Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

LDL CHOLESTEROL, DIRECT (BCL4733)

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 (BCL4733)

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

LEPTIN (146712)

Facility

$135.00

Service Code	CPT 83520
Hospital Charge Code	4035202
Hospital Revenue Code	301
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

LEPTIN (146712)

Facility

$135.00

Service Code	CPT 83520
Hospital Charge Code	4035202
Hospital Revenue Code	301
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

LEPTOSPIRA IGM AB

Facility

$196.10

Service Code	CPT 86720
Hospital Charge Code	4087950
Hospital Revenue Code	300
Min. Negotiated Rate	$137.27
Max. Negotiated Rate	$196.10
Rate for Payer: Aetna Commercial	$186.29
Rate for Payer: Aetna Medicare	$176.49
Rate for Payer: BCBS MT CHIP	$176.49
Rate for Payer: BCBS MT Closed Plan Network	$186.29
Rate for Payer: BCBS MT HealthLink	$176.49
Rate for Payer: BCBS MT Medicare	$176.49
Rate for Payer: BCBS MT POS	$186.29
Rate for Payer: BCBS MT Traditional	$196.10
Rate for Payer: Cash Price	$176.49
Rate for Payer: Cigna Commercial	$186.29
Rate for Payer: Cigna Medicare	$176.49
Rate for Payer: Medicaid All Medicaid	$180.41
Rate for Payer: Medicare All Medicare	$137.27
Rate for Payer: Monida Allegiance	$186.29
Rate for Payer: Monida First Choice Health	$190.22
Rate for Payer: Monida Montana Health Co-op	$186.29
Rate for Payer: Monida PacificSource	$186.29

LEPTOSPIRA IGM AB

Facility

$196.10

Service Code	CPT 86720
Hospital Charge Code	4087950
Hospital Revenue Code	300
Min. Negotiated Rate	$137.27
Max. Negotiated Rate	$196.10
Rate for Payer: Aetna Commercial	$186.29
Rate for Payer: Aetna Medicare	$176.49
Rate for Payer: BCBS MT CHIP	$176.49
Rate for Payer: BCBS MT Closed Plan Network	$186.29
Rate for Payer: BCBS MT HealthLink	$176.49
Rate for Payer: BCBS MT Medicare	$176.49
Rate for Payer: BCBS MT POS	$186.29
Rate for Payer: BCBS MT Traditional	$196.10
Rate for Payer: Cash Price	$176.49
Rate for Payer: Cigna Commercial	$186.29
Rate for Payer: Cigna Medicare	$176.49
Rate for Payer: Medicaid All Medicaid	$180.41
Rate for Payer: Medicare All Medicare	$137.27
Rate for Payer: Monida Allegiance	$186.29
Rate for Payer: Monida First Choice Health	$190.22
Rate for Payer: Monida Montana Health Co-op	$186.29
Rate for Payer: Monida PacificSource	$186.29

LEVEL IV SURG PATH, GROSS & MICROSCOPIC

Facility

$203.00

Service Code	CPT 88305
Hospital Charge Code	8088305
Hospital Revenue Code	521
Min. Negotiated Rate	$142.10
Max. Negotiated Rate	$203.00
Rate for Payer: Aetna Commercial	$192.85
Rate for Payer: Aetna Medicare	$182.70
Rate for Payer: BCBS MT CHIP	$182.70
Rate for Payer: BCBS MT Closed Plan Network	$192.85
Rate for Payer: BCBS MT HealthLink	$182.70
Rate for Payer: BCBS MT Medicare	$182.70
Rate for Payer: BCBS MT POS	$192.85
Rate for Payer: BCBS MT Traditional	$203.00
Rate for Payer: Cash Price	$182.70
Rate for Payer: Cigna Commercial	$192.85
Rate for Payer: Cigna Medicare	$182.70
Rate for Payer: Medicaid All Medicaid	$186.76
Rate for Payer: Medicare All Medicare	$142.10
Rate for Payer: Monida Allegiance	$192.85
Rate for Payer: Monida First Choice Health	$196.91
Rate for Payer: Monida Montana Health Co-op	$192.85
Rate for Payer: Monida PacificSource	$192.85

LEVEL IV SURG PATH, GROSS & MICROSCOPIC

Facility

$203.00

Service Code	CPT 88305
Hospital Charge Code	8088305
Hospital Revenue Code	521
Min. Negotiated Rate	$142.10
Max. Negotiated Rate	$203.00
Rate for Payer: Aetna Commercial	$192.85
Rate for Payer: Aetna Medicare	$182.70
Rate for Payer: BCBS MT CHIP	$182.70
Rate for Payer: BCBS MT Closed Plan Network	$192.85
Rate for Payer: BCBS MT HealthLink	$182.70
Rate for Payer: BCBS MT Medicare	$182.70
Rate for Payer: BCBS MT POS	$192.85
Rate for Payer: BCBS MT Traditional	$203.00
Rate for Payer: Cash Price	$182.70
Rate for Payer: Cigna Commercial	$192.85
Rate for Payer: Cigna Medicare	$182.70
Rate for Payer: Medicaid All Medicaid	$186.76
Rate for Payer: Medicare All Medicare	$142.10
Rate for Payer: Monida Allegiance	$192.85
Rate for Payer: Monida First Choice Health	$196.91
Rate for Payer: Monida Montana Health Co-op	$192.85
Rate for Payer: Monida PacificSource	$192.85

LEVEMIR 100U/ML 10ML VIAL-NF

Facility

$702.60

Hospital Charge Code	3007249
Hospital Revenue Code	250
Min. Negotiated Rate	$491.82
Max. Negotiated Rate	$702.60
Rate for Payer: Aetna Commercial	$667.47
Rate for Payer: Aetna Medicare	$632.34
Rate for Payer: BCBS MT CHIP	$632.34
Rate for Payer: BCBS MT Closed Plan Network	$667.47
Rate for Payer: BCBS MT HealthLink	$632.34
Rate for Payer: BCBS MT Medicare	$632.34
Rate for Payer: BCBS MT POS	$667.47
Rate for Payer: BCBS MT Traditional	$702.60
Rate for Payer: Cash Price	$632.34
Rate for Payer: Cigna Commercial	$667.47
Rate for Payer: Cigna Medicare	$632.34
Rate for Payer: Medicaid All Medicaid	$646.39
Rate for Payer: Medicare All Medicare	$491.82
Rate for Payer: Monida Allegiance	$667.47
Rate for Payer: Monida First Choice Health	$681.52
Rate for Payer: Monida Montana Health Co-op	$667.47
Rate for Payer: Monida PacificSource	$667.47

LEVEMIR 100U/ML 10ML VIAL-NF

Facility

$702.60

Hospital Charge Code	3007249
Hospital Revenue Code	250
Min. Negotiated Rate	$491.82
Max. Negotiated Rate	$702.60
Rate for Payer: Aetna Commercial	$667.47
Rate for Payer: Aetna Medicare	$632.34
Rate for Payer: BCBS MT CHIP	$632.34
Rate for Payer: BCBS MT Closed Plan Network	$667.47
Rate for Payer: BCBS MT HealthLink	$632.34
Rate for Payer: BCBS MT Medicare	$632.34
Rate for Payer: BCBS MT POS	$667.47
Rate for Payer: BCBS MT Traditional	$702.60
Rate for Payer: Cash Price	$632.34
Rate for Payer: Cigna Commercial	$667.47
Rate for Payer: Cigna Medicare	$632.34
Rate for Payer: Medicaid All Medicaid	$646.39
Rate for Payer: Medicare All Medicare	$491.82
Rate for Payer: Monida Allegiance	$667.47
Rate for Payer: Monida First Choice Health	$681.52
Rate for Payer: Monida Montana Health Co-op	$667.47
Rate for Payer: Monida PacificSource	$667.47

LEVETIRACETAM 500MG TAB

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000270
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

LEVETIRACETAM 500MG TAB

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000270
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

LEVETIRACETAM (716936)

Facility

$92.00

Service Code	CPT 80177
Hospital Charge Code	4080299
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

LEVETIRACETAM (716936)

Facility

$92.00

Service Code	CPT 80177
Hospital Charge Code	4080299
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

Know your out-of-pocket cost for care.

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