Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TRIAMTER/ HCTZ CAP [37.5-25 MG] NF

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] NF

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

Facility

$139.00

Service Code	CPT 87661
Hospital Charge Code	8087661
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

TRICHOMONAS

Facility

$139.00

Service Code	CPT 87661
Hospital Charge Code	8087661
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

TRICHOMONAS VAG URINE NAAT 87661

Facility

$314.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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

TRIGGER POINT INJ 1-2 MUSCLES

Facility

$348.00

Service Code	CPT 20552
Hospital Charge Code	8020552
Hospital Revenue Code	521
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

TRIGGER POINT INJ 1-2 MUSCLES

Facility

$348.00

Service Code	CPT 20552
Hospital Charge Code	8020552
Hospital Revenue Code	521
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

TRIGLYCERIDES

Facility

$76.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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 # G0127

Facility

$98.00

Service Code	HCPCS G0127
Hospital Charge Code	8000127
Hospital Revenue Code	521
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

TRIMMING DYSTROPHIC NAILS-ANY # G0127

Facility

$98.00

Service Code	HCPCS G0127
Hospital Charge Code	8000127
Hospital Revenue Code	521
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

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

TRIMMING NONDYSTROPHIC NAILS ANY #

Facility

$80.00

Service Code	CPT 11719
Hospital Charge Code	8011719
Hospital Revenue Code	521
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

TRIMMING NONDYSTROPHIC NAILS ANY #

Facility

$80.00

Service Code	CPT 11719
Hospital Charge Code	8011719
Hospital Revenue Code	521
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

TR IMMUNIZATION ADMIN EA ADDTL VACCINE

Facility

$38.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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

Know your out-of-pocket cost for care.

All Charges