Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

US BREAST UNI REAL TIME WITH IMAGE LIMIT

Facility

$520.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	5176642
Hospital Revenue Code	402
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

US BREAST UNI REAL TIME WITH IMAGE LIMIT

Facility

$520.00

Service Code	HCPCS 76642 TC
Hospital Charge Code	5176642
Hospital Revenue Code	402
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

US CAROTID BILATERAL

Facility

$694.00

Service Code	HCPCS 93880
Hospital Charge Code	5193880
Hospital Revenue Code	402
Min. Negotiated Rate	$485.80
Max. Negotiated Rate	$694.00
Rate for Payer: Aetna Commercial	$659.30
Rate for Payer: Aetna Medicare	$624.60
Rate for Payer: BCBS MT CHIP	$624.60
Rate for Payer: BCBS MT Closed Plan Network	$659.30
Rate for Payer: BCBS MT HealthLink	$624.60
Rate for Payer: BCBS MT Medicare	$624.60
Rate for Payer: BCBS MT POS	$659.30
Rate for Payer: BCBS MT Traditional	$694.00
Rate for Payer: Cash Price	$624.60
Rate for Payer: Cigna Commercial	$659.30
Rate for Payer: Cigna Medicare	$624.60
Rate for Payer: Medicaid All Medicaid	$638.48
Rate for Payer: Medicare All Medicare	$485.80
Rate for Payer: Monida Allegiance	$659.30
Rate for Payer: Monida First Choice Health	$673.18
Rate for Payer: Monida Montana Health Co-op	$659.30
Rate for Payer: Monida PacificSource	$659.30

US CAROTID BILATERAL

Facility

$694.00

Service Code	HCPCS 93880
Hospital Charge Code	5193880
Hospital Revenue Code	402
Min. Negotiated Rate	$485.80
Max. Negotiated Rate	$694.00
Rate for Payer: Aetna Commercial	$659.30
Rate for Payer: Aetna Medicare	$624.60
Rate for Payer: BCBS MT CHIP	$624.60
Rate for Payer: BCBS MT Closed Plan Network	$659.30
Rate for Payer: BCBS MT HealthLink	$624.60
Rate for Payer: BCBS MT Medicare	$624.60
Rate for Payer: BCBS MT POS	$659.30
Rate for Payer: BCBS MT Traditional	$694.00
Rate for Payer: Cash Price	$624.60
Rate for Payer: Cigna Commercial	$659.30
Rate for Payer: Cigna Medicare	$624.60
Rate for Payer: Medicaid All Medicaid	$638.48
Rate for Payer: Medicare All Medicare	$485.80
Rate for Payer: Monida Allegiance	$659.30
Rate for Payer: Monida First Choice Health	$673.18
Rate for Payer: Monida Montana Health Co-op	$659.30
Rate for Payer: Monida PacificSource	$659.30

US CAROTID UNILATERAL

Facility

$410.00

Service Code	HCPCS 93882
Hospital Charge Code	5193882
Hospital Revenue Code	402
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

US CAROTID UNILATERAL

Facility

$410.00

Service Code	HCPCS 93882
Hospital Charge Code	5193882
Hospital Revenue Code	402
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

US COMPLETE TTHRC ECHO CONGENI CARDIAC A

Facility

$631.00

Service Code	HCPCS 93303 TC
Hospital Charge Code	5193303
Hospital Revenue Code	402
Min. Negotiated Rate	$441.70
Max. Negotiated Rate	$631.00
Rate for Payer: Aetna Commercial	$599.45
Rate for Payer: Aetna Medicare	$567.90
Rate for Payer: BCBS MT CHIP	$567.90
Rate for Payer: BCBS MT Closed Plan Network	$599.45
Rate for Payer: BCBS MT HealthLink	$567.90
Rate for Payer: BCBS MT Medicare	$567.90
Rate for Payer: BCBS MT POS	$599.45
Rate for Payer: BCBS MT Traditional	$631.00
Rate for Payer: Cash Price	$567.90
Rate for Payer: Cigna Commercial	$599.45
Rate for Payer: Cigna Medicare	$567.90
Rate for Payer: Medicaid All Medicaid	$580.52
Rate for Payer: Medicare All Medicare	$441.70
Rate for Payer: Monida Allegiance	$599.45
Rate for Payer: Monida First Choice Health	$612.07
Rate for Payer: Monida Montana Health Co-op	$599.45
Rate for Payer: Monida PacificSource	$599.45

US COMPLETE TTHRC ECHO CONGENI CARDIAC A

Facility

$631.00

Service Code	HCPCS 93303 TC
Hospital Charge Code	5193303
Hospital Revenue Code	402
Min. Negotiated Rate	$441.70
Max. Negotiated Rate	$631.00
Rate for Payer: Aetna Commercial	$599.45
Rate for Payer: Aetna Medicare	$567.90
Rate for Payer: BCBS MT CHIP	$567.90
Rate for Payer: BCBS MT Closed Plan Network	$599.45
Rate for Payer: BCBS MT HealthLink	$567.90
Rate for Payer: BCBS MT Medicare	$567.90
Rate for Payer: BCBS MT POS	$599.45
Rate for Payer: BCBS MT Traditional	$631.00
Rate for Payer: Cash Price	$567.90
Rate for Payer: Cigna Commercial	$599.45
Rate for Payer: Cigna Medicare	$567.90
Rate for Payer: Medicaid All Medicaid	$580.52
Rate for Payer: Medicare All Medicare	$441.70
Rate for Payer: Monida Allegiance	$599.45
Rate for Payer: Monida First Choice Health	$612.07
Rate for Payer: Monida Montana Health Co-op	$599.45
Rate for Payer: Monida PacificSource	$599.45

US COMPL JOINT R-T W/IMAGE DOCUMENTATION

Facility

$375.00

Service Code	HCPCS 76881 TC
Hospital Charge Code	5176881
Hospital Revenue Code	402
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

US COMPL JOINT R-T W/IMAGE DOCUMENTATION

Facility

$375.00

Service Code	HCPCS 76881 TC
Hospital Charge Code	5176881
Hospital Revenue Code	402
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

US DOP ECHOCARD PULSE WAVE W/SPECT F-UP/

Facility

$220.00

Service Code	HCPCS 93321 TC
Hospital Charge Code	5193321
Hospital Revenue Code	402
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$220.00
Rate for Payer: Aetna Commercial	$209.00
Rate for Payer: Aetna Medicare	$198.00
Rate for Payer: BCBS MT CHIP	$198.00
Rate for Payer: BCBS MT Closed Plan Network	$209.00
Rate for Payer: BCBS MT HealthLink	$198.00
Rate for Payer: BCBS MT Medicare	$198.00
Rate for Payer: BCBS MT POS	$209.00
Rate for Payer: BCBS MT Traditional	$220.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial	$209.00
Rate for Payer: Cigna Medicare	$198.00
Rate for Payer: Medicaid All Medicaid	$202.40
Rate for Payer: Medicare All Medicare	$154.00
Rate for Payer: Monida Allegiance	$209.00
Rate for Payer: Monida First Choice Health	$213.40
Rate for Payer: Monida Montana Health Co-op	$209.00
Rate for Payer: Monida PacificSource	$209.00

US DOP ECHOCARD PULSE WAVE W/SPECT F-UP/

Facility

$220.00

Service Code	HCPCS 93321 TC
Hospital Charge Code	5193321
Hospital Revenue Code	402
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$220.00
Rate for Payer: Aetna Commercial	$209.00
Rate for Payer: Aetna Medicare	$198.00
Rate for Payer: BCBS MT CHIP	$198.00
Rate for Payer: BCBS MT Closed Plan Network	$209.00
Rate for Payer: BCBS MT HealthLink	$198.00
Rate for Payer: BCBS MT Medicare	$198.00
Rate for Payer: BCBS MT POS	$209.00
Rate for Payer: BCBS MT Traditional	$220.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial	$209.00
Rate for Payer: Cigna Medicare	$198.00
Rate for Payer: Medicaid All Medicaid	$202.40
Rate for Payer: Medicare All Medicare	$154.00
Rate for Payer: Monida Allegiance	$209.00
Rate for Payer: Monida First Choice Health	$213.40
Rate for Payer: Monida Montana Health Co-op	$209.00
Rate for Payer: Monida PacificSource	$209.00

US DOPPLER COLOR FLOW ADD-ON

Facility

$941.00

Service Code	HCPCS 93325
Hospital Charge Code	5193325
Hospital Revenue Code	402
Min. Negotiated Rate	$658.70
Max. Negotiated Rate	$941.00
Rate for Payer: Aetna Commercial	$893.95
Rate for Payer: Aetna Medicare	$846.90
Rate for Payer: BCBS MT CHIP	$846.90
Rate for Payer: BCBS MT Closed Plan Network	$893.95
Rate for Payer: BCBS MT HealthLink	$846.90
Rate for Payer: BCBS MT Medicare	$846.90
Rate for Payer: BCBS MT POS	$893.95
Rate for Payer: BCBS MT Traditional	$941.00
Rate for Payer: Cash Price	$846.90
Rate for Payer: Cigna Commercial	$893.95
Rate for Payer: Cigna Medicare	$846.90
Rate for Payer: Medicaid All Medicaid	$865.72
Rate for Payer: Medicare All Medicare	$658.70
Rate for Payer: Monida Allegiance	$893.95
Rate for Payer: Monida First Choice Health	$912.77
Rate for Payer: Monida Montana Health Co-op	$893.95
Rate for Payer: Monida PacificSource	$893.95

US DOPPLER COLOR FLOW ADD-ON

Facility

$941.00

Service Code	HCPCS 93325
Hospital Charge Code	5193325
Hospital Revenue Code	402
Min. Negotiated Rate	$658.70
Max. Negotiated Rate	$941.00
Rate for Payer: Aetna Commercial	$893.95
Rate for Payer: Aetna Medicare	$846.90
Rate for Payer: BCBS MT CHIP	$846.90
Rate for Payer: BCBS MT Closed Plan Network	$893.95
Rate for Payer: BCBS MT HealthLink	$846.90
Rate for Payer: BCBS MT Medicare	$846.90
Rate for Payer: BCBS MT POS	$893.95
Rate for Payer: BCBS MT Traditional	$941.00
Rate for Payer: Cash Price	$846.90
Rate for Payer: Cigna Commercial	$893.95
Rate for Payer: Cigna Medicare	$846.90
Rate for Payer: Medicaid All Medicaid	$865.72
Rate for Payer: Medicare All Medicare	$658.70
Rate for Payer: Monida Allegiance	$893.95
Rate for Payer: Monida First Choice Health	$912.77
Rate for Payer: Monida Montana Health Co-op	$893.95
Rate for Payer: Monida PacificSource	$893.95

US DUP-SCAN ARTL FLO ABD/PEL/SCRO/RPR OR

Facility

$708.00

Service Code	HCPCS 93975
Hospital Charge Code	5193975
Hospital Revenue Code	402
Min. Negotiated Rate	$495.60
Max. Negotiated Rate	$708.00
Rate for Payer: Aetna Commercial	$672.60
Rate for Payer: Aetna Medicare	$637.20
Rate for Payer: BCBS MT CHIP	$637.20
Rate for Payer: BCBS MT Closed Plan Network	$672.60
Rate for Payer: BCBS MT HealthLink	$637.20
Rate for Payer: BCBS MT Medicare	$637.20
Rate for Payer: BCBS MT POS	$672.60
Rate for Payer: BCBS MT Traditional	$708.00
Rate for Payer: Cash Price	$637.20
Rate for Payer: Cigna Commercial	$672.60
Rate for Payer: Cigna Medicare	$637.20
Rate for Payer: Medicaid All Medicaid	$651.36
Rate for Payer: Medicare All Medicare	$495.60
Rate for Payer: Monida Allegiance	$672.60
Rate for Payer: Monida First Choice Health	$686.76
Rate for Payer: Monida Montana Health Co-op	$672.60
Rate for Payer: Monida PacificSource	$672.60

US DUP-SCAN ARTL FLO ABD/PEL/SCRO/RPR OR

Facility

$708.00

Service Code	HCPCS 93975
Hospital Charge Code	5193975
Hospital Revenue Code	402
Min. Negotiated Rate	$495.60
Max. Negotiated Rate	$708.00
Rate for Payer: Aetna Commercial	$672.60
Rate for Payer: Aetna Medicare	$637.20
Rate for Payer: BCBS MT CHIP	$637.20
Rate for Payer: BCBS MT Closed Plan Network	$672.60
Rate for Payer: BCBS MT HealthLink	$637.20
Rate for Payer: BCBS MT Medicare	$637.20
Rate for Payer: BCBS MT POS	$672.60
Rate for Payer: BCBS MT Traditional	$708.00
Rate for Payer: Cash Price	$637.20
Rate for Payer: Cigna Commercial	$672.60
Rate for Payer: Cigna Medicare	$637.20
Rate for Payer: Medicaid All Medicaid	$651.36
Rate for Payer: Medicare All Medicare	$495.60
Rate for Payer: Monida Allegiance	$672.60
Rate for Payer: Monida First Choice Health	$686.76
Rate for Payer: Monida Montana Health Co-op	$672.60
Rate for Payer: Monida PacificSource	$672.60

US ELASTOGRAPHY EA ADDL TAGET LE

Facility

$275.00

Service Code	HCPCS 76983 TC
Hospital Charge Code	5176983
Hospital Revenue Code	402
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$275.00
Rate for Payer: Aetna Commercial	$261.25
Rate for Payer: Aetna Medicare	$247.50
Rate for Payer: BCBS MT CHIP	$247.50
Rate for Payer: BCBS MT Closed Plan Network	$261.25
Rate for Payer: BCBS MT HealthLink	$247.50
Rate for Payer: BCBS MT Medicare	$247.50
Rate for Payer: BCBS MT POS	$261.25
Rate for Payer: BCBS MT Traditional	$275.00
Rate for Payer: Cash Price	$247.50
Rate for Payer: Cigna Commercial	$261.25
Rate for Payer: Cigna Medicare	$247.50
Rate for Payer: Medicaid All Medicaid	$253.00
Rate for Payer: Medicare All Medicare	$192.50
Rate for Payer: Monida Allegiance	$261.25
Rate for Payer: Monida First Choice Health	$266.75
Rate for Payer: Monida Montana Health Co-op	$261.25
Rate for Payer: Monida PacificSource	$261.25

US ELASTOGRAPHY EA ADDL TAGET LE

Facility

$275.00

Service Code	HCPCS 76983 TC
Hospital Charge Code	5176983
Hospital Revenue Code	402
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$275.00
Rate for Payer: Aetna Commercial	$261.25
Rate for Payer: Aetna Medicare	$247.50
Rate for Payer: BCBS MT CHIP	$247.50
Rate for Payer: BCBS MT Closed Plan Network	$261.25
Rate for Payer: BCBS MT HealthLink	$247.50
Rate for Payer: BCBS MT Medicare	$247.50
Rate for Payer: BCBS MT POS	$261.25
Rate for Payer: BCBS MT Traditional	$275.00
Rate for Payer: Cash Price	$247.50
Rate for Payer: Cigna Commercial	$261.25
Rate for Payer: Cigna Medicare	$247.50
Rate for Payer: Medicaid All Medicaid	$253.00
Rate for Payer: Medicare All Medicare	$192.50
Rate for Payer: Monida Allegiance	$261.25
Rate for Payer: Monida First Choice Health	$266.75
Rate for Payer: Monida Montana Health Co-op	$261.25
Rate for Payer: Monida PacificSource	$261.25

US ELASTOGRAPHY FIRST TARGET LESION

Facility

$361.00

Service Code	HCPCS 76982 TC
Hospital Charge Code	5176982
Hospital Revenue Code	402
Min. Negotiated Rate	$252.70
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.95
Rate for Payer: Aetna Medicare	$324.90
Rate for Payer: BCBS MT CHIP	$324.90
Rate for Payer: BCBS MT Closed Plan Network	$342.95
Rate for Payer: BCBS MT HealthLink	$324.90
Rate for Payer: BCBS MT Medicare	$324.90
Rate for Payer: BCBS MT POS	$342.95
Rate for Payer: BCBS MT Traditional	$361.00
Rate for Payer: Cash Price	$324.90
Rate for Payer: Cigna Commercial	$342.95
Rate for Payer: Cigna Medicare	$324.90
Rate for Payer: Medicaid All Medicaid	$332.12
Rate for Payer: Medicare All Medicare	$252.70
Rate for Payer: Monida Allegiance	$342.95
Rate for Payer: Monida First Choice Health	$350.17
Rate for Payer: Monida Montana Health Co-op	$342.95
Rate for Payer: Monida PacificSource	$342.95

US ELASTOGRAPHY FIRST TARGET LESION

Facility

$361.00

Service Code	HCPCS 76982 TC
Hospital Charge Code	5176982
Hospital Revenue Code	402
Min. Negotiated Rate	$252.70
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.95
Rate for Payer: Aetna Medicare	$324.90
Rate for Payer: BCBS MT CHIP	$324.90
Rate for Payer: BCBS MT Closed Plan Network	$342.95
Rate for Payer: BCBS MT HealthLink	$324.90
Rate for Payer: BCBS MT Medicare	$324.90
Rate for Payer: BCBS MT POS	$342.95
Rate for Payer: BCBS MT Traditional	$361.00
Rate for Payer: Cash Price	$324.90
Rate for Payer: Cigna Commercial	$342.95
Rate for Payer: Cigna Medicare	$324.90
Rate for Payer: Medicaid All Medicaid	$332.12
Rate for Payer: Medicare All Medicare	$252.70
Rate for Payer: Monida Allegiance	$342.95
Rate for Payer: Monida First Choice Health	$350.17
Rate for Payer: Monida Montana Health Co-op	$342.95
Rate for Payer: Monida PacificSource	$342.95

US ELASTOGRAPHY OF ORGAN TISSUE

Facility

$427.00

Service Code	HCPCS 76981 TC
Hospital Charge Code	5176981
Hospital Revenue Code	402
Min. Negotiated Rate	$298.90
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$405.65
Rate for Payer: Aetna Medicare	$384.30
Rate for Payer: BCBS MT CHIP	$384.30
Rate for Payer: BCBS MT Closed Plan Network	$405.65
Rate for Payer: BCBS MT HealthLink	$384.30
Rate for Payer: BCBS MT Medicare	$384.30
Rate for Payer: BCBS MT POS	$405.65
Rate for Payer: BCBS MT Traditional	$427.00
Rate for Payer: Cash Price	$384.30
Rate for Payer: Cigna Commercial	$405.65
Rate for Payer: Cigna Medicare	$384.30
Rate for Payer: Medicaid All Medicaid	$392.84
Rate for Payer: Medicare All Medicare	$298.90
Rate for Payer: Monida Allegiance	$405.65
Rate for Payer: Monida First Choice Health	$414.19
Rate for Payer: Monida Montana Health Co-op	$405.65
Rate for Payer: Monida PacificSource	$405.65

US ELASTOGRAPHY OF ORGAN TISSUE

Facility

$427.00

Service Code	HCPCS 76981 TC
Hospital Charge Code	5176981
Hospital Revenue Code	402
Min. Negotiated Rate	$298.90
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$405.65
Rate for Payer: Aetna Medicare	$384.30
Rate for Payer: BCBS MT CHIP	$384.30
Rate for Payer: BCBS MT Closed Plan Network	$405.65
Rate for Payer: BCBS MT HealthLink	$384.30
Rate for Payer: BCBS MT Medicare	$384.30
Rate for Payer: BCBS MT POS	$405.65
Rate for Payer: BCBS MT Traditional	$427.00
Rate for Payer: Cash Price	$384.30
Rate for Payer: Cigna Commercial	$405.65
Rate for Payer: Cigna Medicare	$384.30
Rate for Payer: Medicaid All Medicaid	$392.84
Rate for Payer: Medicare All Medicare	$298.90
Rate for Payer: Monida Allegiance	$405.65
Rate for Payer: Monida First Choice Health	$414.19
Rate for Payer: Monida Montana Health Co-op	$405.65
Rate for Payer: Monida PacificSource	$405.65

US FETAL BIOPHYS PROF W/O NON STRESS TES

Facility

$673.00

Service Code	HCPCS 76819 TC
Hospital Charge Code	5176819
Hospital Revenue Code	402
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

US FETAL BIOPHYS PROF W/O NON STRESS TES

Facility

$673.00

Service Code	HCPCS 76819 TC
Hospital Charge Code	5176819
Hospital Revenue Code	402
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

Know your out-of-pocket cost for care.

All Charges