Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ZEPTOMETRIX MRSA/SA POS QC

Facility

$380.00

Hospital Charge Code	90197179
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

ZEPTOMETRIX MRSA/SA POS QC

Facility

$380.00

Hospital Charge Code	90197179
Hospital Revenue Code	270
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$361.00
Rate for Payer: Aetna Medicare	$342.00
Rate for Payer: BCBS MT CHIP	$342.00
Rate for Payer: BCBS MT Closed Plan Network	$361.00
Rate for Payer: BCBS MT HealthLink	$342.00
Rate for Payer: BCBS MT Medicare	$342.00
Rate for Payer: BCBS MT POS	$361.00
Rate for Payer: BCBS MT Traditional	$380.00
Rate for Payer: Cash Price	$342.00
Rate for Payer: Cigna Commercial	$361.00
Rate for Payer: Cigna Medicare	$342.00
Rate for Payer: Medicaid All Medicaid	$349.60
Rate for Payer: Medicare All Medicare	$266.00
Rate for Payer: Monida Allegiance	$361.00
Rate for Payer: Monida First Choice Health	$368.60
Rate for Payer: Monida Montana Health Co-op	$361.00
Rate for Payer: Monida PacificSource	$361.00

ZEPTOMETRIX NATVNEG-6C

Facility

$214.00

Hospital Charge Code	90197153
Hospital Revenue Code	270
Min. Negotiated Rate	$149.80
Max. Negotiated Rate	$214.00
Rate for Payer: Aetna Commercial	$203.30
Rate for Payer: Aetna Medicare	$192.60
Rate for Payer: BCBS MT CHIP	$192.60
Rate for Payer: BCBS MT Closed Plan Network	$203.30
Rate for Payer: BCBS MT HealthLink	$192.60
Rate for Payer: BCBS MT Medicare	$192.60
Rate for Payer: BCBS MT POS	$203.30
Rate for Payer: BCBS MT Traditional	$214.00
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cigna Commercial	$203.30
Rate for Payer: Cigna Medicare	$192.60
Rate for Payer: Medicaid All Medicaid	$196.88
Rate for Payer: Medicare All Medicare	$149.80
Rate for Payer: Monida Allegiance	$203.30
Rate for Payer: Monida First Choice Health	$207.58
Rate for Payer: Monida Montana Health Co-op	$203.30
Rate for Payer: Monida PacificSource	$203.30

ZEPTOMETRIX NATVNEG-6C

Facility

$214.00

Hospital Charge Code	90197153
Hospital Revenue Code	270
Min. Negotiated Rate	$149.80
Max. Negotiated Rate	$214.00
Rate for Payer: Aetna Commercial	$203.30
Rate for Payer: Aetna Medicare	$192.60
Rate for Payer: BCBS MT CHIP	$192.60
Rate for Payer: BCBS MT Closed Plan Network	$203.30
Rate for Payer: BCBS MT HealthLink	$192.60
Rate for Payer: BCBS MT Medicare	$192.60
Rate for Payer: BCBS MT POS	$203.30
Rate for Payer: BCBS MT Traditional	$214.00
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cigna Commercial	$203.30
Rate for Payer: Cigna Medicare	$192.60
Rate for Payer: Medicaid All Medicaid	$196.88
Rate for Payer: Medicare All Medicare	$149.80
Rate for Payer: Monida Allegiance	$203.30
Rate for Payer: Monida First Choice Health	$207.58
Rate for Payer: Monida Montana Health Co-op	$203.30
Rate for Payer: Monida PacificSource	$203.30

ZEPTOMETRIX NATVPOS-6C

Facility

$375.00

Hospital Charge Code	90197152
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

ZEPTOMETRIX NATVPOS-6C

Facility

$375.00

Hospital Charge Code	90197152
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

ZINC (001800)

Facility

$45.00

Service Code	CPT 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	CPT 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 A9150
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 A9150
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	CPT 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	CPT 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 A9150
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 A9150
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 TRANSPORTER 8 ANTIBODY

Facility

$700.00

Service Code	CPT 86341
Hospital Charge Code	4088003
Hospital Revenue Code	302
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

ZINC TRANSPORTER 8 ANTIBODY

Facility

$700.00

Service Code	CPT 86341
Hospital Charge Code	4088003
Hospital Revenue Code	302
Min. Negotiated Rate	$490.00
Max. Negotiated Rate	$700.00
Rate for Payer: Aetna Commercial	$665.00
Rate for Payer: Aetna Medicare	$630.00
Rate for Payer: BCBS MT CHIP	$630.00
Rate for Payer: BCBS MT Closed Plan Network	$665.00
Rate for Payer: BCBS MT HealthLink	$630.00
Rate for Payer: BCBS MT Medicare	$630.00
Rate for Payer: BCBS MT POS	$665.00
Rate for Payer: BCBS MT Traditional	$700.00
Rate for Payer: Cash Price	$630.00
Rate for Payer: Cigna Commercial	$665.00
Rate for Payer: Cigna Medicare	$630.00
Rate for Payer: Medicaid All Medicaid	$644.00
Rate for Payer: Medicare All Medicare	$490.00
Rate for Payer: Monida Allegiance	$665.00
Rate for Payer: Monida First Choice Health	$679.00
Rate for Payer: Monida Montana Health Co-op	$665.00
Rate for Payer: Monida PacificSource	$665.00

ZOFRAN 1 MG RVA

Facility

$53.00

Service Code	HCPCS J2405
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
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 ACID [5MG/100ML] PREMIX NF

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] PREMIX NF

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] NF

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] NF

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

Know your out-of-pocket cost for care.

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