Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAB VWF ACTIVITY

Facility

$373.00

Service Code	HCPCS 85397
Hospital Charge Code	4000055
Hospital Revenue Code	300
Min. Negotiated Rate	$261.10
Max. Negotiated Rate	$373.00
Rate for Payer: Aetna Commercial	$354.35
Rate for Payer: Aetna Medicare	$335.70
Rate for Payer: BCBS MT CHIP	$335.70
Rate for Payer: BCBS MT Closed Plan Network	$354.35
Rate for Payer: BCBS MT HealthLink	$335.70
Rate for Payer: BCBS MT Medicare	$335.70
Rate for Payer: BCBS MT POS	$354.35
Rate for Payer: BCBS MT Traditional	$373.00
Rate for Payer: Cash Price	$335.70
Rate for Payer: Cigna Commercial	$354.35
Rate for Payer: Cigna Medicare	$335.70
Rate for Payer: Medicaid All Medicaid	$343.16
Rate for Payer: Medicare All Medicare	$261.10
Rate for Payer: Monida Allegiance	$354.35
Rate for Payer: Monida First Choice Health	$361.81
Rate for Payer: Monida Montana Health Co-op	$354.35
Rate for Payer: Monida PacificSource	$354.35

LAB VWF ACTIVITY

Facility

$373.00

Service Code	HCPCS 85397
Hospital Charge Code	4000055
Hospital Revenue Code	300
Min. Negotiated Rate	$261.10
Max. Negotiated Rate	$373.00
Rate for Payer: Aetna Commercial	$354.35
Rate for Payer: Aetna Medicare	$335.70
Rate for Payer: BCBS MT CHIP	$335.70
Rate for Payer: BCBS MT Closed Plan Network	$354.35
Rate for Payer: BCBS MT HealthLink	$335.70
Rate for Payer: BCBS MT Medicare	$335.70
Rate for Payer: BCBS MT POS	$354.35
Rate for Payer: BCBS MT Traditional	$373.00
Rate for Payer: Cash Price	$335.70
Rate for Payer: Cigna Commercial	$354.35
Rate for Payer: Cigna Medicare	$335.70
Rate for Payer: Medicaid All Medicaid	$343.16
Rate for Payer: Medicare All Medicare	$261.10
Rate for Payer: Monida Allegiance	$354.35
Rate for Payer: Monida First Choice Health	$361.81
Rate for Payer: Monida Montana Health Co-op	$354.35
Rate for Payer: Monida PacificSource	$354.35

LAB WBC ALKALINE PHOSPHATASE

Facility

$61.00

Service Code	HCPCS 85540
Hospital Charge Code	4085540
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$61.00
Rate for Payer: Aetna Commercial	$57.95
Rate for Payer: Aetna Medicare	$54.90
Rate for Payer: BCBS MT CHIP	$54.90
Rate for Payer: BCBS MT Closed Plan Network	$57.95
Rate for Payer: BCBS MT HealthLink	$54.90
Rate for Payer: BCBS MT Medicare	$54.90
Rate for Payer: BCBS MT POS	$57.95
Rate for Payer: BCBS MT Traditional	$61.00
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cigna Commercial	$57.95
Rate for Payer: Cigna Medicare	$54.90
Rate for Payer: Medicaid All Medicaid	$56.12
Rate for Payer: Medicare All Medicare	$42.70
Rate for Payer: Monida Allegiance	$57.95
Rate for Payer: Monida First Choice Health	$59.17
Rate for Payer: Monida Montana Health Co-op	$57.95
Rate for Payer: Monida PacificSource	$57.95

LAB WBC ALKALINE PHOSPHATASE

Facility

$61.00

Service Code	HCPCS 85540
Hospital Charge Code	4085540
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$61.00
Rate for Payer: Aetna Commercial	$57.95
Rate for Payer: Aetna Medicare	$54.90
Rate for Payer: BCBS MT CHIP	$54.90
Rate for Payer: BCBS MT Closed Plan Network	$57.95
Rate for Payer: BCBS MT HealthLink	$54.90
Rate for Payer: BCBS MT Medicare	$54.90
Rate for Payer: BCBS MT POS	$57.95
Rate for Payer: BCBS MT Traditional	$61.00
Rate for Payer: Cash Price	$54.90
Rate for Payer: Cigna Commercial	$57.95
Rate for Payer: Cigna Medicare	$54.90
Rate for Payer: Medicaid All Medicaid	$56.12
Rate for Payer: Medicare All Medicare	$42.70
Rate for Payer: Monida Allegiance	$57.95
Rate for Payer: Monida First Choice Health	$59.17
Rate for Payer: Monida Montana Health Co-op	$57.95
Rate for Payer: Monida PacificSource	$57.95

LAB WEST NILE VIRUS IGG (SERUM)

Facility

$68.00

Service Code	HCPCS 86789
Hospital Charge Code	4086789
Hospital Revenue Code	302
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

LAB WEST NILE VIRUS IGG (SERUM)

Facility

$68.00

Service Code	HCPCS 86789
Hospital Charge Code	4086789
Hospital Revenue Code	302
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

LAB WEST NILE VIRUS IGM (SERUM)

Facility

$68.00

Service Code	HCPCS 86788
Hospital Charge Code	4086788
Hospital Revenue Code	302
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

LAB WEST NILE VIRUS IGM (SERUM)

Facility

$68.00

Service Code	HCPCS 86788
Hospital Charge Code	4086788
Hospital Revenue Code	302
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

LACTASE CHEW TAB [9000 FCC UNITS]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000265
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

LACTASE CHEW TAB [9000 FCC UNITS]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000265
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

LACTIC ACID

Facility

$143.00

Service Code	HCPCS 83605
Hospital Charge Code	4083605
Hospital Revenue Code	300
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$135.85
Rate for Payer: Aetna Medicare	$128.70
Rate for Payer: BCBS MT CHIP	$128.70
Rate for Payer: BCBS MT Closed Plan Network	$135.85
Rate for Payer: BCBS MT HealthLink	$128.70
Rate for Payer: BCBS MT Medicare	$128.70
Rate for Payer: BCBS MT POS	$135.85
Rate for Payer: BCBS MT Traditional	$143.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cigna Commercial	$135.85
Rate for Payer: Cigna Medicare	$128.70
Rate for Payer: Medicaid All Medicaid	$131.56
Rate for Payer: Medicare All Medicare	$100.10
Rate for Payer: Monida Allegiance	$135.85
Rate for Payer: Monida First Choice Health	$138.71
Rate for Payer: Monida Montana Health Co-op	$135.85
Rate for Payer: Monida PacificSource	$135.85

LACTIC ACID

Facility

$143.00

Service Code	HCPCS 83605
Hospital Charge Code	4083605
Hospital Revenue Code	300
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$135.85
Rate for Payer: Aetna Medicare	$128.70
Rate for Payer: BCBS MT CHIP	$128.70
Rate for Payer: BCBS MT Closed Plan Network	$135.85
Rate for Payer: BCBS MT HealthLink	$128.70
Rate for Payer: BCBS MT Medicare	$128.70
Rate for Payer: BCBS MT POS	$135.85
Rate for Payer: BCBS MT Traditional	$143.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cigna Commercial	$135.85
Rate for Payer: Cigna Medicare	$128.70
Rate for Payer: Medicaid All Medicaid	$131.56
Rate for Payer: Medicare All Medicare	$100.10
Rate for Payer: Monida Allegiance	$135.85
Rate for Payer: Monida First Choice Health	$138.71
Rate for Payer: Monida Montana Health Co-op	$135.85
Rate for Payer: Monida PacificSource	$135.85

LACTOFERRIN, STOOL (123016)

Facility

$263.00

Service Code	HCPCS 83631
Hospital Charge Code	4083631
Hospital Revenue Code	300
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

LACTOFERRIN, STOOL (123016)

Facility

$263.00

Service Code	HCPCS 83631
Hospital Charge Code	4083631
Hospital Revenue Code	300
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

LACTULOSE LIQ [20 GM/30 ML] 30ML CUP

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000266
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

LACTULOSE LIQ [20 GM/30 ML] 30ML CUP

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000266
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

LAMOTRIGINE 150MG TAB-NF

Facility

$8.00

Service Code	NDC 60687069301
Hospital Charge Code	3007312
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

LAMOTRIGINE 150MG TAB-NF

Facility

$8.00

Service Code	NDC 60687069301
Hospital Charge Code	3007312
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

LAMOTRIGINE 200MG TAB-NF

Facility

$19.00

Service Code	HCPCS J3490
Hospital Charge Code	3000267
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

LAMOTRIGINE 200MG TAB-NF

Facility

$19.00

Service Code	HCPCS J3490
Hospital Charge Code	3000267
Hospital Revenue Code	250
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$19.00
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: BCBS MT CHIP	$17.10
Rate for Payer: BCBS MT Closed Plan Network	$18.05
Rate for Payer: BCBS MT HealthLink	$17.10
Rate for Payer: BCBS MT Medicare	$17.10
Rate for Payer: BCBS MT POS	$18.05
Rate for Payer: BCBS MT Traditional	$19.00
Rate for Payer: Cash Price	$17.10
Rate for Payer: Cigna Commercial	$18.05
Rate for Payer: Cigna Medicare	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

LAMOTRIGINE (716944)

Facility

$92.00

Service Code	HCPCS 80175
Hospital Charge Code	4080175
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

LAMOTRIGINE (716944)

Facility

$92.00

Service Code	HCPCS 80175
Hospital Charge Code	4080175
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

LAMOTRIGINE ER [50 MG] TAB NF

Facility

$42.00

Service Code	HCPCS J3490
Hospital Charge Code	3000548
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

LAMOTRIGINE ER [50 MG] TAB NF

Facility

$42.00

Service Code	HCPCS J3490
Hospital Charge Code	3000548
Hospital Revenue Code	250
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

LAMOTRIGINE TAB [100 MG] NF

Facility

$8.00

Service Code	NDC 68084031901
Hospital Charge Code	3007399
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

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