Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

VAC - COVID PF COMIRNATY [.3 ML]

Facility

$201.00

Service Code	CPT 91320
Hospital Charge Code	8007071
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

VAC - COVID PF COMIRNATY [.3 ML]

Facility

$201.00

Service Code	CPT 91320
Hospital Charge Code	8007071
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

VAC - HAEMOPHILUS b CONJUGATE [0.5 ML]

Facility

$82.00

Service Code	CPT 90648
Hospital Charge Code	8007024
Hospital Revenue Code	521
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

VAC - HAEMOPHILUS b CONJUGATE [0.5 ML]

Facility

$82.00

Service Code	CPT 90648
Hospital Charge Code	8007024
Hospital Revenue Code	521
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

VAC - HEPATITIS A [720 U/0.5 ML] HAVRIX

Facility

$149.00

Service Code	CPT 90633
Hospital Charge Code	8007025
Hospital Revenue Code	521
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$149.00
Rate for Payer: Aetna Commercial	$141.55
Rate for Payer: Aetna Medicare	$134.10
Rate for Payer: BCBS MT CHIP	$134.10
Rate for Payer: BCBS MT Closed Plan Network	$141.55
Rate for Payer: BCBS MT HealthLink	$134.10
Rate for Payer: BCBS MT Medicare	$134.10
Rate for Payer: BCBS MT POS	$141.55
Rate for Payer: BCBS MT Traditional	$149.00
Rate for Payer: Cash Price	$134.10
Rate for Payer: Cigna Commercial	$141.55
Rate for Payer: Cigna Medicare	$134.10
Rate for Payer: Medicaid All Medicaid	$137.08
Rate for Payer: Medicare All Medicare	$104.30
Rate for Payer: Monida Allegiance	$141.55
Rate for Payer: Monida First Choice Health	$144.53
Rate for Payer: Monida Montana Health Co-op	$141.55
Rate for Payer: Monida PacificSource	$141.55

VAC - HEPATITIS A [720 U/0.5 ML] HAVRIX

Facility

$149.00

Service Code	CPT 90633
Hospital Charge Code	8007025
Hospital Revenue Code	521
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$149.00
Rate for Payer: Aetna Commercial	$141.55
Rate for Payer: Aetna Medicare	$134.10
Rate for Payer: BCBS MT CHIP	$134.10
Rate for Payer: BCBS MT Closed Plan Network	$141.55
Rate for Payer: BCBS MT HealthLink	$134.10
Rate for Payer: BCBS MT Medicare	$134.10
Rate for Payer: BCBS MT POS	$141.55
Rate for Payer: BCBS MT Traditional	$149.00
Rate for Payer: Cash Price	$134.10
Rate for Payer: Cigna Commercial	$141.55
Rate for Payer: Cigna Medicare	$134.10
Rate for Payer: Medicaid All Medicaid	$137.08
Rate for Payer: Medicare All Medicare	$104.30
Rate for Payer: Monida Allegiance	$141.55
Rate for Payer: Monida First Choice Health	$144.53
Rate for Payer: Monida Montana Health Co-op	$141.55
Rate for Payer: Monida PacificSource	$141.55

VAC - HEPATITIS B INJ [20 MCG/ML] ADULT

Facility

$271.00

Service Code	CPT 90746
Hospital Charge Code	8007026
Hospital Revenue Code	521
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$271.00
Rate for Payer: Aetna Commercial	$257.45
Rate for Payer: Aetna Medicare	$243.90
Rate for Payer: BCBS MT CHIP	$243.90
Rate for Payer: BCBS MT Closed Plan Network	$257.45
Rate for Payer: BCBS MT HealthLink	$243.90
Rate for Payer: BCBS MT Medicare	$243.90
Rate for Payer: BCBS MT POS	$257.45
Rate for Payer: BCBS MT Traditional	$271.00
Rate for Payer: Cash Price	$243.90
Rate for Payer: Cigna Commercial	$257.45
Rate for Payer: Cigna Medicare	$243.90
Rate for Payer: Medicaid All Medicaid	$249.32
Rate for Payer: Medicare All Medicare	$189.70
Rate for Payer: Monida Allegiance	$257.45
Rate for Payer: Monida First Choice Health	$262.87
Rate for Payer: Monida Montana Health Co-op	$257.45
Rate for Payer: Monida PacificSource	$257.45

VAC - HEPATITIS B INJ [20 MCG/ML] ADULT

Facility

$271.00

Service Code	CPT 90746
Hospital Charge Code	8007026
Hospital Revenue Code	521
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$271.00
Rate for Payer: Aetna Commercial	$257.45
Rate for Payer: Aetna Medicare	$243.90
Rate for Payer: BCBS MT CHIP	$243.90
Rate for Payer: BCBS MT Closed Plan Network	$257.45
Rate for Payer: BCBS MT HealthLink	$243.90
Rate for Payer: BCBS MT Medicare	$243.90
Rate for Payer: BCBS MT POS	$257.45
Rate for Payer: BCBS MT Traditional	$271.00
Rate for Payer: Cash Price	$243.90
Rate for Payer: Cigna Commercial	$257.45
Rate for Payer: Cigna Medicare	$243.90
Rate for Payer: Medicaid All Medicaid	$249.32
Rate for Payer: Medicare All Medicare	$189.70
Rate for Payer: Monida Allegiance	$257.45
Rate for Payer: Monida First Choice Health	$262.87
Rate for Payer: Monida Montana Health Co-op	$257.45
Rate for Payer: Monida PacificSource	$257.45

VAC - HEP B INJ 10MCG/0.5ml PEDIATRIC

Facility

$111.00

Service Code	CPT 90744
Hospital Charge Code	8007036
Hospital Revenue Code	521
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

VAC - HEP B INJ 10MCG/0.5ml PEDIATRIC

Facility

$111.00

Service Code	CPT 90744
Hospital Charge Code	8007036
Hospital Revenue Code	521
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

VAC - HUMAN PAPILLOMAVIRUS RECOMBINANT 9

Facility

$650.00

Service Code	CPT 90651
Hospital Charge Code	8007027
Hospital Revenue Code	521
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$650.00
Rate for Payer: Aetna Commercial	$617.50
Rate for Payer: Aetna Medicare	$585.00
Rate for Payer: BCBS MT CHIP	$585.00
Rate for Payer: BCBS MT Closed Plan Network	$617.50
Rate for Payer: BCBS MT HealthLink	$585.00
Rate for Payer: BCBS MT Medicare	$585.00
Rate for Payer: BCBS MT POS	$617.50
Rate for Payer: BCBS MT Traditional	$650.00
Rate for Payer: Cash Price	$585.00
Rate for Payer: Cigna Commercial	$617.50
Rate for Payer: Cigna Medicare	$585.00
Rate for Payer: Medicaid All Medicaid	$598.00
Rate for Payer: Medicare All Medicare	$455.00
Rate for Payer: Monida Allegiance	$617.50
Rate for Payer: Monida First Choice Health	$630.50
Rate for Payer: Monida Montana Health Co-op	$617.50
Rate for Payer: Monida PacificSource	$617.50

VAC - HUMAN PAPILLOMAVIRUS RECOMBINANT 9

Facility

$650.00

Service Code	CPT 90651
Hospital Charge Code	8007027
Hospital Revenue Code	521
Min. Negotiated Rate	$455.00
Max. Negotiated Rate	$650.00
Rate for Payer: Aetna Commercial	$617.50
Rate for Payer: Aetna Medicare	$585.00
Rate for Payer: BCBS MT CHIP	$585.00
Rate for Payer: BCBS MT Closed Plan Network	$617.50
Rate for Payer: BCBS MT HealthLink	$585.00
Rate for Payer: BCBS MT Medicare	$585.00
Rate for Payer: BCBS MT POS	$617.50
Rate for Payer: BCBS MT Traditional	$650.00
Rate for Payer: Cash Price	$585.00
Rate for Payer: Cigna Commercial	$617.50
Rate for Payer: Cigna Medicare	$585.00
Rate for Payer: Medicaid All Medicaid	$598.00
Rate for Payer: Medicare All Medicare	$455.00
Rate for Payer: Monida Allegiance	$617.50
Rate for Payer: Monida First Choice Health	$630.50
Rate for Payer: Monida Montana Health Co-op	$617.50
Rate for Payer: Monida PacificSource	$617.50

VAC - INFANRIX - DTap INJ [0.5ML]

Facility

$112.00

Service Code	CPT 90700
Hospital Charge Code	8007037
Hospital Revenue Code	521
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

VAC - INFANRIX - DTap INJ [0.5ML]

Facility

$112.00

Service Code	CPT 90700
Hospital Charge Code	8007037
Hospital Revenue Code	521
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

VAC - INFLUENZA EGG FREE CLINIC

Facility

$70.00

Service Code	CPT 90682
Hospital Charge Code	8007038
Hospital Revenue Code	521
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

VAC - INFLUENZA EGG FREE CLINIC

Facility

$70.00

Service Code	CPT 90682
Hospital Charge Code	8007038
Hospital Revenue Code	521
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

VAC - INFLUENZA EGG FREE HOSPITAL

Facility

$63.00

Service Code	CPT 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	CPT 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 FLUBLOK CLINIC (HD)

Facility

$97.00

Service Code	CPT 90673
Hospital Charge Code	8007039
Hospital Revenue Code	521
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$92.15
Rate for Payer: Aetna Medicare	$87.30
Rate for Payer: BCBS MT CHIP	$87.30
Rate for Payer: BCBS MT Closed Plan Network	$92.15
Rate for Payer: BCBS MT HealthLink	$87.30
Rate for Payer: BCBS MT Medicare	$87.30
Rate for Payer: BCBS MT POS	$92.15
Rate for Payer: BCBS MT Traditional	$97.00
Rate for Payer: Cash Price	$87.30
Rate for Payer: Cigna Commercial	$92.15
Rate for Payer: Cigna Medicare	$87.30
Rate for Payer: Medicaid All Medicaid	$89.24
Rate for Payer: Medicare All Medicare	$67.90
Rate for Payer: Monida Allegiance	$92.15
Rate for Payer: Monida First Choice Health	$94.09
Rate for Payer: Monida Montana Health Co-op	$92.15
Rate for Payer: Monida PacificSource	$92.15

VAC - INFLUENZA FLUBLOK CLINIC (HD)

Facility

$97.00

Service Code	CPT 90673
Hospital Charge Code	8007039
Hospital Revenue Code	521
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$92.15
Rate for Payer: Aetna Medicare	$87.30
Rate for Payer: BCBS MT CHIP	$87.30
Rate for Payer: BCBS MT Closed Plan Network	$92.15
Rate for Payer: BCBS MT HealthLink	$87.30
Rate for Payer: BCBS MT Medicare	$87.30
Rate for Payer: BCBS MT POS	$92.15
Rate for Payer: BCBS MT Traditional	$97.00
Rate for Payer: Cash Price	$87.30
Rate for Payer: Cigna Commercial	$92.15
Rate for Payer: Cigna Medicare	$87.30
Rate for Payer: Medicaid All Medicaid	$89.24
Rate for Payer: Medicare All Medicare	$67.90
Rate for Payer: Monida Allegiance	$92.15
Rate for Payer: Monida First Choice Health	$94.09
Rate for Payer: Monida Montana Health Co-op	$92.15
Rate for Payer: Monida PacificSource	$92.15

VAC - INFLUENZA FLUZONE CLINIC

Facility

$26.00

Service Code	CPT 90656
Hospital Charge Code	8007040
Hospital Revenue Code	521
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 FLUZONE CLINIC

Facility

$26.00

Service Code	CPT 90656
Hospital Charge Code	8007040
Hospital Revenue Code	521
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 HD HOSPITAL

Facility

$97.00

Service Code	CPT 90673
Hospital Charge Code	3000467
Hospital Revenue Code	636
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$92.15
Rate for Payer: Aetna Medicare	$87.30
Rate for Payer: BCBS MT CHIP	$87.30
Rate for Payer: BCBS MT Closed Plan Network	$92.15
Rate for Payer: BCBS MT HealthLink	$87.30
Rate for Payer: BCBS MT Medicare	$87.30
Rate for Payer: BCBS MT POS	$92.15
Rate for Payer: BCBS MT Traditional	$97.00
Rate for Payer: Cash Price	$87.30
Rate for Payer: Cigna Commercial	$92.15
Rate for Payer: Cigna Medicare	$87.30
Rate for Payer: Medicaid All Medicaid	$89.24
Rate for Payer: Medicare All Medicare	$67.90
Rate for Payer: Monida Allegiance	$92.15
Rate for Payer: Monida First Choice Health	$94.09
Rate for Payer: Monida Montana Health Co-op	$92.15
Rate for Payer: Monida PacificSource	$92.15

VAC - INFLUENZA HD HOSPITAL

Facility

$97.00

Service Code	CPT 90673
Hospital Charge Code	3000467
Hospital Revenue Code	636
Min. Negotiated Rate	$67.90
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$92.15
Rate for Payer: Aetna Medicare	$87.30
Rate for Payer: BCBS MT CHIP	$87.30
Rate for Payer: BCBS MT Closed Plan Network	$92.15
Rate for Payer: BCBS MT HealthLink	$87.30
Rate for Payer: BCBS MT Medicare	$87.30
Rate for Payer: BCBS MT POS	$92.15
Rate for Payer: BCBS MT Traditional	$97.00
Rate for Payer: Cash Price	$87.30
Rate for Payer: Cigna Commercial	$92.15
Rate for Payer: Cigna Medicare	$87.30
Rate for Payer: Medicaid All Medicaid	$89.24
Rate for Payer: Medicare All Medicare	$67.90
Rate for Payer: Monida Allegiance	$92.15
Rate for Payer: Monida First Choice Health	$94.09
Rate for Payer: Monida Montana Health Co-op	$92.15
Rate for Payer: Monida PacificSource	$92.15

Know your out-of-pocket cost for care.

All Charges