Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

VAC - INFLUENZA INTRANASAL 0.2 ML

Facility

$99.00

Service Code	CPT 90660
Hospital Charge Code	8007028
Hospital Revenue Code	521
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

VAC - INFLUENZA INTRANASAL 0.2 ML

Facility

$99.00

Service Code	CPT 90660
Hospital Charge Code	8007028
Hospital Revenue Code	521
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

VAC - INFLUENZA REGULAR DOSE HOSP

Facility

$26.00

Service Code	CPT 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	CPT 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 - KINRIX - DTaP-IPV INJ [0.5 ML]

Facility

$282.00

Service Code	CPT 90696
Hospital Charge Code	8007022
Hospital Revenue Code	521
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

VAC - KINRIX - DTaP-IPV INJ [0.5 ML]

Facility

$282.00

Service Code	CPT 90696
Hospital Charge Code	8007022
Hospital Revenue Code	521
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

VAC - MEASLES, MUMPS & RUBELLA

Facility

$35.00

Service Code	CPT 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	CPT 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 - MENQUADFI - MENINGOCOCCAL [0.5 ML]

Facility

$576.00

Service Code	CPT 90619
Hospital Charge Code	8007030
Hospital Revenue Code	521
Min. Negotiated Rate	$403.20
Max. Negotiated Rate	$576.00
Rate for Payer: Aetna Commercial	$547.20
Rate for Payer: Aetna Medicare	$518.40
Rate for Payer: BCBS MT CHIP	$518.40
Rate for Payer: BCBS MT Closed Plan Network	$547.20
Rate for Payer: BCBS MT HealthLink	$518.40
Rate for Payer: BCBS MT Medicare	$518.40
Rate for Payer: BCBS MT POS	$547.20
Rate for Payer: BCBS MT Traditional	$576.00
Rate for Payer: Cash Price	$518.40
Rate for Payer: Cigna Commercial	$547.20
Rate for Payer: Cigna Medicare	$518.40
Rate for Payer: Medicaid All Medicaid	$529.92
Rate for Payer: Medicare All Medicare	$403.20
Rate for Payer: Monida Allegiance	$547.20
Rate for Payer: Monida First Choice Health	$558.72
Rate for Payer: Monida Montana Health Co-op	$547.20
Rate for Payer: Monida PacificSource	$547.20

VAC - MENQUADFI - MENINGOCOCCAL [0.5 ML]

Facility

$576.00

Service Code	CPT 90619
Hospital Charge Code	8007030
Hospital Revenue Code	521
Min. Negotiated Rate	$403.20
Max. Negotiated Rate	$576.00
Rate for Payer: Aetna Commercial	$547.20
Rate for Payer: Aetna Medicare	$518.40
Rate for Payer: BCBS MT CHIP	$518.40
Rate for Payer: BCBS MT Closed Plan Network	$547.20
Rate for Payer: BCBS MT HealthLink	$518.40
Rate for Payer: BCBS MT Medicare	$518.40
Rate for Payer: BCBS MT POS	$547.20
Rate for Payer: BCBS MT Traditional	$576.00
Rate for Payer: Cash Price	$518.40
Rate for Payer: Cigna Commercial	$547.20
Rate for Payer: Cigna Medicare	$518.40
Rate for Payer: Medicaid All Medicaid	$529.92
Rate for Payer: Medicare All Medicare	$403.20
Rate for Payer: Monida Allegiance	$547.20
Rate for Payer: Monida First Choice Health	$558.72
Rate for Payer: Monida Montana Health Co-op	$547.20
Rate for Payer: Monida PacificSource	$547.20

VAC - Novavax COVID-19 Vaccine, [0.5ML]

Facility

$34.00

Service Code	CPT 91304
Hospital Charge Code	8007087
Hospital Revenue Code	521
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

VAC - Novavax COVID-19 Vaccine, [0.5ML]

Facility

$34.00

Service Code	CPT 91304
Hospital Charge Code	8007087
Hospital Revenue Code	521
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

VAC - PEDIARIX TaP-Hepatitis B Recom-IPV

Facility

$374.00

Service Code	CPT 90723
Hospital Charge Code	8007021
Hospital Revenue Code	521
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

VAC - PEDIARIX TaP-Hepatitis B Recom-IPV

Facility

$374.00

Service Code	CPT 90723
Hospital Charge Code	8007021
Hospital Revenue Code	521
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

VAC - PENTACEL DTaP-IPV-Hib INJ [0.5 ML]

Facility

$451.00

Service Code	CPT 90698
Hospital Charge Code	8007023
Hospital Revenue Code	521
Min. Negotiated Rate	$315.70
Max. Negotiated Rate	$451.00
Rate for Payer: Aetna Commercial	$428.45
Rate for Payer: Aetna Medicare	$405.90
Rate for Payer: BCBS MT CHIP	$405.90
Rate for Payer: BCBS MT Closed Plan Network	$428.45
Rate for Payer: BCBS MT HealthLink	$405.90
Rate for Payer: BCBS MT Medicare	$405.90
Rate for Payer: BCBS MT POS	$428.45
Rate for Payer: BCBS MT Traditional	$451.00
Rate for Payer: Cash Price	$405.90
Rate for Payer: Cigna Commercial	$428.45
Rate for Payer: Cigna Medicare	$405.90
Rate for Payer: Medicaid All Medicaid	$414.92
Rate for Payer: Medicare All Medicare	$315.70
Rate for Payer: Monida Allegiance	$428.45
Rate for Payer: Monida First Choice Health	$437.47
Rate for Payer: Monida Montana Health Co-op	$428.45
Rate for Payer: Monida PacificSource	$428.45

VAC - PENTACEL DTaP-IPV-Hib INJ [0.5 ML]

Facility

$451.00

Service Code	CPT 90698
Hospital Charge Code	8007023
Hospital Revenue Code	521
Min. Negotiated Rate	$315.70
Max. Negotiated Rate	$451.00
Rate for Payer: Aetna Commercial	$428.45
Rate for Payer: Aetna Medicare	$405.90
Rate for Payer: BCBS MT CHIP	$405.90
Rate for Payer: BCBS MT Closed Plan Network	$428.45
Rate for Payer: BCBS MT HealthLink	$405.90
Rate for Payer: BCBS MT Medicare	$405.90
Rate for Payer: BCBS MT POS	$428.45
Rate for Payer: BCBS MT Traditional	$451.00
Rate for Payer: Cash Price	$405.90
Rate for Payer: Cigna Commercial	$428.45
Rate for Payer: Cigna Medicare	$405.90
Rate for Payer: Medicaid All Medicaid	$414.92
Rate for Payer: Medicare All Medicare	$315.70
Rate for Payer: Monida Allegiance	$428.45
Rate for Payer: Monida First Choice Health	$437.47
Rate for Payer: Monida Montana Health Co-op	$428.45
Rate for Payer: Monida PacificSource	$428.45

VAC - PNEUMOCOCCAL 13 [1 ML]

Facility

$663.00

Service Code	CPT 90670
Hospital Charge Code	8007032
Hospital Revenue Code	521
Min. Negotiated Rate	$464.10
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Commercial	$629.85
Rate for Payer: Aetna Medicare	$596.70
Rate for Payer: BCBS MT CHIP	$596.70
Rate for Payer: BCBS MT Closed Plan Network	$629.85
Rate for Payer: BCBS MT HealthLink	$596.70
Rate for Payer: BCBS MT Medicare	$596.70
Rate for Payer: BCBS MT POS	$629.85
Rate for Payer: BCBS MT Traditional	$663.00
Rate for Payer: Cash Price	$596.70
Rate for Payer: Cigna Commercial	$629.85
Rate for Payer: Cigna Medicare	$596.70
Rate for Payer: Medicaid All Medicaid	$609.96
Rate for Payer: Medicare All Medicare	$464.10
Rate for Payer: Monida Allegiance	$629.85
Rate for Payer: Monida First Choice Health	$643.11
Rate for Payer: Monida Montana Health Co-op	$629.85
Rate for Payer: Monida PacificSource	$629.85

VAC - PNEUMOCOCCAL 13 [1 ML]

Facility

$663.00

Service Code	CPT 90670
Hospital Charge Code	8007032
Hospital Revenue Code	521
Min. Negotiated Rate	$464.10
Max. Negotiated Rate	$663.00
Rate for Payer: Aetna Commercial	$629.85
Rate for Payer: Aetna Medicare	$596.70
Rate for Payer: BCBS MT CHIP	$596.70
Rate for Payer: BCBS MT Closed Plan Network	$629.85
Rate for Payer: BCBS MT HealthLink	$596.70
Rate for Payer: BCBS MT Medicare	$596.70
Rate for Payer: BCBS MT POS	$629.85
Rate for Payer: BCBS MT Traditional	$663.00
Rate for Payer: Cash Price	$596.70
Rate for Payer: Cigna Commercial	$629.85
Rate for Payer: Cigna Medicare	$596.70
Rate for Payer: Medicaid All Medicaid	$609.96
Rate for Payer: Medicare All Medicare	$464.10
Rate for Payer: Monida Allegiance	$629.85
Rate for Payer: Monida First Choice Health	$643.11
Rate for Payer: Monida Montana Health Co-op	$629.85
Rate for Payer: Monida PacificSource	$629.85

VAC - PNEUMOCOCCAL 20 (0.5 ML)

Facility

$614.00

Service Code	CPT 90677
Hospital Charge Code	8007070
Hospital Revenue Code	521
Min. Negotiated Rate	$429.80
Max. Negotiated Rate	$614.00
Rate for Payer: Aetna Commercial	$583.30
Rate for Payer: Aetna Medicare	$552.60
Rate for Payer: BCBS MT CHIP	$552.60
Rate for Payer: BCBS MT Closed Plan Network	$583.30
Rate for Payer: BCBS MT HealthLink	$552.60
Rate for Payer: BCBS MT Medicare	$552.60
Rate for Payer: BCBS MT POS	$583.30
Rate for Payer: BCBS MT Traditional	$614.00
Rate for Payer: Cash Price	$552.60
Rate for Payer: Cigna Commercial	$583.30
Rate for Payer: Cigna Medicare	$552.60
Rate for Payer: Medicaid All Medicaid	$564.88
Rate for Payer: Medicare All Medicare	$429.80
Rate for Payer: Monida Allegiance	$583.30
Rate for Payer: Monida First Choice Health	$595.58
Rate for Payer: Monida Montana Health Co-op	$583.30
Rate for Payer: Monida PacificSource	$583.30

VAC - PNEUMOCOCCAL 20 (0.5 ML)

Facility

$614.00

Service Code	CPT 90677
Hospital Charge Code	8007070
Hospital Revenue Code	521
Min. Negotiated Rate	$429.80
Max. Negotiated Rate	$614.00
Rate for Payer: Aetna Commercial	$583.30
Rate for Payer: Aetna Medicare	$552.60
Rate for Payer: BCBS MT CHIP	$552.60
Rate for Payer: BCBS MT Closed Plan Network	$583.30
Rate for Payer: BCBS MT HealthLink	$552.60
Rate for Payer: BCBS MT Medicare	$552.60
Rate for Payer: BCBS MT POS	$583.30
Rate for Payer: BCBS MT Traditional	$614.00
Rate for Payer: Cash Price	$552.60
Rate for Payer: Cigna Commercial	$583.30
Rate for Payer: Cigna Medicare	$552.60
Rate for Payer: Medicaid All Medicaid	$564.88
Rate for Payer: Medicare All Medicare	$429.80
Rate for Payer: Monida Allegiance	$583.30
Rate for Payer: Monida First Choice Health	$595.58
Rate for Payer: Monida Montana Health Co-op	$583.30
Rate for Payer: Monida PacificSource	$583.30

VAC - PNEUMOCOCCAL 20 (0.5 ML) - MEDICAR

Facility

$614.00

Service Code	CPT 90677
Hospital Charge Code	8007073
Hospital Revenue Code	521
Min. Negotiated Rate	$429.80
Max. Negotiated Rate	$614.00
Rate for Payer: Aetna Commercial	$583.30
Rate for Payer: Aetna Medicare	$552.60
Rate for Payer: BCBS MT CHIP	$552.60
Rate for Payer: BCBS MT Closed Plan Network	$583.30
Rate for Payer: BCBS MT HealthLink	$552.60
Rate for Payer: BCBS MT Medicare	$552.60
Rate for Payer: BCBS MT POS	$583.30
Rate for Payer: BCBS MT Traditional	$614.00
Rate for Payer: Cash Price	$552.60
Rate for Payer: Cigna Commercial	$583.30
Rate for Payer: Cigna Medicare	$552.60
Rate for Payer: Medicaid All Medicaid	$564.88
Rate for Payer: Medicare All Medicare	$429.80
Rate for Payer: Monida Allegiance	$583.30
Rate for Payer: Monida First Choice Health	$595.58
Rate for Payer: Monida Montana Health Co-op	$583.30
Rate for Payer: Monida PacificSource	$583.30

VAC - PNEUMOCOCCAL 20 (0.5 ML) - MEDICAR

Facility

$614.00

Service Code	CPT 90677
Hospital Charge Code	8007073
Hospital Revenue Code	521
Min. Negotiated Rate	$429.80
Max. Negotiated Rate	$614.00
Rate for Payer: Aetna Commercial	$583.30
Rate for Payer: Aetna Medicare	$552.60
Rate for Payer: BCBS MT CHIP	$552.60
Rate for Payer: BCBS MT Closed Plan Network	$583.30
Rate for Payer: BCBS MT HealthLink	$552.60
Rate for Payer: BCBS MT Medicare	$552.60
Rate for Payer: BCBS MT POS	$583.30
Rate for Payer: BCBS MT Traditional	$614.00
Rate for Payer: Cash Price	$552.60
Rate for Payer: Cigna Commercial	$583.30
Rate for Payer: Cigna Medicare	$552.60
Rate for Payer: Medicaid All Medicaid	$564.88
Rate for Payer: Medicare All Medicare	$429.80
Rate for Payer: Monida Allegiance	$583.30
Rate for Payer: Monida First Choice Health	$595.58
Rate for Payer: Monida Montana Health Co-op	$583.30
Rate for Payer: Monida PacificSource	$583.30

VAC - PNEUMOVAX 23 INJ [0.5 ML]

Facility

$450.00

Service Code	CPT 90732
Hospital Charge Code	8007033
Hospital Revenue Code	521
Min. Negotiated Rate	$315.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$427.50
Rate for Payer: Aetna Medicare	$405.00
Rate for Payer: BCBS MT CHIP	$405.00
Rate for Payer: BCBS MT Closed Plan Network	$427.50
Rate for Payer: BCBS MT HealthLink	$405.00
Rate for Payer: BCBS MT Medicare	$405.00
Rate for Payer: BCBS MT POS	$427.50
Rate for Payer: BCBS MT Traditional	$450.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Cigna Commercial	$427.50
Rate for Payer: Cigna Medicare	$405.00
Rate for Payer: Medicaid All Medicaid	$414.00
Rate for Payer: Medicare All Medicare	$315.00
Rate for Payer: Monida Allegiance	$427.50
Rate for Payer: Monida First Choice Health	$436.50
Rate for Payer: Monida Montana Health Co-op	$427.50
Rate for Payer: Monida PacificSource	$427.50

VAC - PNEUMOVAX 23 INJ [0.5 ML]

Facility

$450.00

Service Code	CPT 90732
Hospital Charge Code	8007033
Hospital Revenue Code	521
Min. Negotiated Rate	$315.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna Commercial	$427.50
Rate for Payer: Aetna Medicare	$405.00
Rate for Payer: BCBS MT CHIP	$405.00
Rate for Payer: BCBS MT Closed Plan Network	$427.50
Rate for Payer: BCBS MT HealthLink	$405.00
Rate for Payer: BCBS MT Medicare	$405.00
Rate for Payer: BCBS MT POS	$427.50
Rate for Payer: BCBS MT Traditional	$450.00
Rate for Payer: Cash Price	$405.00
Rate for Payer: Cigna Commercial	$427.50
Rate for Payer: Cigna Medicare	$405.00
Rate for Payer: Medicaid All Medicaid	$414.00
Rate for Payer: Medicare All Medicare	$315.00
Rate for Payer: Monida Allegiance	$427.50
Rate for Payer: Monida First Choice Health	$436.50
Rate for Payer: Monida Montana Health Co-op	$427.50
Rate for Payer: Monida PacificSource	$427.50

VAC - PROQUAD - MMR-VARICELLA [0.5 ML]

Facility

$633.00

Service Code	CPT 90710
Hospital Charge Code	8007031
Hospital Revenue Code	521
Min. Negotiated Rate	$443.10
Max. Negotiated Rate	$633.00
Rate for Payer: Aetna Commercial	$601.35
Rate for Payer: Aetna Medicare	$569.70
Rate for Payer: BCBS MT CHIP	$569.70
Rate for Payer: BCBS MT Closed Plan Network	$601.35
Rate for Payer: BCBS MT HealthLink	$569.70
Rate for Payer: BCBS MT Medicare	$569.70
Rate for Payer: BCBS MT POS	$601.35
Rate for Payer: BCBS MT Traditional	$633.00
Rate for Payer: Cash Price	$569.70
Rate for Payer: Cigna Commercial	$601.35
Rate for Payer: Cigna Medicare	$569.70
Rate for Payer: Medicaid All Medicaid	$582.36
Rate for Payer: Medicare All Medicare	$443.10
Rate for Payer: Monida Allegiance	$601.35
Rate for Payer: Monida First Choice Health	$614.01
Rate for Payer: Monida Montana Health Co-op	$601.35
Rate for Payer: Monida PacificSource	$601.35

Know your out-of-pocket cost for care.

All Charges