Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HEPATITIS C VIRUS ANTIBODY

Facility

$71.00

Service Code	CPT 86803
Hospital Charge Code	4086803
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

HEPATITIS C VIRUS FIBROSURE (550123)

Facility

$394.00

Service Code	CPT 81596
Hospital Charge Code	4081596
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

HEPATITIS C VIRUS FIBROSURE (550123)

Facility

$394.00

Service Code	CPT 81596
Hospital Charge Code	4081596
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

HEP B CORE AB IGM

Facility

$85.00

Service Code	CPT 86705
Hospital Charge Code	4088075
Hospital Revenue Code	302
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$80.75
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS MT CHIP	$76.50
Rate for Payer: BCBS MT Closed Plan Network	$80.75
Rate for Payer: BCBS MT HealthLink	$76.50
Rate for Payer: BCBS MT Medicare	$76.50
Rate for Payer: BCBS MT POS	$80.75
Rate for Payer: BCBS MT Traditional	$85.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Cigna Medicare	$76.50
Rate for Payer: Medicaid All Medicaid	$78.20
Rate for Payer: Medicare All Medicare	$59.50
Rate for Payer: Monida Allegiance	$80.75
Rate for Payer: Monida First Choice Health	$82.45
Rate for Payer: Monida Montana Health Co-op	$80.75
Rate for Payer: Monida PacificSource	$80.75

HEP B CORE AB IGM

Facility

$85.00

Service Code	CPT 86705
Hospital Charge Code	4088075
Hospital Revenue Code	302
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$80.75
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS MT CHIP	$76.50
Rate for Payer: BCBS MT Closed Plan Network	$80.75
Rate for Payer: BCBS MT HealthLink	$76.50
Rate for Payer: BCBS MT Medicare	$76.50
Rate for Payer: BCBS MT POS	$80.75
Rate for Payer: BCBS MT Traditional	$85.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Cigna Medicare	$76.50
Rate for Payer: Medicaid All Medicaid	$78.20
Rate for Payer: Medicare All Medicare	$59.50
Rate for Payer: Monida Allegiance	$80.75
Rate for Payer: Monida First Choice Health	$82.45
Rate for Payer: Monida Montana Health Co-op	$80.75
Rate for Payer: Monida PacificSource	$80.75

HEP B CORE AB TOTAL W/ RFLX IGM (160101)

Facility

$68.00

Service Code	CPT 86704
Hospital Charge Code	4067041
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

HEP B CORE AB TOTAL W/ RFLX IGM (160101)

Facility

$68.00

Service Code	CPT 86704
Hospital Charge Code	4067041
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

HEP B VIRUS QUANTITATIVE AG

Facility

$120.00

Service Code	CPT 87517
Hospital Charge Code	4088088
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

HEP B VIRUS QUANTITATIVE AG

Facility

$120.00

Service Code	CPT 87517
Hospital Charge Code	4088088
Hospital Revenue Code	302
Min. Negotiated Rate	$84.00
Max. Negotiated Rate	$120.00
Rate for Payer: Aetna Commercial	$114.00
Rate for Payer: Aetna Medicare	$108.00
Rate for Payer: BCBS MT CHIP	$108.00
Rate for Payer: BCBS MT Closed Plan Network	$114.00
Rate for Payer: BCBS MT HealthLink	$108.00
Rate for Payer: BCBS MT Medicare	$108.00
Rate for Payer: BCBS MT POS	$114.00
Rate for Payer: BCBS MT Traditional	$120.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cigna Commercial	$114.00
Rate for Payer: Cigna Medicare	$108.00
Rate for Payer: Medicaid All Medicaid	$110.40
Rate for Payer: Medicare All Medicare	$84.00
Rate for Payer: Monida Allegiance	$114.00
Rate for Payer: Monida First Choice Health	$116.40
Rate for Payer: Monida Montana Health Co-op	$114.00
Rate for Payer: Monida PacificSource	$114.00

HIP DISLOCATION CLOSED W/O ANESTH

Facility

$1,065.00

Service Code	CPT 27250
Hospital Charge Code	8027250
Hospital Revenue Code	521
Min. Negotiated Rate	$745.50
Max. Negotiated Rate	$1,065.00
Rate for Payer: Aetna Commercial	$1,011.75
Rate for Payer: Aetna Medicare	$958.50
Rate for Payer: BCBS MT CHIP	$958.50
Rate for Payer: BCBS MT Closed Plan Network	$1,011.75
Rate for Payer: BCBS MT HealthLink	$958.50
Rate for Payer: BCBS MT Medicare	$958.50
Rate for Payer: BCBS MT POS	$1,011.75
Rate for Payer: BCBS MT Traditional	$1,065.00
Rate for Payer: Cash Price	$958.50
Rate for Payer: Cigna Commercial	$1,011.75
Rate for Payer: Cigna Medicare	$958.50
Rate for Payer: Medicaid All Medicaid	$979.80
Rate for Payer: Medicare All Medicare	$745.50
Rate for Payer: Monida Allegiance	$1,011.75
Rate for Payer: Monida First Choice Health	$1,033.05
Rate for Payer: Monida Montana Health Co-op	$1,011.75
Rate for Payer: Monida PacificSource	$1,011.75

HIP DISLOCATION CLOSED W/O ANESTH

Facility

$1,065.00

Service Code	CPT 27250
Hospital Charge Code	8027250
Hospital Revenue Code	521
Min. Negotiated Rate	$745.50
Max. Negotiated Rate	$1,065.00
Rate for Payer: Aetna Commercial	$1,011.75
Rate for Payer: Aetna Medicare	$958.50
Rate for Payer: BCBS MT CHIP	$958.50
Rate for Payer: BCBS MT Closed Plan Network	$1,011.75
Rate for Payer: BCBS MT HealthLink	$958.50
Rate for Payer: BCBS MT Medicare	$958.50
Rate for Payer: BCBS MT POS	$1,011.75
Rate for Payer: BCBS MT Traditional	$1,065.00
Rate for Payer: Cash Price	$958.50
Rate for Payer: Cigna Commercial	$1,011.75
Rate for Payer: Cigna Medicare	$958.50
Rate for Payer: Medicaid All Medicaid	$979.80
Rate for Payer: Medicare All Medicare	$745.50
Rate for Payer: Monida Allegiance	$1,011.75
Rate for Payer: Monida First Choice Health	$1,033.05
Rate for Payer: Monida Montana Health Co-op	$1,011.75
Rate for Payer: Monida PacificSource	$1,011.75

HISTAMINE 24 HR URINE

Facility

$230.00

Service Code	CPT 83008
Hospital Charge Code	4088013
Hospital Revenue Code	302
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

HISTAMINE 24 HR URINE

Facility

$230.00

Service Code	CPT 83008
Hospital Charge Code	4088013
Hospital Revenue Code	302
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

HISTAMINE 83088

Facility

$303.00

Service Code	CPT 83088
Hospital Charge Code	4083088
Hospital Revenue Code	300
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

HISTAMINE 83088

Facility

$303.00

Service Code	CPT 83088
Hospital Charge Code	4083088
Hospital Revenue Code	300
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

HISTOLOGIC CONFIRMATION

Facility

$104.33

Service Code	CPT 88302
Hospital Charge Code	4087929
Hospital Revenue Code	310
Min. Negotiated Rate	$73.03
Max. Negotiated Rate	$104.33
Rate for Payer: Aetna Commercial	$99.11
Rate for Payer: Aetna Medicare	$93.90
Rate for Payer: BCBS MT CHIP	$93.90
Rate for Payer: BCBS MT Closed Plan Network	$99.11
Rate for Payer: BCBS MT HealthLink	$93.90
Rate for Payer: BCBS MT Medicare	$93.90
Rate for Payer: BCBS MT POS	$99.11
Rate for Payer: BCBS MT Traditional	$104.33
Rate for Payer: Cash Price	$93.90
Rate for Payer: Cigna Commercial	$99.11
Rate for Payer: Cigna Medicare	$93.90
Rate for Payer: Medicaid All Medicaid	$95.98
Rate for Payer: Medicare All Medicare	$73.03
Rate for Payer: Monida Allegiance	$99.11
Rate for Payer: Monida First Choice Health	$101.20
Rate for Payer: Monida Montana Health Co-op	$99.11
Rate for Payer: Monida PacificSource	$99.11

HISTOLOGIC CONFIRMATION

Facility

$104.33

Service Code	CPT 88302
Hospital Charge Code	4087929
Hospital Revenue Code	310
Min. Negotiated Rate	$73.03
Max. Negotiated Rate	$104.33
Rate for Payer: Aetna Commercial	$99.11
Rate for Payer: Aetna Medicare	$93.90
Rate for Payer: BCBS MT CHIP	$93.90
Rate for Payer: BCBS MT Closed Plan Network	$99.11
Rate for Payer: BCBS MT HealthLink	$93.90
Rate for Payer: BCBS MT Medicare	$93.90
Rate for Payer: BCBS MT POS	$99.11
Rate for Payer: BCBS MT Traditional	$104.33
Rate for Payer: Cash Price	$93.90
Rate for Payer: Cigna Commercial	$99.11
Rate for Payer: Cigna Medicare	$93.90
Rate for Payer: Medicaid All Medicaid	$95.98
Rate for Payer: Medicare All Medicare	$73.03
Rate for Payer: Monida Allegiance	$99.11
Rate for Payer: Monida First Choice Health	$101.20
Rate for Payer: Monida Montana Health Co-op	$99.11
Rate for Payer: Monida PacificSource	$99.11

HISTOPLASMA AB COMPLIMENT FIX

Facility

$116.00

Service Code	CPT 86698
Hospital Charge Code	4087969
Hospital Revenue Code	302
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

HISTOPLASMA AB COMPLIMENT FIX

Facility

$116.00

Service Code	CPT 86698
Hospital Charge Code	4087969
Hospital Revenue Code	302
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

HISTOPLASMA AG QUAN EIA

Facility

$197.00

Service Code	CPT 84153
Hospital Charge Code	4087968
Hospital Revenue Code	302
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

HISTOPLASMA AG QUAN EIA

Facility

$197.00

Service Code	CPT 84153
Hospital Charge Code	4087968
Hospital Revenue Code	302
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

HIV-1 RNA QUANTITATIVE, PCR (550880)

Facility

$1,154.00

Service Code	CPT 87536
Hospital Charge Code	4087536
Hospital Revenue Code	306
Min. Negotiated Rate	$807.80
Max. Negotiated Rate	$1,154.00
Rate for Payer: Aetna Commercial	$1,096.30
Rate for Payer: Aetna Medicare	$1,038.60
Rate for Payer: BCBS MT CHIP	$1,038.60
Rate for Payer: BCBS MT Closed Plan Network	$1,096.30
Rate for Payer: BCBS MT HealthLink	$1,038.60
Rate for Payer: BCBS MT Medicare	$1,038.60
Rate for Payer: BCBS MT POS	$1,096.30
Rate for Payer: BCBS MT Traditional	$1,154.00
Rate for Payer: Cash Price	$1,038.60
Rate for Payer: Cigna Commercial	$1,096.30
Rate for Payer: Cigna Medicare	$1,038.60
Rate for Payer: Medicaid All Medicaid	$1,061.68
Rate for Payer: Medicare All Medicare	$807.80
Rate for Payer: Monida Allegiance	$1,096.30
Rate for Payer: Monida First Choice Health	$1,119.38
Rate for Payer: Monida Montana Health Co-op	$1,096.30
Rate for Payer: Monida PacificSource	$1,096.30

HIV-1 RNA QUANTITATIVE, PCR (550880)

Facility

$1,154.00

Service Code	CPT 87536
Hospital Charge Code	4087536
Hospital Revenue Code	306
Min. Negotiated Rate	$807.80
Max. Negotiated Rate	$1,154.00
Rate for Payer: Aetna Commercial	$1,096.30
Rate for Payer: Aetna Medicare	$1,038.60
Rate for Payer: BCBS MT CHIP	$1,038.60
Rate for Payer: BCBS MT Closed Plan Network	$1,096.30
Rate for Payer: BCBS MT HealthLink	$1,038.60
Rate for Payer: BCBS MT Medicare	$1,038.60
Rate for Payer: BCBS MT POS	$1,096.30
Rate for Payer: BCBS MT Traditional	$1,154.00
Rate for Payer: Cash Price	$1,038.60
Rate for Payer: Cigna Commercial	$1,096.30
Rate for Payer: Cigna Medicare	$1,038.60
Rate for Payer: Medicaid All Medicaid	$1,061.68
Rate for Payer: Medicare All Medicare	$807.80
Rate for Payer: Monida Allegiance	$1,096.30
Rate for Payer: Monida First Choice Health	$1,119.38
Rate for Payer: Monida Montana Health Co-op	$1,096.30
Rate for Payer: Monida PacificSource	$1,096.30

HIV AG/AB ASSAY CONFI

Facility

$84.00

Service Code	CPT 87389
Hospital Charge Code	4087906
Hospital Revenue Code	300
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

HIV AG/AB ASSAY CONFI

Facility

$84.00

Service Code	CPT 87389
Hospital Charge Code	4087906
Hospital Revenue Code	300
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

Know your out-of-pocket cost for care.

All Charges