Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ANTI-MULLERIAN HORMONE (500183)

Facility

$202.00

Service Code	CPT 82397
Hospital Charge Code	4082397
Hospital Revenue Code	300
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$202.00
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: BCBS MT CHIP	$181.80
Rate for Payer: BCBS MT Closed Plan Network	$191.90
Rate for Payer: BCBS MT HealthLink	$181.80
Rate for Payer: BCBS MT Medicare	$181.80
Rate for Payer: BCBS MT POS	$191.90
Rate for Payer: BCBS MT Traditional	$202.00
Rate for Payer: Cash Price	$181.80
Rate for Payer: Cigna Commercial	$191.90
Rate for Payer: Cigna Medicare	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

ANTI MUSK ANTIBODY

Facility

$850.00

Service Code	CPT 86041
Hospital Charge Code	4087909
Hospital Revenue Code	300
Min. Negotiated Rate	$595.00
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$807.50
Rate for Payer: Aetna Medicare	$765.00
Rate for Payer: BCBS MT CHIP	$765.00
Rate for Payer: BCBS MT Closed Plan Network	$807.50
Rate for Payer: BCBS MT HealthLink	$765.00
Rate for Payer: BCBS MT Medicare	$765.00
Rate for Payer: BCBS MT POS	$807.50
Rate for Payer: BCBS MT Traditional	$850.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial	$807.50
Rate for Payer: Cigna Medicare	$765.00
Rate for Payer: Medicaid All Medicaid	$782.00
Rate for Payer: Medicare All Medicare	$595.00
Rate for Payer: Monida Allegiance	$807.50
Rate for Payer: Monida First Choice Health	$824.50
Rate for Payer: Monida Montana Health Co-op	$807.50
Rate for Payer: Monida PacificSource	$807.50

ANTI MUSK ANTIBODY

Facility

$850.00

Service Code	CPT 86041
Hospital Charge Code	4087909
Hospital Revenue Code	300
Min. Negotiated Rate	$595.00
Max. Negotiated Rate	$850.00
Rate for Payer: Aetna Commercial	$807.50
Rate for Payer: Aetna Medicare	$765.00
Rate for Payer: BCBS MT CHIP	$765.00
Rate for Payer: BCBS MT Closed Plan Network	$807.50
Rate for Payer: BCBS MT HealthLink	$765.00
Rate for Payer: BCBS MT Medicare	$765.00
Rate for Payer: BCBS MT POS	$807.50
Rate for Payer: BCBS MT Traditional	$850.00
Rate for Payer: Cash Price	$765.00
Rate for Payer: Cigna Commercial	$807.50
Rate for Payer: Cigna Medicare	$765.00
Rate for Payer: Medicaid All Medicaid	$782.00
Rate for Payer: Medicare All Medicare	$595.00
Rate for Payer: Monida Allegiance	$807.50
Rate for Payer: Monida First Choice Health	$824.50
Rate for Payer: Monida Montana Health Co-op	$807.50
Rate for Payer: Monida PacificSource	$807.50

ANTI NEUTROPHILIC CYTO ANCA IFA

Facility

$165.00

Service Code	CPT 86036
Hospital Charge Code	4088048
Hospital Revenue Code	302
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

ANTI NEUTROPHILIC CYTO ANCA IFA

Facility

$165.00

Service Code	CPT 86036
Hospital Charge Code	4088048
Hospital Revenue Code	302
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

ANTI NUCLEAR AB, HEP2 SUBSTRAT

Facility

$82.00

Service Code	CPT 86039
Hospital Charge Code	4087890
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

ANTI NUCLEAR AB, HEP2 SUBSTRAT

Facility

$82.00

Service Code	CPT 86039
Hospital Charge Code	4087890
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

ANTIPHOSPHOLIPID ANTIBODY PANEL (378377)

Facility

$210.00

Service Code	CPT 86147
Hospital Charge Code	4000147
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

ANTIPHOSPHOLIPID ANTIBODY PANEL (378377)

Facility

$210.00

Service Code	CPT 86147
Hospital Charge Code	4000147
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

ANTIRIBOSOMAL P ANTIBODIES (012700)

Facility

$100.00

Service Code	CPT 83516
Hospital Charge Code	4003516
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: BCBS MT CHIP	$90.00
Rate for Payer: BCBS MT Closed Plan Network	$95.00
Rate for Payer: BCBS MT HealthLink	$90.00
Rate for Payer: BCBS MT Medicare	$90.00
Rate for Payer: BCBS MT POS	$95.00
Rate for Payer: BCBS MT Traditional	$100.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Cigna Medicare	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

ANTIRIBOSOMAL P ANTIBODIES (012700)

Facility

$100.00

Service Code	CPT 83516
Hospital Charge Code	4003516
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$100.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: BCBS MT CHIP	$90.00
Rate for Payer: BCBS MT Closed Plan Network	$95.00
Rate for Payer: BCBS MT HealthLink	$90.00
Rate for Payer: BCBS MT Medicare	$90.00
Rate for Payer: BCBS MT POS	$95.00
Rate for Payer: BCBS MT Traditional	$100.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Cigna Commercial	$95.00
Rate for Payer: Cigna Medicare	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

ANTISCLERODERMA-70 AB (50599)

Facility

$144.50

Service Code	CPT 86235
Hospital Charge Code	4000064
Hospital Revenue Code	300
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$144.50
Rate for Payer: Aetna Commercial	$137.28
Rate for Payer: Aetna Medicare	$130.05
Rate for Payer: BCBS MT CHIP	$130.05
Rate for Payer: BCBS MT Closed Plan Network	$137.28
Rate for Payer: BCBS MT HealthLink	$130.05
Rate for Payer: BCBS MT Medicare	$130.05
Rate for Payer: BCBS MT POS	$137.28
Rate for Payer: BCBS MT Traditional	$144.50
Rate for Payer: Cash Price	$130.05
Rate for Payer: Cigna Commercial	$137.28
Rate for Payer: Cigna Medicare	$130.05
Rate for Payer: Medicaid All Medicaid	$132.94
Rate for Payer: Medicare All Medicare	$101.15
Rate for Payer: Monida Allegiance	$137.28
Rate for Payer: Monida First Choice Health	$140.16
Rate for Payer: Monida Montana Health Co-op	$137.28
Rate for Payer: Monida PacificSource	$137.28

ANTISCLERODERMA-70 AB (50599)

Facility

$144.50

Service Code	CPT 86235
Hospital Charge Code	4000064
Hospital Revenue Code	300
Min. Negotiated Rate	$101.15
Max. Negotiated Rate	$144.50
Rate for Payer: Aetna Commercial	$137.28
Rate for Payer: Aetna Medicare	$130.05
Rate for Payer: BCBS MT CHIP	$130.05
Rate for Payer: BCBS MT Closed Plan Network	$137.28
Rate for Payer: BCBS MT HealthLink	$130.05
Rate for Payer: BCBS MT Medicare	$130.05
Rate for Payer: BCBS MT POS	$137.28
Rate for Payer: BCBS MT Traditional	$144.50
Rate for Payer: Cash Price	$130.05
Rate for Payer: Cigna Commercial	$137.28
Rate for Payer: Cigna Medicare	$130.05
Rate for Payer: Medicaid All Medicaid	$132.94
Rate for Payer: Medicare All Medicare	$101.15
Rate for Payer: Monida Allegiance	$137.28
Rate for Payer: Monida First Choice Health	$140.16
Rate for Payer: Monida Montana Health Co-op	$137.28
Rate for Payer: Monida PacificSource	$137.28

ANTITHROMBIN ACTIVITY (015040)

Facility

$71.00

Service Code	CPT 85300
Hospital Charge Code	4085300
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

ANTITHROMBIN ACTIVITY (015040)

Facility

$71.00

Service Code	CPT 85300
Hospital Charge Code	4085300
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

ANTITHROMBIN ANTIGEN

Facility

$92.00

Service Code	CPT 85301
Hospital Charge Code	4088037
Hospital Revenue Code	302
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

ANTITHROMBIN ANTIGEN

Facility

$92.00

Service Code	CPT 85301
Hospital Charge Code	4088037
Hospital Revenue Code	302
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

APIXABAN TAB [2.5 MG]

Facility

$39.00

Service Code	HCPCS J8499
Hospital Charge Code	3007274
Hospital Revenue Code	250
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

APIXABAN TAB [2.5 MG]

Facility

$39.00

Service Code	HCPCS J8499
Hospital Charge Code	3007274
Hospital Revenue Code	250
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

APIXABAN TAB [5 MG]

Facility

$40.00

Service Code	HCPCS J8499
Hospital Charge Code	3000573
Hospital Revenue Code	250
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

APIXABAN TAB [5 MG]

Facility

$40.00

Service Code	HCPCS J8499
Hospital Charge Code	3000573
Hospital Revenue Code	250
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

APOLIPOPROTEIN AAND B

Facility

$110.00

Service Code	CPT 82172
Hospital Charge Code	4087885
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

APOLIPOPROTEIN AAND B

Facility

$110.00

Service Code	CPT 82172
Hospital Charge Code	4087885
Hospital Revenue Code	301
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

APOLIPOPROTEIN B

Facility

$81.00

Service Code	CPT 82172
Hospital Charge Code	4088082
Hospital Revenue Code	302
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

APOLIPOPROTEIN B

Facility

$81.00

Service Code	CPT 82172
Hospital Charge Code	4088082
Hospital Revenue Code	302
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

Know your out-of-pocket cost for care.

All Charges