Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR UPPER EXTREMITY RT INFANT

Facility

$231.00

Service Code	HCPCS 73092 TC,RT
Hospital Charge Code	5000001
Hospital Revenue Code	320
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

XR UPPER EXTREMITY RT INFANT

Facility

$231.00

Service Code	HCPCS 73092 TC,RT
Hospital Charge Code	5000001
Hospital Revenue Code	320
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

XR WRIST BILATERAL 2 VIEWS

Facility

$374.00

Service Code	HCPCS 73100 TC,50
Hospital Charge Code	5000244
Hospital Revenue Code	320
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

XR WRIST BILATERAL 2 VIEWS

Facility

$374.00

Service Code	HCPCS 73100 TC,50
Hospital Charge Code	5000244
Hospital Revenue Code	320
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

XR WRIST BILATERAL COMPLETE

Facility

$452.00

Service Code	HCPCS 73110 TC,50
Hospital Charge Code	5000245
Hospital Revenue Code	320
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

XR WRIST BILATERAL COMPLETE

Facility

$452.00

Service Code	HCPCS 73110 TC,50
Hospital Charge Code	5000245
Hospital Revenue Code	320
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

XR WRIST LT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73100 TC,LT
Hospital Charge Code	5000246
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR WRIST LT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73100 TC,LT
Hospital Charge Code	5000246
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR WRIST LT COMPLETE

Facility

$301.00

Service Code	HCPCS 73110 TC,LT
Hospital Charge Code	5000247
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR WRIST LT COMPLETE

Facility

$301.00

Service Code	HCPCS 73110 TC,LT
Hospital Charge Code	5000247
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR WRIST RT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73100 TC,RT
Hospital Charge Code	5000248
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR WRIST RT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73100 TC,RT
Hospital Charge Code	5000248
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR WRIST RT COMPLETE

Facility

$301.00

Service Code	HCPCS 73110 TC,RT
Hospital Charge Code	5000249
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR WRIST RT COMPLETE

Facility

$301.00

Service Code	HCPCS 73110 TC,RT
Hospital Charge Code	5000249
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

xxPOTASSIUM CHLORIDE INJ. 20MEQ 50ML

Facility

$26.00

Service Code	HCPCS J3480
Hospital Charge Code	3007224
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

xxPOTASSIUM CHLORIDE INJ. 20MEQ 50ML

Facility

$26.00

Service Code	HCPCS J3480
Hospital Charge Code	3007224
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

XX PREDNISOLONE LIQ [5 MG/5 ML] UD CUP

Facility

$14.00

Service Code	HCPCS J7510
Hospital Charge Code	3000398
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

XX PREDNISOLONE LIQ [5 MG/5 ML] UD CUP

Facility

$14.00

Service Code	HCPCS J7510
Hospital Charge Code	3000398
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

XX SEMAGLUTIDE INJ. 2.68MG/ML

Facility

$1,572.10

Service Code	NDC 00169477212
Hospital Charge Code	3007411
Hospital Revenue Code	250
Min. Negotiated Rate	$1,100.47
Max. Negotiated Rate	$1,572.10
Rate for Payer: Aetna Commercial	$1,493.49
Rate for Payer: Aetna Medicare	$1,414.89
Rate for Payer: BCBS MT CHIP	$1,414.89
Rate for Payer: BCBS MT Closed Plan Network	$1,493.49
Rate for Payer: BCBS MT HealthLink	$1,414.89
Rate for Payer: BCBS MT Medicare	$1,414.89
Rate for Payer: BCBS MT POS	$1,493.49
Rate for Payer: BCBS MT Traditional	$1,572.10
Rate for Payer: Cash Price	$1,414.89
Rate for Payer: Cigna Commercial	$1,493.49
Rate for Payer: Cigna Medicare	$1,414.89
Rate for Payer: Medicaid All Medicaid	$1,446.33
Rate for Payer: Medicare All Medicare	$1,100.47
Rate for Payer: Monida Allegiance	$1,493.49
Rate for Payer: Monida First Choice Health	$1,524.94
Rate for Payer: Monida Montana Health Co-op	$1,493.49
Rate for Payer: Monida PacificSource	$1,493.49

XX SEMAGLUTIDE INJ. 2.68MG/ML

Facility

$1,572.10

Service Code	NDC 00169477212
Hospital Charge Code	3007411
Hospital Revenue Code	250
Min. Negotiated Rate	$1,100.47
Max. Negotiated Rate	$1,572.10
Rate for Payer: Aetna Commercial	$1,493.49
Rate for Payer: Aetna Medicare	$1,414.89
Rate for Payer: BCBS MT CHIP	$1,414.89
Rate for Payer: BCBS MT Closed Plan Network	$1,493.49
Rate for Payer: BCBS MT HealthLink	$1,414.89
Rate for Payer: BCBS MT Medicare	$1,414.89
Rate for Payer: BCBS MT POS	$1,493.49
Rate for Payer: BCBS MT Traditional	$1,572.10
Rate for Payer: Cash Price	$1,414.89
Rate for Payer: Cigna Commercial	$1,493.49
Rate for Payer: Cigna Medicare	$1,414.89
Rate for Payer: Medicaid All Medicaid	$1,446.33
Rate for Payer: Medicare All Medicare	$1,100.47
Rate for Payer: Monida Allegiance	$1,493.49
Rate for Payer: Monida First Choice Health	$1,524.94
Rate for Payer: Monida Montana Health Co-op	$1,493.49
Rate for Payer: Monida PacificSource	$1,493.49

XX SEMAGLUTIDE SUBQ [0.68MG/ML]

Facility

$1,628.00

Service Code	NDC 00169418113
Hospital Charge Code	3007393
Hospital Revenue Code	250
Min. Negotiated Rate	$1,139.60
Max. Negotiated Rate	$1,628.00
Rate for Payer: Aetna Commercial	$1,546.60
Rate for Payer: Aetna Medicare	$1,465.20
Rate for Payer: BCBS MT CHIP	$1,465.20
Rate for Payer: BCBS MT Closed Plan Network	$1,546.60
Rate for Payer: BCBS MT HealthLink	$1,465.20
Rate for Payer: BCBS MT Medicare	$1,465.20
Rate for Payer: BCBS MT POS	$1,546.60
Rate for Payer: BCBS MT Traditional	$1,628.00
Rate for Payer: Cash Price	$1,465.20
Rate for Payer: Cigna Commercial	$1,546.60
Rate for Payer: Cigna Medicare	$1,465.20
Rate for Payer: Medicaid All Medicaid	$1,497.76
Rate for Payer: Medicare All Medicare	$1,139.60
Rate for Payer: Monida Allegiance	$1,546.60
Rate for Payer: Monida First Choice Health	$1,579.16
Rate for Payer: Monida Montana Health Co-op	$1,546.60
Rate for Payer: Monida PacificSource	$1,546.60

XX SEMAGLUTIDE SUBQ [0.68MG/ML]

Facility

$1,628.00

Service Code	NDC 00169418113
Hospital Charge Code	3007393
Hospital Revenue Code	250
Min. Negotiated Rate	$1,139.60
Max. Negotiated Rate	$1,628.00
Rate for Payer: Aetna Commercial	$1,546.60
Rate for Payer: Aetna Medicare	$1,465.20
Rate for Payer: BCBS MT CHIP	$1,465.20
Rate for Payer: BCBS MT Closed Plan Network	$1,546.60
Rate for Payer: BCBS MT HealthLink	$1,465.20
Rate for Payer: BCBS MT Medicare	$1,465.20
Rate for Payer: BCBS MT POS	$1,546.60
Rate for Payer: BCBS MT Traditional	$1,628.00
Rate for Payer: Cash Price	$1,465.20
Rate for Payer: Cigna Commercial	$1,546.60
Rate for Payer: Cigna Medicare	$1,465.20
Rate for Payer: Medicaid All Medicaid	$1,497.76
Rate for Payer: Medicare All Medicare	$1,139.60
Rate for Payer: Monida Allegiance	$1,546.60
Rate for Payer: Monida First Choice Health	$1,579.16
Rate for Payer: Monida Montana Health Co-op	$1,546.60
Rate for Payer: Monida PacificSource	$1,546.60

XX TRESIBA 100U/1ML INJ 10ML

Facility

$726.00

Service Code	NDC 00169266211
Hospital Charge Code	3007217
Hospital Revenue Code	250
Min. Negotiated Rate	$508.20
Max. Negotiated Rate	$726.00
Rate for Payer: Aetna Commercial	$689.70
Rate for Payer: Aetna Medicare	$653.40
Rate for Payer: BCBS MT CHIP	$653.40
Rate for Payer: BCBS MT Closed Plan Network	$689.70
Rate for Payer: BCBS MT HealthLink	$653.40
Rate for Payer: BCBS MT Medicare	$653.40
Rate for Payer: BCBS MT POS	$689.70
Rate for Payer: BCBS MT Traditional	$726.00
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cigna Commercial	$689.70
Rate for Payer: Cigna Medicare	$653.40
Rate for Payer: Medicaid All Medicaid	$667.92
Rate for Payer: Medicare All Medicare	$508.20
Rate for Payer: Monida Allegiance	$689.70
Rate for Payer: Monida First Choice Health	$704.22
Rate for Payer: Monida Montana Health Co-op	$689.70
Rate for Payer: Monida PacificSource	$689.70

XX TRESIBA 100U/1ML INJ 10ML

Facility

$726.00

Service Code	NDC 00169266211
Hospital Charge Code	3007217
Hospital Revenue Code	250
Min. Negotiated Rate	$508.20
Max. Negotiated Rate	$726.00
Rate for Payer: Aetna Commercial	$689.70
Rate for Payer: Aetna Medicare	$653.40
Rate for Payer: BCBS MT CHIP	$653.40
Rate for Payer: BCBS MT Closed Plan Network	$689.70
Rate for Payer: BCBS MT HealthLink	$653.40
Rate for Payer: BCBS MT Medicare	$653.40
Rate for Payer: BCBS MT POS	$689.70
Rate for Payer: BCBS MT Traditional	$726.00
Rate for Payer: Cash Price	$653.40
Rate for Payer: Cigna Commercial	$689.70
Rate for Payer: Cigna Medicare	$653.40
Rate for Payer: Medicaid All Medicaid	$667.92
Rate for Payer: Medicare All Medicare	$508.20
Rate for Payer: Monida Allegiance	$689.70
Rate for Payer: Monida First Choice Health	$704.22
Rate for Payer: Monida Montana Health Co-op	$689.70
Rate for Payer: Monida PacificSource	$689.70

xxVITAMIN E [180 MG]

Facility

$71.00

Service Code	HCPCS 84446
Hospital Charge Code	4084446
Hospital Revenue Code	301
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

Know your out-of-pocket cost for care.

All Charges