Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

URSODIOL CAP [300 MG] NF

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000464
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

URSODIOL CAP [300 MG] NF

Facility

$26.00

Service Code	HCPCS J3490
Hospital Charge Code	3000464
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

US 3D RENDERING W/INTERPRET POST PROCE

Facility

$696.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5176376
Hospital Revenue Code	402
Min. Negotiated Rate	$487.20
Max. Negotiated Rate	$696.00
Rate for Payer: Aetna Commercial	$661.20
Rate for Payer: Aetna Medicare	$626.40
Rate for Payer: BCBS MT CHIP	$626.40
Rate for Payer: BCBS MT Closed Plan Network	$661.20
Rate for Payer: BCBS MT HealthLink	$626.40
Rate for Payer: BCBS MT Medicare	$626.40
Rate for Payer: BCBS MT POS	$661.20
Rate for Payer: BCBS MT Traditional	$696.00
Rate for Payer: Cash Price	$626.40
Rate for Payer: Cigna Commercial	$661.20
Rate for Payer: Cigna Medicare	$626.40
Rate for Payer: Medicaid All Medicaid	$640.32
Rate for Payer: Medicare All Medicare	$487.20
Rate for Payer: Monida Allegiance	$661.20
Rate for Payer: Monida First Choice Health	$675.12
Rate for Payer: Monida Montana Health Co-op	$661.20
Rate for Payer: Monida PacificSource	$661.20

US 3D RENDERING W/INTERPRET POST PROCE

Facility

$696.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5176376
Hospital Revenue Code	402
Min. Negotiated Rate	$487.20
Max. Negotiated Rate	$696.00
Rate for Payer: Aetna Commercial	$661.20
Rate for Payer: Aetna Medicare	$626.40
Rate for Payer: BCBS MT CHIP	$626.40
Rate for Payer: BCBS MT Closed Plan Network	$661.20
Rate for Payer: BCBS MT HealthLink	$626.40
Rate for Payer: BCBS MT Medicare	$626.40
Rate for Payer: BCBS MT POS	$661.20
Rate for Payer: BCBS MT Traditional	$696.00
Rate for Payer: Cash Price	$626.40
Rate for Payer: Cigna Commercial	$661.20
Rate for Payer: Cigna Medicare	$626.40
Rate for Payer: Medicaid All Medicaid	$640.32
Rate for Payer: Medicare All Medicare	$487.20
Rate for Payer: Monida Allegiance	$661.20
Rate for Payer: Monida First Choice Health	$675.12
Rate for Payer: Monida Montana Health Co-op	$661.20
Rate for Payer: Monida PacificSource	$661.20

US 3D RENDER W/INTERP&POSTPROC DIFF WORK

Facility

$885.00

Service Code	HCPCS 76377 TC
Hospital Charge Code	5176377
Hospital Revenue Code	402
Min. Negotiated Rate	$619.50
Max. Negotiated Rate	$885.00
Rate for Payer: Aetna Commercial	$840.75
Rate for Payer: Aetna Medicare	$796.50
Rate for Payer: BCBS MT CHIP	$796.50
Rate for Payer: BCBS MT Closed Plan Network	$840.75
Rate for Payer: BCBS MT HealthLink	$796.50
Rate for Payer: BCBS MT Medicare	$796.50
Rate for Payer: BCBS MT POS	$840.75
Rate for Payer: BCBS MT Traditional	$885.00
Rate for Payer: Cash Price	$796.50
Rate for Payer: Cigna Commercial	$840.75
Rate for Payer: Cigna Medicare	$796.50
Rate for Payer: Medicaid All Medicaid	$814.20
Rate for Payer: Medicare All Medicare	$619.50
Rate for Payer: Monida Allegiance	$840.75
Rate for Payer: Monida First Choice Health	$858.45
Rate for Payer: Monida Montana Health Co-op	$840.75
Rate for Payer: Monida PacificSource	$840.75

US 3D RENDER W/INTERP&POSTPROC DIFF WORK

Facility

$885.00

Service Code	HCPCS 76377 TC
Hospital Charge Code	5176377
Hospital Revenue Code	402
Min. Negotiated Rate	$619.50
Max. Negotiated Rate	$885.00
Rate for Payer: Aetna Commercial	$840.75
Rate for Payer: Aetna Medicare	$796.50
Rate for Payer: BCBS MT CHIP	$796.50
Rate for Payer: BCBS MT Closed Plan Network	$840.75
Rate for Payer: BCBS MT HealthLink	$796.50
Rate for Payer: BCBS MT Medicare	$796.50
Rate for Payer: BCBS MT POS	$840.75
Rate for Payer: BCBS MT Traditional	$885.00
Rate for Payer: Cash Price	$796.50
Rate for Payer: Cigna Commercial	$840.75
Rate for Payer: Cigna Medicare	$796.50
Rate for Payer: Medicaid All Medicaid	$814.20
Rate for Payer: Medicare All Medicare	$619.50
Rate for Payer: Monida Allegiance	$840.75
Rate for Payer: Monida First Choice Health	$858.45
Rate for Payer: Monida Montana Health Co-op	$840.75
Rate for Payer: Monida PacificSource	$840.75

US ABDOMEN COMPLETE

Facility

$597.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	5176700
Hospital Revenue Code	402
Min. Negotiated Rate	$417.90
Max. Negotiated Rate	$597.00
Rate for Payer: Aetna Commercial	$567.15
Rate for Payer: Aetna Medicare	$537.30
Rate for Payer: BCBS MT CHIP	$537.30
Rate for Payer: BCBS MT Closed Plan Network	$567.15
Rate for Payer: BCBS MT HealthLink	$537.30
Rate for Payer: BCBS MT Medicare	$537.30
Rate for Payer: BCBS MT POS	$567.15
Rate for Payer: BCBS MT Traditional	$597.00
Rate for Payer: Cash Price	$537.30
Rate for Payer: Cigna Commercial	$567.15
Rate for Payer: Cigna Medicare	$537.30
Rate for Payer: Medicaid All Medicaid	$549.24
Rate for Payer: Medicare All Medicare	$417.90
Rate for Payer: Monida Allegiance	$567.15
Rate for Payer: Monida First Choice Health	$579.09
Rate for Payer: Monida Montana Health Co-op	$567.15
Rate for Payer: Monida PacificSource	$567.15

US ABDOMEN COMPLETE

Facility

$597.00

Service Code	HCPCS 76700 TC
Hospital Charge Code	5176700
Hospital Revenue Code	402
Min. Negotiated Rate	$417.90
Max. Negotiated Rate	$597.00
Rate for Payer: Aetna Commercial	$567.15
Rate for Payer: Aetna Medicare	$537.30
Rate for Payer: BCBS MT CHIP	$537.30
Rate for Payer: BCBS MT Closed Plan Network	$567.15
Rate for Payer: BCBS MT HealthLink	$537.30
Rate for Payer: BCBS MT Medicare	$537.30
Rate for Payer: BCBS MT POS	$567.15
Rate for Payer: BCBS MT Traditional	$597.00
Rate for Payer: Cash Price	$537.30
Rate for Payer: Cigna Commercial	$567.15
Rate for Payer: Cigna Medicare	$537.30
Rate for Payer: Medicaid All Medicaid	$549.24
Rate for Payer: Medicare All Medicare	$417.90
Rate for Payer: Monida Allegiance	$567.15
Rate for Payer: Monida First Choice Health	$579.09
Rate for Payer: Monida Montana Health Co-op	$567.15
Rate for Payer: Monida PacificSource	$567.15

US ABDOMEN DOPP LMT

Facility

$499.00

Service Code	HCPCS 93976
Hospital Charge Code	5193976
Hospital Revenue Code	402
Min. Negotiated Rate	$349.30
Max. Negotiated Rate	$499.00
Rate for Payer: Aetna Commercial	$474.05
Rate for Payer: Aetna Medicare	$449.10
Rate for Payer: BCBS MT CHIP	$449.10
Rate for Payer: BCBS MT Closed Plan Network	$474.05
Rate for Payer: BCBS MT HealthLink	$449.10
Rate for Payer: BCBS MT Medicare	$449.10
Rate for Payer: BCBS MT POS	$474.05
Rate for Payer: BCBS MT Traditional	$499.00
Rate for Payer: Cash Price	$449.10
Rate for Payer: Cigna Commercial	$474.05
Rate for Payer: Cigna Medicare	$449.10
Rate for Payer: Medicaid All Medicaid	$459.08
Rate for Payer: Medicare All Medicare	$349.30
Rate for Payer: Monida Allegiance	$474.05
Rate for Payer: Monida First Choice Health	$484.03
Rate for Payer: Monida Montana Health Co-op	$474.05
Rate for Payer: Monida PacificSource	$474.05

US ABDOMEN DOPP LMT

Facility

$499.00

Service Code	HCPCS 93976
Hospital Charge Code	5193976
Hospital Revenue Code	402
Min. Negotiated Rate	$349.30
Max. Negotiated Rate	$499.00
Rate for Payer: Aetna Commercial	$474.05
Rate for Payer: Aetna Medicare	$449.10
Rate for Payer: BCBS MT CHIP	$449.10
Rate for Payer: BCBS MT Closed Plan Network	$474.05
Rate for Payer: BCBS MT HealthLink	$449.10
Rate for Payer: BCBS MT Medicare	$449.10
Rate for Payer: BCBS MT POS	$474.05
Rate for Payer: BCBS MT Traditional	$499.00
Rate for Payer: Cash Price	$449.10
Rate for Payer: Cigna Commercial	$474.05
Rate for Payer: Cigna Medicare	$449.10
Rate for Payer: Medicaid All Medicaid	$459.08
Rate for Payer: Medicare All Medicare	$349.30
Rate for Payer: Monida Allegiance	$474.05
Rate for Payer: Monida First Choice Health	$484.03
Rate for Payer: Monida Montana Health Co-op	$474.05
Rate for Payer: Monida PacificSource	$474.05

US ABDOMEN LIMITED

Facility

$443.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5176705
Hospital Revenue Code	402
Min. Negotiated Rate	$310.10
Max. Negotiated Rate	$443.00
Rate for Payer: Aetna Commercial	$420.85
Rate for Payer: Aetna Medicare	$398.70
Rate for Payer: BCBS MT CHIP	$398.70
Rate for Payer: BCBS MT Closed Plan Network	$420.85
Rate for Payer: BCBS MT HealthLink	$398.70
Rate for Payer: BCBS MT Medicare	$398.70
Rate for Payer: BCBS MT POS	$420.85
Rate for Payer: BCBS MT Traditional	$443.00
Rate for Payer: Cash Price	$398.70
Rate for Payer: Cigna Commercial	$420.85
Rate for Payer: Cigna Medicare	$398.70
Rate for Payer: Medicaid All Medicaid	$407.56
Rate for Payer: Medicare All Medicare	$310.10
Rate for Payer: Monida Allegiance	$420.85
Rate for Payer: Monida First Choice Health	$429.71
Rate for Payer: Monida Montana Health Co-op	$420.85
Rate for Payer: Monida PacificSource	$420.85

US ABDOMEN LIMITED

Facility

$443.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5176705
Hospital Revenue Code	402
Min. Negotiated Rate	$310.10
Max. Negotiated Rate	$443.00
Rate for Payer: Aetna Commercial	$420.85
Rate for Payer: Aetna Medicare	$398.70
Rate for Payer: BCBS MT CHIP	$398.70
Rate for Payer: BCBS MT Closed Plan Network	$420.85
Rate for Payer: BCBS MT HealthLink	$398.70
Rate for Payer: BCBS MT Medicare	$398.70
Rate for Payer: BCBS MT POS	$420.85
Rate for Payer: BCBS MT Traditional	$443.00
Rate for Payer: Cash Price	$398.70
Rate for Payer: Cigna Commercial	$420.85
Rate for Payer: Cigna Medicare	$398.70
Rate for Payer: Medicaid All Medicaid	$407.56
Rate for Payer: Medicare All Medicare	$310.10
Rate for Payer: Monida Allegiance	$420.85
Rate for Payer: Monida First Choice Health	$429.71
Rate for Payer: Monida Montana Health Co-op	$420.85
Rate for Payer: Monida PacificSource	$420.85

US ABDOMINAL AORTA REAL TIME SCREEN STUD

Facility

$266.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	5176706
Hospital Revenue Code	402
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

US ABDOMINAL AORTA REAL TIME SCREEN STUD

Facility

$266.00

Service Code	HCPCS 76706 TC
Hospital Charge Code	5176706
Hospital Revenue Code	402
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

US ABI

Facility

$289.00

Service Code	HCPCS 93922
Hospital Charge Code	5193922
Hospital Revenue Code	402
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 ABI

Facility

$289.00

Service Code	HCPCS 93922
Hospital Charge Code	5193922
Hospital Revenue Code	402
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 AORTA SCREEN/MC

Facility

$374.00

Service Code	HCPCS 93979
Hospital Charge Code	5100004
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

US AORTA SCREEN/MC

Facility

$374.00

Service Code	HCPCS 93979
Hospital Charge Code	5100004
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

US ARTERY BYPASS GRAFT

Facility

$374.00

Service Code	HCPCS 93979
Hospital Charge Code	5193979
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

US ARTERY BYPASS GRAFT

Facility

$374.00

Service Code	HCPCS 93979
Hospital Charge Code	5193979
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

US BLADDER PRE/POST

Facility

$230.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	5176857
Hospital Revenue Code	402
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

US BLADDER PRE/POST

Facility

$230.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	5176857
Hospital Revenue Code	402
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

US BLADDER SCANNER POST

Facility

$151.00

Service Code	HCPCS 51798
Hospital Charge Code	151799
Hospital Revenue Code	920
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$151.00
Rate for Payer: Aetna Commercial	$143.45
Rate for Payer: Aetna Medicare	$135.90
Rate for Payer: BCBS MT CHIP	$135.90
Rate for Payer: BCBS MT Closed Plan Network	$143.45
Rate for Payer: BCBS MT HealthLink	$135.90
Rate for Payer: BCBS MT Medicare	$135.90
Rate for Payer: BCBS MT POS	$143.45
Rate for Payer: BCBS MT Traditional	$151.00
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cigna Commercial	$143.45
Rate for Payer: Cigna Medicare	$135.90
Rate for Payer: Medicaid All Medicaid	$138.92
Rate for Payer: Medicare All Medicare	$105.70
Rate for Payer: Monida Allegiance	$143.45
Rate for Payer: Monida First Choice Health	$146.47
Rate for Payer: Monida Montana Health Co-op	$143.45
Rate for Payer: Monida PacificSource	$143.45

US BLADDER SCANNER POST

Facility

$151.00

Service Code	HCPCS 51798
Hospital Charge Code	151799
Hospital Revenue Code	920
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$151.00
Rate for Payer: Aetna Commercial	$143.45
Rate for Payer: Aetna Medicare	$135.90
Rate for Payer: BCBS MT CHIP	$135.90
Rate for Payer: BCBS MT Closed Plan Network	$143.45
Rate for Payer: BCBS MT HealthLink	$135.90
Rate for Payer: BCBS MT Medicare	$135.90
Rate for Payer: BCBS MT POS	$143.45
Rate for Payer: BCBS MT Traditional	$151.00
Rate for Payer: Cash Price	$135.90
Rate for Payer: Cigna Commercial	$143.45
Rate for Payer: Cigna Medicare	$135.90
Rate for Payer: Medicaid All Medicaid	$138.92
Rate for Payer: Medicare All Medicare	$105.70
Rate for Payer: Monida Allegiance	$143.45
Rate for Payer: Monida First Choice Health	$146.47
Rate for Payer: Monida Montana Health Co-op	$143.45
Rate for Payer: Monida PacificSource	$143.45

US BREAST

Facility

$298.00

Service Code	HCPCS 76641 TC
Hospital Charge Code	5176641
Hospital Revenue Code	402
Min. Negotiated Rate	$208.60
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$283.10
Rate for Payer: Aetna Medicare	$268.20
Rate for Payer: BCBS MT CHIP	$268.20
Rate for Payer: BCBS MT Closed Plan Network	$283.10
Rate for Payer: BCBS MT HealthLink	$268.20
Rate for Payer: BCBS MT Medicare	$268.20
Rate for Payer: BCBS MT POS	$283.10
Rate for Payer: BCBS MT Traditional	$298.00
Rate for Payer: Cash Price	$268.20
Rate for Payer: Cigna Commercial	$283.10
Rate for Payer: Cigna Medicare	$268.20
Rate for Payer: Medicaid All Medicaid	$274.16
Rate for Payer: Medicare All Medicare	$208.60
Rate for Payer: Monida Allegiance	$283.10
Rate for Payer: Monida First Choice Health	$289.06
Rate for Payer: Monida Montana Health Co-op	$283.10
Rate for Payer: Monida PacificSource	$283.10

Know your out-of-pocket cost for care.

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