Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$277.00

Hospital Charge Code	2893494
Hospital Revenue Code	290
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

SAM PELVIC SLING LG

Facility

$277.00

Hospital Charge Code	2893494
Hospital Revenue Code	290
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

SAM PELVIC SLING MD

Facility

$277.00

Hospital Charge Code	2893493
Hospital Revenue Code	290
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

SAM PELVIC SLING MD

Facility

$277.00

Hospital Charge Code	2893493
Hospital Revenue Code	290
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$277.00
Rate for Payer: Aetna Commercial	$263.15
Rate for Payer: Aetna Medicare	$249.30
Rate for Payer: BCBS MT CHIP	$249.30
Rate for Payer: BCBS MT Closed Plan Network	$263.15
Rate for Payer: BCBS MT HealthLink	$249.30
Rate for Payer: BCBS MT Medicare	$249.30
Rate for Payer: BCBS MT POS	$263.15
Rate for Payer: BCBS MT Traditional	$277.00
Rate for Payer: Cash Price	$249.30
Rate for Payer: Cigna Commercial	$263.15
Rate for Payer: Cigna Medicare	$249.30
Rate for Payer: Medicaid All Medicaid	$254.84
Rate for Payer: Medicare All Medicare	$193.90
Rate for Payer: Monida Allegiance	$263.15
Rate for Payer: Monida First Choice Health	$268.69
Rate for Payer: Monida Montana Health Co-op	$263.15
Rate for Payer: Monida PacificSource	$263.15

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

$46.00

Hospital Charge Code	2893495
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

SAM SPLINT 4 1/4"X36''

Facility

$46.00

Hospital Charge Code	2893495
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

SAM SPLINT 4.25"X36" FLAT

Facility

$46.00

Hospital Charge Code	2893496
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

SAM SPLINT 4.25"X36" FLAT

Facility

$46.00

Hospital Charge Code	2893496
Hospital Revenue Code	290
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$46.00
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: BCBS MT CHIP	$41.40
Rate for Payer: BCBS MT Closed Plan Network	$43.70
Rate for Payer: BCBS MT HealthLink	$41.40
Rate for Payer: BCBS MT Medicare	$41.40
Rate for Payer: BCBS MT POS	$43.70
Rate for Payer: BCBS MT Traditional	$46.00
Rate for Payer: Cash Price	$41.40
Rate for Payer: Cigna Commercial	$43.70
Rate for Payer: Cigna Medicare	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

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

$552.00

Service Code	HCPCS 87637
Hospital Charge Code	4050241
Hospital Revenue Code	300
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$552.00
Rate for Payer: Aetna Commercial	$524.40
Rate for Payer: Aetna Medicare	$496.80
Rate for Payer: BCBS MT CHIP	$496.80
Rate for Payer: BCBS MT Closed Plan Network	$524.40
Rate for Payer: BCBS MT HealthLink	$496.80
Rate for Payer: BCBS MT Medicare	$496.80
Rate for Payer: BCBS MT POS	$524.40
Rate for Payer: BCBS MT Traditional	$552.00
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cigna Commercial	$524.40
Rate for Payer: Cigna Medicare	$496.80
Rate for Payer: Medicaid All Medicaid	$507.84
Rate for Payer: Medicare All Medicare	$386.40
Rate for Payer: Monida Allegiance	$524.40
Rate for Payer: Monida First Choice Health	$535.44
Rate for Payer: Monida Montana Health Co-op	$524.40
Rate for Payer: Monida PacificSource	$524.40

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

Facility

$552.00

Service Code	HCPCS 87637
Hospital Charge Code	4050241
Hospital Revenue Code	300
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$552.00
Rate for Payer: Aetna Commercial	$524.40
Rate for Payer: Aetna Medicare	$496.80
Rate for Payer: BCBS MT CHIP	$496.80
Rate for Payer: BCBS MT Closed Plan Network	$524.40
Rate for Payer: BCBS MT HealthLink	$496.80
Rate for Payer: BCBS MT Medicare	$496.80
Rate for Payer: BCBS MT POS	$524.40
Rate for Payer: BCBS MT Traditional	$552.00
Rate for Payer: Cash Price	$496.80
Rate for Payer: Cigna Commercial	$524.40
Rate for Payer: Cigna Medicare	$496.80
Rate for Payer: Medicaid All Medicaid	$507.84
Rate for Payer: Medicare All Medicare	$386.40
Rate for Payer: Monida Allegiance	$524.40
Rate for Payer: Monida First Choice Health	$535.44
Rate for Payer: Monida Montana Health Co-op	$524.40
Rate for Payer: Monida PacificSource	$524.40

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

Facility

$265.00

Service Code	HCPCS 87636
Hospital Charge Code	4050240
Hospital Revenue Code	300
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

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

Facility

$265.00

Service Code	HCPCS 87636
Hospital Charge Code	4050240
Hospital Revenue Code	300
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

SARS-COV-2, ID NOW - TRAVEL

Facility

$111.00

Service Code	HCPCS 87635
Hospital Charge Code	4000076
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SARS-COV-2, ID NOW - TRAVEL

Facility

$111.00

Service Code	HCPCS 87635
Hospital Charge Code	4000076
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

SARS-COV-2, RT-PCR

Facility

$215.00

Service Code	HCPCS 87635
Hospital Charge Code	4087635
Hospital Revenue Code	300
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

SARS-COV-2, RT-PCR

Facility

$215.00

Service Code	HCPCS 87635
Hospital Charge Code	4087635
Hospital Revenue Code	300
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$215.00
Rate for Payer: Aetna Commercial	$204.25
Rate for Payer: Aetna Medicare	$193.50
Rate for Payer: BCBS MT CHIP	$193.50
Rate for Payer: BCBS MT Closed Plan Network	$204.25
Rate for Payer: BCBS MT HealthLink	$193.50
Rate for Payer: BCBS MT Medicare	$193.50
Rate for Payer: BCBS MT POS	$204.25
Rate for Payer: BCBS MT Traditional	$215.00
Rate for Payer: Cash Price	$193.50
Rate for Payer: Cigna Commercial	$204.25
Rate for Payer: Cigna Medicare	$193.50
Rate for Payer: Medicaid All Medicaid	$197.80
Rate for Payer: Medicare All Medicare	$150.50
Rate for Payer: Monida Allegiance	$204.25
Rate for Payer: Monida First Choice Health	$208.55
Rate for Payer: Monida Montana Health Co-op	$204.25
Rate for Payer: Monida PacificSource	$204.25

SARS-COV-2 SEMI-QUANT IGG AB (164055)

Facility

$111.00

Service Code	HCPCS 86769
Hospital Charge Code	4086769
Hospital Revenue Code	300
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

Know your out-of-pocket cost for care.

All Charges