Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OXYGEN PER DAY

Facility

$126.00

Hospital Charge Code	6630147
Hospital Revenue Code	270
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: BCBS MT CHIP	$113.40
Rate for Payer: BCBS MT Closed Plan Network	$119.70
Rate for Payer: BCBS MT HealthLink	$113.40
Rate for Payer: BCBS MT Medicare	$113.40
Rate for Payer: BCBS MT POS	$119.70
Rate for Payer: BCBS MT Traditional	$126.00
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial	$119.70
Rate for Payer: Cigna Medicare	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

OXYMETAZOLINE NASAL [0.05%] 12HR

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000374
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

OXYMETAZOLINE NASAL [0.05%] 12HR

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000374
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

OXYTOCIN INJ [10 U/ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000375
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

OXYTOCIN INJ [10 U/ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000375
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

PAIN ROOM FACILITY LEVEL 2

Facility

$3,557.00

Hospital Charge Code	1500212
Hospital Revenue Code	761
Min. Negotiated Rate	$2,489.90
Max. Negotiated Rate	$3,557.00
Rate for Payer: Aetna Commercial	$3,379.15
Rate for Payer: Aetna Medicare	$3,201.30
Rate for Payer: BCBS MT CHIP	$3,201.30
Rate for Payer: BCBS MT Closed Plan Network	$3,379.15
Rate for Payer: BCBS MT HealthLink	$3,201.30
Rate for Payer: BCBS MT Medicare	$3,201.30
Rate for Payer: BCBS MT POS	$3,379.15
Rate for Payer: BCBS MT Traditional	$3,557.00
Rate for Payer: Cash Price	$3,201.30
Rate for Payer: Cigna Commercial	$3,379.15
Rate for Payer: Cigna Medicare	$3,201.30
Rate for Payer: Medicaid All Medicaid	$3,272.44
Rate for Payer: Medicare All Medicare	$2,489.90
Rate for Payer: Monida Allegiance	$3,379.15
Rate for Payer: Monida First Choice Health	$3,450.29
Rate for Payer: Monida Montana Health Co-op	$3,379.15
Rate for Payer: Monida PacificSource	$3,379.15

PAIN ROOM FACILITY LEVEL 2

Facility

$3,557.00

Hospital Charge Code	1500212
Hospital Revenue Code	761
Min. Negotiated Rate	$2,489.90
Max. Negotiated Rate	$3,557.00
Rate for Payer: Aetna Commercial	$3,379.15
Rate for Payer: Aetna Medicare	$3,201.30
Rate for Payer: BCBS MT CHIP	$3,201.30
Rate for Payer: BCBS MT Closed Plan Network	$3,379.15
Rate for Payer: BCBS MT HealthLink	$3,201.30
Rate for Payer: BCBS MT Medicare	$3,201.30
Rate for Payer: BCBS MT POS	$3,379.15
Rate for Payer: BCBS MT Traditional	$3,557.00
Rate for Payer: Cash Price	$3,201.30
Rate for Payer: Cigna Commercial	$3,379.15
Rate for Payer: Cigna Medicare	$3,201.30
Rate for Payer: Medicaid All Medicaid	$3,272.44
Rate for Payer: Medicare All Medicare	$2,489.90
Rate for Payer: Monida Allegiance	$3,379.15
Rate for Payer: Monida First Choice Health	$3,450.29
Rate for Payer: Monida Montana Health Co-op	$3,379.15
Rate for Payer: Monida PacificSource	$3,379.15

PAIN ROOM FACILITY LEVEL 3

Facility

$4,509.00

Hospital Charge Code	1500213
Hospital Revenue Code	761
Min. Negotiated Rate	$3,156.30
Max. Negotiated Rate	$4,509.00
Rate for Payer: Aetna Commercial	$4,283.55
Rate for Payer: Aetna Medicare	$4,058.10
Rate for Payer: BCBS MT CHIP	$4,058.10
Rate for Payer: BCBS MT Closed Plan Network	$4,283.55
Rate for Payer: BCBS MT HealthLink	$4,058.10
Rate for Payer: BCBS MT Medicare	$4,058.10
Rate for Payer: BCBS MT POS	$4,283.55
Rate for Payer: BCBS MT Traditional	$4,509.00
Rate for Payer: Cash Price	$4,058.10
Rate for Payer: Cigna Commercial	$4,283.55
Rate for Payer: Cigna Medicare	$4,058.10
Rate for Payer: Medicaid All Medicaid	$4,148.28
Rate for Payer: Medicare All Medicare	$3,156.30
Rate for Payer: Monida Allegiance	$4,283.55
Rate for Payer: Monida First Choice Health	$4,373.73
Rate for Payer: Monida Montana Health Co-op	$4,283.55
Rate for Payer: Monida PacificSource	$4,283.55

PAIN ROOM FACILITY LEVEL 3

Facility

$4,509.00

Hospital Charge Code	1500213
Hospital Revenue Code	761
Min. Negotiated Rate	$3,156.30
Max. Negotiated Rate	$4,509.00
Rate for Payer: Aetna Commercial	$4,283.55
Rate for Payer: Aetna Medicare	$4,058.10
Rate for Payer: BCBS MT CHIP	$4,058.10
Rate for Payer: BCBS MT Closed Plan Network	$4,283.55
Rate for Payer: BCBS MT HealthLink	$4,058.10
Rate for Payer: BCBS MT Medicare	$4,058.10
Rate for Payer: BCBS MT POS	$4,283.55
Rate for Payer: BCBS MT Traditional	$4,509.00
Rate for Payer: Cash Price	$4,058.10
Rate for Payer: Cigna Commercial	$4,283.55
Rate for Payer: Cigna Medicare	$4,058.10
Rate for Payer: Medicaid All Medicaid	$4,148.28
Rate for Payer: Medicare All Medicare	$3,156.30
Rate for Payer: Monida Allegiance	$4,283.55
Rate for Payer: Monida First Choice Health	$4,373.73
Rate for Payer: Monida Montana Health Co-op	$4,283.55
Rate for Payer: Monida PacificSource	$4,283.55

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

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

PAP SMEAR AUTO SCREEN(W/MAN REV) 88175

Facility

$99.00

Service Code	HCPCS 88175
Hospital Charge Code	4088175
Hospital Revenue Code	310
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

PAP SMEAR AUTO SCREEN(W/MAN REV) 88175

Facility

$99.00

Service Code	HCPCS 88175
Hospital Charge Code	4088175
Hospital Revenue Code	310
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

PARATHYROID HORMONE, INTACT (015610)

Facility

$110.00

Service Code	HCPCS 83970
Hospital Charge Code	4083970
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

PARATHYROID HORMONE, INTACT (015610)

Facility

$110.00

Service Code	HCPCS 83970
Hospital Charge Code	4083970
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

PAROXETINE TAB [20 MG] NF

Facility

$9.00

Service Code	HCPCS J8499
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] NF

Facility

$9.00

Service Code	HCPCS J8499
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

PARVOVIRUS PCR

Facility

$280.00

Service Code	HCPCS 87798
Hospital Charge Code	4087940
Hospital Revenue Code	300
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna Commercial	$266.00
Rate for Payer: Aetna Medicare	$252.00
Rate for Payer: BCBS MT CHIP	$252.00
Rate for Payer: BCBS MT Closed Plan Network	$266.00
Rate for Payer: BCBS MT HealthLink	$252.00
Rate for Payer: BCBS MT Medicare	$252.00
Rate for Payer: BCBS MT POS	$266.00
Rate for Payer: BCBS MT Traditional	$280.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cigna Commercial	$266.00
Rate for Payer: Cigna Medicare	$252.00
Rate for Payer: Medicaid All Medicaid	$257.60
Rate for Payer: Medicare All Medicare	$196.00
Rate for Payer: Monida Allegiance	$266.00
Rate for Payer: Monida First Choice Health	$271.60
Rate for Payer: Monida Montana Health Co-op	$266.00
Rate for Payer: Monida PacificSource	$266.00

PARVOVIRUS PCR

Facility

$280.00

Service Code	HCPCS 87798
Hospital Charge Code	4087940
Hospital Revenue Code	300
Min. Negotiated Rate	$196.00
Max. Negotiated Rate	$280.00
Rate for Payer: Aetna Commercial	$266.00
Rate for Payer: Aetna Medicare	$252.00
Rate for Payer: BCBS MT CHIP	$252.00
Rate for Payer: BCBS MT Closed Plan Network	$266.00
Rate for Payer: BCBS MT HealthLink	$252.00
Rate for Payer: BCBS MT Medicare	$252.00
Rate for Payer: BCBS MT POS	$266.00
Rate for Payer: BCBS MT Traditional	$280.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cigna Commercial	$266.00
Rate for Payer: Cigna Medicare	$252.00
Rate for Payer: Medicaid All Medicaid	$257.60
Rate for Payer: Medicare All Medicare	$196.00
Rate for Payer: Monida Allegiance	$266.00
Rate for Payer: Monida First Choice Health	$271.60
Rate for Payer: Monida Montana Health Co-op	$266.00
Rate for Payer: Monida PacificSource	$266.00

PATELLA STRAP LG

Facility

$46.00

Hospital Charge Code	2893456
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

PATELLA STRAP LG

Facility

$46.00

Hospital Charge Code	2893456
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

Know your out-of-pocket cost for care.

All Charges