Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

xxVITAMIN E [180 MG]

Facility

$71.00

Service Code	HCPCS 84446
Hospital Charge Code	4084446
Hospital Revenue Code	301
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

YANKAUER SUCTION TIP

Facility

$12.00

Hospital Charge Code	80030299
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

YANKAUER SUCTION TIP

Facility

$12.00

Hospital Charge Code	80030299
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ZEPTOMETRIX FLU/RSV/SARS NEG QC

Facility

$229.00

Hospital Charge Code	90197137
Hospital Revenue Code	270
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

ZEPTOMETRIX FLU/RSV/SARS NEG QC

Facility

$229.00

Hospital Charge Code	90197137
Hospital Revenue Code	270
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

ZEPTOMETRIX FLU/RSV/SARS POS QC

Facility

$263.00

Hospital Charge Code	90197136
Hospital Revenue Code	270
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

ZEPTOMETRIX FLU/RSV/SARS POS QC

Facility

$263.00

Hospital Charge Code	90197136
Hospital Revenue Code	270
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

ZINC (001800)

Facility

$45.00

Service Code	HCPCS 84630
Hospital Charge Code	4084630
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

ZINC (001800)

Facility

$45.00

Service Code	HCPCS 84630
Hospital Charge Code	4084630
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

ZINC OXIDE/MENTHOL OINT [20.6%/0.44%] NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3000540
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ZINC OXIDE/MENTHOL OINT [20.6%/0.44%] NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3000540
Hospital Revenue Code	250
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

ZINC, RBC (070029)

Facility

$243.00

Service Code	HCPCS 84630
Hospital Charge Code	4046301
Hospital Revenue Code	301
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: BCBS MT CHIP	$218.70
Rate for Payer: BCBS MT Closed Plan Network	$230.85
Rate for Payer: BCBS MT HealthLink	$218.70
Rate for Payer: BCBS MT Medicare	$218.70
Rate for Payer: BCBS MT POS	$230.85
Rate for Payer: BCBS MT Traditional	$243.00
Rate for Payer: Cash Price	$218.70
Rate for Payer: Cigna Commercial	$230.85
Rate for Payer: Cigna Medicare	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

ZINC, RBC (070029)

Facility

$243.00

Service Code	HCPCS 84630
Hospital Charge Code	4046301
Hospital Revenue Code	301
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: BCBS MT CHIP	$218.70
Rate for Payer: BCBS MT Closed Plan Network	$230.85
Rate for Payer: BCBS MT HealthLink	$218.70
Rate for Payer: BCBS MT Medicare	$218.70
Rate for Payer: BCBS MT POS	$230.85
Rate for Payer: BCBS MT Traditional	$243.00
Rate for Payer: Cash Price	$218.70
Rate for Payer: Cigna Commercial	$230.85
Rate for Payer: Cigna Medicare	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

ZINC SULFATE CAP [50 MG] 220MG NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000488
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

ZINC SULFATE CAP [50 MG] 220MG NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000488
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

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 ER TAB [6.25 MG] NF

Facility

$20.00

Service Code	HCPCS J3490
Hospital Charge Code	3000600
Hospital Revenue Code	250
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

ZOLPIDEM ER TAB [6.25 MG] NF

Facility

$20.00

Service Code	HCPCS J3490
Hospital Charge Code	3000600
Hospital Revenue Code	250
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

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

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