Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

$764.00

Service Code	HCPCS J3490
Hospital Charge Code	3000188
Hospital Revenue Code	250
Min. Negotiated Rate	$534.80
Max. Negotiated Rate	$764.00
Rate for Payer: Aetna Commercial	$725.80
Rate for Payer: Aetna Medicare	$687.60
Rate for Payer: BCBS MT CHIP	$687.60
Rate for Payer: BCBS MT Closed Plan Network	$725.80
Rate for Payer: BCBS MT HealthLink	$687.60
Rate for Payer: BCBS MT Medicare	$687.60
Rate for Payer: BCBS MT POS	$725.80
Rate for Payer: BCBS MT Traditional	$764.00
Rate for Payer: Cash Price	$687.60
Rate for Payer: Cigna Commercial	$725.80
Rate for Payer: Cigna Medicare	$687.60
Rate for Payer: Medicaid All Medicaid	$702.88
Rate for Payer: Medicare All Medicare	$534.80
Rate for Payer: Monida Allegiance	$725.80
Rate for Payer: Monida First Choice Health	$741.08
Rate for Payer: Monida Montana Health Co-op	$725.80
Rate for Payer: Monida PacificSource	$725.80

FLUTICASONE/SALMET DISKUS [250-50 MCG]

Facility

$764.00

Service Code	HCPCS J3490
Hospital Charge Code	3000188
Hospital Revenue Code	250
Min. Negotiated Rate	$534.80
Max. Negotiated Rate	$764.00
Rate for Payer: Aetna Commercial	$725.80
Rate for Payer: Aetna Medicare	$687.60
Rate for Payer: BCBS MT CHIP	$687.60
Rate for Payer: BCBS MT Closed Plan Network	$725.80
Rate for Payer: BCBS MT HealthLink	$687.60
Rate for Payer: BCBS MT Medicare	$687.60
Rate for Payer: BCBS MT POS	$725.80
Rate for Payer: BCBS MT Traditional	$764.00
Rate for Payer: Cash Price	$687.60
Rate for Payer: Cigna Commercial	$725.80
Rate for Payer: Cigna Medicare	$687.60
Rate for Payer: Medicaid All Medicaid	$702.88
Rate for Payer: Medicare All Medicare	$534.80
Rate for Payer: Monida Allegiance	$725.80
Rate for Payer: Monida First Choice Health	$741.08
Rate for Payer: Monida Montana Health Co-op	$725.80
Rate for Payer: Monida PacificSource	$725.80

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

$1,139.00

Service Code	NDC 00173088710
Hospital Charge Code	3007134
Hospital Revenue Code	250
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$1,139.00
Rate for Payer: Aetna Commercial	$1,082.05
Rate for Payer: Aetna Medicare	$1,025.10
Rate for Payer: BCBS MT CHIP	$1,025.10
Rate for Payer: BCBS MT Closed Plan Network	$1,082.05
Rate for Payer: BCBS MT HealthLink	$1,025.10
Rate for Payer: BCBS MT Medicare	$1,025.10
Rate for Payer: BCBS MT POS	$1,082.05
Rate for Payer: BCBS MT Traditional	$1,139.00
Rate for Payer: Cash Price	$1,025.10
Rate for Payer: Cigna Commercial	$1,082.05
Rate for Payer: Cigna Medicare	$1,025.10
Rate for Payer: Medicaid All Medicaid	$1,047.88
Rate for Payer: Medicare All Medicare	$797.30
Rate for Payer: Monida Allegiance	$1,082.05
Rate for Payer: Monida First Choice Health	$1,104.83
Rate for Payer: Monida Montana Health Co-op	$1,082.05
Rate for Payer: Monida PacificSource	$1,082.05

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

Facility

$1,139.00

Service Code	NDC 00173088710
Hospital Charge Code	3007134
Hospital Revenue Code	250
Min. Negotiated Rate	$797.30
Max. Negotiated Rate	$1,139.00
Rate for Payer: Aetna Commercial	$1,082.05
Rate for Payer: Aetna Medicare	$1,025.10
Rate for Payer: BCBS MT CHIP	$1,025.10
Rate for Payer: BCBS MT Closed Plan Network	$1,082.05
Rate for Payer: BCBS MT HealthLink	$1,025.10
Rate for Payer: BCBS MT Medicare	$1,025.10
Rate for Payer: BCBS MT POS	$1,082.05
Rate for Payer: BCBS MT Traditional	$1,139.00
Rate for Payer: Cash Price	$1,025.10
Rate for Payer: Cigna Commercial	$1,082.05
Rate for Payer: Cigna Medicare	$1,025.10
Rate for Payer: Medicaid All Medicaid	$1,047.88
Rate for Payer: Medicare All Medicare	$797.30
Rate for Payer: Monida Allegiance	$1,082.05
Rate for Payer: Monida First Choice Health	$1,104.83
Rate for Payer: Monida Montana Health Co-op	$1,082.05
Rate for Payer: Monida PacificSource	$1,082.05

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

$21.00

Service Code	HCPCS 82746
Hospital Charge Code	4082746
Hospital Revenue Code	301
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

FOLATE (002014)

Facility

$21.00

Service Code	HCPCS 82746
Hospital Charge Code	4082746
Hospital Revenue Code	301
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

FOLATE ASSAY

Facility

$117.00

Hospital Charge Code	90197098
Hospital Revenue Code	270
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare	$105.30
Rate for Payer: BCBS MT CHIP	$105.30
Rate for Payer: BCBS MT Closed Plan Network	$111.15
Rate for Payer: BCBS MT HealthLink	$105.30
Rate for Payer: BCBS MT Medicare	$105.30
Rate for Payer: BCBS MT POS	$111.15
Rate for Payer: BCBS MT Traditional	$117.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cigna Commercial	$111.15
Rate for Payer: Cigna Medicare	$105.30
Rate for Payer: Medicaid All Medicaid	$107.64
Rate for Payer: Medicare All Medicare	$81.90
Rate for Payer: Monida Allegiance	$111.15
Rate for Payer: Monida First Choice Health	$113.49
Rate for Payer: Monida Montana Health Co-op	$111.15
Rate for Payer: Monida PacificSource	$111.15

FOLATE ASSAY

Facility

$117.00

Hospital Charge Code	90197098
Hospital Revenue Code	270
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$117.00
Rate for Payer: Aetna Commercial	$111.15
Rate for Payer: Aetna Medicare	$105.30
Rate for Payer: BCBS MT CHIP	$105.30
Rate for Payer: BCBS MT Closed Plan Network	$111.15
Rate for Payer: BCBS MT HealthLink	$105.30
Rate for Payer: BCBS MT Medicare	$105.30
Rate for Payer: BCBS MT POS	$111.15
Rate for Payer: BCBS MT Traditional	$117.00
Rate for Payer: Cash Price	$105.30
Rate for Payer: Cigna Commercial	$111.15
Rate for Payer: Cigna Medicare	$105.30
Rate for Payer: Medicaid All Medicaid	$107.64
Rate for Payer: Medicare All Medicare	$81.90
Rate for Payer: Monida Allegiance	$111.15
Rate for Payer: Monida First Choice Health	$113.49
Rate for Payer: Monida Montana Health Co-op	$111.15
Rate for Payer: Monida PacificSource	$111.15

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

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

FOSPHENYTOIN INJ [50 MG PE/1 ML] 2ML

Facility

$57.00

Service Code	HCPCS Q2009
Hospital Charge Code	3000577
Hospital Revenue Code	250
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

FOSPHENYTOIN INJ [50 MG PE/1 ML] 2ML

Facility

$57.00

Service Code	HCPCS Q2009
Hospital Charge Code	3000577
Hospital Revenue Code	250
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

FOX SPLINT (CARDBOARD) 12''

Facility

$24.00

Hospital Charge Code	80040158
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

FOX SPLINT (CARDBOARD) 12''

Facility

$24.00

Hospital Charge Code	80040158
Hospital Revenue Code	270
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

Know your out-of-pocket cost for care.

All Charges