Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PHENYTOIN ER CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000386
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

PHENYTOIN ER CAP [100 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000386
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

PHENYTOIN INJ 100MG/2ML

Facility

$26.00

Service Code	HCPCS J1165
Hospital Charge Code	3000387
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

PHENYTOIN INJ 100MG/2ML

Facility

$26.00

Service Code	HCPCS J1165
Hospital Charge Code	3000387
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

PHENYTOIN TOTAL AND FREE

Facility

$100.78

Service Code	HCPCS 80186
Hospital Charge Code	4087938
Hospital Revenue Code	300
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$100.78
Rate for Payer: Aetna Commercial	$95.74
Rate for Payer: Aetna Medicare	$90.70
Rate for Payer: BCBS MT CHIP	$90.70
Rate for Payer: BCBS MT Closed Plan Network	$95.74
Rate for Payer: BCBS MT HealthLink	$90.70
Rate for Payer: BCBS MT Medicare	$90.70
Rate for Payer: BCBS MT POS	$95.74
Rate for Payer: BCBS MT Traditional	$100.78
Rate for Payer: Cash Price	$90.70
Rate for Payer: Cigna Commercial	$95.74
Rate for Payer: Cigna Medicare	$90.70
Rate for Payer: Medicaid All Medicaid	$92.72
Rate for Payer: Medicare All Medicare	$70.55
Rate for Payer: Monida Allegiance	$95.74
Rate for Payer: Monida First Choice Health	$97.76
Rate for Payer: Monida Montana Health Co-op	$95.74
Rate for Payer: Monida PacificSource	$95.74

PHENYTOIN TOTAL AND FREE

Facility

$100.78

Service Code	HCPCS 80186
Hospital Charge Code	4087938
Hospital Revenue Code	300
Min. Negotiated Rate	$70.55
Max. Negotiated Rate	$100.78
Rate for Payer: Aetna Commercial	$95.74
Rate for Payer: Aetna Medicare	$90.70
Rate for Payer: BCBS MT CHIP	$90.70
Rate for Payer: BCBS MT Closed Plan Network	$95.74
Rate for Payer: BCBS MT HealthLink	$90.70
Rate for Payer: BCBS MT Medicare	$90.70
Rate for Payer: BCBS MT POS	$95.74
Rate for Payer: BCBS MT Traditional	$100.78
Rate for Payer: Cash Price	$90.70
Rate for Payer: Cigna Commercial	$95.74
Rate for Payer: Cigna Medicare	$90.70
Rate for Payer: Medicaid All Medicaid	$92.72
Rate for Payer: Medicare All Medicare	$70.55
Rate for Payer: Monida Allegiance	$95.74
Rate for Payer: Monida First Choice Health	$97.76
Rate for Payer: Monida Montana Health Co-op	$95.74
Rate for Payer: Monida PacificSource	$95.74

PHOSPHATIDYLETHANOL CONFIRM

Facility

$169.70

Service Code	HCPCS 80321
Hospital Charge Code	4087952
Hospital Revenue Code	300
Min. Negotiated Rate	$118.79
Max. Negotiated Rate	$169.70
Rate for Payer: Aetna Commercial	$161.22
Rate for Payer: Aetna Medicare	$152.73
Rate for Payer: BCBS MT CHIP	$152.73
Rate for Payer: BCBS MT Closed Plan Network	$161.22
Rate for Payer: BCBS MT HealthLink	$152.73
Rate for Payer: BCBS MT Medicare	$152.73
Rate for Payer: BCBS MT POS	$161.22
Rate for Payer: BCBS MT Traditional	$169.70
Rate for Payer: Cash Price	$152.73
Rate for Payer: Cigna Commercial	$161.22
Rate for Payer: Cigna Medicare	$152.73
Rate for Payer: Medicaid All Medicaid	$156.12
Rate for Payer: Medicare All Medicare	$118.79
Rate for Payer: Monida Allegiance	$161.22
Rate for Payer: Monida First Choice Health	$164.61
Rate for Payer: Monida Montana Health Co-op	$161.22
Rate for Payer: Monida PacificSource	$161.22

PHOSPHATIDYLETHANOL CONFIRM

Facility

$169.70

Service Code	HCPCS 80321
Hospital Charge Code	4087952
Hospital Revenue Code	300
Min. Negotiated Rate	$118.79
Max. Negotiated Rate	$169.70
Rate for Payer: Aetna Commercial	$161.22
Rate for Payer: Aetna Medicare	$152.73
Rate for Payer: BCBS MT CHIP	$152.73
Rate for Payer: BCBS MT Closed Plan Network	$161.22
Rate for Payer: BCBS MT HealthLink	$152.73
Rate for Payer: BCBS MT Medicare	$152.73
Rate for Payer: BCBS MT POS	$161.22
Rate for Payer: BCBS MT Traditional	$169.70
Rate for Payer: Cash Price	$152.73
Rate for Payer: Cigna Commercial	$161.22
Rate for Payer: Cigna Medicare	$152.73
Rate for Payer: Medicaid All Medicaid	$156.12
Rate for Payer: Medicare All Medicare	$118.79
Rate for Payer: Monida Allegiance	$161.22
Rate for Payer: Monida First Choice Health	$164.61
Rate for Payer: Monida Montana Health Co-op	$161.22
Rate for Payer: Monida PacificSource	$161.22

PHOSPHORUS

Facility

$66.00

Service Code	HCPCS 84100
Hospital Charge Code	4084100
Hospital Revenue Code	301
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

PHOSPHORUS

Facility

$66.00

Service Code	HCPCS 84100
Hospital Charge Code	4084100
Hospital Revenue Code	301
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

PHYTONADIONE INJ [10 MG/ML]

Facility

$195.00

Service Code	HCPCS J3430
Hospital Charge Code	3000388
Hospital Revenue Code	259
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

PHYTONADIONE INJ [10 MG/ML]

Facility

$195.00

Service Code	HCPCS J3430
Hospital Charge Code	3000388
Hospital Revenue Code	259
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

PINK BISMUTH SUSP [525 MG/15 ML] NF

Facility

$27.00

Service Code	HCPCS J3490
Hospital Charge Code	3007505
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

PINK BISMUTH SUSP [525 MG/15 ML] NF

Facility

$27.00

Service Code	HCPCS J3490
Hospital Charge Code	3007505
Hospital Revenue Code	250
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

PIPERACILLIN/TAZOBACTAM 4.5GM VIAL

Facility

$70.00

Service Code	HCPCS J2543
Hospital Charge Code	3007376
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

PIPERACILLIN/TAZOBACTAM 4.5GM VIAL

Facility

$70.00

Service Code	HCPCS J2543
Hospital Charge Code	3007376
Hospital Revenue Code	250
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

PIPETTE TRANSFER 5 ML (500/B

Facility

$23.27

Hospital Charge Code	90195104
Hospital Revenue Code	270
Min. Negotiated Rate	$16.29
Max. Negotiated Rate	$23.27
Rate for Payer: Aetna Commercial	$22.11
Rate for Payer: Aetna Medicare	$20.94
Rate for Payer: BCBS MT CHIP	$20.94
Rate for Payer: BCBS MT Closed Plan Network	$22.11
Rate for Payer: BCBS MT HealthLink	$20.94
Rate for Payer: BCBS MT Medicare	$20.94
Rate for Payer: BCBS MT POS	$22.11
Rate for Payer: BCBS MT Traditional	$23.27
Rate for Payer: Cash Price	$20.94
Rate for Payer: Cigna Commercial	$22.11
Rate for Payer: Cigna Medicare	$20.94
Rate for Payer: Medicaid All Medicaid	$21.41
Rate for Payer: Medicare All Medicare	$16.29
Rate for Payer: Monida Allegiance	$22.11
Rate for Payer: Monida First Choice Health	$22.57
Rate for Payer: Monida Montana Health Co-op	$22.11
Rate for Payer: Monida PacificSource	$22.11

PIPETTE TRANSFER 5 ML (500/B

Facility

$23.27

Hospital Charge Code	90195104
Hospital Revenue Code	270
Min. Negotiated Rate	$16.29
Max. Negotiated Rate	$23.27
Rate for Payer: Aetna Commercial	$22.11
Rate for Payer: Aetna Medicare	$20.94
Rate for Payer: BCBS MT CHIP	$20.94
Rate for Payer: BCBS MT Closed Plan Network	$22.11
Rate for Payer: BCBS MT HealthLink	$20.94
Rate for Payer: BCBS MT Medicare	$20.94
Rate for Payer: BCBS MT POS	$22.11
Rate for Payer: BCBS MT Traditional	$23.27
Rate for Payer: Cash Price	$20.94
Rate for Payer: Cigna Commercial	$22.11
Rate for Payer: Cigna Medicare	$20.94
Rate for Payer: Medicaid All Medicaid	$21.41
Rate for Payer: Medicare All Medicare	$16.29
Rate for Payer: Monida Allegiance	$22.11
Rate for Payer: Monida First Choice Health	$22.57
Rate for Payer: Monida Montana Health Co-op	$22.11
Rate for Payer: Monida PacificSource	$22.11

PLAIN PACKING STRIPS 1/4IN

Facility

$35.00

Hospital Charge Code	80030182
Hospital Revenue Code	270
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

PLAIN PACKING STRIPS 1/4IN

Facility

$35.00

Hospital Charge Code	80030182
Hospital Revenue Code	270
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

PLATELET COUNT, BLOOD

Facility

$68.00

Service Code	HCPCS 85049
Hospital Charge Code	4085049
Hospital Revenue Code	305
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

PLATELET COUNT, BLOOD

Facility

$68.00

Service Code	HCPCS 85049
Hospital Charge Code	4085049
Hospital Revenue Code	305
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

PLEURAL DRNG, PERC,W/INS OF CATH-W/O IMA

Facility

$2,196.00

Service Code	HCPCS 32556
Hospital Charge Code	1032556
Hospital Revenue Code	450
Min. Negotiated Rate	$1,537.20
Max. Negotiated Rate	$2,196.00
Rate for Payer: Aetna Commercial	$2,086.20
Rate for Payer: Aetna Medicare	$1,976.40
Rate for Payer: BCBS MT CHIP	$1,976.40
Rate for Payer: BCBS MT Closed Plan Network	$2,086.20
Rate for Payer: BCBS MT HealthLink	$1,976.40
Rate for Payer: BCBS MT Medicare	$1,976.40
Rate for Payer: BCBS MT POS	$2,086.20
Rate for Payer: BCBS MT Traditional	$2,196.00
Rate for Payer: Cash Price	$1,976.40
Rate for Payer: Cigna Commercial	$2,086.20
Rate for Payer: Cigna Medicare	$1,976.40
Rate for Payer: Medicaid All Medicaid	$2,020.32
Rate for Payer: Medicare All Medicare	$1,537.20
Rate for Payer: Monida Allegiance	$2,086.20
Rate for Payer: Monida First Choice Health	$2,130.12
Rate for Payer: Monida Montana Health Co-op	$2,086.20
Rate for Payer: Monida PacificSource	$2,086.20

PLEURAL DRNG, PERC,W/INS OF CATH-W/O IMA

Facility

$2,196.00

Service Code	HCPCS 32556
Hospital Charge Code	1032556
Hospital Revenue Code	450
Min. Negotiated Rate	$1,537.20
Max. Negotiated Rate	$2,196.00
Rate for Payer: Aetna Commercial	$2,086.20
Rate for Payer: Aetna Medicare	$1,976.40
Rate for Payer: BCBS MT CHIP	$1,976.40
Rate for Payer: BCBS MT Closed Plan Network	$2,086.20
Rate for Payer: BCBS MT HealthLink	$1,976.40
Rate for Payer: BCBS MT Medicare	$1,976.40
Rate for Payer: BCBS MT POS	$2,086.20
Rate for Payer: BCBS MT Traditional	$2,196.00
Rate for Payer: Cash Price	$1,976.40
Rate for Payer: Cigna Commercial	$2,086.20
Rate for Payer: Cigna Medicare	$1,976.40
Rate for Payer: Medicaid All Medicaid	$2,020.32
Rate for Payer: Medicare All Medicare	$1,537.20
Rate for Payer: Monida Allegiance	$2,086.20
Rate for Payer: Monida First Choice Health	$2,130.12
Rate for Payer: Monida Montana Health Co-op	$2,086.20
Rate for Payer: Monida PacificSource	$2,086.20

PODDUS BOOT LG

Facility

$58.00

Hospital Charge Code	2840128
Hospital Revenue Code	270
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

Know your out-of-pocket cost for care.

All Charges