Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LIDOCAINE 4% TOPICAL CREAM

Facility

$96.00

Service Code	NDC 39328002415
Hospital Charge Code	3007256
Hospital Revenue Code	250
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

LIDOCAINE EXT SYR 2% GEL [220 MG/11 ML]

Facility

$25.00

Service Code	HCPCS J3490
Hospital Charge Code	3000283
Hospital Revenue Code	636
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

LIDOCAINE EXT SYR 2% GEL [220 MG/11 ML]

Facility

$25.00

Service Code	HCPCS J3490
Hospital Charge Code	3000283
Hospital Revenue Code	636
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.00
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: BCBS MT CHIP	$22.50
Rate for Payer: BCBS MT Closed Plan Network	$23.75
Rate for Payer: BCBS MT HealthLink	$22.50
Rate for Payer: BCBS MT Medicare	$22.50
Rate for Payer: BCBS MT POS	$23.75
Rate for Payer: BCBS MT Traditional	$25.00
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cigna Commercial	$23.75
Rate for Payer: Cigna Medicare	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

LIDOCAINE HCL 2% VISCOUS SOL [15 ML]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000285
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

LIDOCAINE HCL 2% VISCOUS SOL [15 ML]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000285
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

LIDOCAINE PATCH [5%]

Facility

$33.00

Service Code	HCPCS J3490
Hospital Charge Code	3000287
Hospital Revenue Code	250
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

LIDOCAINE PATCH [5%]

Facility

$33.00

Service Code	HCPCS J3490
Hospital Charge Code	3000287
Hospital Revenue Code	250
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

LIDOCAINE/PRILOCAINE [2.5%/2.5%] CREAM

Facility

$32.00

Service Code	HCPCS J3490
Hospital Charge Code	3000290
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

LIDOCAINE/PRILOCAINE [2.5%/2.5%] CREAM

Facility

$32.00

Service Code	HCPCS J3490
Hospital Charge Code	3000290
Hospital Revenue Code	250
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

LIDOCAINE TOPICAL GEL [4%]

Facility

$690.00

Service Code	HCPCS J3490
Hospital Charge Code	3000288
Hospital Revenue Code	250
Min. Negotiated Rate	$483.00
Max. Negotiated Rate	$690.00
Rate for Payer: Aetna Commercial	$655.50
Rate for Payer: Aetna Medicare	$621.00
Rate for Payer: BCBS MT CHIP	$621.00
Rate for Payer: BCBS MT Closed Plan Network	$655.50
Rate for Payer: BCBS MT HealthLink	$621.00
Rate for Payer: BCBS MT Medicare	$621.00
Rate for Payer: BCBS MT POS	$655.50
Rate for Payer: BCBS MT Traditional	$690.00
Rate for Payer: Cash Price	$621.00
Rate for Payer: Cigna Commercial	$655.50
Rate for Payer: Cigna Medicare	$621.00
Rate for Payer: Medicaid All Medicaid	$634.80
Rate for Payer: Medicare All Medicare	$483.00
Rate for Payer: Monida Allegiance	$655.50
Rate for Payer: Monida First Choice Health	$669.30
Rate for Payer: Monida Montana Health Co-op	$655.50
Rate for Payer: Monida PacificSource	$655.50

LIDOCAINE TOPICAL GEL [4%]

Facility

$690.00

Service Code	HCPCS J3490
Hospital Charge Code	3000288
Hospital Revenue Code	250
Min. Negotiated Rate	$483.00
Max. Negotiated Rate	$690.00
Rate for Payer: Aetna Commercial	$655.50
Rate for Payer: Aetna Medicare	$621.00
Rate for Payer: BCBS MT CHIP	$621.00
Rate for Payer: BCBS MT Closed Plan Network	$655.50
Rate for Payer: BCBS MT HealthLink	$621.00
Rate for Payer: BCBS MT Medicare	$621.00
Rate for Payer: BCBS MT POS	$655.50
Rate for Payer: BCBS MT Traditional	$690.00
Rate for Payer: Cash Price	$621.00
Rate for Payer: Cigna Commercial	$655.50
Rate for Payer: Cigna Medicare	$621.00
Rate for Payer: Medicaid All Medicaid	$634.80
Rate for Payer: Medicare All Medicare	$483.00
Rate for Payer: Monida Allegiance	$655.50
Rate for Payer: Monida First Choice Health	$669.30
Rate for Payer: Monida Montana Health Co-op	$655.50
Rate for Payer: Monida PacificSource	$655.50

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] NONFORMULARY

Facility

$559.00

Service Code	HCPCS J3490
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] NONFORMULARY

Facility

$559.00

Service Code	HCPCS J3490
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	HCPCS 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	HCPCS 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 [12K/38K/60K] NF

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	15200
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

LIPASE-PROTEASE-AMYLASE [12K/38K/60K] NF

Facility

$16.00

Service Code	HCPCS J3490
Hospital Charge Code	15200
Hospital Revenue Code	250
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

LIPID PANEL

Facility

$155.00

Service Code	HCPCS 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	HCPCS 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	HCPCS 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	HCPCS 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

Know your out-of-pocket cost for care.

All Charges