Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FLUMAZENIL INJ [0.5 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000184
Hospital Revenue Code	259
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

FLUMAZENIL INJ [0.5 MG/5 ML]

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000184
Hospital Revenue Code	259
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

FLUOXETINE CAP [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000185
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

FLUOXETINE CAP [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000185
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

FLUOXETINE CAP [20 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000547
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

FLUOXETINE CAP [20 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000547
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

FLUTICASONE NASAL SPRAY [50 MCG]

Facility

$273.00

Service Code	HCPCS J3490
Hospital Charge Code	3000186
Hospital Revenue Code	250
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

FLUTICASONE NASAL SPRAY [50 MCG]

Facility

$273.00

Service Code	HCPCS J3490
Hospital Charge Code	3000186
Hospital Revenue Code	250
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

FLUTICASONE/SALMET DISKUS [100-50 MCG]NF

Facility

$714.00

Service Code	HCPCS J3490
Hospital Charge Code	3000187
Hospital Revenue Code	250
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$714.00
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna Medicare	$642.60
Rate for Payer: BCBS MT CHIP	$642.60
Rate for Payer: BCBS MT Closed Plan Network	$678.30
Rate for Payer: BCBS MT HealthLink	$642.60
Rate for Payer: BCBS MT Medicare	$642.60
Rate for Payer: BCBS MT POS	$678.30
Rate for Payer: BCBS MT Traditional	$714.00
Rate for Payer: Cash Price	$642.60
Rate for Payer: Cigna Commercial	$678.30
Rate for Payer: Cigna Medicare	$642.60
Rate for Payer: Medicaid All Medicaid	$656.88
Rate for Payer: Medicare All Medicare	$499.80
Rate for Payer: Monida Allegiance	$678.30
Rate for Payer: Monida First Choice Health	$692.58
Rate for Payer: Monida Montana Health Co-op	$678.30
Rate for Payer: Monida PacificSource	$678.30

FLUTICASONE/SALMET DISKUS [100-50 MCG]NF

Facility

$714.00

Service Code	HCPCS J3490
Hospital Charge Code	3000187
Hospital Revenue Code	250
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$714.00
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna Medicare	$642.60
Rate for Payer: BCBS MT CHIP	$642.60
Rate for Payer: BCBS MT Closed Plan Network	$678.30
Rate for Payer: BCBS MT HealthLink	$642.60
Rate for Payer: BCBS MT Medicare	$642.60
Rate for Payer: BCBS MT POS	$678.30
Rate for Payer: BCBS MT Traditional	$714.00
Rate for Payer: Cash Price	$642.60
Rate for Payer: Cigna Commercial	$678.30
Rate for Payer: Cigna Medicare	$642.60
Rate for Payer: Medicaid All Medicaid	$656.88
Rate for Payer: Medicare All Medicare	$499.80
Rate for Payer: Monida Allegiance	$678.30
Rate for Payer: Monida First Choice Health	$692.58
Rate for Payer: Monida Montana Health Co-op	$678.30
Rate for Payer: Monida PacificSource	$678.30

FLUTICASONE/SALMET DISKUS [250-50 MCG]

Facility

$802.00

Service Code	HCPCS J3490
Hospital Charge Code	3000188
Hospital Revenue Code	250
Min. Negotiated Rate	$561.40
Max. Negotiated Rate	$802.00
Rate for Payer: Aetna Commercial	$761.90
Rate for Payer: Aetna Medicare	$721.80
Rate for Payer: BCBS MT CHIP	$721.80
Rate for Payer: BCBS MT Closed Plan Network	$761.90
Rate for Payer: BCBS MT HealthLink	$721.80
Rate for Payer: BCBS MT Medicare	$721.80
Rate for Payer: BCBS MT POS	$761.90
Rate for Payer: BCBS MT Traditional	$802.00
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cigna Commercial	$761.90
Rate for Payer: Cigna Medicare	$721.80
Rate for Payer: Medicaid All Medicaid	$737.84
Rate for Payer: Medicare All Medicare	$561.40
Rate for Payer: Monida Allegiance	$761.90
Rate for Payer: Monida First Choice Health	$777.94
Rate for Payer: Monida Montana Health Co-op	$761.90
Rate for Payer: Monida PacificSource	$761.90

FLUTICASONE/SALMET DISKUS [250-50 MCG]

Facility

$802.00

Service Code	HCPCS J3490
Hospital Charge Code	3000188
Hospital Revenue Code	250
Min. Negotiated Rate	$561.40
Max. Negotiated Rate	$802.00
Rate for Payer: Aetna Commercial	$761.90
Rate for Payer: Aetna Medicare	$721.80
Rate for Payer: BCBS MT CHIP	$721.80
Rate for Payer: BCBS MT Closed Plan Network	$761.90
Rate for Payer: BCBS MT HealthLink	$721.80
Rate for Payer: BCBS MT Medicare	$721.80
Rate for Payer: BCBS MT POS	$761.90
Rate for Payer: BCBS MT Traditional	$802.00
Rate for Payer: Cash Price	$721.80
Rate for Payer: Cigna Commercial	$761.90
Rate for Payer: Cigna Medicare	$721.80
Rate for Payer: Medicaid All Medicaid	$737.84
Rate for Payer: Medicare All Medicare	$561.40
Rate for Payer: Monida Allegiance	$761.90
Rate for Payer: Monida First Choice Health	$777.94
Rate for Payer: Monida Montana Health Co-op	$761.90
Rate for Payer: Monida PacificSource	$761.90

FLUTICASONE/SALMET DISKUS [500-50 MCG]

Facility

$1,054.00

Service Code	HCPCS J3490
Hospital Charge Code	3000189
Hospital Revenue Code	250
Min. Negotiated Rate	$737.80
Max. Negotiated Rate	$1,054.00
Rate for Payer: Aetna Commercial	$1,001.30
Rate for Payer: Aetna Medicare	$948.60
Rate for Payer: BCBS MT CHIP	$948.60
Rate for Payer: BCBS MT Closed Plan Network	$1,001.30
Rate for Payer: BCBS MT HealthLink	$948.60
Rate for Payer: BCBS MT Medicare	$948.60
Rate for Payer: BCBS MT POS	$1,001.30
Rate for Payer: BCBS MT Traditional	$1,054.00
Rate for Payer: Cash Price	$948.60
Rate for Payer: Cigna Commercial	$1,001.30
Rate for Payer: Cigna Medicare	$948.60
Rate for Payer: Medicaid All Medicaid	$969.68
Rate for Payer: Medicare All Medicare	$737.80
Rate for Payer: Monida Allegiance	$1,001.30
Rate for Payer: Monida First Choice Health	$1,022.38
Rate for Payer: Monida Montana Health Co-op	$1,001.30
Rate for Payer: Monida PacificSource	$1,001.30

FLUTICASONE/SALMET DISKUS [500-50 MCG]

Facility

$1,054.00

Service Code	HCPCS J3490
Hospital Charge Code	3000189
Hospital Revenue Code	250
Min. Negotiated Rate	$737.80
Max. Negotiated Rate	$1,054.00
Rate for Payer: Aetna Commercial	$1,001.30
Rate for Payer: Aetna Medicare	$948.60
Rate for Payer: BCBS MT CHIP	$948.60
Rate for Payer: BCBS MT Closed Plan Network	$1,001.30
Rate for Payer: BCBS MT HealthLink	$948.60
Rate for Payer: BCBS MT Medicare	$948.60
Rate for Payer: BCBS MT POS	$1,001.30
Rate for Payer: BCBS MT Traditional	$1,054.00
Rate for Payer: Cash Price	$948.60
Rate for Payer: Cigna Commercial	$1,001.30
Rate for Payer: Cigna Medicare	$948.60
Rate for Payer: Medicaid All Medicaid	$969.68
Rate for Payer: Medicare All Medicare	$737.80
Rate for Payer: Monida Allegiance	$1,001.30
Rate for Payer: Monida First Choice Health	$1,022.38
Rate for Payer: Monida Montana Health Co-op	$1,001.30
Rate for Payer: Monida PacificSource	$1,001.30

FLUTIC/UMECLID/VILAN 100/62.5/25MCG NF

Facility

$691.00

Service Code	NDC 00173088714
Hospital Charge Code	3007134
Hospital Revenue Code	250
Min. Negotiated Rate	$483.70
Max. Negotiated Rate	$691.00
Rate for Payer: Aetna Commercial	$656.45
Rate for Payer: Aetna Medicare	$621.90
Rate for Payer: BCBS MT CHIP	$621.90
Rate for Payer: BCBS MT Closed Plan Network	$656.45
Rate for Payer: BCBS MT HealthLink	$621.90
Rate for Payer: BCBS MT Medicare	$621.90
Rate for Payer: BCBS MT POS	$656.45
Rate for Payer: BCBS MT Traditional	$691.00
Rate for Payer: Cash Price	$621.90
Rate for Payer: Cigna Commercial	$656.45
Rate for Payer: Cigna Medicare	$621.90
Rate for Payer: Medicaid All Medicaid	$635.72
Rate for Payer: Medicare All Medicare	$483.70
Rate for Payer: Monida Allegiance	$656.45
Rate for Payer: Monida First Choice Health	$670.27
Rate for Payer: Monida Montana Health Co-op	$656.45
Rate for Payer: Monida PacificSource	$656.45

FLUTIC/UMECLID/VILAN 100/62.5/25MCG NF

Facility

$691.00

Service Code	NDC 00173088714
Hospital Charge Code	3007134
Hospital Revenue Code	250
Min. Negotiated Rate	$483.70
Max. Negotiated Rate	$691.00
Rate for Payer: Aetna Commercial	$656.45
Rate for Payer: Aetna Medicare	$621.90
Rate for Payer: BCBS MT CHIP	$621.90
Rate for Payer: BCBS MT Closed Plan Network	$656.45
Rate for Payer: BCBS MT HealthLink	$621.90
Rate for Payer: BCBS MT Medicare	$621.90
Rate for Payer: BCBS MT POS	$656.45
Rate for Payer: BCBS MT Traditional	$691.00
Rate for Payer: Cash Price	$621.90
Rate for Payer: Cigna Commercial	$656.45
Rate for Payer: Cigna Medicare	$621.90
Rate for Payer: Medicaid All Medicaid	$635.72
Rate for Payer: Medicare All Medicare	$483.70
Rate for Payer: Monida Allegiance	$656.45
Rate for Payer: Monida First Choice Health	$670.27
Rate for Payer: Monida Montana Health Co-op	$656.45
Rate for Payer: Monida PacificSource	$656.45

FLUVOXAMINE MALEATE 50MG TABLET-NF

Facility

$9.00

Service Code	NDC 62559015901
Hospital Charge Code	3007242
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

FLUVOXAMINE MALEATE 50MG TABLET-NF

Facility

$9.00

Service Code	NDC 62559015901
Hospital Charge Code	3007242
Hospital Revenue Code	250
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

FOLATE (002014)

Facility

$20.00

Service Code	HCPCS 82746
Hospital Charge Code	4082746
Hospital Revenue Code	301
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

FOLATE (002014)

Facility

$20.00

Service Code	HCPCS 82746
Hospital Charge Code	4082746
Hospital Revenue Code	301
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

FOLEY CATH TRAY (W/REG DRAIN B

Facility

$59.00

Hospital Charge Code	80030485
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

FOLEY CATH TRAY (W/REG DRAIN B

Facility

$59.00

Hospital Charge Code	80030485
Hospital Revenue Code	270
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

FOLIC ACID INJ [5 MG/ML]

Facility

$14.00

Service Code	HCPCS J3490
Hospital Charge Code	3000190
Hospital Revenue Code	259
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

FOLIC ACID INJ [5 MG/ML]

Facility

$14.00

Service Code	HCPCS J3490
Hospital Charge Code	3000190
Hospital Revenue Code	259
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

FOLIC ACID TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000191
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.

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