Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SOLIFENACIN TAB [5 MG] NF

Facility

$42.00

Service Code	HCPCS J8499
Hospital Charge Code	3007287
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

SOLIFENACIN TAB [5 MG] NF

Facility

$42.00

Service Code	HCPCS J8499
Hospital Charge Code	3007287
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

SOMATOSTATIN QUANTI

Facility

$264.00

Service Code	CPT 84307
Hospital Charge Code	4088055
Hospital Revenue Code	302
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$264.00
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: BCBS MT CHIP	$237.60
Rate for Payer: BCBS MT Closed Plan Network	$250.80
Rate for Payer: BCBS MT HealthLink	$237.60
Rate for Payer: BCBS MT Medicare	$237.60
Rate for Payer: BCBS MT POS	$250.80
Rate for Payer: BCBS MT Traditional	$264.00
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cigna Commercial	$250.80
Rate for Payer: Cigna Medicare	$237.60
Rate for Payer: Medicaid All Medicaid	$242.88
Rate for Payer: Medicare All Medicare	$184.80
Rate for Payer: Monida Allegiance	$250.80
Rate for Payer: Monida First Choice Health	$256.08
Rate for Payer: Monida Montana Health Co-op	$250.80
Rate for Payer: Monida PacificSource	$250.80

SOMATOSTATIN QUANTI

Facility

$264.00

Service Code	CPT 84307
Hospital Charge Code	4088055
Hospital Revenue Code	302
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$264.00
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: BCBS MT CHIP	$237.60
Rate for Payer: BCBS MT Closed Plan Network	$250.80
Rate for Payer: BCBS MT HealthLink	$237.60
Rate for Payer: BCBS MT Medicare	$237.60
Rate for Payer: BCBS MT POS	$250.80
Rate for Payer: BCBS MT Traditional	$264.00
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cigna Commercial	$250.80
Rate for Payer: Cigna Medicare	$237.60
Rate for Payer: Medicaid All Medicaid	$242.88
Rate for Payer: Medicare All Medicare	$184.80
Rate for Payer: Monida Allegiance	$250.80
Rate for Payer: Monida First Choice Health	$256.08
Rate for Payer: Monida Montana Health Co-op	$250.80
Rate for Payer: Monida PacificSource	$250.80

SOTALOL TAB [80 MG] NF

Facility

$9.00

Service Code	HCPCS J8499
Hospital Charge Code	3000433
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

SOTALOL TAB [80 MG] NF

Facility

$9.00

Service Code	HCPCS J8499
Hospital Charge Code	3000433
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

SPECIAL STAIN GROUP 1 MICROORGANISMS I&R

Facility

$299.00

Service Code	CPT 88312
Hospital Charge Code	8088312
Hospital Revenue Code	521
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$299.00
Rate for Payer: Aetna Commercial	$284.05
Rate for Payer: Aetna Medicare	$269.10
Rate for Payer: BCBS MT CHIP	$269.10
Rate for Payer: BCBS MT Closed Plan Network	$284.05
Rate for Payer: BCBS MT HealthLink	$269.10
Rate for Payer: BCBS MT Medicare	$269.10
Rate for Payer: BCBS MT POS	$284.05
Rate for Payer: BCBS MT Traditional	$299.00
Rate for Payer: Cash Price	$269.10
Rate for Payer: Cigna Commercial	$284.05
Rate for Payer: Cigna Medicare	$269.10
Rate for Payer: Medicaid All Medicaid	$275.08
Rate for Payer: Medicare All Medicare	$209.30
Rate for Payer: Monida Allegiance	$284.05
Rate for Payer: Monida First Choice Health	$290.03
Rate for Payer: Monida Montana Health Co-op	$284.05
Rate for Payer: Monida PacificSource	$284.05

SPECIAL STAIN GROUP 1 MICROORGANISMS I&R

Facility

$299.00

Service Code	CPT 88312
Hospital Charge Code	8088312
Hospital Revenue Code	521
Min. Negotiated Rate	$209.30
Max. Negotiated Rate	$299.00
Rate for Payer: Aetna Commercial	$284.05
Rate for Payer: Aetna Medicare	$269.10
Rate for Payer: BCBS MT CHIP	$269.10
Rate for Payer: BCBS MT Closed Plan Network	$284.05
Rate for Payer: BCBS MT HealthLink	$269.10
Rate for Payer: BCBS MT Medicare	$269.10
Rate for Payer: BCBS MT POS	$284.05
Rate for Payer: BCBS MT Traditional	$299.00
Rate for Payer: Cash Price	$269.10
Rate for Payer: Cigna Commercial	$284.05
Rate for Payer: Cigna Medicare	$269.10
Rate for Payer: Medicaid All Medicaid	$275.08
Rate for Payer: Medicare All Medicare	$209.30
Rate for Payer: Monida Allegiance	$284.05
Rate for Payer: Monida First Choice Health	$290.03
Rate for Payer: Monida Montana Health Co-op	$284.05
Rate for Payer: Monida PacificSource	$284.05

SPECIMEN HANDLING CHARGE

Facility

$27.00

Service Code	CPT 99001
Hospital Charge Code	4099000
Hospital Revenue Code	300
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

SPECIMEN HANDLING CHARGE

Facility

$27.00

Service Code	CPT 99001
Hospital Charge Code	4099000
Hospital Revenue Code	300
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

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

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

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

Know your out-of-pocket cost for care.

All Charges