Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

D/C ZINC OXIDE & DIMETHICONE CREAM 113GM

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000487
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

D/C ZINC OXIDE & DIMETHICONE CREAM 113GM

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000487
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

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

DEBRIDEMENT 20SQCM OR LESS-SWG BD 97597

Facility

$343.00

Service Code	HCPCS 97597
Hospital Charge Code	597599
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-SWG BD 97597

Facility

$343.00

Service Code	HCPCS 97597
Hospital Charge Code	597599
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-TRT RM 97597

Facility

$524.00

Service Code	HCPCS 97597
Hospital Charge Code	597597
Hospital Revenue Code	761
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

DEBRIDEMENT 20SQCM OR LESS-TRT RM 97597

Facility

$524.00

Service Code	HCPCS 97597
Hospital Charge Code	597597
Hospital Revenue Code	761
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

DEBRIDEMENT EA ADD 20SQCM-SWG BED 97598

Facility

$406.00

Service Code	HCPCS 97598
Hospital Charge Code	597600
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT EA ADD 20SQCM-SWG BED 97598

Facility

$406.00

Service Code	HCPCS 97598
Hospital Charge Code	597600
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT EA ADD 20SQCM- TRT RM 97598

Facility

$406.00

Service Code	HCPCS 97598
Hospital Charge Code	597598
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT EA ADD 20SQCM- TRT RM 97598

Facility

$406.00

Service Code	HCPCS 97598
Hospital Charge Code	597598
Hospital Revenue Code	761
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$406.00
Rate for Payer: Aetna Commercial	$385.70
Rate for Payer: Aetna Medicare	$365.40
Rate for Payer: BCBS MT CHIP	$365.40
Rate for Payer: BCBS MT Closed Plan Network	$385.70
Rate for Payer: BCBS MT HealthLink	$365.40
Rate for Payer: BCBS MT Medicare	$365.40
Rate for Payer: BCBS MT POS	$385.70
Rate for Payer: BCBS MT Traditional	$406.00
Rate for Payer: Cash Price	$365.40
Rate for Payer: Cigna Commercial	$385.70
Rate for Payer: Cigna Medicare	$365.40
Rate for Payer: Medicaid All Medicaid	$373.52
Rate for Payer: Medicare All Medicare	$284.20
Rate for Payer: Monida Allegiance	$385.70
Rate for Payer: Monida First Choice Health	$393.82
Rate for Payer: Monida Montana Health Co-op	$385.70
Rate for Payer: Monida PacificSource	$385.70

DEBRIDEMENT NON-SELECTIVE W/O ANES 97602

Facility

$364.00

Service Code	HCPCS 97602
Hospital Charge Code	597602
Hospital Revenue Code	761
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

DEBRIDEMENT NON-SELECTIVE W/O ANES 97602

Facility

$364.00

Service Code	HCPCS 97602
Hospital Charge Code	597602
Hospital Revenue Code	761
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

DECLOTTING IMPLANTED DEVICE

Facility

$463.00

Service Code	HCPCS 36593
Hospital Charge Code	1036593
Hospital Revenue Code	761
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

DECLOTTING IMPLANTED DEVICE

Facility

$463.00

Service Code	HCPCS 36593
Hospital Charge Code	1036593
Hospital Revenue Code	761
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

DENOSUMAB INJ [60 MG/ML] SPEC ORDER

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] SPEC ORDER

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

$4,759.00

Service Code	HCPCS 64624
Hospital Charge Code	1564624
Hospital Revenue Code	761
Min. Negotiated Rate	$3,331.30
Max. Negotiated Rate	$4,759.00
Rate for Payer: Aetna Commercial	$4,521.05
Rate for Payer: Aetna Medicare	$4,283.10
Rate for Payer: BCBS MT CHIP	$4,283.10
Rate for Payer: BCBS MT Closed Plan Network	$4,521.05
Rate for Payer: BCBS MT HealthLink	$4,283.10
Rate for Payer: BCBS MT Medicare	$4,283.10
Rate for Payer: BCBS MT POS	$4,521.05
Rate for Payer: BCBS MT Traditional	$4,759.00
Rate for Payer: Cash Price	$4,283.10
Rate for Payer: Cigna Commercial	$4,521.05
Rate for Payer: Cigna Medicare	$4,283.10
Rate for Payer: Medicaid All Medicaid	$4,378.28
Rate for Payer: Medicare All Medicare	$3,331.30
Rate for Payer: Monida Allegiance	$4,521.05
Rate for Payer: Monida First Choice Health	$4,616.23
Rate for Payer: Monida Montana Health Co-op	$4,521.05
Rate for Payer: Monida PacificSource	$4,521.05

DESTRUCTION NEUROLYTIC AGT GENICULAR NE

Facility

$4,759.00

Service Code	HCPCS 64624
Hospital Charge Code	1564624
Hospital Revenue Code	761
Min. Negotiated Rate	$3,331.30
Max. Negotiated Rate	$4,759.00
Rate for Payer: Aetna Commercial	$4,521.05
Rate for Payer: Aetna Medicare	$4,283.10
Rate for Payer: BCBS MT CHIP	$4,283.10
Rate for Payer: BCBS MT Closed Plan Network	$4,521.05
Rate for Payer: BCBS MT HealthLink	$4,283.10
Rate for Payer: BCBS MT Medicare	$4,283.10
Rate for Payer: BCBS MT POS	$4,521.05
Rate for Payer: BCBS MT Traditional	$4,759.00
Rate for Payer: Cash Price	$4,283.10
Rate for Payer: Cigna Commercial	$4,521.05
Rate for Payer: Cigna Medicare	$4,283.10
Rate for Payer: Medicaid All Medicaid	$4,378.28
Rate for Payer: Medicare All Medicare	$3,331.30
Rate for Payer: Monida Allegiance	$4,521.05
Rate for Payer: Monida First Choice Health	$4,616.23
Rate for Payer: Monida Montana Health Co-op	$4,521.05
Rate for Payer: Monida PacificSource	$4,521.05

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