Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

DONOTUSE CERVICAL COLLAR UNIV 3"

Facility

$17.00

Hospital Charge Code	2820005
Hospital Revenue Code	270
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

DONOTUSE CERVICAL COLLAR UNIV 3"

Facility

$17.00

Hospital Charge Code	2820005
Hospital Revenue Code	270
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

DONOTUSE CERVICAL COLLAR UNIV 4"

Facility

$14.00

Hospital Charge Code	2893251
Hospital Revenue Code	290
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

DONOTUSE CERVICAL COLLAR UNIV 4"

Facility

$14.00

Hospital Charge Code	2893251
Hospital Revenue Code	290
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

DONOTUSE CERVICAL COLLAR XLG (FIRM)

Facility

$26.00

Hospital Charge Code	2893255
Hospital Revenue Code	290
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

DONOTUSE CERVICAL COLLAR XLG (FIRM)

Facility

$26.00

Hospital Charge Code	2893255
Hospital Revenue Code	290
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

DO NOT USE GLOVES NITRILE SM LAVENDER

Facility

$53.00

Hospital Charge Code	80030482
Hospital Revenue Code	270
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

DO NOT USE GLOVES NITRILE SM LAVENDER

Facility

$53.00

Hospital Charge Code	80030482
Hospital Revenue Code	270
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

(DO NOT USE) STRESS ECHO WITH CONTRAST

Facility

$2,490.00

Service Code	HCPCS 93350
Hospital Charge Code	5100005
Hospital Revenue Code	402
Min. Negotiated Rate	$1,743.00
Max. Negotiated Rate	$2,490.00
Rate for Payer: Aetna Commercial	$2,365.50
Rate for Payer: Aetna Medicare	$2,241.00
Rate for Payer: BCBS MT CHIP	$2,241.00
Rate for Payer: BCBS MT Closed Plan Network	$2,365.50
Rate for Payer: BCBS MT HealthLink	$2,241.00
Rate for Payer: BCBS MT Medicare	$2,241.00
Rate for Payer: BCBS MT POS	$2,365.50
Rate for Payer: BCBS MT Traditional	$2,490.00
Rate for Payer: Cash Price	$2,241.00
Rate for Payer: Cigna Commercial	$2,365.50
Rate for Payer: Cigna Medicare	$2,241.00
Rate for Payer: Medicaid All Medicaid	$2,290.80
Rate for Payer: Medicare All Medicare	$1,743.00
Rate for Payer: Monida Allegiance	$2,365.50
Rate for Payer: Monida First Choice Health	$2,415.30
Rate for Payer: Monida Montana Health Co-op	$2,365.50
Rate for Payer: Monida PacificSource	$2,365.50

(DO NOT USE) STRESS ECHO WITH CONTRAST

Facility

$2,490.00

Service Code	HCPCS 93350
Hospital Charge Code	5100005
Hospital Revenue Code	402
Min. Negotiated Rate	$1,743.00
Max. Negotiated Rate	$2,490.00
Rate for Payer: Aetna Commercial	$2,365.50
Rate for Payer: Aetna Medicare	$2,241.00
Rate for Payer: BCBS MT CHIP	$2,241.00
Rate for Payer: BCBS MT Closed Plan Network	$2,365.50
Rate for Payer: BCBS MT HealthLink	$2,241.00
Rate for Payer: BCBS MT Medicare	$2,241.00
Rate for Payer: BCBS MT POS	$2,365.50
Rate for Payer: BCBS MT Traditional	$2,490.00
Rate for Payer: Cash Price	$2,241.00
Rate for Payer: Cigna Commercial	$2,365.50
Rate for Payer: Cigna Medicare	$2,241.00
Rate for Payer: Medicaid All Medicaid	$2,290.80
Rate for Payer: Medicare All Medicare	$1,743.00
Rate for Payer: Monida Allegiance	$2,365.50
Rate for Payer: Monida First Choice Health	$2,415.30
Rate for Payer: Monida Montana Health Co-op	$2,365.50
Rate for Payer: Monida PacificSource	$2,365.50

(DO NOT USE) STRESS TEST 99350

Facility

$2,041.00

Service Code	HCPCS 93350
Hospital Charge Code	5193320
Hospital Revenue Code	402
Min. Negotiated Rate	$1,428.70
Max. Negotiated Rate	$2,041.00
Rate for Payer: Aetna Commercial	$1,938.95
Rate for Payer: Aetna Medicare	$1,836.90
Rate for Payer: BCBS MT CHIP	$1,836.90
Rate for Payer: BCBS MT Closed Plan Network	$1,938.95
Rate for Payer: BCBS MT HealthLink	$1,836.90
Rate for Payer: BCBS MT Medicare	$1,836.90
Rate for Payer: BCBS MT POS	$1,938.95
Rate for Payer: BCBS MT Traditional	$2,041.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cigna Commercial	$1,938.95
Rate for Payer: Cigna Medicare	$1,836.90
Rate for Payer: Medicaid All Medicaid	$1,877.72
Rate for Payer: Medicare All Medicare	$1,428.70
Rate for Payer: Monida Allegiance	$1,938.95
Rate for Payer: Monida First Choice Health	$1,979.77
Rate for Payer: Monida Montana Health Co-op	$1,938.95
Rate for Payer: Monida PacificSource	$1,938.95

(DO NOT USE) STRESS TEST 99350

Facility

$2,041.00

Service Code	HCPCS 93350
Hospital Charge Code	5193320
Hospital Revenue Code	402
Min. Negotiated Rate	$1,428.70
Max. Negotiated Rate	$2,041.00
Rate for Payer: Aetna Commercial	$1,938.95
Rate for Payer: Aetna Medicare	$1,836.90
Rate for Payer: BCBS MT CHIP	$1,836.90
Rate for Payer: BCBS MT Closed Plan Network	$1,938.95
Rate for Payer: BCBS MT HealthLink	$1,836.90
Rate for Payer: BCBS MT Medicare	$1,836.90
Rate for Payer: BCBS MT POS	$1,938.95
Rate for Payer: BCBS MT Traditional	$2,041.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cigna Commercial	$1,938.95
Rate for Payer: Cigna Medicare	$1,836.90
Rate for Payer: Medicaid All Medicaid	$1,877.72
Rate for Payer: Medicare All Medicare	$1,428.70
Rate for Payer: Monida Allegiance	$1,938.95
Rate for Payer: Monida First Choice Health	$1,979.77
Rate for Payer: Monida Montana Health Co-op	$1,938.95
Rate for Payer: Monida PacificSource	$1,938.95

DOPAMINE PREMIX [800 MG/500ML]

Facility

$53.00

Service Code	HCPCS J1265
Hospital Charge Code	3000134
Hospital Revenue Code	636
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

DOPAMINE PREMIX [800 MG/500ML]

Facility

$53.00

Service Code	HCPCS J1265
Hospital Charge Code	3000134
Hospital Revenue Code	636
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

DORZOLAMIDE/TIMOLOL 2% / 0.5% OPHTH SOL.

Facility

$491.57

Service Code	NDC 65862094715
Hospital Charge Code	3007392
Hospital Revenue Code	250
Min. Negotiated Rate	$344.10
Max. Negotiated Rate	$491.57
Rate for Payer: Aetna Commercial	$466.99
Rate for Payer: Aetna Medicare	$442.41
Rate for Payer: BCBS MT CHIP	$442.41
Rate for Payer: BCBS MT Closed Plan Network	$466.99
Rate for Payer: BCBS MT HealthLink	$442.41
Rate for Payer: BCBS MT Medicare	$442.41
Rate for Payer: BCBS MT POS	$466.99
Rate for Payer: BCBS MT Traditional	$491.57
Rate for Payer: Cash Price	$442.41
Rate for Payer: Cigna Commercial	$466.99
Rate for Payer: Cigna Medicare	$442.41
Rate for Payer: Medicaid All Medicaid	$452.24
Rate for Payer: Medicare All Medicare	$344.10
Rate for Payer: Monida Allegiance	$466.99
Rate for Payer: Monida First Choice Health	$476.82
Rate for Payer: Monida Montana Health Co-op	$466.99
Rate for Payer: Monida PacificSource	$466.99

DORZOLAMIDE/TIMOLOL 2% / 0.5% OPHTH SOL.

Facility

$491.57

Service Code	NDC 65862094715
Hospital Charge Code	3007392
Hospital Revenue Code	250
Min. Negotiated Rate	$344.10
Max. Negotiated Rate	$491.57
Rate for Payer: Aetna Commercial	$466.99
Rate for Payer: Aetna Medicare	$442.41
Rate for Payer: BCBS MT CHIP	$442.41
Rate for Payer: BCBS MT Closed Plan Network	$466.99
Rate for Payer: BCBS MT HealthLink	$442.41
Rate for Payer: BCBS MT Medicare	$442.41
Rate for Payer: BCBS MT POS	$466.99
Rate for Payer: BCBS MT Traditional	$491.57
Rate for Payer: Cash Price	$442.41
Rate for Payer: Cigna Commercial	$466.99
Rate for Payer: Cigna Medicare	$442.41
Rate for Payer: Medicaid All Medicaid	$452.24
Rate for Payer: Medicare All Medicare	$344.10
Rate for Payer: Monida Allegiance	$466.99
Rate for Payer: Monida First Choice Health	$476.82
Rate for Payer: Monida Montana Health Co-op	$466.99
Rate for Payer: Monida PacificSource	$466.99

DORZOLAMIDE-TIMOLOL 22.3 -6.8MG DROPS-NF

Facility

$390.40

Service Code	NDC 42571014726
Hospital Charge Code	3007246
Hospital Revenue Code	250
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$390.40
Rate for Payer: Aetna Commercial	$370.88
Rate for Payer: Aetna Medicare	$351.36
Rate for Payer: BCBS MT CHIP	$351.36
Rate for Payer: BCBS MT Closed Plan Network	$370.88
Rate for Payer: BCBS MT HealthLink	$351.36
Rate for Payer: BCBS MT Medicare	$351.36
Rate for Payer: BCBS MT POS	$370.88
Rate for Payer: BCBS MT Traditional	$390.40
Rate for Payer: Cash Price	$351.36
Rate for Payer: Cigna Commercial	$370.88
Rate for Payer: Cigna Medicare	$351.36
Rate for Payer: Medicaid All Medicaid	$359.17
Rate for Payer: Medicare All Medicare	$273.28
Rate for Payer: Monida Allegiance	$370.88
Rate for Payer: Monida First Choice Health	$378.69
Rate for Payer: Monida Montana Health Co-op	$370.88
Rate for Payer: Monida PacificSource	$370.88

DORZOLAMIDE-TIMOLOL 22.3 -6.8MG DROPS-NF

Facility

$390.40

Service Code	NDC 42571014726
Hospital Charge Code	3007246
Hospital Revenue Code	250
Min. Negotiated Rate	$273.28
Max. Negotiated Rate	$390.40
Rate for Payer: Aetna Commercial	$370.88
Rate for Payer: Aetna Medicare	$351.36
Rate for Payer: BCBS MT CHIP	$351.36
Rate for Payer: BCBS MT Closed Plan Network	$370.88
Rate for Payer: BCBS MT HealthLink	$351.36
Rate for Payer: BCBS MT Medicare	$351.36
Rate for Payer: BCBS MT POS	$370.88
Rate for Payer: BCBS MT Traditional	$390.40
Rate for Payer: Cash Price	$351.36
Rate for Payer: Cigna Commercial	$370.88
Rate for Payer: Cigna Medicare	$351.36
Rate for Payer: Medicaid All Medicaid	$359.17
Rate for Payer: Medicare All Medicare	$273.28
Rate for Payer: Monida Allegiance	$370.88
Rate for Payer: Monida First Choice Health	$378.69
Rate for Payer: Monida Montana Health Co-op	$370.88
Rate for Payer: Monida PacificSource	$370.88

DOXAZOSIN MESYLATE 4MG TAB NON FORMULARY

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000135
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

DOXAZOSIN MESYLATE 4MG TAB NON FORMULARY

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000135
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

DOXEPIN 50MG CAP NON FORMULARY

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000136
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

DOXEPIN 50MG CAP NON FORMULARY

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000136
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

DOXYCYCLINE TAB [100 MG]

Facility

$19.00

Service Code	HCPCS J3490
Hospital Charge Code	3000137
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

DOXYCYCLINE TAB [100 MG]

Facility

$19.00

Service Code	HCPCS J3490
Hospital Charge Code	3000137
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

DRAIN/INJ JOINT/BURSA W/US 20604

Facility

$344.00

Service Code	HCPCS 20604
Hospital Charge Code	1520604
Hospital Revenue Code	760
Min. Negotiated Rate	$240.80
Max. Negotiated Rate	$344.00
Rate for Payer: Aetna Commercial	$326.80
Rate for Payer: Aetna Medicare	$309.60
Rate for Payer: BCBS MT CHIP	$309.60
Rate for Payer: BCBS MT Closed Plan Network	$326.80
Rate for Payer: BCBS MT HealthLink	$309.60
Rate for Payer: BCBS MT Medicare	$309.60
Rate for Payer: BCBS MT POS	$326.80
Rate for Payer: BCBS MT Traditional	$344.00
Rate for Payer: Cash Price	$309.60
Rate for Payer: Cigna Commercial	$326.80
Rate for Payer: Cigna Medicare	$309.60
Rate for Payer: Medicaid All Medicaid	$316.48
Rate for Payer: Medicare All Medicare	$240.80
Rate for Payer: Monida Allegiance	$326.80
Rate for Payer: Monida First Choice Health	$333.68
Rate for Payer: Monida Montana Health Co-op	$326.80
Rate for Payer: Monida PacificSource	$326.80

Know your out-of-pocket cost for care.

All Charges