Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

URINE CULTURE (008847)

Facility

$18.00

Service Code	HCPCS 87086
Hospital Charge Code	4087086
Hospital Revenue Code	300
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

URINE STRAINERS

Facility

$13.00

Hospital Charge Code	80030556
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

URINE STRAINERS

Facility

$13.00

Hospital Charge Code	80030556
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

URSODIOL CAP [300 MG] NF

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000464
Hospital Revenue Code	250
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

URSODIOL CAP [300 MG] NF

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000464
Hospital Revenue Code	250
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

US 3D RENDERING W/INTERPRET POST PROCE

Facility

$657.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5176376
Hospital Revenue Code	402
Min. Negotiated Rate	$459.90
Max. Negotiated Rate	$657.00
Rate for Payer: Aetna Commercial	$624.15
Rate for Payer: Aetna Medicare	$591.30
Rate for Payer: BCBS MT CHIP	$591.30
Rate for Payer: BCBS MT Closed Plan Network	$624.15
Rate for Payer: BCBS MT HealthLink	$591.30
Rate for Payer: BCBS MT Medicare	$591.30
Rate for Payer: BCBS MT POS	$624.15
Rate for Payer: BCBS MT Traditional	$657.00
Rate for Payer: Cash Price	$591.30
Rate for Payer: Cigna Commercial	$624.15
Rate for Payer: Cigna Medicare	$591.30
Rate for Payer: Medicaid All Medicaid	$604.44
Rate for Payer: Medicare All Medicare	$459.90
Rate for Payer: Monida Allegiance	$624.15
Rate for Payer: Monida First Choice Health	$637.29
Rate for Payer: Monida Montana Health Co-op	$624.15
Rate for Payer: Monida PacificSource	$624.15

US 3D RENDERING W/INTERPRET POST PROCE

Facility

$657.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5176376
Hospital Revenue Code	402
Min. Negotiated Rate	$459.90
Max. Negotiated Rate	$657.00
Rate for Payer: Aetna Commercial	$624.15
Rate for Payer: Aetna Medicare	$591.30
Rate for Payer: BCBS MT CHIP	$591.30
Rate for Payer: BCBS MT Closed Plan Network	$624.15
Rate for Payer: BCBS MT HealthLink	$591.30
Rate for Payer: BCBS MT Medicare	$591.30
Rate for Payer: BCBS MT POS	$624.15
Rate for Payer: BCBS MT Traditional	$657.00
Rate for Payer: Cash Price	$591.30
Rate for Payer: Cigna Commercial	$624.15
Rate for Payer: Cigna Medicare	$591.30
Rate for Payer: Medicaid All Medicaid	$604.44
Rate for Payer: Medicare All Medicare	$459.90
Rate for Payer: Monida Allegiance	$624.15
Rate for Payer: Monida First Choice Health	$637.29
Rate for Payer: Monida Montana Health Co-op	$624.15
Rate for Payer: Monida PacificSource	$624.15

US 3D RENDER W/INTERP&POSTPROC DIFF WORK

Facility

$835.00

Service Code	HCPCS 76377 TC
Hospital Charge Code	5176377
Hospital Revenue Code	402
Min. Negotiated Rate	$584.50
Max. Negotiated Rate	$835.00
Rate for Payer: Aetna Commercial	$793.25
Rate for Payer: Aetna Medicare	$751.50
Rate for Payer: BCBS MT CHIP	$751.50
Rate for Payer: BCBS MT Closed Plan Network	$793.25
Rate for Payer: BCBS MT HealthLink	$751.50
Rate for Payer: BCBS MT Medicare	$751.50
Rate for Payer: BCBS MT POS	$793.25
Rate for Payer: BCBS MT Traditional	$835.00
Rate for Payer: Cash Price	$751.50
Rate for Payer: Cigna Commercial	$793.25
Rate for Payer: Cigna Medicare	$751.50
Rate for Payer: Medicaid All Medicaid	$768.20
Rate for Payer: Medicare All Medicare	$584.50
Rate for Payer: Monida Allegiance	$793.25
Rate for Payer: Monida First Choice Health	$809.95
Rate for Payer: Monida Montana Health Co-op	$793.25
Rate for Payer: Monida PacificSource	$793.25

US 3D RENDER W/INTERP&POSTPROC DIFF WORK

Facility

$835.00

Service Code	HCPCS 76377 TC
Hospital Charge Code	5176377
Hospital Revenue Code	402
Min. Negotiated Rate	$584.50
Max. Negotiated Rate	$835.00
Rate for Payer: Aetna Commercial	$793.25
Rate for Payer: Aetna Medicare	$751.50
Rate for Payer: BCBS MT CHIP	$751.50
Rate for Payer: BCBS MT Closed Plan Network	$793.25
Rate for Payer: BCBS MT HealthLink	$751.50
Rate for Payer: BCBS MT Medicare	$751.50
Rate for Payer: BCBS MT POS	$793.25
Rate for Payer: BCBS MT Traditional	$835.00
Rate for Payer: Cash Price	$751.50
Rate for Payer: Cigna Commercial	$793.25
Rate for Payer: Cigna Medicare	$751.50
Rate for Payer: Medicaid All Medicaid	$768.20
Rate for Payer: Medicare All Medicare	$584.50
Rate for Payer: Monida Allegiance	$793.25
Rate for Payer: Monida First Choice Health	$809.95
Rate for Payer: Monida Montana Health Co-op	$793.25
Rate for Payer: Monida PacificSource	$793.25

US ABDOMEN COMPLETE

Facility

$563.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	5176700
Hospital Revenue Code	402
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

US ABDOMEN COMPLETE

Facility

$563.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	5176700
Hospital Revenue Code	402
Min. Negotiated Rate	$394.10
Max. Negotiated Rate	$563.00
Rate for Payer: Aetna Commercial	$534.85
Rate for Payer: Aetna Medicare	$506.70
Rate for Payer: BCBS MT CHIP	$506.70
Rate for Payer: BCBS MT Closed Plan Network	$534.85
Rate for Payer: BCBS MT HealthLink	$506.70
Rate for Payer: BCBS MT Medicare	$506.70
Rate for Payer: BCBS MT POS	$534.85
Rate for Payer: BCBS MT Traditional	$563.00
Rate for Payer: Cash Price	$506.70
Rate for Payer: Cigna Commercial	$534.85
Rate for Payer: Cigna Medicare	$506.70
Rate for Payer: Medicaid All Medicaid	$517.96
Rate for Payer: Medicare All Medicare	$394.10
Rate for Payer: Monida Allegiance	$534.85
Rate for Payer: Monida First Choice Health	$546.11
Rate for Payer: Monida Montana Health Co-op	$534.85
Rate for Payer: Monida PacificSource	$534.85

US ABDOMEN DOPP LMT

Facility

$471.00

Service Code	HCPCS 93976
Hospital Charge Code	5193976
Hospital Revenue Code	402
Min. Negotiated Rate	$329.70
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$447.45
Rate for Payer: Aetna Medicare	$423.90
Rate for Payer: BCBS MT CHIP	$423.90
Rate for Payer: BCBS MT Closed Plan Network	$447.45
Rate for Payer: BCBS MT HealthLink	$423.90
Rate for Payer: BCBS MT Medicare	$423.90
Rate for Payer: BCBS MT POS	$447.45
Rate for Payer: BCBS MT Traditional	$471.00
Rate for Payer: Cash Price	$423.90
Rate for Payer: Cigna Commercial	$447.45
Rate for Payer: Cigna Medicare	$423.90
Rate for Payer: Medicaid All Medicaid	$433.32
Rate for Payer: Medicare All Medicare	$329.70
Rate for Payer: Monida Allegiance	$447.45
Rate for Payer: Monida First Choice Health	$456.87
Rate for Payer: Monida Montana Health Co-op	$447.45
Rate for Payer: Monida PacificSource	$447.45

US ABDOMEN DOPP LMT

Facility

$471.00

Service Code	HCPCS 93976
Hospital Charge Code	5193976
Hospital Revenue Code	402
Min. Negotiated Rate	$329.70
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$447.45
Rate for Payer: Aetna Medicare	$423.90
Rate for Payer: BCBS MT CHIP	$423.90
Rate for Payer: BCBS MT Closed Plan Network	$447.45
Rate for Payer: BCBS MT HealthLink	$423.90
Rate for Payer: BCBS MT Medicare	$423.90
Rate for Payer: BCBS MT POS	$447.45
Rate for Payer: BCBS MT Traditional	$471.00
Rate for Payer: Cash Price	$423.90
Rate for Payer: Cigna Commercial	$447.45
Rate for Payer: Cigna Medicare	$423.90
Rate for Payer: Medicaid All Medicaid	$433.32
Rate for Payer: Medicare All Medicare	$329.70
Rate for Payer: Monida Allegiance	$447.45
Rate for Payer: Monida First Choice Health	$456.87
Rate for Payer: Monida Montana Health Co-op	$447.45
Rate for Payer: Monida PacificSource	$447.45

US ABDOMEN LIMITED

Facility

$418.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5176705
Hospital Revenue Code	402
Min. Negotiated Rate	$292.60
Max. Negotiated Rate	$418.00
Rate for Payer: Aetna Commercial	$397.10
Rate for Payer: Aetna Medicare	$376.20
Rate for Payer: BCBS MT CHIP	$376.20
Rate for Payer: BCBS MT Closed Plan Network	$397.10
Rate for Payer: BCBS MT HealthLink	$376.20
Rate for Payer: BCBS MT Medicare	$376.20
Rate for Payer: BCBS MT POS	$397.10
Rate for Payer: BCBS MT Traditional	$418.00
Rate for Payer: Cash Price	$376.20
Rate for Payer: Cigna Commercial	$397.10
Rate for Payer: Cigna Medicare	$376.20
Rate for Payer: Medicaid All Medicaid	$384.56
Rate for Payer: Medicare All Medicare	$292.60
Rate for Payer: Monida Allegiance	$397.10
Rate for Payer: Monida First Choice Health	$405.46
Rate for Payer: Monida Montana Health Co-op	$397.10
Rate for Payer: Monida PacificSource	$397.10

US ABDOMEN LIMITED

Facility

$418.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5176705
Hospital Revenue Code	402
Min. Negotiated Rate	$292.60
Max. Negotiated Rate	$418.00
Rate for Payer: Aetna Commercial	$397.10
Rate for Payer: Aetna Medicare	$376.20
Rate for Payer: BCBS MT CHIP	$376.20
Rate for Payer: BCBS MT Closed Plan Network	$397.10
Rate for Payer: BCBS MT HealthLink	$376.20
Rate for Payer: BCBS MT Medicare	$376.20
Rate for Payer: BCBS MT POS	$397.10
Rate for Payer: BCBS MT Traditional	$418.00
Rate for Payer: Cash Price	$376.20
Rate for Payer: Cigna Commercial	$397.10
Rate for Payer: Cigna Medicare	$376.20
Rate for Payer: Medicaid All Medicaid	$384.56
Rate for Payer: Medicare All Medicare	$292.60
Rate for Payer: Monida Allegiance	$397.10
Rate for Payer: Monida First Choice Health	$405.46
Rate for Payer: Monida Montana Health Co-op	$397.10
Rate for Payer: Monida PacificSource	$397.10

US ABDOMINAL AORTA REAL TIME SCREEN STUD

Facility

$251.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	5176706
Hospital Revenue Code	402
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

US ABDOMINAL AORTA REAL TIME SCREEN STUD

Facility

$251.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	5176706
Hospital Revenue Code	402
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

US ABI

Facility

$273.00

Service Code	HCPCS 93922
Hospital Charge Code	5193922
Hospital Revenue Code	402
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

US ABI

Facility

$273.00

Service Code	HCPCS 93922
Hospital Charge Code	5193922
Hospital Revenue Code	402
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

US AORTA SCREEN/MC

Facility

$353.00

Service Code	HCPCS 93979
Hospital Charge Code	5100004
Hospital Revenue Code	402
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

US AORTA SCREEN/MC

Facility

$353.00

Service Code	HCPCS 93979
Hospital Charge Code	5100004
Hospital Revenue Code	402
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

US ARTERY BYPASS GRAFT

Facility

$353.00

Service Code	HCPCS 93979
Hospital Charge Code	5193979
Hospital Revenue Code	402
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

US ARTERY BYPASS GRAFT

Facility

$353.00

Service Code	HCPCS 93979
Hospital Charge Code	5193979
Hospital Revenue Code	402
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

US BLADDER PRE/POST

Facility

$217.00

Service Code	HCPCS 76857
Hospital Charge Code	5176857
Hospital Revenue Code	402
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$217.00
Rate for Payer: Aetna Commercial	$206.15
Rate for Payer: Aetna Medicare	$195.30
Rate for Payer: BCBS MT CHIP	$195.30
Rate for Payer: BCBS MT Closed Plan Network	$206.15
Rate for Payer: BCBS MT HealthLink	$195.30
Rate for Payer: BCBS MT Medicare	$195.30
Rate for Payer: BCBS MT POS	$206.15
Rate for Payer: BCBS MT Traditional	$217.00
Rate for Payer: Cash Price	$195.30
Rate for Payer: Cigna Commercial	$206.15
Rate for Payer: Cigna Medicare	$195.30
Rate for Payer: Medicaid All Medicaid	$199.64
Rate for Payer: Medicare All Medicare	$151.90
Rate for Payer: Monida Allegiance	$206.15
Rate for Payer: Monida First Choice Health	$210.49
Rate for Payer: Monida Montana Health Co-op	$206.15
Rate for Payer: Monida PacificSource	$206.15

US BLADDER PRE/POST

Facility

$217.00

Service Code	HCPCS 76857
Hospital Charge Code	5176857
Hospital Revenue Code	402
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$217.00
Rate for Payer: Aetna Commercial	$206.15
Rate for Payer: Aetna Medicare	$195.30
Rate for Payer: BCBS MT CHIP	$195.30
Rate for Payer: BCBS MT Closed Plan Network	$206.15
Rate for Payer: BCBS MT HealthLink	$195.30
Rate for Payer: BCBS MT Medicare	$195.30
Rate for Payer: BCBS MT POS	$206.15
Rate for Payer: BCBS MT Traditional	$217.00
Rate for Payer: Cash Price	$195.30
Rate for Payer: Cigna Commercial	$206.15
Rate for Payer: Cigna Medicare	$195.30
Rate for Payer: Medicaid All Medicaid	$199.64
Rate for Payer: Medicare All Medicare	$151.90
Rate for Payer: Monida Allegiance	$206.15
Rate for Payer: Monida First Choice Health	$210.49
Rate for Payer: Monida Montana Health Co-op	$206.15
Rate for Payer: Monida PacificSource	$206.15

Know your out-of-pocket cost for care.

All Charges