Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

NITROGLYCERIN SL TAB [0.4 MG]

Facility

$86.00

Service Code	HCPCS J8499
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 J8499
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	CPT 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	CPT 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	CPT 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	CPT 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

NMR LIPOPROTEIN WITH GRAPH (123810)

Facility

$163.95

Service Code	CPT 80061
Hospital Charge Code	4087972
Hospital Revenue Code	302
Min. Negotiated Rate	$114.77
Max. Negotiated Rate	$163.95
Rate for Payer: Aetna Commercial	$155.75
Rate for Payer: Aetna Medicare	$147.56
Rate for Payer: BCBS MT CHIP	$147.56
Rate for Payer: BCBS MT Closed Plan Network	$155.75
Rate for Payer: BCBS MT HealthLink	$147.56
Rate for Payer: BCBS MT Medicare	$147.56
Rate for Payer: BCBS MT POS	$155.75
Rate for Payer: BCBS MT Traditional	$163.95
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cigna Commercial	$155.75
Rate for Payer: Cigna Medicare	$147.56
Rate for Payer: Medicaid All Medicaid	$150.83
Rate for Payer: Medicare All Medicare	$114.77
Rate for Payer: Monida Allegiance	$155.75
Rate for Payer: Monida First Choice Health	$159.03
Rate for Payer: Monida Montana Health Co-op	$155.75
Rate for Payer: Monida PacificSource	$155.75

NMR LIPOPROTEIN WITH GRAPH (123810)

Facility

$163.95

Service Code	CPT 80061
Hospital Charge Code	4087972
Hospital Revenue Code	302
Min. Negotiated Rate	$114.77
Max. Negotiated Rate	$163.95
Rate for Payer: Aetna Commercial	$155.75
Rate for Payer: Aetna Medicare	$147.56
Rate for Payer: BCBS MT CHIP	$147.56
Rate for Payer: BCBS MT Closed Plan Network	$155.75
Rate for Payer: BCBS MT HealthLink	$147.56
Rate for Payer: BCBS MT Medicare	$147.56
Rate for Payer: BCBS MT POS	$155.75
Rate for Payer: BCBS MT Traditional	$163.95
Rate for Payer: Cash Price	$147.56
Rate for Payer: Cigna Commercial	$155.75
Rate for Payer: Cigna Medicare	$147.56
Rate for Payer: Medicaid All Medicaid	$150.83
Rate for Payer: Medicare All Medicare	$114.77
Rate for Payer: Monida Allegiance	$155.75
Rate for Payer: Monida First Choice Health	$159.03
Rate for Payer: Monida Montana Health Co-op	$155.75
Rate for Payer: Monida PacificSource	$155.75

NONPHYSICIAN TELEPHONE ASSESSMENT 11-20

Facility

$58.00

Service Code	CPT 98967
Hospital Charge Code	8098967
Hospital Revenue Code	521
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

NONPHYSICIAN TELEPHONE ASSESSMENT 11-20

Facility

$58.00

Service Code	CPT 98967
Hospital Charge Code	8098967
Hospital Revenue Code	521
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

NONPHYSICIAN TELEPHONE ASSESSMENT 21-30

Facility

$64.00

Service Code	CPT 98968
Hospital Charge Code	8098968
Hospital Revenue Code	521
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

NONPHYSICIAN TELEPHONE ASSESSMENT 21-30

Facility

$64.00

Service Code	CPT 98968
Hospital Charge Code	8098968
Hospital Revenue Code	521
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

NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 M

Facility

$49.00

Service Code	CPT 98966
Hospital Charge Code	8098966
Hospital Revenue Code	521
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: BCBS MT CHIP	$44.10
Rate for Payer: BCBS MT Closed Plan Network	$46.55
Rate for Payer: BCBS MT HealthLink	$44.10
Rate for Payer: BCBS MT Medicare	$44.10
Rate for Payer: BCBS MT POS	$46.55
Rate for Payer: BCBS MT Traditional	$49.00
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna Commercial	$46.55
Rate for Payer: Cigna Medicare	$44.10
Rate for Payer: Medicaid All Medicaid	$45.08
Rate for Payer: Medicare All Medicare	$34.30
Rate for Payer: Monida Allegiance	$46.55
Rate for Payer: Monida First Choice Health	$47.53
Rate for Payer: Monida Montana Health Co-op	$46.55
Rate for Payer: Monida PacificSource	$46.55

NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 M

Facility

$49.00

Service Code	CPT 98966
Hospital Charge Code	8098966
Hospital Revenue Code	521
Min. Negotiated Rate	$34.30
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna Medicare	$44.10
Rate for Payer: BCBS MT CHIP	$44.10
Rate for Payer: BCBS MT Closed Plan Network	$46.55
Rate for Payer: BCBS MT HealthLink	$44.10
Rate for Payer: BCBS MT Medicare	$44.10
Rate for Payer: BCBS MT POS	$46.55
Rate for Payer: BCBS MT Traditional	$49.00
Rate for Payer: Cash Price	$44.10
Rate for Payer: Cigna Commercial	$46.55
Rate for Payer: Cigna Medicare	$44.10
Rate for Payer: Medicaid All Medicaid	$45.08
Rate for Payer: Medicare All Medicare	$34.30
Rate for Payer: Monida Allegiance	$46.55
Rate for Payer: Monida First Choice Health	$47.53
Rate for Payer: Monida Montana Health Co-op	$46.55
Rate for Payer: Monida PacificSource	$46.55

NOREPINEPHRINE [1 MG/ML] 4ML

Facility

$41.00

Service Code	HCPCS J3490
Hospital Charge Code	3000354
Hospital Revenue Code	250
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

NOREPINEPHRINE [1 MG/ML] 4ML

Facility

$41.00

Service Code	HCPCS J3490
Hospital Charge Code	3000354
Hospital Revenue Code	250
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

NOROVIRUS DETECTION, RT-PCR (138307)

Facility

$473.00

Service Code	CPT 87798
Hospital Charge Code	4087798
Hospital Revenue Code	306
Min. Negotiated Rate	$331.10
Max. Negotiated Rate	$473.00
Rate for Payer: Aetna Commercial	$449.35
Rate for Payer: Aetna Medicare	$425.70
Rate for Payer: BCBS MT CHIP	$425.70
Rate for Payer: BCBS MT Closed Plan Network	$449.35
Rate for Payer: BCBS MT HealthLink	$425.70
Rate for Payer: BCBS MT Medicare	$425.70
Rate for Payer: BCBS MT POS	$449.35
Rate for Payer: BCBS MT Traditional	$473.00
Rate for Payer: Cash Price	$425.70
Rate for Payer: Cigna Commercial	$449.35
Rate for Payer: Cigna Medicare	$425.70
Rate for Payer: Medicaid All Medicaid	$435.16
Rate for Payer: Medicare All Medicare	$331.10
Rate for Payer: Monida Allegiance	$449.35
Rate for Payer: Monida First Choice Health	$458.81
Rate for Payer: Monida Montana Health Co-op	$449.35
Rate for Payer: Monida PacificSource	$449.35

NOROVIRUS DETECTION, RT-PCR (138307)

Facility

$473.00

Service Code	CPT 87798
Hospital Charge Code	4087798
Hospital Revenue Code	306
Min. Negotiated Rate	$331.10
Max. Negotiated Rate	$473.00
Rate for Payer: Aetna Commercial	$449.35
Rate for Payer: Aetna Medicare	$425.70
Rate for Payer: BCBS MT CHIP	$425.70
Rate for Payer: BCBS MT Closed Plan Network	$449.35
Rate for Payer: BCBS MT HealthLink	$425.70
Rate for Payer: BCBS MT Medicare	$425.70
Rate for Payer: BCBS MT POS	$449.35
Rate for Payer: BCBS MT Traditional	$473.00
Rate for Payer: Cash Price	$425.70
Rate for Payer: Cigna Commercial	$449.35
Rate for Payer: Cigna Medicare	$425.70
Rate for Payer: Medicaid All Medicaid	$435.16
Rate for Payer: Medicare All Medicare	$331.10
Rate for Payer: Monida Allegiance	$449.35
Rate for Payer: Monida First Choice Health	$458.81
Rate for Payer: Monida Montana Health Co-op	$449.35
Rate for Payer: Monida PacificSource	$449.35

NORTRIPTYLINE HCL CAP [25 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007711
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

NORTRIPTYLINE HCL CAP [25 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007711
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

NORTRIPYLINE TAB [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007313
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

NORTRIPYLINE TAB [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007313
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

NPA 12F

Facility

$45.00

Hospital Charge Code	80030234
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

Know your out-of-pocket cost for care.

All Charges