Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

D/C - VITAMIN C 500MG (001805)

Facility

$53.00

Service Code	HCPCS 82180
Hospital Charge Code	4082180
Hospital Revenue Code	300
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

D/C - VITAMIN C 500MG (001805)

Facility

$53.00

Service Code	HCPCS 82180
Hospital Charge Code	4082180
Hospital Revenue Code	300
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

D-DIMER QUANTITIVE

Facility

$174.00

Service Code	HCPCS 85379
Hospital Charge Code	4085379
Hospital Revenue Code	305
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

D-DIMER QUANTITIVE

Facility

$174.00

Service Code	HCPCS 85379
Hospital Charge Code	4085379
Hospital Revenue Code	305
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

Deactivated-METHYLPREDNISOL INJ [125 MG]

Facility

$40.00

Service Code	HCPCS J2930
Hospital Charge Code	3000315
Hospital Revenue Code	636
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

Deactivated-METHYLPREDNISOL INJ [125 MG]

Facility

$40.00

Service Code	HCPCS J2930
Hospital Charge Code	3000315
Hospital Revenue Code	636
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

deactivated SUGAMMADEX [500 MG/5 ML]

Facility

$706.00

Service Code	HCPCS J3490
Hospital Charge Code	3000436
Hospital Revenue Code	259
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

deactivated SUGAMMADEX [500 MG/5 ML]

Facility

$706.00

Service Code	HCPCS J3490
Hospital Charge Code	3000436
Hospital Revenue Code	259
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

DEBRIDEMENT 20SQCM OR LESS 97597

Facility

$343.00

Service Code	HCPCS 97597
Hospital Charge Code	597597
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

DEBRIDEMENT 20SQCM OR LESS 97597

Facility

$343.00

Service Code	HCPCS 97597
Hospital Charge Code	597597
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

DEBRIDEMENT EA ADD 20SQCM 97598

Facility

$1,524.00

Service Code	HCPCS 97598
Hospital Charge Code	597598
Hospital Revenue Code	761
Min. Negotiated Rate	$1,066.80
Max. Negotiated Rate	$1,524.00
Rate for Payer: Aetna Commercial	$1,447.80
Rate for Payer: Aetna Medicare	$1,371.60
Rate for Payer: BCBS MT CHIP	$1,371.60
Rate for Payer: BCBS MT Closed Plan Network	$1,447.80
Rate for Payer: BCBS MT HealthLink	$1,371.60
Rate for Payer: BCBS MT Medicare	$1,371.60
Rate for Payer: BCBS MT POS	$1,447.80
Rate for Payer: BCBS MT Traditional	$1,524.00
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Cigna Commercial	$1,447.80
Rate for Payer: Cigna Medicare	$1,371.60
Rate for Payer: Medicaid All Medicaid	$1,402.08
Rate for Payer: Medicare All Medicare	$1,066.80
Rate for Payer: Monida Allegiance	$1,447.80
Rate for Payer: Monida First Choice Health	$1,478.28
Rate for Payer: Monida Montana Health Co-op	$1,447.80
Rate for Payer: Monida PacificSource	$1,447.80

DEBRIDEMENT EA ADD 20SQCM 97598

Facility

$1,524.00

Service Code	HCPCS 97598
Hospital Charge Code	597598
Hospital Revenue Code	761
Min. Negotiated Rate	$1,066.80
Max. Negotiated Rate	$1,524.00
Rate for Payer: Aetna Commercial	$1,447.80
Rate for Payer: Aetna Medicare	$1,371.60
Rate for Payer: BCBS MT CHIP	$1,371.60
Rate for Payer: BCBS MT Closed Plan Network	$1,447.80
Rate for Payer: BCBS MT HealthLink	$1,371.60
Rate for Payer: BCBS MT Medicare	$1,371.60
Rate for Payer: BCBS MT POS	$1,447.80
Rate for Payer: BCBS MT Traditional	$1,524.00
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Cigna Commercial	$1,447.80
Rate for Payer: Cigna Medicare	$1,371.60
Rate for Payer: Medicaid All Medicaid	$1,402.08
Rate for Payer: Medicare All Medicare	$1,066.80
Rate for Payer: Monida Allegiance	$1,447.80
Rate for Payer: Monida First Choice Health	$1,478.28
Rate for Payer: Monida Montana Health Co-op	$1,447.80
Rate for Payer: Monida PacificSource	$1,447.80

DEBRIDEMENT NON-SELECTIVE W/O ANES 97602

Facility

$343.00

Service Code	HCPCS 97602
Hospital Charge Code	597602
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

DEBRIDEMENT NON-SELECTIVE W/O ANES 97602

Facility

$343.00

Service Code	HCPCS 97602
Hospital Charge Code	597602
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

DECLOTTING IMPLANTED DEVICE

Facility

$437.00

Service Code	HCPCS 36593
Hospital Charge Code	1036593
Hospital Revenue Code	761
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$437.00
Rate for Payer: Aetna Commercial	$415.15
Rate for Payer: Aetna Medicare	$393.30
Rate for Payer: BCBS MT CHIP	$393.30
Rate for Payer: BCBS MT Closed Plan Network	$415.15
Rate for Payer: BCBS MT HealthLink	$393.30
Rate for Payer: BCBS MT Medicare	$393.30
Rate for Payer: BCBS MT POS	$415.15
Rate for Payer: BCBS MT Traditional	$437.00
Rate for Payer: Cash Price	$393.30
Rate for Payer: Cigna Commercial	$415.15
Rate for Payer: Cigna Medicare	$393.30
Rate for Payer: Medicaid All Medicaid	$402.04
Rate for Payer: Medicare All Medicare	$305.90
Rate for Payer: Monida Allegiance	$415.15
Rate for Payer: Monida First Choice Health	$423.89
Rate for Payer: Monida Montana Health Co-op	$415.15
Rate for Payer: Monida PacificSource	$415.15

DECLOTTING IMPLANTED DEVICE

Facility

$437.00

Service Code	HCPCS 36593
Hospital Charge Code	1036593
Hospital Revenue Code	761
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$437.00
Rate for Payer: Aetna Commercial	$415.15
Rate for Payer: Aetna Medicare	$393.30
Rate for Payer: BCBS MT CHIP	$393.30
Rate for Payer: BCBS MT Closed Plan Network	$415.15
Rate for Payer: BCBS MT HealthLink	$393.30
Rate for Payer: BCBS MT Medicare	$393.30
Rate for Payer: BCBS MT POS	$415.15
Rate for Payer: BCBS MT Traditional	$437.00
Rate for Payer: Cash Price	$393.30
Rate for Payer: Cigna Commercial	$415.15
Rate for Payer: Cigna Medicare	$393.30
Rate for Payer: Medicaid All Medicaid	$402.04
Rate for Payer: Medicare All Medicare	$305.90
Rate for Payer: Monida Allegiance	$415.15
Rate for Payer: Monida First Choice Health	$423.89
Rate for Payer: Monida Montana Health Co-op	$415.15
Rate for Payer: Monida PacificSource	$415.15

DENOSUMAB INJ [60 MG/ML]

Facility

$2,530.00

Service Code	HCPCS J0897
Hospital Charge Code	3000108
Hospital Revenue Code	636
Min. Negotiated Rate	$1,771.00
Max. Negotiated Rate	$2,530.00
Rate for Payer: Aetna Commercial	$2,403.50
Rate for Payer: Aetna Medicare	$2,277.00
Rate for Payer: BCBS MT CHIP	$2,277.00
Rate for Payer: BCBS MT Closed Plan Network	$2,403.50
Rate for Payer: BCBS MT HealthLink	$2,277.00
Rate for Payer: BCBS MT Medicare	$2,277.00
Rate for Payer: BCBS MT POS	$2,403.50
Rate for Payer: BCBS MT Traditional	$2,530.00
Rate for Payer: Cash Price	$2,277.00
Rate for Payer: Cigna Commercial	$2,403.50
Rate for Payer: Cigna Medicare	$2,277.00
Rate for Payer: Medicaid All Medicaid	$2,327.60
Rate for Payer: Medicare All Medicare	$1,771.00
Rate for Payer: Monida Allegiance	$2,403.50
Rate for Payer: Monida First Choice Health	$2,454.10
Rate for Payer: Monida Montana Health Co-op	$2,403.50
Rate for Payer: Monida PacificSource	$2,403.50

DENOSUMAB INJ [60 MG/ML]

Facility

$2,530.00

Service Code	HCPCS J0897
Hospital Charge Code	3000108
Hospital Revenue Code	636
Min. Negotiated Rate	$1,771.00
Max. Negotiated Rate	$2,530.00
Rate for Payer: Aetna Commercial	$2,403.50
Rate for Payer: Aetna Medicare	$2,277.00
Rate for Payer: BCBS MT CHIP	$2,277.00
Rate for Payer: BCBS MT Closed Plan Network	$2,403.50
Rate for Payer: BCBS MT HealthLink	$2,277.00
Rate for Payer: BCBS MT Medicare	$2,277.00
Rate for Payer: BCBS MT POS	$2,403.50
Rate for Payer: BCBS MT Traditional	$2,530.00
Rate for Payer: Cash Price	$2,277.00
Rate for Payer: Cigna Commercial	$2,403.50
Rate for Payer: Cigna Medicare	$2,277.00
Rate for Payer: Medicaid All Medicaid	$2,327.60
Rate for Payer: Medicare All Medicare	$1,771.00
Rate for Payer: Monida Allegiance	$2,403.50
Rate for Payer: Monida First Choice Health	$2,454.10
Rate for Payer: Monida Montana Health Co-op	$2,403.50
Rate for Payer: Monida PacificSource	$2,403.50

DERMAFLEX

Facility

$63.00

Hospital Charge Code	80040171
Hospital Revenue Code	270
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

DERMAFLEX

Facility

$63.00

Hospital Charge Code	80040171
Hospital Revenue Code	270
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

DESTRUCTION NEUROLYTIC AGT GENICULAR NE

Facility

$4,490.00

Service Code	HCPCS 64624
Hospital Charge Code	1564624
Hospital Revenue Code	761
Min. Negotiated Rate	$3,143.00
Max. Negotiated Rate	$4,490.00
Rate for Payer: Aetna Commercial	$4,265.50
Rate for Payer: Aetna Medicare	$4,041.00
Rate for Payer: BCBS MT CHIP	$4,041.00
Rate for Payer: BCBS MT Closed Plan Network	$4,265.50
Rate for Payer: BCBS MT HealthLink	$4,041.00
Rate for Payer: BCBS MT Medicare	$4,041.00
Rate for Payer: BCBS MT POS	$4,265.50
Rate for Payer: BCBS MT Traditional	$4,490.00
Rate for Payer: Cash Price	$4,041.00
Rate for Payer: Cigna Commercial	$4,265.50
Rate for Payer: Cigna Medicare	$4,041.00
Rate for Payer: Medicaid All Medicaid	$4,130.80
Rate for Payer: Medicare All Medicare	$3,143.00
Rate for Payer: Monida Allegiance	$4,265.50
Rate for Payer: Monida First Choice Health	$4,355.30
Rate for Payer: Monida Montana Health Co-op	$4,265.50
Rate for Payer: Monida PacificSource	$4,265.50

DESTRUCTION NEUROLYTIC AGT GENICULAR NE

Facility

$4,490.00

Service Code	HCPCS 64624
Hospital Charge Code	1564624
Hospital Revenue Code	761
Min. Negotiated Rate	$3,143.00
Max. Negotiated Rate	$4,490.00
Rate for Payer: Aetna Commercial	$4,265.50
Rate for Payer: Aetna Medicare	$4,041.00
Rate for Payer: BCBS MT CHIP	$4,041.00
Rate for Payer: BCBS MT Closed Plan Network	$4,265.50
Rate for Payer: BCBS MT HealthLink	$4,041.00
Rate for Payer: BCBS MT Medicare	$4,041.00
Rate for Payer: BCBS MT POS	$4,265.50
Rate for Payer: BCBS MT Traditional	$4,490.00
Rate for Payer: Cash Price	$4,041.00
Rate for Payer: Cigna Commercial	$4,265.50
Rate for Payer: Cigna Medicare	$4,041.00
Rate for Payer: Medicaid All Medicaid	$4,130.80
Rate for Payer: Medicare All Medicare	$3,143.00
Rate for Payer: Monida Allegiance	$4,265.50
Rate for Payer: Monida First Choice Health	$4,355.30
Rate for Payer: Monida Montana Health Co-op	$4,265.50
Rate for Payer: Monida PacificSource	$4,265.50

DEXAMETHASONE

Facility

$160.00

Service Code	HCPCS 83695
Hospital Charge Code	4087887
Hospital Revenue Code	301
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial	$152.00
Rate for Payer: Aetna Medicare	$144.00
Rate for Payer: BCBS MT CHIP	$144.00
Rate for Payer: BCBS MT Closed Plan Network	$152.00
Rate for Payer: BCBS MT HealthLink	$144.00
Rate for Payer: BCBS MT Medicare	$144.00
Rate for Payer: BCBS MT POS	$152.00
Rate for Payer: BCBS MT Traditional	$160.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna Commercial	$152.00
Rate for Payer: Cigna Medicare	$144.00
Rate for Payer: Medicaid All Medicaid	$147.20
Rate for Payer: Medicare All Medicare	$112.00
Rate for Payer: Monida Allegiance	$152.00
Rate for Payer: Monida First Choice Health	$155.20
Rate for Payer: Monida Montana Health Co-op	$152.00
Rate for Payer: Monida PacificSource	$152.00

DEXAMETHASONE

Facility

$160.00

Service Code	HCPCS 83695
Hospital Charge Code	4087887
Hospital Revenue Code	301
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial	$152.00
Rate for Payer: Aetna Medicare	$144.00
Rate for Payer: BCBS MT CHIP	$144.00
Rate for Payer: BCBS MT Closed Plan Network	$152.00
Rate for Payer: BCBS MT HealthLink	$144.00
Rate for Payer: BCBS MT Medicare	$144.00
Rate for Payer: BCBS MT POS	$152.00
Rate for Payer: BCBS MT Traditional	$160.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna Commercial	$152.00
Rate for Payer: Cigna Medicare	$144.00
Rate for Payer: Medicaid All Medicaid	$147.20
Rate for Payer: Medicare All Medicare	$112.00
Rate for Payer: Monida Allegiance	$152.00
Rate for Payer: Monida First Choice Health	$155.20
Rate for Payer: Monida Montana Health Co-op	$152.00
Rate for Payer: Monida PacificSource	$152.00

DEXAMETHASONE 10MG/ML VL (PAIN INJ)

Facility

$26.00

Service Code	HCPCS J1100
Hospital Charge Code	3000109
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

Know your out-of-pocket cost for care.

All Charges