Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MIRENA IUD [21 MCG/24 HR] SPECIAL ORDER

Facility

$2,041.00

Service Code	HCPCS J7298
Hospital Charge Code	3000622
Hospital Revenue Code	521
Min. Negotiated Rate	$1,428.70
Max. Negotiated Rate	$2,041.00
Rate for Payer: Aetna Commercial	$1,938.95
Rate for Payer: Aetna Medicare	$1,836.90
Rate for Payer: BCBS MT CHIP	$1,836.90
Rate for Payer: BCBS MT Closed Plan Network	$1,938.95
Rate for Payer: BCBS MT HealthLink	$1,836.90
Rate for Payer: BCBS MT Medicare	$1,836.90
Rate for Payer: BCBS MT POS	$1,938.95
Rate for Payer: BCBS MT Traditional	$2,041.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cigna Commercial	$1,938.95
Rate for Payer: Cigna Medicare	$1,836.90
Rate for Payer: Medicaid All Medicaid	$1,877.72
Rate for Payer: Medicare All Medicare	$1,428.70
Rate for Payer: Monida Allegiance	$1,938.95
Rate for Payer: Monida First Choice Health	$1,979.77
Rate for Payer: Monida Montana Health Co-op	$1,938.95
Rate for Payer: Monida PacificSource	$1,938.95

MIRENA IUD [21 MCG/24 HR] SPECIAL ORDER

Facility

$2,041.00

Service Code	HCPCS J7298
Hospital Charge Code	3000622
Hospital Revenue Code	521
Min. Negotiated Rate	$1,428.70
Max. Negotiated Rate	$2,041.00
Rate for Payer: Aetna Commercial	$1,938.95
Rate for Payer: Aetna Medicare	$1,836.90
Rate for Payer: BCBS MT CHIP	$1,836.90
Rate for Payer: BCBS MT Closed Plan Network	$1,938.95
Rate for Payer: BCBS MT HealthLink	$1,836.90
Rate for Payer: BCBS MT Medicare	$1,836.90
Rate for Payer: BCBS MT POS	$1,938.95
Rate for Payer: BCBS MT Traditional	$2,041.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cigna Commercial	$1,938.95
Rate for Payer: Cigna Medicare	$1,836.90
Rate for Payer: Medicaid All Medicaid	$1,877.72
Rate for Payer: Medicare All Medicare	$1,428.70
Rate for Payer: Monida Allegiance	$1,938.95
Rate for Payer: Monida First Choice Health	$1,979.77
Rate for Payer: Monida Montana Health Co-op	$1,938.95
Rate for Payer: Monida PacificSource	$1,938.95

MIRTAZAPINE TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007049
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

MIRTAZAPINE TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007049
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

MIRTAZAPINE TAB [45 MG] NF

Facility

$10.00

Service Code	HCPCS J8499
Hospital Charge Code	3007074
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

MIRTAZAPINE TAB [45 MG] NF

Facility

$10.00

Service Code	HCPCS J8499
Hospital Charge Code	3007074
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

MISOPROSTOL TAB [200 MCG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3007340
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

MISOPROSTOL TAB [200 MCG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3007340
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

MITOCHONDRIAL ANTIBODY (006650)

Facility

$26.00

Service Code	CPT 86381
Hospital Charge Code	4000516
Hospital Revenue Code	301
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

MITOCHONDRIAL ANTIBODY (006650)

Facility

$26.00

Service Code	CPT 86381
Hospital Charge Code	4000516
Hospital Revenue Code	301
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

MOLECULAR PATHOLOGY PROCEDURE LEVEL 6

Facility

$859.08

Service Code	CPT 81405
Hospital Charge Code	4081405
Hospital Revenue Code	310
Min. Negotiated Rate	$601.36
Max. Negotiated Rate	$859.08
Rate for Payer: Aetna Commercial	$816.13
Rate for Payer: Aetna Medicare	$773.17
Rate for Payer: BCBS MT CHIP	$773.17
Rate for Payer: BCBS MT Closed Plan Network	$816.13
Rate for Payer: BCBS MT HealthLink	$773.17
Rate for Payer: BCBS MT Medicare	$773.17
Rate for Payer: BCBS MT POS	$816.13
Rate for Payer: BCBS MT Traditional	$859.08
Rate for Payer: Cash Price	$773.17
Rate for Payer: Cigna Commercial	$816.13
Rate for Payer: Cigna Medicare	$773.17
Rate for Payer: Medicaid All Medicaid	$790.35
Rate for Payer: Medicare All Medicare	$601.36
Rate for Payer: Monida Allegiance	$816.13
Rate for Payer: Monida First Choice Health	$833.31
Rate for Payer: Monida Montana Health Co-op	$816.13
Rate for Payer: Monida PacificSource	$816.13

MOLECULAR PATHOLOGY PROCEDURE LEVEL 6

Facility

$859.08

Service Code	CPT 81405
Hospital Charge Code	4081405
Hospital Revenue Code	310
Min. Negotiated Rate	$601.36
Max. Negotiated Rate	$859.08
Rate for Payer: Aetna Commercial	$816.13
Rate for Payer: Aetna Medicare	$773.17
Rate for Payer: BCBS MT CHIP	$773.17
Rate for Payer: BCBS MT Closed Plan Network	$816.13
Rate for Payer: BCBS MT HealthLink	$773.17
Rate for Payer: BCBS MT Medicare	$773.17
Rate for Payer: BCBS MT POS	$816.13
Rate for Payer: BCBS MT Traditional	$859.08
Rate for Payer: Cash Price	$773.17
Rate for Payer: Cigna Commercial	$816.13
Rate for Payer: Cigna Medicare	$773.17
Rate for Payer: Medicaid All Medicaid	$790.35
Rate for Payer: Medicare All Medicare	$601.36
Rate for Payer: Monida Allegiance	$816.13
Rate for Payer: Monida First Choice Health	$833.31
Rate for Payer: Monida Montana Health Co-op	$816.13
Rate for Payer: Monida PacificSource	$816.13

MOMETASONE FUR 100MCG/5MCG INH NF

Facility

$640.10

Hospital Charge Code	3007386
Hospital Revenue Code	250
Min. Negotiated Rate	$448.07
Max. Negotiated Rate	$640.10
Rate for Payer: Aetna Commercial	$608.10
Rate for Payer: Aetna Medicare	$576.09
Rate for Payer: BCBS MT CHIP	$576.09
Rate for Payer: BCBS MT Closed Plan Network	$608.10
Rate for Payer: BCBS MT HealthLink	$576.09
Rate for Payer: BCBS MT Medicare	$576.09
Rate for Payer: BCBS MT POS	$608.10
Rate for Payer: BCBS MT Traditional	$640.10
Rate for Payer: Cash Price	$576.09
Rate for Payer: Cigna Commercial	$608.10
Rate for Payer: Cigna Medicare	$576.09
Rate for Payer: Medicaid All Medicaid	$588.89
Rate for Payer: Medicare All Medicare	$448.07
Rate for Payer: Monida Allegiance	$608.10
Rate for Payer: Monida First Choice Health	$620.90
Rate for Payer: Monida Montana Health Co-op	$608.10
Rate for Payer: Monida PacificSource	$608.10

MOMETASONE FUR 100MCG/5MCG INH NF

Facility

$640.10

Hospital Charge Code	3007386
Hospital Revenue Code	250
Min. Negotiated Rate	$448.07
Max. Negotiated Rate	$640.10
Rate for Payer: Aetna Commercial	$608.10
Rate for Payer: Aetna Medicare	$576.09
Rate for Payer: BCBS MT CHIP	$576.09
Rate for Payer: BCBS MT Closed Plan Network	$608.10
Rate for Payer: BCBS MT HealthLink	$576.09
Rate for Payer: BCBS MT Medicare	$576.09
Rate for Payer: BCBS MT POS	$608.10
Rate for Payer: BCBS MT Traditional	$640.10
Rate for Payer: Cash Price	$576.09
Rate for Payer: Cigna Commercial	$608.10
Rate for Payer: Cigna Medicare	$576.09
Rate for Payer: Medicaid All Medicaid	$588.89
Rate for Payer: Medicare All Medicare	$448.07
Rate for Payer: Monida Allegiance	$608.10
Rate for Payer: Monida First Choice Health	$620.90
Rate for Payer: Monida Montana Health Co-op	$608.10
Rate for Payer: Monida PacificSource	$608.10

MONTELUKAST TAB [10 MG]

Facility

$18.00

Service Code	HCPCS J8499
Hospital Charge Code	3000335
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

MONTELUKAST TAB [10 MG]

Facility

$18.00

Service Code	HCPCS J8499
Hospital Charge Code	3000335
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

MORPHINE INJ [10 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000337
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

MORPHINE INJ [10 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000337
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

MORPHINE INJ [4 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000338
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

MORPHINE INJ [4 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000338
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

MORPHINE ORAL SLN [20 MG/ML]

Facility

$81.00

Service Code	HCPCS J8499
Hospital Charge Code	3000559
Hospital Revenue Code	250
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

MORPHINE ORAL SLN [20 MG/ML]

Facility

$81.00

Service Code	HCPCS J8499
Hospital Charge Code	3000559
Hospital Revenue Code	250
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

MORPHINE SOLN (ROXANOL) 10MG/5ML UD CUP

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007063
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

MORPHINE SOLN (ROXANOL) 10MG/5ML UD CUP

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007063
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

Know your out-of-pocket cost for care.

All Charges