Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TR GI SERVICES GENERAL

Facility

$2,499.00

Service Code	HCPCS 43246
Hospital Charge Code	1043246
Hospital Revenue Code	761
Min. Negotiated Rate	$1,749.30
Max. Negotiated Rate	$2,499.00
Rate for Payer: Aetna Commercial	$2,374.05
Rate for Payer: Aetna Medicare	$2,249.10
Rate for Payer: BCBS MT CHIP	$2,249.10
Rate for Payer: BCBS MT Closed Plan Network	$2,374.05
Rate for Payer: BCBS MT HealthLink	$2,249.10
Rate for Payer: BCBS MT Medicare	$2,249.10
Rate for Payer: BCBS MT POS	$2,374.05
Rate for Payer: BCBS MT Traditional	$2,499.00
Rate for Payer: Cash Price	$2,249.10
Rate for Payer: Cigna Commercial	$2,374.05
Rate for Payer: Cigna Medicare	$2,249.10
Rate for Payer: Medicaid All Medicaid	$2,299.08
Rate for Payer: Medicare All Medicare	$1,749.30
Rate for Payer: Monida Allegiance	$2,374.05
Rate for Payer: Monida First Choice Health	$2,424.03
Rate for Payer: Monida Montana Health Co-op	$2,374.05
Rate for Payer: Monida PacificSource	$2,374.05

TR GI SERVICES GENERAL

Facility

$2,499.00

Service Code	HCPCS 43246
Hospital Charge Code	1043246
Hospital Revenue Code	761
Min. Negotiated Rate	$1,749.30
Max. Negotiated Rate	$2,499.00
Rate for Payer: Aetna Commercial	$2,374.05
Rate for Payer: Aetna Medicare	$2,249.10
Rate for Payer: BCBS MT CHIP	$2,249.10
Rate for Payer: BCBS MT Closed Plan Network	$2,374.05
Rate for Payer: BCBS MT HealthLink	$2,249.10
Rate for Payer: BCBS MT Medicare	$2,249.10
Rate for Payer: BCBS MT POS	$2,374.05
Rate for Payer: BCBS MT Traditional	$2,499.00
Rate for Payer: Cash Price	$2,249.10
Rate for Payer: Cigna Commercial	$2,374.05
Rate for Payer: Cigna Medicare	$2,249.10
Rate for Payer: Medicaid All Medicaid	$2,299.08
Rate for Payer: Medicare All Medicare	$1,749.30
Rate for Payer: Monida Allegiance	$2,374.05
Rate for Payer: Monida First Choice Health	$2,424.03
Rate for Payer: Monida Montana Health Co-op	$2,374.05
Rate for Payer: Monida PacificSource	$2,374.05

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

TRICHOMONAS VAG URINE NAAT 87661

Facility

$314.00

Service Code	HCPCS 87661
Hospital Charge Code	4087924
Hospital Revenue Code	300
Min. Negotiated Rate	$219.80
Max. Negotiated Rate	$314.00
Rate for Payer: Aetna Commercial	$298.30
Rate for Payer: Aetna Medicare	$282.60
Rate for Payer: BCBS MT CHIP	$282.60
Rate for Payer: BCBS MT Closed Plan Network	$298.30
Rate for Payer: BCBS MT HealthLink	$282.60
Rate for Payer: BCBS MT Medicare	$282.60
Rate for Payer: BCBS MT POS	$298.30
Rate for Payer: BCBS MT Traditional	$314.00
Rate for Payer: Cash Price	$282.60
Rate for Payer: Cigna Commercial	$298.30
Rate for Payer: Cigna Medicare	$282.60
Rate for Payer: Medicaid All Medicaid	$288.88
Rate for Payer: Medicare All Medicare	$219.80
Rate for Payer: Monida Allegiance	$298.30
Rate for Payer: Monida First Choice Health	$304.58
Rate for Payer: Monida Montana Health Co-op	$298.30
Rate for Payer: Monida PacificSource	$298.30

TRICHOMONAS VAG URINE NAAT 87661

Facility

$314.00

Service Code	HCPCS 87661
Hospital Charge Code	4087924
Hospital Revenue Code	300
Min. Negotiated Rate	$219.80
Max. Negotiated Rate	$314.00
Rate for Payer: Aetna Commercial	$298.30
Rate for Payer: Aetna Medicare	$282.60
Rate for Payer: BCBS MT CHIP	$282.60
Rate for Payer: BCBS MT Closed Plan Network	$298.30
Rate for Payer: BCBS MT HealthLink	$282.60
Rate for Payer: BCBS MT Medicare	$282.60
Rate for Payer: BCBS MT POS	$298.30
Rate for Payer: BCBS MT Traditional	$314.00
Rate for Payer: Cash Price	$282.60
Rate for Payer: Cigna Commercial	$298.30
Rate for Payer: Cigna Medicare	$282.60
Rate for Payer: Medicaid All Medicaid	$288.88
Rate for Payer: Medicare All Medicare	$219.80
Rate for Payer: Monida Allegiance	$298.30
Rate for Payer: Monida First Choice Health	$304.58
Rate for Payer: Monida Montana Health Co-op	$298.30
Rate for Payer: Monida PacificSource	$298.30

TR I & D PILONIDAL CYST SIMPLE

Facility

$375.00

Service Code	HCPCS 10080
Hospital Charge Code	1010080
Hospital Revenue Code	761
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

TR I & D PILONIDAL CYST SIMPLE

Facility

$375.00

Service Code	HCPCS 10080
Hospital Charge Code	1010080
Hospital Revenue Code	761
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

TRIGLYCERIDES

Facility

$76.00

Service Code	HCPCS 84478
Hospital Charge Code	4084478
Hospital Revenue Code	301
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

TRIGLYCERIDES

Facility

$76.00

Service Code	HCPCS 84478
Hospital Charge Code	4084478
Hospital Revenue Code	301
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

TRIMETHYLAMIN N-OXIDE

Facility

$150.00

Service Code	HCPCS 82542
Hospital Charge Code	4087937
Hospital Revenue Code	300
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

TRIMETHYLAMIN N-OXIDE

Facility

$150.00

Service Code	HCPCS 82542
Hospital Charge Code	4087937
Hospital Revenue Code	300
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

TRIMMING DYSTROPHIC NAILS-ANY # TR G0127

Facility

$343.00

Service Code	HCPCS G0127
Hospital Charge Code	590127
Hospital Revenue Code	761
Min. Negotiated Rate	$240.10
Max. Negotiated Rate	$343.00
Rate for Payer: Aetna Commercial	$325.85
Rate for Payer: Aetna Medicare	$308.70
Rate for Payer: BCBS MT CHIP	$308.70
Rate for Payer: BCBS MT Closed Plan Network	$325.85
Rate for Payer: BCBS MT HealthLink	$308.70
Rate for Payer: BCBS MT Medicare	$308.70
Rate for Payer: BCBS MT POS	$325.85
Rate for Payer: BCBS MT Traditional	$343.00
Rate for Payer: Cash Price	$308.70
Rate for Payer: Cigna Commercial	$325.85
Rate for Payer: Cigna Medicare	$308.70
Rate for Payer: Medicaid All Medicaid	$315.56
Rate for Payer: Medicare All Medicare	$240.10
Rate for Payer: Monida Allegiance	$325.85
Rate for Payer: Monida First Choice Health	$332.71
Rate for Payer: Monida Montana Health Co-op	$325.85
Rate for Payer: Monida PacificSource	$325.85

TRIMMING DYSTROPHIC NAILS-ANY # TR G0127

Facility

$343.00

Service Code	HCPCS G0127
Hospital Charge Code	590127
Hospital Revenue Code	761
Min. Negotiated Rate	$240.10
Max. Negotiated Rate	$343.00
Rate for Payer: Aetna Commercial	$325.85
Rate for Payer: Aetna Medicare	$308.70
Rate for Payer: BCBS MT CHIP	$308.70
Rate for Payer: BCBS MT Closed Plan Network	$325.85
Rate for Payer: BCBS MT HealthLink	$308.70
Rate for Payer: BCBS MT Medicare	$308.70
Rate for Payer: BCBS MT POS	$325.85
Rate for Payer: BCBS MT Traditional	$343.00
Rate for Payer: Cash Price	$308.70
Rate for Payer: Cigna Commercial	$325.85
Rate for Payer: Cigna Medicare	$308.70
Rate for Payer: Medicaid All Medicaid	$315.56
Rate for Payer: Medicare All Medicare	$240.10
Rate for Payer: Monida Allegiance	$325.85
Rate for Payer: Monida First Choice Health	$332.71
Rate for Payer: Monida Montana Health Co-op	$325.85
Rate for Payer: Monida PacificSource	$325.85

TR IMMUNIZATION ADMIN EA ADDTL VACCINE

Facility

$38.00

Service Code	HCPCS 90472
Hospital Charge Code	590472
Hospital Revenue Code	771
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

TR IMMUNIZATION ADMIN EA ADDTL VACCINE

Facility

$38.00

Service Code	HCPCS 90472
Hospital Charge Code	590472
Hospital Revenue Code	771
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

TR IMMUNIZATION ADMIN - SINGLE VACCINE

Facility

$73.00

Service Code	HCPCS 90471
Hospital Charge Code	590471
Hospital Revenue Code	771
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

TR IMMUNIZATION ADMIN - SINGLE VACCINE

Facility

$73.00

Service Code	HCPCS 90471
Hospital Charge Code	590471
Hospital Revenue Code	771
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

TR INCISION AND DRAINAGE

Facility

$506.00

Service Code	HCPCS 27603
Hospital Charge Code	1027603
Hospital Revenue Code	761
Min. Negotiated Rate	$354.20
Max. Negotiated Rate	$506.00
Rate for Payer: Aetna Commercial	$480.70
Rate for Payer: Aetna Medicare	$455.40
Rate for Payer: BCBS MT CHIP	$455.40
Rate for Payer: BCBS MT Closed Plan Network	$480.70
Rate for Payer: BCBS MT HealthLink	$455.40
Rate for Payer: BCBS MT Medicare	$455.40
Rate for Payer: BCBS MT POS	$480.70
Rate for Payer: BCBS MT Traditional	$506.00
Rate for Payer: Cash Price	$455.40
Rate for Payer: Cigna Commercial	$480.70
Rate for Payer: Cigna Medicare	$455.40
Rate for Payer: Medicaid All Medicaid	$465.52
Rate for Payer: Medicare All Medicare	$354.20
Rate for Payer: Monida Allegiance	$480.70
Rate for Payer: Monida First Choice Health	$490.82
Rate for Payer: Monida Montana Health Co-op	$480.70
Rate for Payer: Monida PacificSource	$480.70

TR INCISION AND DRAINAGE

Facility

$506.00

Service Code	HCPCS 27603
Hospital Charge Code	1027603
Hospital Revenue Code	761
Min. Negotiated Rate	$354.20
Max. Negotiated Rate	$506.00
Rate for Payer: Aetna Commercial	$480.70
Rate for Payer: Aetna Medicare	$455.40
Rate for Payer: BCBS MT CHIP	$455.40
Rate for Payer: BCBS MT Closed Plan Network	$480.70
Rate for Payer: BCBS MT HealthLink	$455.40
Rate for Payer: BCBS MT Medicare	$455.40
Rate for Payer: BCBS MT POS	$480.70
Rate for Payer: BCBS MT Traditional	$506.00
Rate for Payer: Cash Price	$455.40
Rate for Payer: Cigna Commercial	$480.70
Rate for Payer: Cigna Medicare	$455.40
Rate for Payer: Medicaid All Medicaid	$465.52
Rate for Payer: Medicare All Medicare	$354.20
Rate for Payer: Monida Allegiance	$480.70
Rate for Payer: Monida First Choice Health	$490.82
Rate for Payer: Monida Montana Health Co-op	$480.70
Rate for Payer: Monida PacificSource	$480.70

TR INCISION AND DRAINAGE ABCESS SIMPLE

Facility

$441.00

Service Code	HCPCS 10060
Hospital Charge Code	1010060
Hospital Revenue Code	761
Min. Negotiated Rate	$308.70
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna Commercial	$418.95
Rate for Payer: Aetna Medicare	$396.90
Rate for Payer: BCBS MT CHIP	$396.90
Rate for Payer: BCBS MT Closed Plan Network	$418.95
Rate for Payer: BCBS MT HealthLink	$396.90
Rate for Payer: BCBS MT Medicare	$396.90
Rate for Payer: BCBS MT POS	$418.95
Rate for Payer: BCBS MT Traditional	$441.00
Rate for Payer: Cash Price	$396.90
Rate for Payer: Cigna Commercial	$418.95
Rate for Payer: Cigna Medicare	$396.90
Rate for Payer: Medicaid All Medicaid	$405.72
Rate for Payer: Medicare All Medicare	$308.70
Rate for Payer: Monida Allegiance	$418.95
Rate for Payer: Monida First Choice Health	$427.77
Rate for Payer: Monida Montana Health Co-op	$418.95
Rate for Payer: Monida PacificSource	$418.95

Know your out-of-pocket cost for care.

All Charges