Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

NEBULIZER 7'' 50/CS

Facility

$19.00

Hospital Charge Code	80030224
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

NEBULIZER 7'' 50/CS

Facility

$19.00

Hospital Charge Code	80030224
Hospital Revenue Code	270
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

NEBULIZER PEDS MASK ( FISH)

Facility

$18.00

Hospital Charge Code	80030221
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

NEBULIZER PEDS MASK ( FISH)

Facility

$18.00

Hospital Charge Code	80030221
Hospital Revenue Code	270
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

NEBULIZER TREATMENT-HOSPITAL

Facility

$89.00

Service Code	HCPCS 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

NEBULIZER TREATMENT-HOSPITAL

Facility

$89.00

Service Code	HCPCS 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$554.00

Service Code	HCPCS 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$387.80
Max. Negotiated Rate	$554.00
Rate for Payer: Aetna Commercial	$526.30
Rate for Payer: Aetna Medicare	$498.60
Rate for Payer: BCBS MT CHIP	$498.60
Rate for Payer: BCBS MT Closed Plan Network	$526.30
Rate for Payer: BCBS MT HealthLink	$498.60
Rate for Payer: BCBS MT Medicare	$498.60
Rate for Payer: BCBS MT POS	$526.30
Rate for Payer: BCBS MT Traditional	$554.00
Rate for Payer: Cash Price	$498.60
Rate for Payer: Cigna Commercial	$526.30
Rate for Payer: Cigna Medicare	$498.60
Rate for Payer: Medicaid All Medicaid	$509.68
Rate for Payer: Medicare All Medicare	$387.80
Rate for Payer: Monida Allegiance	$526.30
Rate for Payer: Monida First Choice Health	$537.38
Rate for Payer: Monida Montana Health Co-op	$526.30
Rate for Payer: Monida PacificSource	$526.30

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$554.00

Service Code	HCPCS 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$387.80
Max. Negotiated Rate	$554.00
Rate for Payer: Aetna Commercial	$526.30
Rate for Payer: Aetna Medicare	$498.60
Rate for Payer: BCBS MT CHIP	$498.60
Rate for Payer: BCBS MT Closed Plan Network	$526.30
Rate for Payer: BCBS MT HealthLink	$498.60
Rate for Payer: BCBS MT Medicare	$498.60
Rate for Payer: BCBS MT POS	$526.30
Rate for Payer: BCBS MT Traditional	$554.00
Rate for Payer: Cash Price	$498.60
Rate for Payer: Cigna Commercial	$526.30
Rate for Payer: Cigna Medicare	$498.60
Rate for Payer: Medicaid All Medicaid	$509.68
Rate for Payer: Medicare All Medicare	$387.80
Rate for Payer: Monida Allegiance	$526.30
Rate for Payer: Monida First Choice Health	$537.38
Rate for Payer: Monida Montana Health Co-op	$526.30
Rate for Payer: Monida PacificSource	$526.30

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$55.00

Service Code	HCPCS 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$55.00

Service Code	HCPCS 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

NETARSUDIL 0.02% SOLUTION 2.5 ML-NF

Facility

$677.40

Service Code	NDC 70727049725
Hospital Charge Code	3007247
Hospital Revenue Code	250
Min. Negotiated Rate	$474.18
Max. Negotiated Rate	$677.40
Rate for Payer: Aetna Commercial	$643.53
Rate for Payer: Aetna Medicare	$609.66
Rate for Payer: BCBS MT CHIP	$609.66
Rate for Payer: BCBS MT Closed Plan Network	$643.53
Rate for Payer: BCBS MT HealthLink	$609.66
Rate for Payer: BCBS MT Medicare	$609.66
Rate for Payer: BCBS MT POS	$643.53
Rate for Payer: BCBS MT Traditional	$677.40
Rate for Payer: Cash Price	$609.66
Rate for Payer: Cigna Commercial	$643.53
Rate for Payer: Cigna Medicare	$609.66
Rate for Payer: Medicaid All Medicaid	$623.21
Rate for Payer: Medicare All Medicare	$474.18
Rate for Payer: Monida Allegiance	$643.53
Rate for Payer: Monida First Choice Health	$657.08
Rate for Payer: Monida Montana Health Co-op	$643.53
Rate for Payer: Monida PacificSource	$643.53

NETARSUDIL 0.02% SOLUTION 2.5 ML-NF

Facility

$677.40

Service Code	NDC 70727049725
Hospital Charge Code	3007247
Hospital Revenue Code	250
Min. Negotiated Rate	$474.18
Max. Negotiated Rate	$677.40
Rate for Payer: Aetna Commercial	$643.53
Rate for Payer: Aetna Medicare	$609.66
Rate for Payer: BCBS MT CHIP	$609.66
Rate for Payer: BCBS MT Closed Plan Network	$643.53
Rate for Payer: BCBS MT HealthLink	$609.66
Rate for Payer: BCBS MT Medicare	$609.66
Rate for Payer: BCBS MT POS	$643.53
Rate for Payer: BCBS MT Traditional	$677.40
Rate for Payer: Cash Price	$609.66
Rate for Payer: Cigna Commercial	$643.53
Rate for Payer: Cigna Medicare	$609.66
Rate for Payer: Medicaid All Medicaid	$623.21
Rate for Payer: Medicare All Medicare	$474.18
Rate for Payer: Monida Allegiance	$643.53
Rate for Payer: Monida First Choice Health	$657.08
Rate for Payer: Monida Montana Health Co-op	$643.53
Rate for Payer: Monida PacificSource	$643.53

NF-Anoro Ellipta Inhalation Powder

Facility

$374.32

Service Code	NDC 00173086906
Hospital Charge Code	3007173
Hospital Revenue Code	250
Min. Negotiated Rate	$262.02
Max. Negotiated Rate	$374.32
Rate for Payer: Aetna Commercial	$355.60
Rate for Payer: Aetna Medicare	$336.89
Rate for Payer: BCBS MT CHIP	$336.89
Rate for Payer: BCBS MT Closed Plan Network	$355.60
Rate for Payer: BCBS MT HealthLink	$336.89
Rate for Payer: BCBS MT Medicare	$336.89
Rate for Payer: BCBS MT POS	$355.60
Rate for Payer: BCBS MT Traditional	$374.32
Rate for Payer: Cash Price	$336.89
Rate for Payer: Cigna Commercial	$355.60
Rate for Payer: Cigna Medicare	$336.89
Rate for Payer: Medicaid All Medicaid	$344.37
Rate for Payer: Medicare All Medicare	$262.02
Rate for Payer: Monida Allegiance	$355.60
Rate for Payer: Monida First Choice Health	$363.09
Rate for Payer: Monida Montana Health Co-op	$355.60
Rate for Payer: Monida PacificSource	$355.60

NF-Anoro Ellipta Inhalation Powder

Facility

$374.32

Service Code	NDC 00173086906
Hospital Charge Code	3007173
Hospital Revenue Code	250
Min. Negotiated Rate	$262.02
Max. Negotiated Rate	$374.32
Rate for Payer: Aetna Commercial	$355.60
Rate for Payer: Aetna Medicare	$336.89
Rate for Payer: BCBS MT CHIP	$336.89
Rate for Payer: BCBS MT Closed Plan Network	$355.60
Rate for Payer: BCBS MT HealthLink	$336.89
Rate for Payer: BCBS MT Medicare	$336.89
Rate for Payer: BCBS MT POS	$355.60
Rate for Payer: BCBS MT Traditional	$374.32
Rate for Payer: Cash Price	$336.89
Rate for Payer: Cigna Commercial	$355.60
Rate for Payer: Cigna Medicare	$336.89
Rate for Payer: Medicaid All Medicaid	$344.37
Rate for Payer: Medicare All Medicare	$262.02
Rate for Payer: Monida Allegiance	$355.60
Rate for Payer: Monida First Choice Health	$363.09
Rate for Payer: Monida Montana Health Co-op	$355.60
Rate for Payer: Monida PacificSource	$355.60

NF-Budesonide-Formoterol INH 80-4.5MCG

Facility

$756.20

Service Code	NDC 00186037220
Hospital Charge Code	3007191
Hospital Revenue Code	250
Min. Negotiated Rate	$529.34
Max. Negotiated Rate	$756.20
Rate for Payer: Aetna Commercial	$718.39
Rate for Payer: Aetna Medicare	$680.58
Rate for Payer: BCBS MT CHIP	$680.58
Rate for Payer: BCBS MT Closed Plan Network	$718.39
Rate for Payer: BCBS MT HealthLink	$680.58
Rate for Payer: BCBS MT Medicare	$680.58
Rate for Payer: BCBS MT POS	$718.39
Rate for Payer: BCBS MT Traditional	$756.20
Rate for Payer: Cash Price	$680.58
Rate for Payer: Cigna Commercial	$718.39
Rate for Payer: Cigna Medicare	$680.58
Rate for Payer: Medicaid All Medicaid	$695.70
Rate for Payer: Medicare All Medicare	$529.34
Rate for Payer: Monida Allegiance	$718.39
Rate for Payer: Monida First Choice Health	$733.51
Rate for Payer: Monida Montana Health Co-op	$718.39
Rate for Payer: Monida PacificSource	$718.39

NF-Budesonide-Formoterol INH 80-4.5MCG

Facility

$756.20

Service Code	NDC 00186037220
Hospital Charge Code	3007191
Hospital Revenue Code	250
Min. Negotiated Rate	$529.34
Max. Negotiated Rate	$756.20
Rate for Payer: Aetna Commercial	$718.39
Rate for Payer: Aetna Medicare	$680.58
Rate for Payer: BCBS MT CHIP	$680.58
Rate for Payer: BCBS MT Closed Plan Network	$718.39
Rate for Payer: BCBS MT HealthLink	$680.58
Rate for Payer: BCBS MT Medicare	$680.58
Rate for Payer: BCBS MT POS	$718.39
Rate for Payer: BCBS MT Traditional	$756.20
Rate for Payer: Cash Price	$680.58
Rate for Payer: Cigna Commercial	$718.39
Rate for Payer: Cigna Medicare	$680.58
Rate for Payer: Medicaid All Medicaid	$695.70
Rate for Payer: Medicare All Medicare	$529.34
Rate for Payer: Monida Allegiance	$718.39
Rate for Payer: Monida First Choice Health	$733.51
Rate for Payer: Monida Montana Health Co-op	$718.39
Rate for Payer: Monida PacificSource	$718.39

NF-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

NF-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

NIACIN TAB [500 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000508
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

NIACIN TAB [500 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000508
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

NICARDIPINE 20MG / 200ML NS PREMIX

Facility

$313.00

Service Code	HCPCS J3490
Hospital Charge Code	3007218
Hospital Revenue Code	258
Min. Negotiated Rate	$219.10
Max. Negotiated Rate	$313.00
Rate for Payer: Aetna Commercial	$297.35
Rate for Payer: Aetna Medicare	$281.70
Rate for Payer: BCBS MT CHIP	$281.70
Rate for Payer: BCBS MT Closed Plan Network	$297.35
Rate for Payer: BCBS MT HealthLink	$281.70
Rate for Payer: BCBS MT Medicare	$281.70
Rate for Payer: BCBS MT POS	$297.35
Rate for Payer: BCBS MT Traditional	$313.00
Rate for Payer: Cash Price	$281.70
Rate for Payer: Cigna Commercial	$297.35
Rate for Payer: Cigna Medicare	$281.70
Rate for Payer: Medicaid All Medicaid	$287.96
Rate for Payer: Medicare All Medicare	$219.10
Rate for Payer: Monida Allegiance	$297.35
Rate for Payer: Monida First Choice Health	$303.61
Rate for Payer: Monida Montana Health Co-op	$297.35
Rate for Payer: Monida PacificSource	$297.35

NICARDIPINE 20MG / 200ML NS PREMIX

Facility

$313.00

Service Code	HCPCS J3490
Hospital Charge Code	3007218
Hospital Revenue Code	258
Min. Negotiated Rate	$219.10
Max. Negotiated Rate	$313.00
Rate for Payer: Aetna Commercial	$297.35
Rate for Payer: Aetna Medicare	$281.70
Rate for Payer: BCBS MT CHIP	$281.70
Rate for Payer: BCBS MT Closed Plan Network	$297.35
Rate for Payer: BCBS MT HealthLink	$281.70
Rate for Payer: BCBS MT Medicare	$281.70
Rate for Payer: BCBS MT POS	$297.35
Rate for Payer: BCBS MT Traditional	$313.00
Rate for Payer: Cash Price	$281.70
Rate for Payer: Cigna Commercial	$297.35
Rate for Payer: Cigna Medicare	$281.70
Rate for Payer: Medicaid All Medicaid	$287.96
Rate for Payer: Medicare All Medicare	$219.10
Rate for Payer: Monida Allegiance	$297.35
Rate for Payer: Monida First Choice Health	$303.61
Rate for Payer: Monida Montana Health Co-op	$297.35
Rate for Payer: Monida PacificSource	$297.35

NICOTINE PATCH [14 MG/24 HR] NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3000518
Hospital Revenue Code	259
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

NICOTINE PATCH [14 MG/24 HR] NF

Facility

$12.00

Service Code	HCPCS J3490
Hospital Charge Code	3000518
Hospital Revenue Code	259
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

NICOTINE PATCH [21 MG/24 HR] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000346
Hospital Revenue Code	259
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.

All Charges