Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

KNEE WRAP HINGED MD

Facility

$196.00

Hospital Charge Code	2893373
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

KNEE WRAP HINGED MD

Facility

$196.00

Hospital Charge Code	2893373
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

KNEE WRAP HINGED SM

Facility

$196.00

Hospital Charge Code	2893372
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

KNEE WRAP HINGED SM

Facility

$196.00

Hospital Charge Code	2893372
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

KNEE WRAP HINGED XL

Facility

$196.00

Hospital Charge Code	2893375
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

KNEE WRAP HINGED XL

Facility

$196.00

Hospital Charge Code	2893375
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

KOH PREP: SKIN, HAIR, OR NAILS

Facility

$58.00

Service Code	CPT 87220
Hospital Charge Code	4087220
Hospital Revenue Code	306
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

KOH PREP: SKIN, HAIR, OR NAILS

Facility

$58.00

Service Code	CPT 87220
Hospital Charge Code	4087220
Hospital Revenue Code	306
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

KOVA CENTRIF TUBE

Facility

$9.39

Hospital Charge Code	90197060
Hospital Revenue Code	300
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$9.39
Rate for Payer: Aetna Commercial	$8.92
Rate for Payer: Aetna Medicare	$8.45
Rate for Payer: BCBS MT CHIP	$8.45
Rate for Payer: BCBS MT Closed Plan Network	$8.92
Rate for Payer: BCBS MT HealthLink	$8.45
Rate for Payer: BCBS MT Medicare	$8.45
Rate for Payer: BCBS MT POS	$8.92
Rate for Payer: BCBS MT Traditional	$9.39
Rate for Payer: Cash Price	$8.45
Rate for Payer: Cigna Commercial	$8.92
Rate for Payer: Cigna Medicare	$8.45
Rate for Payer: Medicaid All Medicaid	$8.64
Rate for Payer: Medicare All Medicare	$6.57
Rate for Payer: Monida Allegiance	$8.92
Rate for Payer: Monida First Choice Health	$9.11
Rate for Payer: Monida Montana Health Co-op	$8.92
Rate for Payer: Monida PacificSource	$8.92

KOVA CENTRIF TUBE

Facility

$9.39

Hospital Charge Code	90197060
Hospital Revenue Code	300
Min. Negotiated Rate	$6.57
Max. Negotiated Rate	$9.39
Rate for Payer: Aetna Commercial	$8.92
Rate for Payer: Aetna Medicare	$8.45
Rate for Payer: BCBS MT CHIP	$8.45
Rate for Payer: BCBS MT Closed Plan Network	$8.92
Rate for Payer: BCBS MT HealthLink	$8.45
Rate for Payer: BCBS MT Medicare	$8.45
Rate for Payer: BCBS MT POS	$8.92
Rate for Payer: BCBS MT Traditional	$9.39
Rate for Payer: Cash Price	$8.45
Rate for Payer: Cigna Commercial	$8.92
Rate for Payer: Cigna Medicare	$8.45
Rate for Payer: Medicaid All Medicaid	$8.64
Rate for Payer: Medicare All Medicare	$6.57
Rate for Payer: Monida Allegiance	$8.92
Rate for Payer: Monida First Choice Health	$9.11
Rate for Payer: Monida Montana Health Co-op	$8.92
Rate for Payer: Monida PacificSource	$8.92

LAB 24HR URINE CYSTINE

Facility

$73.00

Service Code	CPT 82131
Hospital Charge Code	4082131
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 24HR URINE CYSTINE

Facility

$73.00

Service Code	CPT 82131
Hospital Charge Code	4082131
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 ACETYLCHOLINE RECEPTOR AB BINDING

Facility

$175.00

Service Code	CPT 84238
Hospital Charge Code	4084299
Hospital Revenue Code	301
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

LAB ACETYLCHOLINE RECEPTOR AB BINDING

Facility

$175.00

Service Code	CPT 84238
Hospital Charge Code	4084299
Hospital Revenue Code	301
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

LAB ACETYLCHOLINE RECEPTOR AB MODULATIN

Facility

$175.00

Service Code	CPT 84238
Hospital Charge Code	4084238
Hospital Revenue Code	301
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

LAB ACETYLCHOLINE RECEPTOR AB MODULATIN

Facility

$175.00

Service Code	CPT 84238
Hospital Charge Code	4084238
Hospital Revenue Code	301
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

LAB ACYLEARNITINE DISORDER

Facility

$109.00

Service Code	CPT 82017
Hospital Charge Code	4082017
Hospital Revenue Code	300
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

LAB ACYLEARNITINE DISORDER

Facility

$109.00

Service Code	CPT 82017
Hospital Charge Code	4082017
Hospital Revenue Code	300
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

LAB ALKALOIDS

Facility

$64.00

Service Code	CPT 80323
Hospital Charge Code	4080323
Hospital Revenue Code	300
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

LAB ALKALOIDS

Facility

$64.00

Service Code	CPT 80323
Hospital Charge Code	4080323
Hospital Revenue Code	300
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

LAB ALLERGY TEST: ALMOND

Facility

$56.00

Service Code	CPT 86003
Hospital Charge Code	4000310
Hospital Revenue Code	300
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

LAB ALLERGY TEST: ALMOND

Facility

$56.00

Service Code	CPT 86003
Hospital Charge Code	4000310
Hospital Revenue Code	300
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

LAB ALLERGY TEST: BRAZIL NUT

Facility

$36.00

Service Code	CPT 86003
Hospital Charge Code	4060044
Hospital Revenue Code	300
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

LAB ALLERGY TEST: BRAZIL NUT

Facility

$36.00

Service Code	CPT 86003
Hospital Charge Code	4060044
Hospital Revenue Code	300
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

LAB ALLERGY TEST: CASHEW NUT

Facility

$56.00

Service Code	CPT 86003
Hospital Charge Code	4060038
Hospital Revenue Code	300
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$56.00
Rate for Payer: Aetna Commercial	$53.20
Rate for Payer: Aetna Medicare	$50.40
Rate for Payer: BCBS MT CHIP	$50.40
Rate for Payer: BCBS MT Closed Plan Network	$53.20
Rate for Payer: BCBS MT HealthLink	$50.40
Rate for Payer: BCBS MT Medicare	$50.40
Rate for Payer: BCBS MT POS	$53.20
Rate for Payer: BCBS MT Traditional	$56.00
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cigna Commercial	$53.20
Rate for Payer: Cigna Medicare	$50.40
Rate for Payer: Medicaid All Medicaid	$51.52
Rate for Payer: Medicare All Medicare	$39.20
Rate for Payer: Monida Allegiance	$53.20
Rate for Payer: Monida First Choice Health	$54.32
Rate for Payer: Monida Montana Health Co-op	$53.20
Rate for Payer: Monida PacificSource	$53.20

Know your out-of-pocket cost for care.

All Charges