Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAB VIPER VENOM PROTHROMBIN TIME

Facility

$64.00

Service Code	CPT 85612
Hospital Charge Code	4085612
Hospital Revenue Code	300
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

LAB VIPER VENOM PROTHROMBIN TIME

Facility

$64.00

Service Code	CPT 85612
Hospital Charge Code	4085612
Hospital Revenue Code	300
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

LAB VIRUS/ANY CULTURE

Facility

$156.00

Service Code	CPT 87252
Hospital Charge Code	4087252
Hospital Revenue Code	306
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare	$140.40
Rate for Payer: BCBS MT CHIP	$140.40
Rate for Payer: BCBS MT Closed Plan Network	$148.20
Rate for Payer: BCBS MT HealthLink	$140.40
Rate for Payer: BCBS MT Medicare	$140.40
Rate for Payer: BCBS MT POS	$148.20
Rate for Payer: BCBS MT Traditional	$156.00
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cigna Commercial	$148.20
Rate for Payer: Cigna Medicare	$140.40
Rate for Payer: Medicaid All Medicaid	$143.52
Rate for Payer: Medicare All Medicare	$109.20
Rate for Payer: Monida Allegiance	$148.20
Rate for Payer: Monida First Choice Health	$151.32
Rate for Payer: Monida Montana Health Co-op	$148.20
Rate for Payer: Monida PacificSource	$148.20

LAB VIRUS/ANY CULTURE

Facility

$156.00

Service Code	CPT 87252
Hospital Charge Code	4087252
Hospital Revenue Code	306
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$148.20
Rate for Payer: Aetna Medicare	$140.40
Rate for Payer: BCBS MT CHIP	$140.40
Rate for Payer: BCBS MT Closed Plan Network	$148.20
Rate for Payer: BCBS MT HealthLink	$140.40
Rate for Payer: BCBS MT Medicare	$140.40
Rate for Payer: BCBS MT POS	$148.20
Rate for Payer: BCBS MT Traditional	$156.00
Rate for Payer: Cash Price	$140.40
Rate for Payer: Cigna Commercial	$148.20
Rate for Payer: Cigna Medicare	$140.40
Rate for Payer: Medicaid All Medicaid	$143.52
Rate for Payer: Medicare All Medicare	$109.20
Rate for Payer: Monida Allegiance	$148.20
Rate for Payer: Monida First Choice Health	$151.32
Rate for Payer: Monida Montana Health Co-op	$148.20
Rate for Payer: Monida PacificSource	$148.20

LAB VMA

Facility

$135.00

Service Code	CPT 84585
Hospital Charge Code	4084585
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

LAB VMA

Facility

$135.00

Service Code	CPT 84585
Hospital Charge Code	4084585
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

LAB VWF ACTIVITY

Facility

$373.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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

$70.00

Service Code	CPT 86789
Hospital Charge Code	4086789
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

LAB WEST NILE VIRUS IGG (SERUM)

Facility

$70.00

Service Code	CPT 86789
Hospital Charge Code	4086789
Hospital Revenue Code	302
Min. Negotiated Rate	$49.00
Max. Negotiated Rate	$70.00
Rate for Payer: Aetna Commercial	$66.50
Rate for Payer: Aetna Medicare	$63.00
Rate for Payer: BCBS MT CHIP	$63.00
Rate for Payer: BCBS MT Closed Plan Network	$66.50
Rate for Payer: BCBS MT HealthLink	$63.00
Rate for Payer: BCBS MT Medicare	$63.00
Rate for Payer: BCBS MT POS	$66.50
Rate for Payer: BCBS MT Traditional	$70.00
Rate for Payer: Cash Price	$63.00
Rate for Payer: Cigna Commercial	$66.50
Rate for Payer: Cigna Medicare	$63.00
Rate for Payer: Medicaid All Medicaid	$64.40
Rate for Payer: Medicare All Medicare	$49.00
Rate for Payer: Monida Allegiance	$66.50
Rate for Payer: Monida First Choice Health	$67.90
Rate for Payer: Monida Montana Health Co-op	$66.50
Rate for Payer: Monida PacificSource	$66.50

LAB WEST NILE VIRUS IGM (SERUM)

Facility

$68.00

Service Code	CPT 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	CPT 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

LACOSAMIDE

Facility

$278.00

Service Code	CPT 80235
Hospital Charge Code	4087944
Hospital Revenue Code	300
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

LACOSAMIDE

Facility

$278.00

Service Code	CPT 80235
Hospital Charge Code	4087944
Hospital Revenue Code	300
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

LAC REPAIR CMPLX 2.6<7.5CM

Facility

$776.00

Service Code	CPT 13101
Hospital Charge Code	8013101
Hospital Revenue Code	521
Min. Negotiated Rate	$543.20
Max. Negotiated Rate	$776.00
Rate for Payer: Aetna Commercial	$737.20
Rate for Payer: Aetna Medicare	$698.40
Rate for Payer: BCBS MT CHIP	$698.40
Rate for Payer: BCBS MT Closed Plan Network	$737.20
Rate for Payer: BCBS MT HealthLink	$698.40
Rate for Payer: BCBS MT Medicare	$698.40
Rate for Payer: BCBS MT POS	$737.20
Rate for Payer: BCBS MT Traditional	$776.00
Rate for Payer: Cash Price	$698.40
Rate for Payer: Cigna Commercial	$737.20
Rate for Payer: Cigna Medicare	$698.40
Rate for Payer: Medicaid All Medicaid	$713.92
Rate for Payer: Medicare All Medicare	$543.20
Rate for Payer: Monida Allegiance	$737.20
Rate for Payer: Monida First Choice Health	$752.72
Rate for Payer: Monida Montana Health Co-op	$737.20
Rate for Payer: Monida PacificSource	$737.20

LAC REPAIR CMPLX 2.6<7.5CM

Facility

$776.00

Service Code	CPT 13101
Hospital Charge Code	8013101
Hospital Revenue Code	521
Min. Negotiated Rate	$543.20
Max. Negotiated Rate	$776.00
Rate for Payer: Aetna Commercial	$737.20
Rate for Payer: Aetna Medicare	$698.40
Rate for Payer: BCBS MT CHIP	$698.40
Rate for Payer: BCBS MT Closed Plan Network	$737.20
Rate for Payer: BCBS MT HealthLink	$698.40
Rate for Payer: BCBS MT Medicare	$698.40
Rate for Payer: BCBS MT POS	$737.20
Rate for Payer: BCBS MT Traditional	$776.00
Rate for Payer: Cash Price	$698.40
Rate for Payer: Cigna Commercial	$737.20
Rate for Payer: Cigna Medicare	$698.40
Rate for Payer: Medicaid All Medicaid	$713.92
Rate for Payer: Medicare All Medicare	$543.20
Rate for Payer: Monida Allegiance	$737.20
Rate for Payer: Monida First Choice Health	$752.72
Rate for Payer: Monida Montana Health Co-op	$737.20
Rate for Payer: Monida PacificSource	$737.20

LAC REPAIR COMP 2.6-7.5CM

Facility

$899.00

Service Code	CPT 13121
Hospital Charge Code	8013121
Hospital Revenue Code	521
Min. Negotiated Rate	$629.30
Max. Negotiated Rate	$899.00
Rate for Payer: Aetna Commercial	$854.05
Rate for Payer: Aetna Medicare	$809.10
Rate for Payer: BCBS MT CHIP	$809.10
Rate for Payer: BCBS MT Closed Plan Network	$854.05
Rate for Payer: BCBS MT HealthLink	$809.10
Rate for Payer: BCBS MT Medicare	$809.10
Rate for Payer: BCBS MT POS	$854.05
Rate for Payer: BCBS MT Traditional	$899.00
Rate for Payer: Cash Price	$809.10
Rate for Payer: Cigna Commercial	$854.05
Rate for Payer: Cigna Medicare	$809.10
Rate for Payer: Medicaid All Medicaid	$827.08
Rate for Payer: Medicare All Medicare	$629.30
Rate for Payer: Monida Allegiance	$854.05
Rate for Payer: Monida First Choice Health	$872.03
Rate for Payer: Monida Montana Health Co-op	$854.05
Rate for Payer: Monida PacificSource	$854.05

LAC REPAIR COMP 2.6-7.5CM

Facility

$899.00

Service Code	CPT 13121
Hospital Charge Code	8013121
Hospital Revenue Code	521
Min. Negotiated Rate	$629.30
Max. Negotiated Rate	$899.00
Rate for Payer: Aetna Commercial	$854.05
Rate for Payer: Aetna Medicare	$809.10
Rate for Payer: BCBS MT CHIP	$809.10
Rate for Payer: BCBS MT Closed Plan Network	$854.05
Rate for Payer: BCBS MT HealthLink	$809.10
Rate for Payer: BCBS MT Medicare	$809.10
Rate for Payer: BCBS MT POS	$854.05
Rate for Payer: BCBS MT Traditional	$899.00
Rate for Payer: Cash Price	$809.10
Rate for Payer: Cigna Commercial	$854.05
Rate for Payer: Cigna Medicare	$809.10
Rate for Payer: Medicaid All Medicaid	$827.08
Rate for Payer: Medicare All Medicare	$629.30
Rate for Payer: Monida Allegiance	$854.05
Rate for Payer: Monida First Choice Health	$872.03
Rate for Payer: Monida Montana Health Co-op	$854.05
Rate for Payer: Monida PacificSource	$854.05

LAC REPAIR COMP ADD SCALP/ARM/LEGS

Facility

$290.00

Service Code	CPT 13122
Hospital Charge Code	8013122
Hospital Revenue Code	521
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

LAC REPAIR COMP ADD SCALP/ARM/LEGS

Facility

$290.00

Service Code	CPT 13122
Hospital Charge Code	8013122
Hospital Revenue Code	521
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

LAC REPAIR COMPLEXFC/HND/FT ADD ON =<5CM

Facility

$572.00

Service Code	CPT 13133
Hospital Charge Code	8013133
Hospital Revenue Code	521
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

LAC REPAIR COMPLEXFC/HND/FT ADD ON =<5CM

Facility

$572.00

Service Code	CPT 13133
Hospital Charge Code	8013133
Hospital Revenue Code	521
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

LAC REPAIR COMPLEX FC/HN/FT 2.6-7.5CM

Facility

$981.00

Service Code	CPT 13132
Hospital Charge Code	8013132
Hospital Revenue Code	521
Min. Negotiated Rate	$686.70
Max. Negotiated Rate	$981.00
Rate for Payer: Aetna Commercial	$931.95
Rate for Payer: Aetna Medicare	$882.90
Rate for Payer: BCBS MT CHIP	$882.90
Rate for Payer: BCBS MT Closed Plan Network	$931.95
Rate for Payer: BCBS MT HealthLink	$882.90
Rate for Payer: BCBS MT Medicare	$882.90
Rate for Payer: BCBS MT POS	$931.95
Rate for Payer: BCBS MT Traditional	$981.00
Rate for Payer: Cash Price	$882.90
Rate for Payer: Cigna Commercial	$931.95
Rate for Payer: Cigna Medicare	$882.90
Rate for Payer: Medicaid All Medicaid	$902.52
Rate for Payer: Medicare All Medicare	$686.70
Rate for Payer: Monida Allegiance	$931.95
Rate for Payer: Monida First Choice Health	$951.57
Rate for Payer: Monida Montana Health Co-op	$931.95
Rate for Payer: Monida PacificSource	$931.95

Know your out-of-pocket cost for care.

All Charges