Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MIRENA IUD [21 MCG/24 HR] SPECIAL ORDER

Facility

$2,041.00

Service Code	HCPCS J7298
Hospital Charge Code	3000622
Hospital Revenue Code	521
Min. Negotiated Rate	$1,428.70
Max. Negotiated Rate	$2,041.00
Rate for Payer: Aetna Commercial	$1,938.95
Rate for Payer: Aetna Medicare	$1,836.90
Rate for Payer: BCBS MT CHIP	$1,836.90
Rate for Payer: BCBS MT Closed Plan Network	$1,938.95
Rate for Payer: BCBS MT HealthLink	$1,836.90
Rate for Payer: BCBS MT Medicare	$1,836.90
Rate for Payer: BCBS MT POS	$1,938.95
Rate for Payer: BCBS MT Traditional	$2,041.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cigna Commercial	$1,938.95
Rate for Payer: Cigna Medicare	$1,836.90
Rate for Payer: Medicaid All Medicaid	$1,877.72
Rate for Payer: Medicare All Medicare	$1,428.70
Rate for Payer: Monida Allegiance	$1,938.95
Rate for Payer: Monida First Choice Health	$1,979.77
Rate for Payer: Monida Montana Health Co-op	$1,938.95
Rate for Payer: Monida PacificSource	$1,938.95

MIRTAZAPINE TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007049
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

MIRTAZAPINE TAB [15 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007049
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

MIRTAZAPINE TAB [45 MG] NF

Facility

$10.00

Service Code	HCPCS J8499
Hospital Charge Code	3007074
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

MIRTAZAPINE TAB [45 MG] NF

Facility

$10.00

Service Code	HCPCS J8499
Hospital Charge Code	3007074
Hospital Revenue Code	250
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$10.00
Rate for Payer: Aetna Commercial	$9.50
Rate for Payer: Aetna Medicare	$9.00
Rate for Payer: BCBS MT CHIP	$9.00
Rate for Payer: BCBS MT Closed Plan Network	$9.50
Rate for Payer: BCBS MT HealthLink	$9.00
Rate for Payer: BCBS MT Medicare	$9.00
Rate for Payer: BCBS MT POS	$9.50
Rate for Payer: BCBS MT Traditional	$10.00
Rate for Payer: Cash Price	$9.00
Rate for Payer: Cigna Commercial	$9.50
Rate for Payer: Cigna Medicare	$9.00
Rate for Payer: Medicaid All Medicaid	$9.20
Rate for Payer: Medicare All Medicare	$7.00
Rate for Payer: Monida Allegiance	$9.50
Rate for Payer: Monida First Choice Health	$9.70
Rate for Payer: Monida Montana Health Co-op	$9.50
Rate for Payer: Monida PacificSource	$9.50

MISOPROSTOL TAB [200 MCG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007340
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

MISOPROSTOL TAB [200 MCG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3007340
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

MITOCHONDRIAL ANTIBODY (006650)

Facility

$26.00

Service Code	CPT 86381
Hospital Charge Code	4000516
Hospital Revenue Code	301
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MITOCHONDRIAL ANTIBODY (006650)

Facility

$26.00

Service Code	CPT 86381
Hospital Charge Code	4000516
Hospital Revenue Code	301
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MNT GREEN, LIHEP PST, 13 X 100 MM, 4.5 M

Facility

$28.82

Hospital Charge Code	90196677
Hospital Revenue Code	270
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$28.82
Rate for Payer: Aetna Commercial	$27.38
Rate for Payer: Aetna Medicare	$25.94
Rate for Payer: BCBS MT CHIP	$25.94
Rate for Payer: BCBS MT Closed Plan Network	$27.38
Rate for Payer: BCBS MT HealthLink	$25.94
Rate for Payer: BCBS MT Medicare	$25.94
Rate for Payer: BCBS MT POS	$27.38
Rate for Payer: BCBS MT Traditional	$28.82
Rate for Payer: Cash Price	$25.94
Rate for Payer: Cigna Commercial	$27.38
Rate for Payer: Cigna Medicare	$25.94
Rate for Payer: Medicaid All Medicaid	$26.51
Rate for Payer: Medicare All Medicare	$20.17
Rate for Payer: Monida Allegiance	$27.38
Rate for Payer: Monida First Choice Health	$27.96
Rate for Payer: Monida Montana Health Co-op	$27.38
Rate for Payer: Monida PacificSource	$27.38

MNT GREEN, LIHEP PST, 13 X 100 MM, 4.5 M

Facility

$28.82

Hospital Charge Code	90196677
Hospital Revenue Code	270
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$28.82
Rate for Payer: Aetna Commercial	$27.38
Rate for Payer: Aetna Medicare	$25.94
Rate for Payer: BCBS MT CHIP	$25.94
Rate for Payer: BCBS MT Closed Plan Network	$27.38
Rate for Payer: BCBS MT HealthLink	$25.94
Rate for Payer: BCBS MT Medicare	$25.94
Rate for Payer: BCBS MT POS	$27.38
Rate for Payer: BCBS MT Traditional	$28.82
Rate for Payer: Cash Price	$25.94
Rate for Payer: Cigna Commercial	$27.38
Rate for Payer: Cigna Medicare	$25.94
Rate for Payer: Medicaid All Medicaid	$26.51
Rate for Payer: Medicare All Medicare	$20.17
Rate for Payer: Monida Allegiance	$27.38
Rate for Payer: Monida First Choice Health	$27.96
Rate for Payer: Monida Montana Health Co-op	$27.38
Rate for Payer: Monida PacificSource	$27.38

MODAFINIL TAB [200 MG] NF

Facility

$107.00

Service Code	HCPCS J8499
Hospital Charge Code	3007758
Hospital Revenue Code	250
Min. Negotiated Rate	$74.90
Max. Negotiated Rate	$107.00
Rate for Payer: Aetna Commercial	$101.65
Rate for Payer: Aetna Medicare	$96.30
Rate for Payer: BCBS MT CHIP	$96.30
Rate for Payer: BCBS MT Closed Plan Network	$101.65
Rate for Payer: BCBS MT HealthLink	$96.30
Rate for Payer: BCBS MT Medicare	$96.30
Rate for Payer: BCBS MT POS	$101.65
Rate for Payer: BCBS MT Traditional	$107.00
Rate for Payer: Cash Price	$96.30
Rate for Payer: Cigna Commercial	$101.65
Rate for Payer: Cigna Medicare	$96.30
Rate for Payer: Medicaid All Medicaid	$98.44
Rate for Payer: Medicare All Medicare	$74.90
Rate for Payer: Monida Allegiance	$101.65
Rate for Payer: Monida First Choice Health	$103.79
Rate for Payer: Monida Montana Health Co-op	$101.65
Rate for Payer: Monida PacificSource	$101.65

MODAFINIL TAB [200 MG] NF

Facility

$107.00

Service Code	HCPCS J8499
Hospital Charge Code	3007758
Hospital Revenue Code	250
Min. Negotiated Rate	$74.90
Max. Negotiated Rate	$107.00
Rate for Payer: Aetna Commercial	$101.65
Rate for Payer: Aetna Medicare	$96.30
Rate for Payer: BCBS MT CHIP	$96.30
Rate for Payer: BCBS MT Closed Plan Network	$101.65
Rate for Payer: BCBS MT HealthLink	$96.30
Rate for Payer: BCBS MT Medicare	$96.30
Rate for Payer: BCBS MT POS	$101.65
Rate for Payer: BCBS MT Traditional	$107.00
Rate for Payer: Cash Price	$96.30
Rate for Payer: Cigna Commercial	$101.65
Rate for Payer: Cigna Medicare	$96.30
Rate for Payer: Medicaid All Medicaid	$98.44
Rate for Payer: Medicare All Medicare	$74.90
Rate for Payer: Monida Allegiance	$101.65
Rate for Payer: Monida First Choice Health	$103.79
Rate for Payer: Monida Montana Health Co-op	$101.65
Rate for Payer: Monida PacificSource	$101.65

MOD SED INIT 15M AGE <5

Facility

$324.00

Service Code	CPT 99151
Hospital Charge Code	1099151
Hospital Revenue Code	450
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

MOD SED INIT 15M AGE <5

Facility

$324.00

Service Code	CPT 99151
Hospital Charge Code	1099151
Hospital Revenue Code	450
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

MOLECULAR CYTOGEN INTERPRETATION

Facility

$110.00

Service Code	CPT 88291
Hospital Charge Code	4088291
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

MOLECULAR CYTOGEN INTERPRETATION

Facility

$110.00

Service Code	CPT 88291
Hospital Charge Code	4088291
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

MOLECULAR PATH LEV4

Facility

$400.00

Service Code	CPT 81403
Hospital Charge Code	4088138
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

MOLECULAR PATH LEV4

Facility

$400.00

Service Code	CPT 81403
Hospital Charge Code	4088138
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

MOLECULAR PATH LEV5

Facility

$400.00

Service Code	CPT 81404
Hospital Charge Code	4088139
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

MOLECULAR PATH LEV5

Facility

$400.00

Service Code	CPT 81404
Hospital Charge Code	4088139
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

MOLECULAR PATH LEV6

Facility

$400.00

Service Code	CPT 81405
Hospital Charge Code	4088140
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

MOLECULAR PATH LEV6

Facility

$400.00

Service Code	CPT 81405
Hospital Charge Code	4088140
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

MOLECULAR PATH LEV7

Facility

$400.00

Service Code	CPT 81406
Hospital Charge Code	4088141
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

MOLECULAR PATH LEV7

Facility

$400.00

Service Code	CPT 81406
Hospital Charge Code	4088141
Hospital Revenue Code	310
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

Know your out-of-pocket cost for care.

All Charges