Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US FETAL UMBILICAL CORD OCCLUSION W/US

Facility

$306.00

Service Code	HCPCS 59072
Hospital Charge Code	5159072
Hospital Revenue Code	450
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$306.00
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: BCBS MT CHIP	$275.40
Rate for Payer: BCBS MT Closed Plan Network	$290.70
Rate for Payer: BCBS MT HealthLink	$275.40
Rate for Payer: BCBS MT Medicare	$275.40
Rate for Payer: BCBS MT POS	$290.70
Rate for Payer: BCBS MT Traditional	$306.00
Rate for Payer: Cash Price	$275.40
Rate for Payer: Cigna Commercial	$290.70
Rate for Payer: Cigna Medicare	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

US FETAL UMBILICAL CORD OCCLUSION W/US

Facility

$306.00

Service Code	HCPCS 59072
Hospital Charge Code	5159072
Hospital Revenue Code	450
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$306.00
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: BCBS MT CHIP	$275.40
Rate for Payer: BCBS MT Closed Plan Network	$290.70
Rate for Payer: BCBS MT HealthLink	$275.40
Rate for Payer: BCBS MT Medicare	$275.40
Rate for Payer: BCBS MT POS	$290.70
Rate for Payer: BCBS MT Traditional	$306.00
Rate for Payer: Cash Price	$275.40
Rate for Payer: Cigna Commercial	$290.70
Rate for Payer: Cigna Medicare	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

US GASTRO/INTEST SUPERVISION AND INTERPR

Facility

$262.00

Service Code	HCPCS 76975 TC
Hospital Charge Code	5176975
Hospital Revenue Code	402
Min. Negotiated Rate	$183.40
Max. Negotiated Rate	$262.00
Rate for Payer: Aetna Commercial	$248.90
Rate for Payer: Aetna Medicare	$235.80
Rate for Payer: BCBS MT CHIP	$235.80
Rate for Payer: BCBS MT Closed Plan Network	$248.90
Rate for Payer: BCBS MT HealthLink	$235.80
Rate for Payer: BCBS MT Medicare	$235.80
Rate for Payer: BCBS MT POS	$248.90
Rate for Payer: BCBS MT Traditional	$262.00
Rate for Payer: Cash Price	$235.80
Rate for Payer: Cigna Commercial	$248.90
Rate for Payer: Cigna Medicare	$235.80
Rate for Payer: Medicaid All Medicaid	$241.04
Rate for Payer: Medicare All Medicare	$183.40
Rate for Payer: Monida Allegiance	$248.90
Rate for Payer: Monida First Choice Health	$254.14
Rate for Payer: Monida Montana Health Co-op	$248.90
Rate for Payer: Monida PacificSource	$248.90

US GASTRO/INTEST SUPERVISION AND INTERPR

Facility

$262.00

Service Code	HCPCS 76975 TC
Hospital Charge Code	5176975
Hospital Revenue Code	402
Min. Negotiated Rate	$183.40
Max. Negotiated Rate	$262.00
Rate for Payer: Aetna Commercial	$248.90
Rate for Payer: Aetna Medicare	$235.80
Rate for Payer: BCBS MT CHIP	$235.80
Rate for Payer: BCBS MT Closed Plan Network	$248.90
Rate for Payer: BCBS MT HealthLink	$235.80
Rate for Payer: BCBS MT Medicare	$235.80
Rate for Payer: BCBS MT POS	$248.90
Rate for Payer: BCBS MT Traditional	$262.00
Rate for Payer: Cash Price	$235.80
Rate for Payer: Cigna Commercial	$248.90
Rate for Payer: Cigna Medicare	$235.80
Rate for Payer: Medicaid All Medicaid	$241.04
Rate for Payer: Medicare All Medicare	$183.40
Rate for Payer: Monida Allegiance	$248.90
Rate for Payer: Monida First Choice Health	$254.14
Rate for Payer: Monida Montana Health Co-op	$248.90
Rate for Payer: Monida PacificSource	$248.90

US GUIDE VASCULAR ACCESS

Facility

$175.00

Service Code	HCPCS 76937 TC
Hospital Charge Code	5176937
Hospital Revenue Code	402
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

US GUIDE VASCULAR ACCESS

Facility

$175.00

Service Code	HCPCS 76937 TC
Hospital Charge Code	5176937
Hospital Revenue Code	402
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$175.00
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: BCBS MT CHIP	$157.50
Rate for Payer: BCBS MT Closed Plan Network	$166.25
Rate for Payer: BCBS MT HealthLink	$157.50
Rate for Payer: BCBS MT Medicare	$157.50
Rate for Payer: BCBS MT POS	$166.25
Rate for Payer: BCBS MT Traditional	$175.00
Rate for Payer: Cash Price	$157.50
Rate for Payer: Cigna Commercial	$166.25
Rate for Payer: Cigna Medicare	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

US LOWER EXT ARTERIAL DUPLEX BILATERAL

Facility

$668.00

Service Code	HCPCS 93925
Hospital Charge Code	5193925
Hospital Revenue Code	402
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$668.00
Rate for Payer: Aetna Commercial	$634.60
Rate for Payer: Aetna Medicare	$601.20
Rate for Payer: BCBS MT CHIP	$601.20
Rate for Payer: BCBS MT Closed Plan Network	$634.60
Rate for Payer: BCBS MT HealthLink	$601.20
Rate for Payer: BCBS MT Medicare	$601.20
Rate for Payer: BCBS MT POS	$634.60
Rate for Payer: BCBS MT Traditional	$668.00
Rate for Payer: Cash Price	$601.20
Rate for Payer: Cigna Commercial	$634.60
Rate for Payer: Cigna Medicare	$601.20
Rate for Payer: Medicaid All Medicaid	$614.56
Rate for Payer: Medicare All Medicare	$467.60
Rate for Payer: Monida Allegiance	$634.60
Rate for Payer: Monida First Choice Health	$647.96
Rate for Payer: Monida Montana Health Co-op	$634.60
Rate for Payer: Monida PacificSource	$634.60

US LOWER EXT ARTERIAL DUPLEX BILATERAL

Facility

$668.00

Service Code	HCPCS 93925
Hospital Charge Code	5193925
Hospital Revenue Code	402
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$668.00
Rate for Payer: Aetna Commercial	$634.60
Rate for Payer: Aetna Medicare	$601.20
Rate for Payer: BCBS MT CHIP	$601.20
Rate for Payer: BCBS MT Closed Plan Network	$634.60
Rate for Payer: BCBS MT HealthLink	$601.20
Rate for Payer: BCBS MT Medicare	$601.20
Rate for Payer: BCBS MT POS	$634.60
Rate for Payer: BCBS MT Traditional	$668.00
Rate for Payer: Cash Price	$601.20
Rate for Payer: Cigna Commercial	$634.60
Rate for Payer: Cigna Medicare	$601.20
Rate for Payer: Medicaid All Medicaid	$614.56
Rate for Payer: Medicare All Medicare	$467.60
Rate for Payer: Monida Allegiance	$634.60
Rate for Payer: Monida First Choice Health	$647.96
Rate for Payer: Monida Montana Health Co-op	$634.60
Rate for Payer: Monida PacificSource	$634.60

US LOWER EXTREMITY STUDY UNILATERAL

Facility

$480.00

Service Code	HCPCS 93926
Hospital Charge Code	5193926
Hospital Revenue Code	402
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$480.00
Rate for Payer: Aetna Commercial	$456.00
Rate for Payer: Aetna Medicare	$432.00
Rate for Payer: BCBS MT CHIP	$432.00
Rate for Payer: BCBS MT Closed Plan Network	$456.00
Rate for Payer: BCBS MT HealthLink	$432.00
Rate for Payer: BCBS MT Medicare	$432.00
Rate for Payer: BCBS MT POS	$456.00
Rate for Payer: BCBS MT Traditional	$480.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cigna Commercial	$456.00
Rate for Payer: Cigna Medicare	$432.00
Rate for Payer: Medicaid All Medicaid	$441.60
Rate for Payer: Medicare All Medicare	$336.00
Rate for Payer: Monida Allegiance	$456.00
Rate for Payer: Monida First Choice Health	$465.60
Rate for Payer: Monida Montana Health Co-op	$456.00
Rate for Payer: Monida PacificSource	$456.00

US LOWER EXTREMITY STUDY UNILATERAL

Facility

$480.00

Service Code	HCPCS 93926
Hospital Charge Code	5193926
Hospital Revenue Code	402
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$480.00
Rate for Payer: Aetna Commercial	$456.00
Rate for Payer: Aetna Medicare	$432.00
Rate for Payer: BCBS MT CHIP	$432.00
Rate for Payer: BCBS MT Closed Plan Network	$456.00
Rate for Payer: BCBS MT HealthLink	$432.00
Rate for Payer: BCBS MT Medicare	$432.00
Rate for Payer: BCBS MT POS	$456.00
Rate for Payer: BCBS MT Traditional	$480.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Cigna Commercial	$456.00
Rate for Payer: Cigna Medicare	$432.00
Rate for Payer: Medicaid All Medicaid	$441.60
Rate for Payer: Medicare All Medicare	$336.00
Rate for Payer: Monida Allegiance	$456.00
Rate for Payer: Monida First Choice Health	$465.60
Rate for Payer: Monida Montana Health Co-op	$456.00
Rate for Payer: Monida PacificSource	$456.00

US/MONITORING OF HEART OF FETUS BIOPHYPR

Facility

$369.00

Service Code	HCPCS 76818 TC
Hospital Charge Code	5176818
Hospital Revenue Code	402
Min. Negotiated Rate	$258.30
Max. Negotiated Rate	$369.00
Rate for Payer: Aetna Commercial	$350.55
Rate for Payer: Aetna Medicare	$332.10
Rate for Payer: BCBS MT CHIP	$332.10
Rate for Payer: BCBS MT Closed Plan Network	$350.55
Rate for Payer: BCBS MT HealthLink	$332.10
Rate for Payer: BCBS MT Medicare	$332.10
Rate for Payer: BCBS MT POS	$350.55
Rate for Payer: BCBS MT Traditional	$369.00
Rate for Payer: Cash Price	$332.10
Rate for Payer: Cigna Commercial	$350.55
Rate for Payer: Cigna Medicare	$332.10
Rate for Payer: Medicaid All Medicaid	$339.48
Rate for Payer: Medicare All Medicare	$258.30
Rate for Payer: Monida Allegiance	$350.55
Rate for Payer: Monida First Choice Health	$357.93
Rate for Payer: Monida Montana Health Co-op	$350.55
Rate for Payer: Monida PacificSource	$350.55

US/MONITORING OF HEART OF FETUS BIOPHYPR

Facility

$369.00

Service Code	HCPCS 76818 TC
Hospital Charge Code	5176818
Hospital Revenue Code	402
Min. Negotiated Rate	$258.30
Max. Negotiated Rate	$369.00
Rate for Payer: Aetna Commercial	$350.55
Rate for Payer: Aetna Medicare	$332.10
Rate for Payer: BCBS MT CHIP	$332.10
Rate for Payer: BCBS MT Closed Plan Network	$350.55
Rate for Payer: BCBS MT HealthLink	$332.10
Rate for Payer: BCBS MT Medicare	$332.10
Rate for Payer: BCBS MT POS	$350.55
Rate for Payer: BCBS MT Traditional	$369.00
Rate for Payer: Cash Price	$332.10
Rate for Payer: Cigna Commercial	$350.55
Rate for Payer: Cigna Medicare	$332.10
Rate for Payer: Medicaid All Medicaid	$339.48
Rate for Payer: Medicare All Medicare	$258.30
Rate for Payer: Monida Allegiance	$350.55
Rate for Payer: Monida First Choice Health	$357.93
Rate for Payer: Monida Montana Health Co-op	$350.55
Rate for Payer: Monida PacificSource	$350.55

US OF BONE DENSITY MEASUREMENT

Facility

$35.00

Service Code	HCPCS 76977 TC
Hospital Charge Code	5176977
Hospital Revenue Code	402
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

US OF BONE DENSITY MEASUREMENT

Facility

$35.00

Service Code	HCPCS 76977 TC
Hospital Charge Code	5176977
Hospital Revenue Code	402
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

US OF CORNEAL STRUCTURE AND MEASUREMENT

Facility

$96.00

Service Code	HCPCS 76514 TC
Hospital Charge Code	5176514
Hospital Revenue Code	402
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

US OF CORNEAL STRUCTURE AND MEASUREMENT

Facility

$96.00

Service Code	HCPCS 76514 TC
Hospital Charge Code	5176514
Hospital Revenue Code	402
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

US OF EYE DISEASE, GROWTH, OR STRUCTURE

Facility

$474.00

Service Code	HCPCS 76512 TC
Hospital Charge Code	5176512
Hospital Revenue Code	402
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

US OF EYE DISEASE, GROWTH, OR STRUCTURE

Facility

$474.00

Service Code	HCPCS 76512 TC
Hospital Charge Code	5176512
Hospital Revenue Code	402
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

US OF EYE DISEASE OR GROWTH

Facility

$555.00

Service Code	HCPCS 76511 TC
Hospital Charge Code	5176511
Hospital Revenue Code	402
Min. Negotiated Rate	$388.50
Max. Negotiated Rate	$555.00
Rate for Payer: Aetna Commercial	$527.25
Rate for Payer: Aetna Medicare	$499.50
Rate for Payer: BCBS MT CHIP	$499.50
Rate for Payer: BCBS MT Closed Plan Network	$527.25
Rate for Payer: BCBS MT HealthLink	$499.50
Rate for Payer: BCBS MT Medicare	$499.50
Rate for Payer: BCBS MT POS	$527.25
Rate for Payer: BCBS MT Traditional	$555.00
Rate for Payer: Cash Price	$499.50
Rate for Payer: Cigna Commercial	$527.25
Rate for Payer: Cigna Medicare	$499.50
Rate for Payer: Medicaid All Medicaid	$510.60
Rate for Payer: Medicare All Medicare	$388.50
Rate for Payer: Monida Allegiance	$527.25
Rate for Payer: Monida First Choice Health	$538.35
Rate for Payer: Monida Montana Health Co-op	$527.25
Rate for Payer: Monida PacificSource	$527.25

US OF EYE DISEASE OR GROWTH

Facility

$555.00

Service Code	HCPCS 76511 TC
Hospital Charge Code	5176511
Hospital Revenue Code	402
Min. Negotiated Rate	$388.50
Max. Negotiated Rate	$555.00
Rate for Payer: Aetna Commercial	$527.25
Rate for Payer: Aetna Medicare	$499.50
Rate for Payer: BCBS MT CHIP	$499.50
Rate for Payer: BCBS MT Closed Plan Network	$527.25
Rate for Payer: BCBS MT HealthLink	$499.50
Rate for Payer: BCBS MT Medicare	$499.50
Rate for Payer: BCBS MT POS	$527.25
Rate for Payer: BCBS MT Traditional	$555.00
Rate for Payer: Cash Price	$499.50
Rate for Payer: Cigna Commercial	$527.25
Rate for Payer: Cigna Medicare	$499.50
Rate for Payer: Medicaid All Medicaid	$510.60
Rate for Payer: Medicare All Medicare	$388.50
Rate for Payer: Monida Allegiance	$527.25
Rate for Payer: Monida First Choice Health	$538.35
Rate for Payer: Monida Montana Health Co-op	$527.25
Rate for Payer: Monida PacificSource	$527.25

US OF EYE FOR DETERMINATION LENS POWER

Facility

$439.00

Service Code	HCPCS 76519 TC
Hospital Charge Code	5176519
Hospital Revenue Code	402
Min. Negotiated Rate	$307.30
Max. Negotiated Rate	$439.00
Rate for Payer: Aetna Commercial	$417.05
Rate for Payer: Aetna Medicare	$395.10
Rate for Payer: BCBS MT CHIP	$395.10
Rate for Payer: BCBS MT Closed Plan Network	$417.05
Rate for Payer: BCBS MT HealthLink	$395.10
Rate for Payer: BCBS MT Medicare	$395.10
Rate for Payer: BCBS MT POS	$417.05
Rate for Payer: BCBS MT Traditional	$439.00
Rate for Payer: Cash Price	$395.10
Rate for Payer: Cigna Commercial	$417.05
Rate for Payer: Cigna Medicare	$395.10
Rate for Payer: Medicaid All Medicaid	$403.88
Rate for Payer: Medicare All Medicare	$307.30
Rate for Payer: Monida Allegiance	$417.05
Rate for Payer: Monida First Choice Health	$425.83
Rate for Payer: Monida Montana Health Co-op	$417.05
Rate for Payer: Monida PacificSource	$417.05

US OF EYE FOR DETERMINATION LENS POWER

Facility

$439.00

Service Code	HCPCS 76519 TC
Hospital Charge Code	5176519
Hospital Revenue Code	402
Min. Negotiated Rate	$307.30
Max. Negotiated Rate	$439.00
Rate for Payer: Aetna Commercial	$417.05
Rate for Payer: Aetna Medicare	$395.10
Rate for Payer: BCBS MT CHIP	$395.10
Rate for Payer: BCBS MT Closed Plan Network	$417.05
Rate for Payer: BCBS MT HealthLink	$395.10
Rate for Payer: BCBS MT Medicare	$395.10
Rate for Payer: BCBS MT POS	$417.05
Rate for Payer: BCBS MT Traditional	$439.00
Rate for Payer: Cash Price	$395.10
Rate for Payer: Cigna Commercial	$417.05
Rate for Payer: Cigna Medicare	$395.10
Rate for Payer: Medicaid All Medicaid	$403.88
Rate for Payer: Medicare All Medicare	$307.30
Rate for Payer: Monida Allegiance	$417.05
Rate for Payer: Monida First Choice Health	$425.83
Rate for Payer: Monida Montana Health Co-op	$417.05
Rate for Payer: Monida PacificSource	$417.05

US OF EYE FOREIGN BODY LOCALIZATION

Facility

$89.00

Service Code	HCPCS 76529 TC
Hospital Charge Code	5176529
Hospital Revenue Code	402
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

US OF EYE FOREIGN BODY LOCALIZATION

Facility

$89.00

Service Code	HCPCS 76529 TC
Hospital Charge Code	5176529
Hospital Revenue Code	402
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

US OF EYE TISSUE AND STRUCTURES

Facility

$831.00

Service Code	HCPCS 76516 TC
Hospital Charge Code	5176510
Hospital Revenue Code	402
Min. Negotiated Rate	$581.70
Max. Negotiated Rate	$831.00
Rate for Payer: Aetna Commercial	$789.45
Rate for Payer: Aetna Medicare	$747.90
Rate for Payer: BCBS MT CHIP	$747.90
Rate for Payer: BCBS MT Closed Plan Network	$789.45
Rate for Payer: BCBS MT HealthLink	$747.90
Rate for Payer: BCBS MT Medicare	$747.90
Rate for Payer: BCBS MT POS	$789.45
Rate for Payer: BCBS MT Traditional	$831.00
Rate for Payer: Cash Price	$747.90
Rate for Payer: Cigna Commercial	$789.45
Rate for Payer: Cigna Medicare	$747.90
Rate for Payer: Medicaid All Medicaid	$764.52
Rate for Payer: Medicare All Medicare	$581.70
Rate for Payer: Monida Allegiance	$789.45
Rate for Payer: Monida First Choice Health	$806.07
Rate for Payer: Monida Montana Health Co-op	$789.45
Rate for Payer: Monida PacificSource	$789.45

Know your out-of-pocket cost for care.

All Charges