Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$35.09

Hospital Charge Code	90197084
Hospital Revenue Code	270
Min. Negotiated Rate	$24.56
Max. Negotiated Rate	$35.09
Rate for Payer: Aetna Commercial	$33.34
Rate for Payer: Aetna Medicare	$31.58
Rate for Payer: BCBS MT CHIP	$31.58
Rate for Payer: BCBS MT Closed Plan Network	$33.34
Rate for Payer: BCBS MT HealthLink	$31.58
Rate for Payer: BCBS MT Medicare	$31.58
Rate for Payer: BCBS MT POS	$33.34
Rate for Payer: BCBS MT Traditional	$35.09
Rate for Payer: Cash Price	$31.58
Rate for Payer: Cigna Commercial	$33.34
Rate for Payer: Cigna Medicare	$31.58
Rate for Payer: Medicaid All Medicaid	$32.28
Rate for Payer: Medicare All Medicare	$24.56
Rate for Payer: Monida Allegiance	$33.34
Rate for Payer: Monida First Choice Health	$34.04
Rate for Payer: Monida Montana Health Co-op	$33.34
Rate for Payer: Monida PacificSource	$33.34

SIEMENS AMMONIA

Facility

$35.09

Hospital Charge Code	90197084
Hospital Revenue Code	270
Min. Negotiated Rate	$24.56
Max. Negotiated Rate	$35.09
Rate for Payer: Aetna Commercial	$33.34
Rate for Payer: Aetna Medicare	$31.58
Rate for Payer: BCBS MT CHIP	$31.58
Rate for Payer: BCBS MT Closed Plan Network	$33.34
Rate for Payer: BCBS MT HealthLink	$31.58
Rate for Payer: BCBS MT Medicare	$31.58
Rate for Payer: BCBS MT POS	$33.34
Rate for Payer: BCBS MT Traditional	$35.09
Rate for Payer: Cash Price	$31.58
Rate for Payer: Cigna Commercial	$33.34
Rate for Payer: Cigna Medicare	$31.58
Rate for Payer: Medicaid All Medicaid	$32.28
Rate for Payer: Medicare All Medicare	$24.56
Rate for Payer: Monida Allegiance	$33.34
Rate for Payer: Monida First Choice Health	$34.04
Rate for Payer: Monida Montana Health Co-op	$33.34
Rate for Payer: Monida PacificSource	$33.34

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 SULFADIAZINE CRM [1 %] 20G TUBE

Facility

$93.00

Service Code	HCPCS J8499
Hospital Charge Code	3000424
Hospital Revenue Code	250
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

SILVER SULFADIAZINE CRM [1 %] 20G TUBE

Facility

$93.00

Service Code	HCPCS J8499
Hospital Charge Code	3000424
Hospital Revenue Code	250
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

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

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

SIMPLY SALINE 12/CS

Facility

$5.00

Hospital Charge Code	80062609
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

SIMPLY SALINE 12/CS

Facility

$5.00

Hospital Charge Code	80062609
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

SIMVASTATIN TAB [20 MG]

Facility

$16.00

Service Code	HCPCS J8499
Hospital Charge Code	3000426
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

SIMVASTATIN TAB [20 MG]

Facility

$16.00

Service Code	HCPCS J8499
Hospital Charge Code	3000426
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

SIROLIMUS (716712)

Facility

$158.00

Service Code	CPT 80195
Hospital Charge Code	4080195
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

SIROLIMUS (716712)

Facility

$158.00

Service Code	CPT 80195
Hospital Charge Code	4080195
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

SKIN MARKERS

Facility

$4.00

Hospital Charge Code	80040170
Hospital Revenue Code	259
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

SKIN MARKERS

Facility

$4.00

Hospital Charge Code	80040170
Hospital Revenue Code	259
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

SKIN PROTECTANT BOA VIDA

Facility

$21.00

Hospital Charge Code	2840186
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

SKIN PROTECTANT BOA VIDA

Facility

$21.00

Hospital Charge Code	2840186
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

Know your out-of-pocket cost for care.

All Charges