Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MS CONTIN TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000336
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

MS CONTIN TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000336
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

MTHFR (511238)

Facility

$219.00

Service Code	CPT 81291
Hospital Charge Code	4081291
Hospital Revenue Code	300
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

MTHFR (511238)

Facility

$219.00

Service Code	CPT 81291
Hospital Charge Code	4081291
Hospital Revenue Code	300
Min. Negotiated Rate	$153.30
Max. Negotiated Rate	$219.00
Rate for Payer: Aetna Commercial	$208.05
Rate for Payer: Aetna Medicare	$197.10
Rate for Payer: BCBS MT CHIP	$197.10
Rate for Payer: BCBS MT Closed Plan Network	$208.05
Rate for Payer: BCBS MT HealthLink	$197.10
Rate for Payer: BCBS MT Medicare	$197.10
Rate for Payer: BCBS MT POS	$208.05
Rate for Payer: BCBS MT Traditional	$219.00
Rate for Payer: Cash Price	$197.10
Rate for Payer: Cigna Commercial	$208.05
Rate for Payer: Cigna Medicare	$197.10
Rate for Payer: Medicaid All Medicaid	$201.48
Rate for Payer: Medicare All Medicare	$153.30
Rate for Payer: Monida Allegiance	$208.05
Rate for Payer: Monida First Choice Health	$212.43
Rate for Payer: Monida Montana Health Co-op	$208.05
Rate for Payer: Monida PacificSource	$208.05

MULTI VITAMIN TAB ADULT

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3000340
Hospital Revenue Code	250
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

MULTI VITAMIN TAB ADULT

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3000340
Hospital Revenue Code	250
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

MUMPS AB, IGG (096552)

Facility

$69.00

Service Code	CPT 86735
Hospital Charge Code	4086735
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

MUMPS AB, IGG (096552)

Facility

$69.00

Service Code	CPT 86735
Hospital Charge Code	4086735
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

MUMPS AB, IGM (160499)

Facility

$84.00

Service Code	CPT 86735
Hospital Charge Code	4067351
Hospital Revenue Code	300
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

MUMPS AB, IGM (160499)

Facility

$84.00

Service Code	CPT 86735
Hospital Charge Code	4067351
Hospital Revenue Code	300
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

MUMPS VIRAL CULTURE (186150)

Facility

$507.00

Service Code	CPT 87254
Hospital Charge Code	4087254
Hospital Revenue Code	306
Min. Negotiated Rate	$354.90
Max. Negotiated Rate	$507.00
Rate for Payer: Aetna Commercial	$481.65
Rate for Payer: Aetna Medicare	$456.30
Rate for Payer: BCBS MT CHIP	$456.30
Rate for Payer: BCBS MT Closed Plan Network	$481.65
Rate for Payer: BCBS MT HealthLink	$456.30
Rate for Payer: BCBS MT Medicare	$456.30
Rate for Payer: BCBS MT POS	$481.65
Rate for Payer: BCBS MT Traditional	$507.00
Rate for Payer: Cash Price	$456.30
Rate for Payer: Cigna Commercial	$481.65
Rate for Payer: Cigna Medicare	$456.30
Rate for Payer: Medicaid All Medicaid	$466.44
Rate for Payer: Medicare All Medicare	$354.90
Rate for Payer: Monida Allegiance	$481.65
Rate for Payer: Monida First Choice Health	$491.79
Rate for Payer: Monida Montana Health Co-op	$481.65
Rate for Payer: Monida PacificSource	$481.65

MUMPS VIRAL CULTURE (186150)

Facility

$507.00

Service Code	CPT 87254
Hospital Charge Code	4087254
Hospital Revenue Code	306
Min. Negotiated Rate	$354.90
Max. Negotiated Rate	$507.00
Rate for Payer: Aetna Commercial	$481.65
Rate for Payer: Aetna Medicare	$456.30
Rate for Payer: BCBS MT CHIP	$456.30
Rate for Payer: BCBS MT Closed Plan Network	$481.65
Rate for Payer: BCBS MT HealthLink	$456.30
Rate for Payer: BCBS MT Medicare	$456.30
Rate for Payer: BCBS MT POS	$481.65
Rate for Payer: BCBS MT Traditional	$507.00
Rate for Payer: Cash Price	$456.30
Rate for Payer: Cigna Commercial	$481.65
Rate for Payer: Cigna Medicare	$456.30
Rate for Payer: Medicaid All Medicaid	$466.44
Rate for Payer: Medicare All Medicare	$354.90
Rate for Payer: Monida Allegiance	$481.65
Rate for Payer: Monida First Choice Health	$491.79
Rate for Payer: Monida Montana Health Co-op	$481.65
Rate for Payer: Monida PacificSource	$481.65

MUPIROCIN OINT [2 %] 22GM

Facility

$144.00

Service Code	HCPCS J3490
Hospital Charge Code	3007066
Hospital Revenue Code	250
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

MUPIROCIN OINT [2 %] 22GM

Facility

$144.00

Service Code	HCPCS J3490
Hospital Charge Code	3007066
Hospital Revenue Code	250
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$144.00
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: BCBS MT CHIP	$129.60
Rate for Payer: BCBS MT Closed Plan Network	$136.80
Rate for Payer: BCBS MT HealthLink	$129.60
Rate for Payer: BCBS MT Medicare	$129.60
Rate for Payer: BCBS MT POS	$136.80
Rate for Payer: BCBS MT Traditional	$144.00
Rate for Payer: Cash Price	$129.60
Rate for Payer: Cigna Commercial	$136.80
Rate for Payer: Cigna Medicare	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

MUSCLE TEST, 2 LIMBS

Facility

$394.00

Service Code	CPT 95861
Hospital Charge Code	595861
Hospital Revenue Code	761
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

MUSCLE TEST, 2 LIMBS

Facility

$394.00

Service Code	CPT 95861
Hospital Charge Code	595861
Hospital Revenue Code	761
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

MVI ADULT VITS FOR INFUSION

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	3000341
Hospital Revenue Code	258
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

MVI ADULT VITS FOR INFUSION

Facility

$60.00

Service Code	HCPCS J3490
Hospital Charge Code	3000341
Hospital Revenue Code	258
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

MYCOPHENOLATE MOFETIL TAB [500 MG] NF

Facility

$8.00

Service Code	HCPCS J7517
Hospital Charge Code	3007508
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

MYCOPHENOLATE MOFETIL TAB [500 MG] NF

Facility

$8.00

Service Code	HCPCS J7517
Hospital Charge Code	3007508
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

MYCOPHENOLIC ACID (716795)

Facility

$258.00

Service Code	CPT 80180
Hospital Charge Code	4080180
Hospital Revenue Code	300
Min. Negotiated Rate	$180.60
Max. Negotiated Rate	$258.00
Rate for Payer: Aetna Commercial	$245.10
Rate for Payer: Aetna Medicare	$232.20
Rate for Payer: BCBS MT CHIP	$232.20
Rate for Payer: BCBS MT Closed Plan Network	$245.10
Rate for Payer: BCBS MT HealthLink	$232.20
Rate for Payer: BCBS MT Medicare	$232.20
Rate for Payer: BCBS MT POS	$245.10
Rate for Payer: BCBS MT Traditional	$258.00
Rate for Payer: Cash Price	$232.20
Rate for Payer: Cigna Commercial	$245.10
Rate for Payer: Cigna Medicare	$232.20
Rate for Payer: Medicaid All Medicaid	$237.36
Rate for Payer: Medicare All Medicare	$180.60
Rate for Payer: Monida Allegiance	$245.10
Rate for Payer: Monida First Choice Health	$250.26
Rate for Payer: Monida Montana Health Co-op	$245.10
Rate for Payer: Monida PacificSource	$245.10

MYCOPHENOLIC ACID (716795)

Facility

$258.00

Service Code	CPT 80180
Hospital Charge Code	4080180
Hospital Revenue Code	300
Min. Negotiated Rate	$180.60
Max. Negotiated Rate	$258.00
Rate for Payer: Aetna Commercial	$245.10
Rate for Payer: Aetna Medicare	$232.20
Rate for Payer: BCBS MT CHIP	$232.20
Rate for Payer: BCBS MT Closed Plan Network	$245.10
Rate for Payer: BCBS MT HealthLink	$232.20
Rate for Payer: BCBS MT Medicare	$232.20
Rate for Payer: BCBS MT POS	$245.10
Rate for Payer: BCBS MT Traditional	$258.00
Rate for Payer: Cash Price	$232.20
Rate for Payer: Cigna Commercial	$245.10
Rate for Payer: Cigna Medicare	$232.20
Rate for Payer: Medicaid All Medicaid	$237.36
Rate for Payer: Medicare All Medicare	$180.60
Rate for Payer: Monida Allegiance	$245.10
Rate for Payer: Monida First Choice Health	$250.26
Rate for Payer: Monida Montana Health Co-op	$245.10
Rate for Payer: Monida PacificSource	$245.10

MYELOPEROXIDASE IGG ANTIBODY

Facility

$126.00

Service Code	CPT 83516
Hospital Charge Code	4088011
Hospital Revenue Code	302
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: BCBS MT CHIP	$113.40
Rate for Payer: BCBS MT Closed Plan Network	$119.70
Rate for Payer: BCBS MT HealthLink	$113.40
Rate for Payer: BCBS MT Medicare	$113.40
Rate for Payer: BCBS MT POS	$119.70
Rate for Payer: BCBS MT Traditional	$126.00
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial	$119.70
Rate for Payer: Cigna Medicare	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

MYELOPEROXIDASE IGG ANTIBODY

Facility

$126.00

Service Code	CPT 83516
Hospital Charge Code	4088011
Hospital Revenue Code	302
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: BCBS MT CHIP	$113.40
Rate for Payer: BCBS MT Closed Plan Network	$119.70
Rate for Payer: BCBS MT HealthLink	$113.40
Rate for Payer: BCBS MT Medicare	$113.40
Rate for Payer: BCBS MT POS	$119.70
Rate for Payer: BCBS MT Traditional	$126.00
Rate for Payer: Cash Price	$113.40
Rate for Payer: Cigna Commercial	$119.70
Rate for Payer: Cigna Medicare	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

MYOGLOBIN (010405)

Facility

$79.00

Service Code	CPT 83874
Hospital Charge Code	4083874
Hospital Revenue Code	301
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

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