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

$15.00

Hospital Charge Code	2893251
Hospital Revenue Code	290
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

DONOTUSE CERVICAL COLLAR UNIV 4"

Facility

$15.00

Hospital Charge Code	2893251
Hospital Revenue Code	290
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

DONOTUSE CERVICAL COLLAR XLG (FIRM)

Facility

$28.00

Hospital Charge Code	2893255
Hospital Revenue Code	290
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

DONOTUSE CERVICAL COLLAR XLG (FIRM)

Facility

$28.00

Hospital Charge Code	2893255
Hospital Revenue Code	290
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

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

$2,639.00

Service Code	HCPCS 93350
Hospital Charge Code	5100005
Hospital Revenue Code	402
Min. Negotiated Rate	$1,847.30
Max. Negotiated Rate	$2,639.00
Rate for Payer: Aetna Commercial	$2,507.05
Rate for Payer: Aetna Medicare	$2,375.10
Rate for Payer: BCBS MT CHIP	$2,375.10
Rate for Payer: BCBS MT Closed Plan Network	$2,507.05
Rate for Payer: BCBS MT HealthLink	$2,375.10
Rate for Payer: BCBS MT Medicare	$2,375.10
Rate for Payer: BCBS MT POS	$2,507.05
Rate for Payer: BCBS MT Traditional	$2,639.00
Rate for Payer: Cash Price	$2,375.10
Rate for Payer: Cigna Commercial	$2,507.05
Rate for Payer: Cigna Medicare	$2,375.10
Rate for Payer: Medicaid All Medicaid	$2,427.88
Rate for Payer: Medicare All Medicare	$1,847.30
Rate for Payer: Monida Allegiance	$2,507.05
Rate for Payer: Monida First Choice Health	$2,559.83
Rate for Payer: Monida Montana Health Co-op	$2,507.05
Rate for Payer: Monida PacificSource	$2,507.05

(DO NOT USE) STRESS ECHO WITH CONTRAST

Facility

$2,639.00

Service Code	HCPCS 93350
Hospital Charge Code	5100005
Hospital Revenue Code	402
Min. Negotiated Rate	$1,847.30
Max. Negotiated Rate	$2,639.00
Rate for Payer: Aetna Commercial	$2,507.05
Rate for Payer: Aetna Medicare	$2,375.10
Rate for Payer: BCBS MT CHIP	$2,375.10
Rate for Payer: BCBS MT Closed Plan Network	$2,507.05
Rate for Payer: BCBS MT HealthLink	$2,375.10
Rate for Payer: BCBS MT Medicare	$2,375.10
Rate for Payer: BCBS MT POS	$2,507.05
Rate for Payer: BCBS MT Traditional	$2,639.00
Rate for Payer: Cash Price	$2,375.10
Rate for Payer: Cigna Commercial	$2,507.05
Rate for Payer: Cigna Medicare	$2,375.10
Rate for Payer: Medicaid All Medicaid	$2,427.88
Rate for Payer: Medicare All Medicare	$1,847.30
Rate for Payer: Monida Allegiance	$2,507.05
Rate for Payer: Monida First Choice Health	$2,559.83
Rate for Payer: Monida Montana Health Co-op	$2,507.05
Rate for Payer: Monida PacificSource	$2,507.05

(DO NOT USE) STRESS TEST 99350

Facility

$2,163.00

Service Code	HCPCS 93350 TC
Hospital Charge Code	5193320
Hospital Revenue Code	402
Min. Negotiated Rate	$1,514.10
Max. Negotiated Rate	$2,163.00
Rate for Payer: Aetna Commercial	$2,054.85
Rate for Payer: Aetna Medicare	$1,946.70
Rate for Payer: BCBS MT CHIP	$1,946.70
Rate for Payer: BCBS MT Closed Plan Network	$2,054.85
Rate for Payer: BCBS MT HealthLink	$1,946.70
Rate for Payer: BCBS MT Medicare	$1,946.70
Rate for Payer: BCBS MT POS	$2,054.85
Rate for Payer: BCBS MT Traditional	$2,163.00
Rate for Payer: Cash Price	$1,946.70
Rate for Payer: Cigna Commercial	$2,054.85
Rate for Payer: Cigna Medicare	$1,946.70
Rate for Payer: Medicaid All Medicaid	$1,989.96
Rate for Payer: Medicare All Medicare	$1,514.10
Rate for Payer: Monida Allegiance	$2,054.85
Rate for Payer: Monida First Choice Health	$2,098.11
Rate for Payer: Monida Montana Health Co-op	$2,054.85
Rate for Payer: Monida PacificSource	$2,054.85

(DO NOT USE) STRESS TEST 99350

Facility

$2,163.00

Service Code	HCPCS 93350 TC
Hospital Charge Code	5193320
Hospital Revenue Code	402
Min. Negotiated Rate	$1,514.10
Max. Negotiated Rate	$2,163.00
Rate for Payer: Aetna Commercial	$2,054.85
Rate for Payer: Aetna Medicare	$1,946.70
Rate for Payer: BCBS MT CHIP	$1,946.70
Rate for Payer: BCBS MT Closed Plan Network	$2,054.85
Rate for Payer: BCBS MT HealthLink	$1,946.70
Rate for Payer: BCBS MT Medicare	$1,946.70
Rate for Payer: BCBS MT POS	$2,054.85
Rate for Payer: BCBS MT Traditional	$2,163.00
Rate for Payer: Cash Price	$1,946.70
Rate for Payer: Cigna Commercial	$2,054.85
Rate for Payer: Cigna Medicare	$1,946.70
Rate for Payer: Medicaid All Medicaid	$1,989.96
Rate for Payer: Medicare All Medicare	$1,514.10
Rate for Payer: Monida Allegiance	$2,054.85
Rate for Payer: Monida First Choice Health	$2,098.11
Rate for Payer: Monida Montana Health Co-op	$2,054.85
Rate for Payer: Monida PacificSource	$2,054.85

DOPAMINE PREMIX [400 MG/250 ML]

Facility

$56.00

Service Code	HCPCS J1265
Hospital Charge Code	3000606
Hospital Revenue Code	636
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

DOPAMINE PREMIX [400 MG/250 ML]

Facility

$56.00

Service Code	HCPCS J1265
Hospital Charge Code	3000606
Hospital Revenue Code	636
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

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% OPTH NF

Facility

$216.00

Service Code	HCPCS J3490
Hospital Charge Code	3007392
Hospital Revenue Code	250
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Aetna Medicare	$194.40
Rate for Payer: BCBS MT CHIP	$194.40
Rate for Payer: BCBS MT Closed Plan Network	$205.20
Rate for Payer: BCBS MT HealthLink	$194.40
Rate for Payer: BCBS MT Medicare	$194.40
Rate for Payer: BCBS MT POS	$205.20
Rate for Payer: BCBS MT Traditional	$216.00
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna Commercial	$205.20
Rate for Payer: Cigna Medicare	$194.40
Rate for Payer: Medicaid All Medicaid	$198.72
Rate for Payer: Medicare All Medicare	$151.20
Rate for Payer: Monida Allegiance	$205.20
Rate for Payer: Monida First Choice Health	$209.52
Rate for Payer: Monida Montana Health Co-op	$205.20
Rate for Payer: Monida PacificSource	$205.20

DORZOLAMIDE/TIMOLOL 2% / 0.5% OPTH NF

Facility

$216.00

Service Code	HCPCS J3490
Hospital Charge Code	3007392
Hospital Revenue Code	250
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna Commercial	$205.20
Rate for Payer: Aetna Medicare	$194.40
Rate for Payer: BCBS MT CHIP	$194.40
Rate for Payer: BCBS MT Closed Plan Network	$205.20
Rate for Payer: BCBS MT HealthLink	$194.40
Rate for Payer: BCBS MT Medicare	$194.40
Rate for Payer: BCBS MT POS	$205.20
Rate for Payer: BCBS MT Traditional	$216.00
Rate for Payer: Cash Price	$194.40
Rate for Payer: Cigna Commercial	$205.20
Rate for Payer: Cigna Medicare	$194.40
Rate for Payer: Medicaid All Medicaid	$198.72
Rate for Payer: Medicare All Medicare	$151.20
Rate for Payer: Monida Allegiance	$205.20
Rate for Payer: Monida First Choice Health	$209.52
Rate for Payer: Monida Montana Health Co-op	$205.20
Rate for Payer: Monida PacificSource	$205.20

DOXAZOSIN TAB [4 MG] NF

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 TAB [4 MG] NF

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 CAP [50 MG] NF

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 CAP [50 MG] NF

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 CAP [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 CAP [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

$365.00

Service Code	HCPCS 20604
Hospital Charge Code	1520604
Hospital Revenue Code	760
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

Know your out-of-pocket cost for care.

All Charges