Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INFECTIOUS MONONUCLEOSIS, RAPID TEST

Facility

$90.00

Service Code	HCPCS 86308
Hospital Charge Code	4086308
Hospital Revenue Code	302
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

.INFLUENZA A

Facility

$113.00

Service Code	HCPCS 87804
Hospital Charge Code	4087804
Hospital Revenue Code	300
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

.INFLUENZA A

Facility

$113.00

Service Code	HCPCS 87804
Hospital Charge Code	4087804
Hospital Revenue Code	300
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

.INFLUENZA B

Facility

$113.00

Service Code	HCPCS 87804 59
Hospital Charge Code	4078041
Hospital Revenue Code	300
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

.INFLUENZA B

Facility

$113.00

Service Code	HCPCS 87804 59
Hospital Charge Code	4078041
Hospital Revenue Code	300
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

INFUSURG 1000CC

Facility

$39.00

Hospital Charge Code	80040144
Hospital Revenue Code	270
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

INFUSURG 1000CC

Facility

$39.00

Hospital Charge Code	80040144
Hospital Revenue Code	270
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

INITIAL HOUR OF CHEMO INFUSION

Facility

$890.00

Service Code	HCPCS 96413
Hospital Charge Code	596413
Hospital Revenue Code	280
Min. Negotiated Rate	$623.00
Max. Negotiated Rate	$890.00
Rate for Payer: Aetna Commercial	$845.50
Rate for Payer: Aetna Medicare	$801.00
Rate for Payer: BCBS MT CHIP	$801.00
Rate for Payer: BCBS MT Closed Plan Network	$845.50
Rate for Payer: BCBS MT HealthLink	$801.00
Rate for Payer: BCBS MT Medicare	$801.00
Rate for Payer: BCBS MT POS	$845.50
Rate for Payer: BCBS MT Traditional	$890.00
Rate for Payer: Cash Price	$801.00
Rate for Payer: Cigna Commercial	$845.50
Rate for Payer: Cigna Medicare	$801.00
Rate for Payer: Medicaid All Medicaid	$818.80
Rate for Payer: Medicare All Medicare	$623.00
Rate for Payer: Monida Allegiance	$845.50
Rate for Payer: Monida First Choice Health	$863.30
Rate for Payer: Monida Montana Health Co-op	$845.50
Rate for Payer: Monida PacificSource	$845.50

INITIAL HOUR OF CHEMO INFUSION

Facility

$890.00

Service Code	HCPCS 96413
Hospital Charge Code	596413
Hospital Revenue Code	280
Min. Negotiated Rate	$623.00
Max. Negotiated Rate	$890.00
Rate for Payer: Aetna Commercial	$845.50
Rate for Payer: Aetna Medicare	$801.00
Rate for Payer: BCBS MT CHIP	$801.00
Rate for Payer: BCBS MT Closed Plan Network	$845.50
Rate for Payer: BCBS MT HealthLink	$801.00
Rate for Payer: BCBS MT Medicare	$801.00
Rate for Payer: BCBS MT POS	$845.50
Rate for Payer: BCBS MT Traditional	$890.00
Rate for Payer: Cash Price	$801.00
Rate for Payer: Cigna Commercial	$845.50
Rate for Payer: Cigna Medicare	$801.00
Rate for Payer: Medicaid All Medicaid	$818.80
Rate for Payer: Medicare All Medicare	$623.00
Rate for Payer: Monida Allegiance	$845.50
Rate for Payer: Monida First Choice Health	$863.30
Rate for Payer: Monida Montana Health Co-op	$845.50
Rate for Payer: Monida PacificSource	$845.50

INITIAL PSYCH INTAKE

Facility

$300.00

Service Code	HCPCS 90791
Hospital Charge Code	8190791
Hospital Revenue Code	900
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

INITIAL PSYCH INTAKE

Facility

$300.00

Service Code	HCPCS 90791
Hospital Charge Code	8190791
Hospital Revenue Code	900
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

INITIAL PSYCH INTAKE WITH MEDICAL SERVIC

Facility

$333.00

Service Code	HCPCS 90792
Hospital Charge Code	8190792
Hospital Revenue Code	900
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

INITIAL PSYCH INTAKE WITH MEDICAL SERVIC

Facility

$333.00

Service Code	HCPCS 90792
Hospital Charge Code	8190792
Hospital Revenue Code	900
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

INJ AND/OR ASPIR JNT INTRMD W/O US 20605

Facility

$380.00

Service Code	HCPCS 20605
Hospital Charge Code	520605
Hospital Revenue Code	761
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

INJ AND/OR ASPIR JNT INTRMD W/O US 20605

Facility

$380.00

Service Code	HCPCS 20605
Hospital Charge Code	520605
Hospital Revenue Code	761
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

INJ AND/OR ASPIR JNT SMALL 20600

Facility

$330.00

Service Code	HCPCS 20600
Hospital Charge Code	520600
Hospital Revenue Code	760
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

INJ AND/OR ASPIR JNT SMALL 20600

Facility

$330.00

Service Code	HCPCS 20600
Hospital Charge Code	520600
Hospital Revenue Code	760
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

INJECTION, THERAPEUTIC CARPAL TUNNEL

Facility

$245.00

Service Code	HCPCS 20526
Hospital Charge Code	1520526
Hospital Revenue Code	761
Min. Negotiated Rate	$171.50
Max. Negotiated Rate	$245.00
Rate for Payer: Aetna Commercial	$232.75
Rate for Payer: Aetna Medicare	$220.50
Rate for Payer: BCBS MT CHIP	$220.50
Rate for Payer: BCBS MT Closed Plan Network	$232.75
Rate for Payer: BCBS MT HealthLink	$220.50
Rate for Payer: BCBS MT Medicare	$220.50
Rate for Payer: BCBS MT POS	$232.75
Rate for Payer: BCBS MT Traditional	$245.00
Rate for Payer: Cash Price	$220.50
Rate for Payer: Cigna Commercial	$232.75
Rate for Payer: Cigna Medicare	$220.50
Rate for Payer: Medicaid All Medicaid	$225.40
Rate for Payer: Medicare All Medicare	$171.50
Rate for Payer: Monida Allegiance	$232.75
Rate for Payer: Monida First Choice Health	$237.65
Rate for Payer: Monida Montana Health Co-op	$232.75
Rate for Payer: Monida PacificSource	$232.75

INJECTION, THERAPEUTIC CARPAL TUNNEL

Facility

$245.00

Service Code	HCPCS 20526
Hospital Charge Code	1520526
Hospital Revenue Code	761
Min. Negotiated Rate	$171.50
Max. Negotiated Rate	$245.00
Rate for Payer: Aetna Commercial	$232.75
Rate for Payer: Aetna Medicare	$220.50
Rate for Payer: BCBS MT CHIP	$220.50
Rate for Payer: BCBS MT Closed Plan Network	$232.75
Rate for Payer: BCBS MT HealthLink	$220.50
Rate for Payer: BCBS MT Medicare	$220.50
Rate for Payer: BCBS MT POS	$232.75
Rate for Payer: BCBS MT Traditional	$245.00
Rate for Payer: Cash Price	$220.50
Rate for Payer: Cigna Commercial	$232.75
Rate for Payer: Cigna Medicare	$220.50
Rate for Payer: Medicaid All Medicaid	$225.40
Rate for Payer: Medicare All Medicare	$171.50
Rate for Payer: Monida Allegiance	$232.75
Rate for Payer: Monida First Choice Health	$237.65
Rate for Payer: Monida Montana Health Co-op	$232.75
Rate for Payer: Monida PacificSource	$232.75

INJ SQ/IM NURSE ONLY

Facility

$92.00

Service Code	HCPCS 96372
Hospital Charge Code	540196
Hospital Revenue Code	260
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

INJ SQ/IM NURSE ONLY

Facility

$92.00

Service Code	HCPCS 96372
Hospital Charge Code	540196
Hospital Revenue Code	260
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

INS - DEGLUDEC [1 UNIT/ 0.01 ML] INJ

Facility

$566.00

Service Code	NDC 73070040011
Hospital Charge Code	3000555
Hospital Revenue Code	250
Min. Negotiated Rate	$396.20
Max. Negotiated Rate	$566.00
Rate for Payer: Aetna Commercial	$537.70
Rate for Payer: Aetna Medicare	$509.40
Rate for Payer: BCBS MT CHIP	$509.40
Rate for Payer: BCBS MT Closed Plan Network	$537.70
Rate for Payer: BCBS MT HealthLink	$509.40
Rate for Payer: BCBS MT Medicare	$509.40
Rate for Payer: BCBS MT POS	$537.70
Rate for Payer: BCBS MT Traditional	$566.00
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cigna Commercial	$537.70
Rate for Payer: Cigna Medicare	$509.40
Rate for Payer: Medicaid All Medicaid	$520.72
Rate for Payer: Medicare All Medicare	$396.20
Rate for Payer: Monida Allegiance	$537.70
Rate for Payer: Monida First Choice Health	$549.02
Rate for Payer: Monida Montana Health Co-op	$537.70
Rate for Payer: Monida PacificSource	$537.70

INS - DEGLUDEC [1 UNIT/ 0.01 ML] INJ

Facility

$566.00

Service Code	NDC 73070040011
Hospital Charge Code	3000555
Hospital Revenue Code	250
Min. Negotiated Rate	$396.20
Max. Negotiated Rate	$566.00
Rate for Payer: Aetna Commercial	$537.70
Rate for Payer: Aetna Medicare	$509.40
Rate for Payer: BCBS MT CHIP	$509.40
Rate for Payer: BCBS MT Closed Plan Network	$537.70
Rate for Payer: BCBS MT HealthLink	$509.40
Rate for Payer: BCBS MT Medicare	$509.40
Rate for Payer: BCBS MT POS	$537.70
Rate for Payer: BCBS MT Traditional	$566.00
Rate for Payer: Cash Price	$509.40
Rate for Payer: Cigna Commercial	$537.70
Rate for Payer: Cigna Medicare	$509.40
Rate for Payer: Medicaid All Medicaid	$520.72
Rate for Payer: Medicare All Medicare	$396.20
Rate for Payer: Monida Allegiance	$537.70
Rate for Payer: Monida First Choice Health	$549.02
Rate for Payer: Monida Montana Health Co-op	$537.70
Rate for Payer: Monida PacificSource	$537.70

INSERT DEVICE CENTRAL VENOUS W/PORT >5YR

Facility

$4,825.00

Service Code	HCPCS 36561
Hospital Charge Code	1036561
Hospital Revenue Code	761
Min. Negotiated Rate	$3,377.50
Max. Negotiated Rate	$4,825.00
Rate for Payer: Aetna Commercial	$4,583.75
Rate for Payer: Aetna Medicare	$4,342.50
Rate for Payer: BCBS MT CHIP	$4,342.50
Rate for Payer: BCBS MT Closed Plan Network	$4,583.75
Rate for Payer: BCBS MT HealthLink	$4,342.50
Rate for Payer: BCBS MT Medicare	$4,342.50
Rate for Payer: BCBS MT POS	$4,583.75
Rate for Payer: BCBS MT Traditional	$4,825.00
Rate for Payer: Cash Price	$4,342.50
Rate for Payer: Cigna Commercial	$4,583.75
Rate for Payer: Cigna Medicare	$4,342.50
Rate for Payer: Medicaid All Medicaid	$4,439.00
Rate for Payer: Medicare All Medicare	$3,377.50
Rate for Payer: Monida Allegiance	$4,583.75
Rate for Payer: Monida First Choice Health	$4,680.25
Rate for Payer: Monida Montana Health Co-op	$4,583.75
Rate for Payer: Monida PacificSource	$4,583.75

INSERT DEVICE CENTRAL VENOUS W/PORT >5YR

Facility

$4,825.00

Service Code	HCPCS 36561
Hospital Charge Code	1036561
Hospital Revenue Code	761
Min. Negotiated Rate	$3,377.50
Max. Negotiated Rate	$4,825.00
Rate for Payer: Aetna Commercial	$4,583.75
Rate for Payer: Aetna Medicare	$4,342.50
Rate for Payer: BCBS MT CHIP	$4,342.50
Rate for Payer: BCBS MT Closed Plan Network	$4,583.75
Rate for Payer: BCBS MT HealthLink	$4,342.50
Rate for Payer: BCBS MT Medicare	$4,342.50
Rate for Payer: BCBS MT POS	$4,583.75
Rate for Payer: BCBS MT Traditional	$4,825.00
Rate for Payer: Cash Price	$4,342.50
Rate for Payer: Cigna Commercial	$4,583.75
Rate for Payer: Cigna Medicare	$4,342.50
Rate for Payer: Medicaid All Medicaid	$4,439.00
Rate for Payer: Medicare All Medicare	$3,377.50
Rate for Payer: Monida Allegiance	$4,583.75
Rate for Payer: Monida First Choice Health	$4,680.25
Rate for Payer: Monida Montana Health Co-op	$4,583.75
Rate for Payer: Monida PacificSource	$4,583.75

Know your out-of-pocket cost for care.

All Charges