Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HANDLING FEE SPECIMEN (CLINIC)

Facility

$23.00

Service Code	CPT 99000
Hospital Charge Code	8099000
Hospital Revenue Code	521
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$23.00
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: BCBS MT CHIP	$20.70
Rate for Payer: BCBS MT Closed Plan Network	$21.85
Rate for Payer: BCBS MT HealthLink	$20.70
Rate for Payer: BCBS MT Medicare	$20.70
Rate for Payer: BCBS MT POS	$21.85
Rate for Payer: BCBS MT Traditional	$23.00
Rate for Payer: Cash Price	$20.70
Rate for Payer: Cigna Commercial	$21.85
Rate for Payer: Cigna Medicare	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

HANTAVIRUS ANTIBODIES, ELISA (835027)

Facility

$212.00

Service Code	CPT 86790
Hospital Charge Code	4086790
Hospital Revenue Code	300
Min. Negotiated Rate	$148.40
Max. Negotiated Rate	$212.00
Rate for Payer: Aetna Commercial	$201.40
Rate for Payer: Aetna Medicare	$190.80
Rate for Payer: BCBS MT CHIP	$190.80
Rate for Payer: BCBS MT Closed Plan Network	$201.40
Rate for Payer: BCBS MT HealthLink	$190.80
Rate for Payer: BCBS MT Medicare	$190.80
Rate for Payer: BCBS MT POS	$201.40
Rate for Payer: BCBS MT Traditional	$212.00
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cigna Commercial	$201.40
Rate for Payer: Cigna Medicare	$190.80
Rate for Payer: Medicaid All Medicaid	$195.04
Rate for Payer: Medicare All Medicare	$148.40
Rate for Payer: Monida Allegiance	$201.40
Rate for Payer: Monida First Choice Health	$205.64
Rate for Payer: Monida Montana Health Co-op	$201.40
Rate for Payer: Monida PacificSource	$201.40

HANTAVIRUS ANTIBODIES, ELISA (835027)

Facility

$212.00

Service Code	CPT 86790
Hospital Charge Code	4086790
Hospital Revenue Code	300
Min. Negotiated Rate	$148.40
Max. Negotiated Rate	$212.00
Rate for Payer: Aetna Commercial	$201.40
Rate for Payer: Aetna Medicare	$190.80
Rate for Payer: BCBS MT CHIP	$190.80
Rate for Payer: BCBS MT Closed Plan Network	$201.40
Rate for Payer: BCBS MT HealthLink	$190.80
Rate for Payer: BCBS MT Medicare	$190.80
Rate for Payer: BCBS MT POS	$201.40
Rate for Payer: BCBS MT Traditional	$212.00
Rate for Payer: Cash Price	$190.80
Rate for Payer: Cigna Commercial	$201.40
Rate for Payer: Cigna Medicare	$190.80
Rate for Payer: Medicaid All Medicaid	$195.04
Rate for Payer: Medicare All Medicare	$148.40
Rate for Payer: Monida Allegiance	$201.40
Rate for Payer: Monida First Choice Health	$205.64
Rate for Payer: Monida Montana Health Co-op	$201.40
Rate for Payer: Monida PacificSource	$201.40

HAPTOGLOBIN (001628)

Facility

$68.00

Service Code	CPT 83010
Hospital Charge Code	4083010
Hospital Revenue Code	300
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

HAPTOGLOBIN (001628)

Facility

$68.00

Service Code	CPT 83010
Hospital Charge Code	4083010
Hospital Revenue Code	300
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

HARDY CARY BLAIR MEDIUM

Facility

$204.44

Hospital Charge Code	90197077
Hospital Revenue Code	270
Min. Negotiated Rate	$143.11
Max. Negotiated Rate	$204.44
Rate for Payer: Aetna Commercial	$194.22
Rate for Payer: Aetna Medicare	$184.00
Rate for Payer: BCBS MT CHIP	$184.00
Rate for Payer: BCBS MT Closed Plan Network	$194.22
Rate for Payer: BCBS MT HealthLink	$184.00
Rate for Payer: BCBS MT Medicare	$184.00
Rate for Payer: BCBS MT POS	$194.22
Rate for Payer: BCBS MT Traditional	$204.44
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cigna Commercial	$194.22
Rate for Payer: Cigna Medicare	$184.00
Rate for Payer: Medicaid All Medicaid	$188.08
Rate for Payer: Medicare All Medicare	$143.11
Rate for Payer: Monida Allegiance	$194.22
Rate for Payer: Monida First Choice Health	$198.31
Rate for Payer: Monida Montana Health Co-op	$194.22
Rate for Payer: Monida PacificSource	$194.22

HARDY CARY BLAIR MEDIUM

Facility

$204.44

Hospital Charge Code	90197077
Hospital Revenue Code	270
Min. Negotiated Rate	$143.11
Max. Negotiated Rate	$204.44
Rate for Payer: Aetna Commercial	$194.22
Rate for Payer: Aetna Medicare	$184.00
Rate for Payer: BCBS MT CHIP	$184.00
Rate for Payer: BCBS MT Closed Plan Network	$194.22
Rate for Payer: BCBS MT HealthLink	$184.00
Rate for Payer: BCBS MT Medicare	$184.00
Rate for Payer: BCBS MT POS	$194.22
Rate for Payer: BCBS MT Traditional	$204.44
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cigna Commercial	$194.22
Rate for Payer: Cigna Medicare	$184.00
Rate for Payer: Medicaid All Medicaid	$188.08
Rate for Payer: Medicare All Medicare	$143.11
Rate for Payer: Monida Allegiance	$194.22
Rate for Payer: Monida First Choice Health	$198.31
Rate for Payer: Monida Montana Health Co-op	$194.22
Rate for Payer: Monida PacificSource	$194.22

HCG, BETA, QUANTITATIVE (004416)

Facility

$72.00

Service Code	CPT 84702
Hospital Charge Code	4084702
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

HCG, BETA, QUANTITATIVE (004416)

Facility

$72.00

Service Code	CPT 84702
Hospital Charge Code	4084702
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

HCG, QUALITATIVE, SERUM

Facility

$103.00

Service Code	CPT 81025
Hospital Charge Code	4087896
Hospital Revenue Code	300
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

HCG, QUALITATIVE, SERUM

Facility

$103.00

Service Code	CPT 81025
Hospital Charge Code	4087896
Hospital Revenue Code	300
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

HCG, QUALITATIVE, URINE

Facility

$103.00

Service Code	CPT 81025
Hospital Charge Code	4081025
Hospital Revenue Code	300
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

HCG, QUALITATIVE, URINE

Facility

$103.00

Service Code	CPT 81025
Hospital Charge Code	4081025
Hospital Revenue Code	300
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

HCG, QUAL URINE CONFI

Facility

$103.00

Service Code	CPT 81025
Hospital Charge Code	4087904
Hospital Revenue Code	300
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

HCG, QUAL URINE CONFI

Facility

$103.00

Service Code	CPT 81025
Hospital Charge Code	4087904
Hospital Revenue Code	300
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$103.00
Rate for Payer: Aetna Commercial	$97.85
Rate for Payer: Aetna Medicare	$92.70
Rate for Payer: BCBS MT CHIP	$92.70
Rate for Payer: BCBS MT Closed Plan Network	$97.85
Rate for Payer: BCBS MT HealthLink	$92.70
Rate for Payer: BCBS MT Medicare	$92.70
Rate for Payer: BCBS MT POS	$97.85
Rate for Payer: BCBS MT Traditional	$103.00
Rate for Payer: Cash Price	$92.70
Rate for Payer: Cigna Commercial	$97.85
Rate for Payer: Cigna Medicare	$92.70
Rate for Payer: Medicaid All Medicaid	$94.76
Rate for Payer: Medicare All Medicare	$72.10
Rate for Payer: Monida Allegiance	$97.85
Rate for Payer: Monida First Choice Health	$99.91
Rate for Payer: Monida Montana Health Co-op	$97.85
Rate for Payer: Monida PacificSource	$97.85

HCG QUANTITATIVE RVMC

Facility

$164.00

Service Code	CPT 84702
Hospital Charge Code	4087913
Hospital Revenue Code	301
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$164.00
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$147.60
Rate for Payer: BCBS MT CHIP	$147.60
Rate for Payer: BCBS MT Closed Plan Network	$155.80
Rate for Payer: BCBS MT HealthLink	$147.60
Rate for Payer: BCBS MT Medicare	$147.60
Rate for Payer: BCBS MT POS	$155.80
Rate for Payer: BCBS MT Traditional	$164.00
Rate for Payer: Cash Price	$147.60
Rate for Payer: Cigna Commercial	$155.80
Rate for Payer: Cigna Medicare	$147.60
Rate for Payer: Medicaid All Medicaid	$150.88
Rate for Payer: Medicare All Medicare	$114.80
Rate for Payer: Monida Allegiance	$155.80
Rate for Payer: Monida First Choice Health	$159.08
Rate for Payer: Monida Montana Health Co-op	$155.80
Rate for Payer: Monida PacificSource	$155.80

HCG QUANTITATIVE RVMC

Facility

$164.00

Service Code	CPT 84702
Hospital Charge Code	4087913
Hospital Revenue Code	301
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$164.00
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$147.60
Rate for Payer: BCBS MT CHIP	$147.60
Rate for Payer: BCBS MT Closed Plan Network	$155.80
Rate for Payer: BCBS MT HealthLink	$147.60
Rate for Payer: BCBS MT Medicare	$147.60
Rate for Payer: BCBS MT POS	$155.80
Rate for Payer: BCBS MT Traditional	$164.00
Rate for Payer: Cash Price	$147.60
Rate for Payer: Cigna Commercial	$155.80
Rate for Payer: Cigna Medicare	$147.60
Rate for Payer: Medicaid All Medicaid	$150.88
Rate for Payer: Medicare All Medicare	$114.80
Rate for Payer: Monida Allegiance	$155.80
Rate for Payer: Monida First Choice Health	$159.08
Rate for Payer: Monida Montana Health Co-op	$155.80
Rate for Payer: Monida PacificSource	$155.80

HCG RAPID TEST KIT PREGNANCY

Facility

$37.91

Hospital Charge Code	90196523
Hospital Revenue Code	270
Min. Negotiated Rate	$26.54
Max. Negotiated Rate	$37.91
Rate for Payer: Aetna Commercial	$36.01
Rate for Payer: Aetna Medicare	$34.12
Rate for Payer: BCBS MT CHIP	$34.12
Rate for Payer: BCBS MT Closed Plan Network	$36.01
Rate for Payer: BCBS MT HealthLink	$34.12
Rate for Payer: BCBS MT Medicare	$34.12
Rate for Payer: BCBS MT POS	$36.01
Rate for Payer: BCBS MT Traditional	$37.91
Rate for Payer: Cash Price	$34.12
Rate for Payer: Cigna Commercial	$36.01
Rate for Payer: Cigna Medicare	$34.12
Rate for Payer: Medicaid All Medicaid	$34.88
Rate for Payer: Medicare All Medicare	$26.54
Rate for Payer: Monida Allegiance	$36.01
Rate for Payer: Monida First Choice Health	$36.77
Rate for Payer: Monida Montana Health Co-op	$36.01
Rate for Payer: Monida PacificSource	$36.01

HCG RAPID TEST KIT PREGNANCY

Facility

$37.91

Hospital Charge Code	90196523
Hospital Revenue Code	270
Min. Negotiated Rate	$26.54
Max. Negotiated Rate	$37.91
Rate for Payer: Aetna Commercial	$36.01
Rate for Payer: Aetna Medicare	$34.12
Rate for Payer: BCBS MT CHIP	$34.12
Rate for Payer: BCBS MT Closed Plan Network	$36.01
Rate for Payer: BCBS MT HealthLink	$34.12
Rate for Payer: BCBS MT Medicare	$34.12
Rate for Payer: BCBS MT POS	$36.01
Rate for Payer: BCBS MT Traditional	$37.91
Rate for Payer: Cash Price	$34.12
Rate for Payer: Cigna Commercial	$36.01
Rate for Payer: Cigna Medicare	$34.12
Rate for Payer: Medicaid All Medicaid	$34.88
Rate for Payer: Medicare All Medicare	$26.54
Rate for Payer: Monida Allegiance	$36.01
Rate for Payer: Monida First Choice Health	$36.77
Rate for Payer: Monida Montana Health Co-op	$36.01
Rate for Payer: Monida PacificSource	$36.01

HCG, TUMOR MARKER (140450)

Facility

$72.00

Service Code	CPT 84702
Hospital Charge Code	4047021
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

HCG, TUMOR MARKER (140450)

Facility

$72.00

Service Code	CPT 84702
Hospital Charge Code	4047021
Hospital Revenue Code	300
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

HCV QUANT W REFLEX HCV GENOTYPE

Facility

$209.00

Service Code	CPT 87902
Hospital Charge Code	4068031
Hospital Revenue Code	300
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$209.00
Rate for Payer: Aetna Commercial	$198.55
Rate for Payer: Aetna Medicare	$188.10
Rate for Payer: BCBS MT CHIP	$188.10
Rate for Payer: BCBS MT Closed Plan Network	$198.55
Rate for Payer: BCBS MT HealthLink	$188.10
Rate for Payer: BCBS MT Medicare	$188.10
Rate for Payer: BCBS MT POS	$198.55
Rate for Payer: BCBS MT Traditional	$209.00
Rate for Payer: Cash Price	$188.10
Rate for Payer: Cigna Commercial	$198.55
Rate for Payer: Cigna Medicare	$188.10
Rate for Payer: Medicaid All Medicaid	$192.28
Rate for Payer: Medicare All Medicare	$146.30
Rate for Payer: Monida Allegiance	$198.55
Rate for Payer: Monida First Choice Health	$202.73
Rate for Payer: Monida Montana Health Co-op	$198.55
Rate for Payer: Monida PacificSource	$198.55

HCV QUANT W REFLEX HCV GENOTYPE

Facility

$209.00

Service Code	CPT 87902
Hospital Charge Code	4068031
Hospital Revenue Code	300
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$209.00
Rate for Payer: Aetna Commercial	$198.55
Rate for Payer: Aetna Medicare	$188.10
Rate for Payer: BCBS MT CHIP	$188.10
Rate for Payer: BCBS MT Closed Plan Network	$198.55
Rate for Payer: BCBS MT HealthLink	$188.10
Rate for Payer: BCBS MT Medicare	$188.10
Rate for Payer: BCBS MT POS	$198.55
Rate for Payer: BCBS MT Traditional	$209.00
Rate for Payer: Cash Price	$188.10
Rate for Payer: Cigna Commercial	$198.55
Rate for Payer: Cigna Medicare	$188.10
Rate for Payer: Medicaid All Medicaid	$192.28
Rate for Payer: Medicare All Medicare	$146.30
Rate for Payer: Monida Allegiance	$198.55
Rate for Payer: Monida First Choice Health	$202.73
Rate for Payer: Monida Montana Health Co-op	$198.55
Rate for Payer: Monida PacificSource	$198.55

HCV RNA VIRAL LOAD NAAT (3000572)

Facility

$210.00

Service Code	CPT 86803
Hospital Charge Code	4087948
Hospital Revenue Code	300
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare	$189.00
Rate for Payer: BCBS MT CHIP	$189.00
Rate for Payer: BCBS MT Closed Plan Network	$199.50
Rate for Payer: BCBS MT HealthLink	$189.00
Rate for Payer: BCBS MT Medicare	$189.00
Rate for Payer: BCBS MT POS	$199.50
Rate for Payer: BCBS MT Traditional	$210.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial	$199.50
Rate for Payer: Cigna Medicare	$189.00
Rate for Payer: Medicaid All Medicaid	$193.20
Rate for Payer: Medicare All Medicare	$147.00
Rate for Payer: Monida Allegiance	$199.50
Rate for Payer: Monida First Choice Health	$203.70
Rate for Payer: Monida Montana Health Co-op	$199.50
Rate for Payer: Monida PacificSource	$199.50

HCV RNA VIRAL LOAD NAAT (3000572)

Facility

$210.00

Service Code	CPT 86803
Hospital Charge Code	4087948
Hospital Revenue Code	300
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare	$189.00
Rate for Payer: BCBS MT CHIP	$189.00
Rate for Payer: BCBS MT Closed Plan Network	$199.50
Rate for Payer: BCBS MT HealthLink	$189.00
Rate for Payer: BCBS MT Medicare	$189.00
Rate for Payer: BCBS MT POS	$199.50
Rate for Payer: BCBS MT Traditional	$210.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial	$199.50
Rate for Payer: Cigna Medicare	$189.00
Rate for Payer: Medicaid All Medicaid	$193.20
Rate for Payer: Medicare All Medicare	$147.00
Rate for Payer: Monida Allegiance	$199.50
Rate for Payer: Monida First Choice Health	$203.70
Rate for Payer: Monida Montana Health Co-op	$199.50
Rate for Payer: Monida PacificSource	$199.50

Know your out-of-pocket cost for care.

All Charges