Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US TRANSVAGINAL US OBSTETRIC

Facility

$348.00

Service Code	CPT 76817
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	CPT 76817
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	CPT 76857
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	CPT 76857
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	CPT 76776
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	CPT 76776
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 VENOUS DOPP LOWER EXT BIILATERAL

Facility

$735.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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 DUPLEX W/ INSUFFICIENCY BILAT

Facility

$735.00

Service Code	CPT 93970
Hospital Charge Code	5193924
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 DUPLEX W/ INSUFFICIENCY BILAT

Facility

$735.00

Service Code	CPT 93970
Hospital Charge Code	5193924
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 DUPLEX W/ INSUFFICIENCY UNILAT

Facility

$490.00

Service Code	CPT 93971
Hospital Charge Code	5193923
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 DUPLEX W/ INSUFFICIENCY UNILAT

Facility

$490.00

Service Code	CPT 93971
Hospital Charge Code	5193923
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

UZTEKINUMAB QUANTI WITH ANTIBODIES

Facility

$375.00

Service Code	CPT 80299
Hospital Charge Code	4008034
Hospital Revenue Code	302
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

UZTEKINUMAB QUANTI WITH ANTIBODIES

Facility

$375.00

Service Code	CPT 80299
Hospital Charge Code	4008034
Hospital Revenue Code	302
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

VAC - Beyfortus IM Soln 100MG/1ML

Facility

$901.00

Service Code	CPT 90381
Hospital Charge Code	8007083
Hospital Revenue Code	521
Min. Negotiated Rate	$630.70
Max. Negotiated Rate	$901.00
Rate for Payer: Aetna Commercial	$855.95
Rate for Payer: Aetna Medicare	$810.90
Rate for Payer: BCBS MT CHIP	$810.90
Rate for Payer: BCBS MT Closed Plan Network	$855.95
Rate for Payer: BCBS MT HealthLink	$810.90
Rate for Payer: BCBS MT Medicare	$810.90
Rate for Payer: BCBS MT POS	$855.95
Rate for Payer: BCBS MT Traditional	$901.00
Rate for Payer: Cash Price	$810.90
Rate for Payer: Cigna Commercial	$855.95
Rate for Payer: Cigna Medicare	$810.90
Rate for Payer: Medicaid All Medicaid	$828.92
Rate for Payer: Medicare All Medicare	$630.70
Rate for Payer: Monida Allegiance	$855.95
Rate for Payer: Monida First Choice Health	$873.97
Rate for Payer: Monida Montana Health Co-op	$855.95
Rate for Payer: Monida PacificSource	$855.95

VAC - Beyfortus IM Soln 100MG/1ML

Facility

$901.00

Service Code	CPT 90381
Hospital Charge Code	8007083
Hospital Revenue Code	521
Min. Negotiated Rate	$630.70
Max. Negotiated Rate	$901.00
Rate for Payer: Aetna Commercial	$855.95
Rate for Payer: Aetna Medicare	$810.90
Rate for Payer: BCBS MT CHIP	$810.90
Rate for Payer: BCBS MT Closed Plan Network	$855.95
Rate for Payer: BCBS MT HealthLink	$810.90
Rate for Payer: BCBS MT Medicare	$810.90
Rate for Payer: BCBS MT POS	$855.95
Rate for Payer: BCBS MT Traditional	$901.00
Rate for Payer: Cash Price	$810.90
Rate for Payer: Cigna Commercial	$855.95
Rate for Payer: Cigna Medicare	$810.90
Rate for Payer: Medicaid All Medicaid	$828.92
Rate for Payer: Medicare All Medicare	$630.70
Rate for Payer: Monida Allegiance	$855.95
Rate for Payer: Monida First Choice Health	$873.97
Rate for Payer: Monida Montana Health Co-op	$855.95
Rate for Payer: Monida PacificSource	$855.95

VAC - Beyfortus IM Soln 50MG/0.5ML

Facility

$901.00

Service Code	CPT 90380
Hospital Charge Code	8007082
Hospital Revenue Code	521
Min. Negotiated Rate	$630.70
Max. Negotiated Rate	$901.00
Rate for Payer: Aetna Commercial	$855.95
Rate for Payer: Aetna Medicare	$810.90
Rate for Payer: BCBS MT CHIP	$810.90
Rate for Payer: BCBS MT Closed Plan Network	$855.95
Rate for Payer: BCBS MT HealthLink	$810.90
Rate for Payer: BCBS MT Medicare	$810.90
Rate for Payer: BCBS MT POS	$855.95
Rate for Payer: BCBS MT Traditional	$901.00
Rate for Payer: Cash Price	$810.90
Rate for Payer: Cigna Commercial	$855.95
Rate for Payer: Cigna Medicare	$810.90
Rate for Payer: Medicaid All Medicaid	$828.92
Rate for Payer: Medicare All Medicare	$630.70
Rate for Payer: Monida Allegiance	$855.95
Rate for Payer: Monida First Choice Health	$873.97
Rate for Payer: Monida Montana Health Co-op	$855.95
Rate for Payer: Monida PacificSource	$855.95

VAC - Beyfortus IM Soln 50MG/0.5ML

Facility

$901.00

Service Code	CPT 90380
Hospital Charge Code	8007082
Hospital Revenue Code	521
Min. Negotiated Rate	$630.70
Max. Negotiated Rate	$901.00
Rate for Payer: Aetna Commercial	$855.95
Rate for Payer: Aetna Medicare	$810.90
Rate for Payer: BCBS MT CHIP	$810.90
Rate for Payer: BCBS MT Closed Plan Network	$855.95
Rate for Payer: BCBS MT HealthLink	$810.90
Rate for Payer: BCBS MT Medicare	$810.90
Rate for Payer: BCBS MT POS	$855.95
Rate for Payer: BCBS MT Traditional	$901.00
Rate for Payer: Cash Price	$810.90
Rate for Payer: Cigna Commercial	$855.95
Rate for Payer: Cigna Medicare	$810.90
Rate for Payer: Medicaid All Medicaid	$828.92
Rate for Payer: Medicare All Medicare	$630.70
Rate for Payer: Monida Allegiance	$855.95
Rate for Payer: Monida First Choice Health	$873.97
Rate for Payer: Monida Montana Health Co-op	$855.95
Rate for Payer: Monida PacificSource	$855.95

VAC - COVID PF COMIRNAT - MEDICAR [.3ML]

Facility

$201.00

Service Code	CPT 91320
Hospital Charge Code	8007072
Hospital Revenue Code	521
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$201.00
Rate for Payer: Aetna Commercial	$190.95
Rate for Payer: Aetna Medicare	$180.90
Rate for Payer: BCBS MT CHIP	$180.90
Rate for Payer: BCBS MT Closed Plan Network	$190.95
Rate for Payer: BCBS MT HealthLink	$180.90
Rate for Payer: BCBS MT Medicare	$180.90
Rate for Payer: BCBS MT POS	$190.95
Rate for Payer: BCBS MT Traditional	$201.00
Rate for Payer: Cash Price	$180.90
Rate for Payer: Cigna Commercial	$190.95
Rate for Payer: Cigna Medicare	$180.90
Rate for Payer: Medicaid All Medicaid	$184.92
Rate for Payer: Medicare All Medicare	$140.70
Rate for Payer: Monida Allegiance	$190.95
Rate for Payer: Monida First Choice Health	$194.97
Rate for Payer: Monida Montana Health Co-op	$190.95
Rate for Payer: Monida PacificSource	$190.95

Know your out-of-pocket cost for care.

All Charges