Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PREGNENOLONE (140707)

Facility

$179.00

Service Code	CPT 84140
Hospital Charge Code	4084140
Hospital Revenue Code	300
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

PREGNENOLONE (140707)

Facility

$179.00

Service Code	CPT 84140
Hospital Charge Code	4084140
Hospital Revenue Code	300
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

PRESCRIPTION/ORAL GI COCKTAIL

Facility

$23.00

Service Code	HCPCS J8999
Hospital Charge Code	8008999
Hospital Revenue Code	521
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PRESCRIPTION/ORAL GI COCKTAIL

Facility

$23.00

Service Code	HCPCS J8999
Hospital Charge Code	8008999
Hospital Revenue Code	521
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PRESERVISION AREDS 2 NF

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000507
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

PRESERVISION AREDS 2 NF

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000507
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

PREVENTATIVE COUNSELING 45 MINUTES

Facility

$202.00

Service Code	CPT 99403
Hospital Charge Code	8099403
Hospital Revenue Code	521
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

PREVENTATIVE COUNSELING 45 MINUTES

Facility

$202.00

Service Code	CPT 99403
Hospital Charge Code	8099403
Hospital Revenue Code	521
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

PRIMIDONE TAB [50 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000402
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

PRIMIDONE TAB [50 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000402
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

PRIVATE ROOM

Facility

$1,736.00

Hospital Charge Code	100001
Hospital Revenue Code	120
Min. Negotiated Rate	$1,215.20
Max. Negotiated Rate	$1,736.00
Rate for Payer: Aetna Commercial	$1,649.20
Rate for Payer: Aetna Medicare	$1,562.40
Rate for Payer: BCBS MT CHIP	$1,562.40
Rate for Payer: BCBS MT Closed Plan Network	$1,649.20
Rate for Payer: BCBS MT HealthLink	$1,562.40
Rate for Payer: BCBS MT Medicare	$1,562.40
Rate for Payer: BCBS MT POS	$1,649.20
Rate for Payer: BCBS MT Traditional	$1,736.00
Rate for Payer: Cash Price	$1,562.40
Rate for Payer: Cigna Commercial	$1,649.20
Rate for Payer: Cigna Medicare	$1,562.40
Rate for Payer: Medicaid All Medicaid	$1,597.12
Rate for Payer: Medicare All Medicare	$1,215.20
Rate for Payer: Monida Allegiance	$1,649.20
Rate for Payer: Monida First Choice Health	$1,683.92
Rate for Payer: Monida Montana Health Co-op	$1,649.20
Rate for Payer: Monida PacificSource	$1,649.20

PRIVATE ROOM ISOLATION

Facility

$1,875.00

Hospital Charge Code	100002
Hospital Revenue Code	120
Min. Negotiated Rate	$1,312.50
Max. Negotiated Rate	$1,875.00
Rate for Payer: Aetna Commercial	$1,781.25
Rate for Payer: Aetna Medicare	$1,687.50
Rate for Payer: BCBS MT CHIP	$1,687.50
Rate for Payer: BCBS MT Closed Plan Network	$1,781.25
Rate for Payer: BCBS MT HealthLink	$1,687.50
Rate for Payer: BCBS MT Medicare	$1,687.50
Rate for Payer: BCBS MT POS	$1,781.25
Rate for Payer: BCBS MT Traditional	$1,875.00
Rate for Payer: Cash Price	$1,687.50
Rate for Payer: Cigna Commercial	$1,781.25
Rate for Payer: Cigna Medicare	$1,687.50
Rate for Payer: Medicaid All Medicaid	$1,725.00
Rate for Payer: Medicare All Medicare	$1,312.50
Rate for Payer: Monida Allegiance	$1,781.25
Rate for Payer: Monida First Choice Health	$1,818.75
Rate for Payer: Monida Montana Health Co-op	$1,781.25
Rate for Payer: Monida PacificSource	$1,781.25

PRIVIGEN 10GM/100ML SDV SPEC ORDER

Facility

$2,868.00

Service Code	HCPCS J1459
Hospital Charge Code	3007125
Hospital Revenue Code	636
Min. Negotiated Rate	$2,007.60
Max. Negotiated Rate	$2,868.00
Rate for Payer: Aetna Commercial	$2,724.60
Rate for Payer: Aetna Medicare	$2,581.20
Rate for Payer: BCBS MT CHIP	$2,581.20
Rate for Payer: BCBS MT Closed Plan Network	$2,724.60
Rate for Payer: BCBS MT HealthLink	$2,581.20
Rate for Payer: BCBS MT Medicare	$2,581.20
Rate for Payer: BCBS MT POS	$2,724.60
Rate for Payer: BCBS MT Traditional	$2,868.00
Rate for Payer: Cash Price	$2,581.20
Rate for Payer: Cigna Commercial	$2,724.60
Rate for Payer: Cigna Medicare	$2,581.20
Rate for Payer: Medicaid All Medicaid	$2,638.56
Rate for Payer: Medicare All Medicare	$2,007.60
Rate for Payer: Monida Allegiance	$2,724.60
Rate for Payer: Monida First Choice Health	$2,781.96
Rate for Payer: Monida Montana Health Co-op	$2,724.60
Rate for Payer: Monida PacificSource	$2,724.60

PRIVIGEN 10GM/100ML SDV SPEC ORDER

Facility

$2,868.00

Service Code	HCPCS J1459
Hospital Charge Code	3007125
Hospital Revenue Code	636
Min. Negotiated Rate	$2,007.60
Max. Negotiated Rate	$2,868.00
Rate for Payer: Aetna Commercial	$2,724.60
Rate for Payer: Aetna Medicare	$2,581.20
Rate for Payer: BCBS MT CHIP	$2,581.20
Rate for Payer: BCBS MT Closed Plan Network	$2,724.60
Rate for Payer: BCBS MT HealthLink	$2,581.20
Rate for Payer: BCBS MT Medicare	$2,581.20
Rate for Payer: BCBS MT POS	$2,724.60
Rate for Payer: BCBS MT Traditional	$2,868.00
Rate for Payer: Cash Price	$2,581.20
Rate for Payer: Cigna Commercial	$2,724.60
Rate for Payer: Cigna Medicare	$2,581.20
Rate for Payer: Medicaid All Medicaid	$2,638.56
Rate for Payer: Medicare All Medicare	$2,007.60
Rate for Payer: Monida Allegiance	$2,724.60
Rate for Payer: Monida First Choice Health	$2,781.96
Rate for Payer: Monida Montana Health Co-op	$2,724.60
Rate for Payer: Monida PacificSource	$2,724.60

PRIVIGEN 20GM/200ML SDV SPEC ORDER

Facility

$5,736.00

Service Code	HCPCS J1459
Hospital Charge Code	3007126
Hospital Revenue Code	636
Min. Negotiated Rate	$4,015.20
Max. Negotiated Rate	$5,736.00
Rate for Payer: Aetna Commercial	$5,449.20
Rate for Payer: Aetna Medicare	$5,162.40
Rate for Payer: BCBS MT CHIP	$5,162.40
Rate for Payer: BCBS MT Closed Plan Network	$5,449.20
Rate for Payer: BCBS MT HealthLink	$5,162.40
Rate for Payer: BCBS MT Medicare	$5,162.40
Rate for Payer: BCBS MT POS	$5,449.20
Rate for Payer: BCBS MT Traditional	$5,736.00
Rate for Payer: Cash Price	$5,162.40
Rate for Payer: Cigna Commercial	$5,449.20
Rate for Payer: Cigna Medicare	$5,162.40
Rate for Payer: Medicaid All Medicaid	$5,277.12
Rate for Payer: Medicare All Medicare	$4,015.20
Rate for Payer: Monida Allegiance	$5,449.20
Rate for Payer: Monida First Choice Health	$5,563.92
Rate for Payer: Monida Montana Health Co-op	$5,449.20
Rate for Payer: Monida PacificSource	$5,449.20

PRIVIGEN 20GM/200ML SDV SPEC ORDER

Facility

$5,736.00

Service Code	HCPCS J1459
Hospital Charge Code	3007126
Hospital Revenue Code	636
Min. Negotiated Rate	$4,015.20
Max. Negotiated Rate	$5,736.00
Rate for Payer: Aetna Commercial	$5,449.20
Rate for Payer: Aetna Medicare	$5,162.40
Rate for Payer: BCBS MT CHIP	$5,162.40
Rate for Payer: BCBS MT Closed Plan Network	$5,449.20
Rate for Payer: BCBS MT HealthLink	$5,162.40
Rate for Payer: BCBS MT Medicare	$5,162.40
Rate for Payer: BCBS MT POS	$5,449.20
Rate for Payer: BCBS MT Traditional	$5,736.00
Rate for Payer: Cash Price	$5,162.40
Rate for Payer: Cigna Commercial	$5,449.20
Rate for Payer: Cigna Medicare	$5,162.40
Rate for Payer: Medicaid All Medicaid	$5,277.12
Rate for Payer: Medicare All Medicare	$4,015.20
Rate for Payer: Monida Allegiance	$5,449.20
Rate for Payer: Monida First Choice Health	$5,563.92
Rate for Payer: Monida Montana Health Co-op	$5,449.20
Rate for Payer: Monida PacificSource	$5,449.20

PRIVIGEN 40GM/400 ML

Facility

$12,166.00

Service Code	HCPCS J1459
Hospital Charge Code	3000601
Hospital Revenue Code	636
Min. Negotiated Rate	$8,516.20
Max. Negotiated Rate	$12,166.00
Rate for Payer: Aetna Commercial	$11,557.70
Rate for Payer: Aetna Medicare	$10,949.40
Rate for Payer: BCBS MT CHIP	$10,949.40
Rate for Payer: BCBS MT Closed Plan Network	$11,557.70
Rate for Payer: BCBS MT HealthLink	$10,949.40
Rate for Payer: BCBS MT Medicare	$10,949.40
Rate for Payer: BCBS MT POS	$11,557.70
Rate for Payer: BCBS MT Traditional	$12,166.00
Rate for Payer: Cash Price	$10,949.40
Rate for Payer: Cigna Commercial	$11,557.70
Rate for Payer: Cigna Medicare	$10,949.40
Rate for Payer: Medicaid All Medicaid	$11,192.72
Rate for Payer: Medicare All Medicare	$8,516.20
Rate for Payer: Monida Allegiance	$11,557.70
Rate for Payer: Monida First Choice Health	$11,801.02
Rate for Payer: Monida Montana Health Co-op	$11,557.70
Rate for Payer: Monida PacificSource	$11,557.70

PRIVIGEN 40GM/400 ML

Facility

$12,166.00

Service Code	HCPCS J1459
Hospital Charge Code	3000601
Hospital Revenue Code	636
Min. Negotiated Rate	$8,516.20
Max. Negotiated Rate	$12,166.00
Rate for Payer: Aetna Commercial	$11,557.70
Rate for Payer: Aetna Medicare	$10,949.40
Rate for Payer: BCBS MT CHIP	$10,949.40
Rate for Payer: BCBS MT Closed Plan Network	$11,557.70
Rate for Payer: BCBS MT HealthLink	$10,949.40
Rate for Payer: BCBS MT Medicare	$10,949.40
Rate for Payer: BCBS MT POS	$11,557.70
Rate for Payer: BCBS MT Traditional	$12,166.00
Rate for Payer: Cash Price	$10,949.40
Rate for Payer: Cigna Commercial	$11,557.70
Rate for Payer: Cigna Medicare	$10,949.40
Rate for Payer: Medicaid All Medicaid	$11,192.72
Rate for Payer: Medicare All Medicare	$8,516.20
Rate for Payer: Monida Allegiance	$11,557.70
Rate for Payer: Monida First Choice Health	$11,801.02
Rate for Payer: Monida Montana Health Co-op	$11,557.70
Rate for Payer: Monida PacificSource	$11,557.70

PRIVIGEN 40GM/400ML SDV SPECIAL ORDER

Facility

$12,166.00

Service Code	HCPCS J1459
Hospital Charge Code	3007127
Hospital Revenue Code	636
Min. Negotiated Rate	$8,516.20
Max. Negotiated Rate	$12,166.00
Rate for Payer: Aetna Commercial	$11,557.70
Rate for Payer: Aetna Medicare	$10,949.40
Rate for Payer: BCBS MT CHIP	$10,949.40
Rate for Payer: BCBS MT Closed Plan Network	$11,557.70
Rate for Payer: BCBS MT HealthLink	$10,949.40
Rate for Payer: BCBS MT Medicare	$10,949.40
Rate for Payer: BCBS MT POS	$11,557.70
Rate for Payer: BCBS MT Traditional	$12,166.00
Rate for Payer: Cash Price	$10,949.40
Rate for Payer: Cigna Commercial	$11,557.70
Rate for Payer: Cigna Medicare	$10,949.40
Rate for Payer: Medicaid All Medicaid	$11,192.72
Rate for Payer: Medicare All Medicare	$8,516.20
Rate for Payer: Monida Allegiance	$11,557.70
Rate for Payer: Monida First Choice Health	$11,801.02
Rate for Payer: Monida Montana Health Co-op	$11,557.70
Rate for Payer: Monida PacificSource	$11,557.70

PRIVIGEN 40GM/400ML SDV SPECIAL ORDER

Facility

$12,166.00

Service Code	HCPCS J1459
Hospital Charge Code	3007127
Hospital Revenue Code	636
Min. Negotiated Rate	$8,516.20
Max. Negotiated Rate	$12,166.00
Rate for Payer: Aetna Commercial	$11,557.70
Rate for Payer: Aetna Medicare	$10,949.40
Rate for Payer: BCBS MT CHIP	$10,949.40
Rate for Payer: BCBS MT Closed Plan Network	$11,557.70
Rate for Payer: BCBS MT HealthLink	$10,949.40
Rate for Payer: BCBS MT Medicare	$10,949.40
Rate for Payer: BCBS MT POS	$11,557.70
Rate for Payer: BCBS MT Traditional	$12,166.00
Rate for Payer: Cash Price	$10,949.40
Rate for Payer: Cigna Commercial	$11,557.70
Rate for Payer: Cigna Medicare	$10,949.40
Rate for Payer: Medicaid All Medicaid	$11,192.72
Rate for Payer: Medicare All Medicare	$8,516.20
Rate for Payer: Monida Allegiance	$11,557.70
Rate for Payer: Monida First Choice Health	$11,801.02
Rate for Payer: Monida Montana Health Co-op	$11,557.70
Rate for Payer: Monida PacificSource	$11,557.70

PRIVIGEN 5GM/50ML SDV SPEC ORDER

Facility

$1,437.00

Service Code	HCPCS J1459
Hospital Charge Code	3007124
Hospital Revenue Code	636
Min. Negotiated Rate	$1,005.90
Max. Negotiated Rate	$1,437.00
Rate for Payer: Aetna Commercial	$1,365.15
Rate for Payer: Aetna Medicare	$1,293.30
Rate for Payer: BCBS MT CHIP	$1,293.30
Rate for Payer: BCBS MT Closed Plan Network	$1,365.15
Rate for Payer: BCBS MT HealthLink	$1,293.30
Rate for Payer: BCBS MT Medicare	$1,293.30
Rate for Payer: BCBS MT POS	$1,365.15
Rate for Payer: BCBS MT Traditional	$1,437.00
Rate for Payer: Cash Price	$1,293.30
Rate for Payer: Cigna Commercial	$1,365.15
Rate for Payer: Cigna Medicare	$1,293.30
Rate for Payer: Medicaid All Medicaid	$1,322.04
Rate for Payer: Medicare All Medicare	$1,005.90
Rate for Payer: Monida Allegiance	$1,365.15
Rate for Payer: Monida First Choice Health	$1,393.89
Rate for Payer: Monida Montana Health Co-op	$1,365.15
Rate for Payer: Monida PacificSource	$1,365.15

PRIVIGEN 5GM/50ML SDV SPEC ORDER

Facility

$1,437.00

Service Code	HCPCS J1459
Hospital Charge Code	3007124
Hospital Revenue Code	636
Min. Negotiated Rate	$1,005.90
Max. Negotiated Rate	$1,437.00
Rate for Payer: Aetna Commercial	$1,365.15
Rate for Payer: Aetna Medicare	$1,293.30
Rate for Payer: BCBS MT CHIP	$1,293.30
Rate for Payer: BCBS MT Closed Plan Network	$1,365.15
Rate for Payer: BCBS MT HealthLink	$1,293.30
Rate for Payer: BCBS MT Medicare	$1,293.30
Rate for Payer: BCBS MT POS	$1,365.15
Rate for Payer: BCBS MT Traditional	$1,437.00
Rate for Payer: Cash Price	$1,293.30
Rate for Payer: Cigna Commercial	$1,365.15
Rate for Payer: Cigna Medicare	$1,293.30
Rate for Payer: Medicaid All Medicaid	$1,322.04
Rate for Payer: Medicare All Medicare	$1,005.90
Rate for Payer: Monida Allegiance	$1,365.15
Rate for Payer: Monida First Choice Health	$1,393.89
Rate for Payer: Monida Montana Health Co-op	$1,365.15
Rate for Payer: Monida PacificSource	$1,365.15

PRIVIGEN 80GM/800ML SDV SPECIAL ORDER

Facility

$24,332.00

Service Code	HCPCS J1459
Hospital Charge Code	3000602
Hospital Revenue Code	636
Min. Negotiated Rate	$17,032.40
Max. Negotiated Rate	$24,332.00
Rate for Payer: Aetna Commercial	$23,115.40
Rate for Payer: Aetna Medicare	$21,898.80
Rate for Payer: BCBS MT CHIP	$21,898.80
Rate for Payer: BCBS MT Closed Plan Network	$23,115.40
Rate for Payer: BCBS MT HealthLink	$21,898.80
Rate for Payer: BCBS MT Medicare	$21,898.80
Rate for Payer: BCBS MT POS	$23,115.40
Rate for Payer: BCBS MT Traditional	$24,332.00
Rate for Payer: Cash Price	$21,898.80
Rate for Payer: Cigna Commercial	$23,115.40
Rate for Payer: Cigna Medicare	$21,898.80
Rate for Payer: Medicaid All Medicaid	$22,385.44
Rate for Payer: Medicare All Medicare	$17,032.40
Rate for Payer: Monida Allegiance	$23,115.40
Rate for Payer: Monida First Choice Health	$23,602.04
Rate for Payer: Monida Montana Health Co-op	$23,115.40
Rate for Payer: Monida PacificSource	$23,115.40

PRIVIGEN 80GM/800ML SDV SPECIAL ORDER

Facility

$24,332.00

Service Code	HCPCS J1459
Hospital Charge Code	3000602
Hospital Revenue Code	636
Min. Negotiated Rate	$17,032.40
Max. Negotiated Rate	$24,332.00
Rate for Payer: Aetna Commercial	$23,115.40
Rate for Payer: Aetna Medicare	$21,898.80
Rate for Payer: BCBS MT CHIP	$21,898.80
Rate for Payer: BCBS MT Closed Plan Network	$23,115.40
Rate for Payer: BCBS MT HealthLink	$21,898.80
Rate for Payer: BCBS MT Medicare	$21,898.80
Rate for Payer: BCBS MT POS	$23,115.40
Rate for Payer: BCBS MT Traditional	$24,332.00
Rate for Payer: Cash Price	$21,898.80
Rate for Payer: Cigna Commercial	$23,115.40
Rate for Payer: Cigna Medicare	$21,898.80
Rate for Payer: Medicaid All Medicaid	$22,385.44
Rate for Payer: Medicare All Medicare	$17,032.40
Rate for Payer: Monida Allegiance	$23,115.40
Rate for Payer: Monida First Choice Health	$23,602.04
Rate for Payer: Monida Montana Health Co-op	$23,115.40
Rate for Payer: Monida PacificSource	$23,115.40

PROBIOTIC TABLET

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000008
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