Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

IV - POTASSIUM CL/NS [40 mEq] 1000ML

Facility

$41.00

Service Code	HCPCS J3490
Hospital Charge Code	3000258
Hospital Revenue Code	258
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

IV - POTASSIUM/ NS [10MEQ/ 100ML] PREMIX

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	3000617
Hospital Revenue Code	258
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

IV - POTASSIUM/ NS [10MEQ/ 100ML] PREMIX

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	3000617
Hospital Revenue Code	258
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

IV PUSH EA ADD'L DRUG

Facility

$147.00

Service Code	CPT 96375
Hospital Charge Code	530195
Hospital Revenue Code	260
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$147.00
Rate for Payer: Aetna Commercial	$139.65
Rate for Payer: Aetna Medicare	$132.30
Rate for Payer: BCBS MT CHIP	$132.30
Rate for Payer: BCBS MT Closed Plan Network	$139.65
Rate for Payer: BCBS MT HealthLink	$132.30
Rate for Payer: BCBS MT Medicare	$132.30
Rate for Payer: BCBS MT POS	$139.65
Rate for Payer: BCBS MT Traditional	$147.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial	$139.65
Rate for Payer: Cigna Medicare	$132.30
Rate for Payer: Medicaid All Medicaid	$135.24
Rate for Payer: Medicare All Medicare	$102.90
Rate for Payer: Monida Allegiance	$139.65
Rate for Payer: Monida First Choice Health	$142.59
Rate for Payer: Monida Montana Health Co-op	$139.65
Rate for Payer: Monida PacificSource	$139.65

IV PUSH EA ADD'L DRUG

Facility

$147.00

Service Code	CPT 96375
Hospital Charge Code	530195
Hospital Revenue Code	260
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$147.00
Rate for Payer: Aetna Commercial	$139.65
Rate for Payer: Aetna Medicare	$132.30
Rate for Payer: BCBS MT CHIP	$132.30
Rate for Payer: BCBS MT Closed Plan Network	$139.65
Rate for Payer: BCBS MT HealthLink	$132.30
Rate for Payer: BCBS MT Medicare	$132.30
Rate for Payer: BCBS MT POS	$139.65
Rate for Payer: BCBS MT Traditional	$147.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial	$139.65
Rate for Payer: Cigna Medicare	$132.30
Rate for Payer: Medicaid All Medicaid	$135.24
Rate for Payer: Medicare All Medicare	$102.90
Rate for Payer: Monida Allegiance	$139.65
Rate for Payer: Monida First Choice Health	$142.59
Rate for Payer: Monida Montana Health Co-op	$139.65
Rate for Payer: Monida PacificSource	$139.65

IV PUSH;INITIAL

Facility

$195.00

Service Code	CPT 96374
Hospital Charge Code	530194
Hospital Revenue Code	260
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

IV PUSH;INITIAL

Facility

$195.00

Service Code	CPT 96374
Hospital Charge Code	530194
Hospital Revenue Code	260
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

IV PUSH SAME MED

Facility

$132.00

Service Code	CPT 96376
Hospital Charge Code	530193
Hospital Revenue Code	260
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$132.00
Rate for Payer: Aetna Commercial	$125.40
Rate for Payer: Aetna Medicare	$118.80
Rate for Payer: BCBS MT CHIP	$118.80
Rate for Payer: BCBS MT Closed Plan Network	$125.40
Rate for Payer: BCBS MT HealthLink	$118.80
Rate for Payer: BCBS MT Medicare	$118.80
Rate for Payer: BCBS MT POS	$125.40
Rate for Payer: BCBS MT Traditional	$132.00
Rate for Payer: Cash Price	$118.80
Rate for Payer: Cigna Commercial	$125.40
Rate for Payer: Cigna Medicare	$118.80
Rate for Payer: Medicaid All Medicaid	$121.44
Rate for Payer: Medicare All Medicare	$92.40
Rate for Payer: Monida Allegiance	$125.40
Rate for Payer: Monida First Choice Health	$128.04
Rate for Payer: Monida Montana Health Co-op	$125.40
Rate for Payer: Monida PacificSource	$125.40

IV PUSH SAME MED

Facility

$132.00

Service Code	CPT 96376
Hospital Charge Code	530193
Hospital Revenue Code	260
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$132.00
Rate for Payer: Aetna Commercial	$125.40
Rate for Payer: Aetna Medicare	$118.80
Rate for Payer: BCBS MT CHIP	$118.80
Rate for Payer: BCBS MT Closed Plan Network	$125.40
Rate for Payer: BCBS MT HealthLink	$118.80
Rate for Payer: BCBS MT Medicare	$118.80
Rate for Payer: BCBS MT POS	$125.40
Rate for Payer: BCBS MT Traditional	$132.00
Rate for Payer: Cash Price	$118.80
Rate for Payer: Cigna Commercial	$125.40
Rate for Payer: Cigna Medicare	$118.80
Rate for Payer: Medicaid All Medicaid	$121.44
Rate for Payer: Medicare All Medicare	$92.40
Rate for Payer: Monida Allegiance	$125.40
Rate for Payer: Monida First Choice Health	$128.04
Rate for Payer: Monida Montana Health Co-op	$125.40
Rate for Payer: Monida PacificSource	$125.40

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

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

Know your out-of-pocket cost for care.

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