Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SYSMEX AUTO CELL CLEANER 20ML

Facility

$24.48

Hospital Charge Code	90197164
Hospital Revenue Code	270
Min. Negotiated Rate	$17.14
Max. Negotiated Rate	$24.48
Rate for Payer: Aetna Commercial	$23.26
Rate for Payer: Aetna Medicare	$22.03
Rate for Payer: BCBS MT CHIP	$22.03
Rate for Payer: BCBS MT Closed Plan Network	$23.26
Rate for Payer: BCBS MT HealthLink	$22.03
Rate for Payer: BCBS MT Medicare	$22.03
Rate for Payer: BCBS MT POS	$23.26
Rate for Payer: BCBS MT Traditional	$24.48
Rate for Payer: Cash Price	$22.03
Rate for Payer: Cigna Commercial	$23.26
Rate for Payer: Cigna Medicare	$22.03
Rate for Payer: Medicaid All Medicaid	$22.52
Rate for Payer: Medicare All Medicare	$17.14
Rate for Payer: Monida Allegiance	$23.26
Rate for Payer: Monida First Choice Health	$23.75
Rate for Payer: Monida Montana Health Co-op	$23.26
Rate for Payer: Monida PacificSource	$23.26

SYSMEX AUTO CELL CLEANER 20ML

Facility

$24.48

Hospital Charge Code	90197164
Hospital Revenue Code	270
Min. Negotiated Rate	$17.14
Max. Negotiated Rate	$24.48
Rate for Payer: Aetna Commercial	$23.26
Rate for Payer: Aetna Medicare	$22.03
Rate for Payer: BCBS MT CHIP	$22.03
Rate for Payer: BCBS MT Closed Plan Network	$23.26
Rate for Payer: BCBS MT HealthLink	$22.03
Rate for Payer: BCBS MT Medicare	$22.03
Rate for Payer: BCBS MT POS	$23.26
Rate for Payer: BCBS MT Traditional	$24.48
Rate for Payer: Cash Price	$22.03
Rate for Payer: Cigna Commercial	$23.26
Rate for Payer: Cigna Medicare	$22.03
Rate for Payer: Medicaid All Medicaid	$22.52
Rate for Payer: Medicare All Medicare	$17.14
Rate for Payer: Monida Allegiance	$23.26
Rate for Payer: Monida First Choice Health	$23.75
Rate for Payer: Monida Montana Health Co-op	$23.26
Rate for Payer: Monida PacificSource	$23.26

SYSMEX XN450 ANALYZER

Facility

$44,500.00

Hospital Charge Code	90197160
Hospital Revenue Code	270
Min. Negotiated Rate	$31,150.00
Max. Negotiated Rate	$44,500.00
Rate for Payer: Aetna Commercial	$42,275.00
Rate for Payer: Aetna Medicare	$40,050.00
Rate for Payer: BCBS MT CHIP	$40,050.00
Rate for Payer: BCBS MT Closed Plan Network	$42,275.00
Rate for Payer: BCBS MT HealthLink	$40,050.00
Rate for Payer: BCBS MT Medicare	$40,050.00
Rate for Payer: BCBS MT POS	$42,275.00
Rate for Payer: BCBS MT Traditional	$44,500.00
Rate for Payer: Cash Price	$40,050.00
Rate for Payer: Cigna Commercial	$42,275.00
Rate for Payer: Cigna Medicare	$40,050.00
Rate for Payer: Medicaid All Medicaid	$40,940.00
Rate for Payer: Medicare All Medicare	$31,150.00
Rate for Payer: Monida Allegiance	$42,275.00
Rate for Payer: Monida First Choice Health	$43,165.00
Rate for Payer: Monida Montana Health Co-op	$42,275.00
Rate for Payer: Monida PacificSource	$42,275.00

SYSMEX XN450 ANALYZER

Facility

$44,500.00

Hospital Charge Code	90197160
Hospital Revenue Code	270
Min. Negotiated Rate	$31,150.00
Max. Negotiated Rate	$44,500.00
Rate for Payer: Aetna Commercial	$42,275.00
Rate for Payer: Aetna Medicare	$40,050.00
Rate for Payer: BCBS MT CHIP	$40,050.00
Rate for Payer: BCBS MT Closed Plan Network	$42,275.00
Rate for Payer: BCBS MT HealthLink	$40,050.00
Rate for Payer: BCBS MT Medicare	$40,050.00
Rate for Payer: BCBS MT POS	$42,275.00
Rate for Payer: BCBS MT Traditional	$44,500.00
Rate for Payer: Cash Price	$40,050.00
Rate for Payer: Cigna Commercial	$42,275.00
Rate for Payer: Cigna Medicare	$40,050.00
Rate for Payer: Medicaid All Medicaid	$40,940.00
Rate for Payer: Medicare All Medicare	$31,150.00
Rate for Payer: Monida Allegiance	$42,275.00
Rate for Payer: Monida First Choice Health	$43,165.00
Rate for Payer: Monida Montana Health Co-op	$42,275.00
Rate for Payer: Monida PacificSource	$42,275.00

SYSMEX XS PIERCER SET

Facility

$448.41

Hospital Charge Code	90197085
Hospital Revenue Code	270
Min. Negotiated Rate	$313.89
Max. Negotiated Rate	$448.41
Rate for Payer: Aetna Commercial	$425.99
Rate for Payer: Aetna Medicare	$403.57
Rate for Payer: BCBS MT CHIP	$403.57
Rate for Payer: BCBS MT Closed Plan Network	$425.99
Rate for Payer: BCBS MT HealthLink	$403.57
Rate for Payer: BCBS MT Medicare	$403.57
Rate for Payer: BCBS MT POS	$425.99
Rate for Payer: BCBS MT Traditional	$448.41
Rate for Payer: Cash Price	$403.57
Rate for Payer: Cigna Commercial	$425.99
Rate for Payer: Cigna Medicare	$403.57
Rate for Payer: Medicaid All Medicaid	$412.54
Rate for Payer: Medicare All Medicare	$313.89
Rate for Payer: Monida Allegiance	$425.99
Rate for Payer: Monida First Choice Health	$434.96
Rate for Payer: Monida Montana Health Co-op	$425.99
Rate for Payer: Monida PacificSource	$425.99

SYSMEX XS PIERCER SET

Facility

$448.41

Hospital Charge Code	90197085
Hospital Revenue Code	270
Min. Negotiated Rate	$313.89
Max. Negotiated Rate	$448.41
Rate for Payer: Aetna Commercial	$425.99
Rate for Payer: Aetna Medicare	$403.57
Rate for Payer: BCBS MT CHIP	$403.57
Rate for Payer: BCBS MT Closed Plan Network	$425.99
Rate for Payer: BCBS MT HealthLink	$403.57
Rate for Payer: BCBS MT Medicare	$403.57
Rate for Payer: BCBS MT POS	$425.99
Rate for Payer: BCBS MT Traditional	$448.41
Rate for Payer: Cash Price	$403.57
Rate for Payer: Cigna Commercial	$425.99
Rate for Payer: Cigna Medicare	$403.57
Rate for Payer: Medicaid All Medicaid	$412.54
Rate for Payer: Medicare All Medicare	$313.89
Rate for Payer: Monida Allegiance	$425.99
Rate for Payer: Monida First Choice Health	$434.96
Rate for Payer: Monida Montana Health Co-op	$425.99
Rate for Payer: Monida PacificSource	$425.99

T3, FREE (010389)

Facility

$32.00

Service Code	CPT 84481
Hospital Charge Code	4084481
Hospital Revenue Code	301
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

T3, FREE (010389)

Facility

$32.00

Service Code	CPT 84481
Hospital Charge Code	4084481
Hospital Revenue Code	301
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

T3, REVERSE (070104)

Facility

$516.00

Service Code	CPT 84482
Hospital Charge Code	4084482
Hospital Revenue Code	301
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

T3, REVERSE (070104)

Facility

$516.00

Service Code	CPT 84482
Hospital Charge Code	4084482
Hospital Revenue Code	301
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

T3, TOTAL (002188)

Facility

$71.00

Service Code	CPT 84480
Hospital Charge Code	4084480
Hospital Revenue Code	301
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

T3, TOTAL (002188)

Facility

$71.00

Service Code	CPT 84480
Hospital Charge Code	4084480
Hospital Revenue Code	301
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

T3, UPTAKE (001156)

Facility

$59.00

Service Code	CPT 84479
Hospital Charge Code	4084479
Hospital Revenue Code	301
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

T3, UPTAKE (001156)

Facility

$59.00

Service Code	CPT 84479
Hospital Charge Code	4084479
Hospital Revenue Code	301
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

T4, FREE

Facility

$125.00

Service Code	CPT 84439
Hospital Charge Code	4084439
Hospital Revenue Code	301
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

T4, FREE

Facility

$125.00

Service Code	CPT 84439
Hospital Charge Code	4084439
Hospital Revenue Code	301
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

T4, TOTAL (001149)

Facility

$60.00

Service Code	CPT 84436
Hospital Charge Code	4084436
Hospital Revenue Code	301
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

T4, TOTAL (001149)

Facility

$60.00

Service Code	CPT 84436
Hospital Charge Code	4084436
Hospital Revenue Code	301
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

TACROLIMUS (700248)

Facility

$158.00

Service Code	CPT 80197
Hospital Charge Code	4080197
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

TACROLIMUS (700248)

Facility

$158.00

Service Code	CPT 80197
Hospital Charge Code	4080197
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

TACROLIMUS CAP [0.5 MG] NF

Facility

$8.00

Service Code	HCPCS J7507
Hospital Charge Code	3000440
Hospital Revenue Code	636
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

TACROLIMUS CAP [0.5 MG] NF

Facility

$8.00

Service Code	HCPCS J7507
Hospital Charge Code	3000440
Hospital Revenue Code	636
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

TAMSULOSIN CAP [0.4 MG]

Facility

$14.00

Service Code	HCPCS J8499
Hospital Charge Code	3000441
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TAMSULOSIN CAP [0.4 MG]

Facility

$14.00

Service Code	HCPCS J8499
Hospital Charge Code	3000441
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TAPE COTTON BLEACHED 1/2'

Facility

$12.00

Hospital Charge Code	80030004
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

Know your out-of-pocket cost for care.

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