Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

US OF EYE USING WATER BATH METHOD

Facility

$534.00

Service Code	HCPCS 76513 TC
Hospital Charge Code	5176513
Hospital Revenue Code	402
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

US OF EYE USING WATER BATH METHOD

Facility

$534.00

Service Code	HCPCS 76513 TC
Hospital Charge Code	5176513
Hospital Revenue Code	402
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

US OF FETAL BRAIN ARTERY

Facility

$452.00

Service Code	HCPCS 76821 TC
Hospital Charge Code	5176821
Hospital Revenue Code	402
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

US OF FETAL BRAIN ARTERY

Facility

$452.00

Service Code	HCPCS 76821 TC
Hospital Charge Code	5176821
Hospital Revenue Code	402
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

US OF FETAL UMBILICAL ARTERY FLO

Facility

$431.00

Service Code	HCPCS 76820 TC
Hospital Charge Code	5176820
Hospital Revenue Code	402
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

US OF FETAL UMBILICAL ARTERY FLO

Facility

$431.00

Service Code	HCPCS 76820 TC
Hospital Charge Code	5176820
Hospital Revenue Code	402
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$431.00
Rate for Payer: Aetna Commercial	$409.45
Rate for Payer: Aetna Medicare	$387.90
Rate for Payer: BCBS MT CHIP	$387.90
Rate for Payer: BCBS MT Closed Plan Network	$409.45
Rate for Payer: BCBS MT HealthLink	$387.90
Rate for Payer: BCBS MT Medicare	$387.90
Rate for Payer: BCBS MT POS	$409.45
Rate for Payer: BCBS MT Traditional	$431.00
Rate for Payer: Cash Price	$387.90
Rate for Payer: Cigna Commercial	$409.45
Rate for Payer: Cigna Medicare	$387.90
Rate for Payer: Medicaid All Medicaid	$396.52
Rate for Payer: Medicare All Medicare	$301.70
Rate for Payer: Monida Allegiance	$409.45
Rate for Payer: Monida First Choice Health	$418.07
Rate for Payer: Monida Montana Health Co-op	$409.45
Rate for Payer: Monida PacificSource	$409.45

US OF HIPS, INFANT

Facility

$98.00

Service Code	HCPCS 76886 TC
Hospital Charge Code	5176886
Hospital Revenue Code	402
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

US OF HIPS, INFANT

Facility

$98.00

Service Code	HCPCS 76886 TC
Hospital Charge Code	5176886
Hospital Revenue Code	402
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

US PELVIC COMP NON OB

Facility

$534.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	5176856
Hospital Revenue Code	402
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

US PELVIC COMP NON OB

Facility

$534.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	5176856
Hospital Revenue Code	402
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

US PELVIC LMT NON OB

Facility

$230.00

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

Facility

$230.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	5100002
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 PELVIS BUNDLED

Facility

$534.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	5178581
Hospital Revenue Code	402
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

US PELVIS BUNDLED

Facility

$534.00

Service Code	HCPCS 76856 TC
Hospital Charge Code	5178581
Hospital Revenue Code	402
Min. Negotiated Rate	$373.80
Max. Negotiated Rate	$534.00
Rate for Payer: Aetna Commercial	$507.30
Rate for Payer: Aetna Medicare	$480.60
Rate for Payer: BCBS MT CHIP	$480.60
Rate for Payer: BCBS MT Closed Plan Network	$507.30
Rate for Payer: BCBS MT HealthLink	$480.60
Rate for Payer: BCBS MT Medicare	$480.60
Rate for Payer: BCBS MT POS	$507.30
Rate for Payer: BCBS MT Traditional	$534.00
Rate for Payer: Cash Price	$480.60
Rate for Payer: Cigna Commercial	$507.30
Rate for Payer: Cigna Medicare	$480.60
Rate for Payer: Medicaid All Medicaid	$491.28
Rate for Payer: Medicare All Medicare	$373.80
Rate for Payer: Monida Allegiance	$507.30
Rate for Payer: Monida First Choice Health	$517.98
Rate for Payer: Monida Montana Health Co-op	$507.30
Rate for Payer: Monida PacificSource	$507.30

US POST VOID RESIDUAL

Facility

$220.00

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

Facility

$220.00

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

Facility

$1,673.00

Service Code	HCPCS 75989 TC
Hospital Charge Code	5175989
Hospital Revenue Code	402
Min. Negotiated Rate	$1,171.10
Max. Negotiated Rate	$1,673.00
Rate for Payer: Aetna Commercial	$1,589.35
Rate for Payer: Aetna Medicare	$1,505.70
Rate for Payer: BCBS MT CHIP	$1,505.70
Rate for Payer: BCBS MT Closed Plan Network	$1,589.35
Rate for Payer: BCBS MT HealthLink	$1,505.70
Rate for Payer: BCBS MT Medicare	$1,505.70
Rate for Payer: BCBS MT POS	$1,589.35
Rate for Payer: BCBS MT Traditional	$1,673.00
Rate for Payer: Cash Price	$1,505.70
Rate for Payer: Cigna Commercial	$1,589.35
Rate for Payer: Cigna Medicare	$1,505.70
Rate for Payer: Medicaid All Medicaid	$1,539.16
Rate for Payer: Medicare All Medicare	$1,171.10
Rate for Payer: Monida Allegiance	$1,589.35
Rate for Payer: Monida First Choice Health	$1,622.81
Rate for Payer: Monida Montana Health Co-op	$1,589.35
Rate for Payer: Monida PacificSource	$1,589.35

US RADIOLOGL GUIDANCE PRQ DRG W/PLMT CAT

Facility

$1,673.00

Service Code	HCPCS 75989 TC
Hospital Charge Code	5175989
Hospital Revenue Code	402
Min. Negotiated Rate	$1,171.10
Max. Negotiated Rate	$1,673.00
Rate for Payer: Aetna Commercial	$1,589.35
Rate for Payer: Aetna Medicare	$1,505.70
Rate for Payer: BCBS MT CHIP	$1,505.70
Rate for Payer: BCBS MT Closed Plan Network	$1,589.35
Rate for Payer: BCBS MT HealthLink	$1,505.70
Rate for Payer: BCBS MT Medicare	$1,505.70
Rate for Payer: BCBS MT POS	$1,589.35
Rate for Payer: BCBS MT Traditional	$1,673.00
Rate for Payer: Cash Price	$1,505.70
Rate for Payer: Cigna Commercial	$1,589.35
Rate for Payer: Cigna Medicare	$1,505.70
Rate for Payer: Medicaid All Medicaid	$1,539.16
Rate for Payer: Medicare All Medicare	$1,171.10
Rate for Payer: Monida Allegiance	$1,589.35
Rate for Payer: Monida First Choice Health	$1,622.81
Rate for Payer: Monida Montana Health Co-op	$1,589.35
Rate for Payer: Monida PacificSource	$1,589.35

US RETROPERITONEAL COMP RENALS

Facility

$550.00

Service Code	HCPCS 76770 TC
Hospital Charge Code	5176770
Hospital Revenue Code	402
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

US RETROPERITONEAL COMP RENALS

Facility

$550.00

Service Code	HCPCS 76770 TC
Hospital Charge Code	5176770
Hospital Revenue Code	402
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

US RETROPERITONEAL LMT AORTA

Facility

$393.00

Service Code	HCPCS 76775 TC
Hospital Charge Code	5176775
Hospital Revenue Code	402
Min. Negotiated Rate	$275.10
Max. Negotiated Rate	$393.00
Rate for Payer: Aetna Commercial	$373.35
Rate for Payer: Aetna Medicare	$353.70
Rate for Payer: BCBS MT CHIP	$353.70
Rate for Payer: BCBS MT Closed Plan Network	$373.35
Rate for Payer: BCBS MT HealthLink	$353.70
Rate for Payer: BCBS MT Medicare	$353.70
Rate for Payer: BCBS MT POS	$373.35
Rate for Payer: BCBS MT Traditional	$393.00
Rate for Payer: Cash Price	$353.70
Rate for Payer: Cigna Commercial	$373.35
Rate for Payer: Cigna Medicare	$353.70
Rate for Payer: Medicaid All Medicaid	$361.56
Rate for Payer: Medicare All Medicare	$275.10
Rate for Payer: Monida Allegiance	$373.35
Rate for Payer: Monida First Choice Health	$381.21
Rate for Payer: Monida Montana Health Co-op	$373.35
Rate for Payer: Monida PacificSource	$373.35

US RETROPERITONEAL LMT AORTA

Facility

$393.00

Service Code	HCPCS 76775 TC
Hospital Charge Code	5176775
Hospital Revenue Code	402
Min. Negotiated Rate	$275.10
Max. Negotiated Rate	$393.00
Rate for Payer: Aetna Commercial	$373.35
Rate for Payer: Aetna Medicare	$353.70
Rate for Payer: BCBS MT CHIP	$353.70
Rate for Payer: BCBS MT Closed Plan Network	$373.35
Rate for Payer: BCBS MT HealthLink	$353.70
Rate for Payer: BCBS MT Medicare	$353.70
Rate for Payer: BCBS MT POS	$373.35
Rate for Payer: BCBS MT Traditional	$393.00
Rate for Payer: Cash Price	$353.70
Rate for Payer: Cigna Commercial	$373.35
Rate for Payer: Cigna Medicare	$353.70
Rate for Payer: Medicaid All Medicaid	$361.56
Rate for Payer: Medicare All Medicare	$275.10
Rate for Payer: Monida Allegiance	$373.35
Rate for Payer: Monida First Choice Health	$381.21
Rate for Payer: Monida Montana Health Co-op	$373.35
Rate for Payer: Monida PacificSource	$373.35

US SOFT TISSUE ABDOMEN

Facility

$443.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5100006
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 SOFT TISSUE ABDOMEN

Facility

$443.00

Service Code	HCPCS 76705 TC
Hospital Charge Code	5100006
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

Know your out-of-pocket cost for care.

All Charges