Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

EXCISION BNIGN LSION-SCALP-1.1-2.0(11422

Facility

$469.00

Service Code	CPT 11422
Hospital Charge Code	8011422
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 BNIGN LSION-SCALP-1.1-2.0(11422

Facility

$469.00

Service Code	CPT 11422
Hospital Charge Code	8011422
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 MALIG LESION 0.6-1.0CM (11601)

Facility

$431.00

Service Code	CPT 11601
Hospital Charge Code	8011601
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 MALIG LESION 0.6-1.0CM (11601)

Facility

$431.00

Service Code	CPT 11601
Hospital Charge Code	8011601
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 MALIG LESION 1.1-2.0CM (11602)

Facility

$470.00

Service Code	CPT 11602
Hospital Charge Code	8011602
Hospital Revenue Code	521
Min. Negotiated Rate	$329.00
Max. Negotiated Rate	$470.00
Rate for Payer: Aetna Commercial	$446.50
Rate for Payer: Aetna Medicare	$423.00
Rate for Payer: BCBS MT CHIP	$423.00
Rate for Payer: BCBS MT Closed Plan Network	$446.50
Rate for Payer: BCBS MT HealthLink	$423.00
Rate for Payer: BCBS MT Medicare	$423.00
Rate for Payer: BCBS MT POS	$446.50
Rate for Payer: BCBS MT Traditional	$470.00
Rate for Payer: Cash Price	$423.00
Rate for Payer: Cigna Commercial	$446.50
Rate for Payer: Cigna Medicare	$423.00
Rate for Payer: Medicaid All Medicaid	$432.40
Rate for Payer: Medicare All Medicare	$329.00
Rate for Payer: Monida Allegiance	$446.50
Rate for Payer: Monida First Choice Health	$455.90
Rate for Payer: Monida Montana Health Co-op	$446.50
Rate for Payer: Monida PacificSource	$446.50

EXCISION MALIG LESION 1.1-2.0CM (11602)

Facility

$470.00

Service Code	CPT 11602
Hospital Charge Code	8011602
Hospital Revenue Code	521
Min. Negotiated Rate	$329.00
Max. Negotiated Rate	$470.00
Rate for Payer: Aetna Commercial	$446.50
Rate for Payer: Aetna Medicare	$423.00
Rate for Payer: BCBS MT CHIP	$423.00
Rate for Payer: BCBS MT Closed Plan Network	$446.50
Rate for Payer: BCBS MT HealthLink	$423.00
Rate for Payer: BCBS MT Medicare	$423.00
Rate for Payer: BCBS MT POS	$446.50
Rate for Payer: BCBS MT Traditional	$470.00
Rate for Payer: Cash Price	$423.00
Rate for Payer: Cigna Commercial	$446.50
Rate for Payer: Cigna Medicare	$423.00
Rate for Payer: Medicaid All Medicaid	$432.40
Rate for Payer: Medicare All Medicare	$329.00
Rate for Payer: Monida Allegiance	$446.50
Rate for Payer: Monida First Choice Health	$455.90
Rate for Payer: Monida Montana Health Co-op	$446.50
Rate for Payer: Monida PacificSource	$446.50

EXCISION NAIL INGROWN PART/COMPLT(11750)

Facility

$520.00

Service Code	CPT 11750
Hospital Charge Code	8011750
Hospital Revenue Code	521
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

EXCISION NAIL INGROWN PART/COMPLT(11750)

Facility

$520.00

Service Code	CPT 11750
Hospital Charge Code	8011750
Hospital Revenue Code	521
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

EXCISION OF NAIL FOLD SKIN (11765)

Facility

$303.00

Service Code	CPT 11765
Hospital Charge Code	8011765
Hospital Revenue Code	521
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

EXCISION OF NAIL FOLD SKIN (11765)

Facility

$303.00

Service Code	CPT 11765
Hospital Charge Code	8011765
Hospital Revenue Code	521
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

EXCSION BNIGN LSION + MARG 0.6-1CM(11421

Facility

$586.00

Service Code	CPT 11421
Hospital Charge Code	8011421
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

EXCSION BNIGN LSION + MARG 0.6-1CM(11421

Facility

$586.00

Service Code	CPT 11421
Hospital Charge Code	8011421
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

.EXTRACTABLE NUCLEAR AG AB (160014)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4062350
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

.EXTRACTABLE NUCLEAR AG AB (160014)

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4062350
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

EXTRACTABLE NUCLEAR ANTIGEN 3

Facility

$96.00

Service Code	CPT 86235
Hospital Charge Code	4088099
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

EXTRACTABLE NUCLEAR ANTIGEN 3

Facility

$96.00

Service Code	CPT 86235
Hospital Charge Code	4088099
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

EXTRCBL NUCL AG-EACH AB ANY METH 86235

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4086235
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

EXTRCBL NUCL AG-EACH AB ANY METH 86235

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	4086235
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

EYE PADS

Facility

$4.00

Hospital Charge Code	80030173
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

EYE PADS

Facility

$4.00

Hospital Charge Code	80030173
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

EYE STREAM IRRIGATING RINSE [4 OZ]

Facility

$117.00

Service Code	HCPCS J3490
Hospital Charge Code	3000171
Hospital Revenue Code	250
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare	$105.30
Rate for Payer: BCBS MT CHIP	$105.30
Rate for Payer: BCBS MT Closed Plan Network	$111.15
Rate for Payer: BCBS MT HealthLink	$105.30
Rate for Payer: BCBS MT Medicare	$105.30
Rate for Payer: BCBS MT POS	$111.15
Rate for Payer: BCBS MT Traditional	$117.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cigna Commercial	$111.15
Rate for Payer: Cigna Medicare	$105.30
Rate for Payer: Medicaid All Medicaid	$107.64
Rate for Payer: Medicare All Medicare	$81.90
Rate for Payer: Monida Allegiance	$111.15
Rate for Payer: Monida First Choice Health	$113.49
Rate for Payer: Monida Montana Health Co-op	$111.15
Rate for Payer: Monida PacificSource	$111.15

EYE STREAM IRRIGATING RINSE [4 OZ]

Facility

$117.00

Service Code	HCPCS J3490
Hospital Charge Code	3000171
Hospital Revenue Code	250
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare	$105.30
Rate for Payer: BCBS MT CHIP	$105.30
Rate for Payer: BCBS MT Closed Plan Network	$111.15
Rate for Payer: BCBS MT HealthLink	$105.30
Rate for Payer: BCBS MT Medicare	$105.30
Rate for Payer: BCBS MT POS	$111.15
Rate for Payer: BCBS MT Traditional	$117.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cigna Commercial	$111.15
Rate for Payer: Cigna Medicare	$105.30
Rate for Payer: Medicaid All Medicaid	$107.64
Rate for Payer: Medicare All Medicare	$81.90
Rate for Payer: Monida Allegiance	$111.15
Rate for Payer: Monida First Choice Health	$113.49
Rate for Payer: Monida Montana Health Co-op	$111.15
Rate for Payer: Monida PacificSource	$111.15

EZETIMIBE TAB [10 MG] NF

Facility

$17.00

Service Code	HCPCS J8499
Hospital Charge Code	3000505
Hospital Revenue Code	250
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

EZETIMIBE TAB [10 MG] NF

Facility

$17.00

Service Code	HCPCS J8499
Hospital Charge Code	3000505
Hospital Revenue Code	250
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

EZ SCRUB

Facility

$4.00

Hospital Charge Code	80030499
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

Know your out-of-pocket cost for care.

All Charges