Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

D/C IV - POTASSIUM 20MEQ/D5W/0.45NS 1L

Facility

$22.68

Service Code	NDC 60687075611
Hospital Charge Code	3007385
Hospital Revenue Code	258
Min. Negotiated Rate	$15.88
Max. Negotiated Rate	$22.68
Rate for Payer: Aetna Commercial	$21.55
Rate for Payer: Aetna Medicare	$20.41
Rate for Payer: BCBS MT CHIP	$20.41
Rate for Payer: BCBS MT Closed Plan Network	$21.55
Rate for Payer: BCBS MT HealthLink	$20.41
Rate for Payer: BCBS MT Medicare	$20.41
Rate for Payer: BCBS MT POS	$21.55
Rate for Payer: BCBS MT Traditional	$22.68
Rate for Payer: Cash Price	$20.41
Rate for Payer: Cigna Commercial	$21.55
Rate for Payer: Cigna Medicare	$20.41
Rate for Payer: Medicaid All Medicaid	$20.87
Rate for Payer: Medicare All Medicare	$15.88
Rate for Payer: Monida Allegiance	$21.55
Rate for Payer: Monida First Choice Health	$22.00
Rate for Payer: Monida Montana Health Co-op	$21.55
Rate for Payer: Monida PacificSource	$21.55

D/C LIPASE-PROTEASE-AMYLASE [12K/38K/60K

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	15200
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

D/C LIPASE-PROTEASE-AMYLASE [12K/38K/60K

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	15200
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

D/C METHYLPREDNISOL INJ [125 MG]

Facility

$40.00

Service Code	HCPCS J2930
Hospital Charge Code	3000315
Hospital Revenue Code	636
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

D/C METHYLPREDNISOL INJ [125 MG]

Facility

$40.00

Service Code	HCPCS J2930
Hospital Charge Code	3000315
Hospital Revenue Code	636
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

D/C MORPHINE ORAL SLN [10 MG/ 5ML]100 ML

Facility

$41.00

Service Code	HCPCS J3490
Hospital Charge Code	3000339
Hospital Revenue Code	250
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

D/C MORPHINE ORAL SLN [10 MG/ 5ML]100 ML

Facility

$41.00

Service Code	HCPCS J3490
Hospital Charge Code	3000339
Hospital Revenue Code	250
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

D/C NITRO-TRANSDERM PATCH [0.2 MG / HR]

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	3000353
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

D/C NITRO-TRANSDERM PATCH [0.2 MG / HR]

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	3000353
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

D/C NYSTATIN POWDER [100000U/1GM] 15GM

Facility

$88.00

Service Code	NDC 00574200815
Hospital Charge Code	3000523
Hospital Revenue Code	250
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

D/C NYSTATIN POWDER [100000U/1GM] 15GM

Facility

$88.00

Service Code	NDC 00574200815
Hospital Charge Code	3000523
Hospital Revenue Code	250
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

D/C OXYCODONE/APAP TAB [10 MG/325 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000371
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

D/C OXYCODONE/APAP TAB [10 MG/325 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000371
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

D/C OXYCODONE ER TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000370
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

D/C OXYCODONE ER TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000370
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

D/C Prazosin HCl Oral Capsule 2MG

Facility

$8.00

Service Code	NDC 10135066701
Hospital Charge Code	3007100
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

D/C Prazosin HCl Oral Capsule 2MG

Facility

$8.00

Service Code	NDC 10135066701
Hospital Charge Code	3007100
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

D/C SERTRALINE TAB [25 MG]

Facility

$8.00

Service Code	NDC 65862001130
Hospital Charge Code	3000421
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

D/C SERTRALINE TAB [25 MG]

Facility

$8.00

Service Code	NDC 65862001130
Hospital Charge Code	3000421
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

D/C SUGAMMADEX [500 MG/5 ML]

Facility

$706.00

Service Code	HCPCS J3490
Hospital Charge Code	3000436
Hospital Revenue Code	259
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

D/C SUGAMMADEX [500 MG/5 ML]

Facility

$706.00

Service Code	HCPCS J3490
Hospital Charge Code	3000436
Hospital Revenue Code	259
Min. Negotiated Rate	$494.20
Max. Negotiated Rate	$706.00
Rate for Payer: Aetna Commercial	$670.70
Rate for Payer: Aetna Medicare	$635.40
Rate for Payer: BCBS MT CHIP	$635.40
Rate for Payer: BCBS MT Closed Plan Network	$670.70
Rate for Payer: BCBS MT HealthLink	$635.40
Rate for Payer: BCBS MT Medicare	$635.40
Rate for Payer: BCBS MT POS	$670.70
Rate for Payer: BCBS MT Traditional	$706.00
Rate for Payer: Cash Price	$635.40
Rate for Payer: Cigna Commercial	$670.70
Rate for Payer: Cigna Medicare	$635.40
Rate for Payer: Medicaid All Medicaid	$649.52
Rate for Payer: Medicare All Medicare	$494.20
Rate for Payer: Monida Allegiance	$670.70
Rate for Payer: Monida First Choice Health	$684.82
Rate for Payer: Monida Montana Health Co-op	$670.70
Rate for Payer: Monida PacificSource	$670.70

D/C VANCOMYCIN CAPS [250MG]

Facility

$194.00

Service Code	HCPCS J3490
Hospital Charge Code	3000473
Hospital Revenue Code	250
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

D/C VANCOMYCIN CAPS [250MG]

Facility

$194.00

Service Code	HCPCS J3490
Hospital Charge Code	3000473
Hospital Revenue Code	250
Min. Negotiated Rate	$135.80
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$184.30
Rate for Payer: Aetna Medicare	$174.60
Rate for Payer: BCBS MT CHIP	$174.60
Rate for Payer: BCBS MT Closed Plan Network	$184.30
Rate for Payer: BCBS MT HealthLink	$174.60
Rate for Payer: BCBS MT Medicare	$174.60
Rate for Payer: BCBS MT POS	$184.30
Rate for Payer: BCBS MT Traditional	$194.00
Rate for Payer: Cash Price	$174.60
Rate for Payer: Cigna Commercial	$184.30
Rate for Payer: Cigna Medicare	$174.60
Rate for Payer: Medicaid All Medicaid	$178.48
Rate for Payer: Medicare All Medicare	$135.80
Rate for Payer: Monida Allegiance	$184.30
Rate for Payer: Monida First Choice Health	$188.18
Rate for Payer: Monida Montana Health Co-op	$184.30
Rate for Payer: Monida PacificSource	$184.30

D/C - VITAMIN C 500MG (001805)

Facility

$53.00

Service Code	HCPCS 82180
Hospital Charge Code	4082180
Hospital Revenue Code	300
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

D/C - VITAMIN C 500MG (001805)

Facility

$53.00

Service Code	HCPCS 82180
Hospital Charge Code	4082180
Hospital Revenue Code	300
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

Know your out-of-pocket cost for care.

All Charges