Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HEMOCCULT BLOOD CARD SCREEN-TWIN BRIDGES

Facility

$33.00

Service Code	HCPCS 82270
Hospital Charge Code	8182270
Hospital Revenue Code	270
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

HEMOCCULT BLOOD CARD SCREEN-TWIN BRIDGES

Facility

$33.00

Service Code	HCPCS 82270
Hospital Charge Code	8182270
Hospital Revenue Code	270
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

HEMOCCULT SINGLE SLIDES

Facility

$30.00

Hospital Charge Code	80030188
Hospital Revenue Code	270
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

HEMOCCULT SINGLE SLIDES

Facility

$30.00

Hospital Charge Code	80030188
Hospital Revenue Code	270
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

HEMOCHROMATOSIS HFE GENE (511345)

Facility

$225.00

Service Code	HCPCS 81256
Hospital Charge Code	4081256
Hospital Revenue Code	300
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna Commercial	$213.75
Rate for Payer: Aetna Medicare	$202.50
Rate for Payer: BCBS MT CHIP	$202.50
Rate for Payer: BCBS MT Closed Plan Network	$213.75
Rate for Payer: BCBS MT HealthLink	$202.50
Rate for Payer: BCBS MT Medicare	$202.50
Rate for Payer: BCBS MT POS	$213.75
Rate for Payer: BCBS MT Traditional	$225.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Cigna Commercial	$213.75
Rate for Payer: Cigna Medicare	$202.50
Rate for Payer: Medicaid All Medicaid	$207.00
Rate for Payer: Medicare All Medicare	$157.50
Rate for Payer: Monida Allegiance	$213.75
Rate for Payer: Monida First Choice Health	$218.25
Rate for Payer: Monida Montana Health Co-op	$213.75
Rate for Payer: Monida PacificSource	$213.75

HEMOCHROMATOSIS HFE GENE (511345)

Facility

$225.00

Service Code	HCPCS 81256
Hospital Charge Code	4081256
Hospital Revenue Code	300
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$225.00
Rate for Payer: Aetna Commercial	$213.75
Rate for Payer: Aetna Medicare	$202.50
Rate for Payer: BCBS MT CHIP	$202.50
Rate for Payer: BCBS MT Closed Plan Network	$213.75
Rate for Payer: BCBS MT HealthLink	$202.50
Rate for Payer: BCBS MT Medicare	$202.50
Rate for Payer: BCBS MT POS	$213.75
Rate for Payer: BCBS MT Traditional	$225.00
Rate for Payer: Cash Price	$202.50
Rate for Payer: Cigna Commercial	$213.75
Rate for Payer: Cigna Medicare	$202.50
Rate for Payer: Medicaid All Medicaid	$207.00
Rate for Payer: Medicare All Medicare	$157.50
Rate for Payer: Monida Allegiance	$213.75
Rate for Payer: Monida First Choice Health	$218.25
Rate for Payer: Monida Montana Health Co-op	$213.75
Rate for Payer: Monida PacificSource	$213.75

HEMOGLOBIN A1C

Facility

$105.00

Service Code	HCPCS 83036
Hospital Charge Code	4083036
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

HEMOGLOBIN A1C

Facility

$105.00

Service Code	HCPCS 83036
Hospital Charge Code	4083036
Hospital Revenue Code	300
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

HEMOGLOBIN, BLOOD

Facility

$43.00

Service Code	HCPCS 85018
Hospital Charge Code	4085018
Hospital Revenue Code	305
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

HEMOGLOBIN, BLOOD

Facility

$43.00

Service Code	HCPCS 85018
Hospital Charge Code	4085018
Hospital Revenue Code	305
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

HEMOGLOBINOPATHY FRACTIONATION (121690)

Facility

$69.00

Service Code	HCPCS 83020
Hospital Charge Code	4083020
Hospital Revenue Code	305
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

HEMOGLOBINOPATHY FRACTIONATION (121690)

Facility

$69.00

Service Code	HCPCS 83020
Hospital Charge Code	4083020
Hospital Revenue Code	305
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

HEPARIN DRIP [25,000 UNITS]/D5W 250ML

Facility

$37.00

Service Code	HCPCS J1644
Hospital Charge Code	3000212
Hospital Revenue Code	259
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

HEPARIN DRIP [25,000 UNITS]/D5W 250ML

Facility

$37.00

Service Code	HCPCS J1644
Hospital Charge Code	3000212
Hospital Revenue Code	259
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

HEPARIN INJ 5000 units/ML

Facility

$26.00

Service Code	HCPCS J1644
Hospital Charge Code	3000213
Hospital Revenue Code	636
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

HEPARIN INJ 5000 units/ML

Facility

$26.00

Service Code	HCPCS J1644
Hospital Charge Code	3000213
Hospital Revenue Code	636
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

HEPARIN LOCK FLUSH INJ [100 UNITS/ML]

Facility

$26.00

Service Code	HCPCS J1642
Hospital Charge Code	3000214
Hospital Revenue Code	258
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

HEPARIN LOCK FLUSH INJ [100 UNITS/ML]

Facility

$26.00

Service Code	HCPCS J1642
Hospital Charge Code	3000214
Hospital Revenue Code	258
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

HEPATIC FUNCTION PANEL

Facility

$164.00

Service Code	HCPCS 80076
Hospital Charge Code	4080076
Hospital Revenue Code	300
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$164.00
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$147.60
Rate for Payer: BCBS MT CHIP	$147.60
Rate for Payer: BCBS MT Closed Plan Network	$155.80
Rate for Payer: BCBS MT HealthLink	$147.60
Rate for Payer: BCBS MT Medicare	$147.60
Rate for Payer: BCBS MT POS	$155.80
Rate for Payer: BCBS MT Traditional	$164.00
Rate for Payer: Cash Price	$147.60
Rate for Payer: Cigna Commercial	$155.80
Rate for Payer: Cigna Medicare	$147.60
Rate for Payer: Medicaid All Medicaid	$150.88
Rate for Payer: Medicare All Medicare	$114.80
Rate for Payer: Monida Allegiance	$155.80
Rate for Payer: Monida First Choice Health	$159.08
Rate for Payer: Monida Montana Health Co-op	$155.80
Rate for Payer: Monida PacificSource	$155.80

HEPATIC FUNCTION PANEL

Facility

$164.00

Service Code	HCPCS 80076
Hospital Charge Code	4080076
Hospital Revenue Code	300
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$164.00
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$147.60
Rate for Payer: BCBS MT CHIP	$147.60
Rate for Payer: BCBS MT Closed Plan Network	$155.80
Rate for Payer: BCBS MT HealthLink	$147.60
Rate for Payer: BCBS MT Medicare	$147.60
Rate for Payer: BCBS MT POS	$155.80
Rate for Payer: BCBS MT Traditional	$164.00
Rate for Payer: Cash Price	$147.60
Rate for Payer: Cigna Commercial	$155.80
Rate for Payer: Cigna Medicare	$147.60
Rate for Payer: Medicaid All Medicaid	$150.88
Rate for Payer: Medicare All Medicare	$114.80
Rate for Payer: Monida Allegiance	$155.80
Rate for Payer: Monida First Choice Health	$159.08
Rate for Payer: Monida Montana Health Co-op	$155.80
Rate for Payer: Monida PacificSource	$155.80

HEPATITIS A ANTIBODY, IGM (006734)

Facility

$66.00

Service Code	HCPCS 86709
Hospital Charge Code	4086709
Hospital Revenue Code	302
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

HEPATITIS A ANTIBODY, IGM (006734)

Facility

$66.00

Service Code	HCPCS 86709
Hospital Charge Code	4086709
Hospital Revenue Code	302
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

HEPATITIS A VIRUS AB TOTAL (006726)

Facility

$68.00

Service Code	HCPCS 86708
Hospital Charge Code	4086708
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

HEPATITIS A VIRUS AB TOTAL (006726)

Facility

$68.00

Service Code	HCPCS 86708
Hospital Charge Code	4086708
Hospital Revenue Code	300
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

HEPATITIS B CORE AB, IGM (016881)

Facility

$67.00

Service Code	HCPCS 86705
Hospital Charge Code	4086705
Hospital Revenue Code	302
Min. Negotiated Rate	$46.90
Max. Negotiated Rate	$67.00
Rate for Payer: Aetna Commercial	$63.65
Rate for Payer: Aetna Medicare	$60.30
Rate for Payer: BCBS MT CHIP	$60.30
Rate for Payer: BCBS MT Closed Plan Network	$63.65
Rate for Payer: BCBS MT HealthLink	$60.30
Rate for Payer: BCBS MT Medicare	$60.30
Rate for Payer: BCBS MT POS	$63.65
Rate for Payer: BCBS MT Traditional	$67.00
Rate for Payer: Cash Price	$60.30
Rate for Payer: Cigna Commercial	$63.65
Rate for Payer: Cigna Medicare	$60.30
Rate for Payer: Medicaid All Medicaid	$61.64
Rate for Payer: Medicare All Medicare	$46.90
Rate for Payer: Monida Allegiance	$63.65
Rate for Payer: Monida First Choice Health	$64.99
Rate for Payer: Monida Montana Health Co-op	$63.65
Rate for Payer: Monida PacificSource	$63.65

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