Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XX PREDNISOLONE LIQ [5 MG/5 ML] UD CUP

Facility

$14.00

Service Code	HCPCS J7510
Hospital Charge Code	3000398
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

XX SEMAGLUTIDE INJ. 2.68MG/ML

Facility

$1,572.10

Hospital Charge Code	3007411
Hospital Revenue Code	250
Min. Negotiated Rate	$1,100.47
Max. Negotiated Rate	$1,572.10
Rate for Payer: Aetna Commercial	$1,493.49
Rate for Payer: Aetna Medicare	$1,414.89
Rate for Payer: BCBS MT CHIP	$1,414.89
Rate for Payer: BCBS MT Closed Plan Network	$1,493.49
Rate for Payer: BCBS MT HealthLink	$1,414.89
Rate for Payer: BCBS MT Medicare	$1,414.89
Rate for Payer: BCBS MT POS	$1,493.49
Rate for Payer: BCBS MT Traditional	$1,572.10
Rate for Payer: Cash Price	$1,414.89
Rate for Payer: Cigna Commercial	$1,493.49
Rate for Payer: Cigna Medicare	$1,414.89
Rate for Payer: Medicaid All Medicaid	$1,446.33
Rate for Payer: Medicare All Medicare	$1,100.47
Rate for Payer: Monida Allegiance	$1,493.49
Rate for Payer: Monida First Choice Health	$1,524.94
Rate for Payer: Monida Montana Health Co-op	$1,493.49
Rate for Payer: Monida PacificSource	$1,493.49

XX SEMAGLUTIDE INJ. 2.68MG/ML

Facility

$1,572.10

Hospital Charge Code	3007411
Hospital Revenue Code	250
Min. Negotiated Rate	$1,100.47
Max. Negotiated Rate	$1,572.10
Rate for Payer: Aetna Commercial	$1,493.49
Rate for Payer: Aetna Medicare	$1,414.89
Rate for Payer: BCBS MT CHIP	$1,414.89
Rate for Payer: BCBS MT Closed Plan Network	$1,493.49
Rate for Payer: BCBS MT HealthLink	$1,414.89
Rate for Payer: BCBS MT Medicare	$1,414.89
Rate for Payer: BCBS MT POS	$1,493.49
Rate for Payer: BCBS MT Traditional	$1,572.10
Rate for Payer: Cash Price	$1,414.89
Rate for Payer: Cigna Commercial	$1,493.49
Rate for Payer: Cigna Medicare	$1,414.89
Rate for Payer: Medicaid All Medicaid	$1,446.33
Rate for Payer: Medicare All Medicare	$1,100.47
Rate for Payer: Monida Allegiance	$1,493.49
Rate for Payer: Monida First Choice Health	$1,524.94
Rate for Payer: Monida Montana Health Co-op	$1,493.49
Rate for Payer: Monida PacificSource	$1,493.49

XX SEMAGLUTIDE SUBQ [0.68MG/ML]

Facility

$1,628.00

Hospital Charge Code	3007393
Hospital Revenue Code	250
Min. Negotiated Rate	$1,139.60
Max. Negotiated Rate	$1,628.00
Rate for Payer: Aetna Commercial	$1,546.60
Rate for Payer: Aetna Medicare	$1,465.20
Rate for Payer: BCBS MT CHIP	$1,465.20
Rate for Payer: BCBS MT Closed Plan Network	$1,546.60
Rate for Payer: BCBS MT HealthLink	$1,465.20
Rate for Payer: BCBS MT Medicare	$1,465.20
Rate for Payer: BCBS MT POS	$1,546.60
Rate for Payer: BCBS MT Traditional	$1,628.00
Rate for Payer: Cash Price	$1,465.20
Rate for Payer: Cigna Commercial	$1,546.60
Rate for Payer: Cigna Medicare	$1,465.20
Rate for Payer: Medicaid All Medicaid	$1,497.76
Rate for Payer: Medicare All Medicare	$1,139.60
Rate for Payer: Monida Allegiance	$1,546.60
Rate for Payer: Monida First Choice Health	$1,579.16
Rate for Payer: Monida Montana Health Co-op	$1,546.60
Rate for Payer: Monida PacificSource	$1,546.60

XX SEMAGLUTIDE SUBQ [0.68MG/ML]

Facility

$1,628.00

Hospital Charge Code	3007393
Hospital Revenue Code	250
Min. Negotiated Rate	$1,139.60
Max. Negotiated Rate	$1,628.00
Rate for Payer: Aetna Commercial	$1,546.60
Rate for Payer: Aetna Medicare	$1,465.20
Rate for Payer: BCBS MT CHIP	$1,465.20
Rate for Payer: BCBS MT Closed Plan Network	$1,546.60
Rate for Payer: BCBS MT HealthLink	$1,465.20
Rate for Payer: BCBS MT Medicare	$1,465.20
Rate for Payer: BCBS MT POS	$1,546.60
Rate for Payer: BCBS MT Traditional	$1,628.00
Rate for Payer: Cash Price	$1,465.20
Rate for Payer: Cigna Commercial	$1,546.60
Rate for Payer: Cigna Medicare	$1,465.20
Rate for Payer: Medicaid All Medicaid	$1,497.76
Rate for Payer: Medicare All Medicare	$1,139.60
Rate for Payer: Monida Allegiance	$1,546.60
Rate for Payer: Monida First Choice Health	$1,579.16
Rate for Payer: Monida Montana Health Co-op	$1,546.60
Rate for Payer: Monida PacificSource	$1,546.60

XX TRESIBA 100U/1ML INJ 10ML

Facility

$726.00

Hospital Charge Code	3007217
Hospital Revenue Code	250
Min. Negotiated Rate	$508.20
Max. Negotiated Rate	$726.00
Rate for Payer: Aetna Commercial	$689.70
Rate for Payer: Aetna Medicare	$653.40
Rate for Payer: BCBS MT CHIP	$653.40
Rate for Payer: BCBS MT Closed Plan Network	$689.70
Rate for Payer: BCBS MT HealthLink	$653.40
Rate for Payer: BCBS MT Medicare	$653.40
Rate for Payer: BCBS MT POS	$689.70
Rate for Payer: BCBS MT Traditional	$726.00
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cigna Commercial	$689.70
Rate for Payer: Cigna Medicare	$653.40
Rate for Payer: Medicaid All Medicaid	$667.92
Rate for Payer: Medicare All Medicare	$508.20
Rate for Payer: Monida Allegiance	$689.70
Rate for Payer: Monida First Choice Health	$704.22
Rate for Payer: Monida Montana Health Co-op	$689.70
Rate for Payer: Monida PacificSource	$689.70

XX TRESIBA 100U/1ML INJ 10ML

Facility

$726.00

Hospital Charge Code	3007217
Hospital Revenue Code	250
Min. Negotiated Rate	$508.20
Max. Negotiated Rate	$726.00
Rate for Payer: Aetna Commercial	$689.70
Rate for Payer: Aetna Medicare	$653.40
Rate for Payer: BCBS MT CHIP	$653.40
Rate for Payer: BCBS MT Closed Plan Network	$689.70
Rate for Payer: BCBS MT HealthLink	$653.40
Rate for Payer: BCBS MT Medicare	$653.40
Rate for Payer: BCBS MT POS	$689.70
Rate for Payer: BCBS MT Traditional	$726.00
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cigna Commercial	$689.70
Rate for Payer: Cigna Medicare	$653.40
Rate for Payer: Medicaid All Medicaid	$667.92
Rate for Payer: Medicare All Medicare	$508.20
Rate for Payer: Monida Allegiance	$689.70
Rate for Payer: Monida First Choice Health	$704.22
Rate for Payer: Monida Montana Health Co-op	$689.70
Rate for Payer: Monida PacificSource	$689.70

xxVITAMIN E [180 MG]

Facility

$71.00

Service Code	CPT 84446
Hospital Charge Code	4084446
Hospital Revenue Code	301
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

xxVITAMIN E [180 MG]

Facility

$71.00

Service Code	CPT 84446
Hospital Charge Code	4084446
Hospital Revenue Code	301
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

YANKAUER SUCTION TIP

Facility

$12.00

Hospital Charge Code	80030299
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

YANKAUER SUCTION TIP

Facility

$12.00

Hospital Charge Code	80030299
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ZEPTOMETRIX FLU/RSV/SARS NEG QC

Facility

$229.00

Hospital Charge Code	90197137
Hospital Revenue Code	270
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

ZEPTOMETRIX FLU/RSV/SARS NEG QC

Facility

$229.00

Hospital Charge Code	90197137
Hospital Revenue Code	270
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

ZEPTOMETRIX FLU/RSV/SARS POS QC

Facility

$263.00

Hospital Charge Code	90197136
Hospital Revenue Code	270
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

ZEPTOMETRIX FLU/RSV/SARS POS QC

Facility

$263.00

Hospital Charge Code	90197136
Hospital Revenue Code	270
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

ZEPTOMETRIX NATVNEG-6C

Facility

$214.00

Hospital Charge Code	90197153
Hospital Revenue Code	270
Min. Negotiated Rate	$149.80
Max. Negotiated Rate	$214.00
Rate for Payer: Aetna Commercial	$203.30
Rate for Payer: Aetna Medicare	$192.60
Rate for Payer: BCBS MT CHIP	$192.60
Rate for Payer: BCBS MT Closed Plan Network	$203.30
Rate for Payer: BCBS MT HealthLink	$192.60
Rate for Payer: BCBS MT Medicare	$192.60
Rate for Payer: BCBS MT POS	$203.30
Rate for Payer: BCBS MT Traditional	$214.00
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cigna Commercial	$203.30
Rate for Payer: Cigna Medicare	$192.60
Rate for Payer: Medicaid All Medicaid	$196.88
Rate for Payer: Medicare All Medicare	$149.80
Rate for Payer: Monida Allegiance	$203.30
Rate for Payer: Monida First Choice Health	$207.58
Rate for Payer: Monida Montana Health Co-op	$203.30
Rate for Payer: Monida PacificSource	$203.30

ZEPTOMETRIX NATVNEG-6C

Facility

$214.00

Hospital Charge Code	90197153
Hospital Revenue Code	270
Min. Negotiated Rate	$149.80
Max. Negotiated Rate	$214.00
Rate for Payer: Aetna Commercial	$203.30
Rate for Payer: Aetna Medicare	$192.60
Rate for Payer: BCBS MT CHIP	$192.60
Rate for Payer: BCBS MT Closed Plan Network	$203.30
Rate for Payer: BCBS MT HealthLink	$192.60
Rate for Payer: BCBS MT Medicare	$192.60
Rate for Payer: BCBS MT POS	$203.30
Rate for Payer: BCBS MT Traditional	$214.00
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cigna Commercial	$203.30
Rate for Payer: Cigna Medicare	$192.60
Rate for Payer: Medicaid All Medicaid	$196.88
Rate for Payer: Medicare All Medicare	$149.80
Rate for Payer: Monida Allegiance	$203.30
Rate for Payer: Monida First Choice Health	$207.58
Rate for Payer: Monida Montana Health Co-op	$203.30
Rate for Payer: Monida PacificSource	$203.30

ZEPTOMETRIX NATVPOS-6C

Facility

$375.00

Hospital Charge Code	90197152
Hospital Revenue Code	270
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

ZEPTOMETRIX NATVPOS-6C

Facility

$375.00

Hospital Charge Code	90197152
Hospital Revenue Code	270
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

ZINC (001800)

Facility

$45.00

Service Code	CPT 84630
Hospital Charge Code	4084630
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

ZINC (001800)

Facility

$45.00

Service Code	CPT 84630
Hospital Charge Code	4084630
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

ZINC OXIDE/MENTHOL OINT [20.6%/0.44%] NF

Facility

$12.00

Service Code	HCPCS A9150
Hospital Charge Code	3000540
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ZINC OXIDE/MENTHOL OINT [20.6%/0.44%] NF

Facility

$12.00

Service Code	HCPCS A9150
Hospital Charge Code	3000540
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ZINC, RBC (070029)

Facility

$243.00

Service Code	CPT 84630
Hospital Charge Code	4046301
Hospital Revenue Code	301
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: BCBS MT CHIP	$218.70
Rate for Payer: BCBS MT Closed Plan Network	$230.85
Rate for Payer: BCBS MT HealthLink	$218.70
Rate for Payer: BCBS MT Medicare	$218.70
Rate for Payer: BCBS MT POS	$230.85
Rate for Payer: BCBS MT Traditional	$243.00
Rate for Payer: Cash Price	$218.70
Rate for Payer: Cigna Commercial	$230.85
Rate for Payer: Cigna Medicare	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

ZINC, RBC (070029)

Facility

$243.00

Service Code	CPT 84630
Hospital Charge Code	4046301
Hospital Revenue Code	301
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: BCBS MT CHIP	$218.70
Rate for Payer: BCBS MT Closed Plan Network	$230.85
Rate for Payer: BCBS MT HealthLink	$218.70
Rate for Payer: BCBS MT Medicare	$218.70
Rate for Payer: BCBS MT POS	$230.85
Rate for Payer: BCBS MT Traditional	$243.00
Rate for Payer: Cash Price	$218.70
Rate for Payer: Cigna Commercial	$230.85
Rate for Payer: Cigna Medicare	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

Know your out-of-pocket cost for care.

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