Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INSERTION OF PICC LINE

Facility

$1,858.50

Service Code	HCPCS 36569
Hospital Charge Code	536569
Hospital Revenue Code	761
Min. Negotiated Rate	$1,300.95
Max. Negotiated Rate	$1,858.50
Rate for Payer: Aetna Commercial	$1,765.58
Rate for Payer: Aetna Medicare	$1,672.65
Rate for Payer: BCBS MT CHIP	$1,672.65
Rate for Payer: BCBS MT Closed Plan Network	$1,765.58
Rate for Payer: BCBS MT HealthLink	$1,672.65
Rate for Payer: BCBS MT Medicare	$1,672.65
Rate for Payer: BCBS MT POS	$1,765.58
Rate for Payer: BCBS MT Traditional	$1,858.50
Rate for Payer: Cash Price	$1,672.65
Rate for Payer: Cigna Commercial	$1,765.58
Rate for Payer: Cigna Medicare	$1,672.65
Rate for Payer: Medicaid All Medicaid	$1,709.82
Rate for Payer: Medicare All Medicare	$1,300.95
Rate for Payer: Monida Allegiance	$1,765.58
Rate for Payer: Monida First Choice Health	$1,802.74
Rate for Payer: Monida Montana Health Co-op	$1,765.58
Rate for Payer: Monida PacificSource	$1,765.58

INSERTION OF PICC LINE

Facility

$1,858.50

Service Code	HCPCS 36569
Hospital Charge Code	536569
Hospital Revenue Code	761
Min. Negotiated Rate	$1,300.95
Max. Negotiated Rate	$1,858.50
Rate for Payer: Aetna Commercial	$1,765.58
Rate for Payer: Aetna Medicare	$1,672.65
Rate for Payer: BCBS MT CHIP	$1,672.65
Rate for Payer: BCBS MT Closed Plan Network	$1,765.58
Rate for Payer: BCBS MT HealthLink	$1,672.65
Rate for Payer: BCBS MT Medicare	$1,672.65
Rate for Payer: BCBS MT POS	$1,765.58
Rate for Payer: BCBS MT Traditional	$1,858.50
Rate for Payer: Cash Price	$1,672.65
Rate for Payer: Cigna Commercial	$1,765.58
Rate for Payer: Cigna Medicare	$1,672.65
Rate for Payer: Medicaid All Medicaid	$1,709.82
Rate for Payer: Medicare All Medicare	$1,300.95
Rate for Payer: Monida Allegiance	$1,765.58
Rate for Payer: Monida First Choice Health	$1,802.74
Rate for Payer: Monida Montana Health Co-op	$1,765.58
Rate for Payer: Monida PacificSource	$1,765.58

INS - GLARGINE INJ [1 UNITS/0.01 ML]

Facility

$6.00

Service Code	HCPCS J1815
Hospital Charge Code	3000231
Hospital Revenue Code	250
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

INS - GLARGINE INJ [1 UNITS/0.01 ML]

Facility

$6.00

Service Code	HCPCS J1815
Hospital Charge Code	3000231
Hospital Revenue Code	250
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

INS - LISPRO [1 UN/0.01 ML] MEAL TIME

Facility

$27.00

Service Code	HCPCS J1817
Hospital Charge Code	3000233
Hospital Revenue Code	636
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

INS - LISPRO [1 UN/0.01 ML] MEAL TIME

Facility

$27.00

Service Code	HCPCS J1817
Hospital Charge Code	3000233
Hospital Revenue Code	636
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

INS - NOVOLIN 70/30 MIX [1U/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000236
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN 70/30 MIX [1U/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000236
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN NPH [1 UNITS/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000234
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN NPH [1 UNITS/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000234
Hospital Revenue Code	636
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN REGULAR [1 UNITS/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000235
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS - NOVOLIN REGULAR [1 UNITS/0.01 ML]

Facility

$5.00

Service Code	HCPCS J1815
Hospital Charge Code	3000235
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INS-NOVOLOG 100U/1ML INJECTION 10ML VIAL

Facility

$503.50

Service Code	HCPCS J1817
Hospital Charge Code	3007216
Hospital Revenue Code	250
Min. Negotiated Rate	$352.45
Max. Negotiated Rate	$503.50
Rate for Payer: Aetna Commercial	$478.32
Rate for Payer: Aetna Medicare	$453.15
Rate for Payer: BCBS MT CHIP	$453.15
Rate for Payer: BCBS MT Closed Plan Network	$478.32
Rate for Payer: BCBS MT HealthLink	$453.15
Rate for Payer: BCBS MT Medicare	$453.15
Rate for Payer: BCBS MT POS	$478.32
Rate for Payer: BCBS MT Traditional	$503.50
Rate for Payer: Cash Price	$453.15
Rate for Payer: Cigna Commercial	$478.32
Rate for Payer: Cigna Medicare	$453.15
Rate for Payer: Medicaid All Medicaid	$463.22
Rate for Payer: Medicare All Medicare	$352.45
Rate for Payer: Monida Allegiance	$478.32
Rate for Payer: Monida First Choice Health	$488.40
Rate for Payer: Monida Montana Health Co-op	$478.32
Rate for Payer: Monida PacificSource	$478.32

INS-NOVOLOG 100U/1ML INJECTION 10ML VIAL

Facility

$503.50

Service Code	HCPCS J1817
Hospital Charge Code	3007216
Hospital Revenue Code	250
Min. Negotiated Rate	$352.45
Max. Negotiated Rate	$503.50
Rate for Payer: Aetna Commercial	$478.32
Rate for Payer: Aetna Medicare	$453.15
Rate for Payer: BCBS MT CHIP	$453.15
Rate for Payer: BCBS MT Closed Plan Network	$478.32
Rate for Payer: BCBS MT HealthLink	$453.15
Rate for Payer: BCBS MT Medicare	$453.15
Rate for Payer: BCBS MT POS	$478.32
Rate for Payer: BCBS MT Traditional	$503.50
Rate for Payer: Cash Price	$453.15
Rate for Payer: Cigna Commercial	$478.32
Rate for Payer: Cigna Medicare	$453.15
Rate for Payer: Medicaid All Medicaid	$463.22
Rate for Payer: Medicare All Medicare	$352.45
Rate for Payer: Monida Allegiance	$478.32
Rate for Payer: Monida First Choice Health	$488.40
Rate for Payer: Monida Montana Health Co-op	$478.32
Rate for Payer: Monida PacificSource	$478.32

INS - REGULAR [HUMULIN] 100UN/ML 3ML

Facility

$60.00

Service Code	HCPCS J1815
Hospital Charge Code	3000232
Hospital Revenue Code	636
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

INS - REGULAR [HUMULIN] 100UN/ML 3ML

Facility

$60.00

Service Code	HCPCS J1815
Hospital Charge Code	3000232
Hospital Revenue Code	636
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

INSULIN LEVEL (004333)

Facility

$17.00

Service Code	HCPCS 83525
Hospital Charge Code	4083525
Hospital Revenue Code	301
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

INSULIN LEVEL (004333)

Facility

$17.00

Service Code	HCPCS 83525
Hospital Charge Code	4083525
Hospital Revenue Code	301
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

INSULIN-LIKE GROWTH FACTOR-1 (010363)

Facility

$118.00

Service Code	HCPCS 84305
Hospital Charge Code	4084305
Hospital Revenue Code	301
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$118.00
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare	$106.20
Rate for Payer: BCBS MT CHIP	$106.20
Rate for Payer: BCBS MT Closed Plan Network	$112.10
Rate for Payer: BCBS MT HealthLink	$106.20
Rate for Payer: BCBS MT Medicare	$106.20
Rate for Payer: BCBS MT POS	$112.10
Rate for Payer: BCBS MT Traditional	$118.00
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cigna Commercial	$112.10
Rate for Payer: Cigna Medicare	$106.20
Rate for Payer: Medicaid All Medicaid	$108.56
Rate for Payer: Medicare All Medicare	$82.60
Rate for Payer: Monida Allegiance	$112.10
Rate for Payer: Monida First Choice Health	$114.46
Rate for Payer: Monida Montana Health Co-op	$112.10
Rate for Payer: Monida PacificSource	$112.10

INSULIN-LIKE GROWTH FACTOR-1 (010363)

Facility

$118.00

Service Code	HCPCS 84305
Hospital Charge Code	4084305
Hospital Revenue Code	301
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$118.00
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare	$106.20
Rate for Payer: BCBS MT CHIP	$106.20
Rate for Payer: BCBS MT Closed Plan Network	$112.10
Rate for Payer: BCBS MT HealthLink	$106.20
Rate for Payer: BCBS MT Medicare	$106.20
Rate for Payer: BCBS MT POS	$112.10
Rate for Payer: BCBS MT Traditional	$118.00
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cigna Commercial	$112.10
Rate for Payer: Cigna Medicare	$106.20
Rate for Payer: Medicaid All Medicaid	$108.56
Rate for Payer: Medicare All Medicare	$82.60
Rate for Payer: Monida Allegiance	$112.10
Rate for Payer: Monida First Choice Health	$114.46
Rate for Payer: Monida Montana Health Co-op	$112.10
Rate for Payer: Monida PacificSource	$112.10

INTRA LESION CHEMO ADMIN MORE THAT 7 LES

Facility

$455.00

Service Code	HCPCS 96406
Hospital Charge Code	596406
Hospital Revenue Code	280
Min. Negotiated Rate	$318.50
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial	$432.25
Rate for Payer: Aetna Medicare	$409.50
Rate for Payer: BCBS MT CHIP	$409.50
Rate for Payer: BCBS MT Closed Plan Network	$432.25
Rate for Payer: BCBS MT HealthLink	$409.50
Rate for Payer: BCBS MT Medicare	$409.50
Rate for Payer: BCBS MT POS	$432.25
Rate for Payer: BCBS MT Traditional	$455.00
Rate for Payer: Cash Price	$409.50
Rate for Payer: Cigna Commercial	$432.25
Rate for Payer: Cigna Medicare	$409.50
Rate for Payer: Medicaid All Medicaid	$418.60
Rate for Payer: Medicare All Medicare	$318.50
Rate for Payer: Monida Allegiance	$432.25
Rate for Payer: Monida First Choice Health	$441.35
Rate for Payer: Monida Montana Health Co-op	$432.25
Rate for Payer: Monida PacificSource	$432.25

INTRA LESION CHEMO ADMIN MORE THAT 7 LES

Facility

$455.00

Service Code	HCPCS 96406
Hospital Charge Code	596406
Hospital Revenue Code	280
Min. Negotiated Rate	$318.50
Max. Negotiated Rate	$455.00
Rate for Payer: Aetna Commercial	$432.25
Rate for Payer: Aetna Medicare	$409.50
Rate for Payer: BCBS MT CHIP	$409.50
Rate for Payer: BCBS MT Closed Plan Network	$432.25
Rate for Payer: BCBS MT HealthLink	$409.50
Rate for Payer: BCBS MT Medicare	$409.50
Rate for Payer: BCBS MT POS	$432.25
Rate for Payer: BCBS MT Traditional	$455.00
Rate for Payer: Cash Price	$409.50
Rate for Payer: Cigna Commercial	$432.25
Rate for Payer: Cigna Medicare	$409.50
Rate for Payer: Medicaid All Medicaid	$418.60
Rate for Payer: Medicare All Medicare	$318.50
Rate for Payer: Monida Allegiance	$432.25
Rate for Payer: Monida First Choice Health	$441.35
Rate for Payer: Monida Montana Health Co-op	$432.25
Rate for Payer: Monida PacificSource	$432.25

INTRA LESION CHEMO ADMIN UP TO 7 LES

Facility

$278.00

Service Code	HCPCS 96405
Hospital Charge Code	596405
Hospital Revenue Code	280
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

INTRA LESION CHEMO ADMIN UP TO 7 LES

Facility

$278.00

Service Code	HCPCS 96405
Hospital Charge Code	596405
Hospital Revenue Code	280
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

INTREPID INITIAL EVAL/DISCHARGE

Facility

$176.00

Service Code	HCPCS G0151
Hospital Charge Code	611001
Hospital Revenue Code	421
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$176.00
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$158.40
Rate for Payer: BCBS MT CHIP	$158.40
Rate for Payer: BCBS MT Closed Plan Network	$167.20
Rate for Payer: BCBS MT HealthLink	$158.40
Rate for Payer: BCBS MT Medicare	$158.40
Rate for Payer: BCBS MT POS	$167.20
Rate for Payer: BCBS MT Traditional	$176.00
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cigna Commercial	$167.20
Rate for Payer: Cigna Medicare	$158.40
Rate for Payer: Medicaid All Medicaid	$161.92
Rate for Payer: Medicare All Medicare	$123.20
Rate for Payer: Monida Allegiance	$167.20
Rate for Payer: Monida First Choice Health	$170.72
Rate for Payer: Monida Montana Health Co-op	$167.20
Rate for Payer: Monida PacificSource	$167.20

Know your out-of-pocket cost for care.

All Charges