Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PANCREATIC ELASTASE, STOOL (123234)

Facility

$551.00

Service Code	HCPCS 82653
Hospital Charge Code	4082656
Hospital Revenue Code	301
Min. Negotiated Rate	$385.70
Max. Negotiated Rate	$551.00
Rate for Payer: Aetna Commercial	$523.45
Rate for Payer: Aetna Medicare	$495.90
Rate for Payer: BCBS MT CHIP	$495.90
Rate for Payer: BCBS MT Closed Plan Network	$523.45
Rate for Payer: BCBS MT HealthLink	$495.90
Rate for Payer: BCBS MT Medicare	$495.90
Rate for Payer: BCBS MT POS	$523.45
Rate for Payer: BCBS MT Traditional	$551.00
Rate for Payer: Cash Price	$495.90
Rate for Payer: Cigna Commercial	$523.45
Rate for Payer: Cigna Medicare	$495.90
Rate for Payer: Medicaid All Medicaid	$506.92
Rate for Payer: Medicare All Medicare	$385.70
Rate for Payer: Monida Allegiance	$523.45
Rate for Payer: Monida First Choice Health	$534.47
Rate for Payer: Monida Montana Health Co-op	$523.45
Rate for Payer: Monida PacificSource	$523.45

PANTOPRAZOLE INJ [40MG]

Facility

$20.00

Service Code	HCPCS J2470
Hospital Charge Code	3000376
Hospital Revenue Code	259
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

PANTOPRAZOLE INJ [40MG]

Facility

$20.00

Service Code	HCPCS J2470
Hospital Charge Code	3000376
Hospital Revenue Code	259
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

PANTOPRAZOLE TAB [40 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000377
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

PANTOPRAZOLE TAB [40 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000377
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

PARATHYROID HORMONE, INTACT (015610)

Facility

$33.00

Service Code	HCPCS 83970
Hospital Charge Code	4083970
Hospital Revenue Code	301
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

PARATHYROID HORMONE, INTACT (015610)

Facility

$33.00

Service Code	HCPCS 83970
Hospital Charge Code	4083970
Hospital Revenue Code	301
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

PAROXETINE TAB [20 MG]

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	3000378
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

PAROXETINE TAB [20 MG]

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	3000378
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

PATELLA STRAP LG

Facility

$43.00

Hospital Charge Code	2893456
Hospital Revenue Code	290
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

PATELLA STRAP LG

Facility

$43.00

Hospital Charge Code	2893456
Hospital Revenue Code	290
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

PATELLA STRAP MED

Facility

$54.00

Hospital Charge Code	2840155
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

PATELLA STRAP MED

Facility

$54.00

Hospital Charge Code	2840155
Hospital Revenue Code	270
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

PEAK FLOW METER

Facility

$83.00

Hospital Charge Code	80030025
Hospital Revenue Code	259
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

PEAK FLOW METER

Facility

$83.00

Hospital Charge Code	80030025
Hospital Revenue Code	259
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

PEGFILGRASTIM SYR [6 MG/0.6 ML] SPEC ORD

Facility

$10,782.25

Service Code	HCPCS Q5108
Hospital Charge Code	3000380
Hospital Revenue Code	636
Min. Negotiated Rate	$7,547.58
Max. Negotiated Rate	$10,782.25
Rate for Payer: Aetna Commercial	$10,243.14
Rate for Payer: Aetna Medicare	$9,704.02
Rate for Payer: BCBS MT CHIP	$9,704.02
Rate for Payer: BCBS MT Closed Plan Network	$10,243.14
Rate for Payer: BCBS MT HealthLink	$9,704.02
Rate for Payer: BCBS MT Medicare	$9,704.02
Rate for Payer: BCBS MT POS	$10,243.14
Rate for Payer: BCBS MT Traditional	$10,782.25
Rate for Payer: Cash Price	$9,704.03
Rate for Payer: Cigna Commercial	$10,243.14
Rate for Payer: Cigna Medicare	$9,704.02
Rate for Payer: Medicaid All Medicaid	$9,919.67
Rate for Payer: Medicare All Medicare	$7,547.58
Rate for Payer: Monida Allegiance	$10,243.14
Rate for Payer: Monida First Choice Health	$10,458.78
Rate for Payer: Monida Montana Health Co-op	$10,243.14
Rate for Payer: Monida PacificSource	$10,243.14

PEGFILGRASTIM SYR [6 MG/0.6 ML] SPEC ORD

Facility

$10,782.25

Service Code	HCPCS Q5108
Hospital Charge Code	3000380
Hospital Revenue Code	636
Min. Negotiated Rate	$7,547.58
Max. Negotiated Rate	$10,782.25
Rate for Payer: Aetna Commercial	$10,243.14
Rate for Payer: Aetna Medicare	$9,704.02
Rate for Payer: BCBS MT CHIP	$9,704.02
Rate for Payer: BCBS MT Closed Plan Network	$10,243.14
Rate for Payer: BCBS MT HealthLink	$9,704.02
Rate for Payer: BCBS MT Medicare	$9,704.02
Rate for Payer: BCBS MT POS	$10,243.14
Rate for Payer: BCBS MT Traditional	$10,782.25
Rate for Payer: Cash Price	$9,704.03
Rate for Payer: Cigna Commercial	$10,243.14
Rate for Payer: Cigna Medicare	$9,704.02
Rate for Payer: Medicaid All Medicaid	$9,919.67
Rate for Payer: Medicare All Medicare	$7,547.58
Rate for Payer: Monida Allegiance	$10,243.14
Rate for Payer: Monida First Choice Health	$10,458.78
Rate for Payer: Monida Montana Health Co-op	$10,243.14
Rate for Payer: Monida PacificSource	$10,243.14

PENICILLIN G BENZ INJ [1,200,000 U/2 ML]

Facility

$633.00

Service Code	HCPCS J0561
Hospital Charge Code	3000381
Hospital Revenue Code	636
Min. Negotiated Rate	$443.10
Max. Negotiated Rate	$633.00
Rate for Payer: Aetna Commercial	$601.35
Rate for Payer: Aetna Medicare	$569.70
Rate for Payer: BCBS MT CHIP	$569.70
Rate for Payer: BCBS MT Closed Plan Network	$601.35
Rate for Payer: BCBS MT HealthLink	$569.70
Rate for Payer: BCBS MT Medicare	$569.70
Rate for Payer: BCBS MT POS	$601.35
Rate for Payer: BCBS MT Traditional	$633.00
Rate for Payer: Cash Price	$569.70
Rate for Payer: Cigna Commercial	$601.35
Rate for Payer: Cigna Medicare	$569.70
Rate for Payer: Medicaid All Medicaid	$582.36
Rate for Payer: Medicare All Medicare	$443.10
Rate for Payer: Monida Allegiance	$601.35
Rate for Payer: Monida First Choice Health	$614.01
Rate for Payer: Monida Montana Health Co-op	$601.35
Rate for Payer: Monida PacificSource	$601.35

PENICILLIN G BENZ INJ [1,200,000 U/2 ML]

Facility

$633.00

Service Code	HCPCS J0561
Hospital Charge Code	3000381
Hospital Revenue Code	636
Min. Negotiated Rate	$443.10
Max. Negotiated Rate	$633.00
Rate for Payer: Aetna Commercial	$601.35
Rate for Payer: Aetna Medicare	$569.70
Rate for Payer: BCBS MT CHIP	$569.70
Rate for Payer: BCBS MT Closed Plan Network	$601.35
Rate for Payer: BCBS MT HealthLink	$569.70
Rate for Payer: BCBS MT Medicare	$569.70
Rate for Payer: BCBS MT POS	$601.35
Rate for Payer: BCBS MT Traditional	$633.00
Rate for Payer: Cash Price	$569.70
Rate for Payer: Cigna Commercial	$601.35
Rate for Payer: Cigna Medicare	$569.70
Rate for Payer: Medicaid All Medicaid	$582.36
Rate for Payer: Medicare All Medicare	$443.10
Rate for Payer: Monida Allegiance	$601.35
Rate for Payer: Monida First Choice Health	$614.01
Rate for Payer: Monida Montana Health Co-op	$601.35
Rate for Payer: Monida PacificSource	$601.35

PENICILLIN V K TAB [250 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000382
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

PENICILLIN V K TAB [250 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000382
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

PENTOXIFYLLINE ER 400MG TABLET-NF

Facility

$8.00

Service Code	NDC 60505003306
Hospital Charge Code	3007207
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

PENTOXIFYLLINE ER 400MG TABLET-NF

Facility

$8.00

Service Code	NDC 60505003306
Hospital Charge Code	3007207
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

PERFLUTREN LIPID MICROSPHERE

Facility

$351.00

Service Code	HCPCS Q9957
Hospital Charge Code	3007135
Hospital Revenue Code	250
Min. Negotiated Rate	$245.70
Max. Negotiated Rate	$351.00
Rate for Payer: Aetna Commercial	$333.45
Rate for Payer: Aetna Medicare	$315.90
Rate for Payer: BCBS MT CHIP	$315.90
Rate for Payer: BCBS MT Closed Plan Network	$333.45
Rate for Payer: BCBS MT HealthLink	$315.90
Rate for Payer: BCBS MT Medicare	$315.90
Rate for Payer: BCBS MT POS	$333.45
Rate for Payer: BCBS MT Traditional	$351.00
Rate for Payer: Cash Price	$315.90
Rate for Payer: Cigna Commercial	$333.45
Rate for Payer: Cigna Medicare	$315.90
Rate for Payer: Medicaid All Medicaid	$322.92
Rate for Payer: Medicare All Medicare	$245.70
Rate for Payer: Monida Allegiance	$333.45
Rate for Payer: Monida First Choice Health	$340.47
Rate for Payer: Monida Montana Health Co-op	$333.45
Rate for Payer: Monida PacificSource	$333.45

PERFLUTREN LIPID MICROSPHERE

Facility

$351.00

Service Code	HCPCS Q9957
Hospital Charge Code	3007135
Hospital Revenue Code	250
Min. Negotiated Rate	$245.70
Max. Negotiated Rate	$351.00
Rate for Payer: Aetna Commercial	$333.45
Rate for Payer: Aetna Medicare	$315.90
Rate for Payer: BCBS MT CHIP	$315.90
Rate for Payer: BCBS MT Closed Plan Network	$333.45
Rate for Payer: BCBS MT HealthLink	$315.90
Rate for Payer: BCBS MT Medicare	$315.90
Rate for Payer: BCBS MT POS	$333.45
Rate for Payer: BCBS MT Traditional	$351.00
Rate for Payer: Cash Price	$315.90
Rate for Payer: Cigna Commercial	$333.45
Rate for Payer: Cigna Medicare	$315.90
Rate for Payer: Medicaid All Medicaid	$322.92
Rate for Payer: Medicare All Medicare	$245.70
Rate for Payer: Monida Allegiance	$333.45
Rate for Payer: Monida First Choice Health	$340.47
Rate for Payer: Monida Montana Health Co-op	$333.45
Rate for Payer: Monida PacificSource	$333.45

Know your out-of-pocket cost for care.

All Charges