Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

N METHYLHISTAMINE 24 HR URINE

Facility

$260.00

Service Code	CPT 82542
Hospital Charge Code	4088126
Hospital Revenue Code	302
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

N METHYLHISTAMINE 24 HR URINE

Facility

$260.00

Service Code	CPT 82542
Hospital Charge Code	4088126
Hospital Revenue Code	302
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

NMOLECULAR PATHOLOGY TESTING

Facility

$400.00

Service Code	CPT 81479
Hospital Charge Code	4088144
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

NMOLECULAR PATHOLOGY TESTING

Facility

$400.00

Service Code	CPT 81479
Hospital Charge Code	4088144
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

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

Know your out-of-pocket cost for care.

All Charges