Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INJ SQ/IM NURSE ONLY

Facility

$98.00

Service Code	CPT 96372
Hospital Charge Code	540196
Hospital Revenue Code	260
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 SQ/IM NURSE ONLY

Facility

$98.00

Service Code	CPT 96372
Hospital Charge Code	540196
Hospital Revenue Code	260
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

INS - DEGLUDEC [1 UNIT/ 0.01 ML] SPEC OR

Facility

$566.00

Hospital Charge Code	3000555
Hospital Revenue Code	250
Min. Negotiated Rate	$396.20
Max. Negotiated Rate	$566.00
Rate for Payer: Aetna Commercial	$537.70
Rate for Payer: Aetna Medicare	$509.40
Rate for Payer: BCBS MT CHIP	$509.40
Rate for Payer: BCBS MT Closed Plan Network	$537.70
Rate for Payer: BCBS MT HealthLink	$509.40
Rate for Payer: BCBS MT Medicare	$509.40
Rate for Payer: BCBS MT POS	$537.70
Rate for Payer: BCBS MT Traditional	$566.00
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cigna Commercial	$537.70
Rate for Payer: Cigna Medicare	$509.40
Rate for Payer: Medicaid All Medicaid	$520.72
Rate for Payer: Medicare All Medicare	$396.20
Rate for Payer: Monida Allegiance	$537.70
Rate for Payer: Monida First Choice Health	$549.02
Rate for Payer: Monida Montana Health Co-op	$537.70
Rate for Payer: Monida PacificSource	$537.70

INS - DEGLUDEC [1 UNIT/ 0.01 ML] SPEC OR

Facility

$566.00

Hospital Charge Code	3000555
Hospital Revenue Code	250
Min. Negotiated Rate	$396.20
Max. Negotiated Rate	$566.00
Rate for Payer: Aetna Commercial	$537.70
Rate for Payer: Aetna Medicare	$509.40
Rate for Payer: BCBS MT CHIP	$509.40
Rate for Payer: BCBS MT Closed Plan Network	$537.70
Rate for Payer: BCBS MT HealthLink	$509.40
Rate for Payer: BCBS MT Medicare	$509.40
Rate for Payer: BCBS MT POS	$537.70
Rate for Payer: BCBS MT Traditional	$566.00
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cigna Commercial	$537.70
Rate for Payer: Cigna Medicare	$509.40
Rate for Payer: Medicaid All Medicaid	$520.72
Rate for Payer: Medicare All Medicare	$396.20
Rate for Payer: Monida Allegiance	$537.70
Rate for Payer: Monida First Choice Health	$549.02
Rate for Payer: Monida Montana Health Co-op	$537.70
Rate for Payer: Monida PacificSource	$537.70

INSERT DEVICE CENTRAL VENOUS W/PORT >5YR

Facility

$5,115.00

Service Code	CPT 36561
Hospital Charge Code	1036561
Hospital Revenue Code	761
Min. Negotiated Rate	$3,580.50
Max. Negotiated Rate	$5,115.00
Rate for Payer: Aetna Commercial	$4,859.25
Rate for Payer: Aetna Medicare	$4,603.50
Rate for Payer: BCBS MT CHIP	$4,603.50
Rate for Payer: BCBS MT Closed Plan Network	$4,859.25
Rate for Payer: BCBS MT HealthLink	$4,603.50
Rate for Payer: BCBS MT Medicare	$4,603.50
Rate for Payer: BCBS MT POS	$4,859.25
Rate for Payer: BCBS MT Traditional	$5,115.00
Rate for Payer: Cash Price	$4,603.50
Rate for Payer: Cigna Commercial	$4,859.25
Rate for Payer: Cigna Medicare	$4,603.50
Rate for Payer: Medicaid All Medicaid	$4,705.80
Rate for Payer: Medicare All Medicare	$3,580.50
Rate for Payer: Monida Allegiance	$4,859.25
Rate for Payer: Monida First Choice Health	$4,961.55
Rate for Payer: Monida Montana Health Co-op	$4,859.25
Rate for Payer: Monida PacificSource	$4,859.25

INSERT DEVICE CENTRAL VENOUS W/PORT >5YR

Facility

$5,115.00

Service Code	CPT 36561
Hospital Charge Code	1036561
Hospital Revenue Code	761
Min. Negotiated Rate	$3,580.50
Max. Negotiated Rate	$5,115.00
Rate for Payer: Aetna Commercial	$4,859.25
Rate for Payer: Aetna Medicare	$4,603.50
Rate for Payer: BCBS MT CHIP	$4,603.50
Rate for Payer: BCBS MT Closed Plan Network	$4,859.25
Rate for Payer: BCBS MT HealthLink	$4,603.50
Rate for Payer: BCBS MT Medicare	$4,603.50
Rate for Payer: BCBS MT POS	$4,859.25
Rate for Payer: BCBS MT Traditional	$5,115.00
Rate for Payer: Cash Price	$4,603.50
Rate for Payer: Cigna Commercial	$4,859.25
Rate for Payer: Cigna Medicare	$4,603.50
Rate for Payer: Medicaid All Medicaid	$4,705.80
Rate for Payer: Medicare All Medicare	$3,580.50
Rate for Payer: Monida Allegiance	$4,859.25
Rate for Payer: Monida First Choice Health	$4,961.55
Rate for Payer: Monida Montana Health Co-op	$4,859.25
Rate for Payer: Monida PacificSource	$4,859.25

INSERTION, DRUG-DELIVERY IMPLANT 11981

Facility

$867.00

Service Code	CPT 11981
Hospital Charge Code	8011981
Hospital Revenue Code	521
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$867.00
Rate for Payer: Aetna Commercial	$823.65
Rate for Payer: Aetna Medicare	$780.30
Rate for Payer: BCBS MT CHIP	$780.30
Rate for Payer: BCBS MT Closed Plan Network	$823.65
Rate for Payer: BCBS MT HealthLink	$780.30
Rate for Payer: BCBS MT Medicare	$780.30
Rate for Payer: BCBS MT POS	$823.65
Rate for Payer: BCBS MT Traditional	$867.00
Rate for Payer: Cash Price	$780.30
Rate for Payer: Cigna Commercial	$823.65
Rate for Payer: Cigna Medicare	$780.30
Rate for Payer: Medicaid All Medicaid	$797.64
Rate for Payer: Medicare All Medicare	$606.90
Rate for Payer: Monida Allegiance	$823.65
Rate for Payer: Monida First Choice Health	$840.99
Rate for Payer: Monida Montana Health Co-op	$823.65
Rate for Payer: Monida PacificSource	$823.65

INSERTION, DRUG-DELIVERY IMPLANT 11981

Facility

$867.00

Service Code	CPT 11981
Hospital Charge Code	8011981
Hospital Revenue Code	521
Min. Negotiated Rate	$606.90
Max. Negotiated Rate	$867.00
Rate for Payer: Aetna Commercial	$823.65
Rate for Payer: Aetna Medicare	$780.30
Rate for Payer: BCBS MT CHIP	$780.30
Rate for Payer: BCBS MT Closed Plan Network	$823.65
Rate for Payer: BCBS MT HealthLink	$780.30
Rate for Payer: BCBS MT Medicare	$780.30
Rate for Payer: BCBS MT POS	$823.65
Rate for Payer: BCBS MT Traditional	$867.00
Rate for Payer: Cash Price	$780.30
Rate for Payer: Cigna Commercial	$823.65
Rate for Payer: Cigna Medicare	$780.30
Rate for Payer: Medicaid All Medicaid	$797.64
Rate for Payer: Medicare All Medicare	$606.90
Rate for Payer: Monida Allegiance	$823.65
Rate for Payer: Monida First Choice Health	$840.99
Rate for Payer: Monida Montana Health Co-op	$823.65
Rate for Payer: Monida PacificSource	$823.65

INSERTION OF IUD 58300

Facility

$235.00

Service Code	CPT 58300
Hospital Charge Code	8058300
Hospital Revenue Code	521
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

INSERTION OF IUD 58300

Facility

$235.00

Service Code	CPT 58300
Hospital Charge Code	8058300
Hospital Revenue Code	521
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

INSERTION OF PICC LINE

Facility

$1,970.00

Service Code	CPT 36569
Hospital Charge Code	536569
Hospital Revenue Code	761
Min. Negotiated Rate	$1,379.00
Max. Negotiated Rate	$1,970.00
Rate for Payer: Aetna Commercial	$1,871.50
Rate for Payer: Aetna Medicare	$1,773.00
Rate for Payer: BCBS MT CHIP	$1,773.00
Rate for Payer: BCBS MT Closed Plan Network	$1,871.50
Rate for Payer: BCBS MT HealthLink	$1,773.00
Rate for Payer: BCBS MT Medicare	$1,773.00
Rate for Payer: BCBS MT POS	$1,871.50
Rate for Payer: BCBS MT Traditional	$1,970.00
Rate for Payer: Cash Price	$1,773.00
Rate for Payer: Cigna Commercial	$1,871.50
Rate for Payer: Cigna Medicare	$1,773.00
Rate for Payer: Medicaid All Medicaid	$1,812.40
Rate for Payer: Medicare All Medicare	$1,379.00
Rate for Payer: Monida Allegiance	$1,871.50
Rate for Payer: Monida First Choice Health	$1,910.90
Rate for Payer: Monida Montana Health Co-op	$1,871.50
Rate for Payer: Monida PacificSource	$1,871.50

INSERTION OF PICC LINE

Facility

$1,970.00

Service Code	CPT 36569
Hospital Charge Code	536569
Hospital Revenue Code	761
Min. Negotiated Rate	$1,379.00
Max. Negotiated Rate	$1,970.00
Rate for Payer: Aetna Commercial	$1,871.50
Rate for Payer: Aetna Medicare	$1,773.00
Rate for Payer: BCBS MT CHIP	$1,773.00
Rate for Payer: BCBS MT Closed Plan Network	$1,871.50
Rate for Payer: BCBS MT HealthLink	$1,773.00
Rate for Payer: BCBS MT Medicare	$1,773.00
Rate for Payer: BCBS MT POS	$1,871.50
Rate for Payer: BCBS MT Traditional	$1,970.00
Rate for Payer: Cash Price	$1,773.00
Rate for Payer: Cigna Commercial	$1,871.50
Rate for Payer: Cigna Medicare	$1,773.00
Rate for Payer: Medicaid All Medicaid	$1,812.40
Rate for Payer: Medicare All Medicare	$1,379.00
Rate for Payer: Monida Allegiance	$1,871.50
Rate for Payer: Monida First Choice Health	$1,910.90
Rate for Payer: Monida Montana Health Co-op	$1,871.50
Rate for Payer: Monida PacificSource	$1,871.50

INS - GLARGINE INJ [1 UNITS/0.01 ML]

Facility

$6.00

Service Code	HCPCS J1815
Hospital Charge Code	3000231
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

INS - GLARGINE INJ [1 UNITS/0.01 ML]

Facility

$6.00

Service Code	HCPCS J1815
Hospital Charge Code	3000231
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

INS - LISPRO [1 UN/0.01 ML] MEAL TIME

Facility

$27.00

Service Code	HCPCS J1817
Hospital Charge Code	3000233
Hospital Revenue Code	636
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

INS - LISPRO [1 UN/0.01 ML] MEAL TIME

Facility

$27.00

Service Code	HCPCS J1817
Hospital Charge Code	3000233
Hospital Revenue Code	636
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

INS - NOVOLIN 70/30 MIX [1U/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000236
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN 70/30 MIX [1U/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000236
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN REGULAR [1 UNITS/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000235
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN REGULAR [1 UNITS/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000235
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS-NOVOLOG 100U/1ML INJECTION 10ML VIAL

Facility

$503.50

Service Code	HCPCS J1817
Hospital Charge Code	3007216
Hospital Revenue Code	250
Min. Negotiated Rate	$352.45
Max. Negotiated Rate	$503.50
Rate for Payer: Aetna Commercial	$478.32
Rate for Payer: Aetna Medicare	$453.15
Rate for Payer: BCBS MT CHIP	$453.15
Rate for Payer: BCBS MT Closed Plan Network	$478.32
Rate for Payer: BCBS MT HealthLink	$453.15
Rate for Payer: BCBS MT Medicare	$453.15
Rate for Payer: BCBS MT POS	$478.32
Rate for Payer: BCBS MT Traditional	$503.50
Rate for Payer: Cash Price	$453.15
Rate for Payer: Cigna Commercial	$478.32
Rate for Payer: Cigna Medicare	$453.15
Rate for Payer: Medicaid All Medicaid	$463.22
Rate for Payer: Medicare All Medicare	$352.45
Rate for Payer: Monida Allegiance	$478.32
Rate for Payer: Monida First Choice Health	$488.39
Rate for Payer: Monida Montana Health Co-op	$478.32
Rate for Payer: Monida PacificSource	$478.32

INS-NOVOLOG 100U/1ML INJECTION 10ML VIAL

Facility

$503.50

Service Code	HCPCS J1817
Hospital Charge Code	3007216
Hospital Revenue Code	250
Min. Negotiated Rate	$352.45
Max. Negotiated Rate	$503.50
Rate for Payer: Aetna Commercial	$478.32
Rate for Payer: Aetna Medicare	$453.15
Rate for Payer: BCBS MT CHIP	$453.15
Rate for Payer: BCBS MT Closed Plan Network	$478.32
Rate for Payer: BCBS MT HealthLink	$453.15
Rate for Payer: BCBS MT Medicare	$453.15
Rate for Payer: BCBS MT POS	$478.32
Rate for Payer: BCBS MT Traditional	$503.50
Rate for Payer: Cash Price	$453.15
Rate for Payer: Cigna Commercial	$478.32
Rate for Payer: Cigna Medicare	$453.15
Rate for Payer: Medicaid All Medicaid	$463.22
Rate for Payer: Medicare All Medicare	$352.45
Rate for Payer: Monida Allegiance	$478.32
Rate for Payer: Monida First Choice Health	$488.39
Rate for Payer: Monida Montana Health Co-op	$478.32
Rate for Payer: Monida PacificSource	$478.32

INS - REGULAR [HUMULIN] 100UN/ML 3ML

Facility

$60.00

Service Code	HCPCS J1815
Hospital Charge Code	3000232
Hospital Revenue Code	636
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

INS - REGULAR [HUMULIN] 100UN/ML 3ML

Facility

$60.00

Service Code	HCPCS J1815
Hospital Charge Code	3000232
Hospital Revenue Code	636
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

INSULIN ANTIBODIES

Facility

$96.75

Service Code	CPT 86337
Hospital Charge Code	4087954
Hospital Revenue Code	302
Min. Negotiated Rate	$67.72
Max. Negotiated Rate	$96.75
Rate for Payer: Aetna Commercial	$91.91
Rate for Payer: Aetna Medicare	$87.08
Rate for Payer: BCBS MT CHIP	$87.08
Rate for Payer: BCBS MT Closed Plan Network	$91.91
Rate for Payer: BCBS MT HealthLink	$87.08
Rate for Payer: BCBS MT Medicare	$87.08
Rate for Payer: BCBS MT POS	$91.91
Rate for Payer: BCBS MT Traditional	$96.75
Rate for Payer: Cash Price	$87.08
Rate for Payer: Cigna Commercial	$91.91
Rate for Payer: Cigna Medicare	$87.08
Rate for Payer: Medicaid All Medicaid	$89.01
Rate for Payer: Medicare All Medicare	$67.72
Rate for Payer: Monida Allegiance	$91.91
Rate for Payer: Monida First Choice Health	$93.85
Rate for Payer: Monida Montana Health Co-op	$91.91
Rate for Payer: Monida PacificSource	$91.91

Know your out-of-pocket cost for care.

All Charges