Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US BLADDER SCANNER POST

Facility

$142.00

Service Code	HCPCS 51798
Hospital Charge Code	151799
Hospital Revenue Code	920
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

US BLADDER SCANNER POST

Facility

$142.00

Service Code	HCPCS 51798
Hospital Charge Code	151799
Hospital Revenue Code	920
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

US BREAST

Facility

$281.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	5176641
Hospital Revenue Code	402
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$281.00
Rate for Payer: Aetna Commercial	$266.95
Rate for Payer: Aetna Medicare	$252.90
Rate for Payer: BCBS MT CHIP	$252.90
Rate for Payer: BCBS MT Closed Plan Network	$266.95
Rate for Payer: BCBS MT HealthLink	$252.90
Rate for Payer: BCBS MT Medicare	$252.90
Rate for Payer: BCBS MT POS	$266.95
Rate for Payer: BCBS MT Traditional	$281.00
Rate for Payer: Cash Price	$252.90
Rate for Payer: Cigna Commercial	$266.95
Rate for Payer: Cigna Medicare	$252.90
Rate for Payer: Medicaid All Medicaid	$258.52
Rate for Payer: Medicare All Medicare	$196.70
Rate for Payer: Monida Allegiance	$266.95
Rate for Payer: Monida First Choice Health	$272.57
Rate for Payer: Monida Montana Health Co-op	$266.95
Rate for Payer: Monida PacificSource	$266.95

US BREAST

Facility

$281.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	5176641
Hospital Revenue Code	402
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$281.00
Rate for Payer: Aetna Commercial	$266.95
Rate for Payer: Aetna Medicare	$252.90
Rate for Payer: BCBS MT CHIP	$252.90
Rate for Payer: BCBS MT Closed Plan Network	$266.95
Rate for Payer: BCBS MT HealthLink	$252.90
Rate for Payer: BCBS MT Medicare	$252.90
Rate for Payer: BCBS MT POS	$266.95
Rate for Payer: BCBS MT Traditional	$281.00
Rate for Payer: Cash Price	$252.90
Rate for Payer: Cigna Commercial	$266.95
Rate for Payer: Cigna Medicare	$252.90
Rate for Payer: Medicaid All Medicaid	$258.52
Rate for Payer: Medicare All Medicare	$196.70
Rate for Payer: Monida Allegiance	$266.95
Rate for Payer: Monida First Choice Health	$272.57
Rate for Payer: Monida Montana Health Co-op	$266.95
Rate for Payer: Monida PacificSource	$266.95

US BREAST UNI REAL TIME WITH IMAGE LIMIT

Facility

$491.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	5176642
Hospital Revenue Code	402
Min. Negotiated Rate	$343.70
Max. Negotiated Rate	$491.00
Rate for Payer: Aetna Commercial	$466.45
Rate for Payer: Aetna Medicare	$441.90
Rate for Payer: BCBS MT CHIP	$441.90
Rate for Payer: BCBS MT Closed Plan Network	$466.45
Rate for Payer: BCBS MT HealthLink	$441.90
Rate for Payer: BCBS MT Medicare	$441.90
Rate for Payer: BCBS MT POS	$466.45
Rate for Payer: BCBS MT Traditional	$491.00
Rate for Payer: Cash Price	$441.90
Rate for Payer: Cigna Commercial	$466.45
Rate for Payer: Cigna Medicare	$441.90
Rate for Payer: Medicaid All Medicaid	$451.72
Rate for Payer: Medicare All Medicare	$343.70
Rate for Payer: Monida Allegiance	$466.45
Rate for Payer: Monida First Choice Health	$476.27
Rate for Payer: Monida Montana Health Co-op	$466.45
Rate for Payer: Monida PacificSource	$466.45

US BREAST UNI REAL TIME WITH IMAGE LIMIT

Facility

$491.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	5176642
Hospital Revenue Code	402
Min. Negotiated Rate	$343.70
Max. Negotiated Rate	$491.00
Rate for Payer: Aetna Commercial	$466.45
Rate for Payer: Aetna Medicare	$441.90
Rate for Payer: BCBS MT CHIP	$441.90
Rate for Payer: BCBS MT Closed Plan Network	$466.45
Rate for Payer: BCBS MT HealthLink	$441.90
Rate for Payer: BCBS MT Medicare	$441.90
Rate for Payer: BCBS MT POS	$466.45
Rate for Payer: BCBS MT Traditional	$491.00
Rate for Payer: Cash Price	$441.90
Rate for Payer: Cigna Commercial	$466.45
Rate for Payer: Cigna Medicare	$441.90
Rate for Payer: Medicaid All Medicaid	$451.72
Rate for Payer: Medicare All Medicare	$343.70
Rate for Payer: Monida Allegiance	$466.45
Rate for Payer: Monida First Choice Health	$476.27
Rate for Payer: Monida Montana Health Co-op	$466.45
Rate for Payer: Monida PacificSource	$466.45

US CAROTID BILATERAL

Facility

$655.00

Service Code	HCPCS 93880
Hospital Charge Code	5193880
Hospital Revenue Code	402
Min. Negotiated Rate	$458.50
Max. Negotiated Rate	$655.00
Rate for Payer: Aetna Commercial	$622.25
Rate for Payer: Aetna Medicare	$589.50
Rate for Payer: BCBS MT CHIP	$589.50
Rate for Payer: BCBS MT Closed Plan Network	$622.25
Rate for Payer: BCBS MT HealthLink	$589.50
Rate for Payer: BCBS MT Medicare	$589.50
Rate for Payer: BCBS MT POS	$622.25
Rate for Payer: BCBS MT Traditional	$655.00
Rate for Payer: Cash Price	$589.50
Rate for Payer: Cigna Commercial	$622.25
Rate for Payer: Cigna Medicare	$589.50
Rate for Payer: Medicaid All Medicaid	$602.60
Rate for Payer: Medicare All Medicare	$458.50
Rate for Payer: Monida Allegiance	$622.25
Rate for Payer: Monida First Choice Health	$635.35
Rate for Payer: Monida Montana Health Co-op	$622.25
Rate for Payer: Monida PacificSource	$622.25

US CAROTID BILATERAL

Facility

$655.00

Service Code	HCPCS 93880
Hospital Charge Code	5193880
Hospital Revenue Code	402
Min. Negotiated Rate	$458.50
Max. Negotiated Rate	$655.00
Rate for Payer: Aetna Commercial	$622.25
Rate for Payer: Aetna Medicare	$589.50
Rate for Payer: BCBS MT CHIP	$589.50
Rate for Payer: BCBS MT Closed Plan Network	$622.25
Rate for Payer: BCBS MT HealthLink	$589.50
Rate for Payer: BCBS MT Medicare	$589.50
Rate for Payer: BCBS MT POS	$622.25
Rate for Payer: BCBS MT Traditional	$655.00
Rate for Payer: Cash Price	$589.50
Rate for Payer: Cigna Commercial	$622.25
Rate for Payer: Cigna Medicare	$589.50
Rate for Payer: Medicaid All Medicaid	$602.60
Rate for Payer: Medicare All Medicare	$458.50
Rate for Payer: Monida Allegiance	$622.25
Rate for Payer: Monida First Choice Health	$635.35
Rate for Payer: Monida Montana Health Co-op	$622.25
Rate for Payer: Monida PacificSource	$622.25

US CAROTID UNILATERAL

Facility

$387.00

Service Code	HCPCS 93882
Hospital Charge Code	5193882
Hospital Revenue Code	402
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

US CAROTID UNILATERAL

Facility

$387.00

Service Code	HCPCS 93882
Hospital Charge Code	5193882
Hospital Revenue Code	402
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

US COMPLETE TTHRC ECHO CONGENI CARDIAC A

Facility

$595.00

Service Code	HCPCS 93303
Hospital Charge Code	5193303
Hospital Revenue Code	402
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$595.00
Rate for Payer: Aetna Commercial	$565.25
Rate for Payer: Aetna Medicare	$535.50
Rate for Payer: BCBS MT CHIP	$535.50
Rate for Payer: BCBS MT Closed Plan Network	$565.25
Rate for Payer: BCBS MT HealthLink	$535.50
Rate for Payer: BCBS MT Medicare	$535.50
Rate for Payer: BCBS MT POS	$565.25
Rate for Payer: BCBS MT Traditional	$595.00
Rate for Payer: Cash Price	$535.50
Rate for Payer: Cigna Commercial	$565.25
Rate for Payer: Cigna Medicare	$535.50
Rate for Payer: Medicaid All Medicaid	$547.40
Rate for Payer: Medicare All Medicare	$416.50
Rate for Payer: Monida Allegiance	$565.25
Rate for Payer: Monida First Choice Health	$577.15
Rate for Payer: Monida Montana Health Co-op	$565.25
Rate for Payer: Monida PacificSource	$565.25

US COMPLETE TTHRC ECHO CONGENI CARDIAC A

Facility

$595.00

Service Code	HCPCS 93303
Hospital Charge Code	5193303
Hospital Revenue Code	402
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$595.00
Rate for Payer: Aetna Commercial	$565.25
Rate for Payer: Aetna Medicare	$535.50
Rate for Payer: BCBS MT CHIP	$535.50
Rate for Payer: BCBS MT Closed Plan Network	$565.25
Rate for Payer: BCBS MT HealthLink	$535.50
Rate for Payer: BCBS MT Medicare	$535.50
Rate for Payer: BCBS MT POS	$565.25
Rate for Payer: BCBS MT Traditional	$595.00
Rate for Payer: Cash Price	$535.50
Rate for Payer: Cigna Commercial	$565.25
Rate for Payer: Cigna Medicare	$535.50
Rate for Payer: Medicaid All Medicaid	$547.40
Rate for Payer: Medicare All Medicare	$416.50
Rate for Payer: Monida Allegiance	$565.25
Rate for Payer: Monida First Choice Health	$577.15
Rate for Payer: Monida Montana Health Co-op	$565.25
Rate for Payer: Monida PacificSource	$565.25

US COMPL JOINT R-T W/IMAGE DOCUMENTATION

Facility

$354.00

Service Code	HCPCS 76881 TC
Hospital Charge Code	5176881
Hospital Revenue Code	402
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

US COMPL JOINT R-T W/IMAGE DOCUMENTATION

Facility

$354.00

Service Code	HCPCS 76881 TC
Hospital Charge Code	5176881
Hospital Revenue Code	402
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$354.00
Rate for Payer: Aetna Commercial	$336.30
Rate for Payer: Aetna Medicare	$318.60
Rate for Payer: BCBS MT CHIP	$318.60
Rate for Payer: BCBS MT Closed Plan Network	$336.30
Rate for Payer: BCBS MT HealthLink	$318.60
Rate for Payer: BCBS MT Medicare	$318.60
Rate for Payer: BCBS MT POS	$336.30
Rate for Payer: BCBS MT Traditional	$354.00
Rate for Payer: Cash Price	$318.60
Rate for Payer: Cigna Commercial	$336.30
Rate for Payer: Cigna Medicare	$318.60
Rate for Payer: Medicaid All Medicaid	$325.68
Rate for Payer: Medicare All Medicare	$247.80
Rate for Payer: Monida Allegiance	$336.30
Rate for Payer: Monida First Choice Health	$343.38
Rate for Payer: Monida Montana Health Co-op	$336.30
Rate for Payer: Monida PacificSource	$336.30

US DOP ECHOCARD PULSE WAVE W/SPECT F-UP/

Facility

$208.00

Service Code	HCPCS 93321
Hospital Charge Code	5193321
Hospital Revenue Code	402
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

US DOP ECHOCARD PULSE WAVE W/SPECT F-UP/

Facility

$208.00

Service Code	HCPCS 93321
Hospital Charge Code	5193321
Hospital Revenue Code	402
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

US DOPPLER COLOR FLOW ADD-ON

Facility

$941.00

Service Code	HCPCS 93325
Hospital Charge Code	5193325
Hospital Revenue Code	402
Min. Negotiated Rate	$658.70
Max. Negotiated Rate	$941.00
Rate for Payer: Aetna Commercial	$893.95
Rate for Payer: Aetna Medicare	$846.90
Rate for Payer: BCBS MT CHIP	$846.90
Rate for Payer: BCBS MT Closed Plan Network	$893.95
Rate for Payer: BCBS MT HealthLink	$846.90
Rate for Payer: BCBS MT Medicare	$846.90
Rate for Payer: BCBS MT POS	$893.95
Rate for Payer: BCBS MT Traditional	$941.00
Rate for Payer: Cash Price	$846.90
Rate for Payer: Cigna Commercial	$893.95
Rate for Payer: Cigna Medicare	$846.90
Rate for Payer: Medicaid All Medicaid	$865.72
Rate for Payer: Medicare All Medicare	$658.70
Rate for Payer: Monida Allegiance	$893.95
Rate for Payer: Monida First Choice Health	$912.77
Rate for Payer: Monida Montana Health Co-op	$893.95
Rate for Payer: Monida PacificSource	$893.95

US DOPPLER COLOR FLOW ADD-ON

Facility

$941.00

Service Code	HCPCS 93325
Hospital Charge Code	5193325
Hospital Revenue Code	402
Min. Negotiated Rate	$658.70
Max. Negotiated Rate	$941.00
Rate for Payer: Aetna Commercial	$893.95
Rate for Payer: Aetna Medicare	$846.90
Rate for Payer: BCBS MT CHIP	$846.90
Rate for Payer: BCBS MT Closed Plan Network	$893.95
Rate for Payer: BCBS MT HealthLink	$846.90
Rate for Payer: BCBS MT Medicare	$846.90
Rate for Payer: BCBS MT POS	$893.95
Rate for Payer: BCBS MT Traditional	$941.00
Rate for Payer: Cash Price	$846.90
Rate for Payer: Cigna Commercial	$893.95
Rate for Payer: Cigna Medicare	$846.90
Rate for Payer: Medicaid All Medicaid	$865.72
Rate for Payer: Medicare All Medicare	$658.70
Rate for Payer: Monida Allegiance	$893.95
Rate for Payer: Monida First Choice Health	$912.77
Rate for Payer: Monida Montana Health Co-op	$893.95
Rate for Payer: Monida PacificSource	$893.95

US DUP-SCAN ARTL FLO ABD/PEL/SCRO/RPR OR

Facility

$668.00

Service Code	HCPCS 93975
Hospital Charge Code	5193975
Hospital Revenue Code	402
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$668.00
Rate for Payer: Aetna Commercial	$634.60
Rate for Payer: Aetna Medicare	$601.20
Rate for Payer: BCBS MT CHIP	$601.20
Rate for Payer: BCBS MT Closed Plan Network	$634.60
Rate for Payer: BCBS MT HealthLink	$601.20
Rate for Payer: BCBS MT Medicare	$601.20
Rate for Payer: BCBS MT POS	$634.60
Rate for Payer: BCBS MT Traditional	$668.00
Rate for Payer: Cash Price	$601.20
Rate for Payer: Cigna Commercial	$634.60
Rate for Payer: Cigna Medicare	$601.20
Rate for Payer: Medicaid All Medicaid	$614.56
Rate for Payer: Medicare All Medicare	$467.60
Rate for Payer: Monida Allegiance	$634.60
Rate for Payer: Monida First Choice Health	$647.96
Rate for Payer: Monida Montana Health Co-op	$634.60
Rate for Payer: Monida PacificSource	$634.60

US DUP-SCAN ARTL FLO ABD/PEL/SCRO/RPR OR

Facility

$668.00

Service Code	HCPCS 93975
Hospital Charge Code	5193975
Hospital Revenue Code	402
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$668.00
Rate for Payer: Aetna Commercial	$634.60
Rate for Payer: Aetna Medicare	$601.20
Rate for Payer: BCBS MT CHIP	$601.20
Rate for Payer: BCBS MT Closed Plan Network	$634.60
Rate for Payer: BCBS MT HealthLink	$601.20
Rate for Payer: BCBS MT Medicare	$601.20
Rate for Payer: BCBS MT POS	$634.60
Rate for Payer: BCBS MT Traditional	$668.00
Rate for Payer: Cash Price	$601.20
Rate for Payer: Cigna Commercial	$634.60
Rate for Payer: Cigna Medicare	$601.20
Rate for Payer: Medicaid All Medicaid	$614.56
Rate for Payer: Medicare All Medicare	$467.60
Rate for Payer: Monida Allegiance	$634.60
Rate for Payer: Monida First Choice Health	$647.96
Rate for Payer: Monida Montana Health Co-op	$634.60
Rate for Payer: Monida PacificSource	$634.60

US ECHO BUBBLE STUDY

Facility

$1,798.00

Service Code	HCPCS 93306
Hospital Charge Code	5193307
Hospital Revenue Code	483
Min. Negotiated Rate	$1,258.60
Max. Negotiated Rate	$1,798.00
Rate for Payer: Aetna Commercial	$1,708.10
Rate for Payer: Aetna Medicare	$1,618.20
Rate for Payer: BCBS MT CHIP	$1,618.20
Rate for Payer: BCBS MT Closed Plan Network	$1,708.10
Rate for Payer: BCBS MT HealthLink	$1,618.20
Rate for Payer: BCBS MT Medicare	$1,618.20
Rate for Payer: BCBS MT POS	$1,708.10
Rate for Payer: BCBS MT Traditional	$1,798.00
Rate for Payer: Cash Price	$1,618.20
Rate for Payer: Cigna Commercial	$1,708.10
Rate for Payer: Cigna Medicare	$1,618.20
Rate for Payer: Medicaid All Medicaid	$1,654.16
Rate for Payer: Medicare All Medicare	$1,258.60
Rate for Payer: Monida Allegiance	$1,708.10
Rate for Payer: Monida First Choice Health	$1,744.06
Rate for Payer: Monida Montana Health Co-op	$1,708.10
Rate for Payer: Monida PacificSource	$1,708.10

US ECHO BUBBLE STUDY

Facility

$1,798.00

Service Code	HCPCS 93306
Hospital Charge Code	5193307
Hospital Revenue Code	483
Min. Negotiated Rate	$1,258.60
Max. Negotiated Rate	$1,798.00
Rate for Payer: Aetna Commercial	$1,708.10
Rate for Payer: Aetna Medicare	$1,618.20
Rate for Payer: BCBS MT CHIP	$1,618.20
Rate for Payer: BCBS MT Closed Plan Network	$1,708.10
Rate for Payer: BCBS MT HealthLink	$1,618.20
Rate for Payer: BCBS MT Medicare	$1,618.20
Rate for Payer: BCBS MT POS	$1,708.10
Rate for Payer: BCBS MT Traditional	$1,798.00
Rate for Payer: Cash Price	$1,618.20
Rate for Payer: Cigna Commercial	$1,708.10
Rate for Payer: Cigna Medicare	$1,618.20
Rate for Payer: Medicaid All Medicaid	$1,654.16
Rate for Payer: Medicare All Medicare	$1,258.60
Rate for Payer: Monida Allegiance	$1,708.10
Rate for Payer: Monida First Choice Health	$1,744.06
Rate for Payer: Monida Montana Health Co-op	$1,708.10
Rate for Payer: Monida PacificSource	$1,708.10

US ECHO COMPLETE

Facility

$1,798.00

Service Code	HCPCS 93306
Hospital Charge Code	5193306
Hospital Revenue Code	483
Min. Negotiated Rate	$1,258.60
Max. Negotiated Rate	$1,798.00
Rate for Payer: Aetna Commercial	$1,708.10
Rate for Payer: Aetna Medicare	$1,618.20
Rate for Payer: BCBS MT CHIP	$1,618.20
Rate for Payer: BCBS MT Closed Plan Network	$1,708.10
Rate for Payer: BCBS MT HealthLink	$1,618.20
Rate for Payer: BCBS MT Medicare	$1,618.20
Rate for Payer: BCBS MT POS	$1,708.10
Rate for Payer: BCBS MT Traditional	$1,798.00
Rate for Payer: Cash Price	$1,618.20
Rate for Payer: Cigna Commercial	$1,708.10
Rate for Payer: Cigna Medicare	$1,618.20
Rate for Payer: Medicaid All Medicaid	$1,654.16
Rate for Payer: Medicare All Medicare	$1,258.60
Rate for Payer: Monida Allegiance	$1,708.10
Rate for Payer: Monida First Choice Health	$1,744.06
Rate for Payer: Monida Montana Health Co-op	$1,708.10
Rate for Payer: Monida PacificSource	$1,708.10

US ECHO COMPLETE

Facility

$1,798.00

Service Code	HCPCS 93306
Hospital Charge Code	5193306
Hospital Revenue Code	483
Min. Negotiated Rate	$1,258.60
Max. Negotiated Rate	$1,798.00
Rate for Payer: Aetna Commercial	$1,708.10
Rate for Payer: Aetna Medicare	$1,618.20
Rate for Payer: BCBS MT CHIP	$1,618.20
Rate for Payer: BCBS MT Closed Plan Network	$1,708.10
Rate for Payer: BCBS MT HealthLink	$1,618.20
Rate for Payer: BCBS MT Medicare	$1,618.20
Rate for Payer: BCBS MT POS	$1,708.10
Rate for Payer: BCBS MT Traditional	$1,798.00
Rate for Payer: Cash Price	$1,618.20
Rate for Payer: Cigna Commercial	$1,708.10
Rate for Payer: Cigna Medicare	$1,618.20
Rate for Payer: Medicaid All Medicaid	$1,654.16
Rate for Payer: Medicare All Medicare	$1,258.60
Rate for Payer: Monida Allegiance	$1,708.10
Rate for Payer: Monida First Choice Health	$1,744.06
Rate for Payer: Monida Montana Health Co-op	$1,708.10
Rate for Payer: Monida PacificSource	$1,708.10

US ECHOENCEPHALOGRAPHY REAL TIME IMAGING

Facility

$630.00

Service Code	HCPCS 76506 TC
Hospital Charge Code	5176506
Hospital Revenue Code	402
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

Know your out-of-pocket cost for care.

All Charges