Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$209.00

Service Code	HCPCS 94644
Hospital Charge Code	594644
Hospital Revenue Code	761
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$209.00
Rate for Payer: Aetna Commercial	$198.55
Rate for Payer: Aetna Medicare	$188.10
Rate for Payer: BCBS MT CHIP	$188.10
Rate for Payer: BCBS MT Closed Plan Network	$198.55
Rate for Payer: BCBS MT HealthLink	$188.10
Rate for Payer: BCBS MT Medicare	$188.10
Rate for Payer: BCBS MT POS	$198.55
Rate for Payer: BCBS MT Traditional	$209.00
Rate for Payer: Cash Price	$188.10
Rate for Payer: Cigna Commercial	$198.55
Rate for Payer: Cigna Medicare	$188.10
Rate for Payer: Medicaid All Medicaid	$192.28
Rate for Payer: Medicare All Medicare	$146.30
Rate for Payer: Monida Allegiance	$198.55
Rate for Payer: Monida First Choice Health	$202.73
Rate for Payer: Monida Montana Health Co-op	$198.55
Rate for Payer: Monida PacificSource	$198.55

NEB TR CONTINUOUS 1ST HOUR

Facility

$209.00

Service Code	HCPCS 94644
Hospital Charge Code	594644
Hospital Revenue Code	761
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$209.00
Rate for Payer: Aetna Commercial	$198.55
Rate for Payer: Aetna Medicare	$188.10
Rate for Payer: BCBS MT CHIP	$188.10
Rate for Payer: BCBS MT Closed Plan Network	$198.55
Rate for Payer: BCBS MT HealthLink	$188.10
Rate for Payer: BCBS MT Medicare	$188.10
Rate for Payer: BCBS MT POS	$198.55
Rate for Payer: BCBS MT Traditional	$209.00
Rate for Payer: Cash Price	$188.10
Rate for Payer: Cigna Commercial	$198.55
Rate for Payer: Cigna Medicare	$188.10
Rate for Payer: Medicaid All Medicaid	$192.28
Rate for Payer: Medicare All Medicare	$146.30
Rate for Payer: Monida Allegiance	$198.55
Rate for Payer: Monida First Choice Health	$202.73
Rate for Payer: Monida Montana Health Co-op	$198.55
Rate for Payer: Monida PacificSource	$198.55

NEB TR CONTINUOUS EACH ADDITIONAL HR

Facility

$148.00

Service Code	HCPCS 94645
Hospital Charge Code	594645
Hospital Revenue Code	761
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna Commercial	$140.60
Rate for Payer: Aetna Medicare	$133.20
Rate for Payer: BCBS MT CHIP	$133.20
Rate for Payer: BCBS MT Closed Plan Network	$140.60
Rate for Payer: BCBS MT HealthLink	$133.20
Rate for Payer: BCBS MT Medicare	$133.20
Rate for Payer: BCBS MT POS	$140.60
Rate for Payer: BCBS MT Traditional	$148.00
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cigna Commercial	$140.60
Rate for Payer: Cigna Medicare	$133.20
Rate for Payer: Medicaid All Medicaid	$136.16
Rate for Payer: Medicare All Medicare	$103.60
Rate for Payer: Monida Allegiance	$140.60
Rate for Payer: Monida First Choice Health	$143.56
Rate for Payer: Monida Montana Health Co-op	$140.60
Rate for Payer: Monida PacificSource	$140.60

NEB TR CONTINUOUS EACH ADDITIONAL HR

Facility

$148.00

Service Code	HCPCS 94645
Hospital Charge Code	594645
Hospital Revenue Code	761
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna Commercial	$140.60
Rate for Payer: Aetna Medicare	$133.20
Rate for Payer: BCBS MT CHIP	$133.20
Rate for Payer: BCBS MT Closed Plan Network	$140.60
Rate for Payer: BCBS MT HealthLink	$133.20
Rate for Payer: BCBS MT Medicare	$133.20
Rate for Payer: BCBS MT POS	$140.60
Rate for Payer: BCBS MT Traditional	$148.00
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cigna Commercial	$140.60
Rate for Payer: Cigna Medicare	$133.20
Rate for Payer: Medicaid All Medicaid	$136.16
Rate for Payer: Medicare All Medicare	$103.60
Rate for Payer: Monida Allegiance	$140.60
Rate for Payer: Monida First Choice Health	$143.56
Rate for Payer: Monida Montana Health Co-op	$140.60
Rate for Payer: Monida PacificSource	$140.60

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

$94.00

Service Code	HCPCS 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEBULIZER TREATMENT-HOSPITAL

Facility

$94.00

Service Code	HCPCS 94640
Hospital Charge Code	594640
Hospital Revenue Code	410
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$587.00

Service Code	HCPCS 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$410.90
Max. Negotiated Rate	$587.00
Rate for Payer: Aetna Commercial	$557.65
Rate for Payer: Aetna Medicare	$528.30
Rate for Payer: BCBS MT CHIP	$528.30
Rate for Payer: BCBS MT Closed Plan Network	$557.65
Rate for Payer: BCBS MT HealthLink	$528.30
Rate for Payer: BCBS MT Medicare	$528.30
Rate for Payer: BCBS MT POS	$557.65
Rate for Payer: BCBS MT Traditional	$587.00
Rate for Payer: Cash Price	$528.30
Rate for Payer: Cigna Commercial	$557.65
Rate for Payer: Cigna Medicare	$528.30
Rate for Payer: Medicaid All Medicaid	$540.04
Rate for Payer: Medicare All Medicare	$410.90
Rate for Payer: Monida Allegiance	$557.65
Rate for Payer: Monida First Choice Health	$569.39
Rate for Payer: Monida Montana Health Co-op	$557.65
Rate for Payer: Monida PacificSource	$557.65

NEG PRE WOUND THERAPY W/DISP EQ >50CM

Facility

$587.00

Service Code	HCPCS 97607
Hospital Charge Code	197607
Hospital Revenue Code	761
Min. Negotiated Rate	$410.90
Max. Negotiated Rate	$587.00
Rate for Payer: Aetna Commercial	$557.65
Rate for Payer: Aetna Medicare	$528.30
Rate for Payer: BCBS MT CHIP	$528.30
Rate for Payer: BCBS MT Closed Plan Network	$557.65
Rate for Payer: BCBS MT HealthLink	$528.30
Rate for Payer: BCBS MT Medicare	$528.30
Rate for Payer: BCBS MT POS	$557.65
Rate for Payer: BCBS MT Traditional	$587.00
Rate for Payer: Cash Price	$528.30
Rate for Payer: Cigna Commercial	$557.65
Rate for Payer: Cigna Medicare	$528.30
Rate for Payer: Medicaid All Medicaid	$540.04
Rate for Payer: Medicare All Medicare	$410.90
Rate for Payer: Monida Allegiance	$557.65
Rate for Payer: Monida First Choice Health	$569.39
Rate for Payer: Monida Montana Health Co-op	$557.65
Rate for Payer: Monida PacificSource	$557.65

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$101.00

Service Code	HCPCS 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

NEISSERIA GONORRHOEAE, NAA (188086)

Facility

$101.00

Service Code	HCPCS 87591
Hospital Charge Code	4087591
Hospital Revenue Code	300
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$101.00
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: BCBS MT CHIP	$90.90
Rate for Payer: BCBS MT Closed Plan Network	$95.95
Rate for Payer: BCBS MT HealthLink	$90.90
Rate for Payer: BCBS MT Medicare	$90.90
Rate for Payer: BCBS MT POS	$95.95
Rate for Payer: BCBS MT Traditional	$101.00
Rate for Payer: Cash Price	$90.90
Rate for Payer: Cigna Commercial	$95.95
Rate for Payer: Cigna Medicare	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

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

NEWBORN SCREENING PANEL

Facility

$158.00

Service Code	HCPCS 84030
Hospital Charge Code	4002017
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

NEWBORN SCREENING PANEL

Facility

$158.00

Service Code	HCPCS 84030
Hospital Charge Code	4002017
Hospital Revenue Code	300
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$158.00
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: BCBS MT CHIP	$142.20
Rate for Payer: BCBS MT Closed Plan Network	$150.10
Rate for Payer: BCBS MT HealthLink	$142.20
Rate for Payer: BCBS MT Medicare	$142.20
Rate for Payer: BCBS MT POS	$150.10
Rate for Payer: BCBS MT Traditional	$158.00
Rate for Payer: Cash Price	$142.20
Rate for Payer: Cigna Commercial	$150.10
Rate for Payer: Cigna Medicare	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

nf-ACETYL-L-CARNITINE [500 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000515
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

nf-ACETYL-L-CARNITINE [500 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000515
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

NIACIN TAB [500 MG] NF

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] NF

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

Know your out-of-pocket cost for care.

All Charges