Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PREDNISOLONE LIQ [5 MG/5 ML] UD CUP

Facility

$14.00

Service Code	HCPCS J7510
Hospital Charge Code	3000398
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

PREDNISONE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J7512
Hospital Charge Code	3000399
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

PREDNISONE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J7512
Hospital Charge Code	3000399
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

PREDNISONE TAB [20 MG]

Facility

$8.00

Service Code	HCPCS J7512
Hospital Charge Code	3000400
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

PREDNISONE TAB [20 MG]

Facility

$8.00

Service Code	HCPCS J7512
Hospital Charge Code	3000400
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

PREGABALIN 100 MG CAP-NF

Facility

$8.00

Service Code	NDC 60687050601
Hospital Charge Code	3007282
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

PREGABALIN 100 MG CAP-NF

Facility

$8.00

Service Code	NDC 60687050601
Hospital Charge Code	3007282
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

PREGABALIN 25 MG CAP -NF

Facility

$8.00

Service Code	NDC 60687047301
Hospital Charge Code	3007352
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

PREGABALIN 25 MG CAP -NF

Facility

$8.00

Service Code	NDC 60687047301
Hospital Charge Code	3007352
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

PREGABALIN CAP [75 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000401
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

PREGABALIN CAP [75 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000401
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

PREGNENOLONE (140707)

Facility

$179.00

Service Code	HCPCS 84140
Hospital Charge Code	4084140
Hospital Revenue Code	300
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

PREGNENOLONE (140707)

Facility

$179.00

Service Code	HCPCS 84140
Hospital Charge Code	4084140
Hospital Revenue Code	300
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

PRIMIDONE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000402
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

PRIMIDONE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000402
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

PRIVATE ROOM

Facility

$1,638.00

Hospital Charge Code	100001
Hospital Revenue Code	120
Min. Negotiated Rate	$1,146.60
Max. Negotiated Rate	$1,638.00
Rate for Payer: Aetna Commercial	$1,556.10
Rate for Payer: Aetna Medicare	$1,474.20
Rate for Payer: BCBS MT CHIP	$1,474.20
Rate for Payer: BCBS MT Closed Plan Network	$1,556.10
Rate for Payer: BCBS MT HealthLink	$1,474.20
Rate for Payer: BCBS MT Medicare	$1,474.20
Rate for Payer: BCBS MT POS	$1,556.10
Rate for Payer: BCBS MT Traditional	$1,638.00
Rate for Payer: Cash Price	$1,474.20
Rate for Payer: Cigna Commercial	$1,556.10
Rate for Payer: Cigna Medicare	$1,474.20
Rate for Payer: Medicaid All Medicaid	$1,506.96
Rate for Payer: Medicare All Medicare	$1,146.60
Rate for Payer: Monida Allegiance	$1,556.10
Rate for Payer: Monida First Choice Health	$1,588.86
Rate for Payer: Monida Montana Health Co-op	$1,556.10
Rate for Payer: Monida PacificSource	$1,556.10

PRIVATE ROOM ISOLATION

Facility

$1,769.00

Hospital Charge Code	100002
Hospital Revenue Code	120
Min. Negotiated Rate	$1,238.30
Max. Negotiated Rate	$1,769.00
Rate for Payer: Aetna Commercial	$1,680.55
Rate for Payer: Aetna Medicare	$1,592.10
Rate for Payer: BCBS MT CHIP	$1,592.10
Rate for Payer: BCBS MT Closed Plan Network	$1,680.55
Rate for Payer: BCBS MT HealthLink	$1,592.10
Rate for Payer: BCBS MT Medicare	$1,592.10
Rate for Payer: BCBS MT POS	$1,680.55
Rate for Payer: BCBS MT Traditional	$1,769.00
Rate for Payer: Cash Price	$1,592.10
Rate for Payer: Cigna Commercial	$1,680.55
Rate for Payer: Cigna Medicare	$1,592.10
Rate for Payer: Medicaid All Medicaid	$1,627.48
Rate for Payer: Medicare All Medicare	$1,238.30
Rate for Payer: Monida Allegiance	$1,680.55
Rate for Payer: Monida First Choice Health	$1,715.93
Rate for Payer: Monida Montana Health Co-op	$1,680.55
Rate for Payer: Monida PacificSource	$1,680.55

PRIVIGEN 10GM/100ML SDV NON-FORMULARY

Facility

$2,868.00

Service Code	HCPCS J1459
Hospital Charge Code	3007125
Hospital Revenue Code	636
Min. Negotiated Rate	$2,007.60
Max. Negotiated Rate	$2,868.00
Rate for Payer: Aetna Commercial	$2,724.60
Rate for Payer: Aetna Medicare	$2,581.20
Rate for Payer: BCBS MT CHIP	$2,581.20
Rate for Payer: BCBS MT Closed Plan Network	$2,724.60
Rate for Payer: BCBS MT HealthLink	$2,581.20
Rate for Payer: BCBS MT Medicare	$2,581.20
Rate for Payer: BCBS MT POS	$2,724.60
Rate for Payer: BCBS MT Traditional	$2,868.00
Rate for Payer: Cash Price	$2,581.20
Rate for Payer: Cigna Commercial	$2,724.60
Rate for Payer: Cigna Medicare	$2,581.20
Rate for Payer: Medicaid All Medicaid	$2,638.56
Rate for Payer: Medicare All Medicare	$2,007.60
Rate for Payer: Monida Allegiance	$2,724.60
Rate for Payer: Monida First Choice Health	$2,781.96
Rate for Payer: Monida Montana Health Co-op	$2,724.60
Rate for Payer: Monida PacificSource	$2,724.60

PRIVIGEN 10GM/100ML SDV NON-FORMULARY

Facility

$2,868.00

Service Code	HCPCS J1459
Hospital Charge Code	3007125
Hospital Revenue Code	636
Min. Negotiated Rate	$2,007.60
Max. Negotiated Rate	$2,868.00
Rate for Payer: Aetna Commercial	$2,724.60
Rate for Payer: Aetna Medicare	$2,581.20
Rate for Payer: BCBS MT CHIP	$2,581.20
Rate for Payer: BCBS MT Closed Plan Network	$2,724.60
Rate for Payer: BCBS MT HealthLink	$2,581.20
Rate for Payer: BCBS MT Medicare	$2,581.20
Rate for Payer: BCBS MT POS	$2,724.60
Rate for Payer: BCBS MT Traditional	$2,868.00
Rate for Payer: Cash Price	$2,581.20
Rate for Payer: Cigna Commercial	$2,724.60
Rate for Payer: Cigna Medicare	$2,581.20
Rate for Payer: Medicaid All Medicaid	$2,638.56
Rate for Payer: Medicare All Medicare	$2,007.60
Rate for Payer: Monida Allegiance	$2,724.60
Rate for Payer: Monida First Choice Health	$2,781.96
Rate for Payer: Monida Montana Health Co-op	$2,724.60
Rate for Payer: Monida PacificSource	$2,724.60

PRIVIGEN 20GM/200ML SDV NON-FORMULARY

Facility

$5,736.00

Service Code	HCPCS J1459
Hospital Charge Code	3007126
Hospital Revenue Code	636
Min. Negotiated Rate	$4,015.20
Max. Negotiated Rate	$5,736.00
Rate for Payer: Aetna Commercial	$5,449.20
Rate for Payer: Aetna Medicare	$5,162.40
Rate for Payer: BCBS MT CHIP	$5,162.40
Rate for Payer: BCBS MT Closed Plan Network	$5,449.20
Rate for Payer: BCBS MT HealthLink	$5,162.40
Rate for Payer: BCBS MT Medicare	$5,162.40
Rate for Payer: BCBS MT POS	$5,449.20
Rate for Payer: BCBS MT Traditional	$5,736.00
Rate for Payer: Cash Price	$5,162.40
Rate for Payer: Cigna Commercial	$5,449.20
Rate for Payer: Cigna Medicare	$5,162.40
Rate for Payer: Medicaid All Medicaid	$5,277.12
Rate for Payer: Medicare All Medicare	$4,015.20
Rate for Payer: Monida Allegiance	$5,449.20
Rate for Payer: Monida First Choice Health	$5,563.92
Rate for Payer: Monida Montana Health Co-op	$5,449.20
Rate for Payer: Monida PacificSource	$5,449.20

PRIVIGEN 20GM/200ML SDV NON-FORMULARY

Facility

$5,736.00

Service Code	HCPCS J1459
Hospital Charge Code	3007126
Hospital Revenue Code	636
Min. Negotiated Rate	$4,015.20
Max. Negotiated Rate	$5,736.00
Rate for Payer: Aetna Commercial	$5,449.20
Rate for Payer: Aetna Medicare	$5,162.40
Rate for Payer: BCBS MT CHIP	$5,162.40
Rate for Payer: BCBS MT Closed Plan Network	$5,449.20
Rate for Payer: BCBS MT HealthLink	$5,162.40
Rate for Payer: BCBS MT Medicare	$5,162.40
Rate for Payer: BCBS MT POS	$5,449.20
Rate for Payer: BCBS MT Traditional	$5,736.00
Rate for Payer: Cash Price	$5,162.40
Rate for Payer: Cigna Commercial	$5,449.20
Rate for Payer: Cigna Medicare	$5,162.40
Rate for Payer: Medicaid All Medicaid	$5,277.12
Rate for Payer: Medicare All Medicare	$4,015.20
Rate for Payer: Monida Allegiance	$5,449.20
Rate for Payer: Monida First Choice Health	$5,563.92
Rate for Payer: Monida Montana Health Co-op	$5,449.20
Rate for Payer: Monida PacificSource	$5,449.20

PRIVIGEN 40GM/400ML SDV SPECIAL ORDER

Facility

$11,472.00

Service Code	HCPCS J1459
Hospital Charge Code	3007127
Hospital Revenue Code	636
Min. Negotiated Rate	$8,030.40
Max. Negotiated Rate	$11,472.00
Rate for Payer: Aetna Commercial	$10,898.40
Rate for Payer: Aetna Medicare	$10,324.80
Rate for Payer: BCBS MT CHIP	$10,324.80
Rate for Payer: BCBS MT Closed Plan Network	$10,898.40
Rate for Payer: BCBS MT HealthLink	$10,324.80
Rate for Payer: BCBS MT Medicare	$10,324.80
Rate for Payer: BCBS MT POS	$10,898.40
Rate for Payer: BCBS MT Traditional	$11,472.00
Rate for Payer: Cash Price	$10,324.80
Rate for Payer: Cigna Commercial	$10,898.40
Rate for Payer: Cigna Medicare	$10,324.80
Rate for Payer: Medicaid All Medicaid	$10,554.24
Rate for Payer: Medicare All Medicare	$8,030.40
Rate for Payer: Monida Allegiance	$10,898.40
Rate for Payer: Monida First Choice Health	$11,127.84
Rate for Payer: Monida Montana Health Co-op	$10,898.40
Rate for Payer: Monida PacificSource	$10,898.40

PRIVIGEN 40GM/400ML SDV SPECIAL ORDER

Facility

$11,472.00

Service Code	HCPCS J1459
Hospital Charge Code	3007127
Hospital Revenue Code	636
Min. Negotiated Rate	$8,030.40
Max. Negotiated Rate	$11,472.00
Rate for Payer: Aetna Commercial	$10,898.40
Rate for Payer: Aetna Medicare	$10,324.80
Rate for Payer: BCBS MT CHIP	$10,324.80
Rate for Payer: BCBS MT Closed Plan Network	$10,898.40
Rate for Payer: BCBS MT HealthLink	$10,324.80
Rate for Payer: BCBS MT Medicare	$10,324.80
Rate for Payer: BCBS MT POS	$10,898.40
Rate for Payer: BCBS MT Traditional	$11,472.00
Rate for Payer: Cash Price	$10,324.80
Rate for Payer: Cigna Commercial	$10,898.40
Rate for Payer: Cigna Medicare	$10,324.80
Rate for Payer: Medicaid All Medicaid	$10,554.24
Rate for Payer: Medicare All Medicare	$8,030.40
Rate for Payer: Monida Allegiance	$10,898.40
Rate for Payer: Monida First Choice Health	$11,127.84
Rate for Payer: Monida Montana Health Co-op	$10,898.40
Rate for Payer: Monida PacificSource	$10,898.40

PRIVIGEN 5GM/50ML SDV NON-FORMUALRY

Facility

$1,437.00

Service Code	HCPCS J1459
Hospital Charge Code	3007124
Hospital Revenue Code	636
Min. Negotiated Rate	$1,005.90
Max. Negotiated Rate	$1,437.00
Rate for Payer: Aetna Commercial	$1,365.15
Rate for Payer: Aetna Medicare	$1,293.30
Rate for Payer: BCBS MT CHIP	$1,293.30
Rate for Payer: BCBS MT Closed Plan Network	$1,365.15
Rate for Payer: BCBS MT HealthLink	$1,293.30
Rate for Payer: BCBS MT Medicare	$1,293.30
Rate for Payer: BCBS MT POS	$1,365.15
Rate for Payer: BCBS MT Traditional	$1,437.00
Rate for Payer: Cash Price	$1,293.30
Rate for Payer: Cigna Commercial	$1,365.15
Rate for Payer: Cigna Medicare	$1,293.30
Rate for Payer: Medicaid All Medicaid	$1,322.04
Rate for Payer: Medicare All Medicare	$1,005.90
Rate for Payer: Monida Allegiance	$1,365.15
Rate for Payer: Monida First Choice Health	$1,393.89
Rate for Payer: Monida Montana Health Co-op	$1,365.15
Rate for Payer: Monida PacificSource	$1,365.15

PRIVIGEN 5GM/50ML SDV NON-FORMUALRY

Facility

$1,437.00

Service Code	HCPCS J1459
Hospital Charge Code	3007124
Hospital Revenue Code	636
Min. Negotiated Rate	$1,005.90
Max. Negotiated Rate	$1,437.00
Rate for Payer: Aetna Commercial	$1,365.15
Rate for Payer: Aetna Medicare	$1,293.30
Rate for Payer: BCBS MT CHIP	$1,293.30
Rate for Payer: BCBS MT Closed Plan Network	$1,365.15
Rate for Payer: BCBS MT HealthLink	$1,293.30
Rate for Payer: BCBS MT Medicare	$1,293.30
Rate for Payer: BCBS MT POS	$1,365.15
Rate for Payer: BCBS MT Traditional	$1,437.00
Rate for Payer: Cash Price	$1,293.30
Rate for Payer: Cigna Commercial	$1,365.15
Rate for Payer: Cigna Medicare	$1,293.30
Rate for Payer: Medicaid All Medicaid	$1,322.04
Rate for Payer: Medicare All Medicare	$1,005.90
Rate for Payer: Monida Allegiance	$1,365.15
Rate for Payer: Monida First Choice Health	$1,393.89
Rate for Payer: Monida Montana Health Co-op	$1,365.15
Rate for Payer: Monida PacificSource	$1,365.15

Know your out-of-pocket cost for care.

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