Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TIMOLOL MAL OPTH GTTS [0.5%] NF

Facility

$700.00

Service Code	HCPCS J3490
Hospital Charge Code	3000451
Hospital Revenue Code	250
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

TIOTROPIUM BROMIDE INH [18 MCG] 30-DAY

Facility

$397.00

Service Code	HCPCS J3490
Hospital Charge Code	3000452
Hospital Revenue Code	259
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$397.00
Rate for Payer: Aetna Commercial	$377.15
Rate for Payer: Aetna Medicare	$357.30
Rate for Payer: BCBS MT CHIP	$357.30
Rate for Payer: BCBS MT Closed Plan Network	$377.15
Rate for Payer: BCBS MT HealthLink	$357.30
Rate for Payer: BCBS MT Medicare	$357.30
Rate for Payer: BCBS MT POS	$377.15
Rate for Payer: BCBS MT Traditional	$397.00
Rate for Payer: Cash Price	$357.30
Rate for Payer: Cigna Commercial	$377.15
Rate for Payer: Cigna Medicare	$357.30
Rate for Payer: Medicaid All Medicaid	$365.24
Rate for Payer: Medicare All Medicare	$277.90
Rate for Payer: Monida Allegiance	$377.15
Rate for Payer: Monida First Choice Health	$385.09
Rate for Payer: Monida Montana Health Co-op	$377.15
Rate for Payer: Monida PacificSource	$377.15

TIOTROPIUM BROMIDE INH [18 MCG] 30-DAY

Facility

$397.00

Service Code	HCPCS J3490
Hospital Charge Code	3000452
Hospital Revenue Code	259
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$397.00
Rate for Payer: Aetna Commercial	$377.15
Rate for Payer: Aetna Medicare	$357.30
Rate for Payer: BCBS MT CHIP	$357.30
Rate for Payer: BCBS MT Closed Plan Network	$377.15
Rate for Payer: BCBS MT HealthLink	$357.30
Rate for Payer: BCBS MT Medicare	$357.30
Rate for Payer: BCBS MT POS	$377.15
Rate for Payer: BCBS MT Traditional	$397.00
Rate for Payer: Cash Price	$357.30
Rate for Payer: Cigna Commercial	$377.15
Rate for Payer: Cigna Medicare	$357.30
Rate for Payer: Medicaid All Medicaid	$365.24
Rate for Payer: Medicare All Medicare	$277.90
Rate for Payer: Monida Allegiance	$377.15
Rate for Payer: Monida First Choice Health	$385.09
Rate for Payer: Monida Montana Health Co-op	$377.15
Rate for Payer: Monida PacificSource	$377.15

TIRZEPATIDE INJ [15 MG/0.5 ML] NF

Facility

$616.00

Service Code	HCPCS J3590
Hospital Charge Code	3000584
Hospital Revenue Code	250
Min. Negotiated Rate	$431.20
Max. Negotiated Rate	$616.00
Rate for Payer: Aetna Commercial	$585.20
Rate for Payer: Aetna Medicare	$554.40
Rate for Payer: BCBS MT CHIP	$554.40
Rate for Payer: BCBS MT Closed Plan Network	$585.20
Rate for Payer: BCBS MT HealthLink	$554.40
Rate for Payer: BCBS MT Medicare	$554.40
Rate for Payer: BCBS MT POS	$585.20
Rate for Payer: BCBS MT Traditional	$616.00
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cigna Commercial	$585.20
Rate for Payer: Cigna Medicare	$554.40
Rate for Payer: Medicaid All Medicaid	$566.72
Rate for Payer: Medicare All Medicare	$431.20
Rate for Payer: Monida Allegiance	$585.20
Rate for Payer: Monida First Choice Health	$597.52
Rate for Payer: Monida Montana Health Co-op	$585.20
Rate for Payer: Monida PacificSource	$585.20

TIRZEPATIDE INJ [15 MG/0.5 ML] NF

Facility

$616.00

Service Code	HCPCS J3590
Hospital Charge Code	3000584
Hospital Revenue Code	250
Min. Negotiated Rate	$431.20
Max. Negotiated Rate	$616.00
Rate for Payer: Aetna Commercial	$585.20
Rate for Payer: Aetna Medicare	$554.40
Rate for Payer: BCBS MT CHIP	$554.40
Rate for Payer: BCBS MT Closed Plan Network	$585.20
Rate for Payer: BCBS MT HealthLink	$554.40
Rate for Payer: BCBS MT Medicare	$554.40
Rate for Payer: BCBS MT POS	$585.20
Rate for Payer: BCBS MT Traditional	$616.00
Rate for Payer: Cash Price	$554.40
Rate for Payer: Cigna Commercial	$585.20
Rate for Payer: Cigna Medicare	$554.40
Rate for Payer: Medicaid All Medicaid	$566.72
Rate for Payer: Medicare All Medicare	$431.20
Rate for Payer: Monida Allegiance	$585.20
Rate for Payer: Monida First Choice Health	$597.52
Rate for Payer: Monida Montana Health Co-op	$585.20
Rate for Payer: Monida PacificSource	$585.20

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

TIRZEPATIDE SQ INJ [7.5 MG/0.5 ML] PEN

Facility

$630.00

Service Code	HCPCS J3490
Hospital Charge Code	3007707
Hospital Revenue Code	250
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

TIRZEPATIDE SQ INJ [7.5 MG/0.5 ML] PEN

Facility

$630.00

Service Code	HCPCS J3490
Hospital Charge Code	3007707
Hospital Revenue Code	250
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

TIRZEPATIDE SUBQ [2.5 MG/0.5 ML] NF

Facility

$620.00

Service Code	HCPCS J3490
Hospital Charge Code	3007622
Hospital Revenue Code	250
Min. Negotiated Rate	$434.00
Max. Negotiated Rate	$620.00
Rate for Payer: Aetna Commercial	$589.00
Rate for Payer: Aetna Medicare	$558.00
Rate for Payer: BCBS MT CHIP	$558.00
Rate for Payer: BCBS MT Closed Plan Network	$589.00
Rate for Payer: BCBS MT HealthLink	$558.00
Rate for Payer: BCBS MT Medicare	$558.00
Rate for Payer: BCBS MT POS	$589.00
Rate for Payer: BCBS MT Traditional	$620.00
Rate for Payer: Cash Price	$558.00
Rate for Payer: Cigna Commercial	$589.00
Rate for Payer: Cigna Medicare	$558.00
Rate for Payer: Medicaid All Medicaid	$570.40
Rate for Payer: Medicare All Medicare	$434.00
Rate for Payer: Monida Allegiance	$589.00
Rate for Payer: Monida First Choice Health	$601.40
Rate for Payer: Monida Montana Health Co-op	$589.00
Rate for Payer: Monida PacificSource	$589.00

TIRZEPATIDE SUBQ [2.5 MG/0.5 ML] NF

Facility

$620.00

Service Code	HCPCS J3490
Hospital Charge Code	3007621
Hospital Revenue Code	250
Min. Negotiated Rate	$434.00
Max. Negotiated Rate	$620.00
Rate for Payer: Aetna Commercial	$589.00
Rate for Payer: Aetna Medicare	$558.00
Rate for Payer: BCBS MT CHIP	$558.00
Rate for Payer: BCBS MT Closed Plan Network	$589.00
Rate for Payer: BCBS MT HealthLink	$558.00
Rate for Payer: BCBS MT Medicare	$558.00
Rate for Payer: BCBS MT POS	$589.00
Rate for Payer: BCBS MT Traditional	$620.00
Rate for Payer: Cash Price	$558.00
Rate for Payer: Cigna Commercial	$589.00
Rate for Payer: Cigna Medicare	$558.00
Rate for Payer: Medicaid All Medicaid	$570.40
Rate for Payer: Medicare All Medicare	$434.00
Rate for Payer: Monida Allegiance	$589.00
Rate for Payer: Monida First Choice Health	$601.40
Rate for Payer: Monida Montana Health Co-op	$589.00
Rate for Payer: Monida PacificSource	$589.00

TIRZEPATIDE SUBQ [2.5 MG/0.5 ML] NF

Facility

$620.00

Service Code	HCPCS J3490
Hospital Charge Code	3007622
Hospital Revenue Code	250
Min. Negotiated Rate	$434.00
Max. Negotiated Rate	$620.00
Rate for Payer: Aetna Commercial	$589.00
Rate for Payer: Aetna Medicare	$558.00
Rate for Payer: BCBS MT CHIP	$558.00
Rate for Payer: BCBS MT Closed Plan Network	$589.00
Rate for Payer: BCBS MT HealthLink	$558.00
Rate for Payer: BCBS MT Medicare	$558.00
Rate for Payer: BCBS MT POS	$589.00
Rate for Payer: BCBS MT Traditional	$620.00
Rate for Payer: Cash Price	$558.00
Rate for Payer: Cigna Commercial	$589.00
Rate for Payer: Cigna Medicare	$558.00
Rate for Payer: Medicaid All Medicaid	$570.40
Rate for Payer: Medicare All Medicare	$434.00
Rate for Payer: Monida Allegiance	$589.00
Rate for Payer: Monida First Choice Health	$601.40
Rate for Payer: Monida Montana Health Co-op	$589.00
Rate for Payer: Monida PacificSource	$589.00

TIRZEPATIDE SUBQ [2.5 MG/0.5 ML] NF

Facility

$620.00

Service Code	HCPCS J3490
Hospital Charge Code	3007621
Hospital Revenue Code	250
Min. Negotiated Rate	$434.00
Max. Negotiated Rate	$620.00
Rate for Payer: Aetna Commercial	$589.00
Rate for Payer: Aetna Medicare	$558.00
Rate for Payer: BCBS MT CHIP	$558.00
Rate for Payer: BCBS MT Closed Plan Network	$589.00
Rate for Payer: BCBS MT HealthLink	$558.00
Rate for Payer: BCBS MT Medicare	$558.00
Rate for Payer: BCBS MT POS	$589.00
Rate for Payer: BCBS MT Traditional	$620.00
Rate for Payer: Cash Price	$558.00
Rate for Payer: Cigna Commercial	$589.00
Rate for Payer: Cigna Medicare	$558.00
Rate for Payer: Medicaid All Medicaid	$570.40
Rate for Payer: Medicare All Medicare	$434.00
Rate for Payer: Monida Allegiance	$589.00
Rate for Payer: Monida First Choice Health	$601.40
Rate for Payer: Monida Montana Health Co-op	$589.00
Rate for Payer: Monida PacificSource	$589.00

TISSUE TRANSGLUTAMINASE AB

Facility

$125.00

Service Code	CPT 86364
Hospital Charge Code	4087984
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

TISSUE TRANSGLUTAMINASE AB

Facility

$125.00

Service Code	CPT 86364
Hospital Charge Code	4087984
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

TIZANIDINE TAB [4 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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] NF

Facility

$8.00

Service Code	HCPCS J8499
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	CPT 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	CPT 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] NF

Facility

$8.00

Service Code	HCPCS J8499
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] NF

Facility

$8.00

Service Code	HCPCS J8499
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

Know your out-of-pocket cost for care.

All Charges