Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$724.00

Service Code	HCPCS 26770
Hospital Charge Code	1026770
Hospital Revenue Code	450
Min. Negotiated Rate	$506.80
Max. Negotiated Rate	$724.00
Rate for Payer: Aetna Commercial	$687.80
Rate for Payer: Aetna Medicare	$651.60
Rate for Payer: BCBS MT CHIP	$651.60
Rate for Payer: BCBS MT Closed Plan Network	$687.80
Rate for Payer: BCBS MT HealthLink	$651.60
Rate for Payer: BCBS MT Medicare	$651.60
Rate for Payer: BCBS MT POS	$687.80
Rate for Payer: BCBS MT Traditional	$724.00
Rate for Payer: Cash Price	$651.60
Rate for Payer: Cigna Commercial	$687.80
Rate for Payer: Cigna Medicare	$651.60
Rate for Payer: Medicaid All Medicaid	$666.08
Rate for Payer: Medicare All Medicare	$506.80
Rate for Payer: Monida Allegiance	$687.80
Rate for Payer: Monida First Choice Health	$702.28
Rate for Payer: Monida Montana Health Co-op	$687.80
Rate for Payer: Monida PacificSource	$687.80

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

Facility

$572.00

Service Code	HCPCS 26705
Hospital Charge Code	1026705
Hospital Revenue Code	450
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

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

Facility

$572.00

Service Code	HCPCS 26705
Hospital Charge Code	1026705
Hospital Revenue Code	450
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

ER TX OF TOE FRACTURE

Facility

$435.00

Service Code	HCPCS 28515
Hospital Charge Code	1028515
Hospital Revenue Code	450
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$435.00
Rate for Payer: Aetna Commercial	$413.25
Rate for Payer: Aetna Medicare	$391.50
Rate for Payer: BCBS MT CHIP	$391.50
Rate for Payer: BCBS MT Closed Plan Network	$413.25
Rate for Payer: BCBS MT HealthLink	$391.50
Rate for Payer: BCBS MT Medicare	$391.50
Rate for Payer: BCBS MT POS	$413.25
Rate for Payer: BCBS MT Traditional	$435.00
Rate for Payer: Cash Price	$391.50
Rate for Payer: Cigna Commercial	$413.25
Rate for Payer: Cigna Medicare	$391.50
Rate for Payer: Medicaid All Medicaid	$400.20
Rate for Payer: Medicare All Medicare	$304.50
Rate for Payer: Monida Allegiance	$413.25
Rate for Payer: Monida First Choice Health	$421.95
Rate for Payer: Monida Montana Health Co-op	$413.25
Rate for Payer: Monida PacificSource	$413.25

ER TX OF TOE FRACTURE

Facility

$435.00

Service Code	HCPCS 28515
Hospital Charge Code	1028515
Hospital Revenue Code	450
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$435.00
Rate for Payer: Aetna Commercial	$413.25
Rate for Payer: Aetna Medicare	$391.50
Rate for Payer: BCBS MT CHIP	$391.50
Rate for Payer: BCBS MT Closed Plan Network	$413.25
Rate for Payer: BCBS MT HealthLink	$391.50
Rate for Payer: BCBS MT Medicare	$391.50
Rate for Payer: BCBS MT POS	$413.25
Rate for Payer: BCBS MT Traditional	$435.00
Rate for Payer: Cash Price	$391.50
Rate for Payer: Cigna Commercial	$413.25
Rate for Payer: Cigna Medicare	$391.50
Rate for Payer: Medicaid All Medicaid	$400.20
Rate for Payer: Medicare All Medicare	$304.50
Rate for Payer: Monida Allegiance	$413.25
Rate for Payer: Monida First Choice Health	$421.95
Rate for Payer: Monida Montana Health Co-op	$413.25
Rate for Payer: Monida PacificSource	$413.25

ER TX SHOULDER DISLOC W/O ANEST CLOSED

Facility

$597.00

Service Code	HCPCS 23650
Hospital Charge Code	1023650
Hospital Revenue Code	450
Min. Negotiated Rate	$417.90
Max. Negotiated Rate	$597.00
Rate for Payer: Aetna Commercial	$567.15
Rate for Payer: Aetna Medicare	$537.30
Rate for Payer: BCBS MT CHIP	$537.30
Rate for Payer: BCBS MT Closed Plan Network	$567.15
Rate for Payer: BCBS MT HealthLink	$537.30
Rate for Payer: BCBS MT Medicare	$537.30
Rate for Payer: BCBS MT POS	$567.15
Rate for Payer: BCBS MT Traditional	$597.00
Rate for Payer: Cash Price	$537.30
Rate for Payer: Cigna Commercial	$567.15
Rate for Payer: Cigna Medicare	$537.30
Rate for Payer: Medicaid All Medicaid	$549.24
Rate for Payer: Medicare All Medicare	$417.90
Rate for Payer: Monida Allegiance	$567.15
Rate for Payer: Monida First Choice Health	$579.09
Rate for Payer: Monida Montana Health Co-op	$567.15
Rate for Payer: Monida PacificSource	$567.15

ER TX SHOULDER DISLOC W/O ANEST CLOSED

Facility

$597.00

Service Code	HCPCS 23650
Hospital Charge Code	1023650
Hospital Revenue Code	450
Min. Negotiated Rate	$417.90
Max. Negotiated Rate	$597.00
Rate for Payer: Aetna Commercial	$567.15
Rate for Payer: Aetna Medicare	$537.30
Rate for Payer: BCBS MT CHIP	$537.30
Rate for Payer: BCBS MT Closed Plan Network	$567.15
Rate for Payer: BCBS MT HealthLink	$537.30
Rate for Payer: BCBS MT Medicare	$537.30
Rate for Payer: BCBS MT POS	$567.15
Rate for Payer: BCBS MT Traditional	$597.00
Rate for Payer: Cash Price	$537.30
Rate for Payer: Cigna Commercial	$567.15
Rate for Payer: Cigna Medicare	$537.30
Rate for Payer: Medicaid All Medicaid	$549.24
Rate for Payer: Medicare All Medicare	$417.90
Rate for Payer: Monida Allegiance	$567.15
Rate for Payer: Monida First Choice Health	$579.09
Rate for Payer: Monida Montana Health Co-op	$567.15
Rate for Payer: Monida PacificSource	$567.15

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

$91.00

Service Code	HCPCS 82670
Hospital Charge Code	4082670
Hospital Revenue Code	300
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

ESTRADIOL (004515)

Facility

$91.00

Service Code	HCPCS 82670
Hospital Charge Code	4082670
Hospital Revenue Code	300
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

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 CRM [0.01%] 42.5GM NF

Facility

$590.00

Service Code	NDC 66993000210
Hospital Charge Code	3007400
Hospital Revenue Code	250
Min. Negotiated Rate	$413.00
Max. Negotiated Rate	$590.00
Rate for Payer: Aetna Commercial	$560.50
Rate for Payer: Aetna Medicare	$531.00
Rate for Payer: BCBS MT CHIP	$531.00
Rate for Payer: BCBS MT Closed Plan Network	$560.50
Rate for Payer: BCBS MT HealthLink	$531.00
Rate for Payer: BCBS MT Medicare	$531.00
Rate for Payer: BCBS MT POS	$560.50
Rate for Payer: BCBS MT Traditional	$590.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cigna Commercial	$560.50
Rate for Payer: Cigna Medicare	$531.00
Rate for Payer: Medicaid All Medicaid	$542.80
Rate for Payer: Medicare All Medicare	$413.00
Rate for Payer: Monida Allegiance	$560.50
Rate for Payer: Monida First Choice Health	$572.30
Rate for Payer: Monida Montana Health Co-op	$560.50
Rate for Payer: Monida PacificSource	$560.50

ESTRADIOL VAGINAL CRM [0.01%] 42.5GM NF

Facility

$590.00

Service Code	NDC 66993000210
Hospital Charge Code	3007400
Hospital Revenue Code	250
Min. Negotiated Rate	$413.00
Max. Negotiated Rate	$590.00
Rate for Payer: Aetna Commercial	$560.50
Rate for Payer: Aetna Medicare	$531.00
Rate for Payer: BCBS MT CHIP	$531.00
Rate for Payer: BCBS MT Closed Plan Network	$560.50
Rate for Payer: BCBS MT HealthLink	$531.00
Rate for Payer: BCBS MT Medicare	$531.00
Rate for Payer: BCBS MT POS	$560.50
Rate for Payer: BCBS MT Traditional	$590.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cigna Commercial	$560.50
Rate for Payer: Cigna Medicare	$531.00
Rate for Payer: Medicaid All Medicaid	$542.80
Rate for Payer: Medicare All Medicare	$413.00
Rate for Payer: Monida Allegiance	$560.50
Rate for Payer: Monida First Choice Health	$572.30
Rate for Payer: Monida Montana Health Co-op	$560.50
Rate for Payer: Monida PacificSource	$560.50

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

ESTROGEN CONJUGATED TAB [0.45 MG] NF

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	3007555
Hospital Revenue Code	250
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

ESTROGEN CONJUGATED TAB [0.45 MG] NF

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	3007555
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges