Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LACTOFERRIN, STOOL (123016)

Facility

$263.00

Service Code	CPT 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	CPT 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 J8499
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 J8499
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 (716944)

Facility

$92.00

Service Code	CPT 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	CPT 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 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 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

LANCET YELLOW MCKESSON 17 GAU

Facility

$13.85

Hospital Charge Code	90196595
Hospital Revenue Code	270
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$13.85
Rate for Payer: Aetna Commercial	$13.16
Rate for Payer: Aetna Medicare	$12.46
Rate for Payer: BCBS MT CHIP	$12.46
Rate for Payer: BCBS MT Closed Plan Network	$13.16
Rate for Payer: BCBS MT HealthLink	$12.46
Rate for Payer: BCBS MT Medicare	$12.46
Rate for Payer: BCBS MT POS	$13.16
Rate for Payer: BCBS MT Traditional	$13.85
Rate for Payer: Cash Price	$12.47
Rate for Payer: Cigna Commercial	$13.16
Rate for Payer: Cigna Medicare	$12.46
Rate for Payer: Medicaid All Medicaid	$12.74
Rate for Payer: Medicare All Medicare	$9.70
Rate for Payer: Monida Allegiance	$13.16
Rate for Payer: Monida First Choice Health	$13.43
Rate for Payer: Monida Montana Health Co-op	$13.16
Rate for Payer: Monida PacificSource	$13.16

LANCET YELLOW MCKESSON 17 GAU

Facility

$13.85

Hospital Charge Code	90196595
Hospital Revenue Code	270
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$13.85
Rate for Payer: Aetna Commercial	$13.16
Rate for Payer: Aetna Medicare	$12.46
Rate for Payer: BCBS MT CHIP	$12.46
Rate for Payer: BCBS MT Closed Plan Network	$13.16
Rate for Payer: BCBS MT HealthLink	$12.46
Rate for Payer: BCBS MT Medicare	$12.46
Rate for Payer: BCBS MT POS	$13.16
Rate for Payer: BCBS MT Traditional	$13.85
Rate for Payer: Cash Price	$12.47
Rate for Payer: Cigna Commercial	$13.16
Rate for Payer: Cigna Medicare	$12.46
Rate for Payer: Medicaid All Medicaid	$12.74
Rate for Payer: Medicare All Medicare	$9.70
Rate for Payer: Monida Allegiance	$13.16
Rate for Payer: Monida First Choice Health	$13.43
Rate for Payer: Monida Montana Health Co-op	$13.16
Rate for Payer: Monida PacificSource	$13.16

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

LAWYERS FEE

Facility

$3,000.00

Hospital Charge Code	90197112
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,850.00
Rate for Payer: Aetna Medicare	$2,700.00
Rate for Payer: BCBS MT CHIP	$2,700.00
Rate for Payer: BCBS MT Closed Plan Network	$2,850.00
Rate for Payer: BCBS MT HealthLink	$2,700.00
Rate for Payer: BCBS MT Medicare	$2,700.00
Rate for Payer: BCBS MT POS	$2,850.00
Rate for Payer: BCBS MT Traditional	$3,000.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Cigna Commercial	$2,850.00
Rate for Payer: Cigna Medicare	$2,700.00
Rate for Payer: Medicaid All Medicaid	$2,760.00
Rate for Payer: Medicare All Medicare	$2,100.00
Rate for Payer: Monida Allegiance	$2,850.00
Rate for Payer: Monida First Choice Health	$2,910.00
Rate for Payer: Monida Montana Health Co-op	$2,850.00
Rate for Payer: Monida PacificSource	$2,850.00

LAWYERS FEE

Facility

$3,000.00

Hospital Charge Code	90197112
Min. Negotiated Rate	$2,100.00
Max. Negotiated Rate	$3,000.00
Rate for Payer: Aetna Commercial	$2,850.00
Rate for Payer: Aetna Medicare	$2,700.00
Rate for Payer: BCBS MT CHIP	$2,700.00
Rate for Payer: BCBS MT Closed Plan Network	$2,850.00
Rate for Payer: BCBS MT HealthLink	$2,700.00
Rate for Payer: BCBS MT Medicare	$2,700.00
Rate for Payer: BCBS MT POS	$2,850.00
Rate for Payer: BCBS MT Traditional	$3,000.00
Rate for Payer: Cash Price	$2,700.00
Rate for Payer: Cigna Commercial	$2,850.00
Rate for Payer: Cigna Medicare	$2,700.00
Rate for Payer: Medicaid All Medicaid	$2,760.00
Rate for Payer: Medicare All Medicare	$2,100.00
Rate for Payer: Monida Allegiance	$2,850.00
Rate for Payer: Monida First Choice Health	$2,910.00
Rate for Payer: Monida Montana Health Co-op	$2,850.00
Rate for Payer: Monida PacificSource	$2,850.00

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

LDH ISOENZYMES

Facility

$140.00

Service Code	CPT 83519
Hospital Charge Code	4088122
Hospital Revenue Code	302
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$140.00
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: BCBS MT CHIP	$126.00
Rate for Payer: BCBS MT Closed Plan Network	$133.00
Rate for Payer: BCBS MT HealthLink	$126.00
Rate for Payer: BCBS MT Medicare	$126.00
Rate for Payer: BCBS MT POS	$133.00
Rate for Payer: BCBS MT Traditional	$140.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Cigna Commercial	$133.00
Rate for Payer: Cigna Medicare	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

Know your out-of-pocket cost for care.

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