Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TREATMENT RN NURSE ONLY

Facility

$94.00

Service Code	CPT 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	CPT 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

TRELEGY ELLIPTA INH [200/62.5/25MCG] NF

Facility

$1,173.00

Service Code	HCPCS J8499
Hospital Charge Code	3007750
Hospital Revenue Code	250
Min. Negotiated Rate	$821.10
Max. Negotiated Rate	$1,173.00
Rate for Payer: Aetna Commercial	$1,114.35
Rate for Payer: Aetna Medicare	$1,055.70
Rate for Payer: BCBS MT CHIP	$1,055.70
Rate for Payer: BCBS MT Closed Plan Network	$1,114.35
Rate for Payer: BCBS MT HealthLink	$1,055.70
Rate for Payer: BCBS MT Medicare	$1,055.70
Rate for Payer: BCBS MT POS	$1,114.35
Rate for Payer: BCBS MT Traditional	$1,173.00
Rate for Payer: Cash Price	$1,055.70
Rate for Payer: Cigna Commercial	$1,114.35
Rate for Payer: Cigna Medicare	$1,055.70
Rate for Payer: Medicaid All Medicaid	$1,079.16
Rate for Payer: Medicare All Medicare	$821.10
Rate for Payer: Monida Allegiance	$1,114.35
Rate for Payer: Monida First Choice Health	$1,137.81
Rate for Payer: Monida Montana Health Co-op	$1,114.35
Rate for Payer: Monida PacificSource	$1,114.35

TRELEGY ELLIPTA INH [200/62.5/25MCG] NF

Facility

$1,173.00

Service Code	HCPCS J8499
Hospital Charge Code	3007750
Hospital Revenue Code	250
Min. Negotiated Rate	$821.10
Max. Negotiated Rate	$1,173.00
Rate for Payer: Aetna Commercial	$1,114.35
Rate for Payer: Aetna Medicare	$1,055.70
Rate for Payer: BCBS MT CHIP	$1,055.70
Rate for Payer: BCBS MT Closed Plan Network	$1,114.35
Rate for Payer: BCBS MT HealthLink	$1,055.70
Rate for Payer: BCBS MT Medicare	$1,055.70
Rate for Payer: BCBS MT POS	$1,114.35
Rate for Payer: BCBS MT Traditional	$1,173.00
Rate for Payer: Cash Price	$1,055.70
Rate for Payer: Cigna Commercial	$1,114.35
Rate for Payer: Cigna Medicare	$1,055.70
Rate for Payer: Medicaid All Medicaid	$1,079.16
Rate for Payer: Medicare All Medicare	$821.10
Rate for Payer: Monida Allegiance	$1,114.35
Rate for Payer: Monida First Choice Health	$1,137.81
Rate for Payer: Monida Montana Health Co-op	$1,114.35
Rate for Payer: Monida PacificSource	$1,114.35

TR EXCISION MALIGNANT LESION INC MARGINS

Facility

$562.00

Service Code	CPT 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	CPT 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 GI SERVICES GENERAL

Facility

$2,499.00

Service Code	CPT 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	CPT 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 J3299
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 J3299
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 OINT {0.1 %} 454G NF

Facility

$133.00

Service Code	HCPCS J8499
Hospital Charge Code	3007745
Hospital Revenue Code	250
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

TRIAMCINOLONE OINT {0.1 %} 454G NF

Facility

$133.00

Service Code	HCPCS J8499
Hospital Charge Code	3007745
Hospital Revenue Code	250
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

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

Know your out-of-pocket cost for care.

All Charges