Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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]

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]

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]

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

NICOTINE PATCH [21 MG/24 HR]

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

NICOTINE PATCH (7MG/24HR)

Facility

$8.00

Service Code	NDC 68001043288
Hospital Charge Code	3007154
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

NICOTINE PATCH (7MG/24HR)

Facility

$8.00

Service Code	NDC 68001043288
Hospital Charge Code	3007154
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

NIFEDIPINE ER TAB [30 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000347
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

NIFEDIPINE ER TAB [30 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000347
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

NITROFURANTOIN 50MG CAPSULE

Facility

$14.50

Service Code	NDC 50268062315
Hospital Charge Code	3007205
Hospital Revenue Code	250
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$14.50
Rate for Payer: Aetna Commercial	$13.78
Rate for Payer: Aetna Medicare	$13.05
Rate for Payer: BCBS MT CHIP	$13.05
Rate for Payer: BCBS MT Closed Plan Network	$13.78
Rate for Payer: BCBS MT HealthLink	$13.05
Rate for Payer: BCBS MT Medicare	$13.05
Rate for Payer: BCBS MT POS	$13.78
Rate for Payer: BCBS MT Traditional	$14.50
Rate for Payer: Cash Price	$13.05
Rate for Payer: Cigna Commercial	$13.78
Rate for Payer: Cigna Medicare	$13.05
Rate for Payer: Medicaid All Medicaid	$13.34
Rate for Payer: Medicare All Medicare	$10.15
Rate for Payer: Monida Allegiance	$13.78
Rate for Payer: Monida First Choice Health	$14.06
Rate for Payer: Monida Montana Health Co-op	$13.78
Rate for Payer: Monida PacificSource	$13.78

NITROFURANTOIN 50MG CAPSULE

Facility

$14.50

Service Code	NDC 50268062315
Hospital Charge Code	3007205
Hospital Revenue Code	250
Min. Negotiated Rate	$10.15
Max. Negotiated Rate	$14.50
Rate for Payer: Aetna Commercial	$13.78
Rate for Payer: Aetna Medicare	$13.05
Rate for Payer: BCBS MT CHIP	$13.05
Rate for Payer: BCBS MT Closed Plan Network	$13.78
Rate for Payer: BCBS MT HealthLink	$13.05
Rate for Payer: BCBS MT Medicare	$13.05
Rate for Payer: BCBS MT POS	$13.78
Rate for Payer: BCBS MT Traditional	$14.50
Rate for Payer: Cash Price	$13.05
Rate for Payer: Cigna Commercial	$13.78
Rate for Payer: Cigna Medicare	$13.05
Rate for Payer: Medicaid All Medicaid	$13.34
Rate for Payer: Medicare All Medicare	$10.15
Rate for Payer: Monida Allegiance	$13.78
Rate for Payer: Monida First Choice Health	$14.06
Rate for Payer: Monida Montana Health Co-op	$13.78
Rate for Payer: Monida PacificSource	$13.78

NITROFURANTOIN CAP [100 MG]

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000348
Hospital Revenue Code	250
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

NITROFURANTOIN CAP [100 MG]

Facility

$13.00

Service Code	HCPCS J3490
Hospital Charge Code	3000348
Hospital Revenue Code	250
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

NITROGLYCERIN 2% OINT [30 GM]

Facility

$143.00

Service Code	HCPCS J3490
Hospital Charge Code	3000349
Hospital Revenue Code	250
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$135.85
Rate for Payer: Aetna Medicare	$128.70
Rate for Payer: BCBS MT CHIP	$128.70
Rate for Payer: BCBS MT Closed Plan Network	$135.85
Rate for Payer: BCBS MT HealthLink	$128.70
Rate for Payer: BCBS MT Medicare	$128.70
Rate for Payer: BCBS MT POS	$135.85
Rate for Payer: BCBS MT Traditional	$143.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cigna Commercial	$135.85
Rate for Payer: Cigna Medicare	$128.70
Rate for Payer: Medicaid All Medicaid	$131.56
Rate for Payer: Medicare All Medicare	$100.10
Rate for Payer: Monida Allegiance	$135.85
Rate for Payer: Monida First Choice Health	$138.71
Rate for Payer: Monida Montana Health Co-op	$135.85
Rate for Payer: Monida PacificSource	$135.85

NITROGLYCERIN 2% OINT [30 GM]

Facility

$143.00

Service Code	HCPCS J3490
Hospital Charge Code	3000349
Hospital Revenue Code	250
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$135.85
Rate for Payer: Aetna Medicare	$128.70
Rate for Payer: BCBS MT CHIP	$128.70
Rate for Payer: BCBS MT Closed Plan Network	$135.85
Rate for Payer: BCBS MT HealthLink	$128.70
Rate for Payer: BCBS MT Medicare	$128.70
Rate for Payer: BCBS MT POS	$135.85
Rate for Payer: BCBS MT Traditional	$143.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cigna Commercial	$135.85
Rate for Payer: Cigna Medicare	$128.70
Rate for Payer: Medicaid All Medicaid	$131.56
Rate for Payer: Medicare All Medicare	$100.10
Rate for Payer: Monida Allegiance	$135.85
Rate for Payer: Monida First Choice Health	$138.71
Rate for Payer: Monida Montana Health Co-op	$135.85
Rate for Payer: Monida PacificSource	$135.85

NITROGLYCERIN PATCH [0.1 MG/HR]

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	3000350
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

NITROGLYCERIN PATCH [0.1 MG/HR]

Facility

$9.00

Service Code	HCPCS J3490
Hospital Charge Code	3000350
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

NITROGLYCERIN SL TAB [0.4 MG]

Facility

$86.00

Service Code	HCPCS J3490
Hospital Charge Code	3000351
Hospital Revenue Code	250
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$86.00
Rate for Payer: Aetna Commercial	$81.70
Rate for Payer: Aetna Medicare	$77.40
Rate for Payer: BCBS MT CHIP	$77.40
Rate for Payer: BCBS MT Closed Plan Network	$81.70
Rate for Payer: BCBS MT HealthLink	$77.40
Rate for Payer: BCBS MT Medicare	$77.40
Rate for Payer: BCBS MT POS	$81.70
Rate for Payer: BCBS MT Traditional	$86.00
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cigna Commercial	$81.70
Rate for Payer: Cigna Medicare	$77.40
Rate for Payer: Medicaid All Medicaid	$79.12
Rate for Payer: Medicare All Medicare	$60.20
Rate for Payer: Monida Allegiance	$81.70
Rate for Payer: Monida First Choice Health	$83.42
Rate for Payer: Monida Montana Health Co-op	$81.70
Rate for Payer: Monida PacificSource	$81.70

NITROGLYCERIN SL TAB [0.4 MG]

Facility

$86.00

Service Code	HCPCS J3490
Hospital Charge Code	3000351
Hospital Revenue Code	250
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$86.00
Rate for Payer: Aetna Commercial	$81.70
Rate for Payer: Aetna Medicare	$77.40
Rate for Payer: BCBS MT CHIP	$77.40
Rate for Payer: BCBS MT Closed Plan Network	$81.70
Rate for Payer: BCBS MT HealthLink	$77.40
Rate for Payer: BCBS MT Medicare	$77.40
Rate for Payer: BCBS MT POS	$81.70
Rate for Payer: BCBS MT Traditional	$86.00
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cigna Commercial	$81.70
Rate for Payer: Cigna Medicare	$77.40
Rate for Payer: Medicaid All Medicaid	$79.12
Rate for Payer: Medicare All Medicare	$60.20
Rate for Payer: Monida Allegiance	$81.70
Rate for Payer: Monida First Choice Health	$83.42
Rate for Payer: Monida Montana Health Co-op	$81.70
Rate for Payer: Monida PacificSource	$81.70

NITROPRUSSIDE INJ [25 MG/ML]

Facility

$84.00

Service Code	HCPCS J3490
Hospital Charge Code	3000352
Hospital Revenue Code	250
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

NITROPRUSSIDE INJ [25 MG/ML]

Facility

$84.00

Service Code	HCPCS J3490
Hospital Charge Code	3000352
Hospital Revenue Code	250
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

NJX AA&/STRD NRV NRVTG SI JT 64451

Facility

$1,413.00

Service Code	HCPCS 64451
Hospital Charge Code	1564451
Hospital Revenue Code	761
Min. Negotiated Rate	$989.10
Max. Negotiated Rate	$1,413.00
Rate for Payer: Aetna Commercial	$1,342.35
Rate for Payer: Aetna Medicare	$1,271.70
Rate for Payer: BCBS MT CHIP	$1,271.70
Rate for Payer: BCBS MT Closed Plan Network	$1,342.35
Rate for Payer: BCBS MT HealthLink	$1,271.70
Rate for Payer: BCBS MT Medicare	$1,271.70
Rate for Payer: BCBS MT POS	$1,342.35
Rate for Payer: BCBS MT Traditional	$1,413.00
Rate for Payer: Cash Price	$1,271.70
Rate for Payer: Cigna Commercial	$1,342.35
Rate for Payer: Cigna Medicare	$1,271.70
Rate for Payer: Medicaid All Medicaid	$1,299.96
Rate for Payer: Medicare All Medicare	$989.10
Rate for Payer: Monida Allegiance	$1,342.35
Rate for Payer: Monida First Choice Health	$1,370.61
Rate for Payer: Monida Montana Health Co-op	$1,342.35
Rate for Payer: Monida PacificSource	$1,342.35

NJX AA&/STRD NRV NRVTG SI JT 64451

Facility

$1,413.00

Service Code	HCPCS 64451
Hospital Charge Code	1564451
Hospital Revenue Code	761
Min. Negotiated Rate	$989.10
Max. Negotiated Rate	$1,413.00
Rate for Payer: Aetna Commercial	$1,342.35
Rate for Payer: Aetna Medicare	$1,271.70
Rate for Payer: BCBS MT CHIP	$1,271.70
Rate for Payer: BCBS MT Closed Plan Network	$1,342.35
Rate for Payer: BCBS MT HealthLink	$1,271.70
Rate for Payer: BCBS MT Medicare	$1,271.70
Rate for Payer: BCBS MT POS	$1,342.35
Rate for Payer: BCBS MT Traditional	$1,413.00
Rate for Payer: Cash Price	$1,271.70
Rate for Payer: Cigna Commercial	$1,342.35
Rate for Payer: Cigna Medicare	$1,271.70
Rate for Payer: Medicaid All Medicaid	$1,299.96
Rate for Payer: Medicare All Medicare	$989.10
Rate for Payer: Monida Allegiance	$1,342.35
Rate for Payer: Monida First Choice Health	$1,370.61
Rate for Payer: Monida Montana Health Co-op	$1,342.35
Rate for Payer: Monida PacificSource	$1,342.35

.NK CELLS, TOTAL COUNT (506049)

Facility

$303.00

Service Code	HCPCS 86357
Hospital Charge Code	4063571
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

.NK CELLS, TOTAL COUNT (506049)

Facility

$303.00

Service Code	HCPCS 86357
Hospital Charge Code	4063571
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

Know your out-of-pocket cost for care.

All Charges