Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HOV HOME VISIT EST BRIEF

Facility

$123.00

Service Code	CPT 99347
Hospital Charge Code	799347
Hospital Revenue Code	522
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna Commercial	$116.85
Rate for Payer: Aetna Medicare	$110.70
Rate for Payer: BCBS MT CHIP	$110.70
Rate for Payer: BCBS MT Closed Plan Network	$116.85
Rate for Payer: BCBS MT HealthLink	$110.70
Rate for Payer: BCBS MT Medicare	$110.70
Rate for Payer: BCBS MT POS	$116.85
Rate for Payer: BCBS MT Traditional	$123.00
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial	$116.85
Rate for Payer: Cigna Medicare	$110.70
Rate for Payer: Medicaid All Medicaid	$113.16
Rate for Payer: Medicare All Medicare	$86.10
Rate for Payer: Monida Allegiance	$116.85
Rate for Payer: Monida First Choice Health	$119.31
Rate for Payer: Monida Montana Health Co-op	$116.85
Rate for Payer: Monida PacificSource	$116.85

HOV HOME VISIT EST BRIEF

Facility

$123.00

Service Code	CPT 99347
Hospital Charge Code	799347
Hospital Revenue Code	522
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna Commercial	$116.85
Rate for Payer: Aetna Medicare	$110.70
Rate for Payer: BCBS MT CHIP	$110.70
Rate for Payer: BCBS MT Closed Plan Network	$116.85
Rate for Payer: BCBS MT HealthLink	$110.70
Rate for Payer: BCBS MT Medicare	$110.70
Rate for Payer: BCBS MT POS	$116.85
Rate for Payer: BCBS MT Traditional	$123.00
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial	$116.85
Rate for Payer: Cigna Medicare	$110.70
Rate for Payer: Medicaid All Medicaid	$113.16
Rate for Payer: Medicare All Medicare	$86.10
Rate for Payer: Monida Allegiance	$116.85
Rate for Payer: Monida First Choice Health	$119.31
Rate for Payer: Monida Montana Health Co-op	$116.85
Rate for Payer: Monida PacificSource	$116.85

HOV HOME VISIT EST EXTENDED

Facility

$284.00

Service Code	CPT 99349
Hospital Charge Code	799349
Hospital Revenue Code	522
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

HOV HOME VISIT EST EXTENDED

Facility

$284.00

Service Code	CPT 99349
Hospital Charge Code	799349
Hospital Revenue Code	522
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

HOV HOME VISIT EST INTERMEDIATE

Facility

$190.00

Service Code	CPT 99348
Hospital Charge Code	799348
Hospital Revenue Code	522
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$190.00
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: BCBS MT CHIP	$171.00
Rate for Payer: BCBS MT Closed Plan Network	$180.50
Rate for Payer: BCBS MT HealthLink	$171.00
Rate for Payer: BCBS MT Medicare	$171.00
Rate for Payer: BCBS MT POS	$180.50
Rate for Payer: BCBS MT Traditional	$190.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cigna Commercial	$180.50
Rate for Payer: Cigna Medicare	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

HOV HOME VISIT EST INTERMEDIATE

Facility

$190.00

Service Code	CPT 99348
Hospital Charge Code	799348
Hospital Revenue Code	522
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$190.00
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: BCBS MT CHIP	$171.00
Rate for Payer: BCBS MT Closed Plan Network	$180.50
Rate for Payer: BCBS MT HealthLink	$171.00
Rate for Payer: BCBS MT Medicare	$171.00
Rate for Payer: BCBS MT POS	$180.50
Rate for Payer: BCBS MT Traditional	$190.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cigna Commercial	$180.50
Rate for Payer: Cigna Medicare	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

HPV COMBO ASSAY CA SCREEN

Facility

$254.00

Service Code	HCPCS G0476
Hospital Charge Code	80000476
Hospital Revenue Code	521
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

HPV COMBO ASSAY CA SCREEN

Facility

$254.00

Service Code	HCPCS G0476
Hospital Charge Code	80000476
Hospital Revenue Code	521
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

HPV GARDASIL 9

Facility

$728.00

Service Code	CPT 90651
Hospital Charge Code	8090651
Hospital Revenue Code	521
Min. Negotiated Rate	$509.60
Max. Negotiated Rate	$728.00
Rate for Payer: Aetna Commercial	$691.60
Rate for Payer: Aetna Medicare	$655.20
Rate for Payer: BCBS MT CHIP	$655.20
Rate for Payer: BCBS MT Closed Plan Network	$691.60
Rate for Payer: BCBS MT HealthLink	$655.20
Rate for Payer: BCBS MT Medicare	$655.20
Rate for Payer: BCBS MT POS	$691.60
Rate for Payer: BCBS MT Traditional	$728.00
Rate for Payer: Cash Price	$655.20
Rate for Payer: Cigna Commercial	$691.60
Rate for Payer: Cigna Medicare	$655.20
Rate for Payer: Medicaid All Medicaid	$669.76
Rate for Payer: Medicare All Medicare	$509.60
Rate for Payer: Monida Allegiance	$691.60
Rate for Payer: Monida First Choice Health	$706.16
Rate for Payer: Monida Montana Health Co-op	$691.60
Rate for Payer: Monida PacificSource	$691.60

HPV GARDASIL 9

Facility

$728.00

Service Code	CPT 90651
Hospital Charge Code	8090651
Hospital Revenue Code	521
Min. Negotiated Rate	$509.60
Max. Negotiated Rate	$728.00
Rate for Payer: Aetna Commercial	$691.60
Rate for Payer: Aetna Medicare	$655.20
Rate for Payer: BCBS MT CHIP	$655.20
Rate for Payer: BCBS MT Closed Plan Network	$691.60
Rate for Payer: BCBS MT HealthLink	$655.20
Rate for Payer: BCBS MT Medicare	$655.20
Rate for Payer: BCBS MT POS	$691.60
Rate for Payer: BCBS MT Traditional	$728.00
Rate for Payer: Cash Price	$655.20
Rate for Payer: Cigna Commercial	$691.60
Rate for Payer: Cigna Medicare	$655.20
Rate for Payer: Medicaid All Medicaid	$669.76
Rate for Payer: Medicare All Medicare	$509.60
Rate for Payer: Monida Allegiance	$691.60
Rate for Payer: Monida First Choice Health	$706.16
Rate for Payer: Monida Montana Health Co-op	$691.60
Rate for Payer: Monida PacificSource	$691.60

HPV GENOTYPES 16 AND 18

Facility

$136.00

Service Code	CPT 87625
Hospital Charge Code	4087957
Hospital Revenue Code	310
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna Commercial	$129.20
Rate for Payer: Aetna Medicare	$122.40
Rate for Payer: BCBS MT CHIP	$122.40
Rate for Payer: BCBS MT Closed Plan Network	$129.20
Rate for Payer: BCBS MT HealthLink	$122.40
Rate for Payer: BCBS MT Medicare	$122.40
Rate for Payer: BCBS MT POS	$129.20
Rate for Payer: BCBS MT Traditional	$136.00
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna Commercial	$129.20
Rate for Payer: Cigna Medicare	$122.40
Rate for Payer: Medicaid All Medicaid	$125.12
Rate for Payer: Medicare All Medicare	$95.20
Rate for Payer: Monida Allegiance	$129.20
Rate for Payer: Monida First Choice Health	$131.92
Rate for Payer: Monida Montana Health Co-op	$129.20
Rate for Payer: Monida PacificSource	$129.20

HPV GENOTYPES 16 AND 18

Facility

$136.00

Service Code	CPT 87625
Hospital Charge Code	4087957
Hospital Revenue Code	310
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna Commercial	$129.20
Rate for Payer: Aetna Medicare	$122.40
Rate for Payer: BCBS MT CHIP	$122.40
Rate for Payer: BCBS MT Closed Plan Network	$129.20
Rate for Payer: BCBS MT HealthLink	$122.40
Rate for Payer: BCBS MT Medicare	$122.40
Rate for Payer: BCBS MT POS	$129.20
Rate for Payer: BCBS MT Traditional	$136.00
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna Commercial	$129.20
Rate for Payer: Cigna Medicare	$122.40
Rate for Payer: Medicaid All Medicaid	$125.12
Rate for Payer: Medicare All Medicare	$95.20
Rate for Payer: Monida Allegiance	$129.20
Rate for Payer: Monida First Choice Health	$131.92
Rate for Payer: Monida Montana Health Co-op	$129.20
Rate for Payer: Monida PacificSource	$129.20

HPV GUARDASIL (19-27 YRS)

Facility

$195.00

Service Code	CPT 90649
Hospital Charge Code	8090649
Hospital Revenue Code	521
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

HPV GUARDASIL (19-27 YRS)

Facility

$195.00

Service Code	CPT 90649
Hospital Charge Code	8090649
Hospital Revenue Code	521
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

HPV HIGH-RISK TYPES

Facility

$124.00

Service Code	CPT 87624
Hospital Charge Code	8087624
Hospital Revenue Code	521
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

HPV HIGH-RISK TYPES

Facility

$124.00

Service Code	CPT 87624
Hospital Charge Code	8087624
Hospital Revenue Code	521
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

H PYLORI ANTIBODY

Facility

$92.00

Service Code	CPT 86677
Hospital Charge Code	4086677
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

H PYLORI ANTIBODY

Facility

$92.00

Service Code	CPT 86677
Hospital Charge Code	4086677
Hospital Revenue Code	300
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

H PYLORI ANTIBODY IGG

Facility

$90.00

Service Code	CPT 86677
Hospital Charge Code	4088135
Hospital Revenue Code	300
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

H PYLORI ANTIBODY IGG

Facility

$90.00

Service Code	CPT 86677
Hospital Charge Code	4088135
Hospital Revenue Code	300
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

H PYLORI ANTIGEN, STOOL (180764)

Facility

$171.00

Service Code	CPT 87338
Hospital Charge Code	4087338
Hospital Revenue Code	301
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

H PYLORI ANTIGEN, STOOL (180764)

Facility

$171.00

Service Code	CPT 87338
Hospital Charge Code	4087338
Hospital Revenue Code	301
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna Commercial	$162.45
Rate for Payer: Aetna Medicare	$153.90
Rate for Payer: BCBS MT CHIP	$153.90
Rate for Payer: BCBS MT Closed Plan Network	$162.45
Rate for Payer: BCBS MT HealthLink	$153.90
Rate for Payer: BCBS MT Medicare	$153.90
Rate for Payer: BCBS MT POS	$162.45
Rate for Payer: BCBS MT Traditional	$171.00
Rate for Payer: Cash Price	$153.90
Rate for Payer: Cigna Commercial	$162.45
Rate for Payer: Cigna Medicare	$153.90
Rate for Payer: Medicaid All Medicaid	$157.32
Rate for Payer: Medicare All Medicare	$119.70
Rate for Payer: Monida Allegiance	$162.45
Rate for Payer: Monida First Choice Health	$165.87
Rate for Payer: Monida Montana Health Co-op	$162.45
Rate for Payer: Monida PacificSource	$162.45

H PYLORI BREATH TEST (180836)

Facility

$236.00

Service Code	CPT 83013
Hospital Charge Code	4083013
Hospital Revenue Code	301
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$236.00
Rate for Payer: Aetna Commercial	$224.20
Rate for Payer: Aetna Medicare	$212.40
Rate for Payer: BCBS MT CHIP	$212.40
Rate for Payer: BCBS MT Closed Plan Network	$224.20
Rate for Payer: BCBS MT HealthLink	$212.40
Rate for Payer: BCBS MT Medicare	$212.40
Rate for Payer: BCBS MT POS	$224.20
Rate for Payer: BCBS MT Traditional	$236.00
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$224.20
Rate for Payer: Cigna Medicare	$212.40
Rate for Payer: Medicaid All Medicaid	$217.12
Rate for Payer: Medicare All Medicare	$165.20
Rate for Payer: Monida Allegiance	$224.20
Rate for Payer: Monida First Choice Health	$228.92
Rate for Payer: Monida Montana Health Co-op	$224.20
Rate for Payer: Monida PacificSource	$224.20

H PYLORI BREATH TEST (180836)

Facility

$236.00

Service Code	CPT 83013
Hospital Charge Code	4083013
Hospital Revenue Code	301
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$236.00
Rate for Payer: Aetna Commercial	$224.20
Rate for Payer: Aetna Medicare	$212.40
Rate for Payer: BCBS MT CHIP	$212.40
Rate for Payer: BCBS MT Closed Plan Network	$224.20
Rate for Payer: BCBS MT HealthLink	$212.40
Rate for Payer: BCBS MT Medicare	$212.40
Rate for Payer: BCBS MT POS	$224.20
Rate for Payer: BCBS MT Traditional	$236.00
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$224.20
Rate for Payer: Cigna Medicare	$212.40
Rate for Payer: Medicaid All Medicaid	$217.12
Rate for Payer: Medicare All Medicare	$165.20
Rate for Payer: Monida Allegiance	$224.20
Rate for Payer: Monida First Choice Health	$228.92
Rate for Payer: Monida Montana Health Co-op	$224.20
Rate for Payer: Monida PacificSource	$224.20

H PYLORI KIT

Facility

$149.51

Hospital Charge Code	90197139
Hospital Revenue Code	270
Min. Negotiated Rate	$104.66
Max. Negotiated Rate	$149.51
Rate for Payer: Aetna Commercial	$142.03
Rate for Payer: Aetna Medicare	$134.56
Rate for Payer: BCBS MT CHIP	$134.56
Rate for Payer: BCBS MT Closed Plan Network	$142.03
Rate for Payer: BCBS MT HealthLink	$134.56
Rate for Payer: BCBS MT Medicare	$134.56
Rate for Payer: BCBS MT POS	$142.03
Rate for Payer: BCBS MT Traditional	$149.51
Rate for Payer: Cash Price	$134.56
Rate for Payer: Cigna Commercial	$142.03
Rate for Payer: Cigna Medicare	$134.56
Rate for Payer: Medicaid All Medicaid	$137.55
Rate for Payer: Medicare All Medicare	$104.66
Rate for Payer: Monida Allegiance	$142.03
Rate for Payer: Monida First Choice Health	$145.02
Rate for Payer: Monida Montana Health Co-op	$142.03
Rate for Payer: Monida PacificSource	$142.03

Know your out-of-pocket cost for care.

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