Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ETOMIDATE INJ [2MG/ML]

Facility

$25.00

Service Code	HCPCS J3490
Hospital Charge Code	3000170
Hospital Revenue Code	250
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

ET TUBE SIZE 2.0

Facility

$27.00

Hospital Charge Code	80030162
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

ET TUBE SIZE 2.0

Facility

$27.00

Hospital Charge Code	80030162
Hospital Revenue Code	270
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

ET TUBE SIZE 5.5

Facility

$51.00

Hospital Charge Code	80030161
Hospital Revenue Code	270
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$48.45
Rate for Payer: Aetna Medicare	$45.90
Rate for Payer: BCBS MT CHIP	$45.90
Rate for Payer: BCBS MT Closed Plan Network	$48.45
Rate for Payer: BCBS MT HealthLink	$45.90
Rate for Payer: BCBS MT Medicare	$45.90
Rate for Payer: BCBS MT POS	$48.45
Rate for Payer: BCBS MT Traditional	$51.00
Rate for Payer: Cash Price	$45.90
Rate for Payer: Cigna Commercial	$48.45
Rate for Payer: Cigna Medicare	$45.90
Rate for Payer: Medicaid All Medicaid	$46.92
Rate for Payer: Medicare All Medicare	$35.70
Rate for Payer: Monida Allegiance	$48.45
Rate for Payer: Monida First Choice Health	$49.47
Rate for Payer: Monida Montana Health Co-op	$48.45
Rate for Payer: Monida PacificSource	$48.45

ET TUBE SIZE 5.5

Facility

$51.00

Hospital Charge Code	80030161
Hospital Revenue Code	270
Min. Negotiated Rate	$35.70
Max. Negotiated Rate	$51.00
Rate for Payer: Aetna Commercial	$48.45
Rate for Payer: Aetna Medicare	$45.90
Rate for Payer: BCBS MT CHIP	$45.90
Rate for Payer: BCBS MT Closed Plan Network	$48.45
Rate for Payer: BCBS MT HealthLink	$45.90
Rate for Payer: BCBS MT Medicare	$45.90
Rate for Payer: BCBS MT POS	$48.45
Rate for Payer: BCBS MT Traditional	$51.00
Rate for Payer: Cash Price	$45.90
Rate for Payer: Cigna Commercial	$48.45
Rate for Payer: Cigna Medicare	$45.90
Rate for Payer: Medicaid All Medicaid	$46.92
Rate for Payer: Medicare All Medicare	$35.70
Rate for Payer: Monida Allegiance	$48.45
Rate for Payer: Monida First Choice Health	$49.47
Rate for Payer: Monida Montana Health Co-op	$48.45
Rate for Payer: Monida PacificSource	$48.45

Eucerin Topical Cream-NF

Facility

$18.00

Hospital Charge Code	3007210
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

Eucerin Topical Cream-NF

Facility

$18.00

Hospital Charge Code	3007210
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

EVEROLIMUS (700003)

Facility

$348.00

Service Code	CPT 80169
Hospital Charge Code	4080169
Hospital Revenue Code	300
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

EVEROLIMUS (700003)

Facility

$348.00

Service Code	CPT 80169
Hospital Charge Code	4080169
Hospital Revenue Code	300
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

EXCISION BENIGN LESION 0.5CM/LESS (11400

Facility

$409.00

Service Code	CPT 11400
Hospital Charge Code	8011400
Hospital Revenue Code	521
Min. Negotiated Rate	$286.30
Max. Negotiated Rate	$409.00
Rate for Payer: Aetna Commercial	$388.55
Rate for Payer: Aetna Medicare	$368.10
Rate for Payer: BCBS MT CHIP	$368.10
Rate for Payer: BCBS MT Closed Plan Network	$388.55
Rate for Payer: BCBS MT HealthLink	$368.10
Rate for Payer: BCBS MT Medicare	$368.10
Rate for Payer: BCBS MT POS	$388.55
Rate for Payer: BCBS MT Traditional	$409.00
Rate for Payer: Cash Price	$368.10
Rate for Payer: Cigna Commercial	$388.55
Rate for Payer: Cigna Medicare	$368.10
Rate for Payer: Medicaid All Medicaid	$376.28
Rate for Payer: Medicare All Medicare	$286.30
Rate for Payer: Monida Allegiance	$388.55
Rate for Payer: Monida First Choice Health	$396.73
Rate for Payer: Monida Montana Health Co-op	$388.55
Rate for Payer: Monida PacificSource	$388.55

EXCISION BENIGN LESION 0.5CM/LESS (11400

Facility

$409.00

Service Code	CPT 11400
Hospital Charge Code	8011400
Hospital Revenue Code	521
Min. Negotiated Rate	$286.30
Max. Negotiated Rate	$409.00
Rate for Payer: Aetna Commercial	$388.55
Rate for Payer: Aetna Medicare	$368.10
Rate for Payer: BCBS MT CHIP	$368.10
Rate for Payer: BCBS MT Closed Plan Network	$388.55
Rate for Payer: BCBS MT HealthLink	$368.10
Rate for Payer: BCBS MT Medicare	$368.10
Rate for Payer: BCBS MT POS	$388.55
Rate for Payer: BCBS MT Traditional	$409.00
Rate for Payer: Cash Price	$368.10
Rate for Payer: Cigna Commercial	$388.55
Rate for Payer: Cigna Medicare	$368.10
Rate for Payer: Medicaid All Medicaid	$376.28
Rate for Payer: Medicare All Medicare	$286.30
Rate for Payer: Monida Allegiance	$388.55
Rate for Payer: Monida First Choice Health	$396.73
Rate for Payer: Monida Montana Health Co-op	$388.55
Rate for Payer: Monida PacificSource	$388.55

EXCISION BENIGN LESION 0.5CM LESS(11440)

Facility

$401.00

Service Code	CPT 11440
Hospital Charge Code	8011440
Hospital Revenue Code	521
Min. Negotiated Rate	$280.70
Max. Negotiated Rate	$401.00
Rate for Payer: Aetna Commercial	$380.95
Rate for Payer: Aetna Medicare	$360.90
Rate for Payer: BCBS MT CHIP	$360.90
Rate for Payer: BCBS MT Closed Plan Network	$380.95
Rate for Payer: BCBS MT HealthLink	$360.90
Rate for Payer: BCBS MT Medicare	$360.90
Rate for Payer: BCBS MT POS	$380.95
Rate for Payer: BCBS MT Traditional	$401.00
Rate for Payer: Cash Price	$360.90
Rate for Payer: Cigna Commercial	$380.95
Rate for Payer: Cigna Medicare	$360.90
Rate for Payer: Medicaid All Medicaid	$368.92
Rate for Payer: Medicare All Medicare	$280.70
Rate for Payer: Monida Allegiance	$380.95
Rate for Payer: Monida First Choice Health	$388.97
Rate for Payer: Monida Montana Health Co-op	$380.95
Rate for Payer: Monida PacificSource	$380.95

EXCISION BENIGN LESION 0.5CM LESS(11440)

Facility

$401.00

Service Code	CPT 11440
Hospital Charge Code	8011440
Hospital Revenue Code	521
Min. Negotiated Rate	$280.70
Max. Negotiated Rate	$401.00
Rate for Payer: Aetna Commercial	$380.95
Rate for Payer: Aetna Medicare	$360.90
Rate for Payer: BCBS MT CHIP	$360.90
Rate for Payer: BCBS MT Closed Plan Network	$380.95
Rate for Payer: BCBS MT HealthLink	$360.90
Rate for Payer: BCBS MT Medicare	$360.90
Rate for Payer: BCBS MT POS	$380.95
Rate for Payer: BCBS MT Traditional	$401.00
Rate for Payer: Cash Price	$360.90
Rate for Payer: Cigna Commercial	$380.95
Rate for Payer: Cigna Medicare	$360.90
Rate for Payer: Medicaid All Medicaid	$368.92
Rate for Payer: Medicare All Medicare	$280.70
Rate for Payer: Monida Allegiance	$380.95
Rate for Payer: Monida First Choice Health	$388.97
Rate for Payer: Monida Montana Health Co-op	$380.95
Rate for Payer: Monida PacificSource	$380.95

EXCISION BENIGN LESION 0.6-1.0CM(11401)

Facility

$431.00

Service Code	CPT 11401
Hospital Charge Code	8011401
Hospital Revenue Code	521
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

EXCISION BENIGN LESION 0.6-1.0CM(11401)

Facility

$431.00

Service Code	CPT 11401
Hospital Charge Code	8011401
Hospital Revenue Code	521
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

EXCISION BENIGN LESION 0.6-1.0CM (11441)

Facility

$712.00

Service Code	CPT 11441
Hospital Charge Code	8011441
Hospital Revenue Code	521
Min. Negotiated Rate	$498.40
Max. Negotiated Rate	$712.00
Rate for Payer: Aetna Commercial	$676.40
Rate for Payer: Aetna Medicare	$640.80
Rate for Payer: BCBS MT CHIP	$640.80
Rate for Payer: BCBS MT Closed Plan Network	$676.40
Rate for Payer: BCBS MT HealthLink	$640.80
Rate for Payer: BCBS MT Medicare	$640.80
Rate for Payer: BCBS MT POS	$676.40
Rate for Payer: BCBS MT Traditional	$712.00
Rate for Payer: Cash Price	$640.80
Rate for Payer: Cigna Commercial	$676.40
Rate for Payer: Cigna Medicare	$640.80
Rate for Payer: Medicaid All Medicaid	$655.04
Rate for Payer: Medicare All Medicare	$498.40
Rate for Payer: Monida Allegiance	$676.40
Rate for Payer: Monida First Choice Health	$690.64
Rate for Payer: Monida Montana Health Co-op	$676.40
Rate for Payer: Monida PacificSource	$676.40

EXCISION BENIGN LESION 0.6-1.0CM (11441)

Facility

$712.00

Service Code	CPT 11441
Hospital Charge Code	8011441
Hospital Revenue Code	521
Min. Negotiated Rate	$498.40
Max. Negotiated Rate	$712.00
Rate for Payer: Aetna Commercial	$676.40
Rate for Payer: Aetna Medicare	$640.80
Rate for Payer: BCBS MT CHIP	$640.80
Rate for Payer: BCBS MT Closed Plan Network	$676.40
Rate for Payer: BCBS MT HealthLink	$640.80
Rate for Payer: BCBS MT Medicare	$640.80
Rate for Payer: BCBS MT POS	$676.40
Rate for Payer: BCBS MT Traditional	$712.00
Rate for Payer: Cash Price	$640.80
Rate for Payer: Cigna Commercial	$676.40
Rate for Payer: Cigna Medicare	$640.80
Rate for Payer: Medicaid All Medicaid	$655.04
Rate for Payer: Medicare All Medicare	$498.40
Rate for Payer: Monida Allegiance	$676.40
Rate for Payer: Monida First Choice Health	$690.64
Rate for Payer: Monida Montana Health Co-op	$676.40
Rate for Payer: Monida PacificSource	$676.40

EXCISION BENIGN LESION 1.1-2.0CM(11402)

Facility

$469.00

Service Code	CPT 11402
Hospital Charge Code	8011402
Hospital Revenue Code	521
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

EXCISION BENIGN LESION 1.1-2.0CM(11402)

Facility

$469.00

Service Code	CPT 11402
Hospital Charge Code	8011402
Hospital Revenue Code	521
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

EXCISION BENIGN LESION 2.1-3.0CM(11403)

Facility

$497.00

Service Code	CPT 11403
Hospital Charge Code	8011403
Hospital Revenue Code	521
Min. Negotiated Rate	$347.90
Max. Negotiated Rate	$497.00
Rate for Payer: Aetna Commercial	$472.15
Rate for Payer: Aetna Medicare	$447.30
Rate for Payer: BCBS MT CHIP	$447.30
Rate for Payer: BCBS MT Closed Plan Network	$472.15
Rate for Payer: BCBS MT HealthLink	$447.30
Rate for Payer: BCBS MT Medicare	$447.30
Rate for Payer: BCBS MT POS	$472.15
Rate for Payer: BCBS MT Traditional	$497.00
Rate for Payer: Cash Price	$447.30
Rate for Payer: Cigna Commercial	$472.15
Rate for Payer: Cigna Medicare	$447.30
Rate for Payer: Medicaid All Medicaid	$457.24
Rate for Payer: Medicare All Medicare	$347.90
Rate for Payer: Monida Allegiance	$472.15
Rate for Payer: Monida First Choice Health	$482.09
Rate for Payer: Monida Montana Health Co-op	$472.15
Rate for Payer: Monida PacificSource	$472.15

EXCISION BENIGN LESION 2.1-3.0CM(11403)

Facility

$497.00

Service Code	CPT 11403
Hospital Charge Code	8011403
Hospital Revenue Code	521
Min. Negotiated Rate	$347.90
Max. Negotiated Rate	$497.00
Rate for Payer: Aetna Commercial	$472.15
Rate for Payer: Aetna Medicare	$447.30
Rate for Payer: BCBS MT CHIP	$447.30
Rate for Payer: BCBS MT Closed Plan Network	$472.15
Rate for Payer: BCBS MT HealthLink	$447.30
Rate for Payer: BCBS MT Medicare	$447.30
Rate for Payer: BCBS MT POS	$472.15
Rate for Payer: BCBS MT Traditional	$497.00
Rate for Payer: Cash Price	$447.30
Rate for Payer: Cigna Commercial	$472.15
Rate for Payer: Cigna Medicare	$447.30
Rate for Payer: Medicaid All Medicaid	$457.24
Rate for Payer: Medicare All Medicare	$347.90
Rate for Payer: Monida Allegiance	$472.15
Rate for Payer: Monida First Choice Health	$482.09
Rate for Payer: Monida Montana Health Co-op	$472.15
Rate for Payer: Monida PacificSource	$472.15

EXCISION BENIGN LESION 3.1-4.0 CM(11404)

Facility

$549.00

Service Code	CPT 11404
Hospital Charge Code	8011404
Hospital Revenue Code	521
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$549.00
Rate for Payer: Aetna Commercial	$521.55
Rate for Payer: Aetna Medicare	$494.10
Rate for Payer: BCBS MT CHIP	$494.10
Rate for Payer: BCBS MT Closed Plan Network	$521.55
Rate for Payer: BCBS MT HealthLink	$494.10
Rate for Payer: BCBS MT Medicare	$494.10
Rate for Payer: BCBS MT POS	$521.55
Rate for Payer: BCBS MT Traditional	$549.00
Rate for Payer: Cash Price	$494.10
Rate for Payer: Cigna Commercial	$521.55
Rate for Payer: Cigna Medicare	$494.10
Rate for Payer: Medicaid All Medicaid	$505.08
Rate for Payer: Medicare All Medicare	$384.30
Rate for Payer: Monida Allegiance	$521.55
Rate for Payer: Monida First Choice Health	$532.53
Rate for Payer: Monida Montana Health Co-op	$521.55
Rate for Payer: Monida PacificSource	$521.55

EXCISION BENIGN LESION 3.1-4.0 CM(11404)

Facility

$549.00

Service Code	CPT 11404
Hospital Charge Code	8011404
Hospital Revenue Code	521
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$549.00
Rate for Payer: Aetna Commercial	$521.55
Rate for Payer: Aetna Medicare	$494.10
Rate for Payer: BCBS MT CHIP	$494.10
Rate for Payer: BCBS MT Closed Plan Network	$521.55
Rate for Payer: BCBS MT HealthLink	$494.10
Rate for Payer: BCBS MT Medicare	$494.10
Rate for Payer: BCBS MT POS	$521.55
Rate for Payer: BCBS MT Traditional	$549.00
Rate for Payer: Cash Price	$494.10
Rate for Payer: Cigna Commercial	$521.55
Rate for Payer: Cigna Medicare	$494.10
Rate for Payer: Medicaid All Medicaid	$505.08
Rate for Payer: Medicare All Medicare	$384.30
Rate for Payer: Monida Allegiance	$521.55
Rate for Payer: Monida First Choice Health	$532.53
Rate for Payer: Monida Montana Health Co-op	$521.55
Rate for Payer: Monida PacificSource	$521.55

EXCISION BNIGN LSION + MARG >0.5CM(11420

Facility

$586.00

Service Code	CPT 11420
Hospital Charge Code	8011420
Hospital Revenue Code	521
Min. Negotiated Rate	$410.20
Max. Negotiated Rate	$586.00
Rate for Payer: Aetna Commercial	$556.70
Rate for Payer: Aetna Medicare	$527.40
Rate for Payer: BCBS MT CHIP	$527.40
Rate for Payer: BCBS MT Closed Plan Network	$556.70
Rate for Payer: BCBS MT HealthLink	$527.40
Rate for Payer: BCBS MT Medicare	$527.40
Rate for Payer: BCBS MT POS	$556.70
Rate for Payer: BCBS MT Traditional	$586.00
Rate for Payer: Cash Price	$527.40
Rate for Payer: Cigna Commercial	$556.70
Rate for Payer: Cigna Medicare	$527.40
Rate for Payer: Medicaid All Medicaid	$539.12
Rate for Payer: Medicare All Medicare	$410.20
Rate for Payer: Monida Allegiance	$556.70
Rate for Payer: Monida First Choice Health	$568.42
Rate for Payer: Monida Montana Health Co-op	$556.70
Rate for Payer: Monida PacificSource	$556.70

EXCISION BNIGN LSION + MARG >0.5CM(11420

Facility

$586.00

Service Code	CPT 11420
Hospital Charge Code	8011420
Hospital Revenue Code	521
Min. Negotiated Rate	$410.20
Max. Negotiated Rate	$586.00
Rate for Payer: Aetna Commercial	$556.70
Rate for Payer: Aetna Medicare	$527.40
Rate for Payer: BCBS MT CHIP	$527.40
Rate for Payer: BCBS MT Closed Plan Network	$556.70
Rate for Payer: BCBS MT HealthLink	$527.40
Rate for Payer: BCBS MT Medicare	$527.40
Rate for Payer: BCBS MT POS	$556.70
Rate for Payer: BCBS MT Traditional	$586.00
Rate for Payer: Cash Price	$527.40
Rate for Payer: Cigna Commercial	$556.70
Rate for Payer: Cigna Medicare	$527.40
Rate for Payer: Medicaid All Medicaid	$539.12
Rate for Payer: Medicare All Medicare	$410.20
Rate for Payer: Monida Allegiance	$556.70
Rate for Payer: Monida First Choice Health	$568.42
Rate for Payer: Monida Montana Health Co-op	$556.70
Rate for Payer: Monida PacificSource	$556.70

Know your out-of-pocket cost for care.

All Charges