Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INJ ADMIN BEYFORTUS IM w/ counseling

Facility

$73.00

Service Code	CPT 96380
Hospital Charge Code	8096380
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN BEYFORTUS IM w/ counseling

Facility

$73.00

Service Code	CPT 96380
Hospital Charge Code	8096380
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN BEYFORTUS IM w/o counseling

Facility

$73.00

Service Code	CPT 96381
Hospital Charge Code	8096381
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN BEYFORTUS IM w/o counseling

Facility

$73.00

Service Code	CPT 96381
Hospital Charge Code	8096381
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN IMM EA ADDTL SNGL/CMB (90472)

Facility

$38.00

Service Code	CPT 90472
Hospital Charge Code	8090472
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

INJ ADMIN IMM EA ADDTL SNGL/CMB (90472)

Facility

$38.00

Service Code	CPT 90472
Hospital Charge Code	8090472
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

INJ ADMIN IMMUNIZ INITIAL-CLINIC(90471)

Facility

$73.00

Service Code	CPT 90471
Hospital Charge Code	8090471
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN IMMUNIZ INITIAL-CLINIC(90471)

Facility

$73.00

Service Code	CPT 90471
Hospital Charge Code	8090471
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN INFLUENZA-MEDICARE 90471

Facility

$73.00

Service Code	HCPCS G0008
Hospital Charge Code	8000010
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN INFLUENZA-MEDICARE 90471

Facility

$73.00

Service Code	HCPCS G0008
Hospital Charge Code	8000010
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN INFLUENZA VACCINE 90471

Facility

$73.00

Service Code	CPT 90471
Hospital Charge Code	8000008
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN INFLUENZA VACCINE 90471

Facility

$73.00

Service Code	CPT 90471
Hospital Charge Code	8000008
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN IV MED

Facility

$38.00

Service Code	CPT 90784
Hospital Charge Code	8090784
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

INJ ADMIN IV MED

Facility

$38.00

Service Code	CPT 90784
Hospital Charge Code	8090784
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

INJ ADMIN OF PNEUMOCOCCAL VACCINE

Facility

$73.00

Service Code	CPT 90471
Hospital Charge Code	8000009
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN OF PNEUMOCOCCAL VACCINE

Facility

$73.00

Service Code	CPT 90471
Hospital Charge Code	8000009
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN OF PNEUMOCOCCAL VAC-MEDICARE

Facility

$73.00

Service Code	HCPCS G0009
Hospital Charge Code	8000007
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN OF PNEUMOCOCCAL VAC-MEDICARE

Facility

$73.00

Service Code	HCPCS G0009
Hospital Charge Code	8000007
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

INJ ADMIN OF STATE VACCINE SINGLE

Facility

$15.00

Hospital Charge Code	8090470
Hospital Revenue Code	521
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

INJ ADMIN OF STATE VACCINE SINGLE

Facility

$15.00

Hospital Charge Code	8090470
Hospital Revenue Code	521
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

INJ ADMIN THERAPEUTIC/DIAGNOSTIC (96372)

Facility

$98.00

Service Code	CPT 96372
Hospital Charge Code	8096372
Hospital Revenue Code	521
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

INJ ADMIN THERAPEUTIC/DIAGNOSTIC (96372)

Facility

$98.00

Service Code	CPT 96372
Hospital Charge Code	8096372
Hospital Revenue Code	521
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

INJ ANCEF,CEFAZOLIN 1 GM IM (1000 MG)

Facility

$38.00

Service Code	HCPCS J0690
Hospital Charge Code	8000690
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

INJ ANCEF,CEFAZOLIN 1 GM IM (1000 MG)

Facility

$38.00

Service Code	HCPCS J0690
Hospital Charge Code	8000690
Hospital Revenue Code	521
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

INJ AND/OR ASPIRATION JOINT INJ SMALL

Facility

$396.00

Service Code	CPT 20600
Hospital Charge Code	8020600
Hospital Revenue Code	521
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: Aetna Medicare	$356.40
Rate for Payer: BCBS MT CHIP	$356.40
Rate for Payer: BCBS MT Closed Plan Network	$376.20
Rate for Payer: BCBS MT HealthLink	$356.40
Rate for Payer: BCBS MT Medicare	$356.40
Rate for Payer: BCBS MT POS	$376.20
Rate for Payer: BCBS MT Traditional	$396.00
Rate for Payer: Cash Price	$356.40
Rate for Payer: Cigna Commercial	$376.20
Rate for Payer: Cigna Medicare	$356.40
Rate for Payer: Medicaid All Medicaid	$364.32
Rate for Payer: Medicare All Medicare	$277.20
Rate for Payer: Monida Allegiance	$376.20
Rate for Payer: Monida First Choice Health	$384.12
Rate for Payer: Monida Montana Health Co-op	$376.20
Rate for Payer: Monida PacificSource	$376.20

Know your out-of-pocket cost for care.

All Charges