Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

EKG - OP/HOSPITAL

Facility

$186.00

Service Code	HCPCS 93005
Hospital Charge Code	114001
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

EKG WELCOME TO MEDICARE

Facility

$186.00

Service Code	HCPCS G0404
Hospital Charge Code	114003
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

EKG WELCOME TO MEDICARE

Facility

$186.00

Service Code	HCPCS G0404
Hospital Charge Code	114003
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

ELASTIC SHLDR IMMOB

Facility

$114.00

Service Code	HCPCS L3650
Hospital Charge Code	8003650
Hospital Revenue Code	290
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

ELASTIC SHLDR IMMOB

Facility

$114.00

Service Code	HCPCS L3650
Hospital Charge Code	8003650
Hospital Revenue Code	290
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

ELBOW ORTHOTIC W/O JOINTS

Facility

$284.00

Service Code	HCPCS L3702
Hospital Charge Code	8003702
Hospital Revenue Code	290
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

ELBOW ORTHOTIC W/O JOINTS

Facility

$284.00

Service Code	HCPCS L3702
Hospital Charge Code	8003702
Hospital Revenue Code	290
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

ELECTROLYTES PANEL

Facility

$105.00

Service Code	HCPCS 80051
Hospital Charge Code	4080051
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

ELECTROLYTES PANEL

Facility

$105.00

Service Code	HCPCS 80051
Hospital Charge Code	4080051
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

EMPAGLIFLOZIN 25 MG TABLET-NF

Facility

$75.95

Service Code	NDC 00597015337
Hospital Charge Code	3007396
Hospital Revenue Code	250
Min. Negotiated Rate	$53.16
Max. Negotiated Rate	$75.95
Rate for Payer: Aetna Commercial	$72.15
Rate for Payer: Aetna Medicare	$68.36
Rate for Payer: BCBS MT CHIP	$68.36
Rate for Payer: BCBS MT Closed Plan Network	$72.15
Rate for Payer: BCBS MT HealthLink	$68.36
Rate for Payer: BCBS MT Medicare	$68.36
Rate for Payer: BCBS MT POS	$72.15
Rate for Payer: BCBS MT Traditional	$75.95
Rate for Payer: Cash Price	$68.36
Rate for Payer: Cigna Commercial	$72.15
Rate for Payer: Cigna Medicare	$68.36
Rate for Payer: Medicaid All Medicaid	$69.87
Rate for Payer: Medicare All Medicare	$53.16
Rate for Payer: Monida Allegiance	$72.15
Rate for Payer: Monida First Choice Health	$73.67
Rate for Payer: Monida Montana Health Co-op	$72.15
Rate for Payer: Monida PacificSource	$72.15

EMPAGLIFLOZIN 25 MG TABLET-NF

Facility

$75.95

Service Code	NDC 00597015337
Hospital Charge Code	3007396
Hospital Revenue Code	250
Min. Negotiated Rate	$53.16
Max. Negotiated Rate	$75.95
Rate for Payer: Aetna Commercial	$72.15
Rate for Payer: Aetna Medicare	$68.36
Rate for Payer: BCBS MT CHIP	$68.36
Rate for Payer: BCBS MT Closed Plan Network	$72.15
Rate for Payer: BCBS MT HealthLink	$68.36
Rate for Payer: BCBS MT Medicare	$68.36
Rate for Payer: BCBS MT POS	$72.15
Rate for Payer: BCBS MT Traditional	$75.95
Rate for Payer: Cash Price	$68.36
Rate for Payer: Cigna Commercial	$72.15
Rate for Payer: Cigna Medicare	$68.36
Rate for Payer: Medicaid All Medicaid	$69.87
Rate for Payer: Medicare All Medicare	$53.16
Rate for Payer: Monida Allegiance	$72.15
Rate for Payer: Monida First Choice Health	$73.67
Rate for Payer: Monida Montana Health Co-op	$72.15
Rate for Payer: Monida PacificSource	$72.15

EMPAGLIFLOZIN (JARDIANCE) 10MG TAB NF

Facility

$77.00

Service Code	NDC 00597015237
Hospital Charge Code	3007122
Hospital Revenue Code	250
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

EMPAGLIFLOZIN (JARDIANCE) 10MG TAB NF

Facility

$77.00

Service Code	NDC 00597015237
Hospital Charge Code	3007122
Hospital Revenue Code	250
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

ENDOMYSIAL ANTIBODY, IGA (164996)

Facility

$79.00

Service Code	HCPCS 86231
Hospital Charge Code	4082784
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENDOMYSIAL ANTIBODY, IGA (164996)

Facility

$79.00

Service Code	HCPCS 86231
Hospital Charge Code	4082784
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENEMA BUCKET

Facility

$13.00

Hospital Charge Code	80030169
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

ENEMA BUCKET

Facility

$13.00

Hospital Charge Code	80030169
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

ENOXAPARIN INJ [100 MG/1 ML] - NONFORM

Facility

$79.00

Service Code	HCPCS J1650
Hospital Charge Code	3000139
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENOXAPARIN INJ [100 MG/1 ML] - NONFORM

Facility

$79.00

Service Code	HCPCS J1650
Hospital Charge Code	3000139
Hospital Revenue Code	259
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

ENOXAPARIN INJ [30 MG/0.3 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000140
Hospital Revenue Code	259
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

ENOXAPARIN INJ [30 MG/0.3 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000140
Hospital Revenue Code	259
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

ENOXAPARIN INJ [40 MG/0.4 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000141
Hospital Revenue Code	259
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

ENOXAPARIN INJ [40 MG/0.4 ML]

Facility

$32.00

Service Code	HCPCS J1650
Hospital Charge Code	3000141
Hospital Revenue Code	259
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

ENOXAPARIN INJ [60 MG/0.6ML]-NONFORMULAR

Facility

$48.00

Service Code	HCPCS J1650
Hospital Charge Code	3000142
Hospital Revenue Code	259
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

ENOXAPARIN INJ [60 MG/0.6ML]-NONFORMULAR

Facility

$48.00

Service Code	HCPCS J1650
Hospital Charge Code	3000142
Hospital Revenue Code	259
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

Know your out-of-pocket cost for care.

All Charges