Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US/MONITORING OF HEART OF FETUS BIOPHYPR

Facility

$348.00

Service Code	HCPCS 76818 TC
Hospital Charge Code	5176818
Hospital Revenue Code	402
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

US/MONITORING OF HEART OF FETUS BIOPHYPR

Facility

$348.00

Service Code	HCPCS 76818 TC
Hospital Charge Code	5176818
Hospital Revenue Code	402
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

US OF BONE DENSITY MEASUREMENT

Facility

$33.00

Service Code	HCPCS 76977 TC
Hospital Charge Code	5176977
Hospital Revenue Code	402
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

US OF BONE DENSITY MEASUREMENT

Facility

$33.00

Service Code	HCPCS 76977 TC
Hospital Charge Code	5176977
Hospital Revenue Code	402
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

US OF CORNEAL STRUCTURE AND MEASUREMENT

Facility

$91.00

Service Code	HCPCS 76514 TC
Hospital Charge Code	5176514
Hospital Revenue Code	402
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

US OF CORNEAL STRUCTURE AND MEASUREMENT

Facility

$91.00

Service Code	HCPCS 76514 TC
Hospital Charge Code	5176514
Hospital Revenue Code	402
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

US OF EYE DISEASE, GROWTH, OR STRUCTURE

Facility

$447.00

Service Code	HCPCS 76512 TC
Hospital Charge Code	5176512
Hospital Revenue Code	402
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$447.00
Rate for Payer: Aetna Commercial	$424.65
Rate for Payer: Aetna Medicare	$402.30
Rate for Payer: BCBS MT CHIP	$402.30
Rate for Payer: BCBS MT Closed Plan Network	$424.65
Rate for Payer: BCBS MT HealthLink	$402.30
Rate for Payer: BCBS MT Medicare	$402.30
Rate for Payer: BCBS MT POS	$424.65
Rate for Payer: BCBS MT Traditional	$447.00
Rate for Payer: Cash Price	$402.30
Rate for Payer: Cigna Commercial	$424.65
Rate for Payer: Cigna Medicare	$402.30
Rate for Payer: Medicaid All Medicaid	$411.24
Rate for Payer: Medicare All Medicare	$312.90
Rate for Payer: Monida Allegiance	$424.65
Rate for Payer: Monida First Choice Health	$433.59
Rate for Payer: Monida Montana Health Co-op	$424.65
Rate for Payer: Monida PacificSource	$424.65

US OF EYE DISEASE, GROWTH, OR STRUCTURE

Facility

$447.00

Service Code	HCPCS 76512 TC
Hospital Charge Code	5176512
Hospital Revenue Code	402
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$447.00
Rate for Payer: Aetna Commercial	$424.65
Rate for Payer: Aetna Medicare	$402.30
Rate for Payer: BCBS MT CHIP	$402.30
Rate for Payer: BCBS MT Closed Plan Network	$424.65
Rate for Payer: BCBS MT HealthLink	$402.30
Rate for Payer: BCBS MT Medicare	$402.30
Rate for Payer: BCBS MT POS	$424.65
Rate for Payer: BCBS MT Traditional	$447.00
Rate for Payer: Cash Price	$402.30
Rate for Payer: Cigna Commercial	$424.65
Rate for Payer: Cigna Medicare	$402.30
Rate for Payer: Medicaid All Medicaid	$411.24
Rate for Payer: Medicare All Medicare	$312.90
Rate for Payer: Monida Allegiance	$424.65
Rate for Payer: Monida First Choice Health	$433.59
Rate for Payer: Monida Montana Health Co-op	$424.65
Rate for Payer: Monida PacificSource	$424.65

US OF EYE DISEASE OR GROWTH

Facility

$524.00

Service Code	HCPCS 76511 TC
Hospital Charge Code	5176511
Hospital Revenue Code	402
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

US OF EYE DISEASE OR GROWTH

Facility

$524.00

Service Code	HCPCS 76511 TC
Hospital Charge Code	5176511
Hospital Revenue Code	402
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

US OF EYE FOR DETERMINATION LENS POWER

Facility

$414.00

Service Code	HCPCS 76519 TC
Hospital Charge Code	5176519
Hospital Revenue Code	402
Min. Negotiated Rate	$289.80
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna Commercial	$393.30
Rate for Payer: Aetna Medicare	$372.60
Rate for Payer: BCBS MT CHIP	$372.60
Rate for Payer: BCBS MT Closed Plan Network	$393.30
Rate for Payer: BCBS MT HealthLink	$372.60
Rate for Payer: BCBS MT Medicare	$372.60
Rate for Payer: BCBS MT POS	$393.30
Rate for Payer: BCBS MT Traditional	$414.00
Rate for Payer: Cash Price	$372.60
Rate for Payer: Cigna Commercial	$393.30
Rate for Payer: Cigna Medicare	$372.60
Rate for Payer: Medicaid All Medicaid	$380.88
Rate for Payer: Medicare All Medicare	$289.80
Rate for Payer: Monida Allegiance	$393.30
Rate for Payer: Monida First Choice Health	$401.58
Rate for Payer: Monida Montana Health Co-op	$393.30
Rate for Payer: Monida PacificSource	$393.30

US OF EYE FOR DETERMINATION LENS POWER

Facility

$414.00

Service Code	HCPCS 76519 TC
Hospital Charge Code	5176519
Hospital Revenue Code	402
Min. Negotiated Rate	$289.80
Max. Negotiated Rate	$414.00
Rate for Payer: Aetna Commercial	$393.30
Rate for Payer: Aetna Medicare	$372.60
Rate for Payer: BCBS MT CHIP	$372.60
Rate for Payer: BCBS MT Closed Plan Network	$393.30
Rate for Payer: BCBS MT HealthLink	$372.60
Rate for Payer: BCBS MT Medicare	$372.60
Rate for Payer: BCBS MT POS	$393.30
Rate for Payer: BCBS MT Traditional	$414.00
Rate for Payer: Cash Price	$372.60
Rate for Payer: Cigna Commercial	$393.30
Rate for Payer: Cigna Medicare	$372.60
Rate for Payer: Medicaid All Medicaid	$380.88
Rate for Payer: Medicare All Medicare	$289.80
Rate for Payer: Monida Allegiance	$393.30
Rate for Payer: Monida First Choice Health	$401.58
Rate for Payer: Monida Montana Health Co-op	$393.30
Rate for Payer: Monida PacificSource	$393.30

US OF EYE FOREIGN BODY LOCALIZATION

Facility

$84.00

Service Code	HCPCS 76529 TC
Hospital Charge Code	5176529
Hospital Revenue Code	402
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

US OF EYE FOREIGN BODY LOCALIZATION

Facility

$84.00

Service Code	HCPCS 76529 TC
Hospital Charge Code	5176529
Hospital Revenue Code	402
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

US OF EYE TISSUE AND STRUCTURES

Facility

$784.00

Service Code	HCPCS 76516 TC
Hospital Charge Code	5176510
Hospital Revenue Code	402
Min. Negotiated Rate	$548.80
Max. Negotiated Rate	$784.00
Rate for Payer: Aetna Commercial	$744.80
Rate for Payer: Aetna Medicare	$705.60
Rate for Payer: BCBS MT CHIP	$705.60
Rate for Payer: BCBS MT Closed Plan Network	$744.80
Rate for Payer: BCBS MT HealthLink	$705.60
Rate for Payer: BCBS MT Medicare	$705.60
Rate for Payer: BCBS MT POS	$744.80
Rate for Payer: BCBS MT Traditional	$784.00
Rate for Payer: Cash Price	$705.60
Rate for Payer: Cigna Commercial	$744.80
Rate for Payer: Cigna Medicare	$705.60
Rate for Payer: Medicaid All Medicaid	$721.28
Rate for Payer: Medicare All Medicare	$548.80
Rate for Payer: Monida Allegiance	$744.80
Rate for Payer: Monida First Choice Health	$760.48
Rate for Payer: Monida Montana Health Co-op	$744.80
Rate for Payer: Monida PacificSource	$744.80

US OF EYE TISSUE AND STRUCTURES

Facility

$784.00

Service Code	HCPCS 76516 TC
Hospital Charge Code	5176510
Hospital Revenue Code	402
Min. Negotiated Rate	$548.80
Max. Negotiated Rate	$784.00
Rate for Payer: Aetna Commercial	$744.80
Rate for Payer: Aetna Medicare	$705.60
Rate for Payer: BCBS MT CHIP	$705.60
Rate for Payer: BCBS MT Closed Plan Network	$744.80
Rate for Payer: BCBS MT HealthLink	$705.60
Rate for Payer: BCBS MT Medicare	$705.60
Rate for Payer: BCBS MT POS	$744.80
Rate for Payer: BCBS MT Traditional	$784.00
Rate for Payer: Cash Price	$705.60
Rate for Payer: Cigna Commercial	$744.80
Rate for Payer: Cigna Medicare	$705.60
Rate for Payer: Medicaid All Medicaid	$721.28
Rate for Payer: Medicare All Medicare	$548.80
Rate for Payer: Monida Allegiance	$744.80
Rate for Payer: Monida First Choice Health	$760.48
Rate for Payer: Monida Montana Health Co-op	$744.80
Rate for Payer: Monida PacificSource	$744.80

US OF EYE USING WATER BATH METHOD

Facility

$504.00

Service Code	HCPCS 76513 TC
Hospital Charge Code	5176513
Hospital Revenue Code	402
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$478.80
Rate for Payer: Aetna Medicare	$453.60
Rate for Payer: BCBS MT CHIP	$453.60
Rate for Payer: BCBS MT Closed Plan Network	$478.80
Rate for Payer: BCBS MT HealthLink	$453.60
Rate for Payer: BCBS MT Medicare	$453.60
Rate for Payer: BCBS MT POS	$478.80
Rate for Payer: BCBS MT Traditional	$504.00
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna Commercial	$478.80
Rate for Payer: Cigna Medicare	$453.60
Rate for Payer: Medicaid All Medicaid	$463.68
Rate for Payer: Medicare All Medicare	$352.80
Rate for Payer: Monida Allegiance	$478.80
Rate for Payer: Monida First Choice Health	$488.88
Rate for Payer: Monida Montana Health Co-op	$478.80
Rate for Payer: Monida PacificSource	$478.80

US OF EYE USING WATER BATH METHOD

Facility

$504.00

Service Code	HCPCS 76513 TC
Hospital Charge Code	5176513
Hospital Revenue Code	402
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$478.80
Rate for Payer: Aetna Medicare	$453.60
Rate for Payer: BCBS MT CHIP	$453.60
Rate for Payer: BCBS MT Closed Plan Network	$478.80
Rate for Payer: BCBS MT HealthLink	$453.60
Rate for Payer: BCBS MT Medicare	$453.60
Rate for Payer: BCBS MT POS	$478.80
Rate for Payer: BCBS MT Traditional	$504.00
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna Commercial	$478.80
Rate for Payer: Cigna Medicare	$453.60
Rate for Payer: Medicaid All Medicaid	$463.68
Rate for Payer: Medicare All Medicare	$352.80
Rate for Payer: Monida Allegiance	$478.80
Rate for Payer: Monida First Choice Health	$488.88
Rate for Payer: Monida Montana Health Co-op	$478.80
Rate for Payer: Monida PacificSource	$478.80

US OF FETAL BRAIN ARTERY

Facility

$426.00

Service Code	HCPCS 76821 TC
Hospital Charge Code	5176821
Hospital Revenue Code	402
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$426.00
Rate for Payer: Aetna Commercial	$404.70
Rate for Payer: Aetna Medicare	$383.40
Rate for Payer: BCBS MT CHIP	$383.40
Rate for Payer: BCBS MT Closed Plan Network	$404.70
Rate for Payer: BCBS MT HealthLink	$383.40
Rate for Payer: BCBS MT Medicare	$383.40
Rate for Payer: BCBS MT POS	$404.70
Rate for Payer: BCBS MT Traditional	$426.00
Rate for Payer: Cash Price	$383.40
Rate for Payer: Cigna Commercial	$404.70
Rate for Payer: Cigna Medicare	$383.40
Rate for Payer: Medicaid All Medicaid	$391.92
Rate for Payer: Medicare All Medicare	$298.20
Rate for Payer: Monida Allegiance	$404.70
Rate for Payer: Monida First Choice Health	$413.22
Rate for Payer: Monida Montana Health Co-op	$404.70
Rate for Payer: Monida PacificSource	$404.70

US OF FETAL BRAIN ARTERY

Facility

$426.00

Service Code	HCPCS 76821 TC
Hospital Charge Code	5176821
Hospital Revenue Code	402
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$426.00
Rate for Payer: Aetna Commercial	$404.70
Rate for Payer: Aetna Medicare	$383.40
Rate for Payer: BCBS MT CHIP	$383.40
Rate for Payer: BCBS MT Closed Plan Network	$404.70
Rate for Payer: BCBS MT HealthLink	$383.40
Rate for Payer: BCBS MT Medicare	$383.40
Rate for Payer: BCBS MT POS	$404.70
Rate for Payer: BCBS MT Traditional	$426.00
Rate for Payer: Cash Price	$383.40
Rate for Payer: Cigna Commercial	$404.70
Rate for Payer: Cigna Medicare	$383.40
Rate for Payer: Medicaid All Medicaid	$391.92
Rate for Payer: Medicare All Medicare	$298.20
Rate for Payer: Monida Allegiance	$404.70
Rate for Payer: Monida First Choice Health	$413.22
Rate for Payer: Monida Montana Health Co-op	$404.70
Rate for Payer: Monida PacificSource	$404.70

US OF FETAL UMBILICAL ARTERY FLO

Facility

$407.00

Service Code	HCPCS 76820 TC
Hospital Charge Code	5176820
Hospital Revenue Code	402
Min. Negotiated Rate	$284.90
Max. Negotiated Rate	$407.00
Rate for Payer: Aetna Commercial	$386.65
Rate for Payer: Aetna Medicare	$366.30
Rate for Payer: BCBS MT CHIP	$366.30
Rate for Payer: BCBS MT Closed Plan Network	$386.65
Rate for Payer: BCBS MT HealthLink	$366.30
Rate for Payer: BCBS MT Medicare	$366.30
Rate for Payer: BCBS MT POS	$386.65
Rate for Payer: BCBS MT Traditional	$407.00
Rate for Payer: Cash Price	$366.30
Rate for Payer: Cigna Commercial	$386.65
Rate for Payer: Cigna Medicare	$366.30
Rate for Payer: Medicaid All Medicaid	$374.44
Rate for Payer: Medicare All Medicare	$284.90
Rate for Payer: Monida Allegiance	$386.65
Rate for Payer: Monida First Choice Health	$394.79
Rate for Payer: Monida Montana Health Co-op	$386.65
Rate for Payer: Monida PacificSource	$386.65

US OF FETAL UMBILICAL ARTERY FLO

Facility

$407.00

Service Code	HCPCS 76820 TC
Hospital Charge Code	5176820
Hospital Revenue Code	402
Min. Negotiated Rate	$284.90
Max. Negotiated Rate	$407.00
Rate for Payer: Aetna Commercial	$386.65
Rate for Payer: Aetna Medicare	$366.30
Rate for Payer: BCBS MT CHIP	$366.30
Rate for Payer: BCBS MT Closed Plan Network	$386.65
Rate for Payer: BCBS MT HealthLink	$366.30
Rate for Payer: BCBS MT Medicare	$366.30
Rate for Payer: BCBS MT POS	$386.65
Rate for Payer: BCBS MT Traditional	$407.00
Rate for Payer: Cash Price	$366.30
Rate for Payer: Cigna Commercial	$386.65
Rate for Payer: Cigna Medicare	$366.30
Rate for Payer: Medicaid All Medicaid	$374.44
Rate for Payer: Medicare All Medicare	$284.90
Rate for Payer: Monida Allegiance	$386.65
Rate for Payer: Monida First Choice Health	$394.79
Rate for Payer: Monida Montana Health Co-op	$386.65
Rate for Payer: Monida PacificSource	$386.65

US OF HIPS, INFANT

Facility

$92.00

Service Code	HCPCS 76886
Hospital Charge Code	5176886
Hospital Revenue Code	402
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

US OF HIPS, INFANT

Facility

$92.00

Service Code	HCPCS 76886
Hospital Charge Code	5176886
Hospital Revenue Code	402
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

US PELVIC COMP NON OB

Facility

$504.00

Service Code	HCPCS 76856
Hospital Charge Code	5176856
Hospital Revenue Code	402
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$504.00
Rate for Payer: Aetna Commercial	$478.80
Rate for Payer: Aetna Medicare	$453.60
Rate for Payer: BCBS MT CHIP	$453.60
Rate for Payer: BCBS MT Closed Plan Network	$478.80
Rate for Payer: BCBS MT HealthLink	$453.60
Rate for Payer: BCBS MT Medicare	$453.60
Rate for Payer: BCBS MT POS	$478.80
Rate for Payer: BCBS MT Traditional	$504.00
Rate for Payer: Cash Price	$453.60
Rate for Payer: Cigna Commercial	$478.80
Rate for Payer: Cigna Medicare	$453.60
Rate for Payer: Medicaid All Medicaid	$463.68
Rate for Payer: Medicare All Medicare	$352.80
Rate for Payer: Monida Allegiance	$478.80
Rate for Payer: Monida First Choice Health	$488.88
Rate for Payer: Monida Montana Health Co-op	$478.80
Rate for Payer: Monida PacificSource	$478.80

Know your out-of-pocket cost for care.

All Charges