Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAB PRENATAL PROFILE

Facility

$182.00

Service Code	CPT 80055
Hospital Charge Code	4080055
Hospital Revenue Code	300
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

LAB PRIMIDONE

Facility

$167.00

Service Code	CPT 80188
Hospital Charge Code	4080188
Hospital Revenue Code	300
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

LAB PRIMIDONE

Facility

$167.00

Service Code	CPT 80188
Hospital Charge Code	4080188
Hospital Revenue Code	300
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$167.00
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: BCBS MT CHIP	$150.30
Rate for Payer: BCBS MT Closed Plan Network	$158.65
Rate for Payer: BCBS MT HealthLink	$150.30
Rate for Payer: BCBS MT Medicare	$150.30
Rate for Payer: BCBS MT POS	$158.65
Rate for Payer: BCBS MT Traditional	$167.00
Rate for Payer: Cash Price	$150.30
Rate for Payer: Cigna Commercial	$158.65
Rate for Payer: Cigna Medicare	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

LAB PRO INSULIN

Facility

$189.00

Service Code	CPT 84206
Hospital Charge Code	4084206
Hospital Revenue Code	301
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: BCBS MT CHIP	$170.10
Rate for Payer: BCBS MT Closed Plan Network	$179.55
Rate for Payer: BCBS MT HealthLink	$170.10
Rate for Payer: BCBS MT Medicare	$170.10
Rate for Payer: BCBS MT POS	$179.55
Rate for Payer: BCBS MT Traditional	$189.00
Rate for Payer: Cash Price	$170.10
Rate for Payer: Cigna Commercial	$179.55
Rate for Payer: Cigna Medicare	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

LAB PRO INSULIN

Facility

$189.00

Service Code	CPT 84206
Hospital Charge Code	4084206
Hospital Revenue Code	301
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$189.00
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: BCBS MT CHIP	$170.10
Rate for Payer: BCBS MT Closed Plan Network	$179.55
Rate for Payer: BCBS MT HealthLink	$170.10
Rate for Payer: BCBS MT Medicare	$170.10
Rate for Payer: BCBS MT POS	$179.55
Rate for Payer: BCBS MT Traditional	$189.00
Rate for Payer: Cash Price	$170.10
Rate for Payer: Cigna Commercial	$179.55
Rate for Payer: Cigna Medicare	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

LAB PROSTATE ACID PHOSPHATASE

Facility

$47.00

Service Code	CPT 84066
Hospital Charge Code	4084066
Hospital Revenue Code	301
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

LAB PROSTATE ACID PHOSPHATASE

Facility

$47.00

Service Code	CPT 84066
Hospital Charge Code	4084066
Hospital Revenue Code	301
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

LAB PSA COMPLEXED

Facility

$89.00

Service Code	CPT 84152
Hospital Charge Code	4084152
Hospital Revenue Code	301
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

LAB PSA COMPLEXED

Facility

$89.00

Service Code	CPT 84152
Hospital Charge Code	4084152
Hospital Revenue Code	301
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

LAB PSA SCREENING ONLY

Facility

$148.00

Service Code	HCPCS G0103
Hospital Charge Code	4000103
Hospital Revenue Code	301
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna Commercial	$140.60
Rate for Payer: Aetna Medicare	$133.20
Rate for Payer: BCBS MT CHIP	$133.20
Rate for Payer: BCBS MT Closed Plan Network	$140.60
Rate for Payer: BCBS MT HealthLink	$133.20
Rate for Payer: BCBS MT Medicare	$133.20
Rate for Payer: BCBS MT POS	$140.60
Rate for Payer: BCBS MT Traditional	$148.00
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cigna Commercial	$140.60
Rate for Payer: Cigna Medicare	$133.20
Rate for Payer: Medicaid All Medicaid	$136.16
Rate for Payer: Medicare All Medicare	$103.60
Rate for Payer: Monida Allegiance	$140.60
Rate for Payer: Monida First Choice Health	$143.56
Rate for Payer: Monida Montana Health Co-op	$140.60
Rate for Payer: Monida PacificSource	$140.60

LAB PSA SCREENING ONLY

Facility

$148.00

Service Code	HCPCS G0103
Hospital Charge Code	4000103
Hospital Revenue Code	301
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$148.00
Rate for Payer: Aetna Commercial	$140.60
Rate for Payer: Aetna Medicare	$133.20
Rate for Payer: BCBS MT CHIP	$133.20
Rate for Payer: BCBS MT Closed Plan Network	$140.60
Rate for Payer: BCBS MT HealthLink	$133.20
Rate for Payer: BCBS MT Medicare	$133.20
Rate for Payer: BCBS MT POS	$140.60
Rate for Payer: BCBS MT Traditional	$148.00
Rate for Payer: Cash Price	$133.20
Rate for Payer: Cigna Commercial	$140.60
Rate for Payer: Cigna Medicare	$133.20
Rate for Payer: Medicaid All Medicaid	$136.16
Rate for Payer: Medicare All Medicare	$103.60
Rate for Payer: Monida Allegiance	$140.60
Rate for Payer: Monida First Choice Health	$143.56
Rate for Payer: Monida Montana Health Co-op	$140.60
Rate for Payer: Monida PacificSource	$140.60

LAB PSEUDOCHOLINESTERASE

Facility

$125.00

Service Code	CPT 82480
Hospital Charge Code	4082480
Hospital Revenue Code	300
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

LAB PSEUDOCHOLINESTERASE

Facility

$125.00

Service Code	CPT 82480
Hospital Charge Code	4082480
Hospital Revenue Code	300
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

LAB PYROLINKS-D

Facility

$109.00

Service Code	CPT 82523
Hospital Charge Code	4082523
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 PYROLINKS-D

Facility

$109.00

Service Code	CPT 82523
Hospital Charge Code	4082523
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 RABIES ANTIBODY TITER

Facility

$208.00

Service Code	CPT 86382
Hospital Charge Code	4086382
Hospital Revenue Code	300
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

LAB RABIES ANTIBODY TITER

Facility

$208.00

Service Code	CPT 86382
Hospital Charge Code	4086382
Hospital Revenue Code	300
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

LAB RANDON URIN

Facility

$39.00

Service Code	CPT 82436
Hospital Charge Code	4082436
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

LAB RANDON URIN

Facility

$39.00

Service Code	CPT 82436
Hospital Charge Code	4082436
Hospital Revenue Code	300
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$39.00
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: BCBS MT CHIP	$35.10
Rate for Payer: BCBS MT Closed Plan Network	$37.05
Rate for Payer: BCBS MT HealthLink	$35.10
Rate for Payer: BCBS MT Medicare	$35.10
Rate for Payer: BCBS MT POS	$37.05
Rate for Payer: BCBS MT Traditional	$39.00
Rate for Payer: Cash Price	$35.10
Rate for Payer: Cigna Commercial	$37.05
Rate for Payer: Cigna Medicare	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

LAB RAPID STREP

Facility

$121.00

Service Code	CPT 87430
Hospital Charge Code	4087430
Hospital Revenue Code	300
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

LAB RAPID STREP

Facility

$121.00

Service Code	CPT 87430
Hospital Charge Code	4087430
Hospital Revenue Code	300
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

LAB RESPIRATORY SYNCYTIAL VIRUS

Facility

$93.00

Service Code	CPT 87280
Hospital Charge Code	4087280
Hospital Revenue Code	302
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

LAB RESPIRATORY SYNCYTIAL VIRUS

Facility

$93.00

Service Code	CPT 87280
Hospital Charge Code	4087280
Hospital Revenue Code	302
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

LAB RETIC COUNT

Facility

$47.00

Service Code	CPT 85044
Hospital Charge Code	4085044
Hospital Revenue Code	305
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

LAB RETIC COUNT

Facility

$47.00

Service Code	CPT 85044
Hospital Charge Code	4085044
Hospital Revenue Code	305
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$47.00
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: BCBS MT CHIP	$42.30
Rate for Payer: BCBS MT Closed Plan Network	$44.65
Rate for Payer: BCBS MT HealthLink	$42.30
Rate for Payer: BCBS MT Medicare	$42.30
Rate for Payer: BCBS MT POS	$44.65
Rate for Payer: BCBS MT Traditional	$47.00
Rate for Payer: Cash Price	$42.30
Rate for Payer: Cigna Commercial	$44.65
Rate for Payer: Cigna Medicare	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

Know your out-of-pocket cost for care.

All Charges