Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PATHOLOGY EXAM LOW

Facility

$106.20

Service Code	CPT 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	CPT 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	CPT 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 INTERPRET

Facility

$150.00

Service Code	CPT 88141
Hospital Charge Code	4088043
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

PATHOLOGY INTERPRET

Facility

$150.00

Service Code	CPT 88141
Hospital Charge Code	4088043
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

PATH SPECIAL STAIN

Facility

$120.00

Service Code	CPT 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	CPT 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

PATIENT SCREENED FOR FALL RISK: 2+ IN YR

Facility

$0.01

Service Code	CPT 1100F
Hospital Charge Code	8001100
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

PATIENT SCREENED FOR FALL RISK: 2+ IN YR

Facility

$0.01

Service Code	CPT 1100F
Hospital Charge Code	8001100
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

PATIENT SCREEN FOR FALL RISK: NO FALLS

Facility

$0.01

Service Code	CPT 1101F
Hospital Charge Code	8001101
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

PATIENT SCREEN FOR FALL RISK: NO FALLS

Facility

$0.01

Service Code	CPT 1101F
Hospital Charge Code	8001101
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

PEAK EXPIRATORY FLOW RATE

Facility

$15.00

Service Code	HCPCS S8110
Hospital Charge Code	8008110
Hospital Revenue Code	521
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

PEAK EXPIRATORY FLOW RATE

Facility

$15.00

Service Code	HCPCS S8110
Hospital Charge Code	8008110
Hospital Revenue Code	521
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

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

PEAK FLOW METER HAND HELD

Facility

$64.00

Service Code	HCPCS A4614
Hospital Charge Code	8004614
Hospital Revenue Code	521
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

PEAK FLOW METER HAND HELD

Facility

$64.00

Service Code	HCPCS A4614
Hospital Charge Code	8004614
Hospital Revenue Code	521
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

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] NF

Facility

$8.00

Service Code	HCPCS J8499
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

PENICILLIN V K TAB [250 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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 TAB [400 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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 TAB [400 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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

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