Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

JAK2 EXON 12-15 SEQ POLYCY VERA REFLEX

Facility

$700.00

Service Code	CPT 0027U
Hospital Charge Code	4088104
Hospital Revenue Code	302
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

JAK2 EXON 12-15 SEQ POLYCY VERA REFLEX

Facility

$700.00

Service Code	CPT 0027U
Hospital Charge Code	4088104
Hospital Revenue Code	302
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

JAK2V617F MUTATION DETECTION (489200)

Facility

$525.00

Service Code	CPT 81270
Hospital Charge Code	4081270
Hospital Revenue Code	300
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

JAK2V617F MUTATION DETECTION (489200)

Facility

$525.00

Service Code	CPT 81270
Hospital Charge Code	4081270
Hospital Revenue Code	300
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

JO1 ANTIBODIES IGG

Facility

$82.00

Service Code	CPT 86235
Hospital Charge Code	4088015
Hospital Revenue Code	302
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

JO1 ANTIBODIES IGG

Facility

$82.00

Service Code	CPT 86235
Hospital Charge Code	4088015
Hospital Revenue Code	302
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

JUVEN THERAPEUTIC NUTRITION POWDER

Facility

$9.10

Hospital Charge Code	3007408
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$9.10
Rate for Payer: Aetna Commercial	$8.64
Rate for Payer: Aetna Medicare	$8.19
Rate for Payer: BCBS MT CHIP	$8.19
Rate for Payer: BCBS MT Closed Plan Network	$8.64
Rate for Payer: BCBS MT HealthLink	$8.19
Rate for Payer: BCBS MT Medicare	$8.19
Rate for Payer: BCBS MT POS	$8.64
Rate for Payer: BCBS MT Traditional	$9.10
Rate for Payer: Cash Price	$8.19
Rate for Payer: Cigna Commercial	$8.64
Rate for Payer: Cigna Medicare	$8.19
Rate for Payer: Medicaid All Medicaid	$8.37
Rate for Payer: Medicare All Medicare	$6.37
Rate for Payer: Monida Allegiance	$8.64
Rate for Payer: Monida First Choice Health	$8.83
Rate for Payer: Monida Montana Health Co-op	$8.64
Rate for Payer: Monida PacificSource	$8.64

JUVEN THERAPEUTIC NUTRITION POWDER

Facility

$9.10

Hospital Charge Code	3007408
Hospital Revenue Code	250
Min. Negotiated Rate	$6.37
Max. Negotiated Rate	$9.10
Rate for Payer: Aetna Commercial	$8.64
Rate for Payer: Aetna Medicare	$8.19
Rate for Payer: BCBS MT CHIP	$8.19
Rate for Payer: BCBS MT Closed Plan Network	$8.64
Rate for Payer: BCBS MT HealthLink	$8.19
Rate for Payer: BCBS MT Medicare	$8.19
Rate for Payer: BCBS MT POS	$8.64
Rate for Payer: BCBS MT Traditional	$9.10
Rate for Payer: Cash Price	$8.19
Rate for Payer: Cigna Commercial	$8.64
Rate for Payer: Cigna Medicare	$8.19
Rate for Payer: Medicaid All Medicaid	$8.37
Rate for Payer: Medicare All Medicare	$6.37
Rate for Payer: Monida Allegiance	$8.64
Rate for Payer: Monida First Choice Health	$8.83
Rate for Payer: Monida Montana Health Co-op	$8.64
Rate for Payer: Monida PacificSource	$8.64

KAWASUMI 21G BUTTERFLY NEEDLE

Facility

$45.20

Hospital Charge Code	90197154
Hospital Revenue Code	270
Min. Negotiated Rate	$31.64
Max. Negotiated Rate	$45.20
Rate for Payer: Aetna Commercial	$42.94
Rate for Payer: Aetna Medicare	$40.68
Rate for Payer: BCBS MT CHIP	$40.68
Rate for Payer: BCBS MT Closed Plan Network	$42.94
Rate for Payer: BCBS MT HealthLink	$40.68
Rate for Payer: BCBS MT Medicare	$40.68
Rate for Payer: BCBS MT POS	$42.94
Rate for Payer: BCBS MT Traditional	$45.20
Rate for Payer: Cash Price	$40.68
Rate for Payer: Cigna Commercial	$42.94
Rate for Payer: Cigna Medicare	$40.68
Rate for Payer: Medicaid All Medicaid	$41.58
Rate for Payer: Medicare All Medicare	$31.64
Rate for Payer: Monida Allegiance	$42.94
Rate for Payer: Monida First Choice Health	$43.84
Rate for Payer: Monida Montana Health Co-op	$42.94
Rate for Payer: Monida PacificSource	$42.94

KAWASUMI 21G BUTTERFLY NEEDLE

Facility

$45.20

Hospital Charge Code	90197154
Hospital Revenue Code	270
Min. Negotiated Rate	$31.64
Max. Negotiated Rate	$45.20
Rate for Payer: Aetna Commercial	$42.94
Rate for Payer: Aetna Medicare	$40.68
Rate for Payer: BCBS MT CHIP	$40.68
Rate for Payer: BCBS MT Closed Plan Network	$42.94
Rate for Payer: BCBS MT HealthLink	$40.68
Rate for Payer: BCBS MT Medicare	$40.68
Rate for Payer: BCBS MT POS	$42.94
Rate for Payer: BCBS MT Traditional	$45.20
Rate for Payer: Cash Price	$40.68
Rate for Payer: Cigna Commercial	$42.94
Rate for Payer: Cigna Medicare	$40.68
Rate for Payer: Medicaid All Medicaid	$41.58
Rate for Payer: Medicare All Medicare	$31.64
Rate for Payer: Monida Allegiance	$42.94
Rate for Payer: Monida First Choice Health	$43.84
Rate for Payer: Monida Montana Health Co-op	$42.94
Rate for Payer: Monida PacificSource	$42.94

KAWASUMI 23 G BUTTERFLY NEE

Facility

$28.16

Hospital Charge Code	90197127
Hospital Revenue Code	270
Min. Negotiated Rate	$19.71
Max. Negotiated Rate	$28.16
Rate for Payer: Aetna Commercial	$26.75
Rate for Payer: Aetna Medicare	$25.34
Rate for Payer: BCBS MT CHIP	$25.34
Rate for Payer: BCBS MT Closed Plan Network	$26.75
Rate for Payer: BCBS MT HealthLink	$25.34
Rate for Payer: BCBS MT Medicare	$25.34
Rate for Payer: BCBS MT POS	$26.75
Rate for Payer: BCBS MT Traditional	$28.16
Rate for Payer: Cash Price	$25.34
Rate for Payer: Cigna Commercial	$26.75
Rate for Payer: Cigna Medicare	$25.34
Rate for Payer: Medicaid All Medicaid	$25.91
Rate for Payer: Medicare All Medicare	$19.71
Rate for Payer: Monida Allegiance	$26.75
Rate for Payer: Monida First Choice Health	$27.32
Rate for Payer: Monida Montana Health Co-op	$26.75
Rate for Payer: Monida PacificSource	$26.75

KAWASUMI 23 G BUTTERFLY NEE

Facility

$28.16

Hospital Charge Code	90197127
Hospital Revenue Code	270
Min. Negotiated Rate	$19.71
Max. Negotiated Rate	$28.16
Rate for Payer: Aetna Commercial	$26.75
Rate for Payer: Aetna Medicare	$25.34
Rate for Payer: BCBS MT CHIP	$25.34
Rate for Payer: BCBS MT Closed Plan Network	$26.75
Rate for Payer: BCBS MT HealthLink	$25.34
Rate for Payer: BCBS MT Medicare	$25.34
Rate for Payer: BCBS MT POS	$26.75
Rate for Payer: BCBS MT Traditional	$28.16
Rate for Payer: Cash Price	$25.34
Rate for Payer: Cigna Commercial	$26.75
Rate for Payer: Cigna Medicare	$25.34
Rate for Payer: Medicaid All Medicaid	$25.91
Rate for Payer: Medicare All Medicare	$19.71
Rate for Payer: Monida Allegiance	$26.75
Rate for Payer: Monida First Choice Health	$27.32
Rate for Payer: Monida Montana Health Co-op	$26.75
Rate for Payer: Monida PacificSource	$26.75

KERLIX FLUFFS SUPER SPONGE

Facility

$4.00

Hospital Charge Code	80030119
Hospital Revenue Code	270
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

KERLIX FLUFFS SUPER SPONGE

Facility

$4.00

Hospital Charge Code	80030119
Hospital Revenue Code	270
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

KERLIX ROLLS 4.5X4YDS

Facility

$13.00

Hospital Charge Code	80030118
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

KERLIX ROLLS 4.5X4YDS

Facility

$13.00

Hospital Charge Code	80030118
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

KETAMINE INJ [500 MG/10 ML] MDV

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	3000261
Hospital Revenue Code	250
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

KETAMINE INJ [500 MG/10 ML] MDV

Facility

$28.00

Service Code	HCPCS J3490
Hospital Charge Code	3000261
Hospital Revenue Code	250
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

KETOCONAZOLE CRM 2% 15GM NF

Facility

$99.00

Hospital Charge Code	3007404
Hospital Revenue Code	250
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

KETOCONAZOLE CRM 2% 15GM NF

Facility

$99.00

Hospital Charge Code	3007404
Hospital Revenue Code	250
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

KETOROLAC INJ [15 MG/ML]

Facility

$26.00

Service Code	HCPCS J1885
Hospital Charge Code	3000262
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

KETOROLAC INJ [15 MG/ML]

Facility

$26.00

Service Code	HCPCS J1885
Hospital Charge Code	3000262
Hospital Revenue Code	259
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

KETOROLAC OPTH SLN [0.5 %] NF

Facility

$340.00

Service Code	HCPCS J3490
Hospital Charge Code	3007642
Hospital Revenue Code	250
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$340.00
Rate for Payer: Aetna Commercial	$323.00
Rate for Payer: Aetna Medicare	$306.00
Rate for Payer: BCBS MT CHIP	$306.00
Rate for Payer: BCBS MT Closed Plan Network	$323.00
Rate for Payer: BCBS MT HealthLink	$306.00
Rate for Payer: BCBS MT Medicare	$306.00
Rate for Payer: BCBS MT POS	$323.00
Rate for Payer: BCBS MT Traditional	$340.00
Rate for Payer: Cash Price	$306.00
Rate for Payer: Cigna Commercial	$323.00
Rate for Payer: Cigna Medicare	$306.00
Rate for Payer: Medicaid All Medicaid	$312.80
Rate for Payer: Medicare All Medicare	$238.00
Rate for Payer: Monida Allegiance	$323.00
Rate for Payer: Monida First Choice Health	$329.80
Rate for Payer: Monida Montana Health Co-op	$323.00
Rate for Payer: Monida PacificSource	$323.00

KETOROLAC OPTH SLN [0.5 %] NF

Facility

$340.00

Service Code	HCPCS J3490
Hospital Charge Code	3007642
Hospital Revenue Code	250
Min. Negotiated Rate	$238.00
Max. Negotiated Rate	$340.00
Rate for Payer: Aetna Commercial	$323.00
Rate for Payer: Aetna Medicare	$306.00
Rate for Payer: BCBS MT CHIP	$306.00
Rate for Payer: BCBS MT Closed Plan Network	$323.00
Rate for Payer: BCBS MT HealthLink	$306.00
Rate for Payer: BCBS MT Medicare	$306.00
Rate for Payer: BCBS MT POS	$323.00
Rate for Payer: BCBS MT Traditional	$340.00
Rate for Payer: Cash Price	$306.00
Rate for Payer: Cigna Commercial	$323.00
Rate for Payer: Cigna Medicare	$306.00
Rate for Payer: Medicaid All Medicaid	$312.80
Rate for Payer: Medicare All Medicare	$238.00
Rate for Payer: Monida Allegiance	$323.00
Rate for Payer: Monida First Choice Health	$329.80
Rate for Payer: Monida Montana Health Co-op	$323.00
Rate for Payer: Monida PacificSource	$323.00

KIDNEY STONE ANALYSIS (910180)

Facility

$69.00

Service Code	CPT 82365
Hospital Charge Code	4082365
Hospital Revenue Code	301
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

Know your out-of-pocket cost for care.

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