigna Commercial	$1,566.55
Rate for Payer: Cigna Medicare	$1,484.10
Rate for Payer: Medicaid All Medicaid	$1,517.08
Rate for Payer: Medicare All Medicare	$1,154.30
Rate for Payer: Monida Allegiance	$1,566.55
Rate for Payer: Monida First Choice Health	$1,599.53
Rate for Payer: Monida Montana Health Co-op	$1,566.55
Rate for Payer: Monida PacificSource	$1,566.55

TREATMENT RM CHG TUBE GASTROSTOMY

Facility

$585.00

Service Code	HCPCS 43760
Hospital Charge Code	1043760
Hospital Revenue Code	761
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$585.00
Rate for Payer: Aetna Commercial	$555.75
Rate for Payer: Aetna Medicare	$526.50
Rate for Payer: BCBS MT CHIP	$526.50
Rate for Payer: BCBS MT Closed Plan Network	$555.75
Rate for Payer: BCBS MT HealthLink	$526.50
Rate for Payer: BCBS MT Medicare	$526.50
Rate for Payer: BCBS MT POS	$555.75
Rate for Payer: BCBS MT Traditional	$585.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cigna Commercial	$555.75
Rate for Payer: Cigna Medicare	$526.50
Rate for Payer: Medicaid All Medicaid	$538.20
Rate for Payer: Medicare All Medicare	$409.50
Rate for Payer: Monida Allegiance	$555.75
Rate for Payer: Monida First Choice Health	$567.45
Rate for Payer: Monida Montana Health Co-op	$555.75
Rate for Payer: Monida PacificSource	$555.75

TREATMENT RM CHG TUBE GASTROSTOMY

Facility

$585.00

Service Code	HCPCS 43760
Hospital Charge Code	1043760
Hospital Revenue Code	761
Min. Negotiated Rate	$409.50
Max. Negotiated Rate	$585.00
Rate for Payer: Aetna Commercial	$555.75
Rate for Payer: Aetna Medicare	$526.50
Rate for Payer: BCBS MT CHIP	$526.50
Rate for Payer: BCBS MT Closed Plan Network	$555.75
Rate for Payer: BCBS MT HealthLink	$526.50
Rate for Payer: BCBS MT Medicare	$526.50
Rate for Payer: BCBS MT POS	$555.75
Rate for Payer: BCBS MT Traditional	$585.00
Rate for Payer: Cash Price	$526.50
Rate for Payer: Cigna Commercial	$555.75
Rate for Payer: Cigna Medicare	$526.50
Rate for Payer: Medicaid All Medicaid	$538.20
Rate for Payer: Medicare All Medicare	$409.50
Rate for Payer: Monida Allegiance	$555.75
Rate for Payer: Monida First Choice Health	$567.45
Rate for Payer: Monida Montana Health Co-op	$555.75
Rate for Payer: Monida PacificSource	$555.75

TREATMENT RN NURSE ONLY

Facility

$94.00

Service Code	HCPCS 99211
Hospital Charge Code	530204
Hospital Revenue Code	761
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

TREATMENT RN NURSE ONLY

Facility

$94.00

Service Code	HCPCS 99211
Hospital Charge Code	530204
Hospital Revenue Code	761
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

TR EXCISION MALIGNANT LESION INC MARGINS

Facility

$562.00

Service Code	HCPCS 11602
Hospital Charge Code	1011602
Hospital Revenue Code	761
Min. Negotiated Rate	$393.40
Max. Negotiated Rate	$562.00
Rate for Payer: Aetna Commercial	$533.90
Rate for Payer: Aetna Medicare	$505.80
Rate for Payer: BCBS MT CHIP	$505.80
Rate for Payer: BCBS MT Closed Plan Network	$533.90
Rate for Payer: BCBS MT HealthLink	$505.80
Rate for Payer: BCBS MT Medicare	$505.80
Rate for Payer: BCBS MT POS	$533.90
Rate for Payer: BCBS MT Traditional	$562.00
Rate for Payer: Cash Price	$505.80
Rate for Payer: Cigna Commercial	$533.90
Rate for Payer: Cigna Medicare	$505.80
Rate for Payer: Medicaid All Medicaid	$517.04
Rate for Payer: Medicare All Medicare	$393.40
Rate for Payer: Monida Allegiance	$533.90
Rate for Payer: Monida First Choice Health	$545.14
Rate for Payer: Monida Montana Health Co-op	$533.90
Rate for Payer: Monida PacificSource	$533.90

TR EXCISION MALIGNANT LESION INC MARGINS

Facility

$562.00

Service Code	HCPCS 11602
Hospital Charge Code	1011602
Hospital Revenue Code	761
Min. Negotiated Rate	$393.40
Max. Negotiated Rate	$562.00
Rate for Payer: Aetna Commercial	$533.90
Rate for Payer: Aetna Medicare	$505.80
Rate for Payer: BCBS MT CHIP	$505.80
Rate for Payer: BCBS MT Closed Plan Network	$533.90
Rate for Payer: BCBS MT HealthLink	$505.80
Rate for Payer: BCBS MT Medicare	$505.80
Rate for Payer: BCBS MT POS	$533.90
Rate for Payer: BCBS MT Traditional	$562.00
Rate for Payer: Cash Price	$505.80
Rate for Payer: Cigna Commercial	$533.90
Rate for Payer: Cigna Medicare	$505.80
Rate for Payer: Medicaid All Medicaid	$517.04
Rate for Payer: Medicare All Medicare	$393.40
Rate for Payer: Monida Allegiance	$533.90
Rate for Payer: Monida First Choice Health	$545.14
Rate for Payer: Monida Montana Health Co-op	$533.90
Rate for Payer: Monida PacificSource	$533.90

Know your out-of-pocket cost for care.

All Charges