Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

DIGOXIN

Facility

$144.00

Service Code	HCPCS 80162
Hospital Charge Code	4080162
Hospital Revenue Code	300
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

DIGOXIN

Facility

$144.00

Service Code	HCPCS 80162
Hospital Charge Code	4080162
Hospital Revenue Code	300
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

DIGOXIN INJ [500 MCG/2 ML]

Facility

$26.00

Service Code	HCPCS J1160
Hospital Charge Code	3000119
Hospital Revenue Code	259
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

DIGOXIN INJ [500 MCG/2 ML]

Facility

$26.00

Service Code	HCPCS J1160
Hospital Charge Code	3000119
Hospital Revenue Code	259
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

DIGOXIN TAB [0.125 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000120
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

DIGOXIN TAB [0.125 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000120
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

DIHYDROTESTOSTERONE (500142)

Facility

$236.00

Service Code	HCPCS 82642
Hospital Charge Code	4082642
Hospital Revenue Code	301
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$236.00
Rate for Payer: Aetna Commercial	$224.20
Rate for Payer: Aetna Medicare	$212.40
Rate for Payer: BCBS MT CHIP	$212.40
Rate for Payer: BCBS MT Closed Plan Network	$224.20
Rate for Payer: BCBS MT HealthLink	$212.40
Rate for Payer: BCBS MT Medicare	$212.40
Rate for Payer: BCBS MT POS	$224.20
Rate for Payer: BCBS MT Traditional	$236.00
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$224.20
Rate for Payer: Cigna Medicare	$212.40
Rate for Payer: Medicaid All Medicaid	$217.12
Rate for Payer: Medicare All Medicare	$165.20
Rate for Payer: Monida Allegiance	$224.20
Rate for Payer: Monida First Choice Health	$228.92
Rate for Payer: Monida Montana Health Co-op	$224.20
Rate for Payer: Monida PacificSource	$224.20

DIHYDROTESTOSTERONE (500142)

Facility

$236.00

Service Code	HCPCS 82642
Hospital Charge Code	4082642
Hospital Revenue Code	301
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$236.00
Rate for Payer: Aetna Commercial	$224.20
Rate for Payer: Aetna Medicare	$212.40
Rate for Payer: BCBS MT CHIP	$212.40
Rate for Payer: BCBS MT Closed Plan Network	$224.20
Rate for Payer: BCBS MT HealthLink	$212.40
Rate for Payer: BCBS MT Medicare	$212.40
Rate for Payer: BCBS MT POS	$224.20
Rate for Payer: BCBS MT Traditional	$236.00
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$224.20
Rate for Payer: Cigna Medicare	$212.40
Rate for Payer: Medicaid All Medicaid	$217.12
Rate for Payer: Medicare All Medicare	$165.20
Rate for Payer: Monida Allegiance	$224.20
Rate for Payer: Monida First Choice Health	$228.92
Rate for Payer: Monida Montana Health Co-op	$224.20
Rate for Payer: Monida PacificSource	$224.20

DILTIAZEM 30MG TABLET-NF

Facility

$8.00

Service Code	NDC 00093031801
Hospital Charge Code	3007203
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

DILTIAZEM 30MG TABLET-NF

Facility

$8.00

Service Code	NDC 00093031801
Hospital Charge Code	3007203
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

DILTIAZEM [60 MG] TAB NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000530
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

DILTIAZEM [60 MG] TAB NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000530
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

DILTIAZEM ER CAP [120 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000121
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

DILTIAZEM ER CAP [120 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000121
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

DILTIAZEM ER CAP [180 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000122
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

DILTIAZEM ER CAP [180 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000122
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

DILTIAZEM INJ [25 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000123
Hospital Revenue Code	259
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

DILTIAZEM INJ [25 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000123
Hospital Revenue Code	259
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

DILUTE RUSSELL'S VIPER VENOM (117976)

Facility

$79.00

Service Code	HCPCS 85613
Hospital Charge Code	4085613
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

DILUTE RUSSELL'S VIPER VENOM (117976)

Facility

$79.00

Service Code	HCPCS 85613
Hospital Charge Code	4085613
Hospital Revenue Code	300
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

DIPHENHYDRAMINE BTL [12.5 MG/5 ML] 118ML

Facility

$10.00

Service Code	NDC 00904698520
Hospital Charge Code	3000546
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

DIPHENHYDRAMINE BTL [12.5 MG/5 ML] 118ML

Facility

$10.00

Service Code	NDC 00904698520
Hospital Charge Code	3000546
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

DIPHENHYDRAMINE CAP [25 MG]

Facility

$8.00

Service Code	HCPCS Q0163
Hospital Charge Code	3000124
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

DIPHENHYDRAMINE CAP [25 MG]

Facility

$8.00

Service Code	HCPCS Q0163
Hospital Charge Code	3000124
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

DIPHENHYDRAMINE INJ [50 MG/ML]

Facility

$26.00

Service Code	HCPCS J1200
Hospital Charge Code	3000125
Hospital Revenue Code	250
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

Know your out-of-pocket cost for care.

All Charges