Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FLECAINIDE TAB [50 MG] NF

Facility

$59.00

Service Code	NDC 62559038001
Hospital Charge Code	3007076
Hospital Revenue Code	250
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

FLECAINIDE TAB [50 MG] NF

Facility

$59.00

Service Code	NDC 62559038001
Hospital Charge Code	3007076
Hospital Revenue Code	250
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

.FLOW CYTOMETRY, EACH ADDITIONAL MARKER

Facility

$238.00

Service Code	HCPCS 88185
Hospital Charge Code	4088185
Hospital Revenue Code	310
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$238.00
Rate for Payer: Aetna Commercial	$226.10
Rate for Payer: Aetna Medicare	$214.20
Rate for Payer: BCBS MT CHIP	$214.20
Rate for Payer: BCBS MT Closed Plan Network	$226.10
Rate for Payer: BCBS MT HealthLink	$214.20
Rate for Payer: BCBS MT Medicare	$214.20
Rate for Payer: BCBS MT POS	$226.10
Rate for Payer: BCBS MT Traditional	$238.00
Rate for Payer: Cash Price	$214.20
Rate for Payer: Cigna Commercial	$226.10
Rate for Payer: Cigna Medicare	$214.20
Rate for Payer: Medicaid All Medicaid	$218.96
Rate for Payer: Medicare All Medicare	$166.60
Rate for Payer: Monida Allegiance	$226.10
Rate for Payer: Monida First Choice Health	$230.86
Rate for Payer: Monida Montana Health Co-op	$226.10
Rate for Payer: Monida PacificSource	$226.10

.FLOW CYTOMETRY, EACH ADDITIONAL MARKER

Facility

$238.00

Service Code	HCPCS 88185
Hospital Charge Code	4088185
Hospital Revenue Code	310
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$238.00
Rate for Payer: Aetna Commercial	$226.10
Rate for Payer: Aetna Medicare	$214.20
Rate for Payer: BCBS MT CHIP	$214.20
Rate for Payer: BCBS MT Closed Plan Network	$226.10
Rate for Payer: BCBS MT HealthLink	$214.20
Rate for Payer: BCBS MT Medicare	$214.20
Rate for Payer: BCBS MT POS	$226.10
Rate for Payer: BCBS MT Traditional	$238.00
Rate for Payer: Cash Price	$214.20
Rate for Payer: Cigna Commercial	$226.10
Rate for Payer: Cigna Medicare	$214.20
Rate for Payer: Medicaid All Medicaid	$218.96
Rate for Payer: Medicare All Medicare	$166.60
Rate for Payer: Monida Allegiance	$226.10
Rate for Payer: Monida First Choice Health	$230.86
Rate for Payer: Monida Montana Health Co-op	$226.10
Rate for Payer: Monida PacificSource	$226.10

.FLOW CYTOMETRY, FIRST MARKER

Facility

$342.00

Service Code	HCPCS 88184
Hospital Charge Code	4088184
Hospital Revenue Code	310
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

.FLOW CYTOMETRY, FIRST MARKER

Facility

$342.00

Service Code	HCPCS 88184
Hospital Charge Code	4088184
Hospital Revenue Code	310
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

.FLOW CYTOMETRY, INTERPRETATION

Facility

$238.00

Service Code	HCPCS 88187
Hospital Charge Code	4088187
Hospital Revenue Code	310
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$238.00
Rate for Payer: Aetna Commercial	$226.10
Rate for Payer: Aetna Medicare	$214.20
Rate for Payer: BCBS MT CHIP	$214.20
Rate for Payer: BCBS MT Closed Plan Network	$226.10
Rate for Payer: BCBS MT HealthLink	$214.20
Rate for Payer: BCBS MT Medicare	$214.20
Rate for Payer: BCBS MT POS	$226.10
Rate for Payer: BCBS MT Traditional	$238.00
Rate for Payer: Cash Price	$214.20
Rate for Payer: Cigna Commercial	$226.10
Rate for Payer: Cigna Medicare	$214.20
Rate for Payer: Medicaid All Medicaid	$218.96
Rate for Payer: Medicare All Medicare	$166.60
Rate for Payer: Monida Allegiance	$226.10
Rate for Payer: Monida First Choice Health	$230.86
Rate for Payer: Monida Montana Health Co-op	$226.10
Rate for Payer: Monida PacificSource	$226.10

.FLOW CYTOMETRY, INTERPRETATION

Facility

$238.00

Service Code	HCPCS 88187
Hospital Charge Code	4088187
Hospital Revenue Code	310
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$238.00
Rate for Payer: Aetna Commercial	$226.10
Rate for Payer: Aetna Medicare	$214.20
Rate for Payer: BCBS MT CHIP	$214.20
Rate for Payer: BCBS MT Closed Plan Network	$226.10
Rate for Payer: BCBS MT HealthLink	$214.20
Rate for Payer: BCBS MT Medicare	$214.20
Rate for Payer: BCBS MT POS	$226.10
Rate for Payer: BCBS MT Traditional	$238.00
Rate for Payer: Cash Price	$214.20
Rate for Payer: Cigna Commercial	$226.10
Rate for Payer: Cigna Medicare	$214.20
Rate for Payer: Medicaid All Medicaid	$218.96
Rate for Payer: Medicare All Medicare	$166.60
Rate for Payer: Monida Allegiance	$226.10
Rate for Payer: Monida First Choice Health	$230.86
Rate for Payer: Monida Montana Health Co-op	$226.10
Rate for Payer: Monida PacificSource	$226.10

FLUCONAZOLE 100 MG TABLET

Facility

$28.00

Service Code	NDC 50268033715
Hospital Charge Code	3007306
Hospital Revenue Code	250
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

FLUCONAZOLE 100 MG TABLET

Facility

$28.00

Service Code	NDC 50268033715
Hospital Charge Code	3007306
Hospital Revenue Code	250
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

FLUCONAZOLE TAB [100 MG] NF

Facility

$31.00

Service Code	NDC 50268033711
Hospital Charge Code	3007568
Hospital Revenue Code	250
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$31.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: BCBS MT CHIP	$27.90
Rate for Payer: BCBS MT Closed Plan Network	$29.45
Rate for Payer: BCBS MT HealthLink	$27.90
Rate for Payer: BCBS MT Medicare	$27.90
Rate for Payer: BCBS MT POS	$29.45
Rate for Payer: BCBS MT Traditional	$31.00
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cigna Commercial	$29.45
Rate for Payer: Cigna Medicare	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

FLUCONAZOLE TAB [100 MG] NF

Facility

$31.00

Service Code	NDC 50268033711
Hospital Charge Code	3007568
Hospital Revenue Code	250
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$31.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: BCBS MT CHIP	$27.90
Rate for Payer: BCBS MT Closed Plan Network	$29.45
Rate for Payer: BCBS MT HealthLink	$27.90
Rate for Payer: BCBS MT Medicare	$27.90
Rate for Payer: BCBS MT POS	$29.45
Rate for Payer: BCBS MT Traditional	$31.00
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cigna Commercial	$29.45
Rate for Payer: Cigna Medicare	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

FLUCONAZOLE TAB [150 MG]

Facility

$45.00

Service Code	HCPCS J3490
Hospital Charge Code	3000182
Hospital Revenue Code	250
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

FLUCONAZOLE TAB [150 MG]

Facility

$45.00

Service Code	HCPCS J3490
Hospital Charge Code	3000182
Hospital Revenue Code	250
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

FLUDROCORTISONE TAB [0.1 MG] NF

Facility

$6.00

Service Code	HCPCS J3490
Hospital Charge Code	3000183
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

FLUDROCORTISONE TAB [0.1 MG] NF

Facility

$6.00

Service Code	HCPCS J3490
Hospital Charge Code	3000183
Hospital Revenue Code	250
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.00
Rate for Payer: Aetna Commercial	$5.70
Rate for Payer: Aetna Medicare	$5.40
Rate for Payer: BCBS MT CHIP	$5.40
Rate for Payer: BCBS MT Closed Plan Network	$5.70
Rate for Payer: BCBS MT HealthLink	$5.40
Rate for Payer: BCBS MT Medicare	$5.40
Rate for Payer: BCBS MT POS	$5.70
Rate for Payer: BCBS MT Traditional	$6.00
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cigna Commercial	$5.70
Rate for Payer: Cigna Medicare	$5.40
Rate for Payer: Medicaid All Medicaid	$5.52
Rate for Payer: Medicare All Medicare	$4.20
Rate for Payer: Monida Allegiance	$5.70
Rate for Payer: Monida First Choice Health	$5.82
Rate for Payer: Monida Montana Health Co-op	$5.70
Rate for Payer: Monida PacificSource	$5.70

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

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] NF

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] NF

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]

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]

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 PROP INH [44 MCG] NF

Facility

$618.00

Service Code	HCPCS J3490
Hospital Charge Code	3000608
Hospital Revenue Code	250
Min. Negotiated Rate	$432.60
Max. Negotiated Rate	$618.00
Rate for Payer: Aetna Commercial	$587.10
Rate for Payer: Aetna Medicare	$556.20
Rate for Payer: BCBS MT CHIP	$556.20
Rate for Payer: BCBS MT Closed Plan Network	$587.10
Rate for Payer: BCBS MT HealthLink	$556.20
Rate for Payer: BCBS MT Medicare	$556.20
Rate for Payer: BCBS MT POS	$587.10
Rate for Payer: BCBS MT Traditional	$618.00
Rate for Payer: Cash Price	$556.20
Rate for Payer: Cigna Commercial	$587.10
Rate for Payer: Cigna Medicare	$556.20
Rate for Payer: Medicaid All Medicaid	$568.56
Rate for Payer: Medicare All Medicare	$432.60
Rate for Payer: Monida Allegiance	$587.10
Rate for Payer: Monida First Choice Health	$599.46
Rate for Payer: Monida Montana Health Co-op	$587.10
Rate for Payer: Monida PacificSource	$587.10

Know your out-of-pocket cost for care.

All Charges