Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$318.00

Service Code	HCPCS 90791
Hospital Charge Code	8190791
Hospital Revenue Code	900
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

INITIAL PSYCH INTAKE

Facility

$318.00

Service Code	HCPCS 90791
Hospital Charge Code	8190791
Hospital Revenue Code	900
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

INITIAL PSYCH INTAKE WITH MEDICAL SERVIC

Facility

$353.00

Service Code	HCPCS 90792
Hospital Charge Code	8190792
Hospital Revenue Code	900
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

INITIAL PSYCH INTAKE WITH MEDICAL SERVIC

Facility

$353.00

Service Code	HCPCS 90792
Hospital Charge Code	8190792
Hospital Revenue Code	900
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

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

Facility

$672.00

Service Code	HCPCS 20605
Hospital Charge Code	520605
Hospital Revenue Code	761
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

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

Facility

$672.00

Service Code	HCPCS 20605
Hospital Charge Code	520605
Hospital Revenue Code	761
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

INJ AND/OR ASPIR JNT SMALL 20600

Facility

$396.00

Service Code	HCPCS 20600
Hospital Charge Code	520600
Hospital Revenue Code	760
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: Aetna Medicare	$356.40
Rate for Payer: BCBS MT CHIP	$356.40
Rate for Payer: BCBS MT Closed Plan Network	$376.20
Rate for Payer: BCBS MT HealthLink	$356.40
Rate for Payer: BCBS MT Medicare	$356.40
Rate for Payer: BCBS MT POS	$376.20
Rate for Payer: BCBS MT Traditional	$396.00
Rate for Payer: Cash Price	$356.40
Rate for Payer: Cigna Commercial	$376.20
Rate for Payer: Cigna Medicare	$356.40
Rate for Payer: Medicaid All Medicaid	$364.32
Rate for Payer: Medicare All Medicare	$277.20
Rate for Payer: Monida Allegiance	$376.20
Rate for Payer: Monida First Choice Health	$384.12
Rate for Payer: Monida Montana Health Co-op	$376.20
Rate for Payer: Monida PacificSource	$376.20

INJ AND/OR ASPIR JNT SMALL 20600

Facility

$396.00

Service Code	HCPCS 20600
Hospital Charge Code	520600
Hospital Revenue Code	760
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: Aetna Medicare	$356.40
Rate for Payer: BCBS MT CHIP	$356.40
Rate for Payer: BCBS MT Closed Plan Network	$376.20
Rate for Payer: BCBS MT HealthLink	$356.40
Rate for Payer: BCBS MT Medicare	$356.40
Rate for Payer: BCBS MT POS	$376.20
Rate for Payer: BCBS MT Traditional	$396.00
Rate for Payer: Cash Price	$356.40
Rate for Payer: Cigna Commercial	$376.20
Rate for Payer: Cigna Medicare	$356.40
Rate for Payer: Medicaid All Medicaid	$364.32
Rate for Payer: Medicare All Medicare	$277.20
Rate for Payer: Monida Allegiance	$376.20
Rate for Payer: Monida First Choice Health	$384.12
Rate for Payer: Monida Montana Health Co-op	$376.20
Rate for Payer: Monida PacificSource	$376.20

INJECTION, THERAPEUTIC CARPAL TUNNEL

Facility

$260.00

Service Code	HCPCS 20526
Hospital Charge Code	1520526
Hospital Revenue Code	761
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

INJECTION, THERAPEUTIC CARPAL TUNNEL

Facility

$260.00

Service Code	HCPCS 20526
Hospital Charge Code	1520526
Hospital Revenue Code	761
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

INJ SQ/IM NURSE ONLY

Facility

$98.00

Service Code	HCPCS 96372
Hospital Charge Code	540196
Hospital Revenue Code	260
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

INJ SQ/IM NURSE ONLY

Facility

$98.00

Service Code	HCPCS 96372
Hospital Charge Code	540196
Hospital Revenue Code	260
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

INS - DEGLUDEC [1 UNIT/ 0.01 ML] SPEC OR

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] SPEC OR

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

$5,115.00

Service Code	HCPCS 36561
Hospital Charge Code	1036561
Hospital Revenue Code	761
Min. Negotiated Rate	$3,580.50
Max. Negotiated Rate	$5,115.00
Rate for Payer: Aetna Commercial	$4,859.25
Rate for Payer: Aetna Medicare	$4,603.50
Rate for Payer: BCBS MT CHIP	$4,603.50
Rate for Payer: BCBS MT Closed Plan Network	$4,859.25
Rate for Payer: BCBS MT HealthLink	$4,603.50
Rate for Payer: BCBS MT Medicare	$4,603.50
Rate for Payer: BCBS MT POS	$4,859.25
Rate for Payer: BCBS MT Traditional	$5,115.00
Rate for Payer: Cash Price	$4,603.50
Rate for Payer: Cigna Commercial	$4,859.25
Rate for Payer: Cigna Medicare	$4,603.50
Rate for Payer: Medicaid All Medicaid	$4,705.80
Rate for Payer: Medicare All Medicare	$3,580.50
Rate for Payer: Monida Allegiance	$4,859.25
Rate for Payer: Monida First Choice Health	$4,961.55
Rate for Payer: Monida Montana Health Co-op	$4,859.25
Rate for Payer: Monida PacificSource	$4,859.25

INSERT DEVICE CENTRAL VENOUS W/PORT >5YR

Facility

$5,115.00

Service Code	HCPCS 36561
Hospital Charge Code	1036561
Hospital Revenue Code	761
Min. Negotiated Rate	$3,580.50
Max. Negotiated Rate	$5,115.00
Rate for Payer: Aetna Commercial	$4,859.25
Rate for Payer: Aetna Medicare	$4,603.50
Rate for Payer: BCBS MT CHIP	$4,603.50
Rate for Payer: BCBS MT Closed Plan Network	$4,859.25
Rate for Payer: BCBS MT HealthLink	$4,603.50
Rate for Payer: BCBS MT Medicare	$4,603.50
Rate for Payer: BCBS MT POS	$4,859.25
Rate for Payer: BCBS MT Traditional	$5,115.00
Rate for Payer: Cash Price	$4,603.50
Rate for Payer: Cigna Commercial	$4,859.25
Rate for Payer: Cigna Medicare	$4,603.50
Rate for Payer: Medicaid All Medicaid	$4,705.80
Rate for Payer: Medicare All Medicare	$3,580.50
Rate for Payer: Monida Allegiance	$4,859.25
Rate for Payer: Monida First Choice Health	$4,961.55
Rate for Payer: Monida Montana Health Co-op	$4,859.25
Rate for Payer: Monida PacificSource	$4,859.25

INSERTION OF PICC LINE

Facility

$1,970.00

Service Code	HCPCS 36569
Hospital Charge Code	536569
Hospital Revenue Code	761
Min. Negotiated Rate	$1,379.00
Max. Negotiated Rate	$1,970.00
Rate for Payer: Aetna Commercial	$1,871.50
Rate for Payer: Aetna Medicare	$1,773.00
Rate for Payer: BCBS MT CHIP	$1,773.00
Rate for Payer: BCBS MT Closed Plan Network	$1,871.50
Rate for Payer: BCBS MT HealthLink	$1,773.00
Rate for Payer: BCBS MT Medicare	$1,773.00
Rate for Payer: BCBS MT POS	$1,871.50
Rate for Payer: BCBS MT Traditional	$1,970.00
Rate for Payer: Cash Price	$1,773.00
Rate for Payer: Cigna Commercial	$1,871.50
Rate for Payer: Cigna Medicare	$1,773.00
Rate for Payer: Medicaid All Medicaid	$1,812.40
Rate for Payer: Medicare All Medicare	$1,379.00
Rate for Payer: Monida Allegiance	$1,871.50
Rate for Payer: Monida First Choice Health	$1,910.90
Rate for Payer: Monida Montana Health Co-op	$1,871.50
Rate for Payer: Monida PacificSource	$1,871.50

INSERTION OF PICC LINE

Facility

$1,970.00

Service Code	HCPCS 36569
Hospital Charge Code	536569
Hospital Revenue Code	761
Min. Negotiated Rate	$1,379.00
Max. Negotiated Rate	$1,970.00
Rate for Payer: Aetna Commercial	$1,871.50
Rate for Payer: Aetna Medicare	$1,773.00
Rate for Payer: BCBS MT CHIP	$1,773.00
Rate for Payer: BCBS MT Closed Plan Network	$1,871.50
Rate for Payer: BCBS MT HealthLink	$1,773.00
Rate for Payer: BCBS MT Medicare	$1,773.00
Rate for Payer: BCBS MT POS	$1,871.50
Rate for Payer: BCBS MT Traditional	$1,970.00
Rate for Payer: Cash Price	$1,773.00
Rate for Payer: Cigna Commercial	$1,871.50
Rate for Payer: Cigna Medicare	$1,773.00
Rate for Payer: Medicaid All Medicaid	$1,812.40
Rate for Payer: Medicare All Medicare	$1,379.00
Rate for Payer: Monida Allegiance	$1,871.50
Rate for Payer: Monida First Choice Health	$1,910.90
Rate for Payer: Monida Montana Health Co-op	$1,871.50
Rate for Payer: Monida PacificSource	$1,871.50

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

Know your out-of-pocket cost for care.

All Charges