Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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 (BCL 6650)

Facility

$110.00

Service Code	CPT 87086
Hospital Charge Code	4087086
Hospital Revenue Code	300
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

URINE CULTURE (BCL 6650)

Facility

$110.00

Service Code	CPT 87086
Hospital Charge Code	4087086
Hospital Revenue Code	300
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$110.00
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: BCBS MT CHIP	$99.00
Rate for Payer: BCBS MT Closed Plan Network	$104.50
Rate for Payer: BCBS MT HealthLink	$99.00
Rate for Payer: BCBS MT Medicare	$99.00
Rate for Payer: BCBS MT POS	$104.50
Rate for Payer: BCBS MT Traditional	$110.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Cigna Commercial	$104.50
Rate for Payer: Cigna Medicare	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

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

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

US ABDOMEN DUPLEX COMPLETE

Facility

$708.00

Service Code	CPT 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 ABDOMEN DUPLEX COMPLETE

Facility

$708.00

Service Code	CPT 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 ABDOMEN LIMITED

Facility

$443.00

Service Code	CPT 76705
Hospital Charge Code	5176705
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 ABDOMEN LIMITED

Facility

$443.00

Service Code	CPT 76705
Hospital Charge Code	5176705
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 ABI

Facility

$289.00

Service Code	CPT 93922
Hospital Charge Code	5193922
Hospital Revenue Code	402
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

US ABI

Facility

$289.00

Service Code	CPT 93922
Hospital Charge Code	5193922
Hospital Revenue Code	402
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

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