Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

PATHFAST D-DIMER(60TESTS/BX) D/S

Facility

$620.10

Hospital Charge Code	90197025
Hospital Revenue Code	270
Min. Negotiated Rate	$434.07
Max. Negotiated Rate	$620.10
Rate for Payer: Aetna Commercial	$589.10
Rate for Payer: Aetna Medicare	$558.09
Rate for Payer: BCBS MT CHIP	$558.09
Rate for Payer: BCBS MT Closed Plan Network	$589.10
Rate for Payer: BCBS MT HealthLink	$558.09
Rate for Payer: BCBS MT Medicare	$558.09
Rate for Payer: BCBS MT POS	$589.10
Rate for Payer: BCBS MT Traditional	$620.10
Rate for Payer: Cash Price	$558.09
Rate for Payer: Cigna Commercial	$589.10
Rate for Payer: Cigna Medicare	$558.09
Rate for Payer: Medicaid All Medicaid	$570.49
Rate for Payer: Medicare All Medicare	$434.07
Rate for Payer: Monida Allegiance	$589.10
Rate for Payer: Monida First Choice Health	$601.50
Rate for Payer: Monida Montana Health Co-op	$589.10
Rate for Payer: Monida PacificSource	$589.10

PATHFAST D-DIMER(60TESTS/BX) D/S

Facility

$620.10

Hospital Charge Code	90197025
Hospital Revenue Code	270
Min. Negotiated Rate	$434.07
Max. Negotiated Rate	$620.10
Rate for Payer: Aetna Commercial	$589.10
Rate for Payer: Aetna Medicare	$558.09
Rate for Payer: BCBS MT CHIP	$558.09
Rate for Payer: BCBS MT Closed Plan Network	$589.10
Rate for Payer: BCBS MT HealthLink	$558.09
Rate for Payer: BCBS MT Medicare	$558.09
Rate for Payer: BCBS MT POS	$589.10
Rate for Payer: BCBS MT Traditional	$620.10
Rate for Payer: Cash Price	$558.09
Rate for Payer: Cigna Commercial	$589.10
Rate for Payer: Cigna Medicare	$558.09
Rate for Payer: Medicaid All Medicaid	$570.49
Rate for Payer: Medicare All Medicare	$434.07
Rate for Payer: Monida Allegiance	$589.10
Rate for Payer: Monida First Choice Health	$601.50
Rate for Payer: Monida Montana Health Co-op	$589.10
Rate for Payer: Monida PacificSource	$589.10

PATHFAST NTPROBNP(60TESTS/BX) D/S

Facility

$1,584.74

Hospital Charge Code	90197024
Hospital Revenue Code	270
Min. Negotiated Rate	$1,109.32
Max. Negotiated Rate	$1,584.74
Rate for Payer: Aetna Commercial	$1,505.50
Rate for Payer: Aetna Medicare	$1,426.27
Rate for Payer: BCBS MT CHIP	$1,426.27
Rate for Payer: BCBS MT Closed Plan Network	$1,505.50
Rate for Payer: BCBS MT HealthLink	$1,426.27
Rate for Payer: BCBS MT Medicare	$1,426.27
Rate for Payer: BCBS MT POS	$1,505.50
Rate for Payer: BCBS MT Traditional	$1,584.74
Rate for Payer: Cash Price	$1,426.27
Rate for Payer: Cigna Commercial	$1,505.50
Rate for Payer: Cigna Medicare	$1,426.27
Rate for Payer: Medicaid All Medicaid	$1,457.96
Rate for Payer: Medicare All Medicare	$1,109.32
Rate for Payer: Monida Allegiance	$1,505.50
Rate for Payer: Monida First Choice Health	$1,537.20
Rate for Payer: Monida Montana Health Co-op	$1,505.50
Rate for Payer: Monida PacificSource	$1,505.50

PATHFAST NTPROBNP(60TESTS/BX) D/S

Facility

$1,584.74

Hospital Charge Code	90197024
Hospital Revenue Code	270
Min. Negotiated Rate	$1,109.32
Max. Negotiated Rate	$1,584.74
Rate for Payer: Aetna Commercial	$1,505.50
Rate for Payer: Aetna Medicare	$1,426.27
Rate for Payer: BCBS MT CHIP	$1,426.27
Rate for Payer: BCBS MT Closed Plan Network	$1,505.50
Rate for Payer: BCBS MT HealthLink	$1,426.27
Rate for Payer: BCBS MT Medicare	$1,426.27
Rate for Payer: BCBS MT POS	$1,505.50
Rate for Payer: BCBS MT Traditional	$1,584.74
Rate for Payer: Cash Price	$1,426.27
Rate for Payer: Cigna Commercial	$1,505.50
Rate for Payer: Cigna Medicare	$1,426.27
Rate for Payer: Medicaid All Medicaid	$1,457.96
Rate for Payer: Medicare All Medicare	$1,109.32
Rate for Payer: Monida Allegiance	$1,505.50
Rate for Payer: Monida First Choice Health	$1,537.20
Rate for Payer: Monida Montana Health Co-op	$1,505.50
Rate for Payer: Monida PacificSource	$1,505.50

PATHFAST SERVICE CONTRACT

Facility

$3,995.00

Hospital Charge Code	90197126
Hospital Revenue Code	270
Min. Negotiated Rate	$2,796.50
Max. Negotiated Rate	$3,995.00
Rate for Payer: Aetna Commercial	$3,795.25
Rate for Payer: Aetna Medicare	$3,595.50
Rate for Payer: BCBS MT CHIP	$3,595.50
Rate for Payer: BCBS MT Closed Plan Network	$3,795.25
Rate for Payer: BCBS MT HealthLink	$3,595.50
Rate for Payer: BCBS MT Medicare	$3,595.50
Rate for Payer: BCBS MT POS	$3,795.25
Rate for Payer: BCBS MT Traditional	$3,995.00
Rate for Payer: Cash Price	$3,595.50
Rate for Payer: Cigna Commercial	$3,795.25
Rate for Payer: Cigna Medicare	$3,595.50
Rate for Payer: Medicaid All Medicaid	$3,675.40
Rate for Payer: Medicare All Medicare	$2,796.50
Rate for Payer: Monida Allegiance	$3,795.25
Rate for Payer: Monida First Choice Health	$3,875.15
Rate for Payer: Monida Montana Health Co-op	$3,795.25
Rate for Payer: Monida PacificSource	$3,795.25

PATHFAST SERVICE CONTRACT

Facility

$3,995.00

Hospital Charge Code	90197126
Hospital Revenue Code	270
Min. Negotiated Rate	$2,796.50
Max. Negotiated Rate	$3,995.00
Rate for Payer: Aetna Commercial	$3,795.25
Rate for Payer: Aetna Medicare	$3,595.50
Rate for Payer: BCBS MT CHIP	$3,595.50
Rate for Payer: BCBS MT Closed Plan Network	$3,795.25
Rate for Payer: BCBS MT HealthLink	$3,595.50
Rate for Payer: BCBS MT Medicare	$3,595.50
Rate for Payer: BCBS MT POS	$3,795.25
Rate for Payer: BCBS MT Traditional	$3,995.00
Rate for Payer: Cash Price	$3,595.50
Rate for Payer: Cigna Commercial	$3,795.25
Rate for Payer: Cigna Medicare	$3,595.50
Rate for Payer: Medicaid All Medicaid	$3,675.40
Rate for Payer: Medicare All Medicare	$2,796.50
Rate for Payer: Monida Allegiance	$3,795.25
Rate for Payer: Monida First Choice Health	$3,875.15
Rate for Payer: Monida Montana Health Co-op	$3,795.25
Rate for Payer: Monida PacificSource	$3,795.25

PATHOLOGY EXAM HIGH

Facility

$221.15

Service Code	HCPCS 88307
Hospital Charge Code	4087932
Hospital Revenue Code	310
Min. Negotiated Rate	$154.81
Max. Negotiated Rate	$221.15
Rate for Payer: Aetna Commercial	$210.09
Rate for Payer: Aetna Medicare	$199.03
Rate for Payer: BCBS MT CHIP	$199.03
Rate for Payer: BCBS MT Closed Plan Network	$210.09
Rate for Payer: BCBS MT HealthLink	$199.03
Rate for Payer: BCBS MT Medicare	$199.03
Rate for Payer: BCBS MT POS	$210.09
Rate for Payer: BCBS MT Traditional	$221.15
Rate for Payer: Cash Price	$199.04
Rate for Payer: Cigna Commercial	$210.09
Rate for Payer: Cigna Medicare	$199.03
Rate for Payer: Medicaid All Medicaid	$203.46
Rate for Payer: Medicare All Medicare	$154.81
Rate for Payer: Monida Allegiance	$210.09
Rate for Payer: Monida First Choice Health	$214.52
Rate for Payer: Monida Montana Health Co-op	$210.09
Rate for Payer: Monida PacificSource	$210.09

PATHOLOGY EXAM HIGH

Facility

$221.15

Service Code	HCPCS 88307
Hospital Charge Code	4087932
Hospital Revenue Code	310
Min. Negotiated Rate	$154.81
Max. Negotiated Rate	$221.15
Rate for Payer: Aetna Commercial	$210.09
Rate for Payer: Aetna Medicare	$199.03
Rate for Payer: BCBS MT CHIP	$199.03
Rate for Payer: BCBS MT Closed Plan Network	$210.09
Rate for Payer: BCBS MT HealthLink	$199.03
Rate for Payer: BCBS MT Medicare	$199.03
Rate for Payer: BCBS MT POS	$210.09
Rate for Payer: BCBS MT Traditional	$221.15
Rate for Payer: Cash Price	$199.04
Rate for Payer: Cigna Commercial	$210.09
Rate for Payer: Cigna Medicare	$199.03
Rate for Payer: Medicaid All Medicaid	$203.46
Rate for Payer: Medicare All Medicare	$154.81
Rate for Payer: Monida Allegiance	$210.09
Rate for Payer: Monida First Choice Health	$214.52
Rate for Payer: Monida Montana Health Co-op	$210.09
Rate for Payer: Monida PacificSource	$210.09

PATHOLOGY EXAM LOW

Facility

$106.20

Service Code	HCPCS 88304
Hospital Charge Code	4087930
Hospital Revenue Code	310
Min. Negotiated Rate	$74.34
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna Commercial	$100.89
Rate for Payer: Aetna Medicare	$95.58
Rate for Payer: BCBS MT CHIP	$95.58
Rate for Payer: BCBS MT Closed Plan Network	$100.89
Rate for Payer: BCBS MT HealthLink	$95.58
Rate for Payer: BCBS MT Medicare	$95.58
Rate for Payer: BCBS MT POS	$100.89
Rate for Payer: BCBS MT Traditional	$106.20
Rate for Payer: Cash Price	$95.58
Rate for Payer: Cigna Commercial	$100.89
Rate for Payer: Cigna Medicare	$95.58
Rate for Payer: Medicaid All Medicaid	$97.70
Rate for Payer: Medicare All Medicare	$74.34
Rate for Payer: Monida Allegiance	$100.89
Rate for Payer: Monida First Choice Health	$103.01
Rate for Payer: Monida Montana Health Co-op	$100.89
Rate for Payer: Monida PacificSource	$100.89

PATHOLOGY EXAM LOW

Facility

$106.20

Service Code	HCPCS 88304
Hospital Charge Code	4087930
Hospital Revenue Code	310
Min. Negotiated Rate	$74.34
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna Commercial	$100.89
Rate for Payer: Aetna Medicare	$95.58
Rate for Payer: BCBS MT CHIP	$95.58
Rate for Payer: BCBS MT Closed Plan Network	$100.89
Rate for Payer: BCBS MT HealthLink	$95.58
Rate for Payer: BCBS MT Medicare	$95.58
Rate for Payer: BCBS MT POS	$100.89
Rate for Payer: BCBS MT Traditional	$106.20
Rate for Payer: Cash Price	$95.58
Rate for Payer: Cigna Commercial	$100.89
Rate for Payer: Cigna Medicare	$95.58
Rate for Payer: Medicaid All Medicaid	$97.70
Rate for Payer: Medicare All Medicare	$74.34
Rate for Payer: Monida Allegiance	$100.89
Rate for Payer: Monida First Choice Health	$103.01
Rate for Payer: Monida Montana Health Co-op	$100.89
Rate for Payer: Monida PacificSource	$100.89

PATHOLOGY EXAM MEDIUM

Facility

$126.79

Service Code	HCPCS 88305
Hospital Charge Code	4087931
Hospital Revenue Code	310
Min. Negotiated Rate	$88.75
Max. Negotiated Rate	$126.79
Rate for Payer: Aetna Commercial	$120.45
Rate for Payer: Aetna Medicare	$114.11
Rate for Payer: BCBS MT CHIP	$114.11
Rate for Payer: BCBS MT Closed Plan Network	$120.45
Rate for Payer: BCBS MT HealthLink	$114.11
Rate for Payer: BCBS MT Medicare	$114.11
Rate for Payer: BCBS MT POS	$120.45
Rate for Payer: BCBS MT Traditional	$126.79
Rate for Payer: Cash Price	$114.11
Rate for Payer: Cigna Commercial	$120.45
Rate for Payer: Cigna Medicare	$114.11
Rate for Payer: Medicaid All Medicaid	$116.65
Rate for Payer: Medicare All Medicare	$88.75
Rate for Payer: Monida Allegiance	$120.45
Rate for Payer: Monida First Choice Health	$122.99
Rate for Payer: Monida Montana Health Co-op	$120.45
Rate for Payer: Monida PacificSource	$120.45

PATHOLOGY EXAM MEDIUM

Facility

$126.79

Service Code	HCPCS 88305
Hospital Charge Code	4087931
Hospital Revenue Code	310
Min. Negotiated Rate	$88.75
Max. Negotiated Rate	$126.79
Rate for Payer: Aetna Commercial	$120.45
Rate for Payer: Aetna Medicare	$114.11
Rate for Payer: BCBS MT CHIP	$114.11
Rate for Payer: BCBS MT Closed Plan Network	$120.45
Rate for Payer: BCBS MT HealthLink	$114.11
Rate for Payer: BCBS MT Medicare	$114.11
Rate for Payer: BCBS MT POS	$120.45
Rate for Payer: BCBS MT Traditional	$126.79
Rate for Payer: Cash Price	$114.11
Rate for Payer: Cigna Commercial	$120.45
Rate for Payer: Cigna Medicare	$114.11
Rate for Payer: Medicaid All Medicaid	$116.65
Rate for Payer: Medicare All Medicare	$88.75
Rate for Payer: Monida Allegiance	$120.45
Rate for Payer: Monida First Choice Health	$122.99
Rate for Payer: Monida Montana Health Co-op	$120.45
Rate for Payer: Monida PacificSource	$120.45

PATH SPECIAL STAIN

Facility

$120.00

Service Code	HCPCS 88312
Hospital Charge Code	4087898
Hospital Revenue Code	306
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

PATH SPECIAL STAIN

Facility

$120.00

Service Code	HCPCS 88312
Hospital Charge Code	4087898
Hospital Revenue Code	306
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

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

$3,508.00

Service Code	HCPCS Q5108
Hospital Charge Code	3000582
Hospital Revenue Code	636
Min. Negotiated Rate	$2,455.60
Max. Negotiated Rate	$3,508.00
Rate for Payer: Aetna Commercial	$3,332.60
Rate for Payer: Aetna Medicare	$3,157.20
Rate for Payer: BCBS MT CHIP	$3,157.20
Rate for Payer: BCBS MT Closed Plan Network	$3,332.60
Rate for Payer: BCBS MT HealthLink	$3,157.20
Rate for Payer: BCBS MT Medicare	$3,157.20
Rate for Payer: BCBS MT POS	$3,332.60
Rate for Payer: BCBS MT Traditional	$3,508.00
Rate for Payer: Cash Price	$3,157.20
Rate for Payer: Cigna Commercial	$3,332.60
Rate for Payer: Cigna Medicare	$3,157.20
Rate for Payer: Medicaid All Medicaid	$3,227.36
Rate for Payer: Medicare All Medicare	$2,455.60
Rate for Payer: Monida Allegiance	$3,332.60
Rate for Payer: Monida First Choice Health	$3,402.76
Rate for Payer: Monida Montana Health Co-op	$3,332.60
Rate for Payer: Monida PacificSource	$3,332.60

PEGFILGRASTIM SYR [6 MG/0.6 ML] SPEC ORD

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

PEGFILGRASTIM SYR [6 MG/0.6 ML] SPEC ORD

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

PEGFILGRASTIM SYR [6 MG/0.6 ML] SPEC ORD

Facility

$3,508.00

Service Code	HCPCS Q5108
Hospital Charge Code	3000582
Hospital Revenue Code	636
Min. Negotiated Rate	$2,455.60
Max. Negotiated Rate	$3,508.00
Rate for Payer: Aetna Commercial	$3,332.60
Rate for Payer: Aetna Medicare	$3,157.20
Rate for Payer: BCBS MT CHIP	$3,157.20
Rate for Payer: BCBS MT Closed Plan Network	$3,332.60
Rate for Payer: BCBS MT HealthLink	$3,157.20
Rate for Payer: BCBS MT Medicare	$3,157.20
Rate for Payer: BCBS MT POS	$3,332.60
Rate for Payer: BCBS MT Traditional	$3,508.00
Rate for Payer: Cash Price	$3,157.20
Rate for Payer: Cigna Commercial	$3,332.60
Rate for Payer: Cigna Medicare	$3,157.20
Rate for Payer: Medicaid All Medicaid	$3,227.36
Rate for Payer: Medicare All Medicare	$2,455.60
Rate for Payer: Monida Allegiance	$3,332.60
Rate for Payer: Monida First Choice Health	$3,402.76
Rate for Payer: Monida Montana Health Co-op	$3,332.60
Rate for Payer: Monida PacificSource	$3,332.60

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

Know your out-of-pocket cost for care.

All Charges