Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MICROALBUMIN CONTROL LEVEL 1

Facility

$124.60

Hospital Charge Code	90196625
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

MICROALBUMIN CONTROL LEVEL 1

Facility

$124.60

Hospital Charge Code	90196625
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

MICROALBUMIN CONTROL LEVEL 2

Facility

$124.60

Hospital Charge Code	90196626
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

MICROALBUMIN CONTROL LEVEL 2

Facility

$124.60

Hospital Charge Code	90196626
Hospital Revenue Code	270
Min. Negotiated Rate	$87.22
Max. Negotiated Rate	$124.60
Rate for Payer: Aetna Commercial	$118.37
Rate for Payer: Aetna Medicare	$112.14
Rate for Payer: BCBS MT CHIP	$112.14
Rate for Payer: BCBS MT Closed Plan Network	$118.37
Rate for Payer: BCBS MT HealthLink	$112.14
Rate for Payer: BCBS MT Medicare	$112.14
Rate for Payer: BCBS MT POS	$118.37
Rate for Payer: BCBS MT Traditional	$124.60
Rate for Payer: Cash Price	$112.14
Rate for Payer: Cigna Commercial	$118.37
Rate for Payer: Cigna Medicare	$112.14
Rate for Payer: Medicaid All Medicaid	$114.63
Rate for Payer: Medicare All Medicare	$87.22
Rate for Payer: Monida Allegiance	$118.37
Rate for Payer: Monida First Choice Health	$120.86
Rate for Payer: Monida Montana Health Co-op	$118.37
Rate for Payer: Monida PacificSource	$118.37

.MICROALBUMIN, RANDOM URINE

Facility

$77.00

Service Code	CPT 82043
Hospital Charge Code	4082043
Hospital Revenue Code	300
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

.MICROALBUMIN, RANDOM URINE

Facility

$77.00

Service Code	CPT 82043
Hospital Charge Code	4082043
Hospital Revenue Code	300
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$77.00
Rate for Payer: Aetna Commercial	$73.15
Rate for Payer: Aetna Medicare	$69.30
Rate for Payer: BCBS MT CHIP	$69.30
Rate for Payer: BCBS MT Closed Plan Network	$73.15
Rate for Payer: BCBS MT HealthLink	$69.30
Rate for Payer: BCBS MT Medicare	$69.30
Rate for Payer: BCBS MT POS	$73.15
Rate for Payer: BCBS MT Traditional	$77.00
Rate for Payer: Cash Price	$69.30
Rate for Payer: Cigna Commercial	$73.15
Rate for Payer: Cigna Medicare	$69.30
Rate for Payer: Medicaid All Medicaid	$70.84
Rate for Payer: Medicare All Medicare	$53.90
Rate for Payer: Monida Allegiance	$73.15
Rate for Payer: Monida First Choice Health	$74.69
Rate for Payer: Monida Montana Health Co-op	$73.15
Rate for Payer: Monida PacificSource	$73.15

MIDAZOLAM [10 MG/2 ML] SDV

Facility

$26.00

Service Code	HCPCS J2250
Hospital Charge Code	3007064
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MIDAZOLAM [10 MG/2 ML] SDV

Facility

$26.00

Service Code	HCPCS J2250
Hospital Charge Code	3007064
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MIDAZOLAM HCL [2 MG/2 ML] (PAIN INJ)

Facility

$26.00

Service Code	HCPCS J2250
Hospital Charge Code	3000328
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MIDAZOLAM HCL [2 MG/2 ML] (PAIN INJ)

Facility

$26.00

Service Code	HCPCS J2250
Hospital Charge Code	3000328
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MIDAZOLAM INJ [1 MG/ML] 2ML SDV

Facility

$26.00

Service Code	HCPCS J2250
Hospital Charge Code	3000329
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MIDAZOLAM INJ [1 MG/ML] 2ML SDV

Facility

$26.00

Service Code	HCPCS J2250
Hospital Charge Code	3000329
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MIDODRINE TAB [2.5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000331
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

MIDODRINE TAB [2.5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000331
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

MIDODRINE TAB [5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007388
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

MIDODRINE TAB [5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007388
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$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
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

MILLIPORE REPAIR

Facility

$2,787.43

Hospital Charge Code	90197113
Hospital Revenue Code	270
Min. Negotiated Rate	$1,951.20
Max. Negotiated Rate	$2,787.43
Rate for Payer: Aetna Commercial	$2,648.06
Rate for Payer: Aetna Medicare	$2,508.69
Rate for Payer: BCBS MT CHIP	$2,508.69
Rate for Payer: BCBS MT Closed Plan Network	$2,648.06
Rate for Payer: BCBS MT HealthLink	$2,508.69
Rate for Payer: BCBS MT Medicare	$2,508.69
Rate for Payer: BCBS MT POS	$2,648.06
Rate for Payer: BCBS MT Traditional	$2,787.43
Rate for Payer: Cash Price	$2,508.69
Rate for Payer: Cigna Commercial	$2,648.06
Rate for Payer: Cigna Medicare	$2,508.69
Rate for Payer: Medicaid All Medicaid	$2,564.44
Rate for Payer: Medicare All Medicare	$1,951.20
Rate for Payer: Monida Allegiance	$2,648.06
Rate for Payer: Monida First Choice Health	$2,703.81
Rate for Payer: Monida Montana Health Co-op	$2,648.06
Rate for Payer: Monida PacificSource	$2,648.06

MILLIPORE REPAIR

Facility

$2,787.43

Hospital Charge Code	90197113
Hospital Revenue Code	270
Min. Negotiated Rate	$1,951.20
Max. Negotiated Rate	$2,787.43
Rate for Payer: Aetna Commercial	$2,648.06
Rate for Payer: Aetna Medicare	$2,508.69
Rate for Payer: BCBS MT CHIP	$2,508.69
Rate for Payer: BCBS MT Closed Plan Network	$2,648.06
Rate for Payer: BCBS MT HealthLink	$2,508.69
Rate for Payer: BCBS MT Medicare	$2,508.69
Rate for Payer: BCBS MT POS	$2,648.06
Rate for Payer: BCBS MT Traditional	$2,787.43
Rate for Payer: Cash Price	$2,508.69
Rate for Payer: Cigna Commercial	$2,648.06
Rate for Payer: Cigna Medicare	$2,508.69
Rate for Payer: Medicaid All Medicaid	$2,564.44
Rate for Payer: Medicare All Medicare	$1,951.20
Rate for Payer: Monida Allegiance	$2,648.06
Rate for Payer: Monida First Choice Health	$2,703.81
Rate for Payer: Monida Montana Health Co-op	$2,648.06
Rate for Payer: Monida PacificSource	$2,648.06

MINERAL OIL ENEMA [4.5 FLOZ]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000332
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

MINERAL OIL ENEMA [4.5 FLOZ]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000332
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

MINOXIDIL TAB [2.5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007523
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

MINOXIDIL TAB [2.5 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007523
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

MIRABEGRON TAB ER [25 MG] NF

Facility

$55.00

Service Code	HCPCS J8499
Hospital Charge Code	3007275
Hospital Revenue Code	250
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

MIRABEGRON TAB ER [25 MG] NF

Facility

$55.00

Service Code	HCPCS J8499
Hospital Charge Code	3007275
Hospital Revenue Code	250
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

MIRABEGRON TAB ER [50 MG] NF

Facility

$54.00

Service Code	HCPCS J8499
Hospital Charge Code	3007197
Hospital Revenue Code	250
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

Know your out-of-pocket cost for care.

All Charges