Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

COMPLEMENT, TOTAL (001941)

Facility

$16.00

Service Code	HCPCS 86162
Hospital Charge Code	4086162
Hospital Revenue Code	302
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

.COMPLETE BLOOD COUNT, WITH AUTO DIFF

Facility

$107.00

Service Code	HCPCS 85025
Hospital Charge Code	4085024
Hospital Revenue Code	305
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

.COMPLETE BLOOD COUNT, WITH AUTO DIFF

Facility

$107.00

Service Code	HCPCS 85025
Hospital Charge Code	4085024
Hospital Revenue Code	305
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

.COMPLETE BLOOD COUNT, WITHOUT DIFF

Facility

$88.00

Service Code	HCPCS 85027
Hospital Charge Code	4085027
Hospital Revenue Code	305
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

.COMPLETE BLOOD COUNT, WITHOUT DIFF

Facility

$88.00

Service Code	HCPCS 85027
Hospital Charge Code	4085027
Hospital Revenue Code	305
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

COMPREHENSIVE METABOLIC PANEL

Facility

$215.00

Service Code	HCPCS 80053
Hospital Charge Code	4080053
Hospital Revenue Code	301
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

COMPREHENSIVE METABOLIC PANEL

Facility

$215.00

Service Code	HCPCS 80053
Hospital Charge Code	4080053
Hospital Revenue Code	301
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

.CONCENTRATION INFECTIOUS AGENT

Facility

$92.00

Service Code	HCPCS 87015
Hospital Charge Code	4087015
Hospital Revenue Code	300
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

.CONCENTRATION INFECTIOUS AGENT

Facility

$92.00

Service Code	HCPCS 87015
Hospital Charge Code	4087015
Hospital Revenue Code	300
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

COPPER (001586)

Facility

$53.00

Service Code	HCPCS 82525
Hospital Charge Code	4082525
Hospital Revenue Code	301
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

COPPER (001586)

Facility

$53.00

Service Code	HCPCS 82525
Hospital Charge Code	4082525
Hospital Revenue Code	301
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$53.00
Rate for Payer: Aetna Commercial	$50.35
Rate for Payer: Aetna Medicare	$47.70
Rate for Payer: BCBS MT CHIP	$47.70
Rate for Payer: BCBS MT Closed Plan Network	$50.35
Rate for Payer: BCBS MT HealthLink	$47.70
Rate for Payer: BCBS MT Medicare	$47.70
Rate for Payer: BCBS MT POS	$50.35
Rate for Payer: BCBS MT Traditional	$53.00
Rate for Payer: Cash Price	$47.70
Rate for Payer: Cigna Commercial	$50.35
Rate for Payer: Cigna Medicare	$47.70
Rate for Payer: Medicaid All Medicaid	$48.76
Rate for Payer: Medicare All Medicare	$37.10
Rate for Payer: Monida Allegiance	$50.35
Rate for Payer: Monida First Choice Health	$51.41
Rate for Payer: Monida Montana Health Co-op	$50.35
Rate for Payer: Monida PacificSource	$50.35

.COPPER, URINE

Facility

$80.00

Service Code	HCPCS 82525
Hospital Charge Code	4025251
Hospital Revenue Code	301
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

.COPPER, URINE

Facility

$80.00

Service Code	HCPCS 82525
Hospital Charge Code	4025251
Hospital Revenue Code	301
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

Co Q-10 CAP [100 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000506
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

Co Q-10 CAP [100 MG] NF

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000506
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

CORTISOL (004051)

Facility

$24.00

Service Code	HCPCS 82533
Hospital Charge Code	4082533
Hospital Revenue Code	301
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

CORTISOL (004051)

Facility

$24.00

Service Code	HCPCS 82533
Hospital Charge Code	4082533
Hospital Revenue Code	301
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

CORTISOL, FREE, 24 HOUR URINE (004432)

Facility

$55.00

Service Code	HCPCS 82530
Hospital Charge Code	4082530
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

CORTISOL, FREE, 24 HOUR URINE (004432)

Facility

$55.00

Service Code	HCPCS 82530
Hospital Charge Code	4082530
Hospital Revenue Code	300
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

CORTISOL, SALIVA (500179)

Facility

$121.00

Service Code	HCPCS 82533
Hospital Charge Code	4000053
Hospital Revenue Code	301
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

CORTISOL, SALIVA (500179)

Facility

$121.00

Service Code	HCPCS 82533
Hospital Charge Code	4000053
Hospital Revenue Code	301
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

COVID-19 PFIZER

Facility

$449.00

Service Code	HCPCS M0201
Hospital Charge Code	3000510
Hospital Revenue Code	636
Min. Negotiated Rate	$314.30
Max. Negotiated Rate	$449.00
Rate for Payer: Aetna Commercial	$426.55
Rate for Payer: Aetna Medicare	$404.10
Rate for Payer: BCBS MT CHIP	$404.10
Rate for Payer: BCBS MT Closed Plan Network	$426.55
Rate for Payer: BCBS MT HealthLink	$404.10
Rate for Payer: BCBS MT Medicare	$404.10
Rate for Payer: BCBS MT POS	$426.55
Rate for Payer: BCBS MT Traditional	$449.00
Rate for Payer: Cash Price	$404.10
Rate for Payer: Cigna Commercial	$426.55
Rate for Payer: Cigna Medicare	$404.10
Rate for Payer: Medicaid All Medicaid	$413.08
Rate for Payer: Medicare All Medicare	$314.30
Rate for Payer: Monida Allegiance	$426.55
Rate for Payer: Monida First Choice Health	$435.53
Rate for Payer: Monida Montana Health Co-op	$426.55
Rate for Payer: Monida PacificSource	$426.55

COVID-19 PFIZER

Facility

$449.00

Service Code	HCPCS M0201
Hospital Charge Code	3000510
Hospital Revenue Code	636
Min. Negotiated Rate	$314.30
Max. Negotiated Rate	$449.00
Rate for Payer: Aetna Commercial	$426.55
Rate for Payer: Aetna Medicare	$404.10
Rate for Payer: BCBS MT CHIP	$404.10
Rate for Payer: BCBS MT Closed Plan Network	$426.55
Rate for Payer: BCBS MT HealthLink	$404.10
Rate for Payer: BCBS MT Medicare	$404.10
Rate for Payer: BCBS MT POS	$426.55
Rate for Payer: BCBS MT Traditional	$449.00
Rate for Payer: Cash Price	$404.10
Rate for Payer: Cigna Commercial	$426.55
Rate for Payer: Cigna Medicare	$404.10
Rate for Payer: Medicaid All Medicaid	$413.08
Rate for Payer: Medicare All Medicare	$314.30
Rate for Payer: Monida Allegiance	$426.55
Rate for Payer: Monida First Choice Health	$435.53
Rate for Payer: Monida Montana Health Co-op	$426.55
Rate for Payer: Monida PacificSource	$426.55

C-PEPTIDE (010108)

Facility

$37.00

Service Code	HCPCS 84681
Hospital Charge Code	4084681
Hospital Revenue Code	301
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

C-PEPTIDE (010108)

Facility

$37.00

Service Code	HCPCS 84681
Hospital Charge Code	4084681
Hospital Revenue Code	301
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$37.00
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: BCBS MT CHIP	$33.30
Rate for Payer: BCBS MT Closed Plan Network	$35.15
Rate for Payer: BCBS MT HealthLink	$33.30
Rate for Payer: BCBS MT Medicare	$33.30
Rate for Payer: BCBS MT POS	$35.15
Rate for Payer: BCBS MT Traditional	$37.00
Rate for Payer: Cash Price	$33.30
Rate for Payer: Cigna Commercial	$35.15
Rate for Payer: Cigna Medicare	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

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