Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LIDOCAINE TOP GEL [4%] NF

Facility

$43.00

Service Code	HCPCS J3490
Hospital Charge Code	3000288
Hospital Revenue Code	250
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

LIDOCAINE TOP GEL [4%] NF

Facility

$43.00

Service Code	HCPCS J3490
Hospital Charge Code	3000288
Hospital Revenue Code	250
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

LIDOCAINE TOPICAL SLN [4%] 50ML NF

Facility

$207.00

Service Code	HCPCS J3490
Hospital Charge Code	3000539
Hospital Revenue Code	250
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

LIDOCAINE TOPICAL SLN [4%] 50ML NF

Facility

$207.00

Service Code	HCPCS J3490
Hospital Charge Code	3000539
Hospital Revenue Code	250
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna Commercial	$196.65
Rate for Payer: Aetna Medicare	$186.30
Rate for Payer: BCBS MT CHIP	$186.30
Rate for Payer: BCBS MT Closed Plan Network	$196.65
Rate for Payer: BCBS MT HealthLink	$186.30
Rate for Payer: BCBS MT Medicare	$186.30
Rate for Payer: BCBS MT POS	$196.65
Rate for Payer: BCBS MT Traditional	$207.00
Rate for Payer: Cash Price	$186.30
Rate for Payer: Cigna Commercial	$196.65
Rate for Payer: Cigna Medicare	$186.30
Rate for Payer: Medicaid All Medicaid	$190.44
Rate for Payer: Medicare All Medicare	$144.90
Rate for Payer: Monida Allegiance	$196.65
Rate for Payer: Monida First Choice Health	$200.79
Rate for Payer: Monida Montana Health Co-op	$196.65
Rate for Payer: Monida PacificSource	$196.65

LIDOCAINE W/EPI 1%/1:100000 INJ [1 ML]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000289
Hospital Revenue Code	636
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

LIDOCAINE W/EPI 1%/1:100000 INJ [1 ML]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000289
Hospital Revenue Code	636
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

LINEZOLID TAB [600 MG] NF

Facility

$559.00

Service Code	HCPCS J8499
Hospital Charge Code	3000291
Hospital Revenue Code	250
Min. Negotiated Rate	$391.30
Max. Negotiated Rate	$559.00
Rate for Payer: Aetna Commercial	$531.05
Rate for Payer: Aetna Medicare	$503.10
Rate for Payer: BCBS MT CHIP	$503.10
Rate for Payer: BCBS MT Closed Plan Network	$531.05
Rate for Payer: BCBS MT HealthLink	$503.10
Rate for Payer: BCBS MT Medicare	$503.10
Rate for Payer: BCBS MT POS	$531.05
Rate for Payer: BCBS MT Traditional	$559.00
Rate for Payer: Cash Price	$503.10
Rate for Payer: Cigna Commercial	$531.05
Rate for Payer: Cigna Medicare	$503.10
Rate for Payer: Medicaid All Medicaid	$514.28
Rate for Payer: Medicare All Medicare	$391.30
Rate for Payer: Monida Allegiance	$531.05
Rate for Payer: Monida First Choice Health	$542.23
Rate for Payer: Monida Montana Health Co-op	$531.05
Rate for Payer: Monida PacificSource	$531.05

LINEZOLID TAB [600 MG] NF

Facility

$559.00

Service Code	HCPCS J8499
Hospital Charge Code	3000291
Hospital Revenue Code	250
Min. Negotiated Rate	$391.30
Max. Negotiated Rate	$559.00
Rate for Payer: Aetna Commercial	$531.05
Rate for Payer: Aetna Medicare	$503.10
Rate for Payer: BCBS MT CHIP	$503.10
Rate for Payer: BCBS MT Closed Plan Network	$531.05
Rate for Payer: BCBS MT HealthLink	$503.10
Rate for Payer: BCBS MT Medicare	$503.10
Rate for Payer: BCBS MT POS	$531.05
Rate for Payer: BCBS MT Traditional	$559.00
Rate for Payer: Cash Price	$503.10
Rate for Payer: Cigna Commercial	$531.05
Rate for Payer: Cigna Medicare	$503.10
Rate for Payer: Medicaid All Medicaid	$514.28
Rate for Payer: Medicare All Medicare	$391.30
Rate for Payer: Monida Allegiance	$531.05
Rate for Payer: Monida First Choice Health	$542.23
Rate for Payer: Monida Montana Health Co-op	$531.05
Rate for Payer: Monida PacificSource	$531.05

LIPASE

Facility

$124.00

Service Code	CPT 83690
Hospital Charge Code	4083690
Hospital Revenue Code	300
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

LIPASE

Facility

$124.00

Service Code	CPT 83690
Hospital Charge Code	4083690
Hospital Revenue Code	300
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

LIPASE/PROTEASE/AMYLASE 36K/114K/180K IU

Facility

$50.00

Service Code	HCPCS J8499
Hospital Charge Code	3007551
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

LIPASE/PROTEASE/AMYLASE 36K/114K/180K IU

Facility

$50.00

Service Code	HCPCS J8499
Hospital Charge Code	3007551
Hospital Revenue Code	250
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

LIPASE/PROTEASE/AMYLASE CAP [12,000 IU]

Facility

$17.00

Service Code	HCPCS J8499
Hospital Charge Code	3000593
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

LIPASE/PROTEASE/AMYLASE CAP [12,000 IU]

Facility

$17.00

Service Code	HCPCS J8499
Hospital Charge Code	3000593
Hospital Revenue Code	250
Min. Negotiated Rate	$11.90
Max. Negotiated Rate	$17.00
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna Medicare	$15.30
Rate for Payer: BCBS MT CHIP	$15.30
Rate for Payer: BCBS MT Closed Plan Network	$16.15
Rate for Payer: BCBS MT HealthLink	$15.30
Rate for Payer: BCBS MT Medicare	$15.30
Rate for Payer: BCBS MT POS	$16.15
Rate for Payer: BCBS MT Traditional	$17.00
Rate for Payer: Cash Price	$15.30
Rate for Payer: Cigna Commercial	$16.15
Rate for Payer: Cigna Medicare	$15.30
Rate for Payer: Medicaid All Medicaid	$15.64
Rate for Payer: Medicare All Medicare	$11.90
Rate for Payer: Monida Allegiance	$16.15
Rate for Payer: Monida First Choice Health	$16.49
Rate for Payer: Monida Montana Health Co-op	$16.15
Rate for Payer: Monida PacificSource	$16.15

LIPID PANEL

Facility

$155.00

Service Code	CPT 80061
Hospital Charge Code	4080061
Hospital Revenue Code	301
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

LIPID PANEL

Facility

$155.00

Service Code	CPT 80061
Hospital Charge Code	4080061
Hospital Revenue Code	301
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

LIPID PANEL W/ DIRECT LDL REFLEX

Facility

$155.00

Service Code	CPT 80061
Hospital Charge Code	4000611
Hospital Revenue Code	301
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

LIPID PANEL W/ DIRECT LDL REFLEX

Facility

$155.00

Service Code	CPT 80061
Hospital Charge Code	4000611
Hospital Revenue Code	301
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

LIPL CALIBRATOR

Facility

$42.28

Hospital Charge Code	90195034
Hospital Revenue Code	270
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$42.28
Rate for Payer: Aetna Commercial	$40.17
Rate for Payer: Aetna Medicare	$38.05
Rate for Payer: BCBS MT CHIP	$38.05
Rate for Payer: BCBS MT Closed Plan Network	$40.17
Rate for Payer: BCBS MT HealthLink	$38.05
Rate for Payer: BCBS MT Medicare	$38.05
Rate for Payer: BCBS MT POS	$40.17
Rate for Payer: BCBS MT Traditional	$42.28
Rate for Payer: Cash Price	$38.05
Rate for Payer: Cigna Commercial	$40.17
Rate for Payer: Cigna Medicare	$38.05
Rate for Payer: Medicaid All Medicaid	$38.90
Rate for Payer: Medicare All Medicare	$29.60
Rate for Payer: Monida Allegiance	$40.17
Rate for Payer: Monida First Choice Health	$41.01
Rate for Payer: Monida Montana Health Co-op	$40.17
Rate for Payer: Monida PacificSource	$40.17

LIPL CALIBRATOR

Facility

$42.28

Hospital Charge Code	90195034
Hospital Revenue Code	270
Min. Negotiated Rate	$29.60
Max. Negotiated Rate	$42.28
Rate for Payer: Aetna Commercial	$40.17
Rate for Payer: Aetna Medicare	$38.05
Rate for Payer: BCBS MT CHIP	$38.05
Rate for Payer: BCBS MT Closed Plan Network	$40.17
Rate for Payer: BCBS MT HealthLink	$38.05
Rate for Payer: BCBS MT Medicare	$38.05
Rate for Payer: BCBS MT POS	$40.17
Rate for Payer: BCBS MT Traditional	$42.28
Rate for Payer: Cash Price	$38.05
Rate for Payer: Cigna Commercial	$40.17
Rate for Payer: Cigna Medicare	$38.05
Rate for Payer: Medicaid All Medicaid	$38.90
Rate for Payer: Medicare All Medicare	$29.60
Rate for Payer: Monida Allegiance	$40.17
Rate for Payer: Monida First Choice Health	$41.01
Rate for Payer: Monida Montana Health Co-op	$40.17
Rate for Payer: Monida PacificSource	$40.17

LIPOFIT BY NMR PARTICLE

Facility

$118.00

Service Code	CPT 83704
Hospital Charge Code	4087886
Hospital Revenue Code	301
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$118.00
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare	$106.20
Rate for Payer: BCBS MT CHIP	$106.20
Rate for Payer: BCBS MT Closed Plan Network	$112.10
Rate for Payer: BCBS MT HealthLink	$106.20
Rate for Payer: BCBS MT Medicare	$106.20
Rate for Payer: BCBS MT POS	$112.10
Rate for Payer: BCBS MT Traditional	$118.00
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cigna Commercial	$112.10
Rate for Payer: Cigna Medicare	$106.20
Rate for Payer: Medicaid All Medicaid	$108.56
Rate for Payer: Medicare All Medicare	$82.60
Rate for Payer: Monida Allegiance	$112.10
Rate for Payer: Monida First Choice Health	$114.46
Rate for Payer: Monida Montana Health Co-op	$112.10
Rate for Payer: Monida PacificSource	$112.10

LIPOFIT BY NMR PARTICLE

Facility

$118.00

Service Code	CPT 83704
Hospital Charge Code	4087886
Hospital Revenue Code	301
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$118.00
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare	$106.20
Rate for Payer: BCBS MT CHIP	$106.20
Rate for Payer: BCBS MT Closed Plan Network	$112.10
Rate for Payer: BCBS MT HealthLink	$106.20
Rate for Payer: BCBS MT Medicare	$106.20
Rate for Payer: BCBS MT POS	$112.10
Rate for Payer: BCBS MT Traditional	$118.00
Rate for Payer: Cash Price	$106.20
Rate for Payer: Cigna Commercial	$112.10
Rate for Payer: Cigna Medicare	$106.20
Rate for Payer: Medicaid All Medicaid	$108.56
Rate for Payer: Medicare All Medicare	$82.60
Rate for Payer: Monida Allegiance	$112.10
Rate for Payer: Monida First Choice Health	$114.46
Rate for Payer: Monida Montana Health Co-op	$112.10
Rate for Payer: Monida PacificSource	$112.10

LIPOPROTEIN(a) (120188)

Facility

$69.00

Service Code	CPT 83695
Hospital Charge Code	4083695
Hospital Revenue Code	301
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

LIPOPROTEIN(a) (120188)

Facility

$69.00

Service Code	CPT 83695
Hospital Charge Code	4083695
Hospital Revenue Code	301
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

LIRAGLUTIDE (VICTOZA) 18MG/3ML PEN NF

Facility

$620.00

Service Code	HCPCS J1815
Hospital Charge Code	3007123
Hospital Revenue Code	636
Min. Negotiated Rate	$434.00
Max. Negotiated Rate	$620.00
Rate for Payer: Aetna Commercial	$589.00
Rate for Payer: Aetna Medicare	$558.00
Rate for Payer: BCBS MT CHIP	$558.00
Rate for Payer: BCBS MT Closed Plan Network	$589.00
Rate for Payer: BCBS MT HealthLink	$558.00
Rate for Payer: BCBS MT Medicare	$558.00
Rate for Payer: BCBS MT POS	$589.00
Rate for Payer: BCBS MT Traditional	$620.00
Rate for Payer: Cash Price	$558.00
Rate for Payer: Cigna Commercial	$589.00
Rate for Payer: Cigna Medicare	$558.00
Rate for Payer: Medicaid All Medicaid	$570.40
Rate for Payer: Medicare All Medicare	$434.00
Rate for Payer: Monida Allegiance	$589.00
Rate for Payer: Monida First Choice Health	$601.40
Rate for Payer: Monida Montana Health Co-op	$589.00
Rate for Payer: Monida PacificSource	$589.00

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