Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US STRESS ECHO TREADMILL

Facility

$2,041.00

Service Code	HCPCS 93350
Hospital Charge Code	5193350
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 TREADMILL

Facility

$2,041.00

Service Code	HCPCS 93350
Hospital Charge Code	5193350
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 TESTICULAR SCROTUM

Facility

$425.00

Service Code	HCPCS 76870
Hospital Charge Code	5176870
Hospital Revenue Code	402
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: BCBS MT CHIP	$382.50
Rate for Payer: BCBS MT Closed Plan Network	$403.75
Rate for Payer: BCBS MT HealthLink	$382.50
Rate for Payer: BCBS MT Medicare	$382.50
Rate for Payer: BCBS MT POS	$403.75
Rate for Payer: BCBS MT Traditional	$425.00
Rate for Payer: Cash Price	$382.50
Rate for Payer: Cigna Commercial	$403.75
Rate for Payer: Cigna Medicare	$382.50
Rate for Payer: Medicaid All Medicaid	$391.00
Rate for Payer: Medicare All Medicare	$297.50
Rate for Payer: Monida Allegiance	$403.75
Rate for Payer: Monida First Choice Health	$412.25
Rate for Payer: Monida Montana Health Co-op	$403.75
Rate for Payer: Monida PacificSource	$403.75

US TESTICULAR SCROTUM

Facility

$425.00

Service Code	HCPCS 76870
Hospital Charge Code	5176870
Hospital Revenue Code	402
Min. Negotiated Rate	$297.50
Max. Negotiated Rate	$425.00
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$382.50
Rate for Payer: BCBS MT CHIP	$382.50
Rate for Payer: BCBS MT Closed Plan Network	$403.75
Rate for Payer: BCBS MT HealthLink	$382.50
Rate for Payer: BCBS MT Medicare	$382.50
Rate for Payer: BCBS MT POS	$403.75
Rate for Payer: BCBS MT Traditional	$425.00
Rate for Payer: Cash Price	$382.50
Rate for Payer: Cigna Commercial	$403.75
Rate for Payer: Cigna Medicare	$382.50
Rate for Payer: Medicaid All Medicaid	$391.00
Rate for Payer: Medicare All Medicare	$297.50
Rate for Payer: Monida Allegiance	$403.75
Rate for Payer: Monida First Choice Health	$412.25
Rate for Payer: Monida Montana Health Co-op	$403.75
Rate for Payer: Monida PacificSource	$403.75

US THYROID

Facility

$397.00

Service Code	HCPCS 76536
Hospital Charge Code	5100001
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 THYROID

Facility

$397.00

Service Code	HCPCS 76536
Hospital Charge Code	5100001
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 TO DETERMINE LENGTH FROM CORN

Facility

$332.00

Service Code	HCPCS 76516 TC
Hospital Charge Code	5176516
Hospital Revenue Code	402
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

US TO DETERMINE LENGTH FROM CORN

Facility

$332.00

Service Code	HCPCS 76516 TC
Hospital Charge Code	5176516
Hospital Revenue Code	402
Min. Negotiated Rate	$232.40
Max. Negotiated Rate	$332.00
Rate for Payer: Aetna Commercial	$315.40
Rate for Payer: Aetna Medicare	$298.80
Rate for Payer: BCBS MT CHIP	$298.80
Rate for Payer: BCBS MT Closed Plan Network	$315.40
Rate for Payer: BCBS MT HealthLink	$298.80
Rate for Payer: BCBS MT Medicare	$298.80
Rate for Payer: BCBS MT POS	$315.40
Rate for Payer: BCBS MT Traditional	$332.00
Rate for Payer: Cash Price	$298.80
Rate for Payer: Cigna Commercial	$315.40
Rate for Payer: Cigna Medicare	$298.80
Rate for Payer: Medicaid All Medicaid	$305.44
Rate for Payer: Medicare All Medicare	$232.40
Rate for Payer: Monida Allegiance	$315.40
Rate for Payer: Monida First Choice Health	$322.04
Rate for Payer: Monida Montana Health Co-op	$315.40
Rate for Payer: Monida PacificSource	$315.40

US TRANSCRAN DOPL INTRACRAN ART MICROBUB

Facility

$669.00

Service Code	HCPCS 93893 TC
Hospital Charge Code	5193893
Hospital Revenue Code	402
Min. Negotiated Rate	$468.30
Max. Negotiated Rate	$669.00
Rate for Payer: Aetna Commercial	$635.55
Rate for Payer: Aetna Medicare	$602.10
Rate for Payer: BCBS MT CHIP	$602.10
Rate for Payer: BCBS MT Closed Plan Network	$635.55
Rate for Payer: BCBS MT HealthLink	$602.10
Rate for Payer: BCBS MT Medicare	$602.10
Rate for Payer: BCBS MT POS	$635.55
Rate for Payer: BCBS MT Traditional	$669.00
Rate for Payer: Cash Price	$602.10
Rate for Payer: Cigna Commercial	$635.55
Rate for Payer: Cigna Medicare	$602.10
Rate for Payer: Medicaid All Medicaid	$615.48
Rate for Payer: Medicare All Medicare	$468.30
Rate for Payer: Monida Allegiance	$635.55
Rate for Payer: Monida First Choice Health	$648.93
Rate for Payer: Monida Montana Health Co-op	$635.55
Rate for Payer: Monida PacificSource	$635.55

US TRANSCRAN DOPL INTRACRAN ART MICROBUB

Facility

$669.00

Service Code	HCPCS 93893 TC
Hospital Charge Code	5193893
Hospital Revenue Code	402
Min. Negotiated Rate	$468.30
Max. Negotiated Rate	$669.00
Rate for Payer: Aetna Commercial	$635.55
Rate for Payer: Aetna Medicare	$602.10
Rate for Payer: BCBS MT CHIP	$602.10
Rate for Payer: BCBS MT Closed Plan Network	$635.55
Rate for Payer: BCBS MT HealthLink	$602.10
Rate for Payer: BCBS MT Medicare	$602.10
Rate for Payer: BCBS MT POS	$635.55
Rate for Payer: BCBS MT Traditional	$669.00
Rate for Payer: Cash Price	$602.10
Rate for Payer: Cigna Commercial	$635.55
Rate for Payer: Cigna Medicare	$602.10
Rate for Payer: Medicaid All Medicaid	$615.48
Rate for Payer: Medicare All Medicare	$468.30
Rate for Payer: Monida Allegiance	$635.55
Rate for Payer: Monida First Choice Health	$648.93
Rate for Payer: Monida Montana Health Co-op	$635.55
Rate for Payer: Monida PacificSource	$635.55

US TRANSCRANIAL DOPPLER STDY INTRACRAN A

Facility

$1,229.00

Service Code	HCPCS 93886 TC
Hospital Charge Code	5193886
Hospital Revenue Code	402
Min. Negotiated Rate	$860.30
Max. Negotiated Rate	$1,229.00
Rate for Payer: Aetna Commercial	$1,167.55
Rate for Payer: Aetna Medicare	$1,106.10
Rate for Payer: BCBS MT CHIP	$1,106.10
Rate for Payer: BCBS MT Closed Plan Network	$1,167.55
Rate for Payer: BCBS MT HealthLink	$1,106.10
Rate for Payer: BCBS MT Medicare	$1,106.10
Rate for Payer: BCBS MT POS	$1,167.55
Rate for Payer: BCBS MT Traditional	$1,229.00
Rate for Payer: Cash Price	$1,106.10
Rate for Payer: Cigna Commercial	$1,167.55
Rate for Payer: Cigna Medicare	$1,106.10
Rate for Payer: Medicaid All Medicaid	$1,130.68
Rate for Payer: Medicare All Medicare	$860.30
Rate for Payer: Monida Allegiance	$1,167.55
Rate for Payer: Monida First Choice Health	$1,192.13
Rate for Payer: Monida Montana Health Co-op	$1,167.55
Rate for Payer: Monida PacificSource	$1,167.55

US TRANSCRANIAL DOPPLER STDY INTRACRAN A

Facility

$1,229.00

Service Code	HCPCS 93886 TC
Hospital Charge Code	5193886
Hospital Revenue Code	402
Min. Negotiated Rate	$860.30
Max. Negotiated Rate	$1,229.00
Rate for Payer: Aetna Commercial	$1,167.55
Rate for Payer: Aetna Medicare	$1,106.10
Rate for Payer: BCBS MT CHIP	$1,106.10
Rate for Payer: BCBS MT Closed Plan Network	$1,167.55
Rate for Payer: BCBS MT HealthLink	$1,106.10
Rate for Payer: BCBS MT Medicare	$1,106.10
Rate for Payer: BCBS MT POS	$1,167.55
Rate for Payer: BCBS MT Traditional	$1,229.00
Rate for Payer: Cash Price	$1,106.10
Rate for Payer: Cigna Commercial	$1,167.55
Rate for Payer: Cigna Medicare	$1,106.10
Rate for Payer: Medicaid All Medicaid	$1,130.68
Rate for Payer: Medicare All Medicare	$860.30
Rate for Payer: Monida Allegiance	$1,167.55
Rate for Payer: Monida First Choice Health	$1,192.13
Rate for Payer: Monida Montana Health Co-op	$1,167.55
Rate for Payer: Monida PacificSource	$1,167.55

US TRANSCRANIAL DOPPLER STDY INTRACRANIL

Facility

$714.00

Service Code	HCPCS 93888 TC
Hospital Charge Code	5193888
Hospital Revenue Code	402
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$714.00
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna Medicare	$642.60
Rate for Payer: BCBS MT CHIP	$642.60
Rate for Payer: BCBS MT Closed Plan Network	$678.30
Rate for Payer: BCBS MT HealthLink	$642.60
Rate for Payer: BCBS MT Medicare	$642.60
Rate for Payer: BCBS MT POS	$678.30
Rate for Payer: BCBS MT Traditional	$714.00
Rate for Payer: Cash Price	$642.60
Rate for Payer: Cigna Commercial	$678.30
Rate for Payer: Cigna Medicare	$642.60
Rate for Payer: Medicaid All Medicaid	$656.88
Rate for Payer: Medicare All Medicare	$499.80
Rate for Payer: Monida Allegiance	$678.30
Rate for Payer: Monida First Choice Health	$692.58
Rate for Payer: Monida Montana Health Co-op	$678.30
Rate for Payer: Monida PacificSource	$678.30

US TRANSCRANIAL DOPPLER STDY INTRACRANIL

Facility

$714.00

Service Code	HCPCS 93888 TC
Hospital Charge Code	5193888
Hospital Revenue Code	402
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$714.00
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna Medicare	$642.60
Rate for Payer: BCBS MT CHIP	$642.60
Rate for Payer: BCBS MT Closed Plan Network	$678.30
Rate for Payer: BCBS MT HealthLink	$642.60
Rate for Payer: BCBS MT Medicare	$642.60
Rate for Payer: BCBS MT POS	$678.30
Rate for Payer: BCBS MT Traditional	$714.00
Rate for Payer: Cash Price	$642.60
Rate for Payer: Cigna Commercial	$678.30
Rate for Payer: Cigna Medicare	$642.60
Rate for Payer: Medicaid All Medicaid	$656.88
Rate for Payer: Medicare All Medicare	$499.80
Rate for Payer: Monida Allegiance	$678.30
Rate for Payer: Monida First Choice Health	$692.58
Rate for Payer: Monida Montana Health Co-op	$678.30
Rate for Payer: Monida PacificSource	$678.30

US TRANSCRANL DOPPLER INTRACRAN ART EMBO

Facility

$737.00

Service Code	HCPCS 93892 TC
Hospital Charge Code	5193892
Hospital Revenue Code	402
Min. Negotiated Rate	$515.90
Max. Negotiated Rate	$737.00
Rate for Payer: Aetna Commercial	$700.15
Rate for Payer: Aetna Medicare	$663.30
Rate for Payer: BCBS MT CHIP	$663.30
Rate for Payer: BCBS MT Closed Plan Network	$700.15
Rate for Payer: BCBS MT HealthLink	$663.30
Rate for Payer: BCBS MT Medicare	$663.30
Rate for Payer: BCBS MT POS	$700.15
Rate for Payer: BCBS MT Traditional	$737.00
Rate for Payer: Cash Price	$663.30
Rate for Payer: Cigna Commercial	$700.15
Rate for Payer: Cigna Medicare	$663.30
Rate for Payer: Medicaid All Medicaid	$678.04
Rate for Payer: Medicare All Medicare	$515.90
Rate for Payer: Monida Allegiance	$700.15
Rate for Payer: Monida First Choice Health	$714.89
Rate for Payer: Monida Montana Health Co-op	$700.15
Rate for Payer: Monida PacificSource	$700.15

US TRANSCRANL DOPPLER INTRACRAN ART EMBO

Facility

$737.00

Service Code	HCPCS 93892 TC
Hospital Charge Code	5193892
Hospital Revenue Code	402
Min. Negotiated Rate	$515.90
Max. Negotiated Rate	$737.00
Rate for Payer: Aetna Commercial	$700.15
Rate for Payer: Aetna Medicare	$663.30
Rate for Payer: BCBS MT CHIP	$663.30
Rate for Payer: BCBS MT Closed Plan Network	$700.15
Rate for Payer: BCBS MT HealthLink	$663.30
Rate for Payer: BCBS MT Medicare	$663.30
Rate for Payer: BCBS MT POS	$700.15
Rate for Payer: BCBS MT Traditional	$737.00
Rate for Payer: Cash Price	$663.30
Rate for Payer: Cigna Commercial	$700.15
Rate for Payer: Cigna Medicare	$663.30
Rate for Payer: Medicaid All Medicaid	$678.04
Rate for Payer: Medicare All Medicare	$515.90
Rate for Payer: Monida Allegiance	$700.15
Rate for Payer: Monida First Choice Health	$714.89
Rate for Payer: Monida Montana Health Co-op	$700.15
Rate for Payer: Monida PacificSource	$700.15

US TRANSVAGINAL US NON-OB

Facility

$407.00

Service Code	HCPCS 76830
Hospital Charge Code	5176830
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 TRANSVAGINAL US NON-OB

Facility

$407.00

Service Code	HCPCS 76830
Hospital Charge Code	5176830
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 TRANSVAGINAL US OBSTETRIC

Facility

$328.00

Service Code	HCPCS 76817
Hospital Charge Code	5176817
Hospital Revenue Code	402
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

US TRANSVAGINAL US OBSTETRIC

Facility

$328.00

Service Code	HCPCS 76817
Hospital Charge Code	5176817
Hospital Revenue Code	402
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

US TRANS VAG LMT

Facility

$217.00

Service Code	HCPCS 76857
Hospital Charge Code	5100003
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 TRANS VAG LMT

Facility

$217.00

Service Code	HCPCS 76857
Hospital Charge Code	5100003
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 TRNSPLNT KIDNEY REAL TIME W/IMAGE DOC

Facility

$847.00

Service Code	HCPCS 76776 TC
Hospital Charge Code	5176776
Hospital Revenue Code	402
Min. Negotiated Rate	$592.90
Max. Negotiated Rate	$847.00
Rate for Payer: Aetna Commercial	$804.65
Rate for Payer: Aetna Medicare	$762.30
Rate for Payer: BCBS MT CHIP	$762.30
Rate for Payer: BCBS MT Closed Plan Network	$804.65
Rate for Payer: BCBS MT HealthLink	$762.30
Rate for Payer: BCBS MT Medicare	$762.30
Rate for Payer: BCBS MT POS	$804.65
Rate for Payer: BCBS MT Traditional	$847.00
Rate for Payer: Cash Price	$762.30
Rate for Payer: Cigna Commercial	$804.65
Rate for Payer: Cigna Medicare	$762.30
Rate for Payer: Medicaid All Medicaid	$779.24
Rate for Payer: Medicare All Medicare	$592.90
Rate for Payer: Monida Allegiance	$804.65
Rate for Payer: Monida First Choice Health	$821.59
Rate for Payer: Monida Montana Health Co-op	$804.65
Rate for Payer: Monida PacificSource	$804.65

US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOC

Facility

$847.00

Service Code	HCPCS 76776 TC
Hospital Charge Code	5176776
Hospital Revenue Code	402
Min. Negotiated Rate	$592.90
Max. Negotiated Rate	$847.00
Rate for Payer: Aetna Commercial	$804.65
Rate for Payer: Aetna Medicare	$762.30
Rate for Payer: BCBS MT CHIP	$762.30
Rate for Payer: BCBS MT Closed Plan Network	$804.65
Rate for Payer: BCBS MT HealthLink	$762.30
Rate for Payer: BCBS MT Medicare	$762.30
Rate for Payer: BCBS MT POS	$804.65
Rate for Payer: BCBS MT Traditional	$847.00
Rate for Payer: Cash Price	$762.30
Rate for Payer: Cigna Commercial	$804.65
Rate for Payer: Cigna Medicare	$762.30
Rate for Payer: Medicaid All Medicaid	$779.24
Rate for Payer: Medicare All Medicare	$592.90
Rate for Payer: Monida Allegiance	$804.65
Rate for Payer: Monida First Choice Health	$821.59
Rate for Payer: Monida Montana Health Co-op	$804.65
Rate for Payer: Monida PacificSource	$804.65

US VENOUS DOPP BILATERAL

Facility

$693.00

Service Code	HCPCS 93970
Hospital Charge Code	5193970
Hospital Revenue Code	402
Min. Negotiated Rate	$485.10
Max. Negotiated Rate	$693.00
Rate for Payer: Aetna Commercial	$658.35
Rate for Payer: Aetna Medicare	$623.70
Rate for Payer: BCBS MT CHIP	$623.70
Rate for Payer: BCBS MT Closed Plan Network	$658.35
Rate for Payer: BCBS MT HealthLink	$623.70
Rate for Payer: BCBS MT Medicare	$623.70
Rate for Payer: BCBS MT POS	$658.35
Rate for Payer: BCBS MT Traditional	$693.00
Rate for Payer: Cash Price	$623.70
Rate for Payer: Cigna Commercial	$658.35
Rate for Payer: Cigna Medicare	$623.70
Rate for Payer: Medicaid All Medicaid	$637.56
Rate for Payer: Medicare All Medicare	$485.10
Rate for Payer: Monida Allegiance	$658.35
Rate for Payer: Monida First Choice Health	$672.21
Rate for Payer: Monida Montana Health Co-op	$658.35
Rate for Payer: Monida PacificSource	$658.35

Know your out-of-pocket cost for care.

All Charges