Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

URINALYSIS BI LIQUICHECK CTRL

Facility

$92.30

Hospital Charge Code	90197033
Hospital Revenue Code	270
Min. Negotiated Rate	$64.61
Max. Negotiated Rate	$92.30
Rate for Payer: Aetna Commercial	$87.69
Rate for Payer: Aetna Medicare	$83.07
Rate for Payer: BCBS MT CHIP	$83.07
Rate for Payer: BCBS MT Closed Plan Network	$87.69
Rate for Payer: BCBS MT HealthLink	$83.07
Rate for Payer: BCBS MT Medicare	$83.07
Rate for Payer: BCBS MT POS	$87.69
Rate for Payer: BCBS MT Traditional	$92.30
Rate for Payer: Cash Price	$83.07
Rate for Payer: Cigna Commercial	$87.69
Rate for Payer: Cigna Medicare	$83.07
Rate for Payer: Medicaid All Medicaid	$84.92
Rate for Payer: Medicare All Medicare	$64.61
Rate for Payer: Monida Allegiance	$87.69
Rate for Payer: Monida First Choice Health	$89.53
Rate for Payer: Monida Montana Health Co-op	$87.69
Rate for Payer: Monida PacificSource	$87.69

URINALYSIS BI LIQUICHECK CTRL

Facility

$92.30

Hospital Charge Code	90197033
Hospital Revenue Code	270
Min. Negotiated Rate	$64.61
Max. Negotiated Rate	$92.30
Rate for Payer: Aetna Commercial	$87.69
Rate for Payer: Aetna Medicare	$83.07
Rate for Payer: BCBS MT CHIP	$83.07
Rate for Payer: BCBS MT Closed Plan Network	$87.69
Rate for Payer: BCBS MT HealthLink	$83.07
Rate for Payer: BCBS MT Medicare	$83.07
Rate for Payer: BCBS MT POS	$87.69
Rate for Payer: BCBS MT Traditional	$92.30
Rate for Payer: Cash Price	$83.07
Rate for Payer: Cigna Commercial	$87.69
Rate for Payer: Cigna Medicare	$83.07
Rate for Payer: Medicaid All Medicaid	$84.92
Rate for Payer: Medicare All Medicare	$64.61
Rate for Payer: Monida Allegiance	$87.69
Rate for Payer: Monida First Choice Health	$89.53
Rate for Payer: Monida Montana Health Co-op	$87.69
Rate for Payer: Monida PacificSource	$87.69

.URINALYSIS, DIPSTICK

Facility

$38.00

Service Code	CPT 81003
Hospital Charge Code	4081003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

.URINALYSIS, DIPSTICK

Facility

$38.00

Service Code	CPT 81003
Hospital Charge Code	4081003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

.URINALYSIS, DIPSTICK AND MICROSCOPIC

Facility

$69.00

Service Code	CPT 81001
Hospital Charge Code	4081001
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

.URINALYSIS, DIPSTICK AND MICROSCOPIC

Facility

$69.00

Service Code	CPT 81001
Hospital Charge Code	4081001
Hospital Revenue Code	300
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

URINALYSIS, DIPSTICK - RVMC

Facility

$38.00

Service Code	CPT 81003
Hospital Charge Code	8081003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS, DIPSTICK - RVMC

Facility

$38.00

Service Code	CPT 81003
Hospital Charge Code	8081003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS, DIPSTICK - TWIN BRIDGES

Facility

$38.00

Service Code	CPT 81003
Hospital Charge Code	8181003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS, DIPSTICK - TWIN BRIDGES

Facility

$38.00

Service Code	CPT 81003
Hospital Charge Code	8181003
Hospital Revenue Code	307
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

URINALYSIS MICRO ONLY

Facility

$36.00

Service Code	CPT 81015
Hospital Charge Code	4081015
Hospital Revenue Code	307
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

URINALYSIS MICRO ONLY

Facility

$36.00

Service Code	CPT 81015
Hospital Charge Code	4081015
Hospital Revenue Code	307
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

URINE CULTURE (008847)

Facility

$58.00

Service Code	CPT 87086
Hospital Charge Code	4087086
Hospital Revenue Code	300
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

URINE CULTURE (008847)

Facility

$58.00

Service Code	CPT 87086
Hospital Charge Code	4087086
Hospital Revenue Code	300
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$58.00
Rate for Payer: Aetna Commercial	$55.10
Rate for Payer: Aetna Medicare	$52.20
Rate for Payer: BCBS MT CHIP	$52.20
Rate for Payer: BCBS MT Closed Plan Network	$55.10
Rate for Payer: BCBS MT HealthLink	$52.20
Rate for Payer: BCBS MT Medicare	$52.20
Rate for Payer: BCBS MT POS	$55.10
Rate for Payer: BCBS MT Traditional	$58.00
Rate for Payer: Cash Price	$52.20
Rate for Payer: Cigna Commercial	$55.10
Rate for Payer: Cigna Medicare	$52.20
Rate for Payer: Medicaid All Medicaid	$53.36
Rate for Payer: Medicare All Medicare	$40.60
Rate for Payer: Monida Allegiance	$55.10
Rate for Payer: Monida First Choice Health	$56.26
Rate for Payer: Monida Montana Health Co-op	$55.10
Rate for Payer: Monida PacificSource	$55.10

URINE STRAINERS

Facility

$13.00

Hospital Charge Code	80030556
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

URINE STRAINERS

Facility

$13.00

Hospital Charge Code	80030556
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

URSODIOL CAP [300 MG] NF

Facility

$26.00

Service Code	HCPCS J8499
Hospital Charge Code	3000464
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

URSODIOL CAP [300 MG] NF

Facility

$26.00

Service Code	HCPCS J8499
Hospital Charge Code	3000464
Hospital Revenue Code	250
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

US 3D RENDERING W/INTERPRET POST PROCE

Facility

$696.00

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

US 3D RENDERING W/INTERPRET POST PROCE

Facility

$696.00

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

US 3D RENDER W/INTERP&POSTPROC DIFF WORK

Facility

$885.00

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

US 3D RENDER W/INTERP&POSTPROC DIFF WORK

Facility

$885.00

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

US ABDOMEN COMPLETE

Facility

$597.00

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

US ABDOMEN COMPLETE

Facility

$597.00

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

US ABDOMEN DOPP LMT

Facility

$499.00

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

Know your out-of-pocket cost for care.

All Charges