Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US TRANSVAGINAL US NON-OB

Facility

$431.00

Service Code	HCPCS 76830 TC
Hospital Charge Code	5176830
Hospital Revenue Code	402
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

US TRANSVAGINAL US OBSTETRIC

Facility

$348.00

Service Code	HCPCS 76817 TC
Hospital Charge Code	5176817
Hospital Revenue Code	402
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

US TRANSVAGINAL US OBSTETRIC

Facility

$348.00

Service Code	HCPCS 76817 TC
Hospital Charge Code	5176817
Hospital Revenue Code	402
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

US TRANS VAG LMT

Facility

$230.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	5100003
Hospital Revenue Code	402
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

US TRANS VAG LMT

Facility

$230.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	5100003
Hospital Revenue Code	402
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOC

Facility

$847.00

Service Code	HCPCS 76776 TC
Hospital Charge Code	5176776
Hospital Revenue Code	402
Min. Negotiated Rate	$592.90
Max. Negotiated Rate	$847.00
Rate for Payer: Aetna Commercial	$804.65
Rate for Payer: Aetna Medicare	$762.30
Rate for Payer: BCBS MT CHIP	$762.30
Rate for Payer: BCBS MT Closed Plan Network	$804.65
Rate for Payer: BCBS MT HealthLink	$762.30
Rate for Payer: BCBS MT Medicare	$762.30
Rate for Payer: BCBS MT POS	$804.65
Rate for Payer: BCBS MT Traditional	$847.00
Rate for Payer: Cash Price	$762.30
Rate for Payer: Cigna Commercial	$804.65
Rate for Payer: Cigna Medicare	$762.30
Rate for Payer: Medicaid All Medicaid	$779.24
Rate for Payer: Medicare All Medicare	$592.90
Rate for Payer: Monida Allegiance	$804.65
Rate for Payer: Monida First Choice Health	$821.59
Rate for Payer: Monida Montana Health Co-op	$804.65
Rate for Payer: Monida PacificSource	$804.65

US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOC

Facility

$847.00

Service Code	HCPCS 76776 TC
Hospital Charge Code	5176776
Hospital Revenue Code	402
Min. Negotiated Rate	$592.90
Max. Negotiated Rate	$847.00
Rate for Payer: Aetna Commercial	$804.65
Rate for Payer: Aetna Medicare	$762.30
Rate for Payer: BCBS MT CHIP	$762.30
Rate for Payer: BCBS MT Closed Plan Network	$804.65
Rate for Payer: BCBS MT HealthLink	$762.30
Rate for Payer: BCBS MT Medicare	$762.30
Rate for Payer: BCBS MT POS	$804.65
Rate for Payer: BCBS MT Traditional	$847.00
Rate for Payer: Cash Price	$762.30
Rate for Payer: Cigna Commercial	$804.65
Rate for Payer: Cigna Medicare	$762.30
Rate for Payer: Medicaid All Medicaid	$779.24
Rate for Payer: Medicare All Medicare	$592.90
Rate for Payer: Monida Allegiance	$804.65
Rate for Payer: Monida First Choice Health	$821.59
Rate for Payer: Monida Montana Health Co-op	$804.65
Rate for Payer: Monida PacificSource	$804.65

US UPPER EXT ARTERIAL DUPLEX BILATERAL

Facility

$945.00

Service Code	HCPCS 93930
Hospital Charge Code	5193930
Hospital Revenue Code	402
Min. Negotiated Rate	$661.50
Max. Negotiated Rate	$945.00
Rate for Payer: Aetna Commercial	$897.75
Rate for Payer: Aetna Medicare	$850.50
Rate for Payer: BCBS MT CHIP	$850.50
Rate for Payer: BCBS MT Closed Plan Network	$897.75
Rate for Payer: BCBS MT HealthLink	$850.50
Rate for Payer: BCBS MT Medicare	$850.50
Rate for Payer: BCBS MT POS	$897.75
Rate for Payer: BCBS MT Traditional	$945.00
Rate for Payer: Cash Price	$850.50
Rate for Payer: Cigna Commercial	$897.75
Rate for Payer: Cigna Medicare	$850.50
Rate for Payer: Medicaid All Medicaid	$869.40
Rate for Payer: Medicare All Medicare	$661.50
Rate for Payer: Monida Allegiance	$897.75
Rate for Payer: Monida First Choice Health	$916.65
Rate for Payer: Monida Montana Health Co-op	$897.75
Rate for Payer: Monida PacificSource	$897.75

US UPPER EXT ARTERIAL DUPLEX BILATERAL

Facility

$945.00

Service Code	HCPCS 93930
Hospital Charge Code	5193930
Hospital Revenue Code	402
Min. Negotiated Rate	$661.50
Max. Negotiated Rate	$945.00
Rate for Payer: Aetna Commercial	$897.75
Rate for Payer: Aetna Medicare	$850.50
Rate for Payer: BCBS MT CHIP	$850.50
Rate for Payer: BCBS MT Closed Plan Network	$897.75
Rate for Payer: BCBS MT HealthLink	$850.50
Rate for Payer: BCBS MT Medicare	$850.50
Rate for Payer: BCBS MT POS	$897.75
Rate for Payer: BCBS MT Traditional	$945.00
Rate for Payer: Cash Price	$850.50
Rate for Payer: Cigna Commercial	$897.75
Rate for Payer: Cigna Medicare	$850.50
Rate for Payer: Medicaid All Medicaid	$869.40
Rate for Payer: Medicare All Medicare	$661.50
Rate for Payer: Monida Allegiance	$897.75
Rate for Payer: Monida First Choice Health	$916.65
Rate for Payer: Monida Montana Health Co-op	$897.75
Rate for Payer: Monida PacificSource	$897.75

US VENOUS DOPP LOWER EXT BIILATERAL

Facility

$735.00

Service Code	HCPCS 93970
Hospital Charge Code	5193970
Hospital Revenue Code	402
Min. Negotiated Rate	$514.50
Max. Negotiated Rate	$735.00
Rate for Payer: Aetna Commercial	$698.25
Rate for Payer: Aetna Medicare	$661.50
Rate for Payer: BCBS MT CHIP	$661.50
Rate for Payer: BCBS MT Closed Plan Network	$698.25
Rate for Payer: BCBS MT HealthLink	$661.50
Rate for Payer: BCBS MT Medicare	$661.50
Rate for Payer: BCBS MT POS	$698.25
Rate for Payer: BCBS MT Traditional	$735.00
Rate for Payer: Cash Price	$661.50
Rate for Payer: Cigna Commercial	$698.25
Rate for Payer: Cigna Medicare	$661.50
Rate for Payer: Medicaid All Medicaid	$676.20
Rate for Payer: Medicare All Medicare	$514.50
Rate for Payer: Monida Allegiance	$698.25
Rate for Payer: Monida First Choice Health	$712.95
Rate for Payer: Monida Montana Health Co-op	$698.25
Rate for Payer: Monida PacificSource	$698.25

US VENOUS DOPP LOWER EXT BIILATERAL

Facility

$735.00

Service Code	HCPCS 93970
Hospital Charge Code	5193970
Hospital Revenue Code	402
Min. Negotiated Rate	$514.50
Max. Negotiated Rate	$735.00
Rate for Payer: Aetna Commercial	$698.25
Rate for Payer: Aetna Medicare	$661.50
Rate for Payer: BCBS MT CHIP	$661.50
Rate for Payer: BCBS MT Closed Plan Network	$698.25
Rate for Payer: BCBS MT HealthLink	$661.50
Rate for Payer: BCBS MT Medicare	$661.50
Rate for Payer: BCBS MT POS	$698.25
Rate for Payer: BCBS MT Traditional	$735.00
Rate for Payer: Cash Price	$661.50
Rate for Payer: Cigna Commercial	$698.25
Rate for Payer: Cigna Medicare	$661.50
Rate for Payer: Medicaid All Medicaid	$676.20
Rate for Payer: Medicare All Medicare	$514.50
Rate for Payer: Monida Allegiance	$698.25
Rate for Payer: Monida First Choice Health	$712.95
Rate for Payer: Monida Montana Health Co-op	$698.25
Rate for Payer: Monida PacificSource	$698.25

US VENOUS DOPP LOWER EXT UNILATERAL

Facility

$490.00

Service Code	HCPCS 93971
Hospital Charge Code	5193971
Hospital Revenue Code	402
Min. Negotiated Rate	$343.00
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial	$465.50
Rate for Payer: Aetna Medicare	$441.00
Rate for Payer: BCBS MT CHIP	$441.00
Rate for Payer: BCBS MT Closed Plan Network	$465.50
Rate for Payer: BCBS MT HealthLink	$441.00
Rate for Payer: BCBS MT Medicare	$441.00
Rate for Payer: BCBS MT POS	$465.50
Rate for Payer: BCBS MT Traditional	$490.00
Rate for Payer: Cash Price	$441.00
Rate for Payer: Cigna Commercial	$465.50
Rate for Payer: Cigna Medicare	$441.00
Rate for Payer: Medicaid All Medicaid	$450.80
Rate for Payer: Medicare All Medicare	$343.00
Rate for Payer: Monida Allegiance	$465.50
Rate for Payer: Monida First Choice Health	$475.30
Rate for Payer: Monida Montana Health Co-op	$465.50
Rate for Payer: Monida PacificSource	$465.50

US VENOUS DOPP LOWER EXT UNILATERAL

Facility

$490.00

Service Code	HCPCS 93971
Hospital Charge Code	5193971
Hospital Revenue Code	402
Min. Negotiated Rate	$343.00
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial	$465.50
Rate for Payer: Aetna Medicare	$441.00
Rate for Payer: BCBS MT CHIP	$441.00
Rate for Payer: BCBS MT Closed Plan Network	$465.50
Rate for Payer: BCBS MT HealthLink	$441.00
Rate for Payer: BCBS MT Medicare	$441.00
Rate for Payer: BCBS MT POS	$465.50
Rate for Payer: BCBS MT Traditional	$490.00
Rate for Payer: Cash Price	$441.00
Rate for Payer: Cigna Commercial	$465.50
Rate for Payer: Cigna Medicare	$441.00
Rate for Payer: Medicaid All Medicaid	$450.80
Rate for Payer: Medicare All Medicare	$343.00
Rate for Payer: Monida Allegiance	$465.50
Rate for Payer: Monida First Choice Health	$475.30
Rate for Payer: Monida Montana Health Co-op	$465.50
Rate for Payer: Monida PacificSource	$465.50

US VENOUS DOPP UPPER EXT BIILATERAL

Facility

$735.00

Service Code	HCPCS 93970
Hospital Charge Code	51093971
Hospital Revenue Code	402
Min. Negotiated Rate	$514.50
Max. Negotiated Rate	$735.00
Rate for Payer: Aetna Commercial	$698.25
Rate for Payer: Aetna Medicare	$661.50
Rate for Payer: BCBS MT CHIP	$661.50
Rate for Payer: BCBS MT Closed Plan Network	$698.25
Rate for Payer: BCBS MT HealthLink	$661.50
Rate for Payer: BCBS MT Medicare	$661.50
Rate for Payer: BCBS MT POS	$698.25
Rate for Payer: BCBS MT Traditional	$735.00
Rate for Payer: Cash Price	$661.50
Rate for Payer: Cigna Commercial	$698.25
Rate for Payer: Cigna Medicare	$661.50
Rate for Payer: Medicaid All Medicaid	$676.20
Rate for Payer: Medicare All Medicare	$514.50
Rate for Payer: Monida Allegiance	$698.25
Rate for Payer: Monida First Choice Health	$712.95
Rate for Payer: Monida Montana Health Co-op	$698.25
Rate for Payer: Monida PacificSource	$698.25

US VENOUS DOPP UPPER EXT BIILATERAL

Facility

$735.00

Service Code	HCPCS 93970
Hospital Charge Code	51093971
Hospital Revenue Code	402
Min. Negotiated Rate	$514.50
Max. Negotiated Rate	$735.00
Rate for Payer: Aetna Commercial	$698.25
Rate for Payer: Aetna Medicare	$661.50
Rate for Payer: BCBS MT CHIP	$661.50
Rate for Payer: BCBS MT Closed Plan Network	$698.25
Rate for Payer: BCBS MT HealthLink	$661.50
Rate for Payer: BCBS MT Medicare	$661.50
Rate for Payer: BCBS MT POS	$698.25
Rate for Payer: BCBS MT Traditional	$735.00
Rate for Payer: Cash Price	$661.50
Rate for Payer: Cigna Commercial	$698.25
Rate for Payer: Cigna Medicare	$661.50
Rate for Payer: Medicaid All Medicaid	$676.20
Rate for Payer: Medicare All Medicare	$514.50
Rate for Payer: Monida Allegiance	$698.25
Rate for Payer: Monida First Choice Health	$712.95
Rate for Payer: Monida Montana Health Co-op	$698.25
Rate for Payer: Monida PacificSource	$698.25

US VENOUS DOPP UPPER EXT UNILATERAL

Facility

$490.00

Service Code	HCPCS 93971
Hospital Charge Code	51093970
Hospital Revenue Code	402
Min. Negotiated Rate	$343.00
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial	$465.50
Rate for Payer: Aetna Medicare	$441.00
Rate for Payer: BCBS MT CHIP	$441.00
Rate for Payer: BCBS MT Closed Plan Network	$465.50
Rate for Payer: BCBS MT HealthLink	$441.00
Rate for Payer: BCBS MT Medicare	$441.00
Rate for Payer: BCBS MT POS	$465.50
Rate for Payer: BCBS MT Traditional	$490.00
Rate for Payer: Cash Price	$441.00
Rate for Payer: Cigna Commercial	$465.50
Rate for Payer: Cigna Medicare	$441.00
Rate for Payer: Medicaid All Medicaid	$450.80
Rate for Payer: Medicare All Medicare	$343.00
Rate for Payer: Monida Allegiance	$465.50
Rate for Payer: Monida First Choice Health	$475.30
Rate for Payer: Monida Montana Health Co-op	$465.50
Rate for Payer: Monida PacificSource	$465.50

US VENOUS DOPP UPPER EXT UNILATERAL

Facility

$490.00

Service Code	HCPCS 93971
Hospital Charge Code	51093970
Hospital Revenue Code	402
Min. Negotiated Rate	$343.00
Max. Negotiated Rate	$490.00
Rate for Payer: Aetna Commercial	$465.50
Rate for Payer: Aetna Medicare	$441.00
Rate for Payer: BCBS MT CHIP	$441.00
Rate for Payer: BCBS MT Closed Plan Network	$465.50
Rate for Payer: BCBS MT HealthLink	$441.00
Rate for Payer: BCBS MT Medicare	$441.00
Rate for Payer: BCBS MT POS	$465.50
Rate for Payer: BCBS MT Traditional	$490.00
Rate for Payer: Cash Price	$441.00
Rate for Payer: Cigna Commercial	$465.50
Rate for Payer: Cigna Medicare	$441.00
Rate for Payer: Medicaid All Medicaid	$450.80
Rate for Payer: Medicare All Medicare	$343.00
Rate for Payer: Monida Allegiance	$465.50
Rate for Payer: Monida First Choice Health	$475.30
Rate for Payer: Monida Montana Health Co-op	$465.50
Rate for Payer: Monida PacificSource	$465.50

VAC - INFLUENZA EGG FREE HOSPITAL

Facility

$63.00

Service Code	HCPCS 90682
Hospital Charge Code	3000466
Hospital Revenue Code	250
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

VAC - INFLUENZA EGG FREE HOSPITAL

Facility

$63.00

Service Code	HCPCS 90682
Hospital Charge Code	3000466
Hospital Revenue Code	250
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

VAC - INFLUENZA HD HOSPITAL

Facility

$93.00

Service Code	HCPCS 90662
Hospital Charge Code	3000467
Hospital Revenue Code	636
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

VAC - INFLUENZA HD HOSPITAL

Facility

$93.00

Service Code	HCPCS 90662
Hospital Charge Code	3000467
Hospital Revenue Code	636
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

VAC - INFLUENZA REGULAR DOSE HOSP

Facility

$26.00

Service Code	HCPCS 90656
Hospital Charge Code	3000468
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

VAC - INFLUENZA REGULAR DOSE HOSP

Facility

$26.00

Service Code	HCPCS 90656
Hospital Charge Code	3000468
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

VAC - MEASLES, MUMPS & RUBELLA

Facility

$35.00

Service Code	HCPCS 90707
Hospital Charge Code	3000465
Hospital Revenue Code	636
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

VAC - MEASLES, MUMPS & RUBELLA

Facility

$35.00

Service Code	HCPCS 90707
Hospital Charge Code	3000465
Hospital Revenue Code	636
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

Know your out-of-pocket cost for care.

All Charges