Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

.FLOW CYTOMETRY, INTERPRETATION

Facility

$238.00

Service Code	CPT 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 TAB [100 MG] NF

Facility

$31.00

Service Code	HCPCS J8499
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	HCPCS J8499
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 J8499
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 J8499
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

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000183
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

FLUDROCORTISONE TAB [0.1 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000183
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

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

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 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

FLUOR TREP ANTIBODY FTA-ABS(MTPHL)

Facility

$150.00

Service Code	CPT 86780
Hospital Charge Code	4088147
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

FLUOR TREP ANTIBODY FTA-ABS(MTPHL)

Facility

$150.00

Service Code	CPT 86780
Hospital Charge Code	4088147
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$150.00
Rate for Payer: Aetna Commercial	$142.50
Rate for Payer: Aetna Medicare	$135.00
Rate for Payer: BCBS MT CHIP	$135.00
Rate for Payer: BCBS MT Closed Plan Network	$142.50
Rate for Payer: BCBS MT HealthLink	$135.00
Rate for Payer: BCBS MT Medicare	$135.00
Rate for Payer: BCBS MT POS	$142.50
Rate for Payer: BCBS MT Traditional	$150.00
Rate for Payer: Cash Price	$135.00
Rate for Payer: Cigna Commercial	$142.50
Rate for Payer: Cigna Medicare	$135.00
Rate for Payer: Medicaid All Medicaid	$138.00
Rate for Payer: Medicare All Medicare	$105.00
Rate for Payer: Monida Allegiance	$142.50
Rate for Payer: Monida First Choice Health	$145.50
Rate for Payer: Monida Montana Health Co-op	$142.50
Rate for Payer: Monida PacificSource	$142.50

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 J8499
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 J8499
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

Know your out-of-pocket cost for care.

All Charges