Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

.IMMUNOGLOBULIN LIGHT CHAINS

Facility

$108.00

Service Code	HCPCS 83521
Hospital Charge Code	4083521
Hospital Revenue Code	300
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: BCBS MT CHIP	$97.20
Rate for Payer: BCBS MT Closed Plan Network	$102.60
Rate for Payer: BCBS MT HealthLink	$97.20
Rate for Payer: BCBS MT Medicare	$97.20
Rate for Payer: BCBS MT POS	$102.60
Rate for Payer: BCBS MT Traditional	$108.00
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial	$102.60
Rate for Payer: Cigna Medicare	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

IMMUNOGLOBULIN M (001792)

Facility

$68.00

Service Code	HCPCS 82784
Hospital Charge Code	4000059
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

IMMUNOGLOBULIN M (001792)

Facility

$68.00

Service Code	HCPCS 82784
Hospital Charge Code	4000059
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

.IMMUNOGLOBULIN SUBCLASS

Facility

$38.00

Service Code	HCPCS 82787
Hospital Charge Code	4082787
Hospital Revenue Code	300
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

.IMMUNOGLOBULIN SUBCLASS

Facility

$38.00

Service Code	HCPCS 82787
Hospital Charge Code	4082787
Hospital Revenue Code	300
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

.IMMUNOGLOBULIN SUBCLASS (209601 ONLY)

Facility

$62.00

Service Code	HCPCS 82787
Hospital Charge Code	4027870
Hospital Revenue Code	300
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

.IMMUNOGLOBULIN SUBCLASS (209601 ONLY)

Facility

$62.00

Service Code	HCPCS 82787
Hospital Charge Code	4027870
Hospital Revenue Code	300
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

INCISION OF THROMBOSED HEMORRHOID, EXTER

Facility

$405.00

Service Code	HCPCS 46083
Hospital Charge Code	1046083
Hospital Revenue Code	450
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna Commercial	$384.75
Rate for Payer: Aetna Medicare	$364.50
Rate for Payer: BCBS MT CHIP	$364.50
Rate for Payer: BCBS MT Closed Plan Network	$384.75
Rate for Payer: BCBS MT HealthLink	$364.50
Rate for Payer: BCBS MT Medicare	$364.50
Rate for Payer: BCBS MT POS	$384.75
Rate for Payer: BCBS MT Traditional	$405.00
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cigna Commercial	$384.75
Rate for Payer: Cigna Medicare	$364.50
Rate for Payer: Medicaid All Medicaid	$372.60
Rate for Payer: Medicare All Medicare	$283.50
Rate for Payer: Monida Allegiance	$384.75
Rate for Payer: Monida First Choice Health	$392.85
Rate for Payer: Monida Montana Health Co-op	$384.75
Rate for Payer: Monida PacificSource	$384.75

INCISION OF THROMBOSED HEMORRHOID, EXTER

Facility

$405.00

Service Code	HCPCS 46083
Hospital Charge Code	1046083
Hospital Revenue Code	450
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna Commercial	$384.75
Rate for Payer: Aetna Medicare	$364.50
Rate for Payer: BCBS MT CHIP	$364.50
Rate for Payer: BCBS MT Closed Plan Network	$384.75
Rate for Payer: BCBS MT HealthLink	$364.50
Rate for Payer: BCBS MT Medicare	$364.50
Rate for Payer: BCBS MT POS	$384.75
Rate for Payer: BCBS MT Traditional	$405.00
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cigna Commercial	$384.75
Rate for Payer: Cigna Medicare	$364.50
Rate for Payer: Medicaid All Medicaid	$372.60
Rate for Payer: Medicare All Medicare	$283.50
Rate for Payer: Monida Allegiance	$384.75
Rate for Payer: Monida First Choice Health	$392.85
Rate for Payer: Monida Montana Health Co-op	$384.75
Rate for Payer: Monida PacificSource	$384.75

INDOMETHACIN CAP[25 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000230
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

INDOMETHACIN CAP[25 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000230
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

INFANT CATH KIT

Facility

$18.00

Hospital Charge Code	80040206
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

INFANT CATH KIT

Facility

$18.00

Hospital Charge Code	80040206
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

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

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

INFILXIMAB QUANTITATION WITH REFLEX

Facility

$372.00

Service Code	HCPCS 80230
Hospital Charge Code	4087949
Hospital Revenue Code	300
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$372.00
Rate for Payer: Aetna Commercial	$353.40
Rate for Payer: Aetna Medicare	$334.80
Rate for Payer: BCBS MT CHIP	$334.80
Rate for Payer: BCBS MT Closed Plan Network	$353.40
Rate for Payer: BCBS MT HealthLink	$334.80
Rate for Payer: BCBS MT Medicare	$334.80
Rate for Payer: BCBS MT POS	$353.40
Rate for Payer: BCBS MT Traditional	$372.00
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cigna Commercial	$353.40
Rate for Payer: Cigna Medicare	$334.80
Rate for Payer: Medicaid All Medicaid	$342.24
Rate for Payer: Medicare All Medicare	$260.40
Rate for Payer: Monida Allegiance	$353.40
Rate for Payer: Monida First Choice Health	$360.84
Rate for Payer: Monida Montana Health Co-op	$353.40
Rate for Payer: Monida PacificSource	$353.40

INFILXIMAB QUANTITATION WITH REFLEX

Facility

$372.00

Service Code	HCPCS 80230
Hospital Charge Code	4087949
Hospital Revenue Code	300
Min. Negotiated Rate	$260.40
Max. Negotiated Rate	$372.00
Rate for Payer: Aetna Commercial	$353.40
Rate for Payer: Aetna Medicare	$334.80
Rate for Payer: BCBS MT CHIP	$334.80
Rate for Payer: BCBS MT Closed Plan Network	$353.40
Rate for Payer: BCBS MT HealthLink	$334.80
Rate for Payer: BCBS MT Medicare	$334.80
Rate for Payer: BCBS MT POS	$353.40
Rate for Payer: BCBS MT Traditional	$372.00
Rate for Payer: Cash Price	$334.80
Rate for Payer: Cigna Commercial	$353.40
Rate for Payer: Cigna Medicare	$334.80
Rate for Payer: Medicaid All Medicaid	$342.24
Rate for Payer: Medicare All Medicare	$260.40
Rate for Payer: Monida Allegiance	$353.40
Rate for Payer: Monida First Choice Health	$360.84
Rate for Payer: Monida Montana Health Co-op	$353.40
Rate for Payer: Monida PacificSource	$353.40

.INFLUENZA A

Facility

$120.00

Service Code	HCPCS 87804
Hospital Charge Code	4087804
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

.INFLUENZA A

Facility

$120.00

Service Code	HCPCS 87804
Hospital Charge Code	4087804
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

INFLUENZA A&B, ID NOW

Facility

$255.00

Service Code	HCPCS 87502
Hospital Charge Code	4087920
Hospital Revenue Code	300
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$255.00
Rate for Payer: Aetna Commercial	$242.25
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: BCBS MT CHIP	$229.50
Rate for Payer: BCBS MT Closed Plan Network	$242.25
Rate for Payer: BCBS MT HealthLink	$229.50
Rate for Payer: BCBS MT Medicare	$229.50
Rate for Payer: BCBS MT POS	$242.25
Rate for Payer: BCBS MT Traditional	$255.00
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cigna Commercial	$242.25
Rate for Payer: Cigna Medicare	$229.50
Rate for Payer: Medicaid All Medicaid	$234.60
Rate for Payer: Medicare All Medicare	$178.50
Rate for Payer: Monida Allegiance	$242.25
Rate for Payer: Monida First Choice Health	$247.35
Rate for Payer: Monida Montana Health Co-op	$242.25
Rate for Payer: Monida PacificSource	$242.25

INFLUENZA A&B, ID NOW

Facility

$255.00

Service Code	HCPCS 87502
Hospital Charge Code	4087920
Hospital Revenue Code	300
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$255.00
Rate for Payer: Aetna Commercial	$242.25
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: BCBS MT CHIP	$229.50
Rate for Payer: BCBS MT Closed Plan Network	$242.25
Rate for Payer: BCBS MT HealthLink	$229.50
Rate for Payer: BCBS MT Medicare	$229.50
Rate for Payer: BCBS MT POS	$242.25
Rate for Payer: BCBS MT Traditional	$255.00
Rate for Payer: Cash Price	$229.50
Rate for Payer: Cigna Commercial	$242.25
Rate for Payer: Cigna Medicare	$229.50
Rate for Payer: Medicaid All Medicaid	$234.60
Rate for Payer: Medicare All Medicare	$178.50
Rate for Payer: Monida Allegiance	$242.25
Rate for Payer: Monida First Choice Health	$247.35
Rate for Payer: Monida Montana Health Co-op	$242.25
Rate for Payer: Monida PacificSource	$242.25

.INFLUENZA B

Facility

$120.00

Service Code	HCPCS 87804 59
Hospital Charge Code	4078041
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

.INFLUENZA B

Facility

$120.00

Service Code	HCPCS 87804 59
Hospital Charge Code	4078041
Hospital Revenue Code	300
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

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

Know your out-of-pocket cost for care.

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