Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

VALIUM 5MG/ML IM

Facility

$26.00

Service Code	HCPCS J3360
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
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	CPT 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	CPT 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 J8499
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

VANCOMYCIN CAP [125 MG]

Facility

$101.00

Service Code	HCPCS J8499
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

VANCOMYCIN INJ [750 MG]

Facility

$35.00

Service Code	HCPCS J3373
Hospital Charge Code	3000565
Hospital Revenue Code	250
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

VANCOMYCIN INJ [750 MG]

Facility

$35.00

Service Code	HCPCS J3373
Hospital Charge Code	3000565
Hospital Revenue Code	250
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

VANCOMYCIN, PEAK

Facility

$182.00

Service Code	CPT 80202
Hospital Charge Code	4000045
Hospital Revenue Code	301
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

VANCOMYCIN, PEAK

Facility

$182.00

Service Code	CPT 80202
Hospital Charge Code	4000045
Hospital Revenue Code	301
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

VANCOMYCIN, RANDOM

Facility

$146.00

Service Code	CPT 80202
Hospital Charge Code	4080202
Hospital Revenue Code	301
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$146.00
Rate for Payer: Aetna Commercial	$138.70
Rate for Payer: Aetna Medicare	$131.40
Rate for Payer: BCBS MT CHIP	$131.40
Rate for Payer: BCBS MT Closed Plan Network	$138.70
Rate for Payer: BCBS MT HealthLink	$131.40
Rate for Payer: BCBS MT Medicare	$131.40
Rate for Payer: BCBS MT POS	$138.70
Rate for Payer: BCBS MT Traditional	$146.00
Rate for Payer: Cash Price	$131.40
Rate for Payer: Cigna Commercial	$138.70
Rate for Payer: Cigna Medicare	$131.40
Rate for Payer: Medicaid All Medicaid	$134.32
Rate for Payer: Medicare All Medicare	$102.20
Rate for Payer: Monida Allegiance	$138.70
Rate for Payer: Monida First Choice Health	$141.62
Rate for Payer: Monida Montana Health Co-op	$138.70
Rate for Payer: Monida PacificSource	$138.70

VANCOMYCIN, RANDOM

Facility

$146.00

Service Code	CPT 80202
Hospital Charge Code	4080202
Hospital Revenue Code	301
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$146.00
Rate for Payer: Aetna Commercial	$138.70
Rate for Payer: Aetna Medicare	$131.40
Rate for Payer: BCBS MT CHIP	$131.40
Rate for Payer: BCBS MT Closed Plan Network	$138.70
Rate for Payer: BCBS MT HealthLink	$131.40
Rate for Payer: BCBS MT Medicare	$131.40
Rate for Payer: BCBS MT POS	$138.70
Rate for Payer: BCBS MT Traditional	$146.00
Rate for Payer: Cash Price	$131.40
Rate for Payer: Cigna Commercial	$138.70
Rate for Payer: Cigna Medicare	$131.40
Rate for Payer: Medicaid All Medicaid	$134.32
Rate for Payer: Medicare All Medicare	$102.20
Rate for Payer: Monida Allegiance	$138.70
Rate for Payer: Monida First Choice Health	$141.62
Rate for Payer: Monida Montana Health Co-op	$138.70
Rate for Payer: Monida PacificSource	$138.70

VANCOMYCIN, TROUGH

Facility

$182.00

Service Code	CPT 80202
Hospital Charge Code	4000046
Hospital Revenue Code	301
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

VANCOMYCIN, TROUGH

Facility

$182.00

Service Code	CPT 80202
Hospital Charge Code	4000046
Hospital Revenue Code	301
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

VARICELLA-ZOSTER AB, IGG (096206)

Facility

$69.00

Service Code	CPT 86787
Hospital Charge Code	4086787
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

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