Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CLIN IBUPROFEN LIQUID 100MG / 5ML

Facility

$22.00

Hospital Charge Code	3007104
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

CLINICALLY SIGNIFICANT DEPRESSIVE SYMPTO

Facility

$0.01

Service Code	CPT 3354F
Hospital Charge Code	8003354
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

CLINICALLY SIGNIFICANT DEPRESSIVE SYMPTO

Facility

$0.01

Service Code	CPT 3354F
Hospital Charge Code	8003354
Hospital Revenue Code	521
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Aetna Commercial	$0.01
Rate for Payer: Aetna Medicare	$0.01
Rate for Payer: BCBS MT CHIP	$0.01
Rate for Payer: BCBS MT Closed Plan Network	$0.01
Rate for Payer: BCBS MT HealthLink	$0.01
Rate for Payer: BCBS MT Medicare	$0.01
Rate for Payer: BCBS MT POS	$0.01
Rate for Payer: BCBS MT Traditional	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna Commercial	$0.01
Rate for Payer: Cigna Medicare	$0.01
Rate for Payer: Medicaid All Medicaid	$0.01
Rate for Payer: Medicare All Medicare	$0.01
Rate for Payer: Monida Allegiance	$0.01
Rate for Payer: Monida First Choice Health	$0.01
Rate for Payer: Monida Montana Health Co-op	$0.01
Rate for Payer: Monida PacificSource	$0.01

CLINIC - ED PRO FEE BRIEF

Facility

$90.00

Service Code	CPT 99281
Hospital Charge Code	709281
Hospital Revenue Code	521
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

CLINIC - ED PRO FEE BRIEF

Facility

$90.00

Service Code	CPT 99281
Hospital Charge Code	709281
Hospital Revenue Code	521
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

CLINIC I&D BARTHOLIN'S GLAND ABSC 56420

Facility

$431.00

Service Code	CPT 56420
Hospital Charge Code	8056420
Hospital Revenue Code	521
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

CLINIC I&D BARTHOLIN'S GLAND ABSC 56420

Facility

$431.00

Service Code	CPT 56420
Hospital Charge Code	8056420
Hospital Revenue Code	521
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

CLINIC - PRO FEE ED COMPREHENSIVE

Facility

$408.00

Service Code	CPT 99285
Hospital Charge Code	709285
Hospital Revenue Code	521
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$408.00
Rate for Payer: Aetna Commercial	$387.60
Rate for Payer: Aetna Medicare	$367.20
Rate for Payer: BCBS MT CHIP	$367.20
Rate for Payer: BCBS MT Closed Plan Network	$387.60
Rate for Payer: BCBS MT HealthLink	$367.20
Rate for Payer: BCBS MT Medicare	$367.20
Rate for Payer: BCBS MT POS	$387.60
Rate for Payer: BCBS MT Traditional	$408.00
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna Commercial	$387.60
Rate for Payer: Cigna Medicare	$367.20
Rate for Payer: Medicaid All Medicaid	$375.36
Rate for Payer: Medicare All Medicare	$285.60
Rate for Payer: Monida Allegiance	$387.60
Rate for Payer: Monida First Choice Health	$395.76
Rate for Payer: Monida Montana Health Co-op	$387.60
Rate for Payer: Monida PacificSource	$387.60

CLINIC - PRO FEE ED COMPREHENSIVE

Facility

$408.00

Service Code	CPT 99285
Hospital Charge Code	709285
Hospital Revenue Code	521
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$408.00
Rate for Payer: Aetna Commercial	$387.60
Rate for Payer: Aetna Medicare	$367.20
Rate for Payer: BCBS MT CHIP	$367.20
Rate for Payer: BCBS MT Closed Plan Network	$387.60
Rate for Payer: BCBS MT HealthLink	$367.20
Rate for Payer: BCBS MT Medicare	$367.20
Rate for Payer: BCBS MT POS	$387.60
Rate for Payer: BCBS MT Traditional	$408.00
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cigna Commercial	$387.60
Rate for Payer: Cigna Medicare	$367.20
Rate for Payer: Medicaid All Medicaid	$375.36
Rate for Payer: Medicare All Medicare	$285.60
Rate for Payer: Monida Allegiance	$387.60
Rate for Payer: Monida First Choice Health	$395.76
Rate for Payer: Monida Montana Health Co-op	$387.60
Rate for Payer: Monida PacificSource	$387.60

CLINIC - PRO FEE ED CRITICAL CARE 1ST HR

Facility

$606.00

Service Code	CPT 99291
Hospital Charge Code	709291
Hospital Revenue Code	521
Min. Negotiated Rate	$424.20
Max. Negotiated Rate	$606.00
Rate for Payer: Aetna Commercial	$575.70
Rate for Payer: Aetna Medicare	$545.40
Rate for Payer: BCBS MT CHIP	$545.40
Rate for Payer: BCBS MT Closed Plan Network	$575.70
Rate for Payer: BCBS MT HealthLink	$545.40
Rate for Payer: BCBS MT Medicare	$545.40
Rate for Payer: BCBS MT POS	$575.70
Rate for Payer: BCBS MT Traditional	$606.00
Rate for Payer: Cash Price	$545.40
Rate for Payer: Cigna Commercial	$575.70
Rate for Payer: Cigna Medicare	$545.40
Rate for Payer: Medicaid All Medicaid	$557.52
Rate for Payer: Medicare All Medicare	$424.20
Rate for Payer: Monida Allegiance	$575.70
Rate for Payer: Monida First Choice Health	$587.82
Rate for Payer: Monida Montana Health Co-op	$575.70
Rate for Payer: Monida PacificSource	$575.70

CLINIC - PRO FEE ED CRITICAL CARE 1ST HR

Facility

$606.00

Service Code	CPT 99291
Hospital Charge Code	709291
Hospital Revenue Code	521
Min. Negotiated Rate	$424.20
Max. Negotiated Rate	$606.00
Rate for Payer: Aetna Commercial	$575.70
Rate for Payer: Aetna Medicare	$545.40
Rate for Payer: BCBS MT CHIP	$545.40
Rate for Payer: BCBS MT Closed Plan Network	$575.70
Rate for Payer: BCBS MT HealthLink	$545.40
Rate for Payer: BCBS MT Medicare	$545.40
Rate for Payer: BCBS MT POS	$575.70
Rate for Payer: BCBS MT Traditional	$606.00
Rate for Payer: Cash Price	$545.40
Rate for Payer: Cigna Commercial	$575.70
Rate for Payer: Cigna Medicare	$545.40
Rate for Payer: Medicaid All Medicaid	$557.52
Rate for Payer: Medicare All Medicare	$424.20
Rate for Payer: Monida Allegiance	$575.70
Rate for Payer: Monida First Choice Health	$587.82
Rate for Payer: Monida Montana Health Co-op	$575.70
Rate for Payer: Monida PacificSource	$575.70

CLINIC - PRO FEE ED EXTENDED

Facility

$277.00

Service Code	CPT 99284
Hospital Charge Code	709284
Hospital Revenue Code	521
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

CLINIC - PRO FEE ED EXTENDED

Facility

$277.00

Service Code	CPT 99284
Hospital Charge Code	709284
Hospital Revenue Code	521
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

CLINIC - PRO FEE ED INTERMEDIATE

Facility

$147.00

Service Code	CPT 99283
Hospital Charge Code	709283
Hospital Revenue Code	521
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$147.00
Rate for Payer: Aetna Commercial	$139.65
Rate for Payer: Aetna Medicare	$132.30
Rate for Payer: BCBS MT CHIP	$132.30
Rate for Payer: BCBS MT Closed Plan Network	$139.65
Rate for Payer: BCBS MT HealthLink	$132.30
Rate for Payer: BCBS MT Medicare	$132.30
Rate for Payer: BCBS MT POS	$139.65
Rate for Payer: BCBS MT Traditional	$147.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial	$139.65
Rate for Payer: Cigna Medicare	$132.30
Rate for Payer: Medicaid All Medicaid	$135.24
Rate for Payer: Medicare All Medicare	$102.90
Rate for Payer: Monida Allegiance	$139.65
Rate for Payer: Monida First Choice Health	$142.59
Rate for Payer: Monida Montana Health Co-op	$139.65
Rate for Payer: Monida PacificSource	$139.65

CLINIC - PRO FEE ED INTERMEDIATE

Facility

$147.00

Service Code	CPT 99283
Hospital Charge Code	709283
Hospital Revenue Code	521
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$147.00
Rate for Payer: Aetna Commercial	$139.65
Rate for Payer: Aetna Medicare	$132.30
Rate for Payer: BCBS MT CHIP	$132.30
Rate for Payer: BCBS MT Closed Plan Network	$139.65
Rate for Payer: BCBS MT HealthLink	$132.30
Rate for Payer: BCBS MT Medicare	$132.30
Rate for Payer: BCBS MT POS	$139.65
Rate for Payer: BCBS MT Traditional	$147.00
Rate for Payer: Cash Price	$132.30
Rate for Payer: Cigna Commercial	$139.65
Rate for Payer: Cigna Medicare	$132.30
Rate for Payer: Medicaid All Medicaid	$135.24
Rate for Payer: Medicare All Medicare	$102.90
Rate for Payer: Monida Allegiance	$139.65
Rate for Payer: Monida First Choice Health	$142.59
Rate for Payer: Monida Montana Health Co-op	$139.65
Rate for Payer: Monida PacificSource	$139.65

CLINIC - PRO FEE ED LIMITED

Facility

$101.00

Service Code	CPT 99282
Hospital Charge Code	709282
Hospital Revenue Code	521
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

CLINIC - PRO FEE ED LIMITED

Facility

$101.00

Service Code	CPT 99282
Hospital Charge Code	709282
Hospital Revenue Code	521
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

CLINITEK PRINTER PAPER (5/BX)

Facility

$29.02

Hospital Charge Code	90195003
Hospital Revenue Code	270
Min. Negotiated Rate	$20.31
Max. Negotiated Rate	$29.02
Rate for Payer: Aetna Commercial	$27.57
Rate for Payer: Aetna Medicare	$26.12
Rate for Payer: BCBS MT CHIP	$26.12
Rate for Payer: BCBS MT Closed Plan Network	$27.57
Rate for Payer: BCBS MT HealthLink	$26.12
Rate for Payer: BCBS MT Medicare	$26.12
Rate for Payer: BCBS MT POS	$27.57
Rate for Payer: BCBS MT Traditional	$29.02
Rate for Payer: Cash Price	$26.12
Rate for Payer: Cigna Commercial	$27.57
Rate for Payer: Cigna Medicare	$26.12
Rate for Payer: Medicaid All Medicaid	$26.70
Rate for Payer: Medicare All Medicare	$20.31
Rate for Payer: Monida Allegiance	$27.57
Rate for Payer: Monida First Choice Health	$28.15
Rate for Payer: Monida Montana Health Co-op	$27.57
Rate for Payer: Monida PacificSource	$27.57

CLINITEK PRINTER PAPER (5/BX)

Facility

$29.02

Hospital Charge Code	90195003
Hospital Revenue Code	270
Min. Negotiated Rate	$20.31
Max. Negotiated Rate	$29.02
Rate for Payer: Aetna Commercial	$27.57
Rate for Payer: Aetna Medicare	$26.12
Rate for Payer: BCBS MT CHIP	$26.12
Rate for Payer: BCBS MT Closed Plan Network	$27.57
Rate for Payer: BCBS MT HealthLink	$26.12
Rate for Payer: BCBS MT Medicare	$26.12
Rate for Payer: BCBS MT POS	$27.57
Rate for Payer: BCBS MT Traditional	$29.02
Rate for Payer: Cash Price	$26.12
Rate for Payer: Cigna Commercial	$27.57
Rate for Payer: Cigna Medicare	$26.12
Rate for Payer: Medicaid All Medicaid	$26.70
Rate for Payer: Medicare All Medicare	$20.31
Rate for Payer: Monida Allegiance	$27.57
Rate for Payer: Monida First Choice Health	$28.15
Rate for Payer: Monida Montana Health Co-op	$27.57
Rate for Payer: Monida PacificSource	$27.57

CLIN LIDOCAINE VISCOUS 2% ORAL SLN UD

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007014
Hospital Revenue Code	521
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

CLIN LIDOCAINE VISCOUS 2% ORAL SLN UD

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007014
Hospital Revenue Code	521
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

CLIN NITROGLYCERIN OINT 2% 1G PACKET

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	8007016
Hospital Revenue Code	521
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

CLIN NITROGLYCERIN OINT 2% 1G PACKET

Facility

$10.00

Service Code	HCPCS J3490
Hospital Charge Code	8007016
Hospital Revenue Code	521
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

CLIN NITROGLYCERIN SL TAB [0.4 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007017
Hospital Revenue Code	521
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

CLIN NITROGLYCERIN SL TAB [0.4 MG]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	8007017
Hospital Revenue Code	521
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

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