Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HYDROXYZINE HCL TAB [25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007331
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

HYOSCYAMINE ODT [0.125 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007150
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

HYOSCYAMINE ODT [0.125 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007150
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

HYPERSENSITIVITY PNEUMONITIS EVAL

Facility

$93.25

Service Code	CPT 86609
Hospital Charge Code	4088017
Hospital Revenue Code	302
Min. Negotiated Rate	$65.28
Max. Negotiated Rate	$93.25
Rate for Payer: Aetna Commercial	$88.59
Rate for Payer: Aetna Medicare	$83.92
Rate for Payer: BCBS MT CHIP	$83.92
Rate for Payer: BCBS MT Closed Plan Network	$88.59
Rate for Payer: BCBS MT HealthLink	$83.92
Rate for Payer: BCBS MT Medicare	$83.92
Rate for Payer: BCBS MT POS	$88.59
Rate for Payer: BCBS MT Traditional	$93.25
Rate for Payer: Cash Price	$83.93
Rate for Payer: Cigna Commercial	$88.59
Rate for Payer: Cigna Medicare	$83.92
Rate for Payer: Medicaid All Medicaid	$85.79
Rate for Payer: Medicare All Medicare	$65.28
Rate for Payer: Monida Allegiance	$88.59
Rate for Payer: Monida First Choice Health	$90.45
Rate for Payer: Monida Montana Health Co-op	$88.59
Rate for Payer: Monida PacificSource	$88.59

HYPERSENSITIVITY PNEUMONITIS EVAL

Facility

$93.25

Service Code	CPT 86609
Hospital Charge Code	4088017
Hospital Revenue Code	302
Min. Negotiated Rate	$65.28
Max. Negotiated Rate	$93.25
Rate for Payer: Aetna Commercial	$88.59
Rate for Payer: Aetna Medicare	$83.92
Rate for Payer: BCBS MT CHIP	$83.92
Rate for Payer: BCBS MT Closed Plan Network	$88.59
Rate for Payer: BCBS MT HealthLink	$83.92
Rate for Payer: BCBS MT Medicare	$83.92
Rate for Payer: BCBS MT POS	$88.59
Rate for Payer: BCBS MT Traditional	$93.25
Rate for Payer: Cash Price	$83.93
Rate for Payer: Cigna Commercial	$88.59
Rate for Payer: Cigna Medicare	$83.92
Rate for Payer: Medicaid All Medicaid	$85.79
Rate for Payer: Medicare All Medicare	$65.28
Rate for Payer: Monida Allegiance	$88.59
Rate for Payer: Monida First Choice Health	$90.45
Rate for Payer: Monida Montana Health Co-op	$88.59
Rate for Payer: Monida PacificSource	$88.59

HYPOGLYCEMIC AGENT SCREEN

Facility

$151.00

Service Code	CPT 80377
Hospital Charge Code	4087942
Hospital Revenue Code	300
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$151.00
Rate for Payer: Aetna Commercial	$143.45
Rate for Payer: Aetna Medicare	$135.90
Rate for Payer: BCBS MT CHIP	$135.90
Rate for Payer: BCBS MT Closed Plan Network	$143.45
Rate for Payer: BCBS MT HealthLink	$135.90
Rate for Payer: BCBS MT Medicare	$135.90
Rate for Payer: BCBS MT POS	$143.45
Rate for Payer: BCBS MT Traditional	$151.00
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cigna Commercial	$143.45
Rate for Payer: Cigna Medicare	$135.90
Rate for Payer: Medicaid All Medicaid	$138.92
Rate for Payer: Medicare All Medicare	$105.70
Rate for Payer: Monida Allegiance	$143.45
Rate for Payer: Monida First Choice Health	$146.47
Rate for Payer: Monida Montana Health Co-op	$143.45
Rate for Payer: Monida PacificSource	$143.45

HYPOGLYCEMIC AGENT SCREEN

Facility

$151.00

Service Code	CPT 80377
Hospital Charge Code	4087942
Hospital Revenue Code	300
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$151.00
Rate for Payer: Aetna Commercial	$143.45
Rate for Payer: Aetna Medicare	$135.90
Rate for Payer: BCBS MT CHIP	$135.90
Rate for Payer: BCBS MT Closed Plan Network	$143.45
Rate for Payer: BCBS MT HealthLink	$135.90
Rate for Payer: BCBS MT Medicare	$135.90
Rate for Payer: BCBS MT POS	$143.45
Rate for Payer: BCBS MT Traditional	$151.00
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cigna Commercial	$143.45
Rate for Payer: Cigna Medicare	$135.90
Rate for Payer: Medicaid All Medicaid	$138.92
Rate for Payer: Medicare All Medicare	$105.70
Rate for Payer: Monida Allegiance	$143.45
Rate for Payer: Monida First Choice Health	$146.47
Rate for Payer: Monida Montana Health Co-op	$143.45
Rate for Payer: Monida PacificSource	$143.45

IA2 AUTOANTIBODIES

Facility

$140.00

Service Code	CPT 86341
Hospital Charge Code	4088004
Hospital Revenue Code	302
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS MT CHIP	$126.00
Rate for Payer: BCBS MT Closed Plan Network	$133.00
Rate for Payer: BCBS MT HealthLink	$126.00
Rate for Payer: BCBS MT Medicare	$126.00
Rate for Payer: BCBS MT POS	$133.00
Rate for Payer: BCBS MT Traditional	$140.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial	$133.00
Rate for Payer: Cigna Medicare	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

IA2 AUTOANTIBODIES

Facility

$140.00

Service Code	CPT 86341
Hospital Charge Code	4088004
Hospital Revenue Code	302
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS MT CHIP	$126.00
Rate for Payer: BCBS MT Closed Plan Network	$133.00
Rate for Payer: BCBS MT HealthLink	$126.00
Rate for Payer: BCBS MT Medicare	$126.00
Rate for Payer: BCBS MT POS	$133.00
Rate for Payer: BCBS MT Traditional	$140.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial	$133.00
Rate for Payer: Cigna Medicare	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

[IA] FILGRASTIM INJ [300 MCG/0.5 ML] NF

Facility

$611.00

Service Code	HCPCS Q5125
Hospital Charge Code	3000179
Hospital Revenue Code	636
Min. Negotiated Rate	$427.70
Max. Negotiated Rate	$611.00
Rate for Payer: Aetna Commercial	$580.45
Rate for Payer: Aetna Medicare	$549.90
Rate for Payer: BCBS MT CHIP	$549.90
Rate for Payer: BCBS MT Closed Plan Network	$580.45
Rate for Payer: BCBS MT HealthLink	$549.90
Rate for Payer: BCBS MT Medicare	$549.90
Rate for Payer: BCBS MT POS	$580.45
Rate for Payer: BCBS MT Traditional	$611.00
Rate for Payer: Cash Price	$549.90
Rate for Payer: Cigna Commercial	$580.45
Rate for Payer: Cigna Medicare	$549.90
Rate for Payer: Medicaid All Medicaid	$562.12
Rate for Payer: Medicare All Medicare	$427.70
Rate for Payer: Monida Allegiance	$580.45
Rate for Payer: Monida First Choice Health	$592.67
Rate for Payer: Monida Montana Health Co-op	$580.45
Rate for Payer: Monida PacificSource	$580.45

[IA] FILGRASTIM INJ [300 MCG/0.5 ML] NF

Facility

$611.00

Service Code	HCPCS Q5125
Hospital Charge Code	3000179
Hospital Revenue Code	636
Min. Negotiated Rate	$427.70
Max. Negotiated Rate	$611.00
Rate for Payer: Aetna Commercial	$580.45
Rate for Payer: Aetna Medicare	$549.90
Rate for Payer: BCBS MT CHIP	$549.90
Rate for Payer: BCBS MT Closed Plan Network	$580.45
Rate for Payer: BCBS MT HealthLink	$549.90
Rate for Payer: BCBS MT Medicare	$549.90
Rate for Payer: BCBS MT POS	$580.45
Rate for Payer: BCBS MT Traditional	$611.00
Rate for Payer: Cash Price	$549.90
Rate for Payer: Cigna Commercial	$580.45
Rate for Payer: Cigna Medicare	$549.90
Rate for Payer: Medicaid All Medicaid	$562.12
Rate for Payer: Medicare All Medicare	$427.70
Rate for Payer: Monida Allegiance	$580.45
Rate for Payer: Monida First Choice Health	$592.67
Rate for Payer: Monida Montana Health Co-op	$580.45
Rate for Payer: Monida PacificSource	$580.45

[IA] FILGRASTIM INJ [480 MCG/0.8 ML] NF

Facility

$893.00

Service Code	HCPCS J1442
Hospital Charge Code	3000580
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

[IA] FILGRASTIM INJ [480 MCG/0.8 ML] NF

Facility

$893.00

Service Code	HCPCS J1442
Hospital Charge Code	3000580
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

[IA] FILGRASTIM INJ [480 MCG/0.8 ML] PFS

Facility

$893.00

Service Code	HCPCS J1447
Hospital Charge Code	3000575
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

[IA] FILGRASTIM INJ [480 MCG/0.8 ML] PFS

Facility

$893.00

Service Code	HCPCS J1447
Hospital Charge Code	3000575
Hospital Revenue Code	636
Min. Negotiated Rate	$625.10
Max. Negotiated Rate	$893.00
Rate for Payer: Aetna Commercial	$848.35
Rate for Payer: Aetna Medicare	$803.70
Rate for Payer: BCBS MT CHIP	$803.70
Rate for Payer: BCBS MT Closed Plan Network	$848.35
Rate for Payer: BCBS MT HealthLink	$803.70
Rate for Payer: BCBS MT Medicare	$803.70
Rate for Payer: BCBS MT POS	$848.35
Rate for Payer: BCBS MT Traditional	$893.00
Rate for Payer: Cash Price	$803.70
Rate for Payer: Cigna Commercial	$848.35
Rate for Payer: Cigna Medicare	$803.70
Rate for Payer: Medicaid All Medicaid	$821.56
Rate for Payer: Medicare All Medicare	$625.10
Rate for Payer: Monida Allegiance	$848.35
Rate for Payer: Monida First Choice Health	$866.21
Rate for Payer: Monida Montana Health Co-op	$848.35
Rate for Payer: Monida PacificSource	$848.35

[IA] INS - DEGLUDEC [1 UNIT/ 0.01 ML] NF

Facility

$566.00

Service Code	HCPCS J3490
Hospital Charge Code	3000555
Hospital Revenue Code	250
Min. Negotiated Rate	$396.20
Max. Negotiated Rate	$566.00
Rate for Payer: Aetna Commercial	$537.70
Rate for Payer: Aetna Medicare	$509.40
Rate for Payer: BCBS MT CHIP	$509.40
Rate for Payer: BCBS MT Closed Plan Network	$537.70
Rate for Payer: BCBS MT HealthLink	$509.40
Rate for Payer: BCBS MT Medicare	$509.40
Rate for Payer: BCBS MT POS	$537.70
Rate for Payer: BCBS MT Traditional	$566.00
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cigna Commercial	$537.70
Rate for Payer: Cigna Medicare	$509.40
Rate for Payer: Medicaid All Medicaid	$520.72
Rate for Payer: Medicare All Medicare	$396.20
Rate for Payer: Monida Allegiance	$537.70
Rate for Payer: Monida First Choice Health	$549.02
Rate for Payer: Monida Montana Health Co-op	$537.70
Rate for Payer: Monida PacificSource	$537.70

[IA] INS - DEGLUDEC [1 UNIT/ 0.01 ML] NF

Facility

$566.00

Service Code	HCPCS J3490
Hospital Charge Code	3000555
Hospital Revenue Code	250
Min. Negotiated Rate	$396.20
Max. Negotiated Rate	$566.00
Rate for Payer: Aetna Commercial	$537.70
Rate for Payer: Aetna Medicare	$509.40
Rate for Payer: BCBS MT CHIP	$509.40
Rate for Payer: BCBS MT Closed Plan Network	$537.70
Rate for Payer: BCBS MT HealthLink	$509.40
Rate for Payer: BCBS MT Medicare	$509.40
Rate for Payer: BCBS MT POS	$537.70
Rate for Payer: BCBS MT Traditional	$566.00
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cigna Commercial	$537.70
Rate for Payer: Cigna Medicare	$509.40
Rate for Payer: Medicaid All Medicaid	$520.72
Rate for Payer: Medicare All Medicare	$396.20
Rate for Payer: Monida Allegiance	$537.70
Rate for Payer: Monida First Choice Health	$549.02
Rate for Payer: Monida Montana Health Co-op	$537.70
Rate for Payer: Monida PacificSource	$537.70

[IA] PEGFILGRASTIM SYR [6 MG/0.6 ML] NF

Facility

$10,782.00

Service Code	HCPCS J2506
Hospital Charge Code	3000380
Hospital Revenue Code	636
Min. Negotiated Rate	$7,547.40
Max. Negotiated Rate	$10,782.00
Rate for Payer: Aetna Commercial	$10,242.90
Rate for Payer: Aetna Medicare	$9,703.80
Rate for Payer: BCBS MT CHIP	$9,703.80
Rate for Payer: BCBS MT Closed Plan Network	$10,242.90
Rate for Payer: BCBS MT HealthLink	$9,703.80
Rate for Payer: BCBS MT Medicare	$9,703.80
Rate for Payer: BCBS MT POS	$10,242.90
Rate for Payer: BCBS MT Traditional	$10,782.00
Rate for Payer: Cash Price	$9,703.80
Rate for Payer: Cigna Commercial	$10,242.90
Rate for Payer: Cigna Medicare	$9,703.80
Rate for Payer: Medicaid All Medicaid	$9,919.44
Rate for Payer: Medicare All Medicare	$7,547.40
Rate for Payer: Monida Allegiance	$10,242.90
Rate for Payer: Monida First Choice Health	$10,458.54
Rate for Payer: Monida Montana Health Co-op	$10,242.90
Rate for Payer: Monida PacificSource	$10,242.90

[IA] PEGFILGRASTIM SYR [6 MG/0.6 ML] NF

Facility

$10,782.00

Service Code	HCPCS J2506
Hospital Charge Code	3000380
Hospital Revenue Code	636
Min. Negotiated Rate	$7,547.40
Max. Negotiated Rate	$10,782.00
Rate for Payer: Aetna Commercial	$10,242.90
Rate for Payer: Aetna Medicare	$9,703.80
Rate for Payer: BCBS MT CHIP	$9,703.80
Rate for Payer: BCBS MT Closed Plan Network	$10,242.90
Rate for Payer: BCBS MT HealthLink	$9,703.80
Rate for Payer: BCBS MT Medicare	$9,703.80
Rate for Payer: BCBS MT POS	$10,242.90
Rate for Payer: BCBS MT Traditional	$10,782.00
Rate for Payer: Cash Price	$9,703.80
Rate for Payer: Cigna Commercial	$10,242.90
Rate for Payer: Cigna Medicare	$9,703.80
Rate for Payer: Medicaid All Medicaid	$9,919.44
Rate for Payer: Medicare All Medicare	$7,547.40
Rate for Payer: Monida Allegiance	$10,242.90
Rate for Payer: Monida First Choice Health	$10,458.54
Rate for Payer: Monida Montana Health Co-op	$10,242.90
Rate for Payer: Monida PacificSource	$10,242.90

IBUPROFEN ORAL SUSP [100 MG/5 ML] BTL

Facility

$28.00

Service Code	HCPCS A9150
Hospital Charge Code	3000227
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

IBUPROFEN ORAL SUSP [100 MG/5 ML] BTL

Facility

$28.00

Service Code	HCPCS A9150
Hospital Charge Code	3000227
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

IBUPROFEN TAB [200 MG]

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3000228
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

IBUPROFEN TAB [200 MG]

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3000228
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

ICE PACK SECURE-ALL LG

Facility

$13.00

Hospital Charge Code	2830192
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

ICE PACK SECURE-ALL LG

Facility

$13.00

Hospital Charge Code	2830192
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

Know your out-of-pocket cost for care.

All Charges