Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAB URINE UREA

Facility

$57.00

Service Code	CPT 84540
Hospital Charge Code	4084540
Hospital Revenue Code	301
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

LAB VAP CHOLESTEROL PANEL

Facility

$62.00

Service Code	CPT 83701
Hospital Charge Code	4083701
Hospital Revenue Code	301
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

LAB VAP CHOLESTEROL PANEL

Facility

$62.00

Service Code	CPT 83701
Hospital Charge Code	4083701
Hospital Revenue Code	301
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$62.00
Rate for Payer: Aetna Commercial	$58.90
Rate for Payer: Aetna Medicare	$55.80
Rate for Payer: BCBS MT CHIP	$55.80
Rate for Payer: BCBS MT Closed Plan Network	$58.90
Rate for Payer: BCBS MT HealthLink	$55.80
Rate for Payer: BCBS MT Medicare	$55.80
Rate for Payer: BCBS MT POS	$58.90
Rate for Payer: BCBS MT Traditional	$62.00
Rate for Payer: Cash Price	$55.80
Rate for Payer: Cigna Commercial	$58.90
Rate for Payer: Cigna Medicare	$55.80
Rate for Payer: Medicaid All Medicaid	$57.04
Rate for Payer: Medicare All Medicare	$43.40
Rate for Payer: Monida Allegiance	$58.90
Rate for Payer: Monida First Choice Health	$60.14
Rate for Payer: Monida Montana Health Co-op	$58.90
Rate for Payer: Monida PacificSource	$58.90

LAB VENIPUNCTURE

Facility

$27.00

Service Code	CPT 36415
Hospital Charge Code	4090086
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

LAB VENIPUNCTURE

Facility

$27.00

Service Code	CPT 36415
Hospital Charge Code	4090086
Hospital Revenue Code	300
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

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

$210.00

Service Code	CPT 85397
Hospital Charge Code	4000055
Hospital Revenue Code	300
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare	$189.00
Rate for Payer: BCBS MT CHIP	$189.00
Rate for Payer: BCBS MT Closed Plan Network	$199.50
Rate for Payer: BCBS MT HealthLink	$189.00
Rate for Payer: BCBS MT Medicare	$189.00
Rate for Payer: BCBS MT POS	$199.50
Rate for Payer: BCBS MT Traditional	$210.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial	$199.50
Rate for Payer: Cigna Medicare	$189.00
Rate for Payer: Medicaid All Medicaid	$193.20
Rate for Payer: Medicare All Medicare	$147.00
Rate for Payer: Monida Allegiance	$199.50
Rate for Payer: Monida First Choice Health	$203.70
Rate for Payer: Monida Montana Health Co-op	$199.50
Rate for Payer: Monida PacificSource	$199.50

LAB VWF ACTIVITY

Facility

$210.00

Service Code	CPT 85397
Hospital Charge Code	4000055
Hospital Revenue Code	300
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare	$189.00
Rate for Payer: BCBS MT CHIP	$189.00
Rate for Payer: BCBS MT Closed Plan Network	$199.50
Rate for Payer: BCBS MT HealthLink	$189.00
Rate for Payer: BCBS MT Medicare	$189.00
Rate for Payer: BCBS MT POS	$199.50
Rate for Payer: BCBS MT Traditional	$210.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial	$199.50
Rate for Payer: Cigna Medicare	$189.00
Rate for Payer: Medicaid All Medicaid	$193.20
Rate for Payer: Medicare All Medicare	$147.00
Rate for Payer: Monida Allegiance	$199.50
Rate for Payer: Monida First Choice Health	$203.70
Rate for Payer: Monida Montana Health Co-op	$199.50
Rate for Payer: Monida PacificSource	$199.50

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

LACOSAMIDE TAB [200 MG] NF

Facility

$79.00

Service Code	HCPCS J8499
Hospital Charge Code	3007747
Hospital Revenue Code	250
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

LACOSAMIDE TAB [200 MG] NF

Facility

$79.00

Service Code	HCPCS J8499
Hospital Charge Code	3007747
Hospital Revenue Code	250
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

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

Know your out-of-pocket cost for care.

All Charges