Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SKIN SUBS APPLIC T,A,L 1ST100 SQCM 15273

Facility

$1,806.00

Service Code	HCPCS 15273
Hospital Charge Code	8015273
Hospital Revenue Code	761
Min. Negotiated Rate	$1,264.20
Max. Negotiated Rate	$1,806.00
Rate for Payer: Aetna Commercial	$1,715.70
Rate for Payer: Aetna Medicare	$1,625.40
Rate for Payer: BCBS MT CHIP	$1,625.40
Rate for Payer: BCBS MT Closed Plan Network	$1,715.70
Rate for Payer: BCBS MT HealthLink	$1,625.40
Rate for Payer: BCBS MT Medicare	$1,625.40
Rate for Payer: BCBS MT POS	$1,715.70
Rate for Payer: BCBS MT Traditional	$1,806.00
Rate for Payer: Cash Price	$1,625.40
Rate for Payer: Cigna Commercial	$1,715.70
Rate for Payer: Cigna Medicare	$1,625.40
Rate for Payer: Medicaid All Medicaid	$1,661.52
Rate for Payer: Medicare All Medicare	$1,264.20
Rate for Payer: Monida Allegiance	$1,715.70
Rate for Payer: Monida First Choice Health	$1,751.82
Rate for Payer: Monida Montana Health Co-op	$1,715.70
Rate for Payer: Monida PacificSource	$1,715.70

SKIN SUBS APPLIC T,A,L 1ST100 SQCM 15273

Facility

$1,806.00

Service Code	HCPCS 15273
Hospital Charge Code	8015273
Hospital Revenue Code	761
Min. Negotiated Rate	$1,264.20
Max. Negotiated Rate	$1,806.00
Rate for Payer: Aetna Commercial	$1,715.70
Rate for Payer: Aetna Medicare	$1,625.40
Rate for Payer: BCBS MT CHIP	$1,625.40
Rate for Payer: BCBS MT Closed Plan Network	$1,715.70
Rate for Payer: BCBS MT HealthLink	$1,625.40
Rate for Payer: BCBS MT Medicare	$1,625.40
Rate for Payer: BCBS MT POS	$1,715.70
Rate for Payer: BCBS MT Traditional	$1,806.00
Rate for Payer: Cash Price	$1,625.40
Rate for Payer: Cigna Commercial	$1,715.70
Rate for Payer: Cigna Medicare	$1,625.40
Rate for Payer: Medicaid All Medicaid	$1,661.52
Rate for Payer: Medicare All Medicare	$1,264.20
Rate for Payer: Monida Allegiance	$1,715.70
Rate for Payer: Monida First Choice Health	$1,751.82
Rate for Payer: Monida Montana Health Co-op	$1,715.70
Rate for Payer: Monida PacificSource	$1,715.70

SKIN SUBS APPLIC T,A,L EA100+ SQCM 15274

Facility

$769.00

Service Code	HCPCS 15274
Hospital Charge Code	8015274
Hospital Revenue Code	761
Min. Negotiated Rate	$538.30
Max. Negotiated Rate	$769.00
Rate for Payer: Aetna Commercial	$730.55
Rate for Payer: Aetna Medicare	$692.10
Rate for Payer: BCBS MT CHIP	$692.10
Rate for Payer: BCBS MT Closed Plan Network	$730.55
Rate for Payer: BCBS MT HealthLink	$692.10
Rate for Payer: BCBS MT Medicare	$692.10
Rate for Payer: BCBS MT POS	$730.55
Rate for Payer: BCBS MT Traditional	$769.00
Rate for Payer: Cash Price	$692.10
Rate for Payer: Cigna Commercial	$730.55
Rate for Payer: Cigna Medicare	$692.10
Rate for Payer: Medicaid All Medicaid	$707.48
Rate for Payer: Medicare All Medicare	$538.30
Rate for Payer: Monida Allegiance	$730.55
Rate for Payer: Monida First Choice Health	$745.93
Rate for Payer: Monida Montana Health Co-op	$730.55
Rate for Payer: Monida PacificSource	$730.55

SKIN SUBS APPLIC T,A,L EA100+ SQCM 15274

Facility

$769.00

Service Code	HCPCS 15274
Hospital Charge Code	8015274
Hospital Revenue Code	761
Min. Negotiated Rate	$538.30
Max. Negotiated Rate	$769.00
Rate for Payer: Aetna Commercial	$730.55
Rate for Payer: Aetna Medicare	$692.10
Rate for Payer: BCBS MT CHIP	$692.10
Rate for Payer: BCBS MT Closed Plan Network	$730.55
Rate for Payer: BCBS MT HealthLink	$692.10
Rate for Payer: BCBS MT Medicare	$692.10
Rate for Payer: BCBS MT POS	$730.55
Rate for Payer: BCBS MT Traditional	$769.00
Rate for Payer: Cash Price	$692.10
Rate for Payer: Cigna Commercial	$730.55
Rate for Payer: Cigna Medicare	$692.10
Rate for Payer: Medicaid All Medicaid	$707.48
Rate for Payer: Medicare All Medicare	$538.30
Rate for Payer: Monida Allegiance	$730.55
Rate for Payer: Monida First Choice Health	$745.93
Rate for Payer: Monida Montana Health Co-op	$730.55
Rate for Payer: Monida PacificSource	$730.55

SKIN SUBS APPLIC T,A,L EA 25 SQCM 15272

Facility

$465.00

Service Code	HCPCS 15272
Hospital Charge Code	8015272
Hospital Revenue Code	761
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$465.00
Rate for Payer: Aetna Commercial	$441.75
Rate for Payer: Aetna Medicare	$418.50
Rate for Payer: BCBS MT CHIP	$418.50
Rate for Payer: BCBS MT Closed Plan Network	$441.75
Rate for Payer: BCBS MT HealthLink	$418.50
Rate for Payer: BCBS MT Medicare	$418.50
Rate for Payer: BCBS MT POS	$441.75
Rate for Payer: BCBS MT Traditional	$465.00
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cigna Commercial	$441.75
Rate for Payer: Cigna Medicare	$418.50
Rate for Payer: Medicaid All Medicaid	$427.80
Rate for Payer: Medicare All Medicare	$325.50
Rate for Payer: Monida Allegiance	$441.75
Rate for Payer: Monida First Choice Health	$451.05
Rate for Payer: Monida Montana Health Co-op	$441.75
Rate for Payer: Monida PacificSource	$441.75

SKIN SUBS APPLIC T,A,L EA 25 SQCM 15272

Facility

$465.00

Service Code	HCPCS 15272
Hospital Charge Code	8015272
Hospital Revenue Code	761
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$465.00
Rate for Payer: Aetna Commercial	$441.75
Rate for Payer: Aetna Medicare	$418.50
Rate for Payer: BCBS MT CHIP	$418.50
Rate for Payer: BCBS MT Closed Plan Network	$441.75
Rate for Payer: BCBS MT HealthLink	$418.50
Rate for Payer: BCBS MT Medicare	$418.50
Rate for Payer: BCBS MT POS	$441.75
Rate for Payer: BCBS MT Traditional	$465.00
Rate for Payer: Cash Price	$418.50
Rate for Payer: Cigna Commercial	$441.75
Rate for Payer: Cigna Medicare	$418.50
Rate for Payer: Medicaid All Medicaid	$427.80
Rate for Payer: Medicare All Medicare	$325.50
Rate for Payer: Monida Allegiance	$441.75
Rate for Payer: Monida First Choice Health	$451.05
Rate for Payer: Monida Montana Health Co-op	$441.75
Rate for Payer: Monida PacificSource	$441.75

SLING AND SWATHE LG

Facility

$35.00

Hospital Charge Code	2893511
Hospital Revenue Code	290
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

SLING AND SWATHE LG

Facility

$35.00

Hospital Charge Code	2893511
Hospital Revenue Code	290
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

SLING AND SWATHE MD

Facility

$35.00

Hospital Charge Code	2893510
Hospital Revenue Code	290
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

SLING AND SWATHE MD

Facility

$35.00

Hospital Charge Code	2893510
Hospital Revenue Code	290
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

SLING AND SWATHE SM

Facility

$43.00

Hospital Charge Code	2840095
Hospital Revenue Code	270
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

SLING AND SWATHE SM

Facility

$43.00

Hospital Charge Code	2840095
Hospital Revenue Code	270
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

SMALLBORE EXTENSION SET

Facility

$35.00

Hospital Charge Code	80030040
Hospital Revenue Code	270
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

SMALLBORE EXTENSION SET

Facility

$35.00

Hospital Charge Code	80030040
Hospital Revenue Code	270
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

SMITH ANTIBODIES (016360)

Facility

$114.00

Service Code	HCPCS 86235
Hospital Charge Code	4000065
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

SMITH ANTIBODIES (016360)

Facility

$114.00

Service Code	HCPCS 86235
Hospital Charge Code	4000065
Hospital Revenue Code	300
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

SODIUM

Facility

$53.00

Service Code	HCPCS 84295
Hospital Charge Code	4084295
Hospital Revenue Code	301
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

SODIUM

Facility

$53.00

Service Code	HCPCS 84295
Hospital Charge Code	4084295
Hospital Revenue Code	301
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

SODIUM BICARB INJ 4.2% [5MEQ/10ML] PEDS

Facility

$50.00

Service Code	HCPCS J3490
Hospital Charge Code	3000427
Hospital Revenue Code	259
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

SODIUM BICARB INJ 4.2% [5MEQ/10ML] PEDS

Facility

$50.00

Service Code	HCPCS J3490
Hospital Charge Code	3000427
Hospital Revenue Code	259
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

SODIUM BICARB INJ 8.4% [50 MEQ/50 ML]

Facility

$65.00

Service Code	HCPCS J3490
Hospital Charge Code	3000428
Hospital Revenue Code	259
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

SODIUM BICARB INJ 8.4% [50 MEQ/50 ML]

Facility

$65.00

Service Code	HCPCS J3490
Hospital Charge Code	3000428
Hospital Revenue Code	259
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$65.00
Rate for Payer: Aetna Commercial	$61.75
Rate for Payer: Aetna Medicare	$58.50
Rate for Payer: BCBS MT CHIP	$58.50
Rate for Payer: BCBS MT Closed Plan Network	$61.75
Rate for Payer: BCBS MT HealthLink	$58.50
Rate for Payer: BCBS MT Medicare	$58.50
Rate for Payer: BCBS MT POS	$61.75
Rate for Payer: BCBS MT Traditional	$65.00
Rate for Payer: Cash Price	$58.50
Rate for Payer: Cigna Commercial	$61.75
Rate for Payer: Cigna Medicare	$58.50
Rate for Payer: Medicaid All Medicaid	$59.80
Rate for Payer: Medicare All Medicare	$45.50
Rate for Payer: Monida Allegiance	$61.75
Rate for Payer: Monida First Choice Health	$63.05
Rate for Payer: Monida Montana Health Co-op	$61.75
Rate for Payer: Monida PacificSource	$61.75

SODIUM BICARBONATE TAB [650 MG] NF

Facility

$8.00

Service Code	NDC 77333082725
Hospital Charge Code	3007397
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

SODIUM BICARBONATE TAB [650 MG] NF

Facility

$8.00

Service Code	NDC 77333082725
Hospital Charge Code	3007397
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

SODIUM CHLORIDE 0.9% NEB SOLN [3 ML]

Facility

$8.00

Service Code	HCPCS A4216
Hospital Charge Code	3000429
Hospital Revenue Code	259
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

Know your out-of-pocket cost for care.

All Charges