Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

VISCOSITY, SERUM (004861)

Facility

$67.00

Service Code	CPT 85810
Hospital Charge Code	4085810
Hospital Revenue Code	300
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

VISTA RAK 1250 UL PIPET TIP

Facility

$113.72

Hospital Charge Code	90197182
Hospital Revenue Code	270
Min. Negotiated Rate	$79.60
Max. Negotiated Rate	$113.72
Rate for Payer: Aetna Commercial	$108.03
Rate for Payer: Aetna Medicare	$102.35
Rate for Payer: BCBS MT CHIP	$102.35
Rate for Payer: BCBS MT Closed Plan Network	$108.03
Rate for Payer: BCBS MT HealthLink	$102.35
Rate for Payer: BCBS MT Medicare	$102.35
Rate for Payer: BCBS MT POS	$108.03
Rate for Payer: BCBS MT Traditional	$113.72
Rate for Payer: Cash Price	$102.35
Rate for Payer: Cigna Commercial	$108.03
Rate for Payer: Cigna Medicare	$102.35
Rate for Payer: Medicaid All Medicaid	$104.62
Rate for Payer: Medicare All Medicare	$79.60
Rate for Payer: Monida Allegiance	$108.03
Rate for Payer: Monida First Choice Health	$110.31
Rate for Payer: Monida Montana Health Co-op	$108.03
Rate for Payer: Monida PacificSource	$108.03

VISTA RAK 1250 UL PIPET TIP

Facility

$113.72

Hospital Charge Code	90197182
Hospital Revenue Code	270
Min. Negotiated Rate	$79.60
Max. Negotiated Rate	$113.72
Rate for Payer: Aetna Commercial	$108.03
Rate for Payer: Aetna Medicare	$102.35
Rate for Payer: BCBS MT CHIP	$102.35
Rate for Payer: BCBS MT Closed Plan Network	$108.03
Rate for Payer: BCBS MT HealthLink	$102.35
Rate for Payer: BCBS MT Medicare	$102.35
Rate for Payer: BCBS MT POS	$108.03
Rate for Payer: BCBS MT Traditional	$113.72
Rate for Payer: Cash Price	$102.35
Rate for Payer: Cigna Commercial	$108.03
Rate for Payer: Cigna Medicare	$102.35
Rate for Payer: Medicaid All Medicaid	$104.62
Rate for Payer: Medicare All Medicare	$79.60
Rate for Payer: Monida Allegiance	$108.03
Rate for Payer: Monida First Choice Health	$110.31
Rate for Payer: Monida Montana Health Co-op	$108.03
Rate for Payer: Monida PacificSource	$108.03

VITAMIN A (017509)

Facility

$67.00

Service Code	CPT 84590
Hospital Charge Code	4084590
Hospital Revenue Code	301
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

VITAMIN A (017509)

Facility

$67.00

Service Code	CPT 84590
Hospital Charge Code	4084590
Hospital Revenue Code	301
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

VITAMIN A & D OINT 1.5OZ

Facility

$11.00

Service Code	HCPCS A9150
Hospital Charge Code	3000478
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

VITAMIN A & D OINT 1.5OZ

Facility

$11.00

Service Code	HCPCS A9150
Hospital Charge Code	3000478
Hospital Revenue Code	250
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

VITAMIN A & D OINT [5 GM] PACKET

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3000618
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN A & D OINT [5 GM] PACKET

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3000618
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN B12 (001503)

Facility

$119.00

Service Code	CPT 82607
Hospital Charge Code	4082607
Hospital Revenue Code	301
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$119.00
Rate for Payer: Aetna Commercial	$113.05
Rate for Payer: Aetna Medicare	$107.10
Rate for Payer: BCBS MT CHIP	$107.10
Rate for Payer: BCBS MT Closed Plan Network	$113.05
Rate for Payer: BCBS MT HealthLink	$107.10
Rate for Payer: BCBS MT Medicare	$107.10
Rate for Payer: BCBS MT POS	$113.05
Rate for Payer: BCBS MT Traditional	$119.00
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cigna Commercial	$113.05
Rate for Payer: Cigna Medicare	$107.10
Rate for Payer: Medicaid All Medicaid	$109.48
Rate for Payer: Medicare All Medicare	$83.30
Rate for Payer: Monida Allegiance	$113.05
Rate for Payer: Monida First Choice Health	$115.43
Rate for Payer: Monida Montana Health Co-op	$113.05
Rate for Payer: Monida PacificSource	$113.05

VITAMIN B12 (001503)

Facility

$119.00

Service Code	CPT 82607
Hospital Charge Code	4082607
Hospital Revenue Code	301
Min. Negotiated Rate	$83.30
Max. Negotiated Rate	$119.00
Rate for Payer: Aetna Commercial	$113.05
Rate for Payer: Aetna Medicare	$107.10
Rate for Payer: BCBS MT CHIP	$107.10
Rate for Payer: BCBS MT Closed Plan Network	$113.05
Rate for Payer: BCBS MT HealthLink	$107.10
Rate for Payer: BCBS MT Medicare	$107.10
Rate for Payer: BCBS MT POS	$113.05
Rate for Payer: BCBS MT Traditional	$119.00
Rate for Payer: Cash Price	$107.10
Rate for Payer: Cigna Commercial	$113.05
Rate for Payer: Cigna Medicare	$107.10
Rate for Payer: Medicaid All Medicaid	$109.48
Rate for Payer: Medicare All Medicare	$83.30
Rate for Payer: Monida Allegiance	$113.05
Rate for Payer: Monida First Choice Health	$115.43
Rate for Payer: Monida Montana Health Co-op	$113.05
Rate for Payer: Monida PacificSource	$113.05

VITAMIN B12 TAB [100 MCG] NF

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3007050
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN B12 TAB [100 MCG] NF

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3007050
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN B12 TAB [250 MCG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000574
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

VITAMIN B12 TAB [250 MCG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000574
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

VITAMIN B12 TAB [500 MCG] NF

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3007114
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

VITAMIN B12 TAB [500 MCG] NF

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3007114
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

VITAMIN B-1 TAB 100 MG

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3007138
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

VITAMIN B-1 TAB 100 MG

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3007138
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

VITAMIN B2 (123220)

Facility

$160.00

Service Code	CPT 84252
Hospital Charge Code	4084252
Hospital Revenue Code	300
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial	$152.00
Rate for Payer: Aetna Medicare	$144.00
Rate for Payer: BCBS MT CHIP	$144.00
Rate for Payer: BCBS MT Closed Plan Network	$152.00
Rate for Payer: BCBS MT HealthLink	$144.00
Rate for Payer: BCBS MT Medicare	$144.00
Rate for Payer: BCBS MT POS	$152.00
Rate for Payer: BCBS MT Traditional	$160.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna Commercial	$152.00
Rate for Payer: Cigna Medicare	$144.00
Rate for Payer: Medicaid All Medicaid	$147.20
Rate for Payer: Medicare All Medicare	$112.00
Rate for Payer: Monida Allegiance	$152.00
Rate for Payer: Monida First Choice Health	$155.20
Rate for Payer: Monida Montana Health Co-op	$152.00
Rate for Payer: Monida PacificSource	$152.00

VITAMIN B2 (123220)

Facility

$160.00

Service Code	CPT 84252
Hospital Charge Code	4084252
Hospital Revenue Code	300
Min. Negotiated Rate	$112.00
Max. Negotiated Rate	$160.00
Rate for Payer: Aetna Commercial	$152.00
Rate for Payer: Aetna Medicare	$144.00
Rate for Payer: BCBS MT CHIP	$144.00
Rate for Payer: BCBS MT Closed Plan Network	$152.00
Rate for Payer: BCBS MT HealthLink	$144.00
Rate for Payer: BCBS MT Medicare	$144.00
Rate for Payer: BCBS MT POS	$152.00
Rate for Payer: BCBS MT Traditional	$160.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cigna Commercial	$152.00
Rate for Payer: Cigna Medicare	$144.00
Rate for Payer: Medicaid All Medicaid	$147.20
Rate for Payer: Medicare All Medicare	$112.00
Rate for Payer: Monida Allegiance	$152.00
Rate for Payer: Monida First Choice Health	$155.20
Rate for Payer: Monida Montana Health Co-op	$152.00
Rate for Payer: Monida PacificSource	$152.00

VITAMIN B3 (070115)

Facility

$184.00

Service Code	CPT 84591
Hospital Charge Code	4084591
Hospital Revenue Code	301
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$184.00
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: BCBS MT CHIP	$165.60
Rate for Payer: BCBS MT Closed Plan Network	$174.80
Rate for Payer: BCBS MT HealthLink	$165.60
Rate for Payer: BCBS MT Medicare	$165.60
Rate for Payer: BCBS MT POS	$174.80
Rate for Payer: BCBS MT Traditional	$184.00
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial	$174.80
Rate for Payer: Cigna Medicare	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

VITAMIN B3 (070115)

Facility

$184.00

Service Code	CPT 84591
Hospital Charge Code	4084591
Hospital Revenue Code	301
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$184.00
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: BCBS MT CHIP	$165.60
Rate for Payer: BCBS MT Closed Plan Network	$174.80
Rate for Payer: BCBS MT HealthLink	$165.60
Rate for Payer: BCBS MT Medicare	$165.60
Rate for Payer: BCBS MT POS	$174.80
Rate for Payer: BCBS MT Traditional	$184.00
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial	$174.80
Rate for Payer: Cigna Medicare	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

VITAMIN B6 (004655)

Facility

$112.00

Service Code	CPT 84207
Hospital Charge Code	4084207
Hospital Revenue Code	301
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

VITAMIN B6 (004655)

Facility

$112.00

Service Code	CPT 84207
Hospital Charge Code	4084207
Hospital Revenue Code	301
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

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