Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

US PELVIC LMT NON OB

Facility

$217.00

Service Code	HCPCS 76857
Hospital Charge Code	5100002
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 PELVIC LMT NON OB

Facility

$217.00

Service Code	HCPCS 76857
Hospital Charge Code	5100002
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 PELVIS BUNDLED

Facility

$504.00

Service Code	HCPCS 76856
Hospital Charge Code	5178581
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 PELVIS BUNDLED

Facility

$504.00

Service Code	HCPCS 76856
Hospital Charge Code	5178581
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 POST VOID RESIDUAL

Facility

$208.00

Service Code	HCPCS 51798 TC
Hospital Charge Code	5151798
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 POST VOID RESIDUAL

Facility

$208.00

Service Code	HCPCS 51798 TC
Hospital Charge Code	5151798
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 RADIOLOGL GUIDANCE PRQ DRG W/PLMT CAT

Facility

$1,578.00

Service Code	HCPCS 75989 TC
Hospital Charge Code	5175989
Hospital Revenue Code	402
Min. Negotiated Rate	$1,104.60
Max. Negotiated Rate	$1,578.00
Rate for Payer: Aetna Commercial	$1,499.10
Rate for Payer: Aetna Medicare	$1,420.20
Rate for Payer: BCBS MT CHIP	$1,420.20
Rate for Payer: BCBS MT Closed Plan Network	$1,499.10
Rate for Payer: BCBS MT HealthLink	$1,420.20
Rate for Payer: BCBS MT Medicare	$1,420.20
Rate for Payer: BCBS MT POS	$1,499.10
Rate for Payer: BCBS MT Traditional	$1,578.00
Rate for Payer: Cash Price	$1,420.20
Rate for Payer: Cigna Commercial	$1,499.10
Rate for Payer: Cigna Medicare	$1,420.20
Rate for Payer: Medicaid All Medicaid	$1,451.76
Rate for Payer: Medicare All Medicare	$1,104.60
Rate for Payer: Monida Allegiance	$1,499.10
Rate for Payer: Monida First Choice Health	$1,530.66
Rate for Payer: Monida Montana Health Co-op	$1,499.10
Rate for Payer: Monida PacificSource	$1,499.10

US RADIOLOGL GUIDANCE PRQ DRG W/PLMT CAT

Facility

$1,578.00

Service Code	HCPCS 75989 TC
Hospital Charge Code	5175989
Hospital Revenue Code	402
Min. Negotiated Rate	$1,104.60
Max. Negotiated Rate	$1,578.00
Rate for Payer: Aetna Commercial	$1,499.10
Rate for Payer: Aetna Medicare	$1,420.20
Rate for Payer: BCBS MT CHIP	$1,420.20
Rate for Payer: BCBS MT Closed Plan Network	$1,499.10
Rate for Payer: BCBS MT HealthLink	$1,420.20
Rate for Payer: BCBS MT Medicare	$1,420.20
Rate for Payer: BCBS MT POS	$1,499.10
Rate for Payer: BCBS MT Traditional	$1,578.00
Rate for Payer: Cash Price	$1,420.20
Rate for Payer: Cigna Commercial	$1,499.10
Rate for Payer: Cigna Medicare	$1,420.20
Rate for Payer: Medicaid All Medicaid	$1,451.76
Rate for Payer: Medicare All Medicare	$1,104.60
Rate for Payer: Monida Allegiance	$1,499.10
Rate for Payer: Monida First Choice Health	$1,530.66
Rate for Payer: Monida Montana Health Co-op	$1,499.10
Rate for Payer: Monida PacificSource	$1,499.10

US RETROPERITONEAL COMP RENALS

Facility

$519.00

Service Code	HCPCS 76770 TC
Hospital Charge Code	5176770
Hospital Revenue Code	402
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

US RETROPERITONEAL COMP RENALS

Facility

$519.00

Service Code	HCPCS 76770 TC
Hospital Charge Code	5176770
Hospital Revenue Code	402
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

US RETROPERITONEAL LMT AORTA

Facility

$371.00

Service Code	HCPCS 76775 TC
Hospital Charge Code	5176775
Hospital Revenue Code	402
Min. Negotiated Rate	$259.70
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$352.45
Rate for Payer: Aetna Medicare	$333.90
Rate for Payer: BCBS MT CHIP	$333.90
Rate for Payer: BCBS MT Closed Plan Network	$352.45
Rate for Payer: BCBS MT HealthLink	$333.90
Rate for Payer: BCBS MT Medicare	$333.90
Rate for Payer: BCBS MT POS	$352.45
Rate for Payer: BCBS MT Traditional	$371.00
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cigna Commercial	$352.45
Rate for Payer: Cigna Medicare	$333.90
Rate for Payer: Medicaid All Medicaid	$341.32
Rate for Payer: Medicare All Medicare	$259.70
Rate for Payer: Monida Allegiance	$352.45
Rate for Payer: Monida First Choice Health	$359.87
Rate for Payer: Monida Montana Health Co-op	$352.45
Rate for Payer: Monida PacificSource	$352.45

US RETROPERITONEAL LMT AORTA

Facility

$371.00

Service Code	HCPCS 76775 TC
Hospital Charge Code	5176775
Hospital Revenue Code	402
Min. Negotiated Rate	$259.70
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$352.45
Rate for Payer: Aetna Medicare	$333.90
Rate for Payer: BCBS MT CHIP	$333.90
Rate for Payer: BCBS MT Closed Plan Network	$352.45
Rate for Payer: BCBS MT HealthLink	$333.90
Rate for Payer: BCBS MT Medicare	$333.90
Rate for Payer: BCBS MT POS	$352.45
Rate for Payer: BCBS MT Traditional	$371.00
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cigna Commercial	$352.45
Rate for Payer: Cigna Medicare	$333.90
Rate for Payer: Medicaid All Medicaid	$341.32
Rate for Payer: Medicare All Medicare	$259.70
Rate for Payer: Monida Allegiance	$352.45
Rate for Payer: Monida First Choice Health	$359.87
Rate for Payer: Monida Montana Health Co-op	$352.45
Rate for Payer: Monida PacificSource	$352.45

US SOFT TISSUE ABDOMEN

Facility

$318.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5100006
Hospital Revenue Code	402
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

US SOFT TISSUE ABDOMEN

Facility

$318.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5100006
Hospital Revenue Code	402
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

US SOFT TISSUE CHEST

Facility

$318.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	5176604
Hospital Revenue Code	402
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

US SOFT TISSUE CHEST

Facility

$318.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	5176604
Hospital Revenue Code	402
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

US SOFT TISSUE EXTREMITY LMT

Facility

$509.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	5176882
Hospital Revenue Code	402
Min. Negotiated Rate	$356.30
Max. Negotiated Rate	$509.00
Rate for Payer: Aetna Commercial	$483.55
Rate for Payer: Aetna Medicare	$458.10
Rate for Payer: BCBS MT CHIP	$458.10
Rate for Payer: BCBS MT Closed Plan Network	$483.55
Rate for Payer: BCBS MT HealthLink	$458.10
Rate for Payer: BCBS MT Medicare	$458.10
Rate for Payer: BCBS MT POS	$483.55
Rate for Payer: BCBS MT Traditional	$509.00
Rate for Payer: Cash Price	$458.10
Rate for Payer: Cigna Commercial	$483.55
Rate for Payer: Cigna Medicare	$458.10
Rate for Payer: Medicaid All Medicaid	$468.28
Rate for Payer: Medicare All Medicare	$356.30
Rate for Payer: Monida Allegiance	$483.55
Rate for Payer: Monida First Choice Health	$493.73
Rate for Payer: Monida Montana Health Co-op	$483.55
Rate for Payer: Monida PacificSource	$483.55

US SOFT TISSUE EXTREMITY LMT

Facility

$509.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	5176882
Hospital Revenue Code	402
Min. Negotiated Rate	$356.30
Max. Negotiated Rate	$509.00
Rate for Payer: Aetna Commercial	$483.55
Rate for Payer: Aetna Medicare	$458.10
Rate for Payer: BCBS MT CHIP	$458.10
Rate for Payer: BCBS MT Closed Plan Network	$483.55
Rate for Payer: BCBS MT HealthLink	$458.10
Rate for Payer: BCBS MT Medicare	$458.10
Rate for Payer: BCBS MT POS	$483.55
Rate for Payer: BCBS MT Traditional	$509.00
Rate for Payer: Cash Price	$458.10
Rate for Payer: Cigna Commercial	$483.55
Rate for Payer: Cigna Medicare	$458.10
Rate for Payer: Medicaid All Medicaid	$468.28
Rate for Payer: Medicare All Medicare	$356.30
Rate for Payer: Monida Allegiance	$483.55
Rate for Payer: Monida First Choice Health	$493.73
Rate for Payer: Monida Montana Health Co-op	$483.55
Rate for Payer: Monida PacificSource	$483.55

US SOFT TISSUE HEAD OR NECK

Facility

$397.00

Service Code	HCPCS 76536
Hospital Charge Code	5176536
Hospital Revenue Code	402
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$397.00
Rate for Payer: Aetna Commercial	$377.15
Rate for Payer: Aetna Medicare	$357.30
Rate for Payer: BCBS MT CHIP	$357.30
Rate for Payer: BCBS MT Closed Plan Network	$377.15
Rate for Payer: BCBS MT HealthLink	$357.30
Rate for Payer: BCBS MT Medicare	$357.30
Rate for Payer: BCBS MT POS	$377.15
Rate for Payer: BCBS MT Traditional	$397.00
Rate for Payer: Cash Price	$357.30
Rate for Payer: Cigna Commercial	$377.15
Rate for Payer: Cigna Medicare	$357.30
Rate for Payer: Medicaid All Medicaid	$365.24
Rate for Payer: Medicare All Medicare	$277.90
Rate for Payer: Monida Allegiance	$377.15
Rate for Payer: Monida First Choice Health	$385.09
Rate for Payer: Monida Montana Health Co-op	$377.15
Rate for Payer: Monida PacificSource	$377.15

US SOFT TISSUE HEAD OR NECK

Facility

$397.00

Service Code	HCPCS 76536
Hospital Charge Code	5176536
Hospital Revenue Code	402
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$397.00
Rate for Payer: Aetna Commercial	$377.15
Rate for Payer: Aetna Medicare	$357.30
Rate for Payer: BCBS MT CHIP	$357.30
Rate for Payer: BCBS MT Closed Plan Network	$377.15
Rate for Payer: BCBS MT HealthLink	$357.30
Rate for Payer: BCBS MT Medicare	$357.30
Rate for Payer: BCBS MT POS	$377.15
Rate for Payer: BCBS MT Traditional	$397.00
Rate for Payer: Cash Price	$357.30
Rate for Payer: Cigna Commercial	$377.15
Rate for Payer: Cigna Medicare	$357.30
Rate for Payer: Medicaid All Medicaid	$365.24
Rate for Payer: Medicare All Medicare	$277.90
Rate for Payer: Monida Allegiance	$377.15
Rate for Payer: Monida First Choice Health	$385.09
Rate for Payer: Monida Montana Health Co-op	$377.15
Rate for Payer: Monida PacificSource	$377.15

US SOFT TISSUE PELVIS

Facility

$318.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	5100007
Hospital Revenue Code	402
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

US SOFT TISSUE PELVIS

Facility

$318.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	5100007
Hospital Revenue Code	402
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

US STRESS ECHO DOBUTAMINE

Facility

$2,041.00

Service Code	HCPCS 93350
Hospital Charge Code	5193351
Hospital Revenue Code	482
Min. Negotiated Rate	$1,428.70
Max. Negotiated Rate	$2,041.00
Rate for Payer: Aetna Commercial	$1,938.95
Rate for Payer: Aetna Medicare	$1,836.90
Rate for Payer: BCBS MT CHIP	$1,836.90
Rate for Payer: BCBS MT Closed Plan Network	$1,938.95
Rate for Payer: BCBS MT HealthLink	$1,836.90
Rate for Payer: BCBS MT Medicare	$1,836.90
Rate for Payer: BCBS MT POS	$1,938.95
Rate for Payer: BCBS MT Traditional	$2,041.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cigna Commercial	$1,938.95
Rate for Payer: Cigna Medicare	$1,836.90
Rate for Payer: Medicaid All Medicaid	$1,877.72
Rate for Payer: Medicare All Medicare	$1,428.70
Rate for Payer: Monida Allegiance	$1,938.95
Rate for Payer: Monida First Choice Health	$1,979.77
Rate for Payer: Monida Montana Health Co-op	$1,938.95
Rate for Payer: Monida PacificSource	$1,938.95

US STRESS ECHO DOBUTAMINE

Facility

$2,041.00

Service Code	HCPCS 93350
Hospital Charge Code	5193351
Hospital Revenue Code	482
Min. Negotiated Rate	$1,428.70
Max. Negotiated Rate	$2,041.00
Rate for Payer: Aetna Commercial	$1,938.95
Rate for Payer: Aetna Medicare	$1,836.90
Rate for Payer: BCBS MT CHIP	$1,836.90
Rate for Payer: BCBS MT Closed Plan Network	$1,938.95
Rate for Payer: BCBS MT HealthLink	$1,836.90
Rate for Payer: BCBS MT Medicare	$1,836.90
Rate for Payer: BCBS MT POS	$1,938.95
Rate for Payer: BCBS MT Traditional	$2,041.00
Rate for Payer: Cash Price	$1,836.90
Rate for Payer: Cigna Commercial	$1,938.95
Rate for Payer: Cigna Medicare	$1,836.90
Rate for Payer: Medicaid All Medicaid	$1,877.72
Rate for Payer: Medicare All Medicare	$1,428.70
Rate for Payer: Monida Allegiance	$1,938.95
Rate for Payer: Monida First Choice Health	$1,979.77
Rate for Payer: Monida Montana Health Co-op	$1,938.95
Rate for Payer: Monida PacificSource	$1,938.95

Know your out-of-pocket cost for care.

All Charges