Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US SOFT TISSUE CHEST

Facility

$337.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	5176604
Hospital Revenue Code	402
Min. Negotiated Rate	$235.90
Max. Negotiated Rate	$337.00
Rate for Payer: Aetna Commercial	$320.15
Rate for Payer: Aetna Medicare	$303.30
Rate for Payer: BCBS MT CHIP	$303.30
Rate for Payer: BCBS MT Closed Plan Network	$320.15
Rate for Payer: BCBS MT HealthLink	$303.30
Rate for Payer: BCBS MT Medicare	$303.30
Rate for Payer: BCBS MT POS	$320.15
Rate for Payer: BCBS MT Traditional	$337.00
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna Commercial	$320.15
Rate for Payer: Cigna Medicare	$303.30
Rate for Payer: Medicaid All Medicaid	$310.04
Rate for Payer: Medicare All Medicare	$235.90
Rate for Payer: Monida Allegiance	$320.15
Rate for Payer: Monida First Choice Health	$326.89
Rate for Payer: Monida Montana Health Co-op	$320.15
Rate for Payer: Monida PacificSource	$320.15

US SOFT TISSUE CHEST

Facility

$337.00

Service Code	HCPCS 76604 TC
Hospital Charge Code	5176604
Hospital Revenue Code	402
Min. Negotiated Rate	$235.90
Max. Negotiated Rate	$337.00
Rate for Payer: Aetna Commercial	$320.15
Rate for Payer: Aetna Medicare	$303.30
Rate for Payer: BCBS MT CHIP	$303.30
Rate for Payer: BCBS MT Closed Plan Network	$320.15
Rate for Payer: BCBS MT HealthLink	$303.30
Rate for Payer: BCBS MT Medicare	$303.30
Rate for Payer: BCBS MT POS	$320.15
Rate for Payer: BCBS MT Traditional	$337.00
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna Commercial	$320.15
Rate for Payer: Cigna Medicare	$303.30
Rate for Payer: Medicaid All Medicaid	$310.04
Rate for Payer: Medicare All Medicare	$235.90
Rate for Payer: Monida Allegiance	$320.15
Rate for Payer: Monida First Choice Health	$326.89
Rate for Payer: Monida Montana Health Co-op	$320.15
Rate for Payer: Monida PacificSource	$320.15

US SOFT TISSUE EXTREMITY

Facility

$540.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	5176882
Hospital Revenue Code	402
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna Commercial	$513.00
Rate for Payer: Aetna Medicare	$486.00
Rate for Payer: BCBS MT CHIP	$486.00
Rate for Payer: BCBS MT Closed Plan Network	$513.00
Rate for Payer: BCBS MT HealthLink	$486.00
Rate for Payer: BCBS MT Medicare	$486.00
Rate for Payer: BCBS MT POS	$513.00
Rate for Payer: BCBS MT Traditional	$540.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna Commercial	$513.00
Rate for Payer: Cigna Medicare	$486.00
Rate for Payer: Medicaid All Medicaid	$496.80
Rate for Payer: Medicare All Medicare	$378.00
Rate for Payer: Monida Allegiance	$513.00
Rate for Payer: Monida First Choice Health	$523.80
Rate for Payer: Monida Montana Health Co-op	$513.00
Rate for Payer: Monida PacificSource	$513.00

US SOFT TISSUE EXTREMITY

Facility

$540.00

Service Code	HCPCS 76882 TC
Hospital Charge Code	5176882
Hospital Revenue Code	402
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna Commercial	$513.00
Rate for Payer: Aetna Medicare	$486.00
Rate for Payer: BCBS MT CHIP	$486.00
Rate for Payer: BCBS MT Closed Plan Network	$513.00
Rate for Payer: BCBS MT HealthLink	$486.00
Rate for Payer: BCBS MT Medicare	$486.00
Rate for Payer: BCBS MT POS	$513.00
Rate for Payer: BCBS MT Traditional	$540.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna Commercial	$513.00
Rate for Payer: Cigna Medicare	$486.00
Rate for Payer: Medicaid All Medicaid	$496.80
Rate for Payer: Medicare All Medicare	$378.00
Rate for Payer: Monida Allegiance	$513.00
Rate for Payer: Monida First Choice Health	$523.80
Rate for Payer: Monida Montana Health Co-op	$513.00
Rate for Payer: Monida PacificSource	$513.00

US SOFT TISSUE HEAD OR NECK

Facility

$421.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	5176536
Hospital Revenue Code	402
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

US SOFT TISSUE HEAD OR NECK

Facility

$421.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	5176536
Hospital Revenue Code	402
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

US SOFT TISSUE PELVIS

Facility

$337.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	5100007
Hospital Revenue Code	402
Min. Negotiated Rate	$235.90
Max. Negotiated Rate	$337.00
Rate for Payer: Aetna Commercial	$320.15
Rate for Payer: Aetna Medicare	$303.30
Rate for Payer: BCBS MT CHIP	$303.30
Rate for Payer: BCBS MT Closed Plan Network	$320.15
Rate for Payer: BCBS MT HealthLink	$303.30
Rate for Payer: BCBS MT Medicare	$303.30
Rate for Payer: BCBS MT POS	$320.15
Rate for Payer: BCBS MT Traditional	$337.00
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna Commercial	$320.15
Rate for Payer: Cigna Medicare	$303.30
Rate for Payer: Medicaid All Medicaid	$310.04
Rate for Payer: Medicare All Medicare	$235.90
Rate for Payer: Monida Allegiance	$320.15
Rate for Payer: Monida First Choice Health	$326.89
Rate for Payer: Monida Montana Health Co-op	$320.15
Rate for Payer: Monida PacificSource	$320.15

US SOFT TISSUE PELVIS

Facility

$337.00

Service Code	HCPCS 76857 TC
Hospital Charge Code	5100007
Hospital Revenue Code	402
Min. Negotiated Rate	$235.90
Max. Negotiated Rate	$337.00
Rate for Payer: Aetna Commercial	$320.15
Rate for Payer: Aetna Medicare	$303.30
Rate for Payer: BCBS MT CHIP	$303.30
Rate for Payer: BCBS MT Closed Plan Network	$320.15
Rate for Payer: BCBS MT HealthLink	$303.30
Rate for Payer: BCBS MT Medicare	$303.30
Rate for Payer: BCBS MT POS	$320.15
Rate for Payer: BCBS MT Traditional	$337.00
Rate for Payer: Cash Price	$303.30
Rate for Payer: Cigna Commercial	$320.15
Rate for Payer: Cigna Medicare	$303.30
Rate for Payer: Medicaid All Medicaid	$310.04
Rate for Payer: Medicare All Medicare	$235.90
Rate for Payer: Monida Allegiance	$320.15
Rate for Payer: Monida First Choice Health	$326.89
Rate for Payer: Monida Montana Health Co-op	$320.15
Rate for Payer: Monida PacificSource	$320.15

USTEKINUMAB QUAN WITH AB

Facility

$399.00

Service Code	HCPCS 80299
Hospital Charge Code	4087925
Hospital Revenue Code	301
Min. Negotiated Rate	$279.30
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$379.05
Rate for Payer: Aetna Medicare	$359.10
Rate for Payer: BCBS MT CHIP	$359.10
Rate for Payer: BCBS MT Closed Plan Network	$379.05
Rate for Payer: BCBS MT HealthLink	$359.10
Rate for Payer: BCBS MT Medicare	$359.10
Rate for Payer: BCBS MT POS	$379.05
Rate for Payer: BCBS MT Traditional	$399.00
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial	$379.05
Rate for Payer: Cigna Medicare	$359.10
Rate for Payer: Medicaid All Medicaid	$367.08
Rate for Payer: Medicare All Medicare	$279.30
Rate for Payer: Monida Allegiance	$379.05
Rate for Payer: Monida First Choice Health	$387.03
Rate for Payer: Monida Montana Health Co-op	$379.05
Rate for Payer: Monida PacificSource	$379.05

USTEKINUMAB QUAN WITH AB

Facility

$399.00

Service Code	HCPCS 80299
Hospital Charge Code	4087925
Hospital Revenue Code	301
Min. Negotiated Rate	$279.30
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$379.05
Rate for Payer: Aetna Medicare	$359.10
Rate for Payer: BCBS MT CHIP	$359.10
Rate for Payer: BCBS MT Closed Plan Network	$379.05
Rate for Payer: BCBS MT HealthLink	$359.10
Rate for Payer: BCBS MT Medicare	$359.10
Rate for Payer: BCBS MT POS	$379.05
Rate for Payer: BCBS MT Traditional	$399.00
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial	$379.05
Rate for Payer: Cigna Medicare	$359.10
Rate for Payer: Medicaid All Medicaid	$367.08
Rate for Payer: Medicare All Medicare	$279.30
Rate for Payer: Monida Allegiance	$379.05
Rate for Payer: Monida First Choice Health	$387.03
Rate for Payer: Monida Montana Health Co-op	$379.05
Rate for Payer: Monida PacificSource	$379.05

US TESTICULAR SCROTUM

Facility

$451.00

Service Code	HCPCS 76870 TC
Hospital Charge Code	5176870
Hospital Revenue Code	402
Min. Negotiated Rate	$315.70
Max. Negotiated Rate	$451.00
Rate for Payer: Aetna Commercial	$428.45
Rate for Payer: Aetna Medicare	$405.90
Rate for Payer: BCBS MT CHIP	$405.90
Rate for Payer: BCBS MT Closed Plan Network	$428.45
Rate for Payer: BCBS MT HealthLink	$405.90
Rate for Payer: BCBS MT Medicare	$405.90
Rate for Payer: BCBS MT POS	$428.45
Rate for Payer: BCBS MT Traditional	$451.00
Rate for Payer: Cash Price	$405.90
Rate for Payer: Cigna Commercial	$428.45
Rate for Payer: Cigna Medicare	$405.90
Rate for Payer: Medicaid All Medicaid	$414.92
Rate for Payer: Medicare All Medicare	$315.70
Rate for Payer: Monida Allegiance	$428.45
Rate for Payer: Monida First Choice Health	$437.47
Rate for Payer: Monida Montana Health Co-op	$428.45
Rate for Payer: Monida PacificSource	$428.45

US TESTICULAR SCROTUM

Facility

$451.00

Service Code	HCPCS 76870 TC
Hospital Charge Code	5176870
Hospital Revenue Code	402
Min. Negotiated Rate	$315.70
Max. Negotiated Rate	$451.00
Rate for Payer: Aetna Commercial	$428.45
Rate for Payer: Aetna Medicare	$405.90
Rate for Payer: BCBS MT CHIP	$405.90
Rate for Payer: BCBS MT Closed Plan Network	$428.45
Rate for Payer: BCBS MT HealthLink	$405.90
Rate for Payer: BCBS MT Medicare	$405.90
Rate for Payer: BCBS MT POS	$428.45
Rate for Payer: BCBS MT Traditional	$451.00
Rate for Payer: Cash Price	$405.90
Rate for Payer: Cigna Commercial	$428.45
Rate for Payer: Cigna Medicare	$405.90
Rate for Payer: Medicaid All Medicaid	$414.92
Rate for Payer: Medicare All Medicare	$315.70
Rate for Payer: Monida Allegiance	$428.45
Rate for Payer: Monida First Choice Health	$437.47
Rate for Payer: Monida Montana Health Co-op	$428.45
Rate for Payer: Monida PacificSource	$428.45

US THYROID

Facility

$421.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	5100001
Hospital Revenue Code	402
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

US THYROID

Facility

$421.00

Service Code	HCPCS 76536 TC
Hospital Charge Code	5100001
Hospital Revenue Code	402
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

US TO DETERMINE LENGTH FROM CORN

Facility

$352.00

Service Code	HCPCS 76516 TC
Hospital Charge Code	5176516
Hospital Revenue Code	402
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

US TO DETERMINE LENGTH FROM CORN

Facility

$352.00

Service Code	HCPCS 76516 TC
Hospital Charge Code	5176516
Hospital Revenue Code	402
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$352.00
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: BCBS MT CHIP	$316.80
Rate for Payer: BCBS MT Closed Plan Network	$334.40
Rate for Payer: BCBS MT HealthLink	$316.80
Rate for Payer: BCBS MT Medicare	$316.80
Rate for Payer: BCBS MT POS	$334.40
Rate for Payer: BCBS MT Traditional	$352.00
Rate for Payer: Cash Price	$316.80
Rate for Payer: Cigna Commercial	$334.40
Rate for Payer: Cigna Medicare	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

US TRANSCRAN DOPL INTRACRAN ART MICROBUB

Facility

$709.00

Service Code	HCPCS 93893 TC
Hospital Charge Code	5193893
Hospital Revenue Code	402
Min. Negotiated Rate	$496.30
Max. Negotiated Rate	$709.00
Rate for Payer: Aetna Commercial	$673.55
Rate for Payer: Aetna Medicare	$638.10
Rate for Payer: BCBS MT CHIP	$638.10
Rate for Payer: BCBS MT Closed Plan Network	$673.55
Rate for Payer: BCBS MT HealthLink	$638.10
Rate for Payer: BCBS MT Medicare	$638.10
Rate for Payer: BCBS MT POS	$673.55
Rate for Payer: BCBS MT Traditional	$709.00
Rate for Payer: Cash Price	$638.10
Rate for Payer: Cigna Commercial	$673.55
Rate for Payer: Cigna Medicare	$638.10
Rate for Payer: Medicaid All Medicaid	$652.28
Rate for Payer: Medicare All Medicare	$496.30
Rate for Payer: Monida Allegiance	$673.55
Rate for Payer: Monida First Choice Health	$687.73
Rate for Payer: Monida Montana Health Co-op	$673.55
Rate for Payer: Monida PacificSource	$673.55

US TRANSCRAN DOPL INTRACRAN ART MICROBUB

Facility

$709.00

Service Code	HCPCS 93893 TC
Hospital Charge Code	5193893
Hospital Revenue Code	402
Min. Negotiated Rate	$496.30
Max. Negotiated Rate	$709.00
Rate for Payer: Aetna Commercial	$673.55
Rate for Payer: Aetna Medicare	$638.10
Rate for Payer: BCBS MT CHIP	$638.10
Rate for Payer: BCBS MT Closed Plan Network	$673.55
Rate for Payer: BCBS MT HealthLink	$638.10
Rate for Payer: BCBS MT Medicare	$638.10
Rate for Payer: BCBS MT POS	$673.55
Rate for Payer: BCBS MT Traditional	$709.00
Rate for Payer: Cash Price	$638.10
Rate for Payer: Cigna Commercial	$673.55
Rate for Payer: Cigna Medicare	$638.10
Rate for Payer: Medicaid All Medicaid	$652.28
Rate for Payer: Medicare All Medicare	$496.30
Rate for Payer: Monida Allegiance	$673.55
Rate for Payer: Monida First Choice Health	$687.73
Rate for Payer: Monida Montana Health Co-op	$673.55
Rate for Payer: Monida PacificSource	$673.55

US TRANSCRANIAL DOPPLER STDY INTRACRAN A

Facility

$1,303.00

Service Code	HCPCS 93886 TC
Hospital Charge Code	5193886
Hospital Revenue Code	402
Min. Negotiated Rate	$912.10
Max. Negotiated Rate	$1,303.00
Rate for Payer: Aetna Commercial	$1,237.85
Rate for Payer: Aetna Medicare	$1,172.70
Rate for Payer: BCBS MT CHIP	$1,172.70
Rate for Payer: BCBS MT Closed Plan Network	$1,237.85
Rate for Payer: BCBS MT HealthLink	$1,172.70
Rate for Payer: BCBS MT Medicare	$1,172.70
Rate for Payer: BCBS MT POS	$1,237.85
Rate for Payer: BCBS MT Traditional	$1,303.00
Rate for Payer: Cash Price	$1,172.70
Rate for Payer: Cigna Commercial	$1,237.85
Rate for Payer: Cigna Medicare	$1,172.70
Rate for Payer: Medicaid All Medicaid	$1,198.76
Rate for Payer: Medicare All Medicare	$912.10
Rate for Payer: Monida Allegiance	$1,237.85
Rate for Payer: Monida First Choice Health	$1,263.91
Rate for Payer: Monida Montana Health Co-op	$1,237.85
Rate for Payer: Monida PacificSource	$1,237.85

US TRANSCRANIAL DOPPLER STDY INTRACRAN A

Facility

$1,303.00

Service Code	HCPCS 93886 TC
Hospital Charge Code	5193886
Hospital Revenue Code	402
Min. Negotiated Rate	$912.10
Max. Negotiated Rate	$1,303.00
Rate for Payer: Aetna Commercial	$1,237.85
Rate for Payer: Aetna Medicare	$1,172.70
Rate for Payer: BCBS MT CHIP	$1,172.70
Rate for Payer: BCBS MT Closed Plan Network	$1,237.85
Rate for Payer: BCBS MT HealthLink	$1,172.70
Rate for Payer: BCBS MT Medicare	$1,172.70
Rate for Payer: BCBS MT POS	$1,237.85
Rate for Payer: BCBS MT Traditional	$1,303.00
Rate for Payer: Cash Price	$1,172.70
Rate for Payer: Cigna Commercial	$1,237.85
Rate for Payer: Cigna Medicare	$1,172.70
Rate for Payer: Medicaid All Medicaid	$1,198.76
Rate for Payer: Medicare All Medicare	$912.10
Rate for Payer: Monida Allegiance	$1,237.85
Rate for Payer: Monida First Choice Health	$1,263.91
Rate for Payer: Monida Montana Health Co-op	$1,237.85
Rate for Payer: Monida PacificSource	$1,237.85

US TRANSCRANIAL DOPPLER STDY INTRACRANIL

Facility

$757.00

Service Code	HCPCS 93888 TC
Hospital Charge Code	5193888
Hospital Revenue Code	402
Min. Negotiated Rate	$529.90
Max. Negotiated Rate	$757.00
Rate for Payer: Aetna Commercial	$719.15
Rate for Payer: Aetna Medicare	$681.30
Rate for Payer: BCBS MT CHIP	$681.30
Rate for Payer: BCBS MT Closed Plan Network	$719.15
Rate for Payer: BCBS MT HealthLink	$681.30
Rate for Payer: BCBS MT Medicare	$681.30
Rate for Payer: BCBS MT POS	$719.15
Rate for Payer: BCBS MT Traditional	$757.00
Rate for Payer: Cash Price	$681.30
Rate for Payer: Cigna Commercial	$719.15
Rate for Payer: Cigna Medicare	$681.30
Rate for Payer: Medicaid All Medicaid	$696.44
Rate for Payer: Medicare All Medicare	$529.90
Rate for Payer: Monida Allegiance	$719.15
Rate for Payer: Monida First Choice Health	$734.29
Rate for Payer: Monida Montana Health Co-op	$719.15
Rate for Payer: Monida PacificSource	$719.15

US TRANSCRANIAL DOPPLER STDY INTRACRANIL

Facility

$757.00

Service Code	HCPCS 93888 TC
Hospital Charge Code	5193888
Hospital Revenue Code	402
Min. Negotiated Rate	$529.90
Max. Negotiated Rate	$757.00
Rate for Payer: Aetna Commercial	$719.15
Rate for Payer: Aetna Medicare	$681.30
Rate for Payer: BCBS MT CHIP	$681.30
Rate for Payer: BCBS MT Closed Plan Network	$719.15
Rate for Payer: BCBS MT HealthLink	$681.30
Rate for Payer: BCBS MT Medicare	$681.30
Rate for Payer: BCBS MT POS	$719.15
Rate for Payer: BCBS MT Traditional	$757.00
Rate for Payer: Cash Price	$681.30
Rate for Payer: Cigna Commercial	$719.15
Rate for Payer: Cigna Medicare	$681.30
Rate for Payer: Medicaid All Medicaid	$696.44
Rate for Payer: Medicare All Medicare	$529.90
Rate for Payer: Monida Allegiance	$719.15
Rate for Payer: Monida First Choice Health	$734.29
Rate for Payer: Monida Montana Health Co-op	$719.15
Rate for Payer: Monida PacificSource	$719.15

US TRANSCRANL DOPPLER INTRACRAN ART EMBO

Facility

$781.00

Service Code	HCPCS 93892 TC
Hospital Charge Code	5193892
Hospital Revenue Code	402
Min. Negotiated Rate	$546.70
Max. Negotiated Rate	$781.00
Rate for Payer: Aetna Commercial	$741.95
Rate for Payer: Aetna Medicare	$702.90
Rate for Payer: BCBS MT CHIP	$702.90
Rate for Payer: BCBS MT Closed Plan Network	$741.95
Rate for Payer: BCBS MT HealthLink	$702.90
Rate for Payer: BCBS MT Medicare	$702.90
Rate for Payer: BCBS MT POS	$741.95
Rate for Payer: BCBS MT Traditional	$781.00
Rate for Payer: Cash Price	$702.90
Rate for Payer: Cigna Commercial	$741.95
Rate for Payer: Cigna Medicare	$702.90
Rate for Payer: Medicaid All Medicaid	$718.52
Rate for Payer: Medicare All Medicare	$546.70
Rate for Payer: Monida Allegiance	$741.95
Rate for Payer: Monida First Choice Health	$757.57
Rate for Payer: Monida Montana Health Co-op	$741.95
Rate for Payer: Monida PacificSource	$741.95

US TRANSCRANL DOPPLER INTRACRAN ART EMBO

Facility

$781.00

Service Code	HCPCS 93892 TC
Hospital Charge Code	5193892
Hospital Revenue Code	402
Min. Negotiated Rate	$546.70
Max. Negotiated Rate	$781.00
Rate for Payer: Aetna Commercial	$741.95
Rate for Payer: Aetna Medicare	$702.90
Rate for Payer: BCBS MT CHIP	$702.90
Rate for Payer: BCBS MT Closed Plan Network	$741.95
Rate for Payer: BCBS MT HealthLink	$702.90
Rate for Payer: BCBS MT Medicare	$702.90
Rate for Payer: BCBS MT POS	$741.95
Rate for Payer: BCBS MT Traditional	$781.00
Rate for Payer: Cash Price	$702.90
Rate for Payer: Cigna Commercial	$741.95
Rate for Payer: Cigna Medicare	$702.90
Rate for Payer: Medicaid All Medicaid	$718.52
Rate for Payer: Medicare All Medicare	$546.70
Rate for Payer: Monida Allegiance	$741.95
Rate for Payer: Monida First Choice Health	$757.57
Rate for Payer: Monida Montana Health Co-op	$741.95
Rate for Payer: Monida PacificSource	$741.95

US TRANSVAGINAL US NON-OB

Facility

$431.00

Service Code	HCPCS 76830 TC
Hospital Charge Code	5176830
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

Know your out-of-pocket cost for care.

All Charges