Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

VAC - VAXELIS -DTaP-IPV-Hib-Hep B [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 - VAXELIS -DTaP-IPV-Hib-Hep B [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

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

$70.00

Service Code	HCPCS 80164
Hospital Charge Code	4080164
Hospital Revenue Code	301
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

VALPROIC ACID (007260)

Facility

$70.00

Service Code	HCPCS 80164
Hospital Charge Code	4080164
Hospital Revenue Code	301
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

VALPROIC ACID CAP [250 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000592
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

VALPROIC ACID CAP [250 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000592
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

VALPROIC ACID PO SLN [250 MG/5 ML] UD

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000470
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

VALPROIC ACID PO SLN [250 MG/5 ML] UD

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000470
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

VANCOMYCIN 1.25 GM VIAL

Facility

$77.20

Service Code	HCPCS J3373
Hospital Charge Code	3007278
Hospital Revenue Code	250
Min. Negotiated Rate	$54.04
Max. Negotiated Rate	$77.20
Rate for Payer: Aetna Commercial	$73.34
Rate for Payer: Aetna Medicare	$69.48
Rate for Payer: BCBS MT CHIP	$69.48
Rate for Payer: BCBS MT Closed Plan Network	$73.34
Rate for Payer: BCBS MT HealthLink	$69.48
Rate for Payer: BCBS MT Medicare	$69.48
Rate for Payer: BCBS MT POS	$73.34
Rate for Payer: BCBS MT Traditional	$77.20
Rate for Payer: Cash Price	$69.48
Rate for Payer: Cigna Commercial	$73.34
Rate for Payer: Cigna Medicare	$69.48
Rate for Payer: Medicaid All Medicaid	$71.02
Rate for Payer: Medicare All Medicare	$54.04
Rate for Payer: Monida Allegiance	$73.34
Rate for Payer: Monida First Choice Health	$74.88
Rate for Payer: Monida Montana Health Co-op	$73.34
Rate for Payer: Monida PacificSource	$73.34

VANCOMYCIN 1.25 GM VIAL

Facility

$77.20

Service Code	HCPCS J3373
Hospital Charge Code	3007278
Hospital Revenue Code	250
Min. Negotiated Rate	$54.04
Max. Negotiated Rate	$77.20
Rate for Payer: Aetna Commercial	$73.34
Rate for Payer: Aetna Medicare	$69.48
Rate for Payer: BCBS MT CHIP	$69.48
Rate for Payer: BCBS MT Closed Plan Network	$73.34
Rate for Payer: BCBS MT HealthLink	$69.48
Rate for Payer: BCBS MT Medicare	$69.48
Rate for Payer: BCBS MT POS	$73.34
Rate for Payer: BCBS MT Traditional	$77.20
Rate for Payer: Cash Price	$69.48
Rate for Payer: Cigna Commercial	$73.34
Rate for Payer: Cigna Medicare	$69.48
Rate for Payer: Medicaid All Medicaid	$71.02
Rate for Payer: Medicare All Medicare	$54.04
Rate for Payer: Monida Allegiance	$73.34
Rate for Payer: Monida First Choice Health	$74.88
Rate for Payer: Monida Montana Health Co-op	$73.34
Rate for Payer: Monida PacificSource	$73.34

VANCOMYCIN 1GM VIAL

Facility

$65.00

Service Code	HCPCS J3373
Hospital Charge Code	3000471
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

VANCOMYCIN 1GM VIAL

Facility

$65.00

Service Code	HCPCS J3373
Hospital Charge Code	3000471
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

VANCOMYCIN 500MG VIAL

Facility

$29.00

Service Code	HCPCS J3373
Hospital Charge Code	3000472
Hospital Revenue Code	259
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

VANCOMYCIN 500MG VIAL

Facility

$29.00

Service Code	HCPCS J3373
Hospital Charge Code	3000472
Hospital Revenue Code	259
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

VANCOMYCIN CAP [125 MG]

Facility

$101.00

Service Code	HCPCS J3490
Hospital Charge Code	3007051
Hospital Revenue Code	250
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

Know your out-of-pocket cost for care.

All Charges