Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INJ INTRALESIONAL, UP TO 7 LESIONS

Facility

$182.00

Service Code	CPT 11900
Hospital Charge Code	8011900
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

INJ IPV

Facility

$50.00

Service Code	CPT 90713
Hospital Charge Code	8090713
Hospital Revenue Code	521
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

INJ IPV

Facility

$50.00

Service Code	CPT 90713
Hospital Charge Code	8090713
Hospital Revenue Code	521
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

INJ IV UP TO ONE HR 250-500C

Facility

$5.00

Service Code	CPT 90780
Hospital Charge Code	8090780
Hospital Revenue Code	521
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

INJ IV UP TO ONE HR 250-500C

Facility

$5.00

Service Code	CPT 90780
Hospital Charge Code	8090780
Hospital Revenue Code	521
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

INJ MAJOR JOINT W/US 20611

Facility

$1,042.00

Service Code	CPT 20611
Hospital Charge Code	8020611
Hospital Revenue Code	521
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

INJ MAJOR JOINT W/US 20611

Facility

$1,042.00

Service Code	CPT 20611
Hospital Charge Code	8020611
Hospital Revenue Code	521
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

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

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

Know your out-of-pocket cost for care.

All Charges