Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER TX BURN INITIAL 1ST DEGREE

Facility

$274.00

Service Code	HCPCS 16000
Hospital Charge Code	1016000
Hospital Revenue Code	450
Min. Negotiated Rate	$191.80
Max. Negotiated Rate	$274.00
Rate for Payer: Aetna Commercial	$260.30
Rate for Payer: Aetna Medicare	$246.60
Rate for Payer: BCBS MT CHIP	$246.60
Rate for Payer: BCBS MT Closed Plan Network	$260.30
Rate for Payer: BCBS MT HealthLink	$246.60
Rate for Payer: BCBS MT Medicare	$246.60
Rate for Payer: BCBS MT POS	$260.30
Rate for Payer: BCBS MT Traditional	$274.00
Rate for Payer: Cash Price	$246.60
Rate for Payer: Cigna Commercial	$260.30
Rate for Payer: Cigna Medicare	$246.60
Rate for Payer: Medicaid All Medicaid	$252.08
Rate for Payer: Medicare All Medicare	$191.80
Rate for Payer: Monida Allegiance	$260.30
Rate for Payer: Monida First Choice Health	$265.78
Rate for Payer: Monida Montana Health Co-op	$260.30
Rate for Payer: Monida PacificSource	$260.30

ER TX DISLOC(I-P)JT W/O ANES W/MANIP CLO

Facility

$683.00

Service Code	HCPCS 26770
Hospital Charge Code	1026770
Hospital Revenue Code	450
Min. Negotiated Rate	$478.10
Max. Negotiated Rate	$683.00
Rate for Payer: Aetna Commercial	$648.85
Rate for Payer: Aetna Medicare	$614.70
Rate for Payer: BCBS MT CHIP	$614.70
Rate for Payer: BCBS MT Closed Plan Network	$648.85
Rate for Payer: BCBS MT HealthLink	$614.70
Rate for Payer: BCBS MT Medicare	$614.70
Rate for Payer: BCBS MT POS	$648.85
Rate for Payer: BCBS MT Traditional	$683.00
Rate for Payer: Cash Price	$614.70
Rate for Payer: Cigna Commercial	$648.85
Rate for Payer: Cigna Medicare	$614.70
Rate for Payer: Medicaid All Medicaid	$628.36
Rate for Payer: Medicare All Medicare	$478.10
Rate for Payer: Monida Allegiance	$648.85
Rate for Payer: Monida First Choice Health	$662.51
Rate for Payer: Monida Montana Health Co-op	$648.85
Rate for Payer: Monida PacificSource	$648.85

ER TX DISLOC(I-P)JT W/O ANES W/MANIP CLO

Facility

$683.00

Service Code	HCPCS 26770
Hospital Charge Code	1026770
Hospital Revenue Code	450
Min. Negotiated Rate	$478.10
Max. Negotiated Rate	$683.00
Rate for Payer: Aetna Commercial	$648.85
Rate for Payer: Aetna Medicare	$614.70
Rate for Payer: BCBS MT CHIP	$614.70
Rate for Payer: BCBS MT Closed Plan Network	$648.85
Rate for Payer: BCBS MT HealthLink	$614.70
Rate for Payer: BCBS MT Medicare	$614.70
Rate for Payer: BCBS MT POS	$648.85
Rate for Payer: BCBS MT Traditional	$683.00
Rate for Payer: Cash Price	$614.70
Rate for Payer: Cigna Commercial	$648.85
Rate for Payer: Cigna Medicare	$614.70
Rate for Payer: Medicaid All Medicaid	$628.36
Rate for Payer: Medicare All Medicare	$478.10
Rate for Payer: Monida Allegiance	$648.85
Rate for Payer: Monida First Choice Health	$662.51
Rate for Payer: Monida Montana Health Co-op	$648.85
Rate for Payer: Monida PacificSource	$648.85

ER TX DISLOC(M-P)W/ANES W/MANIP CLOSED

Facility

$540.00

Service Code	HCPCS 26705
Hospital Charge Code	1026705
Hospital Revenue Code	450
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna Commercial	$513.00
Rate for Payer: Aetna Medicare	$486.00
Rate for Payer: BCBS MT CHIP	$486.00
Rate for Payer: BCBS MT Closed Plan Network	$513.00
Rate for Payer: BCBS MT HealthLink	$486.00
Rate for Payer: BCBS MT Medicare	$486.00
Rate for Payer: BCBS MT POS	$513.00
Rate for Payer: BCBS MT Traditional	$540.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna Commercial	$513.00
Rate for Payer: Cigna Medicare	$486.00
Rate for Payer: Medicaid All Medicaid	$496.80
Rate for Payer: Medicare All Medicare	$378.00
Rate for Payer: Monida Allegiance	$513.00
Rate for Payer: Monida First Choice Health	$523.80
Rate for Payer: Monida Montana Health Co-op	$513.00
Rate for Payer: Monida PacificSource	$513.00

ER TX DISLOC(M-P)W/ANES W/MANIP CLOSED

Facility

$540.00

Service Code	HCPCS 26705
Hospital Charge Code	1026705
Hospital Revenue Code	450
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna Commercial	$513.00
Rate for Payer: Aetna Medicare	$486.00
Rate for Payer: BCBS MT CHIP	$486.00
Rate for Payer: BCBS MT Closed Plan Network	$513.00
Rate for Payer: BCBS MT HealthLink	$486.00
Rate for Payer: BCBS MT Medicare	$486.00
Rate for Payer: BCBS MT POS	$513.00
Rate for Payer: BCBS MT Traditional	$540.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna Commercial	$513.00
Rate for Payer: Cigna Medicare	$486.00
Rate for Payer: Medicaid All Medicaid	$496.80
Rate for Payer: Medicare All Medicare	$378.00
Rate for Payer: Monida Allegiance	$513.00
Rate for Payer: Monida First Choice Health	$523.80
Rate for Payer: Monida Montana Health Co-op	$513.00
Rate for Payer: Monida PacificSource	$513.00

ER TX OF TOE FRACTURE

Facility

$410.00

Service Code	HCPCS 28515
Hospital Charge Code	1028515
Hospital Revenue Code	450
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

ER TX OF TOE FRACTURE

Facility

$410.00

Service Code	HCPCS 28515
Hospital Charge Code	1028515
Hospital Revenue Code	450
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

ER TX SHOULDER DISLOC W/O ANEST CLOSED

Facility

$563.00

Service Code	HCPCS 23650
Hospital Charge Code	1023650
Hospital Revenue Code	450
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

ER TX SHOULDER DISLOC W/O ANEST CLOSED

Facility

$563.00

Service Code	HCPCS 23650
Hospital Charge Code	1023650
Hospital Revenue Code	450
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

ERYTHROCYTE SEDIMENTATION RATE, BLOOD

Facility

$58.00

Service Code	HCPCS 85652
Hospital Charge Code	4085651
Hospital Revenue Code	305
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

ERYTHROCYTE SEDIMENTATION RATE, BLOOD

Facility

$58.00

Service Code	HCPCS 85652
Hospital Charge Code	4085651
Hospital Revenue Code	305
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

ERYTHROMYCIN OPTH OINT [3.5 GM]

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	3000167
Hospital Revenue Code	259
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

ERYTHROMYCIN OPTH OINT [3.5 GM]

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	3000167
Hospital Revenue Code	259
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

ERYTHROPOIETIN (140277)

Facility

$32.00

Service Code	HCPCS 82668
Hospital Charge Code	4082668
Hospital Revenue Code	300
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ERYTHROPOIETIN (140277)

Facility

$32.00

Service Code	HCPCS 82668
Hospital Charge Code	4082668
Hospital Revenue Code	300
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

ESCITALOPRAM TAB [10 MG]

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	3000168
Hospital Revenue Code	250
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

ESCITALOPRAM TAB [10 MG]

Facility

$15.00

Service Code	HCPCS J3490
Hospital Charge Code	3000168
Hospital Revenue Code	250
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

ESTRADIOL (004515)

Facility

$60.00

Service Code	HCPCS 82670
Hospital Charge Code	4082670
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

ESTRADIOL (004515)

Facility

$60.00

Service Code	HCPCS 82670
Hospital Charge Code	4082670
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

ESTRADIOL; FREE 82681

Facility

$56.00

Service Code	HCPCS 82681
Hospital Charge Code	4082681
Hospital Revenue Code	300
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

ESTRADIOL; FREE 82681

Facility

$56.00

Service Code	HCPCS 82681
Hospital Charge Code	4082681
Hospital Revenue Code	300
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

ESTRADIOL VAGINAL CREAM 0.01%

Facility

$589.40

Service Code	NDC 66993000210
Hospital Charge Code	3007400
Hospital Revenue Code	250
Min. Negotiated Rate	$412.58
Max. Negotiated Rate	$589.40
Rate for Payer: Aetna Commercial	$559.93
Rate for Payer: Aetna Medicare	$530.46
Rate for Payer: BCBS MT CHIP	$530.46
Rate for Payer: BCBS MT Closed Plan Network	$559.93
Rate for Payer: BCBS MT HealthLink	$530.46
Rate for Payer: BCBS MT Medicare	$530.46
Rate for Payer: BCBS MT POS	$559.93
Rate for Payer: BCBS MT Traditional	$589.40
Rate for Payer: Cash Price	$530.46
Rate for Payer: Cigna Commercial	$559.93
Rate for Payer: Cigna Medicare	$530.46
Rate for Payer: Medicaid All Medicaid	$542.25
Rate for Payer: Medicare All Medicare	$412.58
Rate for Payer: Monida Allegiance	$559.93
Rate for Payer: Monida First Choice Health	$571.72
Rate for Payer: Monida Montana Health Co-op	$559.93
Rate for Payer: Monida PacificSource	$559.93

ESTRADIOL VAGINAL CREAM 0.01%

Facility

$589.40

Service Code	NDC 66993000210
Hospital Charge Code	3007400
Hospital Revenue Code	250
Min. Negotiated Rate	$412.58
Max. Negotiated Rate	$589.40
Rate for Payer: Aetna Commercial	$559.93
Rate for Payer: Aetna Medicare	$530.46
Rate for Payer: BCBS MT CHIP	$530.46
Rate for Payer: BCBS MT Closed Plan Network	$559.93
Rate for Payer: BCBS MT HealthLink	$530.46
Rate for Payer: BCBS MT Medicare	$530.46
Rate for Payer: BCBS MT POS	$559.93
Rate for Payer: BCBS MT Traditional	$589.40
Rate for Payer: Cash Price	$530.46
Rate for Payer: Cigna Commercial	$559.93
Rate for Payer: Cigna Medicare	$530.46
Rate for Payer: Medicaid All Medicaid	$542.25
Rate for Payer: Medicare All Medicare	$412.58
Rate for Payer: Monida Allegiance	$559.93
Rate for Payer: Monida First Choice Health	$571.72
Rate for Payer: Monida Montana Health Co-op	$559.93
Rate for Payer: Monida PacificSource	$559.93

ESTRIOL (004614)

Facility

$74.00

Service Code	HCPCS 82677
Hospital Charge Code	4082677
Hospital Revenue Code	300
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$70.30
Rate for Payer: Aetna Medicare	$66.60
Rate for Payer: BCBS MT CHIP	$66.60
Rate for Payer: BCBS MT Closed Plan Network	$70.30
Rate for Payer: BCBS MT HealthLink	$66.60
Rate for Payer: BCBS MT Medicare	$66.60
Rate for Payer: BCBS MT POS	$70.30
Rate for Payer: BCBS MT Traditional	$74.00
Rate for Payer: Cash Price	$66.60
Rate for Payer: Cigna Commercial	$70.30
Rate for Payer: Cigna Medicare	$66.60
Rate for Payer: Medicaid All Medicaid	$68.08
Rate for Payer: Medicare All Medicare	$51.80
Rate for Payer: Monida Allegiance	$70.30
Rate for Payer: Monida First Choice Health	$71.78
Rate for Payer: Monida Montana Health Co-op	$70.30
Rate for Payer: Monida PacificSource	$70.30

ESTRIOL (004614)

Facility

$74.00

Service Code	HCPCS 82677
Hospital Charge Code	4082677
Hospital Revenue Code	300
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$70.30
Rate for Payer: Aetna Medicare	$66.60
Rate for Payer: BCBS MT CHIP	$66.60
Rate for Payer: BCBS MT Closed Plan Network	$70.30
Rate for Payer: BCBS MT HealthLink	$66.60
Rate for Payer: BCBS MT Medicare	$66.60
Rate for Payer: BCBS MT POS	$70.30
Rate for Payer: BCBS MT Traditional	$74.00
Rate for Payer: Cash Price	$66.60
Rate for Payer: Cigna Commercial	$70.30
Rate for Payer: Cigna Medicare	$66.60
Rate for Payer: Medicaid All Medicaid	$68.08
Rate for Payer: Medicare All Medicare	$51.80
Rate for Payer: Monida Allegiance	$70.30
Rate for Payer: Monida First Choice Health	$71.78
Rate for Payer: Monida Montana Health Co-op	$70.30
Rate for Payer: Monida PacificSource	$70.30

Know your out-of-pocket cost for care.

All Charges