Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FECAL FAT, QUANTITATIVE, 72 HR (001354)

Facility

$73.00

Service Code	CPT 82710
Hospital Charge Code	4082710
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

FECAL FAT, QUANTITATIVE, 72 HR (001354)

Facility

$73.00

Service Code	CPT 82710
Hospital Charge Code	4082710
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

FEEDING PUMP BAG

Facility

$19.00

Hospital Charge Code	80030174
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

FEEDING PUMP BAG

Facility

$19.00

Hospital Charge Code	80030174
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

FENTANYL 12 MCG

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	649378
Hospital Revenue Code	636
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

FENTANYL 12 MCG

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	649378
Hospital Revenue Code	636
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

FENTANYL 50 PATCH (MCG/HR)

Facility

$89.00

Hospital Charge Code	3007169
Hospital Revenue Code	250
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

FENTANYL 50 PATCH (MCG/HR)

Facility

$89.00

Hospital Charge Code	3007169
Hospital Revenue Code	250
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

FENTANYL INJ [100 MCG/ 2 ML] 2ML SDV

Facility

$8.00

Service Code	HCPCS J3010
Hospital Charge Code	3000598
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

FENTANYL INJ [100 MCG/ 2 ML] 2ML SDV

Facility

$8.00

Service Code	HCPCS J3010
Hospital Charge Code	3000598
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

FENTANYL INJ [50 MCG/ML] 1ML

Facility

$8.00

Service Code	HCPCS J3010
Hospital Charge Code	3007342
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

FENTANYL INJ [50 MCG/ML] 1ML

Facility

$8.00

Service Code	HCPCS J3010
Hospital Charge Code	3007342
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

FENTANYL INJ [50 MCG/ML] 2ML VIAL

Facility

$26.00

Service Code	HCPCS J3010
Hospital Charge Code	3000175
Hospital Revenue Code	636
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

FENTANYL INJ [50 MCG/ML] 2ML VIAL

Facility

$26.00

Service Code	HCPCS J3010
Hospital Charge Code	3000175
Hospital Revenue Code	636
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

FENTANYL PATCH [12 MCG/HR]

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	3000176
Hospital Revenue Code	636
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

FENTANYL PATCH [12 MCG/HR]

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	3000176
Hospital Revenue Code	636
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

FENTANYL PATCH [25 MCG/HR]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000177
Hospital Revenue Code	636
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

FENTANYL PATCH [25 MCG/HR]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000177
Hospital Revenue Code	636
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

FENTANYL QC

Facility

$55.46

Hospital Charge Code	90197172
Hospital Revenue Code	270
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$55.46
Rate for Payer: Aetna Commercial	$52.69
Rate for Payer: Aetna Medicare	$49.91
Rate for Payer: BCBS MT CHIP	$49.91
Rate for Payer: BCBS MT Closed Plan Network	$52.69
Rate for Payer: BCBS MT HealthLink	$49.91
Rate for Payer: BCBS MT Medicare	$49.91
Rate for Payer: BCBS MT POS	$52.69
Rate for Payer: BCBS MT Traditional	$55.46
Rate for Payer: Cash Price	$49.91
Rate for Payer: Cigna Commercial	$52.69
Rate for Payer: Cigna Medicare	$49.91
Rate for Payer: Medicaid All Medicaid	$51.02
Rate for Payer: Medicare All Medicare	$38.82
Rate for Payer: Monida Allegiance	$52.69
Rate for Payer: Monida First Choice Health	$53.80
Rate for Payer: Monida Montana Health Co-op	$52.69
Rate for Payer: Monida PacificSource	$52.69

FENTANYL QC

Facility

$55.46

Hospital Charge Code	90197172
Hospital Revenue Code	270
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$55.46
Rate for Payer: Aetna Commercial	$52.69
Rate for Payer: Aetna Medicare	$49.91
Rate for Payer: BCBS MT CHIP	$49.91
Rate for Payer: BCBS MT Closed Plan Network	$52.69
Rate for Payer: BCBS MT HealthLink	$49.91
Rate for Payer: BCBS MT Medicare	$49.91
Rate for Payer: BCBS MT POS	$52.69
Rate for Payer: BCBS MT Traditional	$55.46
Rate for Payer: Cash Price	$49.91
Rate for Payer: Cigna Commercial	$52.69
Rate for Payer: Cigna Medicare	$49.91
Rate for Payer: Medicaid All Medicaid	$51.02
Rate for Payer: Medicare All Medicare	$38.82
Rate for Payer: Monida Allegiance	$52.69
Rate for Payer: Monida First Choice Health	$53.80
Rate for Payer: Monida Montana Health Co-op	$52.69
Rate for Payer: Monida PacificSource	$52.69

FENTANYL SCREEN DAU KIT

Facility

$55.83

Hospital Charge Code	90197143
Hospital Revenue Code	270
Min. Negotiated Rate	$39.08
Max. Negotiated Rate	$55.83
Rate for Payer: Aetna Commercial	$53.04
Rate for Payer: Aetna Medicare	$50.25
Rate for Payer: BCBS MT CHIP	$50.25
Rate for Payer: BCBS MT Closed Plan Network	$53.04
Rate for Payer: BCBS MT HealthLink	$50.25
Rate for Payer: BCBS MT Medicare	$50.25
Rate for Payer: BCBS MT POS	$53.04
Rate for Payer: BCBS MT Traditional	$55.83
Rate for Payer: Cash Price	$50.25
Rate for Payer: Cigna Commercial	$53.04
Rate for Payer: Cigna Medicare	$50.25
Rate for Payer: Medicaid All Medicaid	$51.36
Rate for Payer: Medicare All Medicare	$39.08
Rate for Payer: Monida Allegiance	$53.04
Rate for Payer: Monida First Choice Health	$54.16
Rate for Payer: Monida Montana Health Co-op	$53.04
Rate for Payer: Monida PacificSource	$53.04

FENTANYL SCREEN DAU KIT

Facility

$55.83

Hospital Charge Code	90197143
Hospital Revenue Code	270
Min. Negotiated Rate	$39.08
Max. Negotiated Rate	$55.83
Rate for Payer: Aetna Commercial	$53.04
Rate for Payer: Aetna Medicare	$50.25
Rate for Payer: BCBS MT CHIP	$50.25
Rate for Payer: BCBS MT Closed Plan Network	$53.04
Rate for Payer: BCBS MT HealthLink	$50.25
Rate for Payer: BCBS MT Medicare	$50.25
Rate for Payer: BCBS MT POS	$53.04
Rate for Payer: BCBS MT Traditional	$55.83
Rate for Payer: Cash Price	$50.25
Rate for Payer: Cigna Commercial	$53.04
Rate for Payer: Cigna Medicare	$50.25
Rate for Payer: Medicaid All Medicaid	$51.36
Rate for Payer: Medicare All Medicare	$39.08
Rate for Payer: Monida Allegiance	$53.04
Rate for Payer: Monida First Choice Health	$54.16
Rate for Payer: Monida Montana Health Co-op	$53.04
Rate for Payer: Monida PacificSource	$53.04

FERRIC CARBOXYMALTOSE INJ [750MG/15ML]NF

Facility

$2,842.00

Service Code	HCPCS J1439
Hospital Charge Code	3007687
Hospital Revenue Code	250
Min. Negotiated Rate	$1,989.40
Max. Negotiated Rate	$2,842.00
Rate for Payer: Aetna Commercial	$2,699.90
Rate for Payer: Aetna Medicare	$2,557.80
Rate for Payer: BCBS MT CHIP	$2,557.80
Rate for Payer: BCBS MT Closed Plan Network	$2,699.90
Rate for Payer: BCBS MT HealthLink	$2,557.80
Rate for Payer: BCBS MT Medicare	$2,557.80
Rate for Payer: BCBS MT POS	$2,699.90
Rate for Payer: BCBS MT Traditional	$2,842.00
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Cigna Commercial	$2,699.90
Rate for Payer: Cigna Medicare	$2,557.80
Rate for Payer: Medicaid All Medicaid	$2,614.64
Rate for Payer: Medicare All Medicare	$1,989.40
Rate for Payer: Monida Allegiance	$2,699.90
Rate for Payer: Monida First Choice Health	$2,756.74
Rate for Payer: Monida Montana Health Co-op	$2,699.90
Rate for Payer: Monida PacificSource	$2,699.90

FERRIC CARBOXYMALTOSE INJ [750MG/15ML]NF

Facility

$2,842.00

Service Code	HCPCS J1439
Hospital Charge Code	3007687
Hospital Revenue Code	250
Min. Negotiated Rate	$1,989.40
Max. Negotiated Rate	$2,842.00
Rate for Payer: Aetna Commercial	$2,699.90
Rate for Payer: Aetna Medicare	$2,557.80
Rate for Payer: BCBS MT CHIP	$2,557.80
Rate for Payer: BCBS MT Closed Plan Network	$2,699.90
Rate for Payer: BCBS MT HealthLink	$2,557.80
Rate for Payer: BCBS MT Medicare	$2,557.80
Rate for Payer: BCBS MT POS	$2,699.90
Rate for Payer: BCBS MT Traditional	$2,842.00
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Cigna Commercial	$2,699.90
Rate for Payer: Cigna Medicare	$2,557.80
Rate for Payer: Medicaid All Medicaid	$2,614.64
Rate for Payer: Medicare All Medicare	$1,989.40
Rate for Payer: Monida Allegiance	$2,699.90
Rate for Payer: Monida First Choice Health	$2,756.74
Rate for Payer: Monida Montana Health Co-op	$2,699.90
Rate for Payer: Monida PacificSource	$2,699.90

FERRITIN (004598)

Facility

$58.00

Service Code	CPT 82728
Hospital Charge Code	4082728
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

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