Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAB CULTURE ID OF AEROBIC

Facility

$142.00

Service Code	CPT 87071
Hospital Charge Code	4087071
Hospital Revenue Code	300
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

LAB CULTURE ID OF AEROBIC

Facility

$142.00

Service Code	CPT 87071
Hospital Charge Code	4087071
Hospital Revenue Code	300
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

LAB CULTURE TYPING PER ANTISERUM

Facility

$68.00

Service Code	CPT 87147
Hospital Charge Code	4087147
Hospital Revenue Code	306
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

LAB CULTURE TYPING PER ANTISERUM

Facility

$68.00

Service Code	CPT 87147
Hospital Charge Code	4087147
Hospital Revenue Code	306
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

LAB CYTOMEG DNA QUANT

Facility

$204.00

Service Code	CPT 87497
Hospital Charge Code	4087497
Hospital Revenue Code	300
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$204.00
Rate for Payer: Aetna Commercial	$193.80
Rate for Payer: Aetna Medicare	$183.60
Rate for Payer: BCBS MT CHIP	$183.60
Rate for Payer: BCBS MT Closed Plan Network	$193.80
Rate for Payer: BCBS MT HealthLink	$183.60
Rate for Payer: BCBS MT Medicare	$183.60
Rate for Payer: BCBS MT POS	$193.80
Rate for Payer: BCBS MT Traditional	$204.00
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cigna Commercial	$193.80
Rate for Payer: Cigna Medicare	$183.60
Rate for Payer: Medicaid All Medicaid	$187.68
Rate for Payer: Medicare All Medicare	$142.80
Rate for Payer: Monida Allegiance	$193.80
Rate for Payer: Monida First Choice Health	$197.88
Rate for Payer: Monida Montana Health Co-op	$193.80
Rate for Payer: Monida PacificSource	$193.80

LAB CYTOMEG DNA QUANT

Facility

$204.00

Service Code	CPT 87497
Hospital Charge Code	4087497
Hospital Revenue Code	300
Min. Negotiated Rate	$142.80
Max. Negotiated Rate	$204.00
Rate for Payer: Aetna Commercial	$193.80
Rate for Payer: Aetna Medicare	$183.60
Rate for Payer: BCBS MT CHIP	$183.60
Rate for Payer: BCBS MT Closed Plan Network	$193.80
Rate for Payer: BCBS MT HealthLink	$183.60
Rate for Payer: BCBS MT Medicare	$183.60
Rate for Payer: BCBS MT POS	$193.80
Rate for Payer: BCBS MT Traditional	$204.00
Rate for Payer: Cash Price	$183.60
Rate for Payer: Cigna Commercial	$193.80
Rate for Payer: Cigna Medicare	$183.60
Rate for Payer: Medicaid All Medicaid	$187.68
Rate for Payer: Medicare All Medicare	$142.80
Rate for Payer: Monida Allegiance	$193.80
Rate for Payer: Monida First Choice Health	$197.88
Rate for Payer: Monida Montana Health Co-op	$193.80
Rate for Payer: Monida PacificSource	$193.80

LAB DETECT AGNT MULT DNA AMPLI

Facility

$312.00

Service Code	CPT 87801
Hospital Charge Code	4087801
Hospital Revenue Code	306
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$312.00
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: BCBS MT CHIP	$280.80
Rate for Payer: BCBS MT Closed Plan Network	$296.40
Rate for Payer: BCBS MT HealthLink	$280.80
Rate for Payer: BCBS MT Medicare	$280.80
Rate for Payer: BCBS MT POS	$296.40
Rate for Payer: BCBS MT Traditional	$312.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cigna Commercial	$296.40
Rate for Payer: Cigna Medicare	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

LAB DETECT AGNT MULT DNA AMPLI

Facility

$312.00

Service Code	CPT 87801
Hospital Charge Code	4087801
Hospital Revenue Code	306
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$312.00
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: BCBS MT CHIP	$280.80
Rate for Payer: BCBS MT Closed Plan Network	$296.40
Rate for Payer: BCBS MT HealthLink	$280.80
Rate for Payer: BCBS MT Medicare	$280.80
Rate for Payer: BCBS MT POS	$296.40
Rate for Payer: BCBS MT Traditional	$312.00
Rate for Payer: Cash Price	$280.80
Rate for Payer: Cigna Commercial	$296.40
Rate for Payer: Cigna Medicare	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

LAB DIMERIC INHIBIN A

Facility

$291.00

Service Code	CPT 86336
Hospital Charge Code	4086336
Hospital Revenue Code	300
Min. Negotiated Rate	$203.70
Max. Negotiated Rate	$291.00
Rate for Payer: Aetna Commercial	$276.45
Rate for Payer: Aetna Medicare	$261.90
Rate for Payer: BCBS MT CHIP	$261.90
Rate for Payer: BCBS MT Closed Plan Network	$276.45
Rate for Payer: BCBS MT HealthLink	$261.90
Rate for Payer: BCBS MT Medicare	$261.90
Rate for Payer: BCBS MT POS	$276.45
Rate for Payer: BCBS MT Traditional	$291.00
Rate for Payer: Cash Price	$261.90
Rate for Payer: Cigna Commercial	$276.45
Rate for Payer: Cigna Medicare	$261.90
Rate for Payer: Medicaid All Medicaid	$267.72
Rate for Payer: Medicare All Medicare	$203.70
Rate for Payer: Monida Allegiance	$276.45
Rate for Payer: Monida First Choice Health	$282.27
Rate for Payer: Monida Montana Health Co-op	$276.45
Rate for Payer: Monida PacificSource	$276.45

LAB DIMERIC INHIBIN A

Facility

$291.00

Service Code	CPT 86336
Hospital Charge Code	4086336
Hospital Revenue Code	300
Min. Negotiated Rate	$203.70
Max. Negotiated Rate	$291.00
Rate for Payer: Aetna Commercial	$276.45
Rate for Payer: Aetna Medicare	$261.90
Rate for Payer: BCBS MT CHIP	$261.90
Rate for Payer: BCBS MT Closed Plan Network	$276.45
Rate for Payer: BCBS MT HealthLink	$261.90
Rate for Payer: BCBS MT Medicare	$261.90
Rate for Payer: BCBS MT POS	$276.45
Rate for Payer: BCBS MT Traditional	$291.00
Rate for Payer: Cash Price	$261.90
Rate for Payer: Cigna Commercial	$276.45
Rate for Payer: Cigna Medicare	$261.90
Rate for Payer: Medicaid All Medicaid	$267.72
Rate for Payer: Medicare All Medicare	$203.70
Rate for Payer: Monida Allegiance	$276.45
Rate for Payer: Monida First Choice Health	$282.27
Rate for Payer: Monida Montana Health Co-op	$276.45
Rate for Payer: Monida PacificSource	$276.45

LAB DNA/RNA AMPLIFIED PROBE ID

Facility

$1,123.00

Service Code	CPT 87150
Hospital Charge Code	4087150
Hospital Revenue Code	300
Min. Negotiated Rate	$786.10
Max. Negotiated Rate	$1,123.00
Rate for Payer: Aetna Commercial	$1,066.85
Rate for Payer: Aetna Medicare	$1,010.70
Rate for Payer: BCBS MT CHIP	$1,010.70
Rate for Payer: BCBS MT Closed Plan Network	$1,066.85
Rate for Payer: BCBS MT HealthLink	$1,010.70
Rate for Payer: BCBS MT Medicare	$1,010.70
Rate for Payer: BCBS MT POS	$1,066.85
Rate for Payer: BCBS MT Traditional	$1,123.00
Rate for Payer: Cash Price	$1,010.70
Rate for Payer: Cigna Commercial	$1,066.85
Rate for Payer: Cigna Medicare	$1,010.70
Rate for Payer: Medicaid All Medicaid	$1,033.16
Rate for Payer: Medicare All Medicare	$786.10
Rate for Payer: Monida Allegiance	$1,066.85
Rate for Payer: Monida First Choice Health	$1,089.31
Rate for Payer: Monida Montana Health Co-op	$1,066.85
Rate for Payer: Monida PacificSource	$1,066.85

LAB DNA/RNA AMPLIFIED PROBE ID

Facility

$1,123.00

Service Code	CPT 87150
Hospital Charge Code	4087150
Hospital Revenue Code	300
Min. Negotiated Rate	$786.10
Max. Negotiated Rate	$1,123.00
Rate for Payer: Aetna Commercial	$1,066.85
Rate for Payer: Aetna Medicare	$1,010.70
Rate for Payer: BCBS MT CHIP	$1,010.70
Rate for Payer: BCBS MT Closed Plan Network	$1,066.85
Rate for Payer: BCBS MT HealthLink	$1,010.70
Rate for Payer: BCBS MT Medicare	$1,010.70
Rate for Payer: BCBS MT POS	$1,066.85
Rate for Payer: BCBS MT Traditional	$1,123.00
Rate for Payer: Cash Price	$1,010.70
Rate for Payer: Cigna Commercial	$1,066.85
Rate for Payer: Cigna Medicare	$1,010.70
Rate for Payer: Medicaid All Medicaid	$1,033.16
Rate for Payer: Medicare All Medicare	$786.10
Rate for Payer: Monida Allegiance	$1,066.85
Rate for Payer: Monida First Choice Health	$1,089.31
Rate for Payer: Monida Montana Health Co-op	$1,066.85
Rate for Payer: Monida PacificSource	$1,066.85

LAB D NASE B ANTIBODY

Facility

$82.00

Service Code	CPT 86215
Hospital Charge Code	4086215
Hospital Revenue Code	300
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

LAB D NASE B ANTIBODY

Facility

$82.00

Service Code	CPT 86215
Hospital Charge Code	4086215
Hospital Revenue Code	300
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

LAB DRUG TEST PRSMV DIR OPT OBS

Facility

$66.00

Service Code	CPT 80305
Hospital Charge Code	4080305
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

LAB DRUG TEST PRSMV DIR OPT OBS

Facility

$66.00

Service Code	CPT 80305
Hospital Charge Code	4080305
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

LAB ESTROGEN

Facility

$99.00

Service Code	CPT 82672
Hospital Charge Code	4082672
Hospital Revenue Code	301
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

LAB ESTROGEN

Facility

$99.00

Service Code	CPT 82672
Hospital Charge Code	4082672
Hospital Revenue Code	301
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

LAB ESTROGEN LEVEL

Facility

$73.00

Service Code	CPT 82671
Hospital Charge Code	4082671
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

LAB ESTROGEN LEVEL

Facility

$73.00

Service Code	CPT 82671
Hospital Charge Code	4082671
Hospital Revenue Code	300
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

LABETALOL INJ [20 MG/4 ML] 4ML SYRINGE

Facility

$30.00

Service Code	HCPCS J1920
Hospital Charge Code	3000264
Hospital Revenue Code	636
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

LABETALOL INJ [20 MG/4 ML] 4ML SYRINGE

Facility

$30.00

Service Code	HCPCS J1920
Hospital Charge Code	3000264
Hospital Revenue Code	636
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

LABETALOL INJ [5 MG/ML] 4ML SDV

Facility

$17.00

Service Code	HCPCS J1920
Hospital Charge Code	3000550
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

LABETALOL INJ [5 MG/ML] 4ML SDV

Facility

$17.00

Service Code	HCPCS J1920
Hospital Charge Code	3000550
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

LAB ETHOSUXIMIDE LEVEL

Facility

$130.00

Service Code	CPT 80168
Hospital Charge Code	4080168
Hospital Revenue Code	300
Min. Negotiated Rate	$91.00
Max. Negotiated Rate	$130.00
Rate for Payer: Aetna Commercial	$123.50
Rate for Payer: Aetna Medicare	$117.00
Rate for Payer: BCBS MT CHIP	$117.00
Rate for Payer: BCBS MT Closed Plan Network	$123.50
Rate for Payer: BCBS MT HealthLink	$117.00
Rate for Payer: BCBS MT Medicare	$117.00
Rate for Payer: BCBS MT POS	$123.50
Rate for Payer: BCBS MT Traditional	$130.00
Rate for Payer: Cash Price	$117.00
Rate for Payer: Cigna Commercial	$123.50
Rate for Payer: Cigna Medicare	$117.00
Rate for Payer: Medicaid All Medicaid	$119.60
Rate for Payer: Medicare All Medicare	$91.00
Rate for Payer: Monida Allegiance	$123.50
Rate for Payer: Monida First Choice Health	$126.10
Rate for Payer: Monida Montana Health Co-op	$123.50
Rate for Payer: Monida PacificSource	$123.50

Know your out-of-pocket cost for care.

All Charges