Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

SARS-COV-2/FLU A/FLU B, RT-PCR

Facility

$250.00

Service Code	HCPCS 0240U
Hospital Charge Code	4050240
Hospital Revenue Code	300
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

SARS-COV-2, ID NOW

Facility

$203.00

Service Code	HCPCS 87635
Hospital Charge Code	4086351
Hospital Revenue Code	300
Min. Negotiated Rate	$142.10
Max. Negotiated Rate	$203.00
Rate for Payer: Aetna Commercial	$192.85
Rate for Payer: Aetna Medicare	$182.70
Rate for Payer: BCBS MT CHIP	$182.70
Rate for Payer: BCBS MT Closed Plan Network	$192.85
Rate for Payer: BCBS MT HealthLink	$182.70
Rate for Payer: BCBS MT Medicare	$182.70
Rate for Payer: BCBS MT POS	$192.85
Rate for Payer: BCBS MT Traditional	$203.00
Rate for Payer: Cash Price	$182.70
Rate for Payer: Cigna Commercial	$192.85
Rate for Payer: Cigna Medicare	$182.70
Rate for Payer: Medicaid All Medicaid	$186.76
Rate for Payer: Medicare All Medicare	$142.10
Rate for Payer: Monida Allegiance	$192.85
Rate for Payer: Monida First Choice Health	$196.91
Rate for Payer: Monida Montana Health Co-op	$192.85
Rate for Payer: Monida PacificSource	$192.85

SARS-COV-2, ID NOW

Facility

$203.00

Service Code	HCPCS 87635
Hospital Charge Code	4086351
Hospital Revenue Code	300
Min. Negotiated Rate	$142.10
Max. Negotiated Rate	$203.00
Rate for Payer: Aetna Commercial	$192.85
Rate for Payer: Aetna Medicare	$182.70
Rate for Payer: BCBS MT CHIP	$182.70
Rate for Payer: BCBS MT Closed Plan Network	$192.85
Rate for Payer: BCBS MT HealthLink	$182.70
Rate for Payer: BCBS MT Medicare	$182.70
Rate for Payer: BCBS MT POS	$192.85
Rate for Payer: BCBS MT Traditional	$203.00
Rate for Payer: Cash Price	$182.70
Rate for Payer: Cigna Commercial	$192.85
Rate for Payer: Cigna Medicare	$182.70
Rate for Payer: Medicaid All Medicaid	$186.76
Rate for Payer: Medicare All Medicare	$142.10
Rate for Payer: Monida Allegiance	$192.85
Rate for Payer: Monida First Choice Health	$196.91
Rate for Payer: Monida Montana Health Co-op	$192.85
Rate for Payer: Monida PacificSource	$192.85

SARS-COV-2, ID NOW - TRAVEL

Facility

$105.00

Service Code	HCPCS 87635
Hospital Charge Code	4000076
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

SARS-COV-2, ID NOW - TRAVEL

Facility

$105.00

Service Code	HCPCS 87635
Hospital Charge Code	4000076
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

SARS-COV-2, RT-PCR

Facility

$203.00

Service Code	HCPCS 87635
Hospital Charge Code	4087635
Hospital Revenue Code	300
Min. Negotiated Rate	$142.10
Max. Negotiated Rate	$203.00
Rate for Payer: Aetna Commercial	$192.85
Rate for Payer: Aetna Medicare	$182.70
Rate for Payer: BCBS MT CHIP	$182.70
Rate for Payer: BCBS MT Closed Plan Network	$192.85
Rate for Payer: BCBS MT HealthLink	$182.70
Rate for Payer: BCBS MT Medicare	$182.70
Rate for Payer: BCBS MT POS	$192.85
Rate for Payer: BCBS MT Traditional	$203.00
Rate for Payer: Cash Price	$182.70
Rate for Payer: Cigna Commercial	$192.85
Rate for Payer: Cigna Medicare	$182.70
Rate for Payer: Medicaid All Medicaid	$186.76
Rate for Payer: Medicare All Medicare	$142.10
Rate for Payer: Monida Allegiance	$192.85
Rate for Payer: Monida First Choice Health	$196.91
Rate for Payer: Monida Montana Health Co-op	$192.85
Rate for Payer: Monida PacificSource	$192.85

SARS-COV-2, RT-PCR

Facility

$203.00

Service Code	HCPCS 87635
Hospital Charge Code	4087635
Hospital Revenue Code	300
Min. Negotiated Rate	$142.10
Max. Negotiated Rate	$203.00
Rate for Payer: Aetna Commercial	$192.85
Rate for Payer: Aetna Medicare	$182.70
Rate for Payer: BCBS MT CHIP	$182.70
Rate for Payer: BCBS MT Closed Plan Network	$192.85
Rate for Payer: BCBS MT HealthLink	$182.70
Rate for Payer: BCBS MT Medicare	$182.70
Rate for Payer: BCBS MT POS	$192.85
Rate for Payer: BCBS MT Traditional	$203.00
Rate for Payer: Cash Price	$182.70
Rate for Payer: Cigna Commercial	$192.85
Rate for Payer: Cigna Medicare	$182.70
Rate for Payer: Medicaid All Medicaid	$186.76
Rate for Payer: Medicare All Medicare	$142.10
Rate for Payer: Monida Allegiance	$192.85
Rate for Payer: Monida First Choice Health	$196.91
Rate for Payer: Monida Montana Health Co-op	$192.85
Rate for Payer: Monida PacificSource	$192.85

SARS-COV-2 SEMI-QUANT IGG AB (164055)

Facility

$111.00

Service Code	HCPCS 86769
Hospital Charge Code	4086769
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SARS-COV-2 SEMI-QUANT IGG AB (164055)

Facility

$111.00

Service Code	HCPCS 86769
Hospital Charge Code	4086769
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SCALPEL #10

Facility

$11.00

Hospital Charge Code	80030255
Hospital Revenue Code	270
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

SCALPEL #10

Facility

$11.00

Hospital Charge Code	80030255
Hospital Revenue Code	270
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

SCOPOLAMINE PATCH [1 MG/3 DAYS]]

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	3000420
Hospital Revenue Code	250
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

SCOPOLAMINE PATCH [1 MG/3 DAYS]]

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	3000420
Hospital Revenue Code	250
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

SELENIUM (716910)

Facility

$180.00

Service Code	HCPCS 84255
Hospital Charge Code	4084255
Hospital Revenue Code	300
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

SELENIUM (716910)

Facility

$180.00

Service Code	HCPCS 84255
Hospital Charge Code	4084255
Hospital Revenue Code	300
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna Commercial	$171.00
Rate for Payer: Aetna Medicare	$162.00
Rate for Payer: BCBS MT CHIP	$162.00
Rate for Payer: BCBS MT Closed Plan Network	$171.00
Rate for Payer: BCBS MT HealthLink	$162.00
Rate for Payer: BCBS MT Medicare	$162.00
Rate for Payer: BCBS MT POS	$171.00
Rate for Payer: BCBS MT Traditional	$180.00
Rate for Payer: Cash Price	$162.00
Rate for Payer: Cigna Commercial	$171.00
Rate for Payer: Cigna Medicare	$162.00
Rate for Payer: Medicaid All Medicaid	$165.60
Rate for Payer: Medicare All Medicare	$126.00
Rate for Payer: Monida Allegiance	$171.00
Rate for Payer: Monida First Choice Health	$174.60
Rate for Payer: Monida Montana Health Co-op	$171.00
Rate for Payer: Monida PacificSource	$171.00

SEMAGLUTIDE INJ. 2.68MG/ML

Facility

$1,572.10

Service Code	NDC 00169477212
Hospital Charge Code	3007411
Hospital Revenue Code	250
Min. Negotiated Rate	$1,100.47
Max. Negotiated Rate	$1,572.10
Rate for Payer: Aetna Commercial	$1,493.50
Rate for Payer: Aetna Medicare	$1,414.89
Rate for Payer: BCBS MT CHIP	$1,414.89
Rate for Payer: BCBS MT Closed Plan Network	$1,493.50
Rate for Payer: BCBS MT HealthLink	$1,414.89
Rate for Payer: BCBS MT Medicare	$1,414.89
Rate for Payer: BCBS MT POS	$1,493.50
Rate for Payer: BCBS MT Traditional	$1,572.10
Rate for Payer: Cash Price	$1,414.89
Rate for Payer: Cigna Commercial	$1,493.50
Rate for Payer: Cigna Medicare	$1,414.89
Rate for Payer: Medicaid All Medicaid	$1,446.33
Rate for Payer: Medicare All Medicare	$1,100.47
Rate for Payer: Monida Allegiance	$1,493.50
Rate for Payer: Monida First Choice Health	$1,524.94
Rate for Payer: Monida Montana Health Co-op	$1,493.50
Rate for Payer: Monida PacificSource	$1,493.50

SEMAGLUTIDE INJ. 2.68MG/ML

Facility

$1,572.10

Service Code	NDC 00169477212
Hospital Charge Code	3007411
Hospital Revenue Code	250
Min. Negotiated Rate	$1,100.47
Max. Negotiated Rate	$1,572.10
Rate for Payer: Aetna Commercial	$1,493.50
Rate for Payer: Aetna Medicare	$1,414.89
Rate for Payer: BCBS MT CHIP	$1,414.89
Rate for Payer: BCBS MT Closed Plan Network	$1,493.50
Rate for Payer: BCBS MT HealthLink	$1,414.89
Rate for Payer: BCBS MT Medicare	$1,414.89
Rate for Payer: BCBS MT POS	$1,493.50
Rate for Payer: BCBS MT Traditional	$1,572.10
Rate for Payer: Cash Price	$1,414.89
Rate for Payer: Cigna Commercial	$1,493.50
Rate for Payer: Cigna Medicare	$1,414.89
Rate for Payer: Medicaid All Medicaid	$1,446.33
Rate for Payer: Medicare All Medicare	$1,100.47
Rate for Payer: Monida Allegiance	$1,493.50
Rate for Payer: Monida First Choice Health	$1,524.94
Rate for Payer: Monida Montana Health Co-op	$1,493.50
Rate for Payer: Monida PacificSource	$1,493.50

SEMAGLUTIDE SUBQ [0.68MG/ML] SPECIAL ORD

Facility

$1,628.00

Service Code	NDC 00169418113
Hospital Charge Code	3007393
Hospital Revenue Code	250
Min. Negotiated Rate	$1,139.60
Max. Negotiated Rate	$1,628.00
Rate for Payer: Aetna Commercial	$1,546.60
Rate for Payer: Aetna Medicare	$1,465.20
Rate for Payer: BCBS MT CHIP	$1,465.20
Rate for Payer: BCBS MT Closed Plan Network	$1,546.60
Rate for Payer: BCBS MT HealthLink	$1,465.20
Rate for Payer: BCBS MT Medicare	$1,465.20
Rate for Payer: BCBS MT POS	$1,546.60
Rate for Payer: BCBS MT Traditional	$1,628.00
Rate for Payer: Cash Price	$1,465.20
Rate for Payer: Cigna Commercial	$1,546.60
Rate for Payer: Cigna Medicare	$1,465.20
Rate for Payer: Medicaid All Medicaid	$1,497.76
Rate for Payer: Medicare All Medicare	$1,139.60
Rate for Payer: Monida Allegiance	$1,546.60
Rate for Payer: Monida First Choice Health	$1,579.16
Rate for Payer: Monida Montana Health Co-op	$1,546.60
Rate for Payer: Monida PacificSource	$1,546.60

SEMAGLUTIDE SUBQ [0.68MG/ML] SPECIAL ORD

Facility

$1,628.00

Service Code	NDC 00169418113
Hospital Charge Code	3007393
Hospital Revenue Code	250
Min. Negotiated Rate	$1,139.60
Max. Negotiated Rate	$1,628.00
Rate for Payer: Aetna Commercial	$1,546.60
Rate for Payer: Aetna Medicare	$1,465.20
Rate for Payer: BCBS MT CHIP	$1,465.20
Rate for Payer: BCBS MT Closed Plan Network	$1,546.60
Rate for Payer: BCBS MT HealthLink	$1,465.20
Rate for Payer: BCBS MT Medicare	$1,465.20
Rate for Payer: BCBS MT POS	$1,546.60
Rate for Payer: BCBS MT Traditional	$1,628.00
Rate for Payer: Cash Price	$1,465.20
Rate for Payer: Cigna Commercial	$1,546.60
Rate for Payer: Cigna Medicare	$1,465.20
Rate for Payer: Medicaid All Medicaid	$1,497.76
Rate for Payer: Medicare All Medicare	$1,139.60
Rate for Payer: Monida Allegiance	$1,546.60
Rate for Payer: Monida First Choice Health	$1,579.16
Rate for Payer: Monida Montana Health Co-op	$1,546.60
Rate for Payer: Monida PacificSource	$1,546.60

.SENSITIVITY, EACH ORGANISM

Facility

$29.00

Service Code	HCPCS 87186
Hospital Charge Code	4087186
Hospital Revenue Code	300
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

.SENSITIVITY, EACH ORGANISM

Facility

$29.00

Service Code	HCPCS 87186
Hospital Charge Code	4087186
Hospital Revenue Code	300
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

SERTRALINE TAB [25 MG] NON FORMULARY

Facility

$8.00

Service Code	NDC 65862001130
Hospital Charge Code	3000421
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

SERTRALINE TAB [25 MG] NON FORMULARY

Facility

$8.00

Service Code	NDC 65862001130
Hospital Charge Code	3000421
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

SERTRALINE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000422
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

SERTRALINE TAB [50 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000422
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