Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US VENOUS DOPP BILATERAL

Facility

$693.00

Service Code	HCPCS 93970
Hospital Charge Code	5193970
Hospital Revenue Code	402
Min. Negotiated Rate	$485.10
Max. Negotiated Rate	$693.00
Rate for Payer: Aetna Commercial	$658.35
Rate for Payer: Aetna Medicare	$623.70
Rate for Payer: BCBS MT CHIP	$623.70
Rate for Payer: BCBS MT Closed Plan Network	$658.35
Rate for Payer: BCBS MT HealthLink	$623.70
Rate for Payer: BCBS MT Medicare	$623.70
Rate for Payer: BCBS MT POS	$658.35
Rate for Payer: BCBS MT Traditional	$693.00
Rate for Payer: Cash Price	$623.70
Rate for Payer: Cigna Commercial	$658.35
Rate for Payer: Cigna Medicare	$623.70
Rate for Payer: Medicaid All Medicaid	$637.56
Rate for Payer: Medicare All Medicare	$485.10
Rate for Payer: Monida Allegiance	$658.35
Rate for Payer: Monida First Choice Health	$672.21
Rate for Payer: Monida Montana Health Co-op	$658.35
Rate for Payer: Monida PacificSource	$658.35

US VENOUS DOPP SINGLE

Facility

$462.00

Service Code	HCPCS 93971
Hospital Charge Code	5193971
Hospital Revenue Code	402
Min. Negotiated Rate	$323.40
Max. Negotiated Rate	$462.00
Rate for Payer: Aetna Commercial	$438.90
Rate for Payer: Aetna Medicare	$415.80
Rate for Payer: BCBS MT CHIP	$415.80
Rate for Payer: BCBS MT Closed Plan Network	$438.90
Rate for Payer: BCBS MT HealthLink	$415.80
Rate for Payer: BCBS MT Medicare	$415.80
Rate for Payer: BCBS MT POS	$438.90
Rate for Payer: BCBS MT Traditional	$462.00
Rate for Payer: Cash Price	$415.80
Rate for Payer: Cigna Commercial	$438.90
Rate for Payer: Cigna Medicare	$415.80
Rate for Payer: Medicaid All Medicaid	$425.04
Rate for Payer: Medicare All Medicare	$323.40
Rate for Payer: Monida Allegiance	$438.90
Rate for Payer: Monida First Choice Health	$448.14
Rate for Payer: Monida Montana Health Co-op	$438.90
Rate for Payer: Monida PacificSource	$438.90

US VENOUS DOPP SINGLE

Facility

$462.00

Service Code	HCPCS 93971
Hospital Charge Code	5193971
Hospital Revenue Code	402
Min. Negotiated Rate	$323.40
Max. Negotiated Rate	$462.00
Rate for Payer: Aetna Commercial	$438.90
Rate for Payer: Aetna Medicare	$415.80
Rate for Payer: BCBS MT CHIP	$415.80
Rate for Payer: BCBS MT Closed Plan Network	$438.90
Rate for Payer: BCBS MT HealthLink	$415.80
Rate for Payer: BCBS MT Medicare	$415.80
Rate for Payer: BCBS MT POS	$438.90
Rate for Payer: BCBS MT Traditional	$462.00
Rate for Payer: Cash Price	$415.80
Rate for Payer: Cigna Commercial	$438.90
Rate for Payer: Cigna Medicare	$415.80
Rate for Payer: Medicaid All Medicaid	$425.04
Rate for Payer: Medicare All Medicare	$323.40
Rate for Payer: Monida Allegiance	$438.90
Rate for Payer: Monida First Choice Health	$448.14
Rate for Payer: Monida Montana Health Co-op	$438.90
Rate for Payer: Monida PacificSource	$438.90

VAC - DTaP-IPV-Hib-Hep B (VAXELIS)[0.5ML

Facility

$508.00

Service Code	HCPCS 90697
Hospital Charge Code	3007093
Hospital Revenue Code	250
Min. Negotiated Rate	$355.60
Max. Negotiated Rate	$508.00
Rate for Payer: Aetna Commercial	$482.60
Rate for Payer: Aetna Medicare	$457.20
Rate for Payer: BCBS MT CHIP	$457.20
Rate for Payer: BCBS MT Closed Plan Network	$482.60
Rate for Payer: BCBS MT HealthLink	$457.20
Rate for Payer: BCBS MT Medicare	$457.20
Rate for Payer: BCBS MT POS	$482.60
Rate for Payer: BCBS MT Traditional	$508.00
Rate for Payer: Cash Price	$457.20
Rate for Payer: Cigna Commercial	$482.60
Rate for Payer: Cigna Medicare	$457.20
Rate for Payer: Medicaid All Medicaid	$467.36
Rate for Payer: Medicare All Medicare	$355.60
Rate for Payer: Monida Allegiance	$482.60
Rate for Payer: Monida First Choice Health	$492.76
Rate for Payer: Monida Montana Health Co-op	$482.60
Rate for Payer: Monida PacificSource	$482.60

VAC - DTaP-IPV-Hib-Hep B (VAXELIS)[0.5ML

Facility

$508.00

Service Code	HCPCS 90697
Hospital Charge Code	3007093
Hospital Revenue Code	250
Min. Negotiated Rate	$355.60
Max. Negotiated Rate	$508.00
Rate for Payer: Aetna Commercial	$482.60
Rate for Payer: Aetna Medicare	$457.20
Rate for Payer: BCBS MT CHIP	$457.20
Rate for Payer: BCBS MT Closed Plan Network	$482.60
Rate for Payer: BCBS MT HealthLink	$457.20
Rate for Payer: BCBS MT Medicare	$457.20
Rate for Payer: BCBS MT POS	$482.60
Rate for Payer: BCBS MT Traditional	$508.00
Rate for Payer: Cash Price	$457.20
Rate for Payer: Cigna Commercial	$482.60
Rate for Payer: Cigna Medicare	$457.20
Rate for Payer: Medicaid All Medicaid	$467.36
Rate for Payer: Medicare All Medicare	$355.60
Rate for Payer: Monida Allegiance	$482.60
Rate for Payer: Monida First Choice Health	$492.76
Rate for Payer: Monida Montana Health Co-op	$482.60
Rate for Payer: Monida PacificSource	$482.60

VAC - INFLUENZA EGG FREE HOSPITAL

Facility

$63.00

Service Code	HCPCS 90682
Hospital Charge Code	3000466
Hospital Revenue Code	250
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

VAC - INFLUENZA EGG FREE HOSPITAL

Facility

$63.00

Service Code	HCPCS 90682
Hospital Charge Code	3000466
Hospital Revenue Code	250
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

VAC - INFLUENZA HD HOSPITAL

Facility

$93.00

Service Code	HCPCS 90662
Hospital Charge Code	3000467
Hospital Revenue Code	636
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

VAC - INFLUENZA HD HOSPITAL

Facility

$93.00

Service Code	HCPCS 90662
Hospital Charge Code	3000467
Hospital Revenue Code	636
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

VAC - INFLUENZA REGULAR DOSE HOSP

Facility

$26.00

Service Code	HCPCS 90656
Hospital Charge Code	3000468
Hospital Revenue Code	250
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

VAC - INFLUENZA REGULAR DOSE HOSP

Facility

$26.00

Service Code	HCPCS 90656
Hospital Charge Code	3000468
Hospital Revenue Code	250
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

VAC - MEASLES, MUMPS & RUBELLA

Facility

$35.00

Service Code	HCPCS 90707
Hospital Charge Code	3000465
Hospital Revenue Code	636
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

VAC - MEASLES, MUMPS & RUBELLA

Facility

$35.00

Service Code	HCPCS 90707
Hospital Charge Code	3000465
Hospital Revenue Code	636
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

VAC - RABIES VACCINE

Facility

$845.00

Service Code	HCPCS 90675
Hospital Charge Code	300667
Hospital Revenue Code	636
Min. Negotiated Rate	$591.50
Max. Negotiated Rate	$845.00
Rate for Payer: Aetna Commercial	$802.75
Rate for Payer: Aetna Medicare	$760.50
Rate for Payer: BCBS MT CHIP	$760.50
Rate for Payer: BCBS MT Closed Plan Network	$802.75
Rate for Payer: BCBS MT HealthLink	$760.50
Rate for Payer: BCBS MT Medicare	$760.50
Rate for Payer: BCBS MT POS	$802.75
Rate for Payer: BCBS MT Traditional	$845.00
Rate for Payer: Cash Price	$760.50
Rate for Payer: Cigna Commercial	$802.75
Rate for Payer: Cigna Medicare	$760.50
Rate for Payer: Medicaid All Medicaid	$777.40
Rate for Payer: Medicare All Medicare	$591.50
Rate for Payer: Monida Allegiance	$802.75
Rate for Payer: Monida First Choice Health	$819.65
Rate for Payer: Monida Montana Health Co-op	$802.75
Rate for Payer: Monida PacificSource	$802.75

VAC - RABIES VACCINE

Facility

$845.00

Service Code	HCPCS 90675
Hospital Charge Code	300667
Hospital Revenue Code	636
Min. Negotiated Rate	$591.50
Max. Negotiated Rate	$845.00
Rate for Payer: Aetna Commercial	$802.75
Rate for Payer: Aetna Medicare	$760.50
Rate for Payer: BCBS MT CHIP	$760.50
Rate for Payer: BCBS MT Closed Plan Network	$802.75
Rate for Payer: BCBS MT HealthLink	$760.50
Rate for Payer: BCBS MT Medicare	$760.50
Rate for Payer: BCBS MT POS	$802.75
Rate for Payer: BCBS MT Traditional	$845.00
Rate for Payer: Cash Price	$760.50
Rate for Payer: Cigna Commercial	$802.75
Rate for Payer: Cigna Medicare	$760.50
Rate for Payer: Medicaid All Medicaid	$777.40
Rate for Payer: Medicare All Medicare	$591.50
Rate for Payer: Monida Allegiance	$802.75
Rate for Payer: Monida First Choice Health	$819.65
Rate for Payer: Monida Montana Health Co-op	$802.75
Rate for Payer: Monida PacificSource	$802.75

VAGINAL SPECULUMS SM

Facility

$18.00

Hospital Charge Code	80040099
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

VAGINAL SPECULUMS SM

Facility

$18.00

Hospital Charge Code	80040099
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

VAGINITIS PANEL PCR

Facility

$460.00

Service Code	HCPCS 81514
Hospital Charge Code	4081514
Hospital Revenue Code	300
Min. Negotiated Rate	$322.00
Max. Negotiated Rate	$460.00
Rate for Payer: Aetna Commercial	$437.00
Rate for Payer: Aetna Medicare	$414.00
Rate for Payer: BCBS MT CHIP	$414.00
Rate for Payer: BCBS MT Closed Plan Network	$437.00
Rate for Payer: BCBS MT HealthLink	$414.00
Rate for Payer: BCBS MT Medicare	$414.00
Rate for Payer: BCBS MT POS	$437.00
Rate for Payer: BCBS MT Traditional	$460.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cigna Commercial	$437.00
Rate for Payer: Cigna Medicare	$414.00
Rate for Payer: Medicaid All Medicaid	$423.20
Rate for Payer: Medicare All Medicare	$322.00
Rate for Payer: Monida Allegiance	$437.00
Rate for Payer: Monida First Choice Health	$446.20
Rate for Payer: Monida Montana Health Co-op	$437.00
Rate for Payer: Monida PacificSource	$437.00

VAGINITIS PANEL PCR

Facility

$460.00

Service Code	HCPCS 81514
Hospital Charge Code	4081514
Hospital Revenue Code	300
Min. Negotiated Rate	$322.00
Max. Negotiated Rate	$460.00
Rate for Payer: Aetna Commercial	$437.00
Rate for Payer: Aetna Medicare	$414.00
Rate for Payer: BCBS MT CHIP	$414.00
Rate for Payer: BCBS MT Closed Plan Network	$437.00
Rate for Payer: BCBS MT HealthLink	$414.00
Rate for Payer: BCBS MT Medicare	$414.00
Rate for Payer: BCBS MT POS	$437.00
Rate for Payer: BCBS MT Traditional	$460.00
Rate for Payer: Cash Price	$414.00
Rate for Payer: Cigna Commercial	$437.00
Rate for Payer: Cigna Medicare	$414.00
Rate for Payer: Medicaid All Medicaid	$423.20
Rate for Payer: Medicare All Medicare	$322.00
Rate for Payer: Monida Allegiance	$437.00
Rate for Payer: Monida First Choice Health	$446.20
Rate for Payer: Monida Montana Health Co-op	$437.00
Rate for Payer: Monida PacificSource	$437.00

VALACYCLOVIR TAB [500 MG]

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000469
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

VALACYCLOVIR TAB [500 MG]

Facility

$24.00

Service Code	HCPCS J3490
Hospital Charge Code	3000469
Hospital Revenue Code	250
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

VALIUM 5MG/ML IM

Facility

$26.00

Service Code	HCPCS J3360 QN
Hospital Charge Code	640701
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

VALIUM 5MG/ML IM

Facility

$26.00

Service Code	HCPCS J3360 QN
Hospital Charge Code	640701
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

VALPROIC ACID (007260)

Facility

$32.00

Service Code	HCPCS 80164
Hospital Charge Code	4080164
Hospital Revenue Code	301
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

VALPROIC ACID (007260)

Facility

$32.00

Service Code	HCPCS 80164
Hospital Charge Code	4080164
Hospital Revenue Code	301
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

Know your out-of-pocket cost for care.

All Charges