Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INFILXIMAB QUANTITATION WITH REFLEX

Facility

$372.00

Service Code	CPT 80230
Hospital Charge Code	4087949
Hospital Revenue Code	300
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$372.00
Rate for Payer: Aetna Commercial	$353.40
Rate for Payer: Aetna Medicare	$334.80
Rate for Payer: BCBS MT CHIP	$334.80
Rate for Payer: BCBS MT Closed Plan Network	$353.40
Rate for Payer: BCBS MT HealthLink	$334.80
Rate for Payer: BCBS MT Medicare	$334.80
Rate for Payer: BCBS MT POS	$353.40
Rate for Payer: BCBS MT Traditional	$372.00
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cigna Commercial	$353.40
Rate for Payer: Cigna Medicare	$334.80
Rate for Payer: Medicaid All Medicaid	$342.24
Rate for Payer: Medicare All Medicare	$260.40
Rate for Payer: Monida Allegiance	$353.40
Rate for Payer: Monida First Choice Health	$360.84
Rate for Payer: Monida Montana Health Co-op	$353.40
Rate for Payer: Monida PacificSource	$353.40

INFILXIMAB QUANTITATION WITH REFLEX

Facility

$372.00

Service Code	CPT 80230
Hospital Charge Code	4087949
Hospital Revenue Code	300
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$372.00
Rate for Payer: Aetna Commercial	$353.40
Rate for Payer: Aetna Medicare	$334.80
Rate for Payer: BCBS MT CHIP	$334.80
Rate for Payer: BCBS MT Closed Plan Network	$353.40
Rate for Payer: BCBS MT HealthLink	$334.80
Rate for Payer: BCBS MT Medicare	$334.80
Rate for Payer: BCBS MT POS	$353.40
Rate for Payer: BCBS MT Traditional	$372.00
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cigna Commercial	$353.40
Rate for Payer: Cigna Medicare	$334.80
Rate for Payer: Medicaid All Medicaid	$342.24
Rate for Payer: Medicare All Medicare	$260.40
Rate for Payer: Monida Allegiance	$353.40
Rate for Payer: Monida First Choice Health	$360.84
Rate for Payer: Monida Montana Health Co-op	$353.40
Rate for Payer: Monida PacificSource	$353.40

.INFLUENZA A

Facility

$120.00

Service Code	CPT 87804
Hospital Charge Code	4087804
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

.INFLUENZA A

Facility

$120.00

Service Code	CPT 87804
Hospital Charge Code	4087804
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

INFLUENZA A&B, ABBOTT

Facility

$255.00

Service Code	CPT 87502
Hospital Charge Code	4087920
Hospital Revenue Code	300
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$255.00
Rate for Payer: Aetna Commercial	$242.25
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: BCBS MT CHIP	$229.50
Rate for Payer: BCBS MT Closed Plan Network	$242.25
Rate for Payer: BCBS MT HealthLink	$229.50
Rate for Payer: BCBS MT Medicare	$229.50
Rate for Payer: BCBS MT POS	$242.25
Rate for Payer: BCBS MT Traditional	$255.00
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cigna Commercial	$242.25
Rate for Payer: Cigna Medicare	$229.50
Rate for Payer: Medicaid All Medicaid	$234.60
Rate for Payer: Medicare All Medicare	$178.50
Rate for Payer: Monida Allegiance	$242.25
Rate for Payer: Monida First Choice Health	$247.35
Rate for Payer: Monida Montana Health Co-op	$242.25
Rate for Payer: Monida PacificSource	$242.25

INFLUENZA A&B, ABBOTT

Facility

$255.00

Service Code	CPT 87502
Hospital Charge Code	4087920
Hospital Revenue Code	300
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$255.00
Rate for Payer: Aetna Commercial	$242.25
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: BCBS MT CHIP	$229.50
Rate for Payer: BCBS MT Closed Plan Network	$242.25
Rate for Payer: BCBS MT HealthLink	$229.50
Rate for Payer: BCBS MT Medicare	$229.50
Rate for Payer: BCBS MT POS	$242.25
Rate for Payer: BCBS MT Traditional	$255.00
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cigna Commercial	$242.25
Rate for Payer: Cigna Medicare	$229.50
Rate for Payer: Medicaid All Medicaid	$234.60
Rate for Payer: Medicare All Medicare	$178.50
Rate for Payer: Monida Allegiance	$242.25
Rate for Payer: Monida First Choice Health	$247.35
Rate for Payer: Monida Montana Health Co-op	$242.25
Rate for Payer: Monida PacificSource	$242.25

.INFLUENZA B

Facility

$120.00

Service Code	CPT 87804
Hospital Charge Code	4078041
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

.INFLUENZA B

Facility

$120.00

Service Code	CPT 87804
Hospital Charge Code	4078041
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

INFLUENZA IMM ADMIN OR PREV RECEIVED

Facility

$0.01

Service Code	CPT 4274F
Hospital Charge Code	8004274
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INFLUENZA IMM ADMIN OR PREV RECEIVED

Facility

$0.01

Service Code	CPT 4274F
Hospital Charge Code	8004274
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INFLUENZA IMM ORDERED / ADMINISTERED

Facility

$0.01

Service Code	CPT 4037F
Hospital Charge Code	8004037
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INFLUENZA IMM ORDERED / ADMINISTERED

Facility

$0.01

Service Code	CPT 4037F
Hospital Charge Code	8004037
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INFLUENZA IMMUNIZATION STATUS ASSESSED

Facility

$0.01

Service Code	CPT 1030F
Hospital Charge Code	8001030
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INFLUENZA IMMUNIZATION STATUS ASSESSED

Facility

$0.01

Service Code	CPT 1030F
Hospital Charge Code	8001030
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INFUSURG 1000CC

Facility

$39.00

Hospital Charge Code	80040144
Hospital Revenue Code	270
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

INFUSURG 1000CC

Facility

$39.00

Hospital Charge Code	80040144
Hospital Revenue Code	270
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

Initial E/M Normal Newborn <8days

Facility

$231.00

Service Code	CPT 99461
Hospital Charge Code	8099461
Hospital Revenue Code	521
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

Initial E/M Normal Newborn <8days

Facility

$231.00

Service Code	CPT 99461
Hospital Charge Code	8099461
Hospital Revenue Code	521
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

INITIAL HOUR OF CHEMO INFUSION

Facility

$890.00

Service Code	CPT 96413
Hospital Charge Code	596413
Hospital Revenue Code	280
Min. Negotiated Rate	$623.00
Max. Negotiated Rate	$890.00
Rate for Payer: Aetna Commercial	$845.50
Rate for Payer: Aetna Medicare	$801.00
Rate for Payer: BCBS MT CHIP	$801.00
Rate for Payer: BCBS MT Closed Plan Network	$845.50
Rate for Payer: BCBS MT HealthLink	$801.00
Rate for Payer: BCBS MT Medicare	$801.00
Rate for Payer: BCBS MT POS	$845.50
Rate for Payer: BCBS MT Traditional	$890.00
Rate for Payer: Cash Price	$801.00
Rate for Payer: Cigna Commercial	$845.50
Rate for Payer: Cigna Medicare	$801.00
Rate for Payer: Medicaid All Medicaid	$818.80
Rate for Payer: Medicare All Medicare	$623.00
Rate for Payer: Monida Allegiance	$845.50
Rate for Payer: Monida First Choice Health	$863.30
Rate for Payer: Monida Montana Health Co-op	$845.50
Rate for Payer: Monida PacificSource	$845.50

INITIAL HOUR OF CHEMO INFUSION

Facility

$890.00

Service Code	CPT 96413
Hospital Charge Code	596413
Hospital Revenue Code	280
Min. Negotiated Rate	$623.00
Max. Negotiated Rate	$890.00
Rate for Payer: Aetna Commercial	$845.50
Rate for Payer: Aetna Medicare	$801.00
Rate for Payer: BCBS MT CHIP	$801.00
Rate for Payer: BCBS MT Closed Plan Network	$845.50
Rate for Payer: BCBS MT HealthLink	$801.00
Rate for Payer: BCBS MT Medicare	$801.00
Rate for Payer: BCBS MT POS	$845.50
Rate for Payer: BCBS MT Traditional	$890.00
Rate for Payer: Cash Price	$801.00
Rate for Payer: Cigna Commercial	$845.50
Rate for Payer: Cigna Medicare	$801.00
Rate for Payer: Medicaid All Medicaid	$818.80
Rate for Payer: Medicare All Medicare	$623.00
Rate for Payer: Monida Allegiance	$845.50
Rate for Payer: Monida First Choice Health	$863.30
Rate for Payer: Monida Montana Health Co-op	$845.50
Rate for Payer: Monida PacificSource	$845.50

INITIAL PRENATAL CARE VISIT

Facility

$0.01

Service Code	CPT 0500F
Hospital Charge Code	8000500
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INITIAL PRENATAL CARE VISIT

Facility

$0.01

Service Code	CPT 0500F
Hospital Charge Code	8000500
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

INITIAL PSYCH INTAKE

Facility

$318.00

Service Code	CPT 90791
Hospital Charge Code	8190791
Hospital Revenue Code	900
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

INITIAL PSYCH INTAKE

Facility

$318.00

Service Code	CPT 90791
Hospital Charge Code	8190791
Hospital Revenue Code	900
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

INITIAL PSYCH INTAKE WITH MEDICAL SERVIC

Facility

$353.00

Service Code	CPT 90792
Hospital Charge Code	8190792
Hospital Revenue Code	900
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

Know your out-of-pocket cost for care.

All Charges