Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

RSV, RAPID TEST

Facility

$125.00

Service Code	HCPCS 87807
Hospital Charge Code	4087807
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

RSV, RAPID TEST

Facility

$125.00

Service Code	HCPCS 87807
Hospital Charge Code	4087807
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

RUBELLA AB, IGG (006197)

Facility

$20.00

Service Code	HCPCS 86762
Hospital Charge Code	4086762
Hospital Revenue Code	302
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

RUBELLA AB, IGG (006197)

Facility

$20.00

Service Code	HCPCS 86762
Hospital Charge Code	4086762
Hospital Revenue Code	302
Min. Negotiated Rate	$14.00
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna Commercial	$19.00
Rate for Payer: Aetna Medicare	$18.00
Rate for Payer: BCBS MT CHIP	$18.00
Rate for Payer: BCBS MT Closed Plan Network	$19.00
Rate for Payer: BCBS MT HealthLink	$18.00
Rate for Payer: BCBS MT Medicare	$18.00
Rate for Payer: BCBS MT POS	$19.00
Rate for Payer: BCBS MT Traditional	$20.00
Rate for Payer: Cash Price	$18.00
Rate for Payer: Cigna Commercial	$19.00
Rate for Payer: Cigna Medicare	$18.00
Rate for Payer: Medicaid All Medicaid	$18.40
Rate for Payer: Medicare All Medicare	$14.00
Rate for Payer: Monida Allegiance	$19.00
Rate for Payer: Monida First Choice Health	$19.40
Rate for Payer: Monida Montana Health Co-op	$19.00
Rate for Payer: Monida PacificSource	$19.00

SACRO-LUMBAR SUPPORT

Facility

$120.00

Service Code	HCPCS L0625
Hospital Charge Code	8000625
Hospital Revenue Code	290
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

SACRO-LUMBAR SUPPORT

Facility

$120.00

Service Code	HCPCS L0625
Hospital Charge Code	8000625
Hospital Revenue Code	290
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

SACUBITRIL/VALSARTAN TAB [24MG/26MG] NF

Facility

$45.00

Service Code	HCPCS J3490
Hospital Charge Code	3000544
Hospital Revenue Code	250
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

SACUBITRIL/VALSARTAN TAB [24MG/26MG] NF

Facility

$45.00

Service Code	HCPCS J3490
Hospital Charge Code	3000544
Hospital Revenue Code	250
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

SALICYLATE

Facility

$174.00

Service Code	HCPCS 80179
Hospital Charge Code	4000044
Hospital Revenue Code	300
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

SALICYLATE

Facility

$174.00

Service Code	HCPCS 80179
Hospital Charge Code	4000044
Hospital Revenue Code	300
Min. Negotiated Rate	$121.80
Max. Negotiated Rate	$174.00
Rate for Payer: Aetna Commercial	$165.30
Rate for Payer: Aetna Medicare	$156.60
Rate for Payer: BCBS MT CHIP	$156.60
Rate for Payer: BCBS MT Closed Plan Network	$165.30
Rate for Payer: BCBS MT HealthLink	$156.60
Rate for Payer: BCBS MT Medicare	$156.60
Rate for Payer: BCBS MT POS	$165.30
Rate for Payer: BCBS MT Traditional	$174.00
Rate for Payer: Cash Price	$156.60
Rate for Payer: Cigna Commercial	$165.30
Rate for Payer: Cigna Medicare	$156.60
Rate for Payer: Medicaid All Medicaid	$160.08
Rate for Payer: Medicare All Medicare	$121.80
Rate for Payer: Monida Allegiance	$165.30
Rate for Payer: Monida First Choice Health	$168.78
Rate for Payer: Monida Montana Health Co-op	$165.30
Rate for Payer: Monida PacificSource	$165.30

SAM PELVIC SLING LG

Facility

$261.00

Hospital Charge Code	2893494
Hospital Revenue Code	290
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

SAM PELVIC SLING LG

Facility

$261.00

Hospital Charge Code	2893494
Hospital Revenue Code	290
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

SAM PELVIC SLING MD

Facility

$261.00

Hospital Charge Code	2893493
Hospital Revenue Code	290
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

SAM PELVIC SLING MD

Facility

$261.00

Hospital Charge Code	2893493
Hospital Revenue Code	290
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

SAM PELVIC SLING SM

Facility

$305.00

Hospital Charge Code	2840119
Hospital Revenue Code	270
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$305.00
Rate for Payer: Aetna Commercial	$289.75
Rate for Payer: Aetna Medicare	$274.50
Rate for Payer: BCBS MT CHIP	$274.50
Rate for Payer: BCBS MT Closed Plan Network	$289.75
Rate for Payer: BCBS MT HealthLink	$274.50
Rate for Payer: BCBS MT Medicare	$274.50
Rate for Payer: BCBS MT POS	$289.75
Rate for Payer: BCBS MT Traditional	$305.00
Rate for Payer: Cash Price	$274.50
Rate for Payer: Cigna Commercial	$289.75
Rate for Payer: Cigna Medicare	$274.50
Rate for Payer: Medicaid All Medicaid	$280.60
Rate for Payer: Medicare All Medicare	$213.50
Rate for Payer: Monida Allegiance	$289.75
Rate for Payer: Monida First Choice Health	$295.85
Rate for Payer: Monida Montana Health Co-op	$289.75
Rate for Payer: Monida PacificSource	$289.75

SAM PELVIC SLING SM

Facility

$305.00

Hospital Charge Code	2840119
Hospital Revenue Code	270
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$305.00
Rate for Payer: Aetna Commercial	$289.75
Rate for Payer: Aetna Medicare	$274.50
Rate for Payer: BCBS MT CHIP	$274.50
Rate for Payer: BCBS MT Closed Plan Network	$289.75
Rate for Payer: BCBS MT HealthLink	$274.50
Rate for Payer: BCBS MT Medicare	$274.50
Rate for Payer: BCBS MT POS	$289.75
Rate for Payer: BCBS MT Traditional	$305.00
Rate for Payer: Cash Price	$274.50
Rate for Payer: Cigna Commercial	$289.75
Rate for Payer: Cigna Medicare	$274.50
Rate for Payer: Medicaid All Medicaid	$280.60
Rate for Payer: Medicare All Medicare	$213.50
Rate for Payer: Monida Allegiance	$289.75
Rate for Payer: Monida First Choice Health	$295.85
Rate for Payer: Monida Montana Health Co-op	$289.75
Rate for Payer: Monida PacificSource	$289.75

SAM SPLINT 4 1/4"X36''

Facility

$43.00

Hospital Charge Code	2893495
Hospital Revenue Code	290
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

SAM SPLINT 4 1/4"X36''

Facility

$43.00

Hospital Charge Code	2893495
Hospital Revenue Code	290
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

SAM SPLINT 4.25"X36" FLAT

Facility

$43.00

Hospital Charge Code	2893496
Hospital Revenue Code	290
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

SAM SPLINT 4.25"X36" FLAT

Facility

$43.00

Hospital Charge Code	2893496
Hospital Revenue Code	290
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$43.00
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: BCBS MT CHIP	$38.70
Rate for Payer: BCBS MT Closed Plan Network	$40.85
Rate for Payer: BCBS MT HealthLink	$38.70
Rate for Payer: BCBS MT Medicare	$38.70
Rate for Payer: BCBS MT POS	$40.85
Rate for Payer: BCBS MT Traditional	$43.00
Rate for Payer: Cash Price	$38.70
Rate for Payer: Cigna Commercial	$40.85
Rate for Payer: Cigna Medicare	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

SARS-COV-2, AG BINAX

Facility

$155.00

Service Code	HCPCS 87426
Hospital Charge Code	4087426
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

SARS-COV-2, AG BINAX

Facility

$155.00

Service Code	HCPCS 87426
Hospital Charge Code	4087426
Hospital Revenue Code	300
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$155.00
Rate for Payer: Aetna Commercial	$147.25
Rate for Payer: Aetna Medicare	$139.50
Rate for Payer: BCBS MT CHIP	$139.50
Rate for Payer: BCBS MT Closed Plan Network	$147.25
Rate for Payer: BCBS MT HealthLink	$139.50
Rate for Payer: BCBS MT Medicare	$139.50
Rate for Payer: BCBS MT POS	$147.25
Rate for Payer: BCBS MT Traditional	$155.00
Rate for Payer: Cash Price	$139.50
Rate for Payer: Cigna Commercial	$147.25
Rate for Payer: Cigna Medicare	$139.50
Rate for Payer: Medicaid All Medicaid	$142.60
Rate for Payer: Medicare All Medicare	$108.50
Rate for Payer: Monida Allegiance	$147.25
Rate for Payer: Monida First Choice Health	$150.35
Rate for Payer: Monida Montana Health Co-op	$147.25
Rate for Payer: Monida PacificSource	$147.25

SARS-COV-2/FLU A/FLU B/RSV, RT-PCR

Facility

$521.00

Service Code	HCPCS 0241U
Hospital Charge Code	4050241
Hospital Revenue Code	300
Min. Negotiated Rate	$364.70
Max. Negotiated Rate	$521.00
Rate for Payer: Aetna Commercial	$494.95
Rate for Payer: Aetna Medicare	$468.90
Rate for Payer: BCBS MT CHIP	$468.90
Rate for Payer: BCBS MT Closed Plan Network	$494.95
Rate for Payer: BCBS MT HealthLink	$468.90
Rate for Payer: BCBS MT Medicare	$468.90
Rate for Payer: BCBS MT POS	$494.95
Rate for Payer: BCBS MT Traditional	$521.00
Rate for Payer: Cash Price	$468.90
Rate for Payer: Cigna Commercial	$494.95
Rate for Payer: Cigna Medicare	$468.90
Rate for Payer: Medicaid All Medicaid	$479.32
Rate for Payer: Medicare All Medicare	$364.70
Rate for Payer: Monida Allegiance	$494.95
Rate for Payer: Monida First Choice Health	$505.37
Rate for Payer: Monida Montana Health Co-op	$494.95
Rate for Payer: Monida PacificSource	$494.95

SARS-COV-2/FLU A/FLU B/RSV, RT-PCR

Facility

$521.00

Service Code	HCPCS 0241U
Hospital Charge Code	4050241
Hospital Revenue Code	300
Min. Negotiated Rate	$364.70
Max. Negotiated Rate	$521.00
Rate for Payer: Aetna Commercial	$494.95
Rate for Payer: Aetna Medicare	$468.90
Rate for Payer: BCBS MT CHIP	$468.90
Rate for Payer: BCBS MT Closed Plan Network	$494.95
Rate for Payer: BCBS MT HealthLink	$468.90
Rate for Payer: BCBS MT Medicare	$468.90
Rate for Payer: BCBS MT POS	$494.95
Rate for Payer: BCBS MT Traditional	$521.00
Rate for Payer: Cash Price	$468.90
Rate for Payer: Cigna Commercial	$494.95
Rate for Payer: Cigna Medicare	$468.90
Rate for Payer: Medicaid All Medicaid	$479.32
Rate for Payer: Medicare All Medicare	$364.70
Rate for Payer: Monida Allegiance	$494.95
Rate for Payer: Monida First Choice Health	$505.37
Rate for Payer: Monida Montana Health Co-op	$494.95
Rate for Payer: Monida PacificSource	$494.95

SARS-COV-2/FLU A/FLU B, RT-PCR

Facility

$250.00

Service Code	HCPCS 0240U
Hospital Charge Code	4050240
Hospital Revenue Code	300
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

Know your out-of-pocket cost for care.

All Charges