Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LIVER FIBROSIS BIOMARKER PANEL 81517

Facility

$394.00

Service Code	CPT 81517
Hospital Charge Code	4081517
Hospital Revenue Code	300
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

LIVER-KIDNEY MICROSOMAL AB (006676)

Facility

$71.00

Service Code	CPT 86376
Hospital Charge Code	4063761
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

LIVER-KIDNEY MICROSOMAL AB (006676)

Facility

$71.00

Service Code	CPT 86376
Hospital Charge Code	4063761
Hospital Revenue Code	300
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$71.00
Rate for Payer: Aetna Commercial	$67.45
Rate for Payer: Aetna Medicare	$63.90
Rate for Payer: BCBS MT CHIP	$63.90
Rate for Payer: BCBS MT Closed Plan Network	$67.45
Rate for Payer: BCBS MT HealthLink	$63.90
Rate for Payer: BCBS MT Medicare	$63.90
Rate for Payer: BCBS MT POS	$67.45
Rate for Payer: BCBS MT Traditional	$71.00
Rate for Payer: Cash Price	$63.90
Rate for Payer: Cigna Commercial	$67.45
Rate for Payer: Cigna Medicare	$63.90
Rate for Payer: Medicaid All Medicaid	$65.32
Rate for Payer: Medicare All Medicare	$49.70
Rate for Payer: Monida Allegiance	$67.45
Rate for Payer: Monida First Choice Health	$68.87
Rate for Payer: Monida Montana Health Co-op	$67.45
Rate for Payer: Monida PacificSource	$67.45

LOPERAMIDE CAP [2 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000295
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

LOPERAMIDE CAP [2 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000295
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

LORATADINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000296
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

LORATADINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000296
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

LORAZEPAM INJ [2 MG/ML]

Facility

$14.00

Service Code	HCPCS J2060
Hospital Charge Code	3000297
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

LORAZEPAM INJ [2 MG/ML]

Facility

$14.00

Service Code	HCPCS J2060
Hospital Charge Code	3000297
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

LORAZEPAM ORAL SLN [2 MG/ML] 30ML

Facility

$154.00

Service Code	HCPCS J8499
Hospital Charge Code	3000560
Hospital Revenue Code	250
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

LORAZEPAM ORAL SLN [2 MG/ML] 30ML

Facility

$154.00

Service Code	HCPCS J8499
Hospital Charge Code	3000560
Hospital Revenue Code	250
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

LORAZEPAM TAB [0.5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000298
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

LORAZEPAM TAB [0.5 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000298
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

LORAZEPAM TAB [2 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000501
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

LORAZEPAM TAB [2 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000501
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

LOSARTAN TAB [25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000299
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

LOSARTAN TAB [25 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000299
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

LOVASTATIN TAB [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007391
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

LOVASTATIN TAB [10 MG] NF

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007391
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

LRP4 AUTOANTIBODY (QUEST)

Facility

$800.00

Service Code	CPT 86255
Hospital Charge Code	4088131
Hospital Revenue Code	302
Min. Negotiated Rate	$560.00
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$760.00
Rate for Payer: Aetna Medicare	$720.00
Rate for Payer: BCBS MT CHIP	$720.00
Rate for Payer: BCBS MT Closed Plan Network	$760.00
Rate for Payer: BCBS MT HealthLink	$720.00
Rate for Payer: BCBS MT Medicare	$720.00
Rate for Payer: BCBS MT POS	$760.00
Rate for Payer: BCBS MT Traditional	$800.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial	$760.00
Rate for Payer: Cigna Medicare	$720.00
Rate for Payer: Medicaid All Medicaid	$736.00
Rate for Payer: Medicare All Medicare	$560.00
Rate for Payer: Monida Allegiance	$760.00
Rate for Payer: Monida First Choice Health	$776.00
Rate for Payer: Monida Montana Health Co-op	$760.00
Rate for Payer: Monida PacificSource	$760.00

LRP4 AUTOANTIBODY (QUEST)

Facility

$800.00

Service Code	CPT 86255
Hospital Charge Code	4088131
Hospital Revenue Code	302
Min. Negotiated Rate	$560.00
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$760.00
Rate for Payer: Aetna Medicare	$720.00
Rate for Payer: BCBS MT CHIP	$720.00
Rate for Payer: BCBS MT Closed Plan Network	$760.00
Rate for Payer: BCBS MT HealthLink	$720.00
Rate for Payer: BCBS MT Medicare	$720.00
Rate for Payer: BCBS MT POS	$760.00
Rate for Payer: BCBS MT Traditional	$800.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial	$760.00
Rate for Payer: Cigna Medicare	$720.00
Rate for Payer: Medicaid All Medicaid	$736.00
Rate for Payer: Medicare All Medicare	$560.00
Rate for Payer: Monida Allegiance	$760.00
Rate for Payer: Monida First Choice Health	$776.00
Rate for Payer: Monida Montana Health Co-op	$760.00
Rate for Payer: Monida PacificSource	$760.00

LUPUS ANTICOAGULANT PROFILE (117054)

Facility

$355.00

Service Code	CPT 85610
Hospital Charge Code	4056130
Hospital Revenue Code	306
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

LUPUS ANTICOAGULANT PROFILE (117054)

Facility

$355.00

Service Code	CPT 85610
Hospital Charge Code	4056130
Hospital Revenue Code	306
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

LUTEIN CAP [20 MG] NF

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3007794
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

LUTEIN CAP [20 MG] NF

Facility

$5.00

Service Code	HCPCS A9150
Hospital Charge Code	3007794
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

Know your out-of-pocket cost for care.

All Charges