Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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 A9150
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 A9150
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 [20 MG/200 ML] PREMIX

Facility

$313.00

Service Code	HCPCS J2404
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 [20 MG/200 ML] PREMIX

Facility

$313.00

Service Code	HCPCS J2404
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 GUM [4 MG] NF

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3007714
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

NICOTINE GUM [4 MG] NF

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3007714
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

NICOTINE PATCH [14 MG/24 HR]

Facility

$12.00

Service Code	HCPCS A9150
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 A9150
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 A9150
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 A9150
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 [7 MG/24 HR]

Facility

$8.00

Service Code	HCPCS A9150
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 [7 MG/24 HR]

Facility

$8.00

Service Code	HCPCS A9150
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 CAP [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007704
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 CAP [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007704
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 J8499
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 J8499
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 CAP [100 MG]

Facility

$13.00

Service Code	HCPCS J8499
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 J8499
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 [50 MG] NF

Facility

$14.50

Service Code	HCPCS J8499
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 [50 MG] NF

Facility

$14.50

Service Code	HCPCS J8499
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

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

Know your out-of-pocket cost for care.

All Charges