Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ZOFRAN 1 MG RVA

Facility

$53.00

Service Code	HCPCS J2405 QN
Hospital Charge Code	643123
Hospital Revenue Code	636
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

ZOFRAN 1 MG RVA

Facility

$53.00

Service Code	HCPCS J2405 QN
Hospital Charge Code	643123
Hospital Revenue Code	636
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

ZOLEDRONIC 4MG/5ML SDV SPECIAL ORDER

Facility

$302.00

Service Code	HCPCS J3489
Hospital Charge Code	3000489
Hospital Revenue Code	636
Min. Negotiated Rate	$211.40
Max. Negotiated Rate	$302.00
Rate for Payer: Aetna Commercial	$286.90
Rate for Payer: Aetna Medicare	$271.80
Rate for Payer: BCBS MT CHIP	$271.80
Rate for Payer: BCBS MT Closed Plan Network	$286.90
Rate for Payer: BCBS MT HealthLink	$271.80
Rate for Payer: BCBS MT Medicare	$271.80
Rate for Payer: BCBS MT POS	$286.90
Rate for Payer: BCBS MT Traditional	$302.00
Rate for Payer: Cash Price	$271.80
Rate for Payer: Cigna Commercial	$286.90
Rate for Payer: Cigna Medicare	$271.80
Rate for Payer: Medicaid All Medicaid	$277.84
Rate for Payer: Medicare All Medicare	$211.40
Rate for Payer: Monida Allegiance	$286.90
Rate for Payer: Monida First Choice Health	$292.94
Rate for Payer: Monida Montana Health Co-op	$286.90
Rate for Payer: Monida PacificSource	$286.90

ZOLEDRONIC 4MG/5ML SDV SPECIAL ORDER

Facility

$302.00

Service Code	HCPCS J3489
Hospital Charge Code	3000489
Hospital Revenue Code	636
Min. Negotiated Rate	$211.40
Max. Negotiated Rate	$302.00
Rate for Payer: Aetna Commercial	$286.90
Rate for Payer: Aetna Medicare	$271.80
Rate for Payer: BCBS MT CHIP	$271.80
Rate for Payer: BCBS MT Closed Plan Network	$286.90
Rate for Payer: BCBS MT HealthLink	$271.80
Rate for Payer: BCBS MT Medicare	$271.80
Rate for Payer: BCBS MT POS	$286.90
Rate for Payer: BCBS MT Traditional	$302.00
Rate for Payer: Cash Price	$271.80
Rate for Payer: Cigna Commercial	$286.90
Rate for Payer: Cigna Medicare	$271.80
Rate for Payer: Medicaid All Medicaid	$277.84
Rate for Payer: Medicare All Medicare	$211.40
Rate for Payer: Monida Allegiance	$286.90
Rate for Payer: Monida First Choice Health	$292.94
Rate for Payer: Monida Montana Health Co-op	$286.90
Rate for Payer: Monida PacificSource	$286.90

ZOLEDRONIC ACID [5MG/100ML] SPECIAL ORDE

Facility

$427.00

Service Code	HCPCS J3489
Hospital Charge Code	3000490
Hospital Revenue Code	636
Min. Negotiated Rate	$298.90
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$405.65
Rate for Payer: Aetna Medicare	$384.30
Rate for Payer: BCBS MT CHIP	$384.30
Rate for Payer: BCBS MT Closed Plan Network	$405.65
Rate for Payer: BCBS MT HealthLink	$384.30
Rate for Payer: BCBS MT Medicare	$384.30
Rate for Payer: BCBS MT POS	$405.65
Rate for Payer: BCBS MT Traditional	$427.00
Rate for Payer: Cash Price	$384.30
Rate for Payer: Cigna Commercial	$405.65
Rate for Payer: Cigna Medicare	$384.30
Rate for Payer: Medicaid All Medicaid	$392.84
Rate for Payer: Medicare All Medicare	$298.90
Rate for Payer: Monida Allegiance	$405.65
Rate for Payer: Monida First Choice Health	$414.19
Rate for Payer: Monida Montana Health Co-op	$405.65
Rate for Payer: Monida PacificSource	$405.65

ZOLEDRONIC ACID [5MG/100ML] SPECIAL ORDE

Facility

$427.00

Service Code	HCPCS J3489
Hospital Charge Code	3000490
Hospital Revenue Code	636
Min. Negotiated Rate	$298.90
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$405.65
Rate for Payer: Aetna Medicare	$384.30
Rate for Payer: BCBS MT CHIP	$384.30
Rate for Payer: BCBS MT Closed Plan Network	$405.65
Rate for Payer: BCBS MT HealthLink	$384.30
Rate for Payer: BCBS MT Medicare	$384.30
Rate for Payer: BCBS MT POS	$405.65
Rate for Payer: BCBS MT Traditional	$427.00
Rate for Payer: Cash Price	$384.30
Rate for Payer: Cigna Commercial	$405.65
Rate for Payer: Cigna Medicare	$384.30
Rate for Payer: Medicaid All Medicaid	$392.84
Rate for Payer: Medicare All Medicare	$298.90
Rate for Payer: Monida Allegiance	$405.65
Rate for Payer: Monida First Choice Health	$414.19
Rate for Payer: Monida Montana Health Co-op	$405.65
Rate for Payer: Monida PacificSource	$405.65

ZOLPIDEM TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000491
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

ZOLPIDEM TAB [5 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000491
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

ZONISAMIDE [100 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000516
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

ZONISAMIDE [100 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000516
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

ZONISAMIDE 25MG CAPSULE-NF

Facility

$8.00

Service Code	NDC 29300042801
Hospital Charge Code	3007268
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

ZONISAMIDE 25MG CAPSULE-NF

Facility

$8.00

Service Code	NDC 29300042801
Hospital Charge Code	3007268
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

ZOSYN 2.25 GRAM VIAL

Facility

$37.00

Service Code	HCPCS J2543
Hospital Charge Code	3000389
Hospital Revenue Code	636
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

ZOSYN 2.25 GRAM VIAL

Facility

$37.00

Service Code	HCPCS J2543
Hospital Charge Code	3000389
Hospital Revenue Code	636
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

ZOSYN 3.375 GRAM VIAL

Facility

$55.00

Service Code	HCPCS J2543
Hospital Charge Code	3000390
Hospital Revenue Code	259
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

ZOSYN 3.375 GRAM VIAL

Facility

$55.00

Service Code	HCPCS J2543
Hospital Charge Code	3000390
Hospital Revenue Code	259
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

Know your out-of-pocket cost for care.

All Charges