Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAC REPAIR INT N/H/F/XTG 7.6-12.5CM

Facility

$665.00

Service Code	CPT 12044
Hospital Charge Code	8012044
Hospital Revenue Code	521
Min. Negotiated Rate	$465.50
Max. Negotiated Rate	$665.00
Rate for Payer: Aetna Commercial	$631.75
Rate for Payer: Aetna Medicare	$598.50
Rate for Payer: BCBS MT CHIP	$598.50
Rate for Payer: BCBS MT Closed Plan Network	$631.75
Rate for Payer: BCBS MT HealthLink	$598.50
Rate for Payer: BCBS MT Medicare	$598.50
Rate for Payer: BCBS MT POS	$631.75
Rate for Payer: BCBS MT Traditional	$665.00
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cigna Commercial	$631.75
Rate for Payer: Cigna Medicare	$598.50
Rate for Payer: Medicaid All Medicaid	$611.80
Rate for Payer: Medicare All Medicare	$465.50
Rate for Payer: Monida Allegiance	$631.75
Rate for Payer: Monida First Choice Health	$645.05
Rate for Payer: Monida Montana Health Co-op	$631.75
Rate for Payer: Monida PacificSource	$631.75

LAC REPAIR INT S/A/T/E=<2.5CM

Facility

$590.00

Service Code	CPT 12031
Hospital Charge Code	8012031
Hospital Revenue Code	521
Min. Negotiated Rate	$413.00
Max. Negotiated Rate	$590.00
Rate for Payer: Aetna Commercial	$560.50
Rate for Payer: Aetna Medicare	$531.00
Rate for Payer: BCBS MT CHIP	$531.00
Rate for Payer: BCBS MT Closed Plan Network	$560.50
Rate for Payer: BCBS MT HealthLink	$531.00
Rate for Payer: BCBS MT Medicare	$531.00
Rate for Payer: BCBS MT POS	$560.50
Rate for Payer: BCBS MT Traditional	$590.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cigna Commercial	$560.50
Rate for Payer: Cigna Medicare	$531.00
Rate for Payer: Medicaid All Medicaid	$542.80
Rate for Payer: Medicare All Medicare	$413.00
Rate for Payer: Monida Allegiance	$560.50
Rate for Payer: Monida First Choice Health	$572.30
Rate for Payer: Monida Montana Health Co-op	$560.50
Rate for Payer: Monida PacificSource	$560.50

LAC REPAIR INT S/A/T/E=<2.5CM

Facility

$590.00

Service Code	CPT 12031
Hospital Charge Code	8012031
Hospital Revenue Code	521
Min. Negotiated Rate	$413.00
Max. Negotiated Rate	$590.00
Rate for Payer: Aetna Commercial	$560.50
Rate for Payer: Aetna Medicare	$531.00
Rate for Payer: BCBS MT CHIP	$531.00
Rate for Payer: BCBS MT Closed Plan Network	$560.50
Rate for Payer: BCBS MT HealthLink	$531.00
Rate for Payer: BCBS MT Medicare	$531.00
Rate for Payer: BCBS MT POS	$560.50
Rate for Payer: BCBS MT Traditional	$590.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cigna Commercial	$560.50
Rate for Payer: Cigna Medicare	$531.00
Rate for Payer: Medicaid All Medicaid	$542.80
Rate for Payer: Medicare All Medicare	$413.00
Rate for Payer: Monida Allegiance	$560.50
Rate for Payer: Monida First Choice Health	$572.30
Rate for Payer: Monida Montana Health Co-op	$560.50
Rate for Payer: Monida PacificSource	$560.50

LAC REPAIR INT S/A/T/E 7.6-12.5CM

Facility

$731.00

Service Code	CPT 12034
Hospital Charge Code	8012034
Hospital Revenue Code	521
Min. Negotiated Rate	$511.70
Max. Negotiated Rate	$731.00
Rate for Payer: Aetna Commercial	$694.45
Rate for Payer: Aetna Medicare	$657.90
Rate for Payer: BCBS MT CHIP	$657.90
Rate for Payer: BCBS MT Closed Plan Network	$694.45
Rate for Payer: BCBS MT HealthLink	$657.90
Rate for Payer: BCBS MT Medicare	$657.90
Rate for Payer: BCBS MT POS	$694.45
Rate for Payer: BCBS MT Traditional	$731.00
Rate for Payer: Cash Price	$657.90
Rate for Payer: Cigna Commercial	$694.45
Rate for Payer: Cigna Medicare	$657.90
Rate for Payer: Medicaid All Medicaid	$672.52
Rate for Payer: Medicare All Medicare	$511.70
Rate for Payer: Monida Allegiance	$694.45
Rate for Payer: Monida First Choice Health	$709.07
Rate for Payer: Monida Montana Health Co-op	$694.45
Rate for Payer: Monida PacificSource	$694.45

LAC REPAIR INT S/A/T/E 7.6-12.5CM

Facility

$731.00

Service Code	CPT 12034
Hospital Charge Code	8012034
Hospital Revenue Code	521
Min. Negotiated Rate	$511.70
Max. Negotiated Rate	$731.00
Rate for Payer: Aetna Commercial	$694.45
Rate for Payer: Aetna Medicare	$657.90
Rate for Payer: BCBS MT CHIP	$657.90
Rate for Payer: BCBS MT Closed Plan Network	$694.45
Rate for Payer: BCBS MT HealthLink	$657.90
Rate for Payer: BCBS MT Medicare	$657.90
Rate for Payer: BCBS MT POS	$694.45
Rate for Payer: BCBS MT Traditional	$731.00
Rate for Payer: Cash Price	$657.90
Rate for Payer: Cigna Commercial	$694.45
Rate for Payer: Cigna Medicare	$657.90
Rate for Payer: Medicaid All Medicaid	$672.52
Rate for Payer: Medicare All Medicare	$511.70
Rate for Payer: Monida Allegiance	$694.45
Rate for Payer: Monida First Choice Health	$709.07
Rate for Payer: Monida Montana Health Co-op	$694.45
Rate for Payer: Monida PacificSource	$694.45

LAC REPAIR SIMPLE=<2.5CM

Facility

$348.00

Service Code	CPT 12001
Hospital Charge Code	8012001
Hospital Revenue Code	521
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

LAC REPAIR SIMPLE=<2.5CM

Facility

$348.00

Service Code	CPT 12001
Hospital Charge Code	8012001
Hospital Revenue Code	521
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

LAC REPAIR SIMPLE 2.6CM-7.5CM

Facility

$358.00

Service Code	CPT 12002
Hospital Charge Code	8012002
Hospital Revenue Code	521
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

LAC REPAIR SIMPLE 2.6CM-7.5CM

Facility

$358.00

Service Code	CPT 12002
Hospital Charge Code	8012002
Hospital Revenue Code	521
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

LAC REPAIR SIMPLE >30 CM

Facility

$428.00

Service Code	CPT 12007
Hospital Charge Code	8012007
Hospital Revenue Code	521
Min. Negotiated Rate	$299.60
Max. Negotiated Rate	$428.00
Rate for Payer: Aetna Commercial	$406.60
Rate for Payer: Aetna Medicare	$385.20
Rate for Payer: BCBS MT CHIP	$385.20
Rate for Payer: BCBS MT Closed Plan Network	$406.60
Rate for Payer: BCBS MT HealthLink	$385.20
Rate for Payer: BCBS MT Medicare	$385.20
Rate for Payer: BCBS MT POS	$406.60
Rate for Payer: BCBS MT Traditional	$428.00
Rate for Payer: Cash Price	$385.20
Rate for Payer: Cigna Commercial	$406.60
Rate for Payer: Cigna Medicare	$385.20
Rate for Payer: Medicaid All Medicaid	$393.76
Rate for Payer: Medicare All Medicare	$299.60
Rate for Payer: Monida Allegiance	$406.60
Rate for Payer: Monida First Choice Health	$415.16
Rate for Payer: Monida Montana Health Co-op	$406.60
Rate for Payer: Monida PacificSource	$406.60

LAC REPAIR SIMPLE >30 CM

Facility

$428.00

Service Code	CPT 12007
Hospital Charge Code	8012007
Hospital Revenue Code	521
Min. Negotiated Rate	$299.60
Max. Negotiated Rate	$428.00
Rate for Payer: Aetna Commercial	$406.60
Rate for Payer: Aetna Medicare	$385.20
Rate for Payer: BCBS MT CHIP	$385.20
Rate for Payer: BCBS MT Closed Plan Network	$406.60
Rate for Payer: BCBS MT HealthLink	$385.20
Rate for Payer: BCBS MT Medicare	$385.20
Rate for Payer: BCBS MT POS	$406.60
Rate for Payer: BCBS MT Traditional	$428.00
Rate for Payer: Cash Price	$385.20
Rate for Payer: Cigna Commercial	$406.60
Rate for Payer: Cigna Medicare	$385.20
Rate for Payer: Medicaid All Medicaid	$393.76
Rate for Payer: Medicare All Medicare	$299.60
Rate for Payer: Monida Allegiance	$406.60
Rate for Payer: Monida First Choice Health	$415.16
Rate for Payer: Monida Montana Health Co-op	$406.60
Rate for Payer: Monida PacificSource	$406.60

LAC REPAIR SIMPLE 7.6-12.5CM

Facility

$376.00

Service Code	CPT 12004
Hospital Charge Code	8012004
Hospital Revenue Code	521
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

LAC REPAIR SIMPLE 7.6-12.5CM

Facility

$376.00

Service Code	CPT 12004
Hospital Charge Code	8012004
Hospital Revenue Code	521
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

LAC REPAIR SIMPLE FACIAL/EAR 2.6CM-5.0CM

Facility

$424.00

Service Code	CPT 12013
Hospital Charge Code	8012013
Hospital Revenue Code	521
Min. Negotiated Rate	$296.80
Max. Negotiated Rate	$424.00
Rate for Payer: Aetna Commercial	$402.80
Rate for Payer: Aetna Medicare	$381.60
Rate for Payer: BCBS MT CHIP	$381.60
Rate for Payer: BCBS MT Closed Plan Network	$402.80
Rate for Payer: BCBS MT HealthLink	$381.60
Rate for Payer: BCBS MT Medicare	$381.60
Rate for Payer: BCBS MT POS	$402.80
Rate for Payer: BCBS MT Traditional	$424.00
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cigna Commercial	$402.80
Rate for Payer: Cigna Medicare	$381.60
Rate for Payer: Medicaid All Medicaid	$390.08
Rate for Payer: Medicare All Medicare	$296.80
Rate for Payer: Monida Allegiance	$402.80
Rate for Payer: Monida First Choice Health	$411.28
Rate for Payer: Monida Montana Health Co-op	$402.80
Rate for Payer: Monida PacificSource	$402.80

LAC REPAIR SIMPLE FACIAL/EAR 2.6CM-5.0CM

Facility

$424.00

Service Code	CPT 12013
Hospital Charge Code	8012013
Hospital Revenue Code	521
Min. Negotiated Rate	$296.80
Max. Negotiated Rate	$424.00
Rate for Payer: Aetna Commercial	$402.80
Rate for Payer: Aetna Medicare	$381.60
Rate for Payer: BCBS MT CHIP	$381.60
Rate for Payer: BCBS MT Closed Plan Network	$402.80
Rate for Payer: BCBS MT HealthLink	$381.60
Rate for Payer: BCBS MT Medicare	$381.60
Rate for Payer: BCBS MT POS	$402.80
Rate for Payer: BCBS MT Traditional	$424.00
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cigna Commercial	$402.80
Rate for Payer: Cigna Medicare	$381.60
Rate for Payer: Medicaid All Medicaid	$390.08
Rate for Payer: Medicare All Medicare	$296.80
Rate for Payer: Monida Allegiance	$402.80
Rate for Payer: Monida First Choice Health	$411.28
Rate for Payer: Monida Montana Health Co-op	$402.80
Rate for Payer: Monida PacificSource	$402.80

LAC REPAIR SIMPLE FACIAL/EAR7.6CM-12.5CM

Facility

$510.00

Service Code	CPT 12015
Hospital Charge Code	8012015
Hospital Revenue Code	521
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

LAC REPAIR SIMPLE FACIAL/EAR7.6CM-12.5CM

Facility

$510.00

Service Code	CPT 12015
Hospital Charge Code	8012015
Hospital Revenue Code	521
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

LAC REPAIR SIMPLE FACIAL/EARS 5.1-7.5CM

Facility

$445.00

Service Code	CPT 12014
Hospital Charge Code	8012014
Hospital Revenue Code	521
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

LAC REPAIR SIMPLE FACIAL/EARS 5.1-7.5CM

Facility

$445.00

Service Code	CPT 12014
Hospital Charge Code	8012014
Hospital Revenue Code	521
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

LAC REPAIR SIMPLE OF FACE,EARS >2.5

Facility

$445.00

Service Code	CPT 12011
Hospital Charge Code	8012011
Hospital Revenue Code	521
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

LAC REPAIR SIMPLE OF FACE,EARS >2.5

Facility

$445.00

Service Code	CPT 12011
Hospital Charge Code	8012011
Hospital Revenue Code	521
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

LACTASE CHEW TAB [9000 FCC UNITS] NF

Facility

$5.00

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] NF

Facility

$5.00

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	CPT 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	CPT 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

Know your out-of-pocket cost for care.

All Charges