Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CYGNUS DUAL- 2X3 SQ CENTIMETER

Facility

$15,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004192
Hospital Revenue Code	636
Min. Negotiated Rate	$10,500.00
Max. Negotiated Rate	$15,000.00
Rate for Payer: Aetna Commercial	$14,250.00
Rate for Payer: Aetna Medicare	$13,500.00
Rate for Payer: BCBS MT CHIP	$13,500.00
Rate for Payer: BCBS MT Closed Plan Network	$14,250.00
Rate for Payer: BCBS MT HealthLink	$13,500.00
Rate for Payer: BCBS MT Medicare	$13,500.00
Rate for Payer: BCBS MT POS	$14,250.00
Rate for Payer: BCBS MT Traditional	$15,000.00
Rate for Payer: Cash Price	$13,500.00
Rate for Payer: Cigna Commercial	$14,250.00
Rate for Payer: Cigna Medicare	$13,500.00
Rate for Payer: Medicaid All Medicaid	$13,800.00
Rate for Payer: Medicare All Medicare	$10,500.00
Rate for Payer: Monida Allegiance	$14,250.00
Rate for Payer: Monida First Choice Health	$14,550.00
Rate for Payer: Monida Montana Health Co-op	$14,250.00
Rate for Payer: Monida PacificSource	$14,250.00

CYGNUS DUAL - 4X4 SQ CENTIMETER

Facility

$40,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004193
Hospital Revenue Code	636
Min. Negotiated Rate	$28,000.00
Max. Negotiated Rate	$40,000.00
Rate for Payer: Aetna Commercial	$38,000.00
Rate for Payer: Aetna Medicare	$36,000.00
Rate for Payer: BCBS MT CHIP	$36,000.00
Rate for Payer: BCBS MT Closed Plan Network	$38,000.00
Rate for Payer: BCBS MT HealthLink	$36,000.00
Rate for Payer: BCBS MT Medicare	$36,000.00
Rate for Payer: BCBS MT POS	$38,000.00
Rate for Payer: BCBS MT Traditional	$40,000.00
Rate for Payer: Cash Price	$36,000.00
Rate for Payer: Cigna Commercial	$38,000.00
Rate for Payer: Cigna Medicare	$36,000.00
Rate for Payer: Medicaid All Medicaid	$36,800.00
Rate for Payer: Medicare All Medicare	$28,000.00
Rate for Payer: Monida Allegiance	$38,000.00
Rate for Payer: Monida First Choice Health	$38,800.00
Rate for Payer: Monida Montana Health Co-op	$38,000.00
Rate for Payer: Monida PacificSource	$38,000.00

CYGNUS DUAL - 4X4 SQ CENTIMETER

Facility

$40,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004193
Hospital Revenue Code	636
Min. Negotiated Rate	$28,000.00
Max. Negotiated Rate	$40,000.00
Rate for Payer: Aetna Commercial	$38,000.00
Rate for Payer: Aetna Medicare	$36,000.00
Rate for Payer: BCBS MT CHIP	$36,000.00
Rate for Payer: BCBS MT Closed Plan Network	$38,000.00
Rate for Payer: BCBS MT HealthLink	$36,000.00
Rate for Payer: BCBS MT Medicare	$36,000.00
Rate for Payer: BCBS MT POS	$38,000.00
Rate for Payer: BCBS MT Traditional	$40,000.00
Rate for Payer: Cash Price	$36,000.00
Rate for Payer: Cigna Commercial	$38,000.00
Rate for Payer: Cigna Medicare	$36,000.00
Rate for Payer: Medicaid All Medicaid	$36,800.00
Rate for Payer: Medicare All Medicare	$28,000.00
Rate for Payer: Monida Allegiance	$38,000.00
Rate for Payer: Monida First Choice Health	$38,800.00
Rate for Payer: Monida Montana Health Co-op	$38,000.00
Rate for Payer: Monida PacificSource	$38,000.00

CYGNUS DUAL - 4X6 SQ CENTIMETER

Facility

$60,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004194
Hospital Revenue Code	636
Min. Negotiated Rate	$42,000.00
Max. Negotiated Rate	$60,000.00
Rate for Payer: Aetna Commercial	$57,000.00
Rate for Payer: Aetna Medicare	$54,000.00
Rate for Payer: BCBS MT CHIP	$54,000.00
Rate for Payer: BCBS MT Closed Plan Network	$57,000.00
Rate for Payer: BCBS MT HealthLink	$54,000.00
Rate for Payer: BCBS MT Medicare	$54,000.00
Rate for Payer: BCBS MT POS	$57,000.00
Rate for Payer: BCBS MT Traditional	$60,000.00
Rate for Payer: Cash Price	$54,000.00
Rate for Payer: Cigna Commercial	$57,000.00
Rate for Payer: Cigna Medicare	$54,000.00
Rate for Payer: Medicaid All Medicaid	$55,200.00
Rate for Payer: Medicare All Medicare	$42,000.00
Rate for Payer: Monida Allegiance	$57,000.00
Rate for Payer: Monida First Choice Health	$58,200.00
Rate for Payer: Monida Montana Health Co-op	$57,000.00
Rate for Payer: Monida PacificSource	$57,000.00

CYGNUS DUAL - 4X6 SQ CENTIMETER

Facility

$60,000.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004194
Hospital Revenue Code	636
Min. Negotiated Rate	$42,000.00
Max. Negotiated Rate	$60,000.00
Rate for Payer: Aetna Commercial	$57,000.00
Rate for Payer: Aetna Medicare	$54,000.00
Rate for Payer: BCBS MT CHIP	$54,000.00
Rate for Payer: BCBS MT Closed Plan Network	$57,000.00
Rate for Payer: BCBS MT HealthLink	$54,000.00
Rate for Payer: BCBS MT Medicare	$54,000.00
Rate for Payer: BCBS MT POS	$57,000.00
Rate for Payer: BCBS MT Traditional	$60,000.00
Rate for Payer: Cash Price	$54,000.00
Rate for Payer: Cigna Commercial	$57,000.00
Rate for Payer: Cigna Medicare	$54,000.00
Rate for Payer: Medicaid All Medicaid	$55,200.00
Rate for Payer: Medicare All Medicare	$42,000.00
Rate for Payer: Monida Allegiance	$57,000.00
Rate for Payer: Monida First Choice Health	$58,200.00
Rate for Payer: Monida Montana Health Co-op	$57,000.00
Rate for Payer: Monida PacificSource	$57,000.00

CYGNUS DUAL - 7X15 SQ CENTIMETER

Facility

$262,500.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004195
Hospital Revenue Code	636
Min. Negotiated Rate	$183,750.00
Max. Negotiated Rate	$262,500.00
Rate for Payer: Aetna Commercial	$249,375.00
Rate for Payer: Aetna Medicare	$236,250.00
Rate for Payer: BCBS MT CHIP	$236,250.00
Rate for Payer: BCBS MT Closed Plan Network	$249,375.00
Rate for Payer: BCBS MT HealthLink	$236,250.00
Rate for Payer: BCBS MT Medicare	$236,250.00
Rate for Payer: BCBS MT POS	$249,375.00
Rate for Payer: BCBS MT Traditional	$262,500.00
Rate for Payer: Cash Price	$236,250.00
Rate for Payer: Cigna Commercial	$249,375.00
Rate for Payer: Cigna Medicare	$236,250.00
Rate for Payer: Medicaid All Medicaid	$241,500.00
Rate for Payer: Medicare All Medicare	$183,750.00
Rate for Payer: Monida Allegiance	$249,375.00
Rate for Payer: Monida First Choice Health	$254,625.00
Rate for Payer: Monida Montana Health Co-op	$249,375.00
Rate for Payer: Monida PacificSource	$249,375.00

CYGNUS DUAL - 7X15 SQ CENTIMETER

Facility

$262,500.00

Service Code	HCPCS Q4282
Hospital Charge Code	8004195
Hospital Revenue Code	636
Min. Negotiated Rate	$183,750.00
Max. Negotiated Rate	$262,500.00
Rate for Payer: Aetna Commercial	$249,375.00
Rate for Payer: Aetna Medicare	$236,250.00
Rate for Payer: BCBS MT CHIP	$236,250.00
Rate for Payer: BCBS MT Closed Plan Network	$249,375.00
Rate for Payer: BCBS MT HealthLink	$236,250.00
Rate for Payer: BCBS MT Medicare	$236,250.00
Rate for Payer: BCBS MT POS	$249,375.00
Rate for Payer: BCBS MT Traditional	$262,500.00
Rate for Payer: Cash Price	$236,250.00
Rate for Payer: Cigna Commercial	$249,375.00
Rate for Payer: Cigna Medicare	$236,250.00
Rate for Payer: Medicaid All Medicaid	$241,500.00
Rate for Payer: Medicare All Medicare	$183,750.00
Rate for Payer: Monida Allegiance	$249,375.00
Rate for Payer: Monida First Choice Health	$254,625.00
Rate for Payer: Monida Montana Health Co-op	$249,375.00
Rate for Payer: Monida PacificSource	$249,375.00

CYGNUS MATRIX-PER SQ CENTIMETER

Facility

$592.00

Service Code	HCPCS Q4199
Hospital Charge Code	8004199
Hospital Revenue Code	636
Min. Negotiated Rate	$414.40
Max. Negotiated Rate	$592.00
Rate for Payer: Aetna Commercial	$562.40
Rate for Payer: Aetna Medicare	$532.80
Rate for Payer: BCBS MT CHIP	$532.80
Rate for Payer: BCBS MT Closed Plan Network	$562.40
Rate for Payer: BCBS MT HealthLink	$532.80
Rate for Payer: BCBS MT Medicare	$532.80
Rate for Payer: BCBS MT POS	$562.40
Rate for Payer: BCBS MT Traditional	$592.00
Rate for Payer: Cash Price	$532.80
Rate for Payer: Cigna Commercial	$562.40
Rate for Payer: Cigna Medicare	$532.80
Rate for Payer: Medicaid All Medicaid	$544.64
Rate for Payer: Medicare All Medicare	$414.40
Rate for Payer: Monida Allegiance	$562.40
Rate for Payer: Monida First Choice Health	$574.24
Rate for Payer: Monida Montana Health Co-op	$562.40
Rate for Payer: Monida PacificSource	$562.40

CYGNUS MATRIX-PER SQ CENTIMETER

Facility

$592.00

Service Code	HCPCS Q4199
Hospital Charge Code	8004199
Hospital Revenue Code	636
Min. Negotiated Rate	$414.40
Max. Negotiated Rate	$592.00
Rate for Payer: Aetna Commercial	$562.40
Rate for Payer: Aetna Medicare	$532.80
Rate for Payer: BCBS MT CHIP	$532.80
Rate for Payer: BCBS MT Closed Plan Network	$562.40
Rate for Payer: BCBS MT HealthLink	$532.80
Rate for Payer: BCBS MT Medicare	$532.80
Rate for Payer: BCBS MT POS	$562.40
Rate for Payer: BCBS MT Traditional	$592.00
Rate for Payer: Cash Price	$532.80
Rate for Payer: Cigna Commercial	$562.40
Rate for Payer: Cigna Medicare	$532.80
Rate for Payer: Medicaid All Medicaid	$544.64
Rate for Payer: Medicare All Medicare	$414.40
Rate for Payer: Monida Allegiance	$562.40
Rate for Payer: Monida First Choice Health	$574.24
Rate for Payer: Monida Montana Health Co-op	$562.40
Rate for Payer: Monida PacificSource	$562.40

CYSTATIN C W/ EGFR (121265)

Facility

$355.00

Service Code	HCPCS 82610
Hospital Charge Code	4082610
Hospital Revenue Code	301
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

CYSTATIN C W/ EGFR (121265)

Facility

$355.00

Service Code	HCPCS 82610
Hospital Charge Code	4082610
Hospital Revenue Code	301
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

CYTOLOGY, URINE (009068)

Facility

$155.00

Service Code	HCPCS 88112
Hospital Charge Code	4088112
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

CYTOLOGY, URINE (009068)

Facility

$155.00

Service Code	HCPCS 88112
Hospital Charge Code	4088112
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

D50W 50% INJ SYR [50 ML]

Facility

$41.00

Service Code	HCPCS J7799
Hospital Charge Code	3000243
Hospital Revenue Code	259
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

D50W 50% INJ SYR [50 ML]

Facility

$41.00

Service Code	HCPCS J7799
Hospital Charge Code	3000243
Hospital Revenue Code	259
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

DAKIN'S SOLUTION 0.25%

Facility

$44.35

Service Code	NDC 00436093616
Hospital Charge Code	3007280
Hospital Revenue Code	250
Min. Negotiated Rate	$31.04
Max. Negotiated Rate	$44.35
Rate for Payer: Aetna Commercial	$42.13
Rate for Payer: Aetna Medicare	$39.92
Rate for Payer: BCBS MT CHIP	$39.92
Rate for Payer: BCBS MT Closed Plan Network	$42.13
Rate for Payer: BCBS MT HealthLink	$39.92
Rate for Payer: BCBS MT Medicare	$39.92
Rate for Payer: BCBS MT POS	$42.13
Rate for Payer: BCBS MT Traditional	$44.35
Rate for Payer: Cash Price	$39.92
Rate for Payer: Cigna Commercial	$42.13
Rate for Payer: Cigna Medicare	$39.92
Rate for Payer: Medicaid All Medicaid	$40.80
Rate for Payer: Medicare All Medicare	$31.04
Rate for Payer: Monida Allegiance	$42.13
Rate for Payer: Monida First Choice Health	$43.02
Rate for Payer: Monida Montana Health Co-op	$42.13
Rate for Payer: Monida PacificSource	$42.13

DAKIN'S SOLUTION 0.25%

Facility

$44.35

Service Code	NDC 00436093616
Hospital Charge Code	3007280
Hospital Revenue Code	250
Min. Negotiated Rate	$31.04
Max. Negotiated Rate	$44.35
Rate for Payer: Aetna Commercial	$42.13
Rate for Payer: Aetna Medicare	$39.92
Rate for Payer: BCBS MT CHIP	$39.92
Rate for Payer: BCBS MT Closed Plan Network	$42.13
Rate for Payer: BCBS MT HealthLink	$39.92
Rate for Payer: BCBS MT Medicare	$39.92
Rate for Payer: BCBS MT POS	$42.13
Rate for Payer: BCBS MT Traditional	$44.35
Rate for Payer: Cash Price	$39.92
Rate for Payer: Cigna Commercial	$42.13
Rate for Payer: Cigna Medicare	$39.92
Rate for Payer: Medicaid All Medicaid	$40.80
Rate for Payer: Medicare All Medicare	$31.04
Rate for Payer: Monida Allegiance	$42.13
Rate for Payer: Monida First Choice Health	$43.02
Rate for Payer: Monida Montana Health Co-op	$42.13
Rate for Payer: Monida PacificSource	$42.13

DAPAGLIFLOZIN TAB [10 MG] NF

Facility

$70.00

Service Code	HCPCS J3490
Hospital Charge Code	3000570
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

DAPAGLIFLOZIN TAB [10 MG] NF

Facility

$70.00

Service Code	HCPCS J3490
Hospital Charge Code	3000570
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

DAPTOMYCIN 500MG INJ

Facility

$231.00

Service Code	HCPCS J0878
Hospital Charge Code	3000107
Hospital Revenue Code	636
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

DAPTOMYCIN 500MG INJ

Facility

$231.00

Service Code	HCPCS J0878
Hospital Charge Code	3000107
Hospital Revenue Code	636
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

DAPTOMYCIN/NS 50ML [500 MG] SPECIAL ORDE

Facility

$231.00

Service Code	HCPCS J0878
Hospital Charge Code	3000549
Hospital Revenue Code	636
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

DAPTOMYCIN/NS 50ML [500 MG] SPECIAL ORDE

Facility

$231.00

Service Code	HCPCS J0878
Hospital Charge Code	3000549
Hospital Revenue Code	636
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

DARBEPOETIN ALFA POLYSORBAT

Facility

$705.88

Service Code	HCPCS J0881
Hospital Charge Code	3007412
Hospital Revenue Code	250
Min. Negotiated Rate	$494.12
Max. Negotiated Rate	$705.88
Rate for Payer: Aetna Commercial	$670.59
Rate for Payer: Aetna Medicare	$635.29
Rate for Payer: BCBS MT CHIP	$635.29
Rate for Payer: BCBS MT Closed Plan Network	$670.59
Rate for Payer: BCBS MT HealthLink	$635.29
Rate for Payer: BCBS MT Medicare	$635.29
Rate for Payer: BCBS MT POS	$670.59
Rate for Payer: BCBS MT Traditional	$705.88
Rate for Payer: Cash Price	$635.29
Rate for Payer: Cigna Commercial	$670.59
Rate for Payer: Cigna Medicare	$635.29
Rate for Payer: Medicaid All Medicaid	$649.41
Rate for Payer: Medicare All Medicare	$494.12
Rate for Payer: Monida Allegiance	$670.59
Rate for Payer: Monida First Choice Health	$684.70
Rate for Payer: Monida Montana Health Co-op	$670.59
Rate for Payer: Monida PacificSource	$670.59

DARBEPOETIN ALFA POLYSORBAT

Facility

$705.88

Service Code	HCPCS J0881
Hospital Charge Code	3007412
Hospital Revenue Code	250
Min. Negotiated Rate	$494.12
Max. Negotiated Rate	$705.88
Rate for Payer: Aetna Commercial	$670.59
Rate for Payer: Aetna Medicare	$635.29
Rate for Payer: BCBS MT CHIP	$635.29
Rate for Payer: BCBS MT Closed Plan Network	$670.59
Rate for Payer: BCBS MT HealthLink	$635.29
Rate for Payer: BCBS MT Medicare	$635.29
Rate for Payer: BCBS MT POS	$670.59
Rate for Payer: BCBS MT Traditional	$705.88
Rate for Payer: Cash Price	$635.29
Rate for Payer: Cigna Commercial	$670.59
Rate for Payer: Cigna Medicare	$635.29
Rate for Payer: Medicaid All Medicaid	$649.41
Rate for Payer: Medicare All Medicare	$494.12
Rate for Payer: Monida Allegiance	$670.59
Rate for Payer: Monida First Choice Health	$684.70
Rate for Payer: Monida Montana Health Co-op	$670.59
Rate for Payer: Monida PacificSource	$670.59

Know your out-of-pocket cost for care.

All Charges