Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ALTEPLASE INJ [2 MG/2 ML]

Facility

$733.00

Service Code	HCPCS J2997
Hospital Charge Code	3000021
Hospital Revenue Code	636
Min. Negotiated Rate	$513.10
Max. Negotiated Rate	$733.00
Rate for Payer: Aetna Commercial	$696.35
Rate for Payer: Aetna Medicare	$659.70
Rate for Payer: BCBS MT CHIP	$659.70
Rate for Payer: BCBS MT Closed Plan Network	$696.35
Rate for Payer: BCBS MT HealthLink	$659.70
Rate for Payer: BCBS MT Medicare	$659.70
Rate for Payer: BCBS MT POS	$696.35
Rate for Payer: BCBS MT Traditional	$733.00
Rate for Payer: Cash Price	$659.70
Rate for Payer: Cigna Commercial	$696.35
Rate for Payer: Cigna Medicare	$659.70
Rate for Payer: Medicaid All Medicaid	$674.36
Rate for Payer: Medicare All Medicare	$513.10
Rate for Payer: Monida Allegiance	$696.35
Rate for Payer: Monida First Choice Health	$711.01
Rate for Payer: Monida Montana Health Co-op	$696.35
Rate for Payer: Monida PacificSource	$696.35

AMBULANCE ALS 2 EMERGENT

Facility

$2,625.00

Service Code	HCPCS A0433 QN
Hospital Charge Code	600433
Hospital Revenue Code	540
Min. Negotiated Rate	$1,837.50
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$2,493.75
Rate for Payer: Aetna Medicare	$2,362.50
Rate for Payer: BCBS MT CHIP	$2,362.50
Rate for Payer: BCBS MT Closed Plan Network	$2,493.75
Rate for Payer: BCBS MT HealthLink	$2,362.50
Rate for Payer: BCBS MT Medicare	$2,362.50
Rate for Payer: BCBS MT POS	$2,493.75
Rate for Payer: BCBS MT Traditional	$2,625.00
Rate for Payer: Cash Price	$2,362.50
Rate for Payer: Cigna Commercial	$2,493.75
Rate for Payer: Cigna Medicare	$2,362.50
Rate for Payer: Medicaid All Medicaid	$2,415.00
Rate for Payer: Medicare All Medicare	$1,837.50
Rate for Payer: Monida Allegiance	$2,493.75
Rate for Payer: Monida First Choice Health	$2,546.25
Rate for Payer: Monida Montana Health Co-op	$2,493.75
Rate for Payer: Monida PacificSource	$2,493.75

AMBULANCE ALS 2 EMERGENT

Facility

$2,625.00

Service Code	HCPCS A0433 QN
Hospital Charge Code	600433
Hospital Revenue Code	540
Min. Negotiated Rate	$1,837.50
Max. Negotiated Rate	$2,625.00
Rate for Payer: Aetna Commercial	$2,493.75
Rate for Payer: Aetna Medicare	$2,362.50
Rate for Payer: BCBS MT CHIP	$2,362.50
Rate for Payer: BCBS MT Closed Plan Network	$2,493.75
Rate for Payer: BCBS MT HealthLink	$2,362.50
Rate for Payer: BCBS MT Medicare	$2,362.50
Rate for Payer: BCBS MT POS	$2,493.75
Rate for Payer: BCBS MT Traditional	$2,625.00
Rate for Payer: Cash Price	$2,362.50
Rate for Payer: Cigna Commercial	$2,493.75
Rate for Payer: Cigna Medicare	$2,362.50
Rate for Payer: Medicaid All Medicaid	$2,415.00
Rate for Payer: Medicare All Medicare	$1,837.50
Rate for Payer: Monida Allegiance	$2,493.75
Rate for Payer: Monida First Choice Health	$2,546.25
Rate for Payer: Monida Montana Health Co-op	$2,493.75
Rate for Payer: Monida PacificSource	$2,493.75

AMBULANCE ALS EMERGENT

Facility

$2,132.00

Service Code	HCPCS A0427 QN
Hospital Charge Code	600427
Hospital Revenue Code	540
Min. Negotiated Rate	$1,492.40
Max. Negotiated Rate	$2,132.00
Rate for Payer: Aetna Commercial	$2,025.40
Rate for Payer: Aetna Medicare	$1,918.80
Rate for Payer: BCBS MT CHIP	$1,918.80
Rate for Payer: BCBS MT Closed Plan Network	$2,025.40
Rate for Payer: BCBS MT HealthLink	$1,918.80
Rate for Payer: BCBS MT Medicare	$1,918.80
Rate for Payer: BCBS MT POS	$2,025.40
Rate for Payer: BCBS MT Traditional	$2,132.00
Rate for Payer: Cash Price	$1,918.80
Rate for Payer: Cigna Commercial	$2,025.40
Rate for Payer: Cigna Medicare	$1,918.80
Rate for Payer: Medicaid All Medicaid	$1,961.44
Rate for Payer: Medicare All Medicare	$1,492.40
Rate for Payer: Monida Allegiance	$2,025.40
Rate for Payer: Monida First Choice Health	$2,068.04
Rate for Payer: Monida Montana Health Co-op	$2,025.40
Rate for Payer: Monida PacificSource	$2,025.40

AMBULANCE ALS EMERGENT

Facility

$2,132.00

Service Code	HCPCS A0427 QN
Hospital Charge Code	600427
Hospital Revenue Code	540
Min. Negotiated Rate	$1,492.40
Max. Negotiated Rate	$2,132.00
Rate for Payer: Aetna Commercial	$2,025.40
Rate for Payer: Aetna Medicare	$1,918.80
Rate for Payer: BCBS MT CHIP	$1,918.80
Rate for Payer: BCBS MT Closed Plan Network	$2,025.40
Rate for Payer: BCBS MT HealthLink	$1,918.80
Rate for Payer: BCBS MT Medicare	$1,918.80
Rate for Payer: BCBS MT POS	$2,025.40
Rate for Payer: BCBS MT Traditional	$2,132.00
Rate for Payer: Cash Price	$1,918.80
Rate for Payer: Cigna Commercial	$2,025.40
Rate for Payer: Cigna Medicare	$1,918.80
Rate for Payer: Medicaid All Medicaid	$1,961.44
Rate for Payer: Medicare All Medicare	$1,492.40
Rate for Payer: Monida Allegiance	$2,025.40
Rate for Payer: Monida First Choice Health	$2,068.04
Rate for Payer: Monida Montana Health Co-op	$2,025.40
Rate for Payer: Monida PacificSource	$2,025.40

AMBULANCE ALS INTUBATION SUPPLIES

Facility

$368.00

Service Code	HCPCS A0396 QN
Hospital Charge Code	600396
Hospital Revenue Code	420
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

AMBULANCE ALS INTUBATION SUPPLIES

Facility

$368.00

Service Code	HCPCS A0396 QN
Hospital Charge Code	600396
Hospital Revenue Code	420
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

AMBULANCE ALS NON EMERGENT

Facility

$1,607.00

Service Code	HCPCS A0426 QN
Hospital Charge Code	600426
Hospital Revenue Code	540
Min. Negotiated Rate	$1,124.90
Max. Negotiated Rate	$1,607.00
Rate for Payer: Aetna Commercial	$1,526.65
Rate for Payer: Aetna Medicare	$1,446.30
Rate for Payer: BCBS MT CHIP	$1,446.30
Rate for Payer: BCBS MT Closed Plan Network	$1,526.65
Rate for Payer: BCBS MT HealthLink	$1,446.30
Rate for Payer: BCBS MT Medicare	$1,446.30
Rate for Payer: BCBS MT POS	$1,526.65
Rate for Payer: BCBS MT Traditional	$1,607.00
Rate for Payer: Cash Price	$1,446.30
Rate for Payer: Cigna Commercial	$1,526.65
Rate for Payer: Cigna Medicare	$1,446.30
Rate for Payer: Medicaid All Medicaid	$1,478.44
Rate for Payer: Medicare All Medicare	$1,124.90
Rate for Payer: Monida Allegiance	$1,526.65
Rate for Payer: Monida First Choice Health	$1,558.79
Rate for Payer: Monida Montana Health Co-op	$1,526.65
Rate for Payer: Monida PacificSource	$1,526.65

AMBULANCE ALS NON EMERGENT

Facility

$1,607.00

Service Code	HCPCS A0426 QN
Hospital Charge Code	600426
Hospital Revenue Code	540
Min. Negotiated Rate	$1,124.90
Max. Negotiated Rate	$1,607.00
Rate for Payer: Aetna Commercial	$1,526.65
Rate for Payer: Aetna Medicare	$1,446.30
Rate for Payer: BCBS MT CHIP	$1,446.30
Rate for Payer: BCBS MT Closed Plan Network	$1,526.65
Rate for Payer: BCBS MT HealthLink	$1,446.30
Rate for Payer: BCBS MT Medicare	$1,446.30
Rate for Payer: BCBS MT POS	$1,526.65
Rate for Payer: BCBS MT Traditional	$1,607.00
Rate for Payer: Cash Price	$1,446.30
Rate for Payer: Cigna Commercial	$1,526.65
Rate for Payer: Cigna Medicare	$1,446.30
Rate for Payer: Medicaid All Medicaid	$1,478.44
Rate for Payer: Medicare All Medicare	$1,124.90
Rate for Payer: Monida Allegiance	$1,526.65
Rate for Payer: Monida First Choice Health	$1,558.79
Rate for Payer: Monida Montana Health Co-op	$1,526.65
Rate for Payer: Monida PacificSource	$1,526.65

AMBULANCE ALS ROUTINE SUPPLIES

Facility

$84.00

Service Code	HCPCS A0398 QN
Hospital Charge Code	600398
Hospital Revenue Code	420
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

AMBULANCE ALS ROUTINE SUPPLIES

Facility

$84.00

Service Code	HCPCS A0398 QN
Hospital Charge Code	600398
Hospital Revenue Code	420
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

AMBULANCE BLS EMERGENT

Facility

$1,397.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	600429
Hospital Revenue Code	540
Min. Negotiated Rate	$977.90
Max. Negotiated Rate	$1,397.00
Rate for Payer: Aetna Commercial	$1,327.15
Rate for Payer: Aetna Medicare	$1,257.30
Rate for Payer: BCBS MT CHIP	$1,257.30
Rate for Payer: BCBS MT Closed Plan Network	$1,327.15
Rate for Payer: BCBS MT HealthLink	$1,257.30
Rate for Payer: BCBS MT Medicare	$1,257.30
Rate for Payer: BCBS MT POS	$1,327.15
Rate for Payer: BCBS MT Traditional	$1,397.00
Rate for Payer: Cash Price	$1,257.30
Rate for Payer: Cigna Commercial	$1,327.15
Rate for Payer: Cigna Medicare	$1,257.30
Rate for Payer: Medicaid All Medicaid	$1,285.24
Rate for Payer: Medicare All Medicare	$977.90
Rate for Payer: Monida Allegiance	$1,327.15
Rate for Payer: Monida First Choice Health	$1,355.09
Rate for Payer: Monida Montana Health Co-op	$1,327.15
Rate for Payer: Monida PacificSource	$1,327.15

AMBULANCE BLS EMERGENT

Facility

$1,397.00

Service Code	HCPCS A0429 QN
Hospital Charge Code	600429
Hospital Revenue Code	540
Min. Negotiated Rate	$977.90
Max. Negotiated Rate	$1,397.00
Rate for Payer: Aetna Commercial	$1,327.15
Rate for Payer: Aetna Medicare	$1,257.30
Rate for Payer: BCBS MT CHIP	$1,257.30
Rate for Payer: BCBS MT Closed Plan Network	$1,327.15
Rate for Payer: BCBS MT HealthLink	$1,257.30
Rate for Payer: BCBS MT Medicare	$1,257.30
Rate for Payer: BCBS MT POS	$1,327.15
Rate for Payer: BCBS MT Traditional	$1,397.00
Rate for Payer: Cash Price	$1,257.30
Rate for Payer: Cigna Commercial	$1,327.15
Rate for Payer: Cigna Medicare	$1,257.30
Rate for Payer: Medicaid All Medicaid	$1,285.24
Rate for Payer: Medicare All Medicare	$977.90
Rate for Payer: Monida Allegiance	$1,327.15
Rate for Payer: Monida First Choice Health	$1,355.09
Rate for Payer: Monida Montana Health Co-op	$1,327.15
Rate for Payer: Monida PacificSource	$1,327.15

AMBULANCE BLS NON EMERGENT

Facility

$998.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	600428
Hospital Revenue Code	540
Min. Negotiated Rate	$698.60
Max. Negotiated Rate	$998.00
Rate for Payer: Aetna Commercial	$948.10
Rate for Payer: Aetna Medicare	$898.20
Rate for Payer: BCBS MT CHIP	$898.20
Rate for Payer: BCBS MT Closed Plan Network	$948.10
Rate for Payer: BCBS MT HealthLink	$898.20
Rate for Payer: BCBS MT Medicare	$898.20
Rate for Payer: BCBS MT POS	$948.10
Rate for Payer: BCBS MT Traditional	$998.00
Rate for Payer: Cash Price	$898.20
Rate for Payer: Cigna Commercial	$948.10
Rate for Payer: Cigna Medicare	$898.20
Rate for Payer: Medicaid All Medicaid	$918.16
Rate for Payer: Medicare All Medicare	$698.60
Rate for Payer: Monida Allegiance	$948.10
Rate for Payer: Monida First Choice Health	$968.06
Rate for Payer: Monida Montana Health Co-op	$948.10
Rate for Payer: Monida PacificSource	$948.10

AMBULANCE BLS NON EMERGENT

Facility

$998.00

Service Code	HCPCS A0428 QN
Hospital Charge Code	600428
Hospital Revenue Code	540
Min. Negotiated Rate	$698.60
Max. Negotiated Rate	$998.00
Rate for Payer: Aetna Commercial	$948.10
Rate for Payer: Aetna Medicare	$898.20
Rate for Payer: BCBS MT CHIP	$898.20
Rate for Payer: BCBS MT Closed Plan Network	$948.10
Rate for Payer: BCBS MT HealthLink	$898.20
Rate for Payer: BCBS MT Medicare	$898.20
Rate for Payer: BCBS MT POS	$948.10
Rate for Payer: BCBS MT Traditional	$998.00
Rate for Payer: Cash Price	$898.20
Rate for Payer: Cigna Commercial	$948.10
Rate for Payer: Cigna Medicare	$898.20
Rate for Payer: Medicaid All Medicaid	$918.16
Rate for Payer: Medicare All Medicare	$698.60
Rate for Payer: Monida Allegiance	$948.10
Rate for Payer: Monida First Choice Health	$968.06
Rate for Payer: Monida Montana Health Co-op	$948.10
Rate for Payer: Monida PacificSource	$948.10

AMBULANCE BLS ROUTINE SUPPLIES

Facility

$63.00

Service Code	HCPCS A0382 QN
Hospital Charge Code	600382
Hospital Revenue Code	420
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

AMBULANCE BLS ROUTINE SUPPLIES

Facility

$63.00

Service Code	HCPCS A0382 QN
Hospital Charge Code	600382
Hospital Revenue Code	420
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

AMBULANCE CPAP

Facility

$105.00

Service Code	HCPCS A0999 QN
Hospital Charge Code	620999
Hospital Revenue Code	420
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

AMBULANCE CPAP

Facility

$105.00

Service Code	HCPCS A0999 QN
Hospital Charge Code	620999
Hospital Revenue Code	420
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

AMBULANCE DEFIBRILLATION SUPPLIES

Facility

$263.00

Service Code	HCPCS A0384 QN
Hospital Charge Code	600384
Hospital Revenue Code	420
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

AMBULANCE DEFIBRILLATION SUPPLIES

Facility

$263.00

Service Code	HCPCS A0384 QN
Hospital Charge Code	600384
Hospital Revenue Code	420
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

AMBULANCE FINGER STICK BLOOD COUNT(GLUCO

Facility

$26.00

Service Code	HCPCS 82948 QN
Hospital Charge Code	682948
Hospital Revenue Code	301
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

AMBULANCE FINGER STICK BLOOD COUNT(GLUCO

Facility

$26.00

Service Code	HCPCS 82948 QN
Hospital Charge Code	682948
Hospital Revenue Code	301
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

AMBULANCE GROUND MILEAGE

Facility

$23.00

Service Code	HCPCS A0425 QN
Hospital Charge Code	600425
Hospital Revenue Code	540
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

AMBULANCE GROUND MILEAGE

Facility

$23.00

Service Code	HCPCS A0390 QN
Hospital Charge Code	600390
Hospital Revenue Code	540
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

Know your out-of-pocket cost for care.

All Charges