Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SHOULDER IMMOB MD

Facility

$30.00

Hospital Charge Code	2893508
Hospital Revenue Code	290
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

SHOULDER IMMOB MD

Facility

$30.00

Hospital Charge Code	2893508
Hospital Revenue Code	290
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

SHOULDER IMMOBSM

Facility

$34.00

Hospital Charge Code	2893509
Hospital Revenue Code	290
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

SHOULDER IMMOBSM

Facility

$34.00

Hospital Charge Code	2893509
Hospital Revenue Code	290
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$34.00
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: BCBS MT CHIP	$30.60
Rate for Payer: BCBS MT Closed Plan Network	$32.30
Rate for Payer: BCBS MT HealthLink	$30.60
Rate for Payer: BCBS MT Medicare	$30.60
Rate for Payer: BCBS MT POS	$32.30
Rate for Payer: BCBS MT Traditional	$34.00
Rate for Payer: Cash Price	$30.60
Rate for Payer: Cigna Commercial	$32.30
Rate for Payer: Cigna Medicare	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

SHOULDER IMMOB. XLG

Facility

$27.00

Hospital Charge Code	2846183
Hospital Revenue Code	270
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

SHOULDER IMMOB. XLG

Facility

$27.00

Hospital Charge Code	2846183
Hospital Revenue Code	270
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

SHOULDER IMMOB. XSM

Facility

$27.00

Hospital Charge Code	2846182
Hospital Revenue Code	270
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

SHOULDER IMMOB. XSM

Facility

$27.00

Hospital Charge Code	2846182
Hospital Revenue Code	270
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

SICKLE SOLUBILITY 85660

Facility

$72.00

Service Code	CPT 85660
Hospital Charge Code	4085660
Hospital Revenue Code	305
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

SICKLE SOLUBILITY 85660

Facility

$72.00

Service Code	CPT 85660
Hospital Charge Code	4085660
Hospital Revenue Code	305
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

SIEMENS AMMONIA

Facility

$93.60

Hospital Charge Code	90197084
Hospital Revenue Code	270
Min. Negotiated Rate	$65.52
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna Commercial	$88.92
Rate for Payer: Aetna Medicare	$84.24
Rate for Payer: BCBS MT CHIP	$84.24
Rate for Payer: BCBS MT Closed Plan Network	$88.92
Rate for Payer: BCBS MT HealthLink	$84.24
Rate for Payer: BCBS MT Medicare	$84.24
Rate for Payer: BCBS MT POS	$88.92
Rate for Payer: BCBS MT Traditional	$93.60
Rate for Payer: Cash Price	$84.24
Rate for Payer: Cigna Commercial	$88.92
Rate for Payer: Cigna Medicare	$84.24
Rate for Payer: Medicaid All Medicaid	$86.11
Rate for Payer: Medicare All Medicare	$65.52
Rate for Payer: Monida Allegiance	$88.92
Rate for Payer: Monida First Choice Health	$90.79
Rate for Payer: Monida Montana Health Co-op	$88.92
Rate for Payer: Monida PacificSource	$88.92

SIEMENS AMMONIA

Facility

$93.60

Hospital Charge Code	90197084
Hospital Revenue Code	270
Min. Negotiated Rate	$65.52
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna Commercial	$88.92
Rate for Payer: Aetna Medicare	$84.24
Rate for Payer: BCBS MT CHIP	$84.24
Rate for Payer: BCBS MT Closed Plan Network	$88.92
Rate for Payer: BCBS MT HealthLink	$84.24
Rate for Payer: BCBS MT Medicare	$84.24
Rate for Payer: BCBS MT POS	$88.92
Rate for Payer: BCBS MT Traditional	$93.60
Rate for Payer: Cash Price	$84.24
Rate for Payer: Cigna Commercial	$88.92
Rate for Payer: Cigna Medicare	$84.24
Rate for Payer: Medicaid All Medicaid	$86.11
Rate for Payer: Medicare All Medicare	$65.52
Rate for Payer: Monida Allegiance	$88.92
Rate for Payer: Monida First Choice Health	$90.79
Rate for Payer: Monida Montana Health Co-op	$88.92
Rate for Payer: Monida PacificSource	$88.92

SIEMENS EXL SERVICE CONTRACT

Facility

$19,250.00

Hospital Charge Code	90197083
Hospital Revenue Code	270
Min. Negotiated Rate	$13,475.00
Max. Negotiated Rate	$19,250.00
Rate for Payer: Aetna Commercial	$18,287.50
Rate for Payer: Aetna Medicare	$17,325.00
Rate for Payer: BCBS MT CHIP	$17,325.00
Rate for Payer: BCBS MT Closed Plan Network	$18,287.50
Rate for Payer: BCBS MT HealthLink	$17,325.00
Rate for Payer: BCBS MT Medicare	$17,325.00
Rate for Payer: BCBS MT POS	$18,287.50
Rate for Payer: BCBS MT Traditional	$19,250.00
Rate for Payer: Cash Price	$17,325.00
Rate for Payer: Cigna Commercial	$18,287.50
Rate for Payer: Cigna Medicare	$17,325.00
Rate for Payer: Medicaid All Medicaid	$17,710.00
Rate for Payer: Medicare All Medicare	$13,475.00
Rate for Payer: Monida Allegiance	$18,287.50
Rate for Payer: Monida First Choice Health	$18,672.50
Rate for Payer: Monida Montana Health Co-op	$18,287.50
Rate for Payer: Monida PacificSource	$18,287.50

SIEMENS EXL SERVICE CONTRACT

Facility

$19,250.00

Hospital Charge Code	90197083
Hospital Revenue Code	270
Min. Negotiated Rate	$13,475.00
Max. Negotiated Rate	$19,250.00
Rate for Payer: Aetna Commercial	$18,287.50
Rate for Payer: Aetna Medicare	$17,325.00
Rate for Payer: BCBS MT CHIP	$17,325.00
Rate for Payer: BCBS MT Closed Plan Network	$18,287.50
Rate for Payer: BCBS MT HealthLink	$17,325.00
Rate for Payer: BCBS MT Medicare	$17,325.00
Rate for Payer: BCBS MT POS	$18,287.50
Rate for Payer: BCBS MT Traditional	$19,250.00
Rate for Payer: Cash Price	$17,325.00
Rate for Payer: Cigna Commercial	$18,287.50
Rate for Payer: Cigna Medicare	$17,325.00
Rate for Payer: Medicaid All Medicaid	$17,710.00
Rate for Payer: Medicare All Medicare	$13,475.00
Rate for Payer: Monida Allegiance	$18,287.50
Rate for Payer: Monida First Choice Health	$18,672.50
Rate for Payer: Monida Montana Health Co-op	$18,287.50
Rate for Payer: Monida PacificSource	$18,287.50

SIGMOIDOSCOPY 45330

Facility

$2,460.00

Service Code	CPT 45330
Hospital Charge Code	5845330
Hospital Revenue Code	750
Min. Negotiated Rate	$1,722.00
Max. Negotiated Rate	$2,460.00
Rate for Payer: Aetna Commercial	$2,337.00
Rate for Payer: Aetna Medicare	$2,214.00
Rate for Payer: BCBS MT CHIP	$2,214.00
Rate for Payer: BCBS MT Closed Plan Network	$2,337.00
Rate for Payer: BCBS MT HealthLink	$2,214.00
Rate for Payer: BCBS MT Medicare	$2,214.00
Rate for Payer: BCBS MT POS	$2,337.00
Rate for Payer: BCBS MT Traditional	$2,460.00
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Cigna Commercial	$2,337.00
Rate for Payer: Cigna Medicare	$2,214.00
Rate for Payer: Medicaid All Medicaid	$2,263.20
Rate for Payer: Medicare All Medicare	$1,722.00
Rate for Payer: Monida Allegiance	$2,337.00
Rate for Payer: Monida First Choice Health	$2,386.20
Rate for Payer: Monida Montana Health Co-op	$2,337.00
Rate for Payer: Monida PacificSource	$2,337.00

SIGMOIDOSCOPY 45330

Facility

$2,460.00

Service Code	CPT 45330
Hospital Charge Code	5845330
Hospital Revenue Code	750
Min. Negotiated Rate	$1,722.00
Max. Negotiated Rate	$2,460.00
Rate for Payer: Aetna Commercial	$2,337.00
Rate for Payer: Aetna Medicare	$2,214.00
Rate for Payer: BCBS MT CHIP	$2,214.00
Rate for Payer: BCBS MT Closed Plan Network	$2,337.00
Rate for Payer: BCBS MT HealthLink	$2,214.00
Rate for Payer: BCBS MT Medicare	$2,214.00
Rate for Payer: BCBS MT POS	$2,337.00
Rate for Payer: BCBS MT Traditional	$2,460.00
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Cigna Commercial	$2,337.00
Rate for Payer: Cigna Medicare	$2,214.00
Rate for Payer: Medicaid All Medicaid	$2,263.20
Rate for Payer: Medicare All Medicare	$1,722.00
Rate for Payer: Monida Allegiance	$2,337.00
Rate for Payer: Monida First Choice Health	$2,386.20
Rate for Payer: Monida Montana Health Co-op	$2,337.00
Rate for Payer: Monida PacificSource	$2,337.00

SIGMOIDOSCOPY SCREENING MCR

Facility

$202.00

Service Code	HCPCS G0104
Hospital Charge Code	8000104
Hospital Revenue Code	521
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

SIGMOIDOSCOPY SCREENING MCR

Facility

$202.00

Service Code	HCPCS G0104
Hospital Charge Code	8000104
Hospital Revenue Code	521
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

SILDENAFIL TAB [20 MG] NF

Facility

$8.00

Hospital Charge Code	3007552
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

SILDENAFIL TAB [20 MG] NF

Facility

$8.00

Hospital Charge Code	3007552
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

SILVER ANTIMICROBIAL GEL [1.5 OZ]

Facility

$103.00

Service Code	HCPCS J3490
Hospital Charge Code	3000423
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

SILVER ANTIMICROBIAL GEL [1.5 OZ]

Facility

$103.00

Service Code	HCPCS J3490
Hospital Charge Code	3000423
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

SILVER SULFADIAZINE CRM [1 %] 25G TUBE

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	3000424
Hospital Revenue Code	250
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

SILVER SULFADIAZINE CRM [1 %] 25G TUBE

Facility

$30.00

Service Code	HCPCS J3490
Hospital Charge Code	3000424
Hospital Revenue Code	250
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

SIMETHICONE CAP [125 MG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000425
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.

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