Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PHENYTOIN TOTAL AND FREE

Facility

$100.78

Service Code	CPT 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	CPT 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

PHLEBOTOMY

Facility

$139.00

Service Code	CPT 99195
Hospital Charge Code	8099195
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

PHLEBOTOMY

Facility

$139.00

Service Code	CPT 99195
Hospital Charge Code	8099195
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

PHLEBOTOMY TRAY

Facility

$138.84

Hospital Charge Code	90197145
Hospital Revenue Code	270
Min. Negotiated Rate	$97.19
Max. Negotiated Rate	$138.84
Rate for Payer: Aetna Commercial	$131.90
Rate for Payer: Aetna Medicare	$124.96
Rate for Payer: BCBS MT CHIP	$124.96
Rate for Payer: BCBS MT Closed Plan Network	$131.90
Rate for Payer: BCBS MT HealthLink	$124.96
Rate for Payer: BCBS MT Medicare	$124.96
Rate for Payer: BCBS MT POS	$131.90
Rate for Payer: BCBS MT Traditional	$138.84
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$131.90
Rate for Payer: Cigna Medicare	$124.96
Rate for Payer: Medicaid All Medicaid	$127.73
Rate for Payer: Medicare All Medicare	$97.19
Rate for Payer: Monida Allegiance	$131.90
Rate for Payer: Monida First Choice Health	$134.67
Rate for Payer: Monida Montana Health Co-op	$131.90
Rate for Payer: Monida PacificSource	$131.90

PHLEBOTOMY TRAY

Facility

$138.84

Hospital Charge Code	90197145
Hospital Revenue Code	270
Min. Negotiated Rate	$97.19
Max. Negotiated Rate	$138.84
Rate for Payer: Aetna Commercial	$131.90
Rate for Payer: Aetna Medicare	$124.96
Rate for Payer: BCBS MT CHIP	$124.96
Rate for Payer: BCBS MT Closed Plan Network	$131.90
Rate for Payer: BCBS MT HealthLink	$124.96
Rate for Payer: BCBS MT Medicare	$124.96
Rate for Payer: BCBS MT POS	$131.90
Rate for Payer: BCBS MT Traditional	$138.84
Rate for Payer: Cash Price	$124.96
Rate for Payer: Cigna Commercial	$131.90
Rate for Payer: Cigna Medicare	$124.96
Rate for Payer: Medicaid All Medicaid	$127.73
Rate for Payer: Medicare All Medicare	$97.19
Rate for Payer: Monida Allegiance	$131.90
Rate for Payer: Monida First Choice Health	$134.67
Rate for Payer: Monida Montana Health Co-op	$131.90
Rate for Payer: Monida PacificSource	$131.90

PHONE E/M PHYS/QHP 11-20 MIN

Facility

$60.00

Service Code	CPT 99442
Hospital Charge Code	8099442
Hospital Revenue Code	521
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

PHONE E/M PHYS/QHP 11-20 MIN

Facility

$60.00

Service Code	CPT 99442
Hospital Charge Code	8099442
Hospital Revenue Code	521
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

PHONE E/M PHYS/QHP 21-30 MIN

Facility

$90.00

Service Code	CPT 99443
Hospital Charge Code	8099443
Hospital Revenue Code	521
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

PHONE E/M PHYS/QHP 21-30 MIN

Facility

$90.00

Service Code	CPT 99443
Hospital Charge Code	8099443
Hospital Revenue Code	521
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

PHONE E/M PHYS/QHP 5-10 MIN

Facility

$30.00

Service Code	CPT 99441
Hospital Charge Code	8099441
Hospital Revenue Code	521
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

PHONE E/M PHYS/QHP 5-10 MIN

Facility

$30.00

Service Code	CPT 99441
Hospital Charge Code	8099441
Hospital Revenue Code	521
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

PHOSPHATIDYLETHANOL CONFIRM

Facility

$169.70

Service Code	CPT 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	CPT 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

PHOSPHOETHANOLAMINE URINE WITH CREA

Facility

$95.00

Service Code	CPT 82131
Hospital Charge Code	4088018
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

PHOSPHOETHANOLAMINE URINE WITH CREA

Facility

$95.00

Service Code	CPT 82131
Hospital Charge Code	4088018
Hospital Revenue Code	302
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

PHOSPHOROUS URINE 24HR

Facility

$70.00

Service Code	CPT 84105
Hospital Charge Code	4088064
Hospital Revenue Code	302
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

PHOSPHOROUS URINE 24HR

Facility

$70.00

Service Code	CPT 84105
Hospital Charge Code	4088064
Hospital Revenue Code	302
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

PHOSPHORUS

Facility

$66.00

Service Code	CPT 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	CPT 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 A9150
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 A9150
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

Know your out-of-pocket cost for care.

All Charges