Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

PERIPHERAL SMEAR CONSULT (005300)

Facility

$71.00

Service Code	HCPCS 85060
Hospital Charge Code	4085060
Hospital Revenue Code	305
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

PERIPHERAL SMEAR CONSULT (005300)

Facility

$71.00

Service Code	HCPCS 85060
Hospital Charge Code	4085060
Hospital Revenue Code	305
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

PETROLEUM GAUZE PACKING STRIPS 3X9

Facility

$21.00

Hospital Charge Code	80040919
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

PETROLEUM GAUZE PACKING STRIPS 3X9

Facility

$21.00

Hospital Charge Code	80040919
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

PFEE OP INJ TRANSFOR C/T 1S 64479

Professional

Both

$674.00

Service Code	HCPCS 64479
Hospital Charge Code	764479
Hospital Revenue Code	964
Min. Negotiated Rate	$471.80
Max. Negotiated Rate	$674.00
Rate for Payer: Aetna Commercial	$640.30
Rate for Payer: Aetna Medicare	$606.60
Rate for Payer: BCBS MT CHIP	$606.60
Rate for Payer: BCBS MT Closed Plan Network	$640.30
Rate for Payer: BCBS MT HealthLink	$606.60
Rate for Payer: BCBS MT Medicare	$606.60
Rate for Payer: BCBS MT POS	$640.30
Rate for Payer: BCBS MT Traditional	$674.00
Rate for Payer: Cash Price	$606.60
Rate for Payer: Cigna Commercial	$640.30
Rate for Payer: Cigna Medicare	$606.60
Rate for Payer: Medicaid All Medicaid	$620.08
Rate for Payer: Medicare All Medicare	$471.80
Rate for Payer: Monida Allegiance	$640.30
Rate for Payer: Monida First Choice Health	$653.78
Rate for Payer: Monida Montana Health Co-op	$640.30
Rate for Payer: Monida PacificSource	$640.30

PF ER CLOSED SHOULDER DISLOC W/ANESTHESI

Professional

Both

$2,198.00

Service Code	HCPCS 23655 AQ
Hospital Charge Code	723655
Hospital Revenue Code	981
Min. Negotiated Rate	$1,538.60
Max. Negotiated Rate	$2,198.00
Rate for Payer: Aetna Commercial	$2,088.10
Rate for Payer: Aetna Medicare	$1,978.20
Rate for Payer: BCBS MT CHIP	$1,978.20
Rate for Payer: BCBS MT Closed Plan Network	$2,088.10
Rate for Payer: BCBS MT HealthLink	$1,978.20
Rate for Payer: BCBS MT Medicare	$1,978.20
Rate for Payer: BCBS MT POS	$2,088.10
Rate for Payer: BCBS MT Traditional	$2,198.00
Rate for Payer: Cash Price	$1,978.20
Rate for Payer: Cigna Commercial	$2,088.10
Rate for Payer: Cigna Medicare	$1,978.20
Rate for Payer: Medicaid All Medicaid	$2,022.16
Rate for Payer: Medicare All Medicare	$1,538.60
Rate for Payer: Monida Allegiance	$2,088.10
Rate for Payer: Monida First Choice Health	$2,132.06
Rate for Payer: Monida Montana Health Co-op	$2,088.10
Rate for Payer: Monida PacificSource	$2,088.10

PF ER CLSD TX HUM SHFT FRAC W/MANI 24505

Professional

Both

$2,445.00

Service Code	HCPCS 24505 AQ
Hospital Charge Code	724505
Hospital Revenue Code	981
Min. Negotiated Rate	$1,711.50
Max. Negotiated Rate	$2,445.00
Rate for Payer: Aetna Commercial	$2,322.75
Rate for Payer: Aetna Medicare	$2,200.50
Rate for Payer: BCBS MT CHIP	$2,200.50
Rate for Payer: BCBS MT Closed Plan Network	$2,322.75
Rate for Payer: BCBS MT HealthLink	$2,200.50
Rate for Payer: BCBS MT Medicare	$2,200.50
Rate for Payer: BCBS MT POS	$2,322.75
Rate for Payer: BCBS MT Traditional	$2,445.00
Rate for Payer: Cash Price	$2,200.50
Rate for Payer: Cigna Commercial	$2,322.75
Rate for Payer: Cigna Medicare	$2,200.50
Rate for Payer: Medicaid All Medicaid	$2,249.40
Rate for Payer: Medicare All Medicare	$1,711.50
Rate for Payer: Monida Allegiance	$2,322.75
Rate for Payer: Monida First Choice Health	$2,371.65
Rate for Payer: Monida Montana Health Co-op	$2,322.75
Rate for Payer: Monida PacificSource	$2,322.75

PF ER MOD CON SED 1ST 15MIN 5&OLDR 99152

Professional

Both

$251.00

Service Code	HCPCS 99152 AQ
Hospital Charge Code	799152
Hospital Revenue Code	981
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

PF ER SHOULDER DISLOCATION W/O ANESTHESI

Professional

Both

$1,648.00

Service Code	HCPCS 23650 AQ
Hospital Charge Code	723650
Hospital Revenue Code	981
Min. Negotiated Rate	$1,153.60
Max. Negotiated Rate	$1,648.00
Rate for Payer: Aetna Commercial	$1,565.60
Rate for Payer: Aetna Medicare	$1,483.20
Rate for Payer: BCBS MT CHIP	$1,483.20
Rate for Payer: BCBS MT Closed Plan Network	$1,565.60
Rate for Payer: BCBS MT HealthLink	$1,483.20
Rate for Payer: BCBS MT Medicare	$1,483.20
Rate for Payer: BCBS MT POS	$1,565.60
Rate for Payer: BCBS MT Traditional	$1,648.00
Rate for Payer: Cash Price	$1,483.20
Rate for Payer: Cigna Commercial	$1,565.60
Rate for Payer: Cigna Medicare	$1,483.20
Rate for Payer: Medicaid All Medicaid	$1,516.16
Rate for Payer: Medicare All Medicare	$1,153.60
Rate for Payer: Monida Allegiance	$1,565.60
Rate for Payer: Monida First Choice Health	$1,598.56
Rate for Payer: Monida Montana Health Co-op	$1,565.60
Rate for Payer: Monida PacificSource	$1,565.60

PF FX CLOSED DISTAL RADIAL WITH MANIPUL

Professional

Both

$2,757.00

Service Code	HCPCS 25605 AQ
Hospital Charge Code	725605
Hospital Revenue Code	981
Min. Negotiated Rate	$1,929.90
Max. Negotiated Rate	$2,757.00
Rate for Payer: Aetna Commercial	$2,619.15
Rate for Payer: Aetna Medicare	$2,481.30
Rate for Payer: BCBS MT CHIP	$2,481.30
Rate for Payer: BCBS MT Closed Plan Network	$2,619.15
Rate for Payer: BCBS MT HealthLink	$2,481.30
Rate for Payer: BCBS MT Medicare	$2,481.30
Rate for Payer: BCBS MT POS	$2,619.15
Rate for Payer: BCBS MT Traditional	$2,757.00
Rate for Payer: Cash Price	$2,481.30
Rate for Payer: Cigna Commercial	$2,619.15
Rate for Payer: Cigna Medicare	$2,481.30
Rate for Payer: Medicaid All Medicaid	$2,536.44
Rate for Payer: Medicare All Medicare	$1,929.90
Rate for Payer: Monida Allegiance	$2,619.15
Rate for Payer: Monida First Choice Health	$2,674.29
Rate for Payer: Monida Montana Health Co-op	$2,619.15
Rate for Payer: Monida PacificSource	$2,619.15

PHENAZOPYRIDINE TAB [95 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000383
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

PHENAZOPYRIDINE TAB [95 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000383
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

PHENOBARBITAL (007823)

Facility

$67.00

Service Code	HCPCS 80184
Hospital Charge Code	4080184
Hospital Revenue Code	301
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

PHENOBARBITAL (007823)

Facility

$67.00

Service Code	HCPCS 80184
Hospital Charge Code	4080184
Hospital Revenue Code	301
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

PHENYLEPHRINE INJ [10 MG/ML]

Facility

$26.00

Service Code	HCPCS J2371
Hospital Charge Code	3000384
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

PHENYLEPHRINE INJ [10 MG/ML]

Facility

$26.00

Service Code	HCPCS J2371
Hospital Charge Code	3000384
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

PHENYLEPHRINE NASAL SPRAY [1%] 1OZ

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000385
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PHENYLEPHRINE NASAL SPRAY [1%] 1OZ

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000385
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PHENYTOIN (007401)

Facility

$69.00

Service Code	HCPCS 80185
Hospital Charge Code	4080185
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

PHENYTOIN (007401)

Facility

$69.00

Service Code	HCPCS 80185
Hospital Charge Code	4080185
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

Know your out-of-pocket cost for care.

All Charges