Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SPEC IMMUNOASSY CTRL L1

Facility

$183.46

Hospital Charge Code	90197088
Hospital Revenue Code	270
Min. Negotiated Rate	$128.42
Max. Negotiated Rate	$183.46
Rate for Payer: Aetna Commercial	$174.29
Rate for Payer: Aetna Medicare	$165.11
Rate for Payer: BCBS MT CHIP	$165.11
Rate for Payer: BCBS MT Closed Plan Network	$174.29
Rate for Payer: BCBS MT HealthLink	$165.11
Rate for Payer: BCBS MT Medicare	$165.11
Rate for Payer: BCBS MT POS	$174.29
Rate for Payer: BCBS MT Traditional	$183.46
Rate for Payer: Cash Price	$165.11
Rate for Payer: Cigna Commercial	$174.29
Rate for Payer: Cigna Medicare	$165.11
Rate for Payer: Medicaid All Medicaid	$168.78
Rate for Payer: Medicare All Medicare	$128.42
Rate for Payer: Monida Allegiance	$174.29
Rate for Payer: Monida First Choice Health	$177.96
Rate for Payer: Monida Montana Health Co-op	$174.29
Rate for Payer: Monida PacificSource	$174.29

SPEC IMMUNOASSY CTRL L1

Facility

$183.46

Hospital Charge Code	90197088
Hospital Revenue Code	270
Min. Negotiated Rate	$128.42
Max. Negotiated Rate	$183.46
Rate for Payer: Aetna Commercial	$174.29
Rate for Payer: Aetna Medicare	$165.11
Rate for Payer: BCBS MT CHIP	$165.11
Rate for Payer: BCBS MT Closed Plan Network	$174.29
Rate for Payer: BCBS MT HealthLink	$165.11
Rate for Payer: BCBS MT Medicare	$165.11
Rate for Payer: BCBS MT POS	$174.29
Rate for Payer: BCBS MT Traditional	$183.46
Rate for Payer: Cash Price	$165.11
Rate for Payer: Cigna Commercial	$174.29
Rate for Payer: Cigna Medicare	$165.11
Rate for Payer: Medicaid All Medicaid	$168.78
Rate for Payer: Medicare All Medicare	$128.42
Rate for Payer: Monida Allegiance	$174.29
Rate for Payer: Monida First Choice Health	$177.96
Rate for Payer: Monida Montana Health Co-op	$174.29
Rate for Payer: Monida PacificSource	$174.29

SPEC IMMUNOASSY CTRL L3

Facility

$183.46

Hospital Charge Code	90197089
Hospital Revenue Code	270
Min. Negotiated Rate	$128.42
Max. Negotiated Rate	$183.46
Rate for Payer: Aetna Commercial	$174.29
Rate for Payer: Aetna Medicare	$165.11
Rate for Payer: BCBS MT CHIP	$165.11
Rate for Payer: BCBS MT Closed Plan Network	$174.29
Rate for Payer: BCBS MT HealthLink	$165.11
Rate for Payer: BCBS MT Medicare	$165.11
Rate for Payer: BCBS MT POS	$174.29
Rate for Payer: BCBS MT Traditional	$183.46
Rate for Payer: Cash Price	$165.11
Rate for Payer: Cigna Commercial	$174.29
Rate for Payer: Cigna Medicare	$165.11
Rate for Payer: Medicaid All Medicaid	$168.78
Rate for Payer: Medicare All Medicare	$128.42
Rate for Payer: Monida Allegiance	$174.29
Rate for Payer: Monida First Choice Health	$177.96
Rate for Payer: Monida Montana Health Co-op	$174.29
Rate for Payer: Monida PacificSource	$174.29

SPEC IMMUNOASSY CTRL L3

Facility

$183.46

Hospital Charge Code	90197089
Hospital Revenue Code	270
Min. Negotiated Rate	$128.42
Max. Negotiated Rate	$183.46
Rate for Payer: Aetna Commercial	$174.29
Rate for Payer: Aetna Medicare	$165.11
Rate for Payer: BCBS MT CHIP	$165.11
Rate for Payer: BCBS MT Closed Plan Network	$174.29
Rate for Payer: BCBS MT HealthLink	$165.11
Rate for Payer: BCBS MT Medicare	$165.11
Rate for Payer: BCBS MT POS	$174.29
Rate for Payer: BCBS MT Traditional	$183.46
Rate for Payer: Cash Price	$165.11
Rate for Payer: Cigna Commercial	$174.29
Rate for Payer: Cigna Medicare	$165.11
Rate for Payer: Medicaid All Medicaid	$168.78
Rate for Payer: Medicare All Medicare	$128.42
Rate for Payer: Monida Allegiance	$174.29
Rate for Payer: Monida First Choice Health	$177.96
Rate for Payer: Monida Montana Health Co-op	$174.29
Rate for Payer: Monida PacificSource	$174.29

SPICA THUMB SPLINT

Facility

$179.00

Service Code	HCPCS L3923
Hospital Charge Code	8003923
Hospital Revenue Code	290
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

SPICA THUMB SPLINT

Facility

$179.00

Service Code	HCPCS L3923
Hospital Charge Code	8003923
Hospital Revenue Code	290
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

SPIROMETRY AFTER BRONCHODILATOR

Facility

$410.00

Service Code	CPT 94060
Hospital Charge Code	8094060
Hospital Revenue Code	521
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

SPIROMETRY AFTER BRONCHODILATOR

Facility

$410.00

Service Code	CPT 94060
Hospital Charge Code	8094060
Hospital Revenue Code	521
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

SPIROMETRY PFT

Facility

$116.00

Service Code	CPT 94010
Hospital Charge Code	8094010
Hospital Revenue Code	521
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

SPIROMETRY PFT

Facility

$116.00

Service Code	CPT 94010
Hospital Charge Code	8094010
Hospital Revenue Code	521
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

SPIRONOLACTONE TAB [25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000434
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

SPIRONOLACTONE TAB [25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000434
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

SPLASHCAP (NON STOCK BSME)

Facility

$5.00

Hospital Charge Code	80040162
Hospital Revenue Code	270
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

SPLASHCAP (NON STOCK BSME)

Facility

$5.00

Hospital Charge Code	80040162
Hospital Revenue Code	270
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

SPLINT COLLES LT/LG PADDED

Facility

$22.00

Hospital Charge Code	2893520
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES LT/LG PADDED

Facility

$22.00

Hospital Charge Code	2893520
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES LT/MED PADDED

Facility

$22.00

Hospital Charge Code	2893519
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES LT/MED PADDED

Facility

$22.00

Hospital Charge Code	2893519
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES LT/SM PADDED

Facility

$22.00

Hospital Charge Code	2893518
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES LT/SM PADDED

Facility

$22.00

Hospital Charge Code	2893518
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES LT/XSM

Facility

$25.00

Service Code	HCPCS A4570
Hospital Charge Code	2830177
Hospital Revenue Code	270
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

SPLINT COLLES LT/XSM

Facility

$25.00

Service Code	HCPCS A4570
Hospital Charge Code	2830177
Hospital Revenue Code	270
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

SPLINT COLLES RT/LG PADDED

Facility

$22.00

Hospital Charge Code	2893524
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES RT/LG PADDED

Facility

$22.00

Hospital Charge Code	2893524
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

SPLINT COLLES RT/MED. PADDED

Facility

$22.00

Hospital Charge Code	2893523
Hospital Revenue Code	290
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

Know your out-of-pocket cost for care.

All Charges