Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CLINIC I&D BARTHOLIN'S GLAND ABSC 56420

Facility

$431.00

Service Code	CPT 56420
Hospital Charge Code	8056420
Hospital Revenue Code	521
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

CLINIC - PRO FEE ED COMPREHENSIVE

Facility

$408.00

Service Code	CPT 99285
Hospital Charge Code	709285
Hospital Revenue Code	521
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$408.00
Rate for Payer: Aetna Commercial	$387.60
Rate for Payer: Aetna Medicare	$367.20
Rate for Payer: BCBS MT CHIP	$367.20
Rate for Payer: BCBS MT Closed Plan Network	$387.60
Rate for Payer: BCBS MT HealthLink	$367.20
Rate for Payer: BCBS MT Medicare	$367.20
Rate for Payer: BCBS MT POS	$387.60
Rate for Payer: BCBS MT Traditional	$408.00
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna Commercial	$387.60
Rate for Payer: Cigna Medicare	$367.20
Rate for Payer: Medicaid All Medicaid	$375.36
Rate for Payer: Medicare All Medicare	$285.60
Rate for Payer: Monida Allegiance	$387.60
Rate for Payer: Monida First Choice Health	$395.76
Rate for Payer: Monida Montana Health Co-op	$387.60
Rate for Payer: Monida PacificSource	$387.60

CLINIC - PRO FEE ED COMPREHENSIVE

Facility

$408.00

Service Code	CPT 99285
Hospital Charge Code	709285
Hospital Revenue Code	521
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$408.00
Rate for Payer: Aetna Commercial	$387.60
Rate for Payer: Aetna Medicare	$367.20
Rate for Payer: BCBS MT CHIP	$367.20
Rate for Payer: BCBS MT Closed Plan Network	$387.60
Rate for Payer: BCBS MT HealthLink	$367.20
Rate for Payer: BCBS MT Medicare	$367.20
Rate for Payer: BCBS MT POS	$387.60
Rate for Payer: BCBS MT Traditional	$408.00
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna Commercial	$387.60
Rate for Payer: Cigna Medicare	$367.20
Rate for Payer: Medicaid All Medicaid	$375.36
Rate for Payer: Medicare All Medicare	$285.60
Rate for Payer: Monida Allegiance	$387.60
Rate for Payer: Monida First Choice Health	$395.76
Rate for Payer: Monida Montana Health Co-op	$387.60
Rate for Payer: Monida PacificSource	$387.60

CLINIC - PRO FEE ED CRITICAL CARE 1ST HR

Facility

$606.00

Service Code	CPT 99291
Hospital Charge Code	709291
Hospital Revenue Code	521
Min. Negotiated Rate	$424.20
Max. Negotiated Rate	$606.00
Rate for Payer: Aetna Commercial	$575.70
Rate for Payer: Aetna Medicare	$545.40
Rate for Payer: BCBS MT CHIP	$545.40
Rate for Payer: BCBS MT Closed Plan Network	$575.70
Rate for Payer: BCBS MT HealthLink	$545.40
Rate for Payer: BCBS MT Medicare	$545.40
Rate for Payer: BCBS MT POS	$575.70
Rate for Payer: BCBS MT Traditional	$606.00
Rate for Payer: Cash Price	$545.40
Rate for Payer: Cigna Commercial	$575.70
Rate for Payer: Cigna Medicare	$545.40
Rate for Payer: Medicaid All Medicaid	$557.52
Rate for Payer: Medicare All Medicare	$424.20
Rate for Payer: Monida Allegiance	$575.70
Rate for Payer: Monida First Choice Health	$587.82
Rate for Payer: Monida Montana Health Co-op	$575.70
Rate for Payer: Monida PacificSource	$575.70

CLINIC - PRO FEE ED CRITICAL CARE 1ST HR

Facility

$606.00

Service Code	CPT 99291
Hospital Charge Code	709291
Hospital Revenue Code	521
Min. Negotiated Rate	$424.20
Max. Negotiated Rate	$606.00
Rate for Payer: Aetna Commercial	$575.70
Rate for Payer: Aetna Medicare	$545.40
Rate for Payer: BCBS MT CHIP	$545.40
Rate for Payer: BCBS MT Closed Plan Network	$575.70
Rate for Payer: BCBS MT HealthLink	$545.40
Rate for Payer: BCBS MT Medicare	$545.40
Rate for Payer: BCBS MT POS	$575.70
Rate for Payer: BCBS MT Traditional	$606.00
Rate for Payer: Cash Price	$545.40
Rate for Payer: Cigna Commercial	$575.70
Rate for Payer: Cigna Medicare	$545.40
Rate for Payer: Medicaid All Medicaid	$557.52
Rate for Payer: Medicare All Medicare	$424.20
Rate for Payer: Monida Allegiance	$575.70
Rate for Payer: Monida First Choice Health	$587.82
Rate for Payer: Monida Montana Health Co-op	$575.70
Rate for Payer: Monida PacificSource	$575.70

CLINIC - PRO FEE ED EXTENDED

Facility

$277.00

Service Code	CPT 99284
Hospital Charge Code	709284
Hospital Revenue Code	521
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

CLINIC - PRO FEE ED EXTENDED

Facility

$277.00

Service Code	CPT 99284
Hospital Charge Code	709284
Hospital Revenue Code	521
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

CLINIC - PRO FEE ED INTERMEDIATE

Facility

$147.00

Service Code	CPT 99283
Hospital Charge Code	709283
Hospital Revenue Code	521
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$147.00
Rate for Payer: Aetna Commercial	$139.65
Rate for Payer: Aetna Medicare	$132.30
Rate for Payer: BCBS MT CHIP	$132.30
Rate for Payer: BCBS MT Closed Plan Network	$139.65
Rate for Payer: BCBS MT HealthLink	$132.30
Rate for Payer: BCBS MT Medicare	$132.30
Rate for Payer: BCBS MT POS	$139.65
Rate for Payer: BCBS MT Traditional	$147.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial	$139.65
Rate for Payer: Cigna Medicare	$132.30
Rate for Payer: Medicaid All Medicaid	$135.24
Rate for Payer: Medicare All Medicare	$102.90
Rate for Payer: Monida Allegiance	$139.65
Rate for Payer: Monida First Choice Health	$142.59
Rate for Payer: Monida Montana Health Co-op	$139.65
Rate for Payer: Monida PacificSource	$139.65

CLINIC - PRO FEE ED INTERMEDIATE

Facility

$147.00

Service Code	CPT 99283
Hospital Charge Code	709283
Hospital Revenue Code	521
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$147.00
Rate for Payer: Aetna Commercial	$139.65
Rate for Payer: Aetna Medicare	$132.30
Rate for Payer: BCBS MT CHIP	$132.30
Rate for Payer: BCBS MT Closed Plan Network	$139.65
Rate for Payer: BCBS MT HealthLink	$132.30
Rate for Payer: BCBS MT Medicare	$132.30
Rate for Payer: BCBS MT POS	$139.65
Rate for Payer: BCBS MT Traditional	$147.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial	$139.65
Rate for Payer: Cigna Medicare	$132.30
Rate for Payer: Medicaid All Medicaid	$135.24
Rate for Payer: Medicare All Medicare	$102.90
Rate for Payer: Monida Allegiance	$139.65
Rate for Payer: Monida First Choice Health	$142.59
Rate for Payer: Monida Montana Health Co-op	$139.65
Rate for Payer: Monida PacificSource	$139.65

CLINIC - PRO FEE ED LIMITED

Facility

$101.00

Service Code	CPT 99282
Hospital Charge Code	709282
Hospital Revenue Code	521
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

CLINIC - PRO FEE ED LIMITED

Facility

$101.00

Service Code	CPT 99282
Hospital Charge Code	709282
Hospital Revenue Code	521
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

CLIN LIDOCAINE VISCOUS 2% ORAL SLN UD

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007014
Hospital Revenue Code	521
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

CLIN LIDOCAINE VISCOUS 2% ORAL SLN UD

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007014
Hospital Revenue Code	521
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

CLIN NITROGLYCERIN OINT 2% 1G PACKET

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	8007016
Hospital Revenue Code	521
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

CLIN NITROGLYCERIN OINT 2% 1G PACKET

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	8007016
Hospital Revenue Code	521
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

CLIN NITROGLYCERIN SL TAB [0.4 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007017
Hospital Revenue Code	521
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

CLIN NITROGLYCERIN SL TAB [0.4 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007017
Hospital Revenue Code	521
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

CLIN ONDANSETRON ODT [4 MG]

Facility

$78.00

Service Code	HCPCS Q0162
Hospital Charge Code	8007018
Hospital Revenue Code	521
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

CLIN ONDANSETRON ODT [4 MG]

Facility

$78.00

Service Code	HCPCS Q0162
Hospital Charge Code	8007018
Hospital Revenue Code	521
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

CLIN TETRACAINE OPTH 0.5% 4ML

Facility

$43.00

Service Code	HCPCS J3490
Hospital Charge Code	8007019
Hospital Revenue Code	521
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

CLIN TETRACAINE OPTH 0.5% 4ML

Facility

$43.00

Service Code	HCPCS J3490
Hospital Charge Code	8007019
Hospital Revenue Code	521
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

CLIN TRIAMCINOLONE INJ [40 MG/ML]

Facility

$38.00

Service Code	HCPCS J3301
Hospital Charge Code	8007020
Hospital Revenue Code	521
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

CLIN TRIAMCINOLONE INJ [40 MG/ML]

Facility

$38.00

Service Code	HCPCS J3301
Hospital Charge Code	8007020
Hospital Revenue Code	521
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

CLOBETASOL CREAM [0.05%] NF

Facility

$431.00

Service Code	HCPCS J3490
Hospital Charge Code	3000097
Hospital Revenue Code	250
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

CLOBETASOL CREAM [0.05%] NF

Facility

$431.00

Service Code	HCPCS J3490
Hospital Charge Code	3000097
Hospital Revenue Code	250
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

Know your out-of-pocket cost for care.

All Charges