Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ACTIN (SMOOTH MUSCLE) ANTIBODY (006643)

Facility

$83.00

Service Code	CPT 86015
Hospital Charge Code	4000255
Hospital Revenue Code	300
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

ACTIVATED CHARCOAL/SORBITOL SUSP [50 GM]

Facility

$76.00

Service Code	HCPCS J8499
Hospital Charge Code	3000009
Hospital Revenue Code	250
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

ACTIVATED CHARCOAL/SORBITOL SUSP [50 GM]

Facility

$76.00

Service Code	HCPCS J8499
Hospital Charge Code	3000009
Hospital Revenue Code	250
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

ACTIVATED CHARCOAL/WATER SUSP [50GM]

Facility

$76.00

Service Code	HCPCS J8499
Hospital Charge Code	3000010
Hospital Revenue Code	250
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

ACTIVATED CHARCOAL/WATER SUSP [50GM]

Facility

$76.00

Service Code	HCPCS J8499
Hospital Charge Code	3000010
Hospital Revenue Code	250
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$76.00
Rate for Payer: Aetna Commercial	$72.20
Rate for Payer: Aetna Medicare	$68.40
Rate for Payer: BCBS MT CHIP	$68.40
Rate for Payer: BCBS MT Closed Plan Network	$72.20
Rate for Payer: BCBS MT HealthLink	$68.40
Rate for Payer: BCBS MT Medicare	$68.40
Rate for Payer: BCBS MT POS	$72.20
Rate for Payer: BCBS MT Traditional	$76.00
Rate for Payer: Cash Price	$68.40
Rate for Payer: Cigna Commercial	$72.20
Rate for Payer: Cigna Medicare	$68.40
Rate for Payer: Medicaid All Medicaid	$69.92
Rate for Payer: Medicare All Medicare	$53.20
Rate for Payer: Monida Allegiance	$72.20
Rate for Payer: Monida First Choice Health	$73.72
Rate for Payer: Monida Montana Health Co-op	$72.20
Rate for Payer: Monida PacificSource	$72.20

ACUTE VIRAL HEPATITIS (144000)

Facility

$119.00

Service Code	CPT 80074
Hospital Charge Code	4080074
Hospital Revenue Code	300
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

ACUTE VIRAL HEPATITIS (144000)

Facility

$119.00

Service Code	CPT 80074
Hospital Charge Code	4080074
Hospital Revenue Code	300
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

ACYCLOVIR TAB [400 MG]

Facility

$12.00

Service Code	HCPCS J8499
Hospital Charge Code	3000011
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ACYCLOVIR TAB [400 MG]

Facility

$12.00

Service Code	HCPCS J8499
Hospital Charge Code	3000011
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ADAPALINE TOP GEL [0.3 %] NF

Facility

$589.00

Hospital Charge Code	3007646
Hospital Revenue Code	250
Min. Negotiated Rate	$412.30
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$559.55
Rate for Payer: Aetna Medicare	$530.10
Rate for Payer: BCBS MT CHIP	$530.10
Rate for Payer: BCBS MT Closed Plan Network	$559.55
Rate for Payer: BCBS MT HealthLink	$530.10
Rate for Payer: BCBS MT Medicare	$530.10
Rate for Payer: BCBS MT POS	$559.55
Rate for Payer: BCBS MT Traditional	$589.00
Rate for Payer: Cash Price	$530.10
Rate for Payer: Cigna Commercial	$559.55
Rate for Payer: Cigna Medicare	$530.10
Rate for Payer: Medicaid All Medicaid	$541.88
Rate for Payer: Medicare All Medicare	$412.30
Rate for Payer: Monida Allegiance	$559.55
Rate for Payer: Monida First Choice Health	$571.33
Rate for Payer: Monida Montana Health Co-op	$559.55
Rate for Payer: Monida PacificSource	$559.55

ADAPALINE TOP GEL [0.3 %] NF

Facility

$589.00

Hospital Charge Code	3007646
Hospital Revenue Code	250
Min. Negotiated Rate	$412.30
Max. Negotiated Rate	$589.00
Rate for Payer: Aetna Commercial	$559.55
Rate for Payer: Aetna Medicare	$530.10
Rate for Payer: BCBS MT CHIP	$530.10
Rate for Payer: BCBS MT Closed Plan Network	$559.55
Rate for Payer: BCBS MT HealthLink	$530.10
Rate for Payer: BCBS MT Medicare	$530.10
Rate for Payer: BCBS MT POS	$559.55
Rate for Payer: BCBS MT Traditional	$589.00
Rate for Payer: Cash Price	$530.10
Rate for Payer: Cigna Commercial	$559.55
Rate for Payer: Cigna Medicare	$530.10
Rate for Payer: Medicaid All Medicaid	$541.88
Rate for Payer: Medicare All Medicare	$412.30
Rate for Payer: Monida Allegiance	$559.55
Rate for Payer: Monida First Choice Health	$571.33
Rate for Payer: Monida Montana Health Co-op	$559.55
Rate for Payer: Monida PacificSource	$559.55

ADAPTIC DRESSING 3 X 8

Facility

$6.00

Hospital Charge Code	80030114
Hospital Revenue Code	270
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

ADAPTIC DRESSING 3 X 8

Facility

$6.00

Hospital Charge Code	80030114
Hospital Revenue Code	270
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

ADD ON HOUR CHEMO IV ADMIN

Facility

$307.00

Service Code	CPT 96415
Hospital Charge Code	596415
Hospital Revenue Code	280
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

ADD ON HOUR CHEMO IV ADMIN

Facility

$307.00

Service Code	CPT 96415
Hospital Charge Code	596415
Hospital Revenue Code	280
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

ADD ON IV INFUSION, HYDRATION

Facility

$376.00

Service Code	CPT 96360
Hospital Charge Code	8096360
Hospital Revenue Code	521
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

ADD ON IV INFUSION, HYDRATION

Facility

$376.00

Service Code	CPT 96360
Hospital Charge Code	8096360
Hospital Revenue Code	521
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

ADENOSINE INJ [6 MG/2 ML]

Facility

$24.00

Service Code	HCPCS J0153
Hospital Charge Code	3000012
Hospital Revenue Code	259
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

ADENOSINE INJ [6 MG/2 ML]

Facility

$24.00

Service Code	HCPCS J0153
Hospital Charge Code	3000012
Hospital Revenue Code	259
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

ADMIN ECG CONTRAST AGENT

Facility

$123.00

Service Code	CPT 93352
Hospital Charge Code	5193352
Hospital Revenue Code	483
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna Commercial	$116.85
Rate for Payer: Aetna Medicare	$110.70
Rate for Payer: BCBS MT CHIP	$110.70
Rate for Payer: BCBS MT Closed Plan Network	$116.85
Rate for Payer: BCBS MT HealthLink	$110.70
Rate for Payer: BCBS MT Medicare	$110.70
Rate for Payer: BCBS MT POS	$116.85
Rate for Payer: BCBS MT Traditional	$123.00
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial	$116.85
Rate for Payer: Cigna Medicare	$110.70
Rate for Payer: Medicaid All Medicaid	$113.16
Rate for Payer: Medicare All Medicare	$86.10
Rate for Payer: Monida Allegiance	$116.85
Rate for Payer: Monida First Choice Health	$119.31
Rate for Payer: Monida Montana Health Co-op	$116.85
Rate for Payer: Monida PacificSource	$116.85

ADMIN ECG CONTRAST AGENT

Facility

$123.00

Service Code	CPT 93352
Hospital Charge Code	5193352
Hospital Revenue Code	483
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna Commercial	$116.85
Rate for Payer: Aetna Medicare	$110.70
Rate for Payer: BCBS MT CHIP	$110.70
Rate for Payer: BCBS MT Closed Plan Network	$116.85
Rate for Payer: BCBS MT HealthLink	$110.70
Rate for Payer: BCBS MT Medicare	$110.70
Rate for Payer: BCBS MT POS	$116.85
Rate for Payer: BCBS MT Traditional	$123.00
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial	$116.85
Rate for Payer: Cigna Medicare	$110.70
Rate for Payer: Medicaid All Medicaid	$113.16
Rate for Payer: Medicare All Medicare	$86.10
Rate for Payer: Monida Allegiance	$116.85
Rate for Payer: Monida First Choice Health	$119.31
Rate for Payer: Monida Montana Health Co-op	$116.85
Rate for Payer: Monida PacificSource	$116.85

ADMINISTRATION OF PNEUMONIA VACCINE

Facility

$52.00

Service Code	HCPCS G0009
Hospital Charge Code	540510
Hospital Revenue Code	771
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

ADMINISTRATION OF PNEUMONIA VACCINE

Facility

$52.00

Service Code	HCPCS G0009
Hospital Charge Code	540510
Hospital Revenue Code	771
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

ADRENOCORTICOTROPIC HORMONE (004440)

Facility

$84.00

Service Code	CPT 82024
Hospital Charge Code	4082024
Hospital Revenue Code	301
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

ADRENOCORTICOTROPIC HORMONE (004440)

Facility

$84.00

Service Code	CPT 82024
Hospital Charge Code	4082024
Hospital Revenue Code	301
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

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