Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ST THERP INTERVENT EA ADDL 15 MIN

Facility

$69.00

Service Code	CPT 97130
Hospital Charge Code	6397130
Hospital Revenue Code	440
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

ST TREATMENT OF SPEECH/LANG (GROUP)

Facility

$171.00

Service Code	CPT 92508
Hospital Charge Code	6392508
Hospital Revenue Code	440
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

ST TREATMENT OF SPEECH/LANG (GROUP)

Facility

$171.00

Service Code	CPT 92508
Hospital Charge Code	6392508
Hospital Revenue Code	440
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

ST TREATMENT OF SPEECH/LANG (INDIV)

Facility

$285.00

Service Code	CPT 92507
Hospital Charge Code	6392507
Hospital Revenue Code	440
Min. Negotiated Rate	$199.50
Max. Negotiated Rate	$285.00
Rate for Payer: Aetna Commercial	$270.75
Rate for Payer: Aetna Medicare	$256.50
Rate for Payer: BCBS MT CHIP	$256.50
Rate for Payer: BCBS MT Closed Plan Network	$270.75
Rate for Payer: BCBS MT HealthLink	$256.50
Rate for Payer: BCBS MT Medicare	$256.50
Rate for Payer: BCBS MT POS	$270.75
Rate for Payer: BCBS MT Traditional	$285.00
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna Commercial	$270.75
Rate for Payer: Cigna Medicare	$256.50
Rate for Payer: Medicaid All Medicaid	$262.20
Rate for Payer: Medicare All Medicare	$199.50
Rate for Payer: Monida Allegiance	$270.75
Rate for Payer: Monida First Choice Health	$276.45
Rate for Payer: Monida Montana Health Co-op	$270.75
Rate for Payer: Monida PacificSource	$270.75

ST TREATMENT OF SPEECH/LANG (INDIV)

Facility

$285.00

Service Code	CPT 92507
Hospital Charge Code	6392507
Hospital Revenue Code	440
Min. Negotiated Rate	$199.50
Max. Negotiated Rate	$285.00
Rate for Payer: Aetna Commercial	$270.75
Rate for Payer: Aetna Medicare	$256.50
Rate for Payer: BCBS MT CHIP	$256.50
Rate for Payer: BCBS MT Closed Plan Network	$270.75
Rate for Payer: BCBS MT HealthLink	$256.50
Rate for Payer: BCBS MT Medicare	$256.50
Rate for Payer: BCBS MT POS	$270.75
Rate for Payer: BCBS MT Traditional	$285.00
Rate for Payer: Cash Price	$256.50
Rate for Payer: Cigna Commercial	$270.75
Rate for Payer: Cigna Medicare	$256.50
Rate for Payer: Medicaid All Medicaid	$262.20
Rate for Payer: Medicare All Medicare	$199.50
Rate for Payer: Monida Allegiance	$270.75
Rate for Payer: Monida First Choice Health	$276.45
Rate for Payer: Monida Montana Health Co-op	$270.75
Rate for Payer: Monida PacificSource	$270.75

ST TREATMENT OF SWALLOWING DYSF

Facility

$286.00

Service Code	CPT 92526
Hospital Charge Code	6392526
Hospital Revenue Code	440
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

ST TREATMENT OF SWALLOWING DYSF

Facility

$286.00

Service Code	CPT 92526
Hospital Charge Code	6392526
Hospital Revenue Code	440
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

ST VIDEO STUDY MOTION FLUOROSCOPIC EVAL

Facility

$796.00

Service Code	CPT 92611
Hospital Charge Code	6392611
Hospital Revenue Code	440
Min. Negotiated Rate	$557.20
Max. Negotiated Rate	$796.00
Rate for Payer: Aetna Commercial	$756.20
Rate for Payer: Aetna Medicare	$716.40
Rate for Payer: BCBS MT CHIP	$716.40
Rate for Payer: BCBS MT Closed Plan Network	$756.20
Rate for Payer: BCBS MT HealthLink	$716.40
Rate for Payer: BCBS MT Medicare	$716.40
Rate for Payer: BCBS MT POS	$756.20
Rate for Payer: BCBS MT Traditional	$796.00
Rate for Payer: Cash Price	$716.40
Rate for Payer: Cigna Commercial	$756.20
Rate for Payer: Cigna Medicare	$716.40
Rate for Payer: Medicaid All Medicaid	$732.32
Rate for Payer: Medicare All Medicare	$557.20
Rate for Payer: Monida Allegiance	$756.20
Rate for Payer: Monida First Choice Health	$772.12
Rate for Payer: Monida Montana Health Co-op	$756.20
Rate for Payer: Monida PacificSource	$756.20

ST VIDEO STUDY MOTION FLUOROSCOPIC EVAL

Facility

$796.00

Service Code	CPT 92611
Hospital Charge Code	6392611
Hospital Revenue Code	440
Min. Negotiated Rate	$557.20
Max. Negotiated Rate	$796.00
Rate for Payer: Aetna Commercial	$756.20
Rate for Payer: Aetna Medicare	$716.40
Rate for Payer: BCBS MT CHIP	$716.40
Rate for Payer: BCBS MT Closed Plan Network	$756.20
Rate for Payer: BCBS MT HealthLink	$716.40
Rate for Payer: BCBS MT Medicare	$716.40
Rate for Payer: BCBS MT POS	$756.20
Rate for Payer: BCBS MT Traditional	$796.00
Rate for Payer: Cash Price	$716.40
Rate for Payer: Cigna Commercial	$756.20
Rate for Payer: Cigna Medicare	$716.40
Rate for Payer: Medicaid All Medicaid	$732.32
Rate for Payer: Medicare All Medicare	$557.20
Rate for Payer: Monida Allegiance	$756.20
Rate for Payer: Monida First Choice Health	$772.12
Rate for Payer: Monida Montana Health Co-op	$756.20
Rate for Payer: Monida PacificSource	$756.20

SUCRALFATE TAB [1 GM]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000435
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

SUCRALFATE TAB [1 GM]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000435
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

SUCTION CATHETER 6FR

Facility

$18.00

Hospital Charge Code	80030298
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

SUCTION CATHETER 6FR

Facility

$18.00

Hospital Charge Code	80030298
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

SUCTION TUBING 6FT

Facility

$27.00

Hospital Charge Code	80030297
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

SUCTION TUBING 6FT

Facility

$27.00

Hospital Charge Code	80030297
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

SUGAMMADEX INJ [200MG/2ML]

Facility

$452.00

Service Code	HCPCS J3490
Hospital Charge Code	3000529
Hospital Revenue Code	250
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

SUGAMMADEX INJ [200MG/2ML]

Facility

$452.00

Service Code	HCPCS J3490
Hospital Charge Code	3000529
Hospital Revenue Code	250
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

SULFAMETH/ TMP DS TAB [800-160 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000437
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

SULFAMETH/ TMP DS TAB [800-160 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000437
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

SULFASASALAZINE TAB [500 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000438
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

SULFASASALAZINE TAB [500 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000438
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

SULFOLYSER

Facility

$132.64

Hospital Charge Code	90197165
Hospital Revenue Code	270
Min. Negotiated Rate	$92.85
Max. Negotiated Rate	$132.64
Rate for Payer: Aetna Commercial	$126.01
Rate for Payer: Aetna Medicare	$119.38
Rate for Payer: BCBS MT CHIP	$119.38
Rate for Payer: BCBS MT Closed Plan Network	$126.01
Rate for Payer: BCBS MT HealthLink	$119.38
Rate for Payer: BCBS MT Medicare	$119.38
Rate for Payer: BCBS MT POS	$126.01
Rate for Payer: BCBS MT Traditional	$132.64
Rate for Payer: Cash Price	$119.38
Rate for Payer: Cigna Commercial	$126.01
Rate for Payer: Cigna Medicare	$119.38
Rate for Payer: Medicaid All Medicaid	$122.03
Rate for Payer: Medicare All Medicare	$92.85
Rate for Payer: Monida Allegiance	$126.01
Rate for Payer: Monida First Choice Health	$128.66
Rate for Payer: Monida Montana Health Co-op	$126.01
Rate for Payer: Monida PacificSource	$126.01

SULFOLYSER

Facility

$132.64

Hospital Charge Code	90197165
Hospital Revenue Code	270
Min. Negotiated Rate	$92.85
Max. Negotiated Rate	$132.64
Rate for Payer: Aetna Commercial	$126.01
Rate for Payer: Aetna Medicare	$119.38
Rate for Payer: BCBS MT CHIP	$119.38
Rate for Payer: BCBS MT Closed Plan Network	$126.01
Rate for Payer: BCBS MT HealthLink	$119.38
Rate for Payer: BCBS MT Medicare	$119.38
Rate for Payer: BCBS MT POS	$126.01
Rate for Payer: BCBS MT Traditional	$132.64
Rate for Payer: Cash Price	$119.38
Rate for Payer: Cigna Commercial	$126.01
Rate for Payer: Cigna Medicare	$119.38
Rate for Payer: Medicaid All Medicaid	$122.03
Rate for Payer: Medicare All Medicare	$92.85
Rate for Payer: Monida Allegiance	$126.01
Rate for Payer: Monida First Choice Health	$128.66
Rate for Payer: Monida Montana Health Co-op	$126.01
Rate for Payer: Monida PacificSource	$126.01

SUMATRIPTAN INJ [6 MG/0.5 ML]

Facility

$286.00

Service Code	HCPCS J3030
Hospital Charge Code	3000439
Hospital Revenue Code	250
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

SUMATRIPTAN INJ [6 MG/0.5 ML]

Facility

$286.00

Service Code	HCPCS J3030
Hospital Charge Code	3000439
Hospital Revenue Code	250
Min. Negotiated Rate	$200.20
Max. Negotiated Rate	$286.00
Rate for Payer: Aetna Commercial	$271.70
Rate for Payer: Aetna Medicare	$257.40
Rate for Payer: BCBS MT CHIP	$257.40
Rate for Payer: BCBS MT Closed Plan Network	$271.70
Rate for Payer: BCBS MT HealthLink	$257.40
Rate for Payer: BCBS MT Medicare	$257.40
Rate for Payer: BCBS MT POS	$271.70
Rate for Payer: BCBS MT Traditional	$286.00
Rate for Payer: Cash Price	$257.40
Rate for Payer: Cigna Commercial	$271.70
Rate for Payer: Cigna Medicare	$257.40
Rate for Payer: Medicaid All Medicaid	$263.12
Rate for Payer: Medicare All Medicare	$200.20
Rate for Payer: Monida Allegiance	$271.70
Rate for Payer: Monida First Choice Health	$277.42
Rate for Payer: Monida Montana Health Co-op	$271.70
Rate for Payer: Monida PacificSource	$271.70

Know your out-of-pocket cost for care.

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