Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

AMBULANCE ALS INTUBATION SUPPLIES

Facility

$390.00

Service Code	HCPCS A0396
Hospital Charge Code	600396
Hospital Revenue Code	420
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$390.00
Rate for Payer: Aetna Commercial	$370.50
Rate for Payer: Aetna Medicare	$351.00
Rate for Payer: BCBS MT CHIP	$351.00
Rate for Payer: BCBS MT Closed Plan Network	$370.50
Rate for Payer: BCBS MT HealthLink	$351.00
Rate for Payer: BCBS MT Medicare	$351.00
Rate for Payer: BCBS MT POS	$370.50
Rate for Payer: BCBS MT Traditional	$390.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cigna Commercial	$370.50
Rate for Payer: Cigna Medicare	$351.00
Rate for Payer: Medicaid All Medicaid	$358.80
Rate for Payer: Medicare All Medicare	$273.00
Rate for Payer: Monida Allegiance	$370.50
Rate for Payer: Monida First Choice Health	$378.30
Rate for Payer: Monida Montana Health Co-op	$370.50
Rate for Payer: Monida PacificSource	$370.50

AMBULANCE ALS INTUBATION SUPPLIES

Facility

$390.00

Service Code	HCPCS A0396
Hospital Charge Code	600396
Hospital Revenue Code	420
Min. Negotiated Rate	$273.00
Max. Negotiated Rate	$390.00
Rate for Payer: Aetna Commercial	$370.50
Rate for Payer: Aetna Medicare	$351.00
Rate for Payer: BCBS MT CHIP	$351.00
Rate for Payer: BCBS MT Closed Plan Network	$370.50
Rate for Payer: BCBS MT HealthLink	$351.00
Rate for Payer: BCBS MT Medicare	$351.00
Rate for Payer: BCBS MT POS	$370.50
Rate for Payer: BCBS MT Traditional	$390.00
Rate for Payer: Cash Price	$351.00
Rate for Payer: Cigna Commercial	$370.50
Rate for Payer: Cigna Medicare	$351.00
Rate for Payer: Medicaid All Medicaid	$358.80
Rate for Payer: Medicare All Medicare	$273.00
Rate for Payer: Monida Allegiance	$370.50
Rate for Payer: Monida First Choice Health	$378.30
Rate for Payer: Monida Montana Health Co-op	$370.50
Rate for Payer: Monida PacificSource	$370.50

AMBULANCE ALS NON EMERGENT

Facility

$1,703.00

Service Code	HCPCS A0426
Hospital Charge Code	600426
Hospital Revenue Code	540
Min. Negotiated Rate	$1,192.10
Max. Negotiated Rate	$1,703.00
Rate for Payer: Aetna Commercial	$1,617.85
Rate for Payer: Aetna Medicare	$1,532.70
Rate for Payer: BCBS MT CHIP	$1,532.70
Rate for Payer: BCBS MT Closed Plan Network	$1,617.85
Rate for Payer: BCBS MT HealthLink	$1,532.70
Rate for Payer: BCBS MT Medicare	$1,532.70
Rate for Payer: BCBS MT POS	$1,617.85
Rate for Payer: BCBS MT Traditional	$1,703.00
Rate for Payer: Cash Price	$1,532.70
Rate for Payer: Cigna Commercial	$1,617.85
Rate for Payer: Cigna Medicare	$1,532.70
Rate for Payer: Medicaid All Medicaid	$1,566.76
Rate for Payer: Medicare All Medicare	$1,192.10
Rate for Payer: Monida Allegiance	$1,617.85
Rate for Payer: Monida First Choice Health	$1,651.91
Rate for Payer: Monida Montana Health Co-op	$1,617.85
Rate for Payer: Monida PacificSource	$1,617.85

AMBULANCE ALS NON EMERGENT

Facility

$1,703.00

Service Code	HCPCS A0426
Hospital Charge Code	600426
Hospital Revenue Code	540
Min. Negotiated Rate	$1,192.10
Max. Negotiated Rate	$1,703.00
Rate for Payer: Aetna Commercial	$1,617.85
Rate for Payer: Aetna Medicare	$1,532.70
Rate for Payer: BCBS MT CHIP	$1,532.70
Rate for Payer: BCBS MT Closed Plan Network	$1,617.85
Rate for Payer: BCBS MT HealthLink	$1,532.70
Rate for Payer: BCBS MT Medicare	$1,532.70
Rate for Payer: BCBS MT POS	$1,617.85
Rate for Payer: BCBS MT Traditional	$1,703.00
Rate for Payer: Cash Price	$1,532.70
Rate for Payer: Cigna Commercial	$1,617.85
Rate for Payer: Cigna Medicare	$1,532.70
Rate for Payer: Medicaid All Medicaid	$1,566.76
Rate for Payer: Medicare All Medicare	$1,192.10
Rate for Payer: Monida Allegiance	$1,617.85
Rate for Payer: Monida First Choice Health	$1,651.91
Rate for Payer: Monida Montana Health Co-op	$1,617.85
Rate for Payer: Monida PacificSource	$1,617.85

AMBULANCE ALS ROUTINE SUPPLIES

Facility

$89.00

Service Code	HCPCS A0398
Hospital Charge Code	600398
Hospital Revenue Code	420
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

AMBULANCE ALS ROUTINE SUPPLIES

Facility

$89.00

Service Code	HCPCS A0398
Hospital Charge Code	600398
Hospital Revenue Code	420
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

AMBULANCE BLS EMERGENT

Facility

$1,481.00

Service Code	HCPCS A0429
Hospital Charge Code	600429
Hospital Revenue Code	540
Min. Negotiated Rate	$1,036.70
Max. Negotiated Rate	$1,481.00
Rate for Payer: Aetna Commercial	$1,406.95
Rate for Payer: Aetna Medicare	$1,332.90
Rate for Payer: BCBS MT CHIP	$1,332.90
Rate for Payer: BCBS MT Closed Plan Network	$1,406.95
Rate for Payer: BCBS MT HealthLink	$1,332.90
Rate for Payer: BCBS MT Medicare	$1,332.90
Rate for Payer: BCBS MT POS	$1,406.95
Rate for Payer: BCBS MT Traditional	$1,481.00
Rate for Payer: Cash Price	$1,332.90
Rate for Payer: Cigna Commercial	$1,406.95
Rate for Payer: Cigna Medicare	$1,332.90
Rate for Payer: Medicaid All Medicaid	$1,362.52
Rate for Payer: Medicare All Medicare	$1,036.70
Rate for Payer: Monida Allegiance	$1,406.95
Rate for Payer: Monida First Choice Health	$1,436.57
Rate for Payer: Monida Montana Health Co-op	$1,406.95
Rate for Payer: Monida PacificSource	$1,406.95

AMBULANCE BLS EMERGENT

Facility

$1,481.00

Service Code	HCPCS A0429
Hospital Charge Code	600429
Hospital Revenue Code	540
Min. Negotiated Rate	$1,036.70
Max. Negotiated Rate	$1,481.00
Rate for Payer: Aetna Commercial	$1,406.95
Rate for Payer: Aetna Medicare	$1,332.90
Rate for Payer: BCBS MT CHIP	$1,332.90
Rate for Payer: BCBS MT Closed Plan Network	$1,406.95
Rate for Payer: BCBS MT HealthLink	$1,332.90
Rate for Payer: BCBS MT Medicare	$1,332.90
Rate for Payer: BCBS MT POS	$1,406.95
Rate for Payer: BCBS MT Traditional	$1,481.00
Rate for Payer: Cash Price	$1,332.90
Rate for Payer: Cigna Commercial	$1,406.95
Rate for Payer: Cigna Medicare	$1,332.90
Rate for Payer: Medicaid All Medicaid	$1,362.52
Rate for Payer: Medicare All Medicare	$1,036.70
Rate for Payer: Monida Allegiance	$1,406.95
Rate for Payer: Monida First Choice Health	$1,436.57
Rate for Payer: Monida Montana Health Co-op	$1,406.95
Rate for Payer: Monida PacificSource	$1,406.95

AMBULANCE BLS NON EMERGENT

Facility

$1,058.00

Service Code	HCPCS A0428
Hospital Charge Code	600428
Hospital Revenue Code	540
Min. Negotiated Rate	$740.60
Max. Negotiated Rate	$1,058.00
Rate for Payer: Aetna Commercial	$1,005.10
Rate for Payer: Aetna Medicare	$952.20
Rate for Payer: BCBS MT CHIP	$952.20
Rate for Payer: BCBS MT Closed Plan Network	$1,005.10
Rate for Payer: BCBS MT HealthLink	$952.20
Rate for Payer: BCBS MT Medicare	$952.20
Rate for Payer: BCBS MT POS	$1,005.10
Rate for Payer: BCBS MT Traditional	$1,058.00
Rate for Payer: Cash Price	$952.20
Rate for Payer: Cigna Commercial	$1,005.10
Rate for Payer: Cigna Medicare	$952.20
Rate for Payer: Medicaid All Medicaid	$973.36
Rate for Payer: Medicare All Medicare	$740.60
Rate for Payer: Monida Allegiance	$1,005.10
Rate for Payer: Monida First Choice Health	$1,026.26
Rate for Payer: Monida Montana Health Co-op	$1,005.10
Rate for Payer: Monida PacificSource	$1,005.10

AMBULANCE BLS NON EMERGENT

Facility

$1,058.00

Service Code	HCPCS A0428
Hospital Charge Code	600428
Hospital Revenue Code	540
Min. Negotiated Rate	$740.60
Max. Negotiated Rate	$1,058.00
Rate for Payer: Aetna Commercial	$1,005.10
Rate for Payer: Aetna Medicare	$952.20
Rate for Payer: BCBS MT CHIP	$952.20
Rate for Payer: BCBS MT Closed Plan Network	$1,005.10
Rate for Payer: BCBS MT HealthLink	$952.20
Rate for Payer: BCBS MT Medicare	$952.20
Rate for Payer: BCBS MT POS	$1,005.10
Rate for Payer: BCBS MT Traditional	$1,058.00
Rate for Payer: Cash Price	$952.20
Rate for Payer: Cigna Commercial	$1,005.10
Rate for Payer: Cigna Medicare	$952.20
Rate for Payer: Medicaid All Medicaid	$973.36
Rate for Payer: Medicare All Medicare	$740.60
Rate for Payer: Monida Allegiance	$1,005.10
Rate for Payer: Monida First Choice Health	$1,026.26
Rate for Payer: Monida Montana Health Co-op	$1,005.10
Rate for Payer: Monida PacificSource	$1,005.10

AMBULANCE BLS ROUTINE SUPPLIES

Facility

$67.00

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

AMBULANCE BLS ROUTINE SUPPLIES

Facility

$67.00

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

AMBULANCE CPAP

Facility

$111.00

Service Code	HCPCS A0999
Hospital Charge Code	620999
Hospital Revenue Code	420
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

Know your out-of-pocket cost for care.

All Charges