Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

US ECHO EXAM OF FETAL HEART

Facility

$1,369.00

Service Code	HCPCS 76825 TC
Hospital Charge Code	5176825
Hospital Revenue Code	402
Min. Negotiated Rate	$958.30
Max. Negotiated Rate	$1,369.00
Rate for Payer: Aetna Commercial	$1,300.55
Rate for Payer: Aetna Medicare	$1,232.10
Rate for Payer: BCBS MT CHIP	$1,232.10
Rate for Payer: BCBS MT Closed Plan Network	$1,300.55
Rate for Payer: BCBS MT HealthLink	$1,232.10
Rate for Payer: BCBS MT Medicare	$1,232.10
Rate for Payer: BCBS MT POS	$1,300.55
Rate for Payer: BCBS MT Traditional	$1,369.00
Rate for Payer: Cash Price	$1,232.10
Rate for Payer: Cigna Commercial	$1,300.55
Rate for Payer: Cigna Medicare	$1,232.10
Rate for Payer: Medicaid All Medicaid	$1,259.48
Rate for Payer: Medicare All Medicare	$958.30
Rate for Payer: Monida Allegiance	$1,300.55
Rate for Payer: Monida First Choice Health	$1,327.93
Rate for Payer: Monida Montana Health Co-op	$1,300.55
Rate for Payer: Monida PacificSource	$1,300.55

US ECHO EXAM OF FETAL HEART

Facility

$1,369.00

Service Code	HCPCS 76825 TC
Hospital Charge Code	5176825
Hospital Revenue Code	402
Min. Negotiated Rate	$958.30
Max. Negotiated Rate	$1,369.00
Rate for Payer: Aetna Commercial	$1,300.55
Rate for Payer: Aetna Medicare	$1,232.10
Rate for Payer: BCBS MT CHIP	$1,232.10
Rate for Payer: BCBS MT Closed Plan Network	$1,300.55
Rate for Payer: BCBS MT HealthLink	$1,232.10
Rate for Payer: BCBS MT Medicare	$1,232.10
Rate for Payer: BCBS MT POS	$1,300.55
Rate for Payer: BCBS MT Traditional	$1,369.00
Rate for Payer: Cash Price	$1,232.10
Rate for Payer: Cigna Commercial	$1,300.55
Rate for Payer: Cigna Medicare	$1,232.10
Rate for Payer: Medicaid All Medicaid	$1,259.48
Rate for Payer: Medicare All Medicare	$958.30
Rate for Payer: Monida Allegiance	$1,300.55
Rate for Payer: Monida First Choice Health	$1,327.93
Rate for Payer: Monida Montana Health Co-op	$1,300.55
Rate for Payer: Monida PacificSource	$1,300.55

US ECHO EXAM UTERUS

Facility

$546.00

Service Code	HCPCS 76831
Hospital Charge Code	5176831
Hospital Revenue Code	402
Min. Negotiated Rate	$382.20
Max. Negotiated Rate	$546.00
Rate for Payer: Aetna Commercial	$518.70
Rate for Payer: Aetna Medicare	$491.40
Rate for Payer: BCBS MT CHIP	$491.40
Rate for Payer: BCBS MT Closed Plan Network	$518.70
Rate for Payer: BCBS MT HealthLink	$491.40
Rate for Payer: BCBS MT Medicare	$491.40
Rate for Payer: BCBS MT POS	$518.70
Rate for Payer: BCBS MT Traditional	$546.00
Rate for Payer: Cash Price	$491.40
Rate for Payer: Cigna Commercial	$518.70
Rate for Payer: Cigna Medicare	$491.40
Rate for Payer: Medicaid All Medicaid	$502.32
Rate for Payer: Medicare All Medicare	$382.20
Rate for Payer: Monida Allegiance	$518.70
Rate for Payer: Monida First Choice Health	$529.62
Rate for Payer: Monida Montana Health Co-op	$518.70
Rate for Payer: Monida PacificSource	$518.70

US ECHO EXAM UTERUS

Facility

$546.00

Service Code	HCPCS 76831
Hospital Charge Code	5176831
Hospital Revenue Code	402
Min. Negotiated Rate	$382.20
Max. Negotiated Rate	$546.00
Rate for Payer: Aetna Commercial	$518.70
Rate for Payer: Aetna Medicare	$491.40
Rate for Payer: BCBS MT CHIP	$491.40
Rate for Payer: BCBS MT Closed Plan Network	$518.70
Rate for Payer: BCBS MT HealthLink	$491.40
Rate for Payer: BCBS MT Medicare	$491.40
Rate for Payer: BCBS MT POS	$518.70
Rate for Payer: BCBS MT Traditional	$546.00
Rate for Payer: Cash Price	$491.40
Rate for Payer: Cigna Commercial	$518.70
Rate for Payer: Cigna Medicare	$491.40
Rate for Payer: Medicaid All Medicaid	$502.32
Rate for Payer: Medicare All Medicare	$382.20
Rate for Payer: Monida Allegiance	$518.70
Rate for Payer: Monida First Choice Health	$529.62
Rate for Payer: Monida Montana Health Co-op	$518.70
Rate for Payer: Monida PacificSource	$518.70

US ECHO LIMITED

Facility

$739.00

Service Code	HCPCS 93308
Hospital Charge Code	5193308
Hospital Revenue Code	402
Min. Negotiated Rate	$517.30
Max. Negotiated Rate	$739.00
Rate for Payer: Aetna Commercial	$702.05
Rate for Payer: Aetna Medicare	$665.10
Rate for Payer: BCBS MT CHIP	$665.10
Rate for Payer: BCBS MT Closed Plan Network	$702.05
Rate for Payer: BCBS MT HealthLink	$665.10
Rate for Payer: BCBS MT Medicare	$665.10
Rate for Payer: BCBS MT POS	$702.05
Rate for Payer: BCBS MT Traditional	$739.00
Rate for Payer: Cash Price	$665.10
Rate for Payer: Cigna Commercial	$702.05
Rate for Payer: Cigna Medicare	$665.10
Rate for Payer: Medicaid All Medicaid	$679.88
Rate for Payer: Medicare All Medicare	$517.30
Rate for Payer: Monida Allegiance	$702.05
Rate for Payer: Monida First Choice Health	$716.83
Rate for Payer: Monida Montana Health Co-op	$702.05
Rate for Payer: Monida PacificSource	$702.05

US ECHO LIMITED

Facility

$739.00

Service Code	HCPCS 93308
Hospital Charge Code	5193308
Hospital Revenue Code	402
Min. Negotiated Rate	$517.30
Max. Negotiated Rate	$739.00
Rate for Payer: Aetna Commercial	$702.05
Rate for Payer: Aetna Medicare	$665.10
Rate for Payer: BCBS MT CHIP	$665.10
Rate for Payer: BCBS MT Closed Plan Network	$702.05
Rate for Payer: BCBS MT HealthLink	$665.10
Rate for Payer: BCBS MT Medicare	$665.10
Rate for Payer: BCBS MT POS	$702.05
Rate for Payer: BCBS MT Traditional	$739.00
Rate for Payer: Cash Price	$665.10
Rate for Payer: Cigna Commercial	$702.05
Rate for Payer: Cigna Medicare	$665.10
Rate for Payer: Medicaid All Medicaid	$679.88
Rate for Payer: Medicare All Medicare	$517.30
Rate for Payer: Monida Allegiance	$702.05
Rate for Payer: Monida First Choice Health	$716.83
Rate for Payer: Monida Montana Health Co-op	$702.05
Rate for Payer: Monida PacificSource	$702.05

US ELASTOGRAPHY EA ADDL TAGET LE

Facility

$259.00

Service Code	HCPCS 76983
Hospital Charge Code	5176983
Hospital Revenue Code	402
Min. Negotiated Rate	$181.30
Max. Negotiated Rate	$259.00
Rate for Payer: Aetna Commercial	$246.05
Rate for Payer: Aetna Medicare	$233.10
Rate for Payer: BCBS MT CHIP	$233.10
Rate for Payer: BCBS MT Closed Plan Network	$246.05
Rate for Payer: BCBS MT HealthLink	$233.10
Rate for Payer: BCBS MT Medicare	$233.10
Rate for Payer: BCBS MT POS	$246.05
Rate for Payer: BCBS MT Traditional	$259.00
Rate for Payer: Cash Price	$233.10
Rate for Payer: Cigna Commercial	$246.05
Rate for Payer: Cigna Medicare	$233.10
Rate for Payer: Medicaid All Medicaid	$238.28
Rate for Payer: Medicare All Medicare	$181.30
Rate for Payer: Monida Allegiance	$246.05
Rate for Payer: Monida First Choice Health	$251.23
Rate for Payer: Monida Montana Health Co-op	$246.05
Rate for Payer: Monida PacificSource	$246.05

US ELASTOGRAPHY EA ADDL TAGET LE

Facility

$259.00

Service Code	HCPCS 76983
Hospital Charge Code	5176983
Hospital Revenue Code	402
Min. Negotiated Rate	$181.30
Max. Negotiated Rate	$259.00
Rate for Payer: Aetna Commercial	$246.05
Rate for Payer: Aetna Medicare	$233.10
Rate for Payer: BCBS MT CHIP	$233.10
Rate for Payer: BCBS MT Closed Plan Network	$246.05
Rate for Payer: BCBS MT HealthLink	$233.10
Rate for Payer: BCBS MT Medicare	$233.10
Rate for Payer: BCBS MT POS	$246.05
Rate for Payer: BCBS MT Traditional	$259.00
Rate for Payer: Cash Price	$233.10
Rate for Payer: Cigna Commercial	$246.05
Rate for Payer: Cigna Medicare	$233.10
Rate for Payer: Medicaid All Medicaid	$238.28
Rate for Payer: Medicare All Medicare	$181.30
Rate for Payer: Monida Allegiance	$246.05
Rate for Payer: Monida First Choice Health	$251.23
Rate for Payer: Monida Montana Health Co-op	$246.05
Rate for Payer: Monida PacificSource	$246.05

US ELASTOGRAPHY FIRST TARGET LESION

Facility

$341.00

Service Code	HCPCS 76982 TC
Hospital Charge Code	5176982
Hospital Revenue Code	402
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

US ELASTOGRAPHY FIRST TARGET LESION

Facility

$341.00

Service Code	HCPCS 76982 TC
Hospital Charge Code	5176982
Hospital Revenue Code	402
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

US ELASTOGRAPHY OF ORGAN TISSUE

Facility

$403.00

Service Code	HCPCS 76981 TC
Hospital Charge Code	5176981
Hospital Revenue Code	402
Min. Negotiated Rate	$282.10
Max. Negotiated Rate	$403.00
Rate for Payer: Aetna Commercial	$382.85
Rate for Payer: Aetna Medicare	$362.70
Rate for Payer: BCBS MT CHIP	$362.70
Rate for Payer: BCBS MT Closed Plan Network	$382.85
Rate for Payer: BCBS MT HealthLink	$362.70
Rate for Payer: BCBS MT Medicare	$362.70
Rate for Payer: BCBS MT POS	$382.85
Rate for Payer: BCBS MT Traditional	$403.00
Rate for Payer: Cash Price	$362.70
Rate for Payer: Cigna Commercial	$382.85
Rate for Payer: Cigna Medicare	$362.70
Rate for Payer: Medicaid All Medicaid	$370.76
Rate for Payer: Medicare All Medicare	$282.10
Rate for Payer: Monida Allegiance	$382.85
Rate for Payer: Monida First Choice Health	$390.91
Rate for Payer: Monida Montana Health Co-op	$382.85
Rate for Payer: Monida PacificSource	$382.85

US ELASTOGRAPHY OF ORGAN TISSUE

Facility

$403.00

Service Code	HCPCS 76981 TC
Hospital Charge Code	5176981
Hospital Revenue Code	402
Min. Negotiated Rate	$282.10
Max. Negotiated Rate	$403.00
Rate for Payer: Aetna Commercial	$382.85
Rate for Payer: Aetna Medicare	$362.70
Rate for Payer: BCBS MT CHIP	$362.70
Rate for Payer: BCBS MT Closed Plan Network	$382.85
Rate for Payer: BCBS MT HealthLink	$362.70
Rate for Payer: BCBS MT Medicare	$362.70
Rate for Payer: BCBS MT POS	$382.85
Rate for Payer: BCBS MT Traditional	$403.00
Rate for Payer: Cash Price	$362.70
Rate for Payer: Cigna Commercial	$382.85
Rate for Payer: Cigna Medicare	$362.70
Rate for Payer: Medicaid All Medicaid	$370.76
Rate for Payer: Medicare All Medicare	$282.10
Rate for Payer: Monida Allegiance	$382.85
Rate for Payer: Monida First Choice Health	$390.91
Rate for Payer: Monida Montana Health Co-op	$382.85
Rate for Payer: Monida PacificSource	$382.85

US FETAL BIOPHYS PROF W/O NON STRESS TES

Facility

$635.00

Service Code	HCPCS 76819 TC
Hospital Charge Code	5176819
Hospital Revenue Code	402
Min. Negotiated Rate	$444.50
Max. Negotiated Rate	$635.00
Rate for Payer: Aetna Commercial	$603.25
Rate for Payer: Aetna Medicare	$571.50
Rate for Payer: BCBS MT CHIP	$571.50
Rate for Payer: BCBS MT Closed Plan Network	$603.25
Rate for Payer: BCBS MT HealthLink	$571.50
Rate for Payer: BCBS MT Medicare	$571.50
Rate for Payer: BCBS MT POS	$603.25
Rate for Payer: BCBS MT Traditional	$635.00
Rate for Payer: Cash Price	$571.50
Rate for Payer: Cigna Commercial	$603.25
Rate for Payer: Cigna Medicare	$571.50
Rate for Payer: Medicaid All Medicaid	$584.20
Rate for Payer: Medicare All Medicare	$444.50
Rate for Payer: Monida Allegiance	$603.25
Rate for Payer: Monida First Choice Health	$615.95
Rate for Payer: Monida Montana Health Co-op	$603.25
Rate for Payer: Monida PacificSource	$603.25

US FETAL BIOPHYS PROF W/O NON STRESS TES

Facility

$635.00

Service Code	HCPCS 76819 TC
Hospital Charge Code	5176819
Hospital Revenue Code	402
Min. Negotiated Rate	$444.50
Max. Negotiated Rate	$635.00
Rate for Payer: Aetna Commercial	$603.25
Rate for Payer: Aetna Medicare	$571.50
Rate for Payer: BCBS MT CHIP	$571.50
Rate for Payer: BCBS MT Closed Plan Network	$603.25
Rate for Payer: BCBS MT HealthLink	$571.50
Rate for Payer: BCBS MT Medicare	$571.50
Rate for Payer: BCBS MT POS	$603.25
Rate for Payer: BCBS MT Traditional	$635.00
Rate for Payer: Cash Price	$571.50
Rate for Payer: Cigna Commercial	$603.25
Rate for Payer: Cigna Medicare	$571.50
Rate for Payer: Medicaid All Medicaid	$584.20
Rate for Payer: Medicare All Medicare	$444.50
Rate for Payer: Monida Allegiance	$603.25
Rate for Payer: Monida First Choice Health	$615.95
Rate for Payer: Monida Montana Health Co-op	$603.25
Rate for Payer: Monida PacificSource	$603.25

US FETAL UMBILICAL CORD OCCLUSION W/US

Facility

$289.00

Service Code	HCPCS 59072
Hospital Charge Code	5159072
Hospital Revenue Code	450
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

US FETAL UMBILICAL CORD OCCLUSION W/US

Facility

$289.00

Service Code	HCPCS 59072
Hospital Charge Code	5159072
Hospital Revenue Code	450
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

US GASTRO/INTEST SUPERVISION AND INTERPR

Facility

$247.00

Service Code	HCPCS 76975
Hospital Charge Code	5176975
Hospital Revenue Code	402
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$247.00
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna Medicare	$222.30
Rate for Payer: BCBS MT CHIP	$222.30
Rate for Payer: BCBS MT Closed Plan Network	$234.65
Rate for Payer: BCBS MT HealthLink	$222.30
Rate for Payer: BCBS MT Medicare	$222.30
Rate for Payer: BCBS MT POS	$234.65
Rate for Payer: BCBS MT Traditional	$247.00
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial	$234.65
Rate for Payer: Cigna Medicare	$222.30
Rate for Payer: Medicaid All Medicaid	$227.24
Rate for Payer: Medicare All Medicare	$172.90
Rate for Payer: Monida Allegiance	$234.65
Rate for Payer: Monida First Choice Health	$239.59
Rate for Payer: Monida Montana Health Co-op	$234.65
Rate for Payer: Monida PacificSource	$234.65

US GASTRO/INTEST SUPERVISION AND INTERPR

Facility

$247.00

Service Code	HCPCS 76975
Hospital Charge Code	5176975
Hospital Revenue Code	402
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$247.00
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna Medicare	$222.30
Rate for Payer: BCBS MT CHIP	$222.30
Rate for Payer: BCBS MT Closed Plan Network	$234.65
Rate for Payer: BCBS MT HealthLink	$222.30
Rate for Payer: BCBS MT Medicare	$222.30
Rate for Payer: BCBS MT POS	$234.65
Rate for Payer: BCBS MT Traditional	$247.00
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial	$234.65
Rate for Payer: Cigna Medicare	$222.30
Rate for Payer: Medicaid All Medicaid	$227.24
Rate for Payer: Medicare All Medicare	$172.90
Rate for Payer: Monida Allegiance	$234.65
Rate for Payer: Monida First Choice Health	$239.59
Rate for Payer: Monida Montana Health Co-op	$234.65
Rate for Payer: Monida PacificSource	$234.65

US GUIDE VASCULAR ACCESS

Facility

$165.00

Service Code	HCPCS 76937
Hospital Charge Code	5176937
Hospital Revenue Code	402
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

US GUIDE VASCULAR ACCESS

Facility

$165.00

Service Code	HCPCS 76937
Hospital Charge Code	5176937
Hospital Revenue Code	402
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$165.00
Rate for Payer: Aetna Commercial	$156.75
Rate for Payer: Aetna Medicare	$148.50
Rate for Payer: BCBS MT CHIP	$148.50
Rate for Payer: BCBS MT Closed Plan Network	$156.75
Rate for Payer: BCBS MT HealthLink	$148.50
Rate for Payer: BCBS MT Medicare	$148.50
Rate for Payer: BCBS MT POS	$156.75
Rate for Payer: BCBS MT Traditional	$165.00
Rate for Payer: Cash Price	$148.50
Rate for Payer: Cigna Commercial	$156.75
Rate for Payer: Cigna Medicare	$148.50
Rate for Payer: Medicaid All Medicaid	$151.80
Rate for Payer: Medicare All Medicare	$115.50
Rate for Payer: Monida Allegiance	$156.75
Rate for Payer: Monida First Choice Health	$160.05
Rate for Payer: Monida Montana Health Co-op	$156.75
Rate for Payer: Monida PacificSource	$156.75

US LOWER EXTREMITY STUDY BILATERAL

Facility

$630.00

Service Code	HCPCS 93925
Hospital Charge Code	5193925
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

US LOWER EXTREMITY STUDY BILATERAL

Facility

$630.00

Service Code	HCPCS 93925
Hospital Charge Code	5193925
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

US LOWER EXTREMITY STUDY UNILATERAL

Facility

$453.00

Service Code	HCPCS 93926
Hospital Charge Code	5193926
Hospital Revenue Code	402
Min. Negotiated Rate	$317.10
Max. Negotiated Rate	$453.00
Rate for Payer: Aetna Commercial	$430.35
Rate for Payer: Aetna Medicare	$407.70
Rate for Payer: BCBS MT CHIP	$407.70
Rate for Payer: BCBS MT Closed Plan Network	$430.35
Rate for Payer: BCBS MT HealthLink	$407.70
Rate for Payer: BCBS MT Medicare	$407.70
Rate for Payer: BCBS MT POS	$430.35
Rate for Payer: BCBS MT Traditional	$453.00
Rate for Payer: Cash Price	$407.70
Rate for Payer: Cigna Commercial	$430.35
Rate for Payer: Cigna Medicare	$407.70
Rate for Payer: Medicaid All Medicaid	$416.76
Rate for Payer: Medicare All Medicare	$317.10
Rate for Payer: Monida Allegiance	$430.35
Rate for Payer: Monida First Choice Health	$439.41
Rate for Payer: Monida Montana Health Co-op	$430.35
Rate for Payer: Monida PacificSource	$430.35

US LOWER EXTREMITY STUDY UNILATERAL

Facility

$453.00

Service Code	HCPCS 93926
Hospital Charge Code	5193926
Hospital Revenue Code	402
Min. Negotiated Rate	$317.10
Max. Negotiated Rate	$453.00
Rate for Payer: Aetna Commercial	$430.35
Rate for Payer: Aetna Medicare	$407.70
Rate for Payer: BCBS MT CHIP	$407.70
Rate for Payer: BCBS MT Closed Plan Network	$430.35
Rate for Payer: BCBS MT HealthLink	$407.70
Rate for Payer: BCBS MT Medicare	$407.70
Rate for Payer: BCBS MT POS	$430.35
Rate for Payer: BCBS MT Traditional	$453.00
Rate for Payer: Cash Price	$407.70
Rate for Payer: Cigna Commercial	$430.35
Rate for Payer: Cigna Medicare	$407.70
Rate for Payer: Medicaid All Medicaid	$416.76
Rate for Payer: Medicare All Medicare	$317.10
Rate for Payer: Monida Allegiance	$430.35
Rate for Payer: Monida First Choice Health	$439.41
Rate for Payer: Monida Montana Health Co-op	$430.35
Rate for Payer: Monida PacificSource	$430.35

Know your out-of-pocket cost for care.

All Charges