Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAMOTRIGINE ER [50 MG] TAB NF

Facility

$42.00

Service Code	HCPCS J8499
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	HCPCS J8499
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

LAMOTRIGINE TAB [100 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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

LAMOTRIGINE TAB [150 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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 TAB [150 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
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 TAB [200 MG] NF

Facility

$19.00

Service Code	HCPCS J8499
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 TAB [200 MG] NF

Facility

$19.00

Service Code	HCPCS J8499
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 TAB [25 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000268
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 TAB [25 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000268
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

LATANOPROST OPTH [0.005%]

Facility

$319.00

Service Code	HCPCS J3490
Hospital Charge Code	3000269
Hospital Revenue Code	250
Min. Negotiated Rate	$223.30
Max. Negotiated Rate	$319.00
Rate for Payer: Aetna Commercial	$303.05
Rate for Payer: Aetna Medicare	$287.10
Rate for Payer: BCBS MT CHIP	$287.10
Rate for Payer: BCBS MT Closed Plan Network	$303.05
Rate for Payer: BCBS MT HealthLink	$287.10
Rate for Payer: BCBS MT Medicare	$287.10
Rate for Payer: BCBS MT POS	$303.05
Rate for Payer: BCBS MT Traditional	$319.00
Rate for Payer: Cash Price	$287.10
Rate for Payer: Cigna Commercial	$303.05
Rate for Payer: Cigna Medicare	$287.10
Rate for Payer: Medicaid All Medicaid	$293.48
Rate for Payer: Medicare All Medicare	$223.30
Rate for Payer: Monida Allegiance	$303.05
Rate for Payer: Monida First Choice Health	$309.43
Rate for Payer: Monida Montana Health Co-op	$303.05
Rate for Payer: Monida PacificSource	$303.05

LATANOPROST OPTH [0.005%]

Facility

$319.00

Service Code	HCPCS J3490
Hospital Charge Code	3000269
Hospital Revenue Code	250
Min. Negotiated Rate	$223.30
Max. Negotiated Rate	$319.00
Rate for Payer: Aetna Commercial	$303.05
Rate for Payer: Aetna Medicare	$287.10
Rate for Payer: BCBS MT CHIP	$287.10
Rate for Payer: BCBS MT Closed Plan Network	$303.05
Rate for Payer: BCBS MT HealthLink	$287.10
Rate for Payer: BCBS MT Medicare	$287.10
Rate for Payer: BCBS MT POS	$303.05
Rate for Payer: BCBS MT Traditional	$319.00
Rate for Payer: Cash Price	$287.10
Rate for Payer: Cigna Commercial	$303.05
Rate for Payer: Cigna Medicare	$287.10
Rate for Payer: Medicaid All Medicaid	$293.48
Rate for Payer: Medicare All Medicare	$223.30
Rate for Payer: Monida Allegiance	$303.05
Rate for Payer: Monida First Choice Health	$309.43
Rate for Payer: Monida Montana Health Co-op	$303.05
Rate for Payer: Monida PacificSource	$303.05

LDH (001115)

Facility

$59.00

Service Code	CPT 83615
Hospital Charge Code	4083615
Hospital Revenue Code	301
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

LDH (001115)

Facility

$59.00

Service Code	CPT 83615
Hospital Charge Code	4083615
Hospital Revenue Code	301
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$59.00
Rate for Payer: Aetna Commercial	$56.05
Rate for Payer: Aetna Medicare	$53.10
Rate for Payer: BCBS MT CHIP	$53.10
Rate for Payer: BCBS MT Closed Plan Network	$56.05
Rate for Payer: BCBS MT HealthLink	$53.10
Rate for Payer: BCBS MT Medicare	$53.10
Rate for Payer: BCBS MT POS	$56.05
Rate for Payer: BCBS MT Traditional	$59.00
Rate for Payer: Cash Price	$53.10
Rate for Payer: Cigna Commercial	$56.05
Rate for Payer: Cigna Medicare	$53.10
Rate for Payer: Medicaid All Medicaid	$54.28
Rate for Payer: Medicare All Medicare	$41.30
Rate for Payer: Monida Allegiance	$56.05
Rate for Payer: Monida First Choice Health	$57.23
Rate for Payer: Monida Montana Health Co-op	$56.05
Rate for Payer: Monida PacificSource	$56.05

LDL CHOLESTEROL, DIRECT (120295)

Facility

$64.00

Service Code	CPT 83721
Hospital Charge Code	4083721
Hospital Revenue Code	301
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

LDL CHOLESTEROL, DIRECT (120295)

Facility

$64.00

Service Code	CPT 83721
Hospital Charge Code	4083721
Hospital Revenue Code	301
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

LEAD, WHOLE BLOOD (007625)

Facility

$66.00

Service Code	CPT 83655
Hospital Charge Code	4083655
Hospital Revenue Code	300
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

LEAD, WHOLE BLOOD (007625)

Facility

$66.00

Service Code	CPT 83655
Hospital Charge Code	4083655
Hospital Revenue Code	300
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

LEFLUNOMIDE TAB [10 MG] NF

Facility

$20.00

Service Code	HCPCS J8499
Hospital Charge Code	3000594
Hospital Revenue Code	250
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

LEFLUNOMIDE TAB [10 MG] NF

Facility

$20.00

Service Code	HCPCS J8499
Hospital Charge Code	3000594
Hospital Revenue Code	250
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

LEG BAG EXTENSION TUBE

Facility

$12.00

Hospital Charge Code	80040167
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

LEG BAG EXTENSION TUBE

Facility

$12.00

Hospital Charge Code	80040167
Hospital Revenue Code	270
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: BCBS MT CHIP	$10.80
Rate for Payer: BCBS MT Closed Plan Network	$11.40
Rate for Payer: BCBS MT HealthLink	$10.80
Rate for Payer: BCBS MT Medicare	$10.80
Rate for Payer: BCBS MT POS	$11.40
Rate for Payer: BCBS MT Traditional	$12.00
Rate for Payer: Cash Price	$10.80
Rate for Payer: Cigna Commercial	$11.40
Rate for Payer: Cigna Medicare	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

LEGIONELLA AG RANDOM URINE

Facility

$87.00

Service Code	CPT 87899
Hospital Charge Code	4088014
Hospital Revenue Code	302
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

LEGIONELLA AG RANDOM URINE

Facility

$87.00

Service Code	CPT 87899
Hospital Charge Code	4088014
Hospital Revenue Code	302
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

LEMON-GLYC SWABS

Facility

$4.00

Hospital Charge Code	80030185
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

LEMON-GLYC SWABS

Facility

$4.00

Hospital Charge Code	80030185
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

Know your out-of-pocket cost for care.

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