Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

METHOCARBAMOL TAB [500 MG] NF

Facility

$10.00

Service Code	HCPCS J8499
Hospital Charge Code	3000502
Hospital Revenue Code	250
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

METHOCARBAMOL TAB [500 MG] NF

Facility

$10.00

Service Code	HCPCS J8499
Hospital Charge Code	3000502
Hospital Revenue Code	250
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

METHOCARBAMOL TAB [750 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000311
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

METHOCARBAMOL TAB [750 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000311
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

METHOTREXATE INJ [25 MG/ML] 2ML NF

Facility

$28.00

Service Code	HCPCS J9260
Hospital Charge Code	3007426
Hospital Revenue Code	250
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

METHOTREXATE INJ [25 MG/ML] 2ML NF

Facility

$28.00

Service Code	HCPCS J9260
Hospital Charge Code	3007426
Hospital Revenue Code	250
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

METHOTREXATE TAB [2.5 MG] NF

Facility

$12.00

Service Code	HCPCS J8610
Hospital Charge Code	3007261
Hospital Revenue Code	250
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

METHOTREXATE TAB [2.5 MG] NF

Facility

$12.00

Service Code	HCPCS J8610
Hospital Charge Code	3007261
Hospital Revenue Code	250
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

METHYLERGONOVINE MALEATE 0.2MG/ML

Facility

$75.90

Service Code	HCPCS J2210
Hospital Charge Code	3007379
Hospital Revenue Code	250
Min. Negotiated Rate	$53.13
Max. Negotiated Rate	$75.90
Rate for Payer: Aetna Commercial	$72.11
Rate for Payer: Aetna Medicare	$68.31
Rate for Payer: BCBS MT CHIP	$68.31
Rate for Payer: BCBS MT Closed Plan Network	$72.11
Rate for Payer: BCBS MT HealthLink	$68.31
Rate for Payer: BCBS MT Medicare	$68.31
Rate for Payer: BCBS MT POS	$72.11
Rate for Payer: BCBS MT Traditional	$75.90
Rate for Payer: Cash Price	$68.31
Rate for Payer: Cigna Commercial	$72.11
Rate for Payer: Cigna Medicare	$68.31
Rate for Payer: Medicaid All Medicaid	$69.83
Rate for Payer: Medicare All Medicare	$53.13
Rate for Payer: Monida Allegiance	$72.11
Rate for Payer: Monida First Choice Health	$73.62
Rate for Payer: Monida Montana Health Co-op	$72.11
Rate for Payer: Monida PacificSource	$72.11

METHYLERGONOVINE MALEATE 0.2MG/ML

Facility

$75.90

Service Code	HCPCS J2210
Hospital Charge Code	3007379
Hospital Revenue Code	250
Min. Negotiated Rate	$53.13
Max. Negotiated Rate	$75.90
Rate for Payer: Aetna Commercial	$72.11
Rate for Payer: Aetna Medicare	$68.31
Rate for Payer: BCBS MT CHIP	$68.31
Rate for Payer: BCBS MT Closed Plan Network	$72.11
Rate for Payer: BCBS MT HealthLink	$68.31
Rate for Payer: BCBS MT Medicare	$68.31
Rate for Payer: BCBS MT POS	$72.11
Rate for Payer: BCBS MT Traditional	$75.90
Rate for Payer: Cash Price	$68.31
Rate for Payer: Cigna Commercial	$72.11
Rate for Payer: Cigna Medicare	$68.31
Rate for Payer: Medicaid All Medicaid	$69.83
Rate for Payer: Medicare All Medicare	$53.13
Rate for Payer: Monida Allegiance	$72.11
Rate for Payer: Monida First Choice Health	$73.62
Rate for Payer: Monida Montana Health Co-op	$72.11
Rate for Payer: Monida PacificSource	$72.11

METHYLMALONIC ACID B12 STATUS (99431)

Facility

$95.00

Service Code	CPT 83921
Hospital Charge Code	4000048
Hospital Revenue Code	301
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

METHYLMALONIC ACID B12 STATUS (99431)

Facility

$95.00

Service Code	CPT 83921
Hospital Charge Code	4000048
Hospital Revenue Code	301
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

METHYLMALONIC ACID, QUANT (706961)

Facility

$131.00

Service Code	CPT 83921
Hospital Charge Code	4083921
Hospital Revenue Code	300
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$131.00
Rate for Payer: Aetna Commercial	$124.45
Rate for Payer: Aetna Medicare	$117.90
Rate for Payer: BCBS MT CHIP	$117.90
Rate for Payer: BCBS MT Closed Plan Network	$124.45
Rate for Payer: BCBS MT HealthLink	$117.90
Rate for Payer: BCBS MT Medicare	$117.90
Rate for Payer: BCBS MT POS	$124.45
Rate for Payer: BCBS MT Traditional	$131.00
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial	$124.45
Rate for Payer: Cigna Medicare	$117.90
Rate for Payer: Medicaid All Medicaid	$120.52
Rate for Payer: Medicare All Medicare	$91.70
Rate for Payer: Monida Allegiance	$124.45
Rate for Payer: Monida First Choice Health	$127.07
Rate for Payer: Monida Montana Health Co-op	$124.45
Rate for Payer: Monida PacificSource	$124.45

METHYLMALONIC ACID, QUANT (706961)

Facility

$131.00

Service Code	CPT 83921
Hospital Charge Code	4083921
Hospital Revenue Code	300
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$131.00
Rate for Payer: Aetna Commercial	$124.45
Rate for Payer: Aetna Medicare	$117.90
Rate for Payer: BCBS MT CHIP	$117.90
Rate for Payer: BCBS MT Closed Plan Network	$124.45
Rate for Payer: BCBS MT HealthLink	$117.90
Rate for Payer: BCBS MT Medicare	$117.90
Rate for Payer: BCBS MT POS	$124.45
Rate for Payer: BCBS MT Traditional	$131.00
Rate for Payer: Cash Price	$117.90
Rate for Payer: Cigna Commercial	$124.45
Rate for Payer: Cigna Medicare	$117.90
Rate for Payer: Medicaid All Medicaid	$120.52
Rate for Payer: Medicare All Medicare	$91.70
Rate for Payer: Monida Allegiance	$124.45
Rate for Payer: Monida First Choice Health	$127.07
Rate for Payer: Monida Montana Health Co-op	$124.45
Rate for Payer: Monida PacificSource	$124.45

METHYLPREDNISOLONE INJ [125 MG]

Facility

$41.00

Service Code	HCPCS J2919
Hospital Charge Code	3000528
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

METHYLPREDNISOLONE INJ [125 MG]

Facility

$41.00

Service Code	HCPCS J2919
Hospital Charge Code	3000528
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

METHYLPREDNISOLONE TAB [4 MG] 21 PACK

Facility

$96.00

Service Code	HCPCS J7509
Hospital Charge Code	3000317
Hospital Revenue Code	250
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

METHYLPREDNISOLONE TAB [4 MG] 21 PACK

Facility

$96.00

Service Code	HCPCS J7509
Hospital Charge Code	3000317
Hospital Revenue Code	250
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

METOCLOPRAMIDE INJ [5 MG/ML] 2ML

Facility

$8.00

Service Code	HCPCS J2765
Hospital Charge Code	3000318
Hospital Revenue Code	258
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

METOCLOPRAMIDE INJ [5 MG/ML] 2ML

Facility

$8.00

Service Code	HCPCS J2765
Hospital Charge Code	3000318
Hospital Revenue Code	258
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

METOCLOPRAMIDE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000319
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

METOCLOPRAMIDE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000319
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

METOCLOPRAMIDE TAB [5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007720
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

METOCLOPRAMIDE TAB [5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007720
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

METOLAZONE TAB [5 MG] NF

Facility

$13.50

Service Code	HCPCS J8499
Hospital Charge Code	3000320
Hospital Revenue Code	250
Min. Negotiated Rate	$9.45
Max. Negotiated Rate	$13.50
Rate for Payer: Aetna Commercial	$12.82
Rate for Payer: Aetna Medicare	$12.15
Rate for Payer: BCBS MT CHIP	$12.15
Rate for Payer: BCBS MT Closed Plan Network	$12.82
Rate for Payer: BCBS MT HealthLink	$12.15
Rate for Payer: BCBS MT Medicare	$12.15
Rate for Payer: BCBS MT POS	$12.82
Rate for Payer: BCBS MT Traditional	$13.50
Rate for Payer: Cash Price	$12.15
Rate for Payer: Cigna Commercial	$12.82
Rate for Payer: Cigna Medicare	$12.15
Rate for Payer: Medicaid All Medicaid	$12.42
Rate for Payer: Medicare All Medicare	$9.45
Rate for Payer: Monida Allegiance	$12.82
Rate for Payer: Monida First Choice Health	$13.10
Rate for Payer: Monida Montana Health Co-op	$12.82
Rate for Payer: Monida PacificSource	$12.82

Know your out-of-pocket cost for care.

All Charges