Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

FLUOROCELL RET

Facility

$286.10

Hospital Charge Code	90197170
Hospital Revenue Code	270
Min. Negotiated Rate	$200.27
Max. Negotiated Rate	$286.10
Rate for Payer: Aetna Commercial	$271.80
Rate for Payer: Aetna Medicare	$257.49
Rate for Payer: BCBS MT CHIP	$257.49
Rate for Payer: BCBS MT Closed Plan Network	$271.80
Rate for Payer: BCBS MT HealthLink	$257.49
Rate for Payer: BCBS MT Medicare	$257.49
Rate for Payer: BCBS MT POS	$271.80
Rate for Payer: BCBS MT Traditional	$286.10
Rate for Payer: Cash Price	$257.49
Rate for Payer: Cigna Commercial	$271.80
Rate for Payer: Cigna Medicare	$257.49
Rate for Payer: Medicaid All Medicaid	$263.21
Rate for Payer: Medicare All Medicare	$200.27
Rate for Payer: Monida Allegiance	$271.80
Rate for Payer: Monida First Choice Health	$277.52
Rate for Payer: Monida Montana Health Co-op	$271.80
Rate for Payer: Monida PacificSource	$271.80

FLUOROCELL WDF

Facility

$437.91

Hospital Charge Code	90197169
Hospital Revenue Code	270
Min. Negotiated Rate	$306.54
Max. Negotiated Rate	$437.91
Rate for Payer: Aetna Commercial	$416.01
Rate for Payer: Aetna Medicare	$394.12
Rate for Payer: BCBS MT CHIP	$394.12
Rate for Payer: BCBS MT Closed Plan Network	$416.01
Rate for Payer: BCBS MT HealthLink	$394.12
Rate for Payer: BCBS MT Medicare	$394.12
Rate for Payer: BCBS MT POS	$416.01
Rate for Payer: BCBS MT Traditional	$437.91
Rate for Payer: Cash Price	$394.12
Rate for Payer: Cigna Commercial	$416.01
Rate for Payer: Cigna Medicare	$394.12
Rate for Payer: Medicaid All Medicaid	$402.88
Rate for Payer: Medicare All Medicare	$306.54
Rate for Payer: Monida Allegiance	$416.01
Rate for Payer: Monida First Choice Health	$424.77
Rate for Payer: Monida Montana Health Co-op	$416.01
Rate for Payer: Monida PacificSource	$416.01

FLUOROCELL WDF

Facility

$437.91

Hospital Charge Code	90197169
Hospital Revenue Code	270
Min. Negotiated Rate	$306.54
Max. Negotiated Rate	$437.91
Rate for Payer: Aetna Commercial	$416.01
Rate for Payer: Aetna Medicare	$394.12
Rate for Payer: BCBS MT CHIP	$394.12
Rate for Payer: BCBS MT Closed Plan Network	$416.01
Rate for Payer: BCBS MT HealthLink	$394.12
Rate for Payer: BCBS MT Medicare	$394.12
Rate for Payer: BCBS MT POS	$416.01
Rate for Payer: BCBS MT Traditional	$437.91
Rate for Payer: Cash Price	$394.12
Rate for Payer: Cigna Commercial	$416.01
Rate for Payer: Cigna Medicare	$394.12
Rate for Payer: Medicaid All Medicaid	$402.88
Rate for Payer: Medicare All Medicare	$306.54
Rate for Payer: Monida Allegiance	$416.01
Rate for Payer: Monida First Choice Health	$424.77
Rate for Payer: Monida Montana Health Co-op	$416.01
Rate for Payer: Monida PacificSource	$416.01

FLUOROCELL WNR

Facility

$267.95

Hospital Charge Code	90197168
Hospital Revenue Code	270
Min. Negotiated Rate	$187.56
Max. Negotiated Rate	$267.95
Rate for Payer: Aetna Commercial	$254.55
Rate for Payer: Aetna Medicare	$241.16
Rate for Payer: BCBS MT CHIP	$241.16
Rate for Payer: BCBS MT Closed Plan Network	$254.55
Rate for Payer: BCBS MT HealthLink	$241.16
Rate for Payer: BCBS MT Medicare	$241.16
Rate for Payer: BCBS MT POS	$254.55
Rate for Payer: BCBS MT Traditional	$267.95
Rate for Payer: Cash Price	$241.16
Rate for Payer: Cigna Commercial	$254.55
Rate for Payer: Cigna Medicare	$241.16
Rate for Payer: Medicaid All Medicaid	$246.51
Rate for Payer: Medicare All Medicare	$187.56
Rate for Payer: Monida Allegiance	$254.55
Rate for Payer: Monida First Choice Health	$259.91
Rate for Payer: Monida Montana Health Co-op	$254.55
Rate for Payer: Monida PacificSource	$254.55

FLUOROCELL WNR

Facility

$267.95

Hospital Charge Code	90197168
Hospital Revenue Code	270
Min. Negotiated Rate	$187.56
Max. Negotiated Rate	$267.95
Rate for Payer: Aetna Commercial	$254.55
Rate for Payer: Aetna Medicare	$241.16
Rate for Payer: BCBS MT CHIP	$241.16
Rate for Payer: BCBS MT Closed Plan Network	$254.55
Rate for Payer: BCBS MT HealthLink	$241.16
Rate for Payer: BCBS MT Medicare	$241.16
Rate for Payer: BCBS MT POS	$254.55
Rate for Payer: BCBS MT Traditional	$267.95
Rate for Payer: Cash Price	$241.16
Rate for Payer: Cigna Commercial	$254.55
Rate for Payer: Cigna Medicare	$241.16
Rate for Payer: Medicaid All Medicaid	$246.51
Rate for Payer: Medicare All Medicare	$187.56
Rate for Payer: Monida Allegiance	$254.55
Rate for Payer: Monida First Choice Health	$259.91
Rate for Payer: Monida Montana Health Co-op	$254.55
Rate for Payer: Monida PacificSource	$254.55

FLUOXETINE CAP [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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 J8499
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 J8499
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 J8499
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

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]NF

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]NF

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

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

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 TAB [50 MG] NF

Facility

$9.00

Service Code	HCPCS J8499
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 TAB [50 MG] NF

Facility

$9.00

Service Code	HCPCS J8499
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 TAB [100 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007710
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

FLUVOXAMINE TAB [100 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007710
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