Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CLONAZEPAM ODT [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000595
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

CLONAZEPAM ODT [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000595
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

CLONAZEPAM TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000098
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

CLONAZEPAM TAB [1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000098
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

CLONIDINE PATCH [0.1 MG/24 HR]

Facility

$111.00

Service Code	HCPCS J8499
Hospital Charge Code	3000099
Hospital Revenue Code	250
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

CLONIDINE PATCH [0.1 MG/24 HR]

Facility

$111.00

Service Code	HCPCS J8499
Hospital Charge Code	3000099
Hospital Revenue Code	250
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

CLONIDINE TAB [0.1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000101
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

CLONIDINE TAB [0.1 MG]

Facility

$8.00

Service Code	HCPCS J8499
Hospital Charge Code	3000101
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

CLOPIDOGREL TAB [75 MG]

Facility

$22.00

Service Code	HCPCS J8499
Hospital Charge Code	3000102
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

CLOPIDOGREL TAB [75 MG]

Facility

$22.00

Service Code	HCPCS J8499
Hospital Charge Code	3000102
Hospital Revenue Code	250
Min. Negotiated Rate	$15.40
Max. Negotiated Rate	$22.00
Rate for Payer: Aetna Commercial	$20.90
Rate for Payer: Aetna Medicare	$19.80
Rate for Payer: BCBS MT CHIP	$19.80
Rate for Payer: BCBS MT Closed Plan Network	$20.90
Rate for Payer: BCBS MT HealthLink	$19.80
Rate for Payer: BCBS MT Medicare	$19.80
Rate for Payer: BCBS MT POS	$20.90
Rate for Payer: BCBS MT Traditional	$22.00
Rate for Payer: Cash Price	$19.80
Rate for Payer: Cigna Commercial	$20.90
Rate for Payer: Cigna Medicare	$19.80
Rate for Payer: Medicaid All Medicaid	$20.24
Rate for Payer: Medicare All Medicare	$15.40
Rate for Payer: Monida Allegiance	$20.90
Rate for Payer: Monida First Choice Health	$21.34
Rate for Payer: Monida Montana Health Co-op	$20.90
Rate for Payer: Monida PacificSource	$20.90

CLOSED TREAT RADIAL HEAD W/O MANI

Facility

$652.00

Service Code	CPT 24650
Hospital Charge Code	1024650
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$652.00
Rate for Payer: Aetna Commercial	$619.40
Rate for Payer: Aetna Medicare	$586.80
Rate for Payer: BCBS MT CHIP	$586.80
Rate for Payer: BCBS MT Closed Plan Network	$619.40
Rate for Payer: BCBS MT HealthLink	$586.80
Rate for Payer: BCBS MT Medicare	$586.80
Rate for Payer: BCBS MT POS	$619.40
Rate for Payer: BCBS MT Traditional	$652.00
Rate for Payer: Cash Price	$586.80
Rate for Payer: Cigna Commercial	$619.40
Rate for Payer: Cigna Medicare	$586.80
Rate for Payer: Medicaid All Medicaid	$599.84
Rate for Payer: Medicare All Medicare	$456.40
Rate for Payer: Monida Allegiance	$619.40
Rate for Payer: Monida First Choice Health	$632.44
Rate for Payer: Monida Montana Health Co-op	$619.40
Rate for Payer: Monida PacificSource	$619.40

CLOSED TREAT RADIAL HEAD W/O MANI

Facility

$652.00

Service Code	CPT 24650
Hospital Charge Code	1024650
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$652.00
Rate for Payer: Aetna Commercial	$619.40
Rate for Payer: Aetna Medicare	$586.80
Rate for Payer: BCBS MT CHIP	$586.80
Rate for Payer: BCBS MT Closed Plan Network	$619.40
Rate for Payer: BCBS MT HealthLink	$586.80
Rate for Payer: BCBS MT Medicare	$586.80
Rate for Payer: BCBS MT POS	$619.40
Rate for Payer: BCBS MT Traditional	$652.00
Rate for Payer: Cash Price	$586.80
Rate for Payer: Cigna Commercial	$619.40
Rate for Payer: Cigna Medicare	$586.80
Rate for Payer: Medicaid All Medicaid	$599.84
Rate for Payer: Medicare All Medicare	$456.40
Rate for Payer: Monida Allegiance	$619.40
Rate for Payer: Monida First Choice Health	$632.44
Rate for Payer: Monida Montana Health Co-op	$619.40
Rate for Payer: Monida PacificSource	$619.40

CLOZAPINE AND METABOLITES

Facility

$92.00

Service Code	CPT 80159
Hospital Charge Code	4088095
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

CLOZAPINE AND METABOLITES

Facility

$92.00

Service Code	CPT 80159
Hospital Charge Code	4088095
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

CLS TRT PATELLAR DISLOCATION, W/O ANESTH

Facility

$367.00

Service Code	CPT 27560
Hospital Charge Code	1027560
Hospital Revenue Code	450
Min. Negotiated Rate	$256.90
Max. Negotiated Rate	$367.00
Rate for Payer: Aetna Commercial	$348.65
Rate for Payer: Aetna Medicare	$330.30
Rate for Payer: BCBS MT CHIP	$330.30
Rate for Payer: BCBS MT Closed Plan Network	$348.65
Rate for Payer: BCBS MT HealthLink	$330.30
Rate for Payer: BCBS MT Medicare	$330.30
Rate for Payer: BCBS MT POS	$348.65
Rate for Payer: BCBS MT Traditional	$367.00
Rate for Payer: Cash Price	$330.30
Rate for Payer: Cigna Commercial	$348.65
Rate for Payer: Cigna Medicare	$330.30
Rate for Payer: Medicaid All Medicaid	$337.64
Rate for Payer: Medicare All Medicare	$256.90
Rate for Payer: Monida Allegiance	$348.65
Rate for Payer: Monida First Choice Health	$355.99
Rate for Payer: Monida Montana Health Co-op	$348.65
Rate for Payer: Monida PacificSource	$348.65

CLS TRT PATELLAR DISLOCATION, W/O ANESTH

Facility

$367.00

Service Code	CPT 27560
Hospital Charge Code	1027560
Hospital Revenue Code	450
Min. Negotiated Rate	$256.90
Max. Negotiated Rate	$367.00
Rate for Payer: Aetna Commercial	$348.65
Rate for Payer: Aetna Medicare	$330.30
Rate for Payer: BCBS MT CHIP	$330.30
Rate for Payer: BCBS MT Closed Plan Network	$348.65
Rate for Payer: BCBS MT HealthLink	$330.30
Rate for Payer: BCBS MT Medicare	$330.30
Rate for Payer: BCBS MT POS	$348.65
Rate for Payer: BCBS MT Traditional	$367.00
Rate for Payer: Cash Price	$330.30
Rate for Payer: Cigna Commercial	$348.65
Rate for Payer: Cigna Medicare	$330.30
Rate for Payer: Medicaid All Medicaid	$337.64
Rate for Payer: Medicare All Medicare	$256.90
Rate for Payer: Monida Allegiance	$348.65
Rate for Payer: Monida First Choice Health	$355.99
Rate for Payer: Monida Montana Health Co-op	$348.65
Rate for Payer: Monida PacificSource	$348.65

CMPLX RPR E/N/E/L 1.1-2.5 CM

Facility

$660.00

Service Code	CPT 13151
Hospital Charge Code	8013151
Hospital Revenue Code	521
Min. Negotiated Rate	$462.00
Max. Negotiated Rate	$660.00
Rate for Payer: Aetna Commercial	$627.00
Rate for Payer: Aetna Medicare	$594.00
Rate for Payer: BCBS MT CHIP	$594.00
Rate for Payer: BCBS MT Closed Plan Network	$627.00
Rate for Payer: BCBS MT HealthLink	$594.00
Rate for Payer: BCBS MT Medicare	$594.00
Rate for Payer: BCBS MT POS	$627.00
Rate for Payer: BCBS MT Traditional	$660.00
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cigna Commercial	$627.00
Rate for Payer: Cigna Medicare	$594.00
Rate for Payer: Medicaid All Medicaid	$607.20
Rate for Payer: Medicare All Medicare	$462.00
Rate for Payer: Monida Allegiance	$627.00
Rate for Payer: Monida First Choice Health	$640.20
Rate for Payer: Monida Montana Health Co-op	$627.00
Rate for Payer: Monida PacificSource	$627.00

CMPLX RPR E/N/E/L 1.1-2.5 CM

Facility

$660.00

Service Code	CPT 13151
Hospital Charge Code	8013151
Hospital Revenue Code	521
Min. Negotiated Rate	$462.00
Max. Negotiated Rate	$660.00
Rate for Payer: Aetna Commercial	$627.00
Rate for Payer: Aetna Medicare	$594.00
Rate for Payer: BCBS MT CHIP	$594.00
Rate for Payer: BCBS MT Closed Plan Network	$627.00
Rate for Payer: BCBS MT HealthLink	$594.00
Rate for Payer: BCBS MT Medicare	$594.00
Rate for Payer: BCBS MT POS	$627.00
Rate for Payer: BCBS MT Traditional	$660.00
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cigna Commercial	$627.00
Rate for Payer: Cigna Medicare	$594.00
Rate for Payer: Medicaid All Medicaid	$607.20
Rate for Payer: Medicare All Medicare	$462.00
Rate for Payer: Monida Allegiance	$627.00
Rate for Payer: Monida First Choice Health	$640.20
Rate for Payer: Monida Montana Health Co-op	$627.00
Rate for Payer: Monida PacificSource	$627.00

CMV AB IGG/IGM

Facility

$92.00

Service Code	CPT 87497
Hospital Charge Code	4088097
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

CMV AB IGG/IGM

Facility

$92.00

Service Code	CPT 87497
Hospital Charge Code	4088097
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

CMV ANTIBODIES, IGG (006494)

Facility

$66.00

Service Code	CPT 86644
Hospital Charge Code	4086644
Hospital Revenue Code	300
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

CMV ANTIBODIES, IGG (006494)

Facility

$66.00

Service Code	CPT 86644
Hospital Charge Code	4086644
Hospital Revenue Code	300
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

CMV ANTIBODIES, IGM (096727)

Facility

$75.00

Service Code	CPT 86645
Hospital Charge Code	4086645
Hospital Revenue Code	300
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

CMV ANTIBODIES, IGM (096727)

Facility

$75.00

Service Code	CPT 86645
Hospital Charge Code	4086645
Hospital Revenue Code	300
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

CMV QUANTITATIVE NAAT

Facility

$120.00

Service Code	CPT 87497
Hospital Charge Code	4088096
Hospital Revenue Code	302
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

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