Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

.ALKALINE PHOS TOTAL (001612)

Facility

$58.00

Service Code	CPT 84075
Hospital Charge Code	4084075
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

.ALKALINE PHOS TOTAL (001612)

Facility

$58.00

Service Code	CPT 84075
Hospital Charge Code	4084075
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

.ALLERGEN SPECIFIC IGE

Facility

$56.00

Service Code	CPT 86003
Hospital Charge Code	4086003
Hospital Revenue Code	300
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

.ALLERGEN SPECIFIC IGE

Facility

$56.00

Service Code	CPT 86003
Hospital Charge Code	4086003
Hospital Revenue Code	300
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

ALLERGEN SPECIFIC IGG QUAN/SEMIQUAN EA

Facility

$323.18

Service Code	CPT 86001
Hospital Charge Code	4086001
Hospital Revenue Code	300
Min. Negotiated Rate	$226.23
Max. Negotiated Rate	$323.18
Rate for Payer: Aetna Commercial	$307.02
Rate for Payer: Aetna Medicare	$290.86
Rate for Payer: BCBS MT CHIP	$290.86
Rate for Payer: BCBS MT Closed Plan Network	$307.02
Rate for Payer: BCBS MT HealthLink	$290.86
Rate for Payer: BCBS MT Medicare	$290.86
Rate for Payer: BCBS MT POS	$307.02
Rate for Payer: BCBS MT Traditional	$323.18
Rate for Payer: Cash Price	$290.86
Rate for Payer: Cigna Commercial	$307.02
Rate for Payer: Cigna Medicare	$290.86
Rate for Payer: Medicaid All Medicaid	$297.33
Rate for Payer: Medicare All Medicare	$226.23
Rate for Payer: Monida Allegiance	$307.02
Rate for Payer: Monida First Choice Health	$313.48
Rate for Payer: Monida Montana Health Co-op	$307.02
Rate for Payer: Monida PacificSource	$307.02

ALLERGEN SPECIFIC IGG QUAN/SEMIQUAN EA

Facility

$323.18

Service Code	CPT 86001
Hospital Charge Code	4086001
Hospital Revenue Code	300
Min. Negotiated Rate	$226.23
Max. Negotiated Rate	$323.18
Rate for Payer: Aetna Commercial	$307.02
Rate for Payer: Aetna Medicare	$290.86
Rate for Payer: BCBS MT CHIP	$290.86
Rate for Payer: BCBS MT Closed Plan Network	$307.02
Rate for Payer: BCBS MT HealthLink	$290.86
Rate for Payer: BCBS MT Medicare	$290.86
Rate for Payer: BCBS MT POS	$307.02
Rate for Payer: BCBS MT Traditional	$323.18
Rate for Payer: Cash Price	$290.86
Rate for Payer: Cigna Commercial	$307.02
Rate for Payer: Cigna Medicare	$290.86
Rate for Payer: Medicaid All Medicaid	$297.33
Rate for Payer: Medicare All Medicare	$226.23
Rate for Payer: Monida Allegiance	$307.02
Rate for Payer: Monida First Choice Health	$313.48
Rate for Payer: Monida Montana Health Co-op	$307.02
Rate for Payer: Monida PacificSource	$307.02

ALLOPURINOL TAB [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000018
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

ALLOPURINOL TAB [100 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000018
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

ALLOPURINOL TAB [300 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007373
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

ALLOPURINOL TAB [300 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007373
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

.ALPHA-1-ANTITRYPSIN

Facility

$81.00

Service Code	CPT 82103
Hospital Charge Code	4082103
Hospital Revenue Code	301
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

.ALPHA-1-ANTITRYPSIN

Facility

$81.00

Service Code	CPT 82103
Hospital Charge Code	4082103
Hospital Revenue Code	301
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

.ALPHA-1-ANTITRYPSIN PHENOTYPE

Facility

$81.00

Service Code	CPT 82104
Hospital Charge Code	4082104
Hospital Revenue Code	301
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

.ALPHA-1-ANTITRYPSIN PHENOTYPE

Facility

$81.00

Service Code	CPT 82104
Hospital Charge Code	4082104
Hospital Revenue Code	301
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

ALPRAZOLAM TAB [0.5MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000019
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

ALPRAZOLAM TAB [0.5MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000019
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

ALT

Facility

$63.00

Service Code	CPT 84460
Hospital Charge Code	4084460
Hospital Revenue Code	301
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

ALT

Facility

$63.00

Service Code	CPT 84460
Hospital Charge Code	4084460
Hospital Revenue Code	301
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

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

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

AMANTADINE CAP [100 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007635
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

AMANTADINE CAP [100 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007635
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

AMBULANCE ALS 2 EMERGENT

Facility

$2,783.00

Service Code	HCPCS A0433
Hospital Charge Code	600433
Hospital Revenue Code	540
Min. Negotiated Rate	$1,948.10
Max. Negotiated Rate	$2,783.00
Rate for Payer: Aetna Commercial	$2,643.85
Rate for Payer: Aetna Medicare	$2,504.70
Rate for Payer: BCBS MT CHIP	$2,504.70
Rate for Payer: BCBS MT Closed Plan Network	$2,643.85
Rate for Payer: BCBS MT HealthLink	$2,504.70
Rate for Payer: BCBS MT Medicare	$2,504.70
Rate for Payer: BCBS MT POS	$2,643.85
Rate for Payer: BCBS MT Traditional	$2,783.00
Rate for Payer: Cash Price	$2,504.70
Rate for Payer: Cigna Commercial	$2,643.85
Rate for Payer: Cigna Medicare	$2,504.70
Rate for Payer: Medicaid All Medicaid	$2,560.36
Rate for Payer: Medicare All Medicare	$1,948.10
Rate for Payer: Monida Allegiance	$2,643.85
Rate for Payer: Monida First Choice Health	$2,699.51
Rate for Payer: Monida Montana Health Co-op	$2,643.85
Rate for Payer: Monida PacificSource	$2,643.85

AMBULANCE ALS 2 EMERGENT

Facility

$2,783.00

Service Code	HCPCS A0433
Hospital Charge Code	600433
Hospital Revenue Code	540
Min. Negotiated Rate	$1,948.10
Max. Negotiated Rate	$2,783.00
Rate for Payer: Aetna Commercial	$2,643.85
Rate for Payer: Aetna Medicare	$2,504.70
Rate for Payer: BCBS MT CHIP	$2,504.70
Rate for Payer: BCBS MT Closed Plan Network	$2,643.85
Rate for Payer: BCBS MT HealthLink	$2,504.70
Rate for Payer: BCBS MT Medicare	$2,504.70
Rate for Payer: BCBS MT POS	$2,643.85
Rate for Payer: BCBS MT Traditional	$2,783.00
Rate for Payer: Cash Price	$2,504.70
Rate for Payer: Cigna Commercial	$2,643.85
Rate for Payer: Cigna Medicare	$2,504.70
Rate for Payer: Medicaid All Medicaid	$2,560.36
Rate for Payer: Medicare All Medicare	$1,948.10
Rate for Payer: Monida Allegiance	$2,643.85
Rate for Payer: Monida First Choice Health	$2,699.51
Rate for Payer: Monida Montana Health Co-op	$2,643.85
Rate for Payer: Monida PacificSource	$2,643.85

AMBULANCE ALS EMERGENT

Facility

$2,260.00

Service Code	HCPCS A0427
Hospital Charge Code	600427
Hospital Revenue Code	540
Min. Negotiated Rate	$1,582.00
Max. Negotiated Rate	$2,260.00
Rate for Payer: Aetna Commercial	$2,147.00
Rate for Payer: Aetna Medicare	$2,034.00
Rate for Payer: BCBS MT CHIP	$2,034.00
Rate for Payer: BCBS MT Closed Plan Network	$2,147.00
Rate for Payer: BCBS MT HealthLink	$2,034.00
Rate for Payer: BCBS MT Medicare	$2,034.00
Rate for Payer: BCBS MT POS	$2,147.00
Rate for Payer: BCBS MT Traditional	$2,260.00
Rate for Payer: Cash Price	$2,034.00
Rate for Payer: Cigna Commercial	$2,147.00
Rate for Payer: Cigna Medicare	$2,034.00
Rate for Payer: Medicaid All Medicaid	$2,079.20
Rate for Payer: Medicare All Medicare	$1,582.00
Rate for Payer: Monida Allegiance	$2,147.00
Rate for Payer: Monida First Choice Health	$2,192.20
Rate for Payer: Monida Montana Health Co-op	$2,147.00
Rate for Payer: Monida PacificSource	$2,147.00

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