Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

APPLICATION LONG ARM SPLINT

Facility

$366.00

Service Code	CPT 29105
Hospital Charge Code	8029105
Hospital Revenue Code	521
Min. Negotiated Rate	$256.20
Max. Negotiated Rate	$366.00
Rate for Payer: Aetna Commercial	$347.70
Rate for Payer: Aetna Medicare	$329.40
Rate for Payer: BCBS MT CHIP	$329.40
Rate for Payer: BCBS MT Closed Plan Network	$347.70
Rate for Payer: BCBS MT HealthLink	$329.40
Rate for Payer: BCBS MT Medicare	$329.40
Rate for Payer: BCBS MT POS	$347.70
Rate for Payer: BCBS MT Traditional	$366.00
Rate for Payer: Cash Price	$329.40
Rate for Payer: Cigna Commercial	$347.70
Rate for Payer: Cigna Medicare	$329.40
Rate for Payer: Medicaid All Medicaid	$336.72
Rate for Payer: Medicare All Medicare	$256.20
Rate for Payer: Monida Allegiance	$347.70
Rate for Payer: Monida First Choice Health	$355.02
Rate for Payer: Monida Montana Health Co-op	$347.70
Rate for Payer: Monida PacificSource	$347.70

APPLICATION LONG ARM SPLINT

Facility

$366.00

Service Code	CPT 29105
Hospital Charge Code	8029105
Hospital Revenue Code	521
Min. Negotiated Rate	$256.20
Max. Negotiated Rate	$366.00
Rate for Payer: Aetna Commercial	$347.70
Rate for Payer: Aetna Medicare	$329.40
Rate for Payer: BCBS MT CHIP	$329.40
Rate for Payer: BCBS MT Closed Plan Network	$347.70
Rate for Payer: BCBS MT HealthLink	$329.40
Rate for Payer: BCBS MT Medicare	$329.40
Rate for Payer: BCBS MT POS	$347.70
Rate for Payer: BCBS MT Traditional	$366.00
Rate for Payer: Cash Price	$329.40
Rate for Payer: Cigna Commercial	$347.70
Rate for Payer: Cigna Medicare	$329.40
Rate for Payer: Medicaid All Medicaid	$336.72
Rate for Payer: Medicare All Medicare	$256.20
Rate for Payer: Monida Allegiance	$347.70
Rate for Payer: Monida First Choice Health	$355.02
Rate for Payer: Monida Montana Health Co-op	$347.70
Rate for Payer: Monida PacificSource	$347.70

APPLICATION LONG LEG SPLINT

Facility

$348.00

Service Code	CPT 29505
Hospital Charge Code	8029505
Hospital Revenue Code	521
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

APPLICATION LONG LEG SPLINT

Facility

$348.00

Service Code	CPT 29505
Hospital Charge Code	8029505
Hospital Revenue Code	521
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

APPLICATION SHORT LEG CAST(KNEE TO TOES)

Facility

$295.00

Service Code	CPT 29405
Hospital Charge Code	8029405
Hospital Revenue Code	521
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$295.00
Rate for Payer: Aetna Commercial	$280.25
Rate for Payer: Aetna Medicare	$265.50
Rate for Payer: BCBS MT CHIP	$265.50
Rate for Payer: BCBS MT Closed Plan Network	$280.25
Rate for Payer: BCBS MT HealthLink	$265.50
Rate for Payer: BCBS MT Medicare	$265.50
Rate for Payer: BCBS MT POS	$280.25
Rate for Payer: BCBS MT Traditional	$295.00
Rate for Payer: Cash Price	$265.50
Rate for Payer: Cigna Commercial	$280.25
Rate for Payer: Cigna Medicare	$265.50
Rate for Payer: Medicaid All Medicaid	$271.40
Rate for Payer: Medicare All Medicare	$206.50
Rate for Payer: Monida Allegiance	$280.25
Rate for Payer: Monida First Choice Health	$286.15
Rate for Payer: Monida Montana Health Co-op	$280.25
Rate for Payer: Monida PacificSource	$280.25

APPLICATION SHORT LEG CAST(KNEE TO TOES)

Facility

$295.00

Service Code	CPT 29405
Hospital Charge Code	8029405
Hospital Revenue Code	521
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$295.00
Rate for Payer: Aetna Commercial	$280.25
Rate for Payer: Aetna Medicare	$265.50
Rate for Payer: BCBS MT CHIP	$265.50
Rate for Payer: BCBS MT Closed Plan Network	$280.25
Rate for Payer: BCBS MT HealthLink	$265.50
Rate for Payer: BCBS MT Medicare	$265.50
Rate for Payer: BCBS MT POS	$280.25
Rate for Payer: BCBS MT Traditional	$295.00
Rate for Payer: Cash Price	$265.50
Rate for Payer: Cigna Commercial	$280.25
Rate for Payer: Cigna Medicare	$265.50
Rate for Payer: Medicaid All Medicaid	$271.40
Rate for Payer: Medicare All Medicare	$206.50
Rate for Payer: Monida Allegiance	$280.25
Rate for Payer: Monida First Choice Health	$286.15
Rate for Payer: Monida Montana Health Co-op	$280.25
Rate for Payer: Monida PacificSource	$280.25

APPLICATION SPLINT HAND-LOWER F-ARM

Facility

$330.00

Service Code	CPT 29125
Hospital Charge Code	8029125
Hospital Revenue Code	521
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

APPLICATION SPLINT HAND-LOWER F-ARM

Facility

$330.00

Service Code	CPT 29125
Hospital Charge Code	8029125
Hospital Revenue Code	521
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

APPLICATION SPLINT SHORT LEG

Facility

$341.00

Service Code	CPT 29515
Hospital Charge Code	8029515
Hospital Revenue Code	521
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

APPLICATION SPLINT SHORT LEG

Facility

$341.00

Service Code	CPT 29515
Hospital Charge Code	8029515
Hospital Revenue Code	521
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

APPLY MULTLAY COMPRS LWR LEG 29581

Facility

$489.00

Service Code	CPT 29581
Hospital Charge Code	8029581
Hospital Revenue Code	521
Min. Negotiated Rate	$342.30
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna Commercial	$464.55
Rate for Payer: Aetna Medicare	$440.10
Rate for Payer: BCBS MT CHIP	$440.10
Rate for Payer: BCBS MT Closed Plan Network	$464.55
Rate for Payer: BCBS MT HealthLink	$440.10
Rate for Payer: BCBS MT Medicare	$440.10
Rate for Payer: BCBS MT POS	$464.55
Rate for Payer: BCBS MT Traditional	$489.00
Rate for Payer: Cash Price	$440.10
Rate for Payer: Cigna Commercial	$464.55
Rate for Payer: Cigna Medicare	$440.10
Rate for Payer: Medicaid All Medicaid	$449.88
Rate for Payer: Medicare All Medicare	$342.30
Rate for Payer: Monida Allegiance	$464.55
Rate for Payer: Monida First Choice Health	$474.33
Rate for Payer: Monida Montana Health Co-op	$464.55
Rate for Payer: Monida PacificSource	$464.55

APPLY MULTLAY COMPRS LWR LEG 29581

Facility

$489.00

Service Code	CPT 29581
Hospital Charge Code	8029581
Hospital Revenue Code	521
Min. Negotiated Rate	$342.30
Max. Negotiated Rate	$489.00
Rate for Payer: Aetna Commercial	$464.55
Rate for Payer: Aetna Medicare	$440.10
Rate for Payer: BCBS MT CHIP	$440.10
Rate for Payer: BCBS MT Closed Plan Network	$464.55
Rate for Payer: BCBS MT HealthLink	$440.10
Rate for Payer: BCBS MT Medicare	$440.10
Rate for Payer: BCBS MT POS	$464.55
Rate for Payer: BCBS MT Traditional	$489.00
Rate for Payer: Cash Price	$440.10
Rate for Payer: Cigna Commercial	$464.55
Rate for Payer: Cigna Medicare	$440.10
Rate for Payer: Medicaid All Medicaid	$449.88
Rate for Payer: Medicare All Medicare	$342.30
Rate for Payer: Monida Allegiance	$464.55
Rate for Payer: Monida First Choice Health	$474.33
Rate for Payer: Monida Montana Health Co-op	$464.55
Rate for Payer: Monida PacificSource	$464.55

APPLY SHORT LEG SPLINT

Facility

$341.00

Service Code	CPT 29515
Hospital Charge Code	1029515
Hospital Revenue Code	761
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

APPLY SHORT LEG SPLINT

Facility

$341.00

Service Code	CPT 29515
Hospital Charge Code	1029515
Hospital Revenue Code	761
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

APTT (005207)

Facility

$63.00

Service Code	CPT 85730
Hospital Charge Code	4085730
Hospital Revenue Code	300
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

APTT (005207)

Facility

$63.00

Service Code	CPT 85730
Hospital Charge Code	4085730
Hospital Revenue Code	300
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

ARIPIPRAZOLE TAB [15 MG] NF

Facility

$102.00

Service Code	HCPCS J8499
Hospital Charge Code	3000604
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$96.90
Rate for Payer: Aetna Medicare	$91.80
Rate for Payer: BCBS MT CHIP	$91.80
Rate for Payer: BCBS MT Closed Plan Network	$96.90
Rate for Payer: BCBS MT HealthLink	$91.80
Rate for Payer: BCBS MT Medicare	$91.80
Rate for Payer: BCBS MT POS	$96.90
Rate for Payer: BCBS MT Traditional	$102.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial	$96.90
Rate for Payer: Cigna Medicare	$91.80
Rate for Payer: Medicaid All Medicaid	$93.84
Rate for Payer: Medicare All Medicare	$71.40
Rate for Payer: Monida Allegiance	$96.90
Rate for Payer: Monida First Choice Health	$98.94
Rate for Payer: Monida Montana Health Co-op	$96.90
Rate for Payer: Monida PacificSource	$96.90

ARIPIPRAZOLE TAB [15 MG] NF

Facility

$102.00

Service Code	HCPCS J8499
Hospital Charge Code	3000604
Hospital Revenue Code	250
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$96.90
Rate for Payer: Aetna Medicare	$91.80
Rate for Payer: BCBS MT CHIP	$91.80
Rate for Payer: BCBS MT Closed Plan Network	$96.90
Rate for Payer: BCBS MT HealthLink	$91.80
Rate for Payer: BCBS MT Medicare	$91.80
Rate for Payer: BCBS MT POS	$96.90
Rate for Payer: BCBS MT Traditional	$102.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial	$96.90
Rate for Payer: Cigna Medicare	$91.80
Rate for Payer: Medicaid All Medicaid	$93.84
Rate for Payer: Medicare All Medicare	$71.40
Rate for Payer: Monida Allegiance	$96.90
Rate for Payer: Monida First Choice Health	$98.94
Rate for Payer: Monida Montana Health Co-op	$96.90
Rate for Payer: Monida PacificSource	$96.90

ARIPIPRAZOLE TAB [2 MG] NF

Facility

$103.00

Service Code	HCPCS J8499
Hospital Charge Code	3000542
Hospital Revenue Code	250
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

ARIPIPRAZOLE TAB [2 MG] NF

Facility

$103.00

Service Code	HCPCS J8499
Hospital Charge Code	3000542
Hospital Revenue Code	250
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

ARIPIPRAZOLE TAB [5 MG] NF

Facility

$108.00

Service Code	HCPCS J8499
Hospital Charge Code	3007069
Hospital Revenue Code	250
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

ARIPIPRAZOLE TAB [5 MG] NF

Facility

$108.00

Service Code	HCPCS J8499
Hospital Charge Code	3007069
Hospital Revenue Code	250
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

ARMOUR THYROID TAB [240 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007617
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

ARMOUR THYROID TAB [240 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007617
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

ARMOUR THYROID TAB [60 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007204
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

Know your out-of-pocket cost for care.

All Charges