Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

VITAMIN B3 (070115)

Facility

$184.00

Service Code	HCPCS 84591
Hospital Charge Code	4084591
Hospital Revenue Code	301
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$184.00
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: BCBS MT CHIP	$165.60
Rate for Payer: BCBS MT Closed Plan Network	$174.80
Rate for Payer: BCBS MT HealthLink	$165.60
Rate for Payer: BCBS MT Medicare	$165.60
Rate for Payer: BCBS MT POS	$174.80
Rate for Payer: BCBS MT Traditional	$184.00
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial	$174.80
Rate for Payer: Cigna Medicare	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

VITAMIN B6 (004655)

Facility

$112.00

Service Code	HCPCS 84207
Hospital Charge Code	4084207
Hospital Revenue Code	301
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

VITAMIN B6 (004655)

Facility

$112.00

Service Code	HCPCS 84207
Hospital Charge Code	4084207
Hospital Revenue Code	301
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

VITAMIN B6 TAB [100 MG] NF

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3007478
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN B6 TAB [100 MG] NF

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3007478
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN B COMPLEX NF

Facility

$5.00

Service Code	NDC 11845006011
Hospital Charge Code	3000517
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN B COMPLEX NF

Facility

$5.00

Service Code	NDC 11845006011
Hospital Charge Code	3000517
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

VITAMIN C [500 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000479
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

VITAMIN C [500 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000479
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

VITAMIN D, 25-OH (081950)

Facility

$60.00

Service Code	HCPCS 82306
Hospital Charge Code	4000047
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

VITAMIN D, 25-OH (081950)

Facility

$60.00

Service Code	HCPCS 82306
Hospital Charge Code	4000047
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

VITAMIN D 25 OH RVMC

Facility

$185.00

Service Code	HCPCS 82306
Hospital Charge Code	4087914
Hospital Revenue Code	301
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$185.00
Rate for Payer: Aetna Commercial	$175.75
Rate for Payer: Aetna Medicare	$166.50
Rate for Payer: BCBS MT CHIP	$166.50
Rate for Payer: BCBS MT Closed Plan Network	$175.75
Rate for Payer: BCBS MT HealthLink	$166.50
Rate for Payer: BCBS MT Medicare	$166.50
Rate for Payer: BCBS MT POS	$175.75
Rate for Payer: BCBS MT Traditional	$185.00
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cigna Commercial	$175.75
Rate for Payer: Cigna Medicare	$166.50
Rate for Payer: Medicaid All Medicaid	$170.20
Rate for Payer: Medicare All Medicare	$129.50
Rate for Payer: Monida Allegiance	$175.75
Rate for Payer: Monida First Choice Health	$179.45
Rate for Payer: Monida Montana Health Co-op	$175.75
Rate for Payer: Monida PacificSource	$175.75

VITAMIN D 25 OH RVMC

Facility

$185.00

Service Code	HCPCS 82306
Hospital Charge Code	4087914
Hospital Revenue Code	301
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$185.00
Rate for Payer: Aetna Commercial	$175.75
Rate for Payer: Aetna Medicare	$166.50
Rate for Payer: BCBS MT CHIP	$166.50
Rate for Payer: BCBS MT Closed Plan Network	$175.75
Rate for Payer: BCBS MT HealthLink	$166.50
Rate for Payer: BCBS MT Medicare	$166.50
Rate for Payer: BCBS MT POS	$175.75
Rate for Payer: BCBS MT Traditional	$185.00
Rate for Payer: Cash Price	$166.50
Rate for Payer: Cigna Commercial	$175.75
Rate for Payer: Cigna Medicare	$166.50
Rate for Payer: Medicaid All Medicaid	$170.20
Rate for Payer: Medicare All Medicare	$129.50
Rate for Payer: Monida Allegiance	$175.75
Rate for Payer: Monida First Choice Health	$179.45
Rate for Payer: Monida Montana Health Co-op	$175.75
Rate for Payer: Monida PacificSource	$175.75

VITAMIN D3 [50,000 IU] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000480
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

VITAMIN D3 [50,000 IU] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000480
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

VITAMIN D3 CAP [5,000 IU]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000482
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

VITAMIN D3 CAP [5,000 IU]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000482
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

VITAMIN D3 TAB [1000 IU] [25MCG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000481
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

VITAMIN D3 TAB [1000 IU] [25MCG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000481
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

VITAMIN D ASSAY

Facility

$1,250.00

Hospital Charge Code	90197094
Hospital Revenue Code	270
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$1,250.00
Rate for Payer: Aetna Commercial	$1,187.50
Rate for Payer: Aetna Medicare	$1,125.00
Rate for Payer: BCBS MT CHIP	$1,125.00
Rate for Payer: BCBS MT Closed Plan Network	$1,187.50
Rate for Payer: BCBS MT HealthLink	$1,125.00
Rate for Payer: BCBS MT Medicare	$1,125.00
Rate for Payer: BCBS MT POS	$1,187.50
Rate for Payer: BCBS MT Traditional	$1,250.00
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Cigna Commercial	$1,187.50
Rate for Payer: Cigna Medicare	$1,125.00
Rate for Payer: Medicaid All Medicaid	$1,150.00
Rate for Payer: Medicare All Medicare	$875.00
Rate for Payer: Monida Allegiance	$1,187.50
Rate for Payer: Monida First Choice Health	$1,212.50
Rate for Payer: Monida Montana Health Co-op	$1,187.50
Rate for Payer: Monida PacificSource	$1,187.50

VITAMIN D ASSAY

Facility

$1,250.00

Hospital Charge Code	90197094
Hospital Revenue Code	270
Min. Negotiated Rate	$875.00
Max. Negotiated Rate	$1,250.00
Rate for Payer: Aetna Commercial	$1,187.50
Rate for Payer: Aetna Medicare	$1,125.00
Rate for Payer: BCBS MT CHIP	$1,125.00
Rate for Payer: BCBS MT Closed Plan Network	$1,187.50
Rate for Payer: BCBS MT HealthLink	$1,125.00
Rate for Payer: BCBS MT Medicare	$1,125.00
Rate for Payer: BCBS MT POS	$1,187.50
Rate for Payer: BCBS MT Traditional	$1,250.00
Rate for Payer: Cash Price	$1,125.00
Rate for Payer: Cigna Commercial	$1,187.50
Rate for Payer: Cigna Medicare	$1,125.00
Rate for Payer: Medicaid All Medicaid	$1,150.00
Rate for Payer: Medicare All Medicare	$875.00
Rate for Payer: Monida Allegiance	$1,187.50
Rate for Payer: Monida First Choice Health	$1,212.50
Rate for Payer: Monida Montana Health Co-op	$1,187.50
Rate for Payer: Monida PacificSource	$1,187.50

VITAMIN K1 (121200)

Facility

$289.00

Service Code	HCPCS 84597
Hospital Charge Code	4084597
Hospital Revenue Code	300
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

VITAMIN K1 (121200)

Facility

$289.00

Service Code	HCPCS 84597
Hospital Charge Code	4084597
Hospital Revenue Code	300
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

VIT B12 ASSAY

Facility

$119.48

Hospital Charge Code	90197100
Hospital Revenue Code	270
Min. Negotiated Rate	$83.64
Max. Negotiated Rate	$119.48
Rate for Payer: Aetna Commercial	$113.51
Rate for Payer: Aetna Medicare	$107.53
Rate for Payer: BCBS MT CHIP	$107.53
Rate for Payer: BCBS MT Closed Plan Network	$113.51
Rate for Payer: BCBS MT HealthLink	$107.53
Rate for Payer: BCBS MT Medicare	$107.53
Rate for Payer: BCBS MT POS	$113.51
Rate for Payer: BCBS MT Traditional	$119.48
Rate for Payer: Cash Price	$107.53
Rate for Payer: Cigna Commercial	$113.51
Rate for Payer: Cigna Medicare	$107.53
Rate for Payer: Medicaid All Medicaid	$109.92
Rate for Payer: Medicare All Medicare	$83.64
Rate for Payer: Monida Allegiance	$113.51
Rate for Payer: Monida First Choice Health	$115.90
Rate for Payer: Monida Montana Health Co-op	$113.51
Rate for Payer: Monida PacificSource	$113.51

VIT B12 ASSAY

Facility

$119.48

Hospital Charge Code	90197100
Hospital Revenue Code	270
Min. Negotiated Rate	$83.64
Max. Negotiated Rate	$119.48
Rate for Payer: Aetna Commercial	$113.51
Rate for Payer: Aetna Medicare	$107.53
Rate for Payer: BCBS MT CHIP	$107.53
Rate for Payer: BCBS MT Closed Plan Network	$113.51
Rate for Payer: BCBS MT HealthLink	$107.53
Rate for Payer: BCBS MT Medicare	$107.53
Rate for Payer: BCBS MT POS	$113.51
Rate for Payer: BCBS MT Traditional	$119.48
Rate for Payer: Cash Price	$107.53
Rate for Payer: Cigna Commercial	$113.51
Rate for Payer: Cigna Medicare	$107.53
Rate for Payer: Medicaid All Medicaid	$109.92
Rate for Payer: Medicare All Medicare	$83.64
Rate for Payer: Monida Allegiance	$113.51
Rate for Payer: Monida First Choice Health	$115.90
Rate for Payer: Monida Montana Health Co-op	$113.51
Rate for Payer: Monida PacificSource	$113.51

Know your out-of-pocket cost for care.

All Charges