Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

THERAPEUTIC PHLEBOTOMY

Facility

$325.00

Service Code	HCPCS 99195
Hospital Charge Code	4099195
Hospital Revenue Code	300
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

THERAPEUTIC PHLEBOTOMY

Facility

$325.00

Service Code	HCPCS 99195
Hospital Charge Code	4099195
Hospital Revenue Code	300
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

THIAMINE (121186)

Facility

$45.00

Service Code	HCPCS 84425
Hospital Charge Code	4084425
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

THIAMINE (121186)

Facility

$45.00

Service Code	HCPCS 84425
Hospital Charge Code	4084425
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

THIAMINE INJ [100 MG/ML] 2 ML

Facility

$40.00

Service Code	HCPCS J3411
Hospital Charge Code	3000448
Hospital Revenue Code	259
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

THIAMINE INJ [100 MG/ML] 2 ML

Facility

$40.00

Service Code	HCPCS J3411
Hospital Charge Code	3000448
Hospital Revenue Code	259
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

THIN PREP PAP

Facility

$81.57

Service Code	HCPCS 88142
Hospital Charge Code	4087934
Hospital Revenue Code	310
Min. Negotiated Rate	$57.10
Max. Negotiated Rate	$81.57
Rate for Payer: Aetna Commercial	$77.49
Rate for Payer: Aetna Medicare	$73.41
Rate for Payer: BCBS MT CHIP	$73.41
Rate for Payer: BCBS MT Closed Plan Network	$77.49
Rate for Payer: BCBS MT HealthLink	$73.41
Rate for Payer: BCBS MT Medicare	$73.41
Rate for Payer: BCBS MT POS	$77.49
Rate for Payer: BCBS MT Traditional	$81.57
Rate for Payer: Cash Price	$73.41
Rate for Payer: Cigna Commercial	$77.49
Rate for Payer: Cigna Medicare	$73.41
Rate for Payer: Medicaid All Medicaid	$75.04
Rate for Payer: Medicare All Medicare	$57.10
Rate for Payer: Monida Allegiance	$77.49
Rate for Payer: Monida First Choice Health	$79.12
Rate for Payer: Monida Montana Health Co-op	$77.49
Rate for Payer: Monida PacificSource	$77.49

THIN PREP PAP

Facility

$81.57

Service Code	HCPCS 88142
Hospital Charge Code	4087934
Hospital Revenue Code	310
Min. Negotiated Rate	$57.10
Max. Negotiated Rate	$81.57
Rate for Payer: Aetna Commercial	$77.49
Rate for Payer: Aetna Medicare	$73.41
Rate for Payer: BCBS MT CHIP	$73.41
Rate for Payer: BCBS MT Closed Plan Network	$77.49
Rate for Payer: BCBS MT HealthLink	$73.41
Rate for Payer: BCBS MT Medicare	$73.41
Rate for Payer: BCBS MT POS	$77.49
Rate for Payer: BCBS MT Traditional	$81.57
Rate for Payer: Cash Price	$73.41
Rate for Payer: Cigna Commercial	$77.49
Rate for Payer: Cigna Medicare	$73.41
Rate for Payer: Medicaid All Medicaid	$75.04
Rate for Payer: Medicare All Medicare	$57.10
Rate for Payer: Monida Allegiance	$77.49
Rate for Payer: Monida First Choice Health	$79.12
Rate for Payer: Monida Montana Health Co-op	$77.49
Rate for Payer: Monida PacificSource	$77.49

THIN PREP SCREEN

Facility

$91.27

Service Code	HCPCS 88175
Hospital Charge Code	4087933
Hospital Revenue Code	310
Min. Negotiated Rate	$63.89
Max. Negotiated Rate	$91.27
Rate for Payer: Aetna Commercial	$86.71
Rate for Payer: Aetna Medicare	$82.14
Rate for Payer: BCBS MT CHIP	$82.14
Rate for Payer: BCBS MT Closed Plan Network	$86.71
Rate for Payer: BCBS MT HealthLink	$82.14
Rate for Payer: BCBS MT Medicare	$82.14
Rate for Payer: BCBS MT POS	$86.71
Rate for Payer: BCBS MT Traditional	$91.27
Rate for Payer: Cash Price	$82.14
Rate for Payer: Cigna Commercial	$86.71
Rate for Payer: Cigna Medicare	$82.14
Rate for Payer: Medicaid All Medicaid	$83.97
Rate for Payer: Medicare All Medicare	$63.89
Rate for Payer: Monida Allegiance	$86.71
Rate for Payer: Monida First Choice Health	$88.53
Rate for Payer: Monida Montana Health Co-op	$86.71
Rate for Payer: Monida PacificSource	$86.71

THIN PREP SCREEN

Facility

$91.27

Service Code	HCPCS 88175
Hospital Charge Code	4087933
Hospital Revenue Code	310
Min. Negotiated Rate	$63.89
Max. Negotiated Rate	$91.27
Rate for Payer: Aetna Commercial	$86.71
Rate for Payer: Aetna Medicare	$82.14
Rate for Payer: BCBS MT CHIP	$82.14
Rate for Payer: BCBS MT Closed Plan Network	$86.71
Rate for Payer: BCBS MT HealthLink	$82.14
Rate for Payer: BCBS MT Medicare	$82.14
Rate for Payer: BCBS MT POS	$86.71
Rate for Payer: BCBS MT Traditional	$91.27
Rate for Payer: Cash Price	$82.14
Rate for Payer: Cigna Commercial	$86.71
Rate for Payer: Cigna Medicare	$82.14
Rate for Payer: Medicaid All Medicaid	$83.97
Rate for Payer: Medicare All Medicare	$63.89
Rate for Payer: Monida Allegiance	$86.71
Rate for Payer: Monida First Choice Health	$88.53
Rate for Payer: Monida Montana Health Co-op	$86.71
Rate for Payer: Monida PacificSource	$86.71

THROMBIN-JMI DILUENT 5000U

Facility

$291.00

Service Code	HCPCS J3490
Hospital Charge Code	3000449
Hospital Revenue Code	250
Min. Negotiated Rate	$203.70
Max. Negotiated Rate	$291.00
Rate for Payer: Aetna Commercial	$276.45
Rate for Payer: Aetna Medicare	$261.90
Rate for Payer: BCBS MT CHIP	$261.90
Rate for Payer: BCBS MT Closed Plan Network	$276.45
Rate for Payer: BCBS MT HealthLink	$261.90
Rate for Payer: BCBS MT Medicare	$261.90
Rate for Payer: BCBS MT POS	$276.45
Rate for Payer: BCBS MT Traditional	$291.00
Rate for Payer: Cash Price	$261.90
Rate for Payer: Cigna Commercial	$276.45
Rate for Payer: Cigna Medicare	$261.90
Rate for Payer: Medicaid All Medicaid	$267.72
Rate for Payer: Medicare All Medicare	$203.70
Rate for Payer: Monida Allegiance	$276.45
Rate for Payer: Monida First Choice Health	$282.27
Rate for Payer: Monida Montana Health Co-op	$276.45
Rate for Payer: Monida PacificSource	$276.45

THROMBIN-JMI DILUENT 5000U

Facility

$291.00

Service Code	HCPCS J3490
Hospital Charge Code	3000449
Hospital Revenue Code	250
Min. Negotiated Rate	$203.70
Max. Negotiated Rate	$291.00
Rate for Payer: Aetna Commercial	$276.45
Rate for Payer: Aetna Medicare	$261.90
Rate for Payer: BCBS MT CHIP	$261.90
Rate for Payer: BCBS MT Closed Plan Network	$276.45
Rate for Payer: BCBS MT HealthLink	$261.90
Rate for Payer: BCBS MT Medicare	$261.90
Rate for Payer: BCBS MT POS	$276.45
Rate for Payer: BCBS MT Traditional	$291.00
Rate for Payer: Cash Price	$261.90
Rate for Payer: Cigna Commercial	$276.45
Rate for Payer: Cigna Medicare	$261.90
Rate for Payer: Medicaid All Medicaid	$267.72
Rate for Payer: Medicare All Medicare	$203.70
Rate for Payer: Monida Allegiance	$276.45
Rate for Payer: Monida First Choice Health	$282.27
Rate for Payer: Monida Montana Health Co-op	$276.45
Rate for Payer: Monida PacificSource	$276.45

THROMBIN TIME (015230)

Facility

$58.00

Service Code	HCPCS 85670
Hospital Charge Code	4085670
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

THROMBIN TIME (015230)

Facility

$58.00

Service Code	HCPCS 85670
Hospital Charge Code	4085670
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

.THROMBOPLASTIN INHIBITION, TISSUE

Facility

$100.00

Service Code	HCPCS 85705
Hospital Charge Code	4085705
Hospital Revenue Code	300
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: BCBS MT CHIP	$90.00
Rate for Payer: BCBS MT Closed Plan Network	$95.00
Rate for Payer: BCBS MT HealthLink	$90.00
Rate for Payer: BCBS MT Medicare	$90.00
Rate for Payer: BCBS MT POS	$95.00
Rate for Payer: BCBS MT Traditional	$100.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Cigna Medicare	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

.THROMBOPLASTIN INHIBITION, TISSUE

Facility

$100.00

Service Code	HCPCS 85705
Hospital Charge Code	4085705
Hospital Revenue Code	300
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: BCBS MT CHIP	$90.00
Rate for Payer: BCBS MT Closed Plan Network	$95.00
Rate for Payer: BCBS MT HealthLink	$90.00
Rate for Payer: BCBS MT Medicare	$90.00
Rate for Payer: BCBS MT POS	$95.00
Rate for Payer: BCBS MT Traditional	$100.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Cigna Medicare	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

.THROMBOPLASTIN TIME PARTIAL, MIXING

Facility

$104.00

Service Code	HCPCS 85732
Hospital Charge Code	4085732
Hospital Revenue Code	300
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$104.00
Rate for Payer: Aetna Commercial	$98.80
Rate for Payer: Aetna Medicare	$93.60
Rate for Payer: BCBS MT CHIP	$93.60
Rate for Payer: BCBS MT Closed Plan Network	$98.80
Rate for Payer: BCBS MT HealthLink	$93.60
Rate for Payer: BCBS MT Medicare	$93.60
Rate for Payer: BCBS MT POS	$98.80
Rate for Payer: BCBS MT Traditional	$104.00
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cigna Commercial	$98.80
Rate for Payer: Cigna Medicare	$93.60
Rate for Payer: Medicaid All Medicaid	$95.68
Rate for Payer: Medicare All Medicare	$72.80
Rate for Payer: Monida Allegiance	$98.80
Rate for Payer: Monida First Choice Health	$100.88
Rate for Payer: Monida Montana Health Co-op	$98.80
Rate for Payer: Monida PacificSource	$98.80

.THROMBOPLASTIN TIME PARTIAL, MIXING

Facility

$104.00

Service Code	HCPCS 85732
Hospital Charge Code	4085732
Hospital Revenue Code	300
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$104.00
Rate for Payer: Aetna Commercial	$98.80
Rate for Payer: Aetna Medicare	$93.60
Rate for Payer: BCBS MT CHIP	$93.60
Rate for Payer: BCBS MT Closed Plan Network	$98.80
Rate for Payer: BCBS MT HealthLink	$93.60
Rate for Payer: BCBS MT Medicare	$93.60
Rate for Payer: BCBS MT POS	$98.80
Rate for Payer: BCBS MT Traditional	$104.00
Rate for Payer: Cash Price	$93.60
Rate for Payer: Cigna Commercial	$98.80
Rate for Payer: Cigna Medicare	$93.60
Rate for Payer: Medicaid All Medicaid	$95.68
Rate for Payer: Medicare All Medicare	$72.80
Rate for Payer: Monida Allegiance	$98.80
Rate for Payer: Monida First Choice Health	$100.88
Rate for Payer: Monida Montana Health Co-op	$98.80
Rate for Payer: Monida PacificSource	$98.80

THUMBOPRENE UNIVERSAL

Facility

$28.00

Hospital Charge Code	2861599
Hospital Revenue Code	274
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

THUMBOPRENE UNIVERSAL

Facility

$28.00

Hospital Charge Code	2861599
Hospital Revenue Code	274
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

THUMB SPICA SPLINT LEFT LG/XL

Facility

$53.00

Hospital Charge Code	2893525
Hospital Revenue Code	290
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

THUMB SPICA SPLINT LEFT LG/XL

Facility

$53.00

Hospital Charge Code	2893525
Hospital Revenue Code	290
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

THUMB SPICA SPLINT LEFT SM/MD

Facility

$63.00

Hospital Charge Code	2840151
Hospital Revenue Code	270
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

THUMB SPICA SPLINT LEFT SM/MD

Facility

$63.00

Hospital Charge Code	2840151
Hospital Revenue Code	270
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

THUMB SPICA SPLINT RIGHT LG/X

Facility

$53.00

Hospital Charge Code	2893527
Hospital Revenue Code	290
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

Know your out-of-pocket cost for care.

All Charges