Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$41.00

Service Code	HCPCS J3480
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 CL/NS [40 mEq] 1000ML

Facility

$41.00

Service Code	HCPCS J3480
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 PUSH EA ADD'L DRUG

Facility

$147.00

Service Code	HCPCS 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	HCPCS 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	HCPCS 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	HCPCS 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	HCPCS 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	HCPCS 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

JAK2V617F MUTATION DETECTION (489200)

Facility

$525.00

Service Code	HCPCS 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	HCPCS 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

JUVEN THERAPEUTIC NUTRITION POWDER

Facility

$9.10

Service Code	NDC 59781066678
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

Service Code	NDC 59781066678
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

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% 30GM

Facility

$166.75

Service Code	NDC 00168009930
Hospital Charge Code	3007404
Hospital Revenue Code	250
Min. Negotiated Rate	$116.72
Max. Negotiated Rate	$166.75
Rate for Payer: Aetna Commercial	$158.41
Rate for Payer: Aetna Medicare	$150.08
Rate for Payer: BCBS MT CHIP	$150.08
Rate for Payer: BCBS MT Closed Plan Network	$158.41
Rate for Payer: BCBS MT HealthLink	$150.08
Rate for Payer: BCBS MT Medicare	$150.08
Rate for Payer: BCBS MT POS	$158.41
Rate for Payer: BCBS MT Traditional	$166.75
Rate for Payer: Cash Price	$150.08
Rate for Payer: Cigna Commercial	$158.41
Rate for Payer: Cigna Medicare	$150.08
Rate for Payer: Medicaid All Medicaid	$153.41
Rate for Payer: Medicare All Medicare	$116.72
Rate for Payer: Monida Allegiance	$158.41
Rate for Payer: Monida First Choice Health	$161.75
Rate for Payer: Monida Montana Health Co-op	$158.41
Rate for Payer: Monida PacificSource	$158.41

KETOCONAZOLE CRM 2% 30GM

Facility

$166.75

Service Code	NDC 00168009930
Hospital Charge Code	3007404
Hospital Revenue Code	250
Min. Negotiated Rate	$116.72
Max. Negotiated Rate	$166.75
Rate for Payer: Aetna Commercial	$158.41
Rate for Payer: Aetna Medicare	$150.08
Rate for Payer: BCBS MT CHIP	$150.08
Rate for Payer: BCBS MT Closed Plan Network	$158.41
Rate for Payer: BCBS MT HealthLink	$150.08
Rate for Payer: BCBS MT Medicare	$150.08
Rate for Payer: BCBS MT POS	$158.41
Rate for Payer: BCBS MT Traditional	$166.75
Rate for Payer: Cash Price	$150.08
Rate for Payer: Cigna Commercial	$158.41
Rate for Payer: Cigna Medicare	$150.08
Rate for Payer: Medicaid All Medicaid	$153.41
Rate for Payer: Medicare All Medicare	$116.72
Rate for Payer: Monida Allegiance	$158.41
Rate for Payer: Monida First Choice Health	$161.75
Rate for Payer: Monida Montana Health Co-op	$158.41
Rate for Payer: Monida PacificSource	$158.41

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

KIDNEY STONE ANALYSIS (910180)

Facility

$39.00

Service Code	HCPCS 82365
Hospital Charge Code	4082365
Hospital Revenue Code	301
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

KIDNEY STONE ANALYSIS (910180)

Facility

$39.00

Service Code	HCPCS 82365
Hospital Charge Code	4082365
Hospital Revenue Code	301
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

KING AIRWAY SIZE 3

Facility

$167.00

Hospital Charge Code	80040150
Hospital Revenue Code	272
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

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