Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MYCOPHENOLIC ACID (716795)

Facility

$258.00

Service Code	HCPCS 80180
Hospital Charge Code	4080180
Hospital Revenue Code	300
Min. Negotiated Rate	$180.60
Max. Negotiated Rate	$258.00
Rate for Payer: Aetna Commercial	$245.10
Rate for Payer: Aetna Medicare	$232.20
Rate for Payer: BCBS MT CHIP	$232.20
Rate for Payer: BCBS MT Closed Plan Network	$245.10
Rate for Payer: BCBS MT HealthLink	$232.20
Rate for Payer: BCBS MT Medicare	$232.20
Rate for Payer: BCBS MT POS	$245.10
Rate for Payer: BCBS MT Traditional	$258.00
Rate for Payer: Cash Price	$232.20
Rate for Payer: Cigna Commercial	$245.10
Rate for Payer: Cigna Medicare	$232.20
Rate for Payer: Medicaid All Medicaid	$237.36
Rate for Payer: Medicare All Medicare	$180.60
Rate for Payer: Monida Allegiance	$245.10
Rate for Payer: Monida First Choice Health	$250.26
Rate for Payer: Monida Montana Health Co-op	$245.10
Rate for Payer: Monida PacificSource	$245.10

MYOGLOBIN (010405)

Facility

$79.00

Service Code	HCPCS 83874
Hospital Charge Code	4083874
Hospital Revenue Code	301
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

MYOGLOBIN (010405)

Facility

$79.00

Service Code	HCPCS 83874
Hospital Charge Code	4083874
Hospital Revenue Code	301
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

NACL 0.9% FLUSH [10 ML]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000342
Hospital Revenue Code	258
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

NACL 0.9% FLUSH [10 ML]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000342
Hospital Revenue Code	258
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

NACL 0.9% INJ [10 ML]

Facility

$5.00

Service Code	HCPCS A4216
Hospital Charge Code	3000254
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

NACL 0.9% INJ [10 ML]

Facility

$5.00

Service Code	HCPCS A4216
Hospital Charge Code	3000254
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

NALBUPHINE INJ [10 MG/ML]

Facility

$26.00

Service Code	HCPCS J2300
Hospital Charge Code	3000343
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

NALBUPHINE INJ [10 MG/ML]

Facility

$26.00

Service Code	HCPCS J2300
Hospital Charge Code	3000343
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

NALOXONE 2MG/2ML PFS

Facility

$133.00

Service Code	HCPCS J2310
Hospital Charge Code	3007061
Hospital Revenue Code	250
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

NALOXONE 2MG/2ML PFS

Facility

$133.00

Service Code	HCPCS J2310
Hospital Charge Code	3007061
Hospital Revenue Code	250
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: BCBS MT CHIP	$119.70
Rate for Payer: BCBS MT Closed Plan Network	$126.35
Rate for Payer: BCBS MT HealthLink	$119.70
Rate for Payer: BCBS MT Medicare	$119.70
Rate for Payer: BCBS MT POS	$126.35
Rate for Payer: BCBS MT Traditional	$133.00
Rate for Payer: Cash Price	$119.70
Rate for Payer: Cigna Commercial	$126.35
Rate for Payer: Cigna Medicare	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

NALOXONE INJ [0.4 MG/ML]

Facility

$60.00

Service Code	HCPCS J2310
Hospital Charge Code	3000344
Hospital Revenue Code	636
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

NALOXONE INJ [0.4 MG/ML]

Facility

$60.00

Service Code	HCPCS J2310
Hospital Charge Code	3000344
Hospital Revenue Code	636
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

NALTREXONE 380MG SUSP-INJ-NF

Facility

$2,520.35

Service Code	NDC 65757030001
Hospital Charge Code	3007257
Hospital Revenue Code	250
Min. Negotiated Rate	$1,764.24
Max. Negotiated Rate	$2,520.35
Rate for Payer: Aetna Commercial	$2,394.33
Rate for Payer: Aetna Medicare	$2,268.32
Rate for Payer: BCBS MT CHIP	$2,268.32
Rate for Payer: BCBS MT Closed Plan Network	$2,394.33
Rate for Payer: BCBS MT HealthLink	$2,268.32
Rate for Payer: BCBS MT Medicare	$2,268.32
Rate for Payer: BCBS MT POS	$2,394.33
Rate for Payer: BCBS MT Traditional	$2,520.35
Rate for Payer: Cash Price	$2,268.32
Rate for Payer: Cigna Commercial	$2,394.33
Rate for Payer: Cigna Medicare	$2,268.32
Rate for Payer: Medicaid All Medicaid	$2,318.72
Rate for Payer: Medicare All Medicare	$1,764.24
Rate for Payer: Monida Allegiance	$2,394.33
Rate for Payer: Monida First Choice Health	$2,444.74
Rate for Payer: Monida Montana Health Co-op	$2,394.33
Rate for Payer: Monida PacificSource	$2,394.33

NALTREXONE 380MG SUSP-INJ-NF

Facility

$2,520.35

Service Code	NDC 65757030001
Hospital Charge Code	3007257
Hospital Revenue Code	250
Min. Negotiated Rate	$1,764.24
Max. Negotiated Rate	$2,520.35
Rate for Payer: Aetna Commercial	$2,394.33
Rate for Payer: Aetna Medicare	$2,268.32
Rate for Payer: BCBS MT CHIP	$2,268.32
Rate for Payer: BCBS MT Closed Plan Network	$2,394.33
Rate for Payer: BCBS MT HealthLink	$2,268.32
Rate for Payer: BCBS MT Medicare	$2,268.32
Rate for Payer: BCBS MT POS	$2,394.33
Rate for Payer: BCBS MT Traditional	$2,520.35
Rate for Payer: Cash Price	$2,268.32
Rate for Payer: Cigna Commercial	$2,394.33
Rate for Payer: Cigna Medicare	$2,268.32
Rate for Payer: Medicaid All Medicaid	$2,318.72
Rate for Payer: Medicare All Medicare	$1,764.24
Rate for Payer: Monida Allegiance	$2,394.33
Rate for Payer: Monida First Choice Health	$2,444.74
Rate for Payer: Monida Montana Health Co-op	$2,394.33
Rate for Payer: Monida PacificSource	$2,394.33

NALTREXONE 50MG TABLET

Facility

$13.82

Service Code	NDC 68084029121
Hospital Charge Code	3007286
Hospital Revenue Code	250
Min. Negotiated Rate	$9.67
Max. Negotiated Rate	$13.82
Rate for Payer: Aetna Commercial	$13.13
Rate for Payer: Aetna Medicare	$12.44
Rate for Payer: BCBS MT CHIP	$12.44
Rate for Payer: BCBS MT Closed Plan Network	$13.13
Rate for Payer: BCBS MT HealthLink	$12.44
Rate for Payer: BCBS MT Medicare	$12.44
Rate for Payer: BCBS MT POS	$13.13
Rate for Payer: BCBS MT Traditional	$13.82
Rate for Payer: Cash Price	$12.44
Rate for Payer: Cigna Commercial	$13.13
Rate for Payer: Cigna Medicare	$12.44
Rate for Payer: Medicaid All Medicaid	$12.71
Rate for Payer: Medicare All Medicare	$9.67
Rate for Payer: Monida Allegiance	$13.13
Rate for Payer: Monida First Choice Health	$13.41
Rate for Payer: Monida Montana Health Co-op	$13.13
Rate for Payer: Monida PacificSource	$13.13

NALTREXONE 50MG TABLET

Facility

$13.82

Service Code	NDC 68084029121
Hospital Charge Code	3007286
Hospital Revenue Code	250
Min. Negotiated Rate	$9.67
Max. Negotiated Rate	$13.82
Rate for Payer: Aetna Commercial	$13.13
Rate for Payer: Aetna Medicare	$12.44
Rate for Payer: BCBS MT CHIP	$12.44
Rate for Payer: BCBS MT Closed Plan Network	$13.13
Rate for Payer: BCBS MT HealthLink	$12.44
Rate for Payer: BCBS MT Medicare	$12.44
Rate for Payer: BCBS MT POS	$13.13
Rate for Payer: BCBS MT Traditional	$13.82
Rate for Payer: Cash Price	$12.44
Rate for Payer: Cigna Commercial	$13.13
Rate for Payer: Cigna Medicare	$12.44
Rate for Payer: Medicaid All Medicaid	$12.71
Rate for Payer: Medicare All Medicare	$9.67
Rate for Payer: Monida Allegiance	$13.13
Rate for Payer: Monida First Choice Health	$13.41
Rate for Payer: Monida Montana Health Co-op	$13.13
Rate for Payer: Monida PacificSource	$13.13

NAPROXEN TAB [500 MG] - NONFORMULARY

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000345
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

NAPROXEN TAB [500 MG] - NONFORMULARY

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000345
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

NARCAN 0.4MG/ML

Facility

$64.00

Service Code	HCPCS J2310 QN
Hospital Charge Code	640467
Hospital Revenue Code	636
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

NARCAN 0.4MG/ML

Facility

$64.00

Service Code	HCPCS J2310 QN
Hospital Charge Code	640467
Hospital Revenue Code	636
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

NEB TR CONTINUOUS 1ST HOUR

Facility

$197.00

Service Code	HCPCS 94644
Hospital Charge Code	594644
Hospital Revenue Code	761
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

NEB TR CONTINUOUS 1ST HOUR

Facility

$197.00

Service Code	HCPCS 94644
Hospital Charge Code	594644
Hospital Revenue Code	761
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

NEB TR CONTINUOUS EACH ADDITIONAL HR

Facility

$140.00

Service Code	HCPCS 94645
Hospital Charge Code	594645
Hospital Revenue Code	761
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS MT CHIP	$126.00
Rate for Payer: BCBS MT Closed Plan Network	$133.00
Rate for Payer: BCBS MT HealthLink	$126.00
Rate for Payer: BCBS MT Medicare	$126.00
Rate for Payer: BCBS MT POS	$133.00
Rate for Payer: BCBS MT Traditional	$140.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial	$133.00
Rate for Payer: Cigna Medicare	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

NEB TR CONTINUOUS EACH ADDITIONAL HR

Facility

$140.00

Service Code	HCPCS 94645
Hospital Charge Code	594645
Hospital Revenue Code	761
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS MT CHIP	$126.00
Rate for Payer: BCBS MT Closed Plan Network	$133.00
Rate for Payer: BCBS MT HealthLink	$126.00
Rate for Payer: BCBS MT Medicare	$126.00
Rate for Payer: BCBS MT POS	$133.00
Rate for Payer: BCBS MT Traditional	$140.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial	$133.00
Rate for Payer: Cigna Medicare	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

Know your out-of-pocket cost for care.

All Charges