Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAB CHROMOGRANIN A

Facility

$94.00

Service Code	HCPCS 86316
Hospital Charge Code	4086316
Hospital Revenue Code	300
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

LAB CHROMOSONE ROUTINE

Facility

$102.00

Service Code	HCPCS 88291
Hospital Charge Code	4088291
Hospital Revenue Code	301
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$96.90
Rate for Payer: Aetna Medicare	$91.80
Rate for Payer: BCBS MT CHIP	$91.80
Rate for Payer: BCBS MT Closed Plan Network	$96.90
Rate for Payer: BCBS MT HealthLink	$91.80
Rate for Payer: BCBS MT Medicare	$91.80
Rate for Payer: BCBS MT POS	$96.90
Rate for Payer: BCBS MT Traditional	$102.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial	$96.90
Rate for Payer: Cigna Medicare	$91.80
Rate for Payer: Medicaid All Medicaid	$93.84
Rate for Payer: Medicare All Medicare	$71.40
Rate for Payer: Monida Allegiance	$96.90
Rate for Payer: Monida First Choice Health	$98.94
Rate for Payer: Monida Montana Health Co-op	$96.90
Rate for Payer: Monida PacificSource	$96.90

LAB CHROMOSONE ROUTINE

Facility

$551.00

Service Code	HCPCS 88230
Hospital Charge Code	4088230
Hospital Revenue Code	301
Min. Negotiated Rate	$385.70
Max. Negotiated Rate	$551.00
Rate for Payer: Aetna Commercial	$523.45
Rate for Payer: Aetna Medicare	$495.90
Rate for Payer: BCBS MT CHIP	$495.90
Rate for Payer: BCBS MT Closed Plan Network	$523.45
Rate for Payer: BCBS MT HealthLink	$495.90
Rate for Payer: BCBS MT Medicare	$495.90
Rate for Payer: BCBS MT POS	$523.45
Rate for Payer: BCBS MT Traditional	$551.00
Rate for Payer: Cash Price	$495.90
Rate for Payer: Cigna Commercial	$523.45
Rate for Payer: Cigna Medicare	$495.90
Rate for Payer: Medicaid All Medicaid	$506.92
Rate for Payer: Medicare All Medicare	$385.70
Rate for Payer: Monida Allegiance	$523.45
Rate for Payer: Monida First Choice Health	$534.47
Rate for Payer: Monida Montana Health Co-op	$523.45
Rate for Payer: Monida PacificSource	$523.45

LAB CHROMOSONE ROUTINE

Facility

$687.00

Service Code	HCPCS 88262
Hospital Charge Code	4088262
Hospital Revenue Code	301
Min. Negotiated Rate	$480.90
Max. Negotiated Rate	$687.00
Rate for Payer: Aetna Commercial	$652.65
Rate for Payer: Aetna Medicare	$618.30
Rate for Payer: BCBS MT CHIP	$618.30
Rate for Payer: BCBS MT Closed Plan Network	$652.65
Rate for Payer: BCBS MT HealthLink	$618.30
Rate for Payer: BCBS MT Medicare	$618.30
Rate for Payer: BCBS MT POS	$652.65
Rate for Payer: BCBS MT Traditional	$687.00
Rate for Payer: Cash Price	$618.30
Rate for Payer: Cigna Commercial	$652.65
Rate for Payer: Cigna Medicare	$618.30
Rate for Payer: Medicaid All Medicaid	$632.04
Rate for Payer: Medicare All Medicare	$480.90
Rate for Payer: Monida Allegiance	$652.65
Rate for Payer: Monida First Choice Health	$666.39
Rate for Payer: Monida Montana Health Co-op	$652.65
Rate for Payer: Monida PacificSource	$652.65

LAB CHROMOSONE ROUTINE

Facility

$102.00

Service Code	HCPCS 88291
Hospital Charge Code	4088291
Hospital Revenue Code	301
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$96.90
Rate for Payer: Aetna Medicare	$91.80
Rate for Payer: BCBS MT CHIP	$91.80
Rate for Payer: BCBS MT Closed Plan Network	$96.90
Rate for Payer: BCBS MT HealthLink	$91.80
Rate for Payer: BCBS MT Medicare	$91.80
Rate for Payer: BCBS MT POS	$96.90
Rate for Payer: BCBS MT Traditional	$102.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial	$96.90
Rate for Payer: Cigna Medicare	$91.80
Rate for Payer: Medicaid All Medicaid	$93.84
Rate for Payer: Medicare All Medicare	$71.40
Rate for Payer: Monida Allegiance	$96.90
Rate for Payer: Monida First Choice Health	$98.94
Rate for Payer: Monida Montana Health Co-op	$96.90
Rate for Payer: Monida PacificSource	$96.90

LAB CHROMOSONE ROUTINE

Facility

$687.00

Service Code	HCPCS 88262
Hospital Charge Code	4088262
Hospital Revenue Code	301
Min. Negotiated Rate	$480.90
Max. Negotiated Rate	$687.00
Rate for Payer: Aetna Commercial	$652.65
Rate for Payer: Aetna Medicare	$618.30
Rate for Payer: BCBS MT CHIP	$618.30
Rate for Payer: BCBS MT Closed Plan Network	$652.65
Rate for Payer: BCBS MT HealthLink	$618.30
Rate for Payer: BCBS MT Medicare	$618.30
Rate for Payer: BCBS MT POS	$652.65
Rate for Payer: BCBS MT Traditional	$687.00
Rate for Payer: Cash Price	$618.30
Rate for Payer: Cigna Commercial	$652.65
Rate for Payer: Cigna Medicare	$618.30
Rate for Payer: Medicaid All Medicaid	$632.04
Rate for Payer: Medicare All Medicare	$480.90
Rate for Payer: Monida Allegiance	$652.65
Rate for Payer: Monida First Choice Health	$666.39
Rate for Payer: Monida Montana Health Co-op	$652.65
Rate for Payer: Monida PacificSource	$652.65

LAB CHROMOSONE ROUTINE

Facility

$551.00

Service Code	HCPCS 88230
Hospital Charge Code	4088230
Hospital Revenue Code	301
Min. Negotiated Rate	$385.70
Max. Negotiated Rate	$551.00
Rate for Payer: Aetna Commercial	$523.45
Rate for Payer: Aetna Medicare	$495.90
Rate for Payer: BCBS MT CHIP	$495.90
Rate for Payer: BCBS MT Closed Plan Network	$523.45
Rate for Payer: BCBS MT HealthLink	$495.90
Rate for Payer: BCBS MT Medicare	$495.90
Rate for Payer: BCBS MT POS	$523.45
Rate for Payer: BCBS MT Traditional	$551.00
Rate for Payer: Cash Price	$495.90
Rate for Payer: Cigna Commercial	$523.45
Rate for Payer: Cigna Medicare	$495.90
Rate for Payer: Medicaid All Medicaid	$506.92
Rate for Payer: Medicare All Medicare	$385.70
Rate for Payer: Monida Allegiance	$523.45
Rate for Payer: Monida First Choice Health	$534.47
Rate for Payer: Monida Montana Health Co-op	$523.45
Rate for Payer: Monida PacificSource	$523.45

LAB CITRATE

Facility

$135.00

Service Code	HCPCS 82507
Hospital Charge Code	4082507
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

LAB CITRATE

Facility

$135.00

Service Code	HCPCS 82507
Hospital Charge Code	4082507
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

LAB CK ISOENZYMES

Facility

$125.00

Service Code	HCPCS 82552
Hospital Charge Code	4082552
Hospital Revenue Code	301
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

LAB CK ISOENZYMES

Facility

$125.00

Service Code	HCPCS 82552
Hospital Charge Code	4082552
Hospital Revenue Code	301
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

LAB CLOMIPRAMINE LEVEL

Facility

$135.00

Service Code	HCPCS 83789
Hospital Charge Code	4083789
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

LAB CLOMIPRAMINE LEVEL

Facility

$135.00

Service Code	HCPCS 83789
Hospital Charge Code	4083789
Hospital Revenue Code	300
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

LAB COLD AGGLUTININS

Facility

$54.00

Service Code	HCPCS 86157
Hospital Charge Code	4086157
Hospital Revenue Code	301
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

LAB COLD AGGLUTININS

Facility

$54.00

Service Code	HCPCS 86157
Hospital Charge Code	4086157
Hospital Revenue Code	301
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

LAB COLO CARE (STOOL BLOOD TEST)

Facility

$7.00

Hospital Charge Code	4056560
Hospital Revenue Code	300
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.65
Rate for Payer: Aetna Medicare	$6.30
Rate for Payer: BCBS MT CHIP	$6.30
Rate for Payer: BCBS MT Closed Plan Network	$6.65
Rate for Payer: BCBS MT HealthLink	$6.30
Rate for Payer: BCBS MT Medicare	$6.30
Rate for Payer: BCBS MT POS	$6.65
Rate for Payer: BCBS MT Traditional	$7.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna Commercial	$6.65
Rate for Payer: Cigna Medicare	$6.30
Rate for Payer: Medicaid All Medicaid	$6.44
Rate for Payer: Medicare All Medicare	$4.90
Rate for Payer: Monida Allegiance	$6.65
Rate for Payer: Monida First Choice Health	$6.79
Rate for Payer: Monida Montana Health Co-op	$6.65
Rate for Payer: Monida PacificSource	$6.65

LAB COLO CARE (STOOL BLOOD TEST)

Facility

$7.00

Hospital Charge Code	4056560
Hospital Revenue Code	300
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$7.00
Rate for Payer: Aetna Commercial	$6.65
Rate for Payer: Aetna Medicare	$6.30
Rate for Payer: BCBS MT CHIP	$6.30
Rate for Payer: BCBS MT Closed Plan Network	$6.65
Rate for Payer: BCBS MT HealthLink	$6.30
Rate for Payer: BCBS MT Medicare	$6.30
Rate for Payer: BCBS MT POS	$6.65
Rate for Payer: BCBS MT Traditional	$7.00
Rate for Payer: Cash Price	$6.30
Rate for Payer: Cigna Commercial	$6.65
Rate for Payer: Cigna Medicare	$6.30
Rate for Payer: Medicaid All Medicaid	$6.44
Rate for Payer: Medicare All Medicare	$4.90
Rate for Payer: Monida Allegiance	$6.65
Rate for Payer: Monida First Choice Health	$6.79
Rate for Payer: Monida Montana Health Co-op	$6.65
Rate for Payer: Monida PacificSource	$6.65

LAB COMP RESPIRATORY PANEL

Facility

$697.00

Service Code	HCPCS 87633
Hospital Charge Code	4087633
Hospital Revenue Code	300
Min. Negotiated Rate	$487.90
Max. Negotiated Rate	$697.00
Rate for Payer: Aetna Commercial	$662.15
Rate for Payer: Aetna Medicare	$627.30
Rate for Payer: BCBS MT CHIP	$627.30
Rate for Payer: BCBS MT Closed Plan Network	$662.15
Rate for Payer: BCBS MT HealthLink	$627.30
Rate for Payer: BCBS MT Medicare	$627.30
Rate for Payer: BCBS MT POS	$662.15
Rate for Payer: BCBS MT Traditional	$697.00
Rate for Payer: Cash Price	$627.30
Rate for Payer: Cigna Commercial	$662.15
Rate for Payer: Cigna Medicare	$627.30
Rate for Payer: Medicaid All Medicaid	$641.24
Rate for Payer: Medicare All Medicare	$487.90
Rate for Payer: Monida Allegiance	$662.15
Rate for Payer: Monida First Choice Health	$676.09
Rate for Payer: Monida Montana Health Co-op	$662.15
Rate for Payer: Monida PacificSource	$662.15

LAB COMP RESPIRATORY PANEL

Facility

$697.00

Service Code	HCPCS 87633
Hospital Charge Code	4087633
Hospital Revenue Code	300
Min. Negotiated Rate	$487.90
Max. Negotiated Rate	$697.00
Rate for Payer: Aetna Commercial	$662.15
Rate for Payer: Aetna Medicare	$627.30
Rate for Payer: BCBS MT CHIP	$627.30
Rate for Payer: BCBS MT Closed Plan Network	$662.15
Rate for Payer: BCBS MT HealthLink	$627.30
Rate for Payer: BCBS MT Medicare	$627.30
Rate for Payer: BCBS MT POS	$662.15
Rate for Payer: BCBS MT Traditional	$697.00
Rate for Payer: Cash Price	$627.30
Rate for Payer: Cigna Commercial	$662.15
Rate for Payer: Cigna Medicare	$627.30
Rate for Payer: Medicaid All Medicaid	$641.24
Rate for Payer: Medicare All Medicare	$487.90
Rate for Payer: Monida Allegiance	$662.15
Rate for Payer: Monida First Choice Health	$676.09
Rate for Payer: Monida Montana Health Co-op	$662.15
Rate for Payer: Monida PacificSource	$662.15

LAB CONGENITAL HYPOTHYROIDISM

Facility

$31.00

Service Code	HCPCS 84437
Hospital Charge Code	4084437
Hospital Revenue Code	301
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$31.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: BCBS MT CHIP	$27.90
Rate for Payer: BCBS MT Closed Plan Network	$29.45
Rate for Payer: BCBS MT HealthLink	$27.90
Rate for Payer: BCBS MT Medicare	$27.90
Rate for Payer: BCBS MT POS	$29.45
Rate for Payer: BCBS MT Traditional	$31.00
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cigna Commercial	$29.45
Rate for Payer: Cigna Medicare	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

LAB CONGENITAL HYPOTHYROIDISM

Facility

$31.00

Service Code	HCPCS 84437
Hospital Charge Code	4084437
Hospital Revenue Code	301
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$31.00
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: BCBS MT CHIP	$27.90
Rate for Payer: BCBS MT Closed Plan Network	$29.45
Rate for Payer: BCBS MT HealthLink	$27.90
Rate for Payer: BCBS MT Medicare	$27.90
Rate for Payer: BCBS MT POS	$29.45
Rate for Payer: BCBS MT Traditional	$31.00
Rate for Payer: Cash Price	$27.90
Rate for Payer: Cigna Commercial	$29.45
Rate for Payer: Cigna Medicare	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

LAB COOMBS DIRECT

Facility

$60.00

Service Code	HCPCS 86880
Hospital Charge Code	4086880
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

LAB COOMBS DIRECT

Facility

$60.00

Service Code	HCPCS 86880
Hospital Charge Code	4086880
Hospital Revenue Code	300
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

LAB CREATINE URINE

Facility

$154.00

Service Code	HCPCS 82540
Hospital Charge Code	4082540
Hospital Revenue Code	300
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

LAB CREATINE URINE

Facility

$154.00

Service Code	HCPCS 82540
Hospital Charge Code	4082540
Hospital Revenue Code	300
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

Know your out-of-pocket cost for care.

All Charges