Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

INSULIN LEVEL (004333)

Facility

$17.00

Service Code	CPT 83525
Hospital Charge Code	4083525
Hospital Revenue Code	301
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

INSULIN LEVEL (004333)

Facility

$17.00

Service Code	CPT 83525
Hospital Charge Code	4083525
Hospital Revenue Code	301
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

INSULIN-LIKE GROWTH FACTOR-1 (010363)

Facility

$118.00

Service Code	CPT 84305
Hospital Charge Code	4084305
Hospital Revenue Code	301
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$118.00
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare	$106.20
Rate for Payer: BCBS MT CHIP	$106.20
Rate for Payer: BCBS MT Closed Plan Network	$112.10
Rate for Payer: BCBS MT HealthLink	$106.20
Rate for Payer: BCBS MT Medicare	$106.20
Rate for Payer: BCBS MT POS	$112.10
Rate for Payer: BCBS MT Traditional	$118.00
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cigna Commercial	$112.10
Rate for Payer: Cigna Medicare	$106.20
Rate for Payer: Medicaid All Medicaid	$108.56
Rate for Payer: Medicare All Medicare	$82.60
Rate for Payer: Monida Allegiance	$112.10
Rate for Payer: Monida First Choice Health	$114.46
Rate for Payer: Monida Montana Health Co-op	$112.10
Rate for Payer: Monida PacificSource	$112.10

INSULIN-LIKE GROWTH FACTOR-1 (010363)

Facility

$118.00

Service Code	CPT 84305
Hospital Charge Code	4084305
Hospital Revenue Code	301
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$118.00
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare	$106.20
Rate for Payer: BCBS MT CHIP	$106.20
Rate for Payer: BCBS MT Closed Plan Network	$112.10
Rate for Payer: BCBS MT HealthLink	$106.20
Rate for Payer: BCBS MT Medicare	$106.20
Rate for Payer: BCBS MT POS	$112.10
Rate for Payer: BCBS MT Traditional	$118.00
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cigna Commercial	$112.10
Rate for Payer: Cigna Medicare	$106.20
Rate for Payer: Medicaid All Medicaid	$108.56
Rate for Payer: Medicare All Medicare	$82.60
Rate for Payer: Monida Allegiance	$112.10
Rate for Payer: Monida First Choice Health	$114.46
Rate for Payer: Monida Montana Health Co-op	$112.10
Rate for Payer: Monida PacificSource	$112.10

INSULIN LIKE GROWTH FACTOR2

Facility

$155.00

Service Code	CPT 83520
Hospital Charge Code	4087941
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

INSULIN LIKE GROWTH FACTOR2

Facility

$155.00

Service Code	CPT 83520
Hospital Charge Code	4087941
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

INTERACTIVE COMPLEXITY

Facility

$35.00

Service Code	CPT 90785
Hospital Charge Code	8190785
Hospital Revenue Code	521
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

INTERACTIVE COMPLEXITY

Facility

$35.00

Service Code	CPT 90785
Hospital Charge Code	8190785
Hospital Revenue Code	521
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

INTRA LESION CHEMO ADMIN MORE THAT 7 LES

Facility

$455.00

Service Code	CPT 96406
Hospital Charge Code	596406
Hospital Revenue Code	280
Min. Negotiated Rate	$318.50
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial	$432.25
Rate for Payer: Aetna Medicare	$409.50
Rate for Payer: BCBS MT CHIP	$409.50
Rate for Payer: BCBS MT Closed Plan Network	$432.25
Rate for Payer: BCBS MT HealthLink	$409.50
Rate for Payer: BCBS MT Medicare	$409.50
Rate for Payer: BCBS MT POS	$432.25
Rate for Payer: BCBS MT Traditional	$455.00
Rate for Payer: Cash Price	$409.50
Rate for Payer: Cigna Commercial	$432.25
Rate for Payer: Cigna Medicare	$409.50
Rate for Payer: Medicaid All Medicaid	$418.60
Rate for Payer: Medicare All Medicare	$318.50
Rate for Payer: Monida Allegiance	$432.25
Rate for Payer: Monida First Choice Health	$441.35
Rate for Payer: Monida Montana Health Co-op	$432.25
Rate for Payer: Monida PacificSource	$432.25

INTRA LESION CHEMO ADMIN MORE THAT 7 LES

Facility

$455.00

Service Code	CPT 96406
Hospital Charge Code	596406
Hospital Revenue Code	280
Min. Negotiated Rate	$318.50
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial	$432.25
Rate for Payer: Aetna Medicare	$409.50
Rate for Payer: BCBS MT CHIP	$409.50
Rate for Payer: BCBS MT Closed Plan Network	$432.25
Rate for Payer: BCBS MT HealthLink	$409.50
Rate for Payer: BCBS MT Medicare	$409.50
Rate for Payer: BCBS MT POS	$432.25
Rate for Payer: BCBS MT Traditional	$455.00
Rate for Payer: Cash Price	$409.50
Rate for Payer: Cigna Commercial	$432.25
Rate for Payer: Cigna Medicare	$409.50
Rate for Payer: Medicaid All Medicaid	$418.60
Rate for Payer: Medicare All Medicare	$318.50
Rate for Payer: Monida Allegiance	$432.25
Rate for Payer: Monida First Choice Health	$441.35
Rate for Payer: Monida Montana Health Co-op	$432.25
Rate for Payer: Monida PacificSource	$432.25

INTRA LESION CHEMO ADMIN UP TO 7 LES

Facility

$278.00

Service Code	CPT 96405
Hospital Charge Code	596405
Hospital Revenue Code	280
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

INTRA LESION CHEMO ADMIN UP TO 7 LES

Facility

$278.00

Service Code	CPT 96405
Hospital Charge Code	596405
Hospital Revenue Code	280
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

INTREPID INITIAL EVAL/DISCHARGE

Facility

$187.00

Service Code	HCPCS G0151
Hospital Charge Code	611001
Hospital Revenue Code	421
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

INTREPID INITIAL EVAL/DISCHARGE

Facility

$187.00

Service Code	HCPCS G0151
Hospital Charge Code	611001
Hospital Revenue Code	421
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

INTREPID ORIENTATION OF STAFF

Facility

$48.00

Hospital Charge Code	611002
Hospital Revenue Code	421
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

INTREPID ORIENTATION OF STAFF

Facility

$48.00

Hospital Charge Code	611002
Hospital Revenue Code	421
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

INTREPID TRAVEL TIME/HR

Facility

$68.00

Hospital Charge Code	611006
Hospital Revenue Code	429
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

INTREPID TRAVEL TIME/HR

Facility

$68.00

Hospital Charge Code	611006
Hospital Revenue Code	429
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

INTREPID VISIT

Facility

$94.00

Service Code	HCPCS G0151
Hospital Charge Code	611005
Hospital Revenue Code	421
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

INTREPID VISIT

Facility

$94.00

Service Code	HCPCS G0151
Hospital Charge Code	611005
Hospital Revenue Code	421
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

INTRINSIC FACTOR BLOCKING ANTIBODY

Facility

$96.00

Service Code	CPT 86340
Hospital Charge Code	4087990
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

INTRINSIC FACTOR BLOCKING ANTIBODY

Facility

$96.00

Service Code	CPT 86340
Hospital Charge Code	4087990
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

INVALID RING

Facility

$9.00

Hospital Charge Code	2830195
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

INVALID RING

Facility

$9.00

Hospital Charge Code	2830195
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

Know your out-of-pocket cost for care.

All Charges