Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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 MG/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 MG/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

SUPERSATURATION URINE 24H

Facility

$270.00

Service Code	CPT 82340
Hospital Charge Code	4088051
Hospital Revenue Code	302
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$256.50
Rate for Payer: Aetna Medicare	$243.00
Rate for Payer: BCBS MT CHIP	$243.00
Rate for Payer: BCBS MT Closed Plan Network	$256.50
Rate for Payer: BCBS MT HealthLink	$243.00
Rate for Payer: BCBS MT Medicare	$243.00
Rate for Payer: BCBS MT POS	$256.50
Rate for Payer: BCBS MT Traditional	$270.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial	$256.50
Rate for Payer: Cigna Medicare	$243.00
Rate for Payer: Medicaid All Medicaid	$248.40
Rate for Payer: Medicare All Medicare	$189.00
Rate for Payer: Monida Allegiance	$256.50
Rate for Payer: Monida First Choice Health	$261.90
Rate for Payer: Monida Montana Health Co-op	$256.50
Rate for Payer: Monida PacificSource	$256.50

SUPERSATURATION URINE 24H

Facility

$270.00

Service Code	CPT 82340
Hospital Charge Code	4088051
Hospital Revenue Code	302
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$256.50
Rate for Payer: Aetna Medicare	$243.00
Rate for Payer: BCBS MT CHIP	$243.00
Rate for Payer: BCBS MT Closed Plan Network	$256.50
Rate for Payer: BCBS MT HealthLink	$243.00
Rate for Payer: BCBS MT Medicare	$243.00
Rate for Payer: BCBS MT POS	$256.50
Rate for Payer: BCBS MT Traditional	$270.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial	$256.50
Rate for Payer: Cigna Medicare	$243.00
Rate for Payer: Medicaid All Medicaid	$248.40
Rate for Payer: Medicare All Medicare	$189.00
Rate for Payer: Monida Allegiance	$256.50
Rate for Payer: Monida First Choice Health	$261.90
Rate for Payer: Monida Montana Health Co-op	$256.50
Rate for Payer: Monida PacificSource	$256.50

SUPPLIES

Facility

$8.00

Service Code	CPT 99070
Hospital Charge Code	8099070
Hospital Revenue Code	290
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

SUPPLIES

Facility

$8.00

Service Code	CPT 99070
Hospital Charge Code	8099070
Hospital Revenue Code	290
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

SUPPLIES AIRCAST ANKLE

Facility

$187.00

Service Code	HCPCS L4350
Hospital Charge Code	8004350
Hospital Revenue Code	290
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

SUPPLIES AIRCAST ANKLE

Facility

$187.00

Service Code	HCPCS L4350
Hospital Charge Code	8004350
Hospital Revenue Code	290
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

SUPPLIES-CERVICAL FOAM COLLAR

Facility

$56.00

Service Code	HCPCS L0120
Hospital Charge Code	8000120
Hospital Revenue Code	290
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

SUPPLIES-CERVICAL FOAM COLLAR

Facility

$56.00

Service Code	HCPCS L0120
Hospital Charge Code	8000120
Hospital Revenue Code	290
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

SUPPLIES CRUTCHES ALL SIZES

Facility

$72.00

Service Code	HCPCS E0114
Hospital Charge Code	8050114
Hospital Revenue Code	290
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

SUPPLIES CRUTCHES ALL SIZES

Facility

$72.00

Service Code	HCPCS E0114
Hospital Charge Code	8050114
Hospital Revenue Code	290
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

SUPPLIES FRACTURE BOOT SM-MED-LG

Facility

$348.00

Service Code	HCPCS L4386
Hospital Charge Code	8004386
Hospital Revenue Code	290
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

Know your out-of-pocket cost for care.

All Charges