Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FENTANYL INJ [100 MCG/ 2 ML] 2ML SDV

Facility

$8.00

Service Code	HCPCS J3010
Hospital Charge Code	3000598
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

FENTANYL INJ [50 MCG/ML] 1ML

Facility

$8.00

Service Code	HCPCS J3010
Hospital Charge Code	3007342
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

FENTANYL INJ [50 MCG/ML] 1ML

Facility

$8.00

Service Code	HCPCS J3010
Hospital Charge Code	3007342
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

FENTANYL INJ [50 MCG/ML] 2ML VIAL

Facility

$26.00

Service Code	HCPCS J3010
Hospital Charge Code	3000175
Hospital Revenue Code	636
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

FENTANYL INJ [50 MCG/ML] 2ML VIAL

Facility

$26.00

Service Code	HCPCS J3010
Hospital Charge Code	3000175
Hospital Revenue Code	636
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

FENTANYL PATCH [12 MCG/HR]

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	3000176
Hospital Revenue Code	636
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

FENTANYL PATCH [12 MCG/HR]

Facility

$68.00

Service Code	HCPCS J3490
Hospital Charge Code	3000176
Hospital Revenue Code	636
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

FENTANYL PATCH [25 MCG/HR]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000177
Hospital Revenue Code	636
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

FENTANYL PATCH [25 MCG/HR]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000177
Hospital Revenue Code	636
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

FENTANYL QC

Facility

$55.46

Hospital Charge Code	90197172
Hospital Revenue Code	270
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$55.46
Rate for Payer: Aetna Commercial	$52.69
Rate for Payer: Aetna Medicare	$49.91
Rate for Payer: BCBS MT CHIP	$49.91
Rate for Payer: BCBS MT Closed Plan Network	$52.69
Rate for Payer: BCBS MT HealthLink	$49.91
Rate for Payer: BCBS MT Medicare	$49.91
Rate for Payer: BCBS MT POS	$52.69
Rate for Payer: BCBS MT Traditional	$55.46
Rate for Payer: Cash Price	$49.91
Rate for Payer: Cigna Commercial	$52.69
Rate for Payer: Cigna Medicare	$49.91
Rate for Payer: Medicaid All Medicaid	$51.02
Rate for Payer: Medicare All Medicare	$38.82
Rate for Payer: Monida Allegiance	$52.69
Rate for Payer: Monida First Choice Health	$53.80
Rate for Payer: Monida Montana Health Co-op	$52.69
Rate for Payer: Monida PacificSource	$52.69

FENTANYL QC

Facility

$55.46

Hospital Charge Code	90197172
Hospital Revenue Code	270
Min. Negotiated Rate	$38.82
Max. Negotiated Rate	$55.46
Rate for Payer: Aetna Commercial	$52.69
Rate for Payer: Aetna Medicare	$49.91
Rate for Payer: BCBS MT CHIP	$49.91
Rate for Payer: BCBS MT Closed Plan Network	$52.69
Rate for Payer: BCBS MT HealthLink	$49.91
Rate for Payer: BCBS MT Medicare	$49.91
Rate for Payer: BCBS MT POS	$52.69
Rate for Payer: BCBS MT Traditional	$55.46
Rate for Payer: Cash Price	$49.91
Rate for Payer: Cigna Commercial	$52.69
Rate for Payer: Cigna Medicare	$49.91
Rate for Payer: Medicaid All Medicaid	$51.02
Rate for Payer: Medicare All Medicare	$38.82
Rate for Payer: Monida Allegiance	$52.69
Rate for Payer: Monida First Choice Health	$53.80
Rate for Payer: Monida Montana Health Co-op	$52.69
Rate for Payer: Monida PacificSource	$52.69

FENTANYL SCREEN DAU KIT

Facility

$55.83

Hospital Charge Code	90197143
Hospital Revenue Code	270
Min. Negotiated Rate	$39.08
Max. Negotiated Rate	$55.83
Rate for Payer: Aetna Commercial	$53.04
Rate for Payer: Aetna Medicare	$50.25
Rate for Payer: BCBS MT CHIP	$50.25
Rate for Payer: BCBS MT Closed Plan Network	$53.04
Rate for Payer: BCBS MT HealthLink	$50.25
Rate for Payer: BCBS MT Medicare	$50.25
Rate for Payer: BCBS MT POS	$53.04
Rate for Payer: BCBS MT Traditional	$55.83
Rate for Payer: Cash Price	$50.25
Rate for Payer: Cigna Commercial	$53.04
Rate for Payer: Cigna Medicare	$50.25
Rate for Payer: Medicaid All Medicaid	$51.36
Rate for Payer: Medicare All Medicare	$39.08
Rate for Payer: Monida Allegiance	$53.04
Rate for Payer: Monida First Choice Health	$54.16
Rate for Payer: Monida Montana Health Co-op	$53.04
Rate for Payer: Monida PacificSource	$53.04

FENTANYL SCREEN DAU KIT

Facility

$55.83

Hospital Charge Code	90197143
Hospital Revenue Code	270
Min. Negotiated Rate	$39.08
Max. Negotiated Rate	$55.83
Rate for Payer: Aetna Commercial	$53.04
Rate for Payer: Aetna Medicare	$50.25
Rate for Payer: BCBS MT CHIP	$50.25
Rate for Payer: BCBS MT Closed Plan Network	$53.04
Rate for Payer: BCBS MT HealthLink	$50.25
Rate for Payer: BCBS MT Medicare	$50.25
Rate for Payer: BCBS MT POS	$53.04
Rate for Payer: BCBS MT Traditional	$55.83
Rate for Payer: Cash Price	$50.25
Rate for Payer: Cigna Commercial	$53.04
Rate for Payer: Cigna Medicare	$50.25
Rate for Payer: Medicaid All Medicaid	$51.36
Rate for Payer: Medicare All Medicare	$39.08
Rate for Payer: Monida Allegiance	$53.04
Rate for Payer: Monida First Choice Health	$54.16
Rate for Payer: Monida Montana Health Co-op	$53.04
Rate for Payer: Monida PacificSource	$53.04

FERRIC CARBOXYMALTOSE INJ [750MG/15ML]NF

Facility

$2,842.00

Service Code	HCPCS J1439
Hospital Charge Code	3007687
Hospital Revenue Code	250
Min. Negotiated Rate	$1,989.40
Max. Negotiated Rate	$2,842.00
Rate for Payer: Aetna Commercial	$2,699.90
Rate for Payer: Aetna Medicare	$2,557.80
Rate for Payer: BCBS MT CHIP	$2,557.80
Rate for Payer: BCBS MT Closed Plan Network	$2,699.90
Rate for Payer: BCBS MT HealthLink	$2,557.80
Rate for Payer: BCBS MT Medicare	$2,557.80
Rate for Payer: BCBS MT POS	$2,699.90
Rate for Payer: BCBS MT Traditional	$2,842.00
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Cigna Commercial	$2,699.90
Rate for Payer: Cigna Medicare	$2,557.80
Rate for Payer: Medicaid All Medicaid	$2,614.64
Rate for Payer: Medicare All Medicare	$1,989.40
Rate for Payer: Monida Allegiance	$2,699.90
Rate for Payer: Monida First Choice Health	$2,756.74
Rate for Payer: Monida Montana Health Co-op	$2,699.90
Rate for Payer: Monida PacificSource	$2,699.90

FERRIC CARBOXYMALTOSE INJ [750MG/15ML]NF

Facility

$2,842.00

Service Code	HCPCS J1439
Hospital Charge Code	3007687
Hospital Revenue Code	250
Min. Negotiated Rate	$1,989.40
Max. Negotiated Rate	$2,842.00
Rate for Payer: Aetna Commercial	$2,699.90
Rate for Payer: Aetna Medicare	$2,557.80
Rate for Payer: BCBS MT CHIP	$2,557.80
Rate for Payer: BCBS MT Closed Plan Network	$2,699.90
Rate for Payer: BCBS MT HealthLink	$2,557.80
Rate for Payer: BCBS MT Medicare	$2,557.80
Rate for Payer: BCBS MT POS	$2,699.90
Rate for Payer: BCBS MT Traditional	$2,842.00
Rate for Payer: Cash Price	$2,557.80
Rate for Payer: Cigna Commercial	$2,699.90
Rate for Payer: Cigna Medicare	$2,557.80
Rate for Payer: Medicaid All Medicaid	$2,614.64
Rate for Payer: Medicare All Medicare	$1,989.40
Rate for Payer: Monida Allegiance	$2,699.90
Rate for Payer: Monida First Choice Health	$2,756.74
Rate for Payer: Monida Montana Health Co-op	$2,699.90
Rate for Payer: Monida PacificSource	$2,699.90

FERRITIN (004598)

Facility

$58.00

Service Code	CPT 82728
Hospital Charge Code	4082728
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

FERRITIN (004598)

Facility

$58.00

Service Code	CPT 82728
Hospital Charge Code	4082728
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

FERRITIN ASSAY

Facility

$144.00

Hospital Charge Code	90197104
Hospital Revenue Code	270
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

FERRITIN ASSAY

Facility

$144.00

Hospital Charge Code	90197104
Hospital Revenue Code	270
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

FERROUS SULFATE TAB [325 MG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000178
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

FERROUS SULFATE TAB [325 MG]

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3000178
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

FEXOFENADINE TAB [180 MG] NF

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3007763
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

FEXOFENADINE TAB [180 MG] NF

Facility

$8.00

Service Code	HCPCS A9150
Hospital Charge Code	3007763
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

FIBRINOGEN (001610)

Facility

$69.00

Service Code	CPT 85384
Hospital Charge Code	4085384
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

FIBRINOGEN (001610)

Facility

$69.00

Service Code	CPT 85384
Hospital Charge Code	4085384
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

Know your out-of-pocket cost for care.

All Charges