Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CYSTATIN C W/ EGFR (121265)

Facility

$355.00

Service Code	CPT 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

CYTOGENETIC STUDIES

Facility

$110.00

Service Code	CPT 88233
Hospital Charge Code	4088149
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

CYTOGENETIC STUDIES

Facility

$110.00

Service Code	CPT 88233
Hospital Charge Code	4088149
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

CYTOLOGY, URINE (009068)

Facility

$155.00

Service Code	CPT 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	CPT 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

CYTP CERV/VAG AUTO THIN LAYER PREP MNL S

Facility

$173.00

Service Code	CPT 88142
Hospital Charge Code	8088142
Hospital Revenue Code	521
Min. Negotiated Rate	$121.10
Max. Negotiated Rate	$173.00
Rate for Payer: Aetna Commercial	$164.35
Rate for Payer: Aetna Medicare	$155.70
Rate for Payer: BCBS MT CHIP	$155.70
Rate for Payer: BCBS MT Closed Plan Network	$164.35
Rate for Payer: BCBS MT HealthLink	$155.70
Rate for Payer: BCBS MT Medicare	$155.70
Rate for Payer: BCBS MT POS	$164.35
Rate for Payer: BCBS MT Traditional	$173.00
Rate for Payer: Cash Price	$155.70
Rate for Payer: Cigna Commercial	$164.35
Rate for Payer: Cigna Medicare	$155.70
Rate for Payer: Medicaid All Medicaid	$159.16
Rate for Payer: Medicare All Medicare	$121.10
Rate for Payer: Monida Allegiance	$164.35
Rate for Payer: Monida First Choice Health	$167.81
Rate for Payer: Monida Montana Health Co-op	$164.35
Rate for Payer: Monida PacificSource	$164.35

CYTP CERV/VAG AUTO THIN LAYER PREP MNL S

Facility

$173.00

Service Code	CPT 88142
Hospital Charge Code	8088142
Hospital Revenue Code	521
Min. Negotiated Rate	$121.10
Max. Negotiated Rate	$173.00
Rate for Payer: Aetna Commercial	$164.35
Rate for Payer: Aetna Medicare	$155.70
Rate for Payer: BCBS MT CHIP	$155.70
Rate for Payer: BCBS MT Closed Plan Network	$164.35
Rate for Payer: BCBS MT HealthLink	$155.70
Rate for Payer: BCBS MT Medicare	$155.70
Rate for Payer: BCBS MT POS	$164.35
Rate for Payer: BCBS MT Traditional	$173.00
Rate for Payer: Cash Price	$155.70
Rate for Payer: Cigna Commercial	$164.35
Rate for Payer: Cigna Medicare	$155.70
Rate for Payer: Medicaid All Medicaid	$159.16
Rate for Payer: Medicare All Medicare	$121.10
Rate for Payer: Monida Allegiance	$164.35
Rate for Payer: Monida First Choice Health	$167.81
Rate for Payer: Monida Montana Health Co-op	$164.35
Rate for Payer: Monida PacificSource	$164.35

[C] ZOLEDRONIC 4MG/5ML SDV NF

Facility

$302.00

Service Code	HCPCS J3489
Hospital Charge Code	3000489
Hospital Revenue Code	636
Min. Negotiated Rate	$211.40
Max. Negotiated Rate	$302.00
Rate for Payer: Aetna Commercial	$286.90
Rate for Payer: Aetna Medicare	$271.80
Rate for Payer: BCBS MT CHIP	$271.80
Rate for Payer: BCBS MT Closed Plan Network	$286.90
Rate for Payer: BCBS MT HealthLink	$271.80
Rate for Payer: BCBS MT Medicare	$271.80
Rate for Payer: BCBS MT POS	$286.90
Rate for Payer: BCBS MT Traditional	$302.00
Rate for Payer: Cash Price	$271.80
Rate for Payer: Cigna Commercial	$286.90
Rate for Payer: Cigna Medicare	$271.80
Rate for Payer: Medicaid All Medicaid	$277.84
Rate for Payer: Medicare All Medicare	$211.40
Rate for Payer: Monida Allegiance	$286.90
Rate for Payer: Monida First Choice Health	$292.94
Rate for Payer: Monida Montana Health Co-op	$286.90
Rate for Payer: Monida PacificSource	$286.90

[C] ZOLEDRONIC 4MG/5ML SDV NF

Facility

$302.00

Service Code	HCPCS J3489
Hospital Charge Code	3000489
Hospital Revenue Code	636
Min. Negotiated Rate	$211.40
Max. Negotiated Rate	$302.00
Rate for Payer: Aetna Commercial	$286.90
Rate for Payer: Aetna Medicare	$271.80
Rate for Payer: BCBS MT CHIP	$271.80
Rate for Payer: BCBS MT Closed Plan Network	$286.90
Rate for Payer: BCBS MT HealthLink	$271.80
Rate for Payer: BCBS MT Medicare	$271.80
Rate for Payer: BCBS MT POS	$286.90
Rate for Payer: BCBS MT Traditional	$302.00
Rate for Payer: Cash Price	$271.80
Rate for Payer: Cigna Commercial	$286.90
Rate for Payer: Cigna Medicare	$271.80
Rate for Payer: Medicaid All Medicaid	$277.84
Rate for Payer: Medicare All Medicare	$211.40
Rate for Payer: Monida Allegiance	$286.90
Rate for Payer: Monida First Choice Health	$292.94
Rate for Payer: Monida Montana Health Co-op	$286.90
Rate for Payer: Monida PacificSource	$286.90

D50W 50% INJ SYR [50 ML]

Facility

$41.00

Service Code	HCPCS J3490
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 J3490
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

Hospital Charge Code	3007280
Hospital Revenue Code	250
Min. Negotiated Rate	$31.05
Max. Negotiated Rate	$44.35
Rate for Payer: Aetna Commercial	$42.13
Rate for Payer: Aetna Medicare	$39.91
Rate for Payer: BCBS MT CHIP	$39.91
Rate for Payer: BCBS MT Closed Plan Network	$42.13
Rate for Payer: BCBS MT HealthLink	$39.91
Rate for Payer: BCBS MT Medicare	$39.91
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	$39.91
Rate for Payer: Medicaid All Medicaid	$40.80
Rate for Payer: Medicare All Medicare	$31.05
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

Hospital Charge Code	3007280
Hospital Revenue Code	250
Min. Negotiated Rate	$31.05
Max. Negotiated Rate	$44.35
Rate for Payer: Aetna Commercial	$42.13
Rate for Payer: Aetna Medicare	$39.91
Rate for Payer: BCBS MT CHIP	$39.91
Rate for Payer: BCBS MT Closed Plan Network	$42.13
Rate for Payer: BCBS MT HealthLink	$39.91
Rate for Payer: BCBS MT Medicare	$39.91
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	$39.91
Rate for Payer: Medicaid All Medicaid	$40.80
Rate for Payer: Medicare All Medicare	$31.05
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

DALFRAMPRIDINE ER TAB [10 MG] NF

Facility

$215.00

Service Code	HCPCS J8499
Hospital Charge Code	3007759
Hospital Revenue Code	250
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

DALFRAMPRIDINE ER TAB [10 MG] NF

Facility

$215.00

Service Code	HCPCS J8499
Hospital Charge Code	3007759
Hospital Revenue Code	250
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

DANTROLENE CAP [25 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007630
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

DANTROLENE CAP [25 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007630
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

DAPAGLIFLOZIN TAB [10 MG] NF

Facility

$77.00

Service Code	HCPCS J8499
Hospital Charge Code	3000570
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

DAPAGLIFLOZIN TAB [10 MG] NF

Facility

$77.00

Service Code	HCPCS J8499
Hospital Charge Code	3000570
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

DAPAGLIFLOZIN TAB [5 MG] NF

Facility

$77.00

Service Code	HCPCS J8499
Hospital Charge Code	3007235
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

DAPAGLIFLOZIN TAB [5 MG] NF

Facility

$77.00

Service Code	HCPCS J8499
Hospital Charge Code	3007235
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

DAPTOMYCIN IVP [500 MG] INJ NF

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 IVP [500 MG] INJ NF

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] NF

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] NF

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

Know your out-of-pocket cost for care.

All Charges