Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

USCIS FEE

Facility

$960.00

Hospital Charge Code	90197116
Min. Negotiated Rate	$672.00
Max. Negotiated Rate	$960.00
Rate for Payer: Aetna Commercial	$912.00
Rate for Payer: Aetna Medicare	$864.00
Rate for Payer: BCBS MT CHIP	$864.00
Rate for Payer: BCBS MT Closed Plan Network	$912.00
Rate for Payer: BCBS MT HealthLink	$864.00
Rate for Payer: BCBS MT Medicare	$864.00
Rate for Payer: BCBS MT POS	$912.00
Rate for Payer: BCBS MT Traditional	$960.00
Rate for Payer: Cash Price	$864.00
Rate for Payer: Cigna Commercial	$912.00
Rate for Payer: Cigna Medicare	$864.00
Rate for Payer: Medicaid All Medicaid	$883.20
Rate for Payer: Medicare All Medicare	$672.00
Rate for Payer: Monida Allegiance	$912.00
Rate for Payer: Monida First Choice Health	$931.20
Rate for Payer: Monida Montana Health Co-op	$912.00
Rate for Payer: Monida PacificSource	$912.00

US COMPLETE TTHRC ECHO CONGENI CARDIAC A

Facility

$631.00

Service Code	CPT 93303
Hospital Charge Code	5193303
Hospital Revenue Code	402
Min. Negotiated Rate	$441.70
Max. Negotiated Rate	$631.00
Rate for Payer: Aetna Commercial	$599.45
Rate for Payer: Aetna Medicare	$567.90
Rate for Payer: BCBS MT CHIP	$567.90
Rate for Payer: BCBS MT Closed Plan Network	$599.45
Rate for Payer: BCBS MT HealthLink	$567.90
Rate for Payer: BCBS MT Medicare	$567.90
Rate for Payer: BCBS MT POS	$599.45
Rate for Payer: BCBS MT Traditional	$631.00
Rate for Payer: Cash Price	$567.90
Rate for Payer: Cigna Commercial	$599.45
Rate for Payer: Cigna Medicare	$567.90
Rate for Payer: Medicaid All Medicaid	$580.52
Rate for Payer: Medicare All Medicare	$441.70
Rate for Payer: Monida Allegiance	$599.45
Rate for Payer: Monida First Choice Health	$612.07
Rate for Payer: Monida Montana Health Co-op	$599.45
Rate for Payer: Monida PacificSource	$599.45

US COMPLETE TTHRC ECHO CONGENI CARDIAC A

Facility

$631.00

Service Code	CPT 93303
Hospital Charge Code	5193303
Hospital Revenue Code	402
Min. Negotiated Rate	$441.70
Max. Negotiated Rate	$631.00
Rate for Payer: Aetna Commercial	$599.45
Rate for Payer: Aetna Medicare	$567.90
Rate for Payer: BCBS MT CHIP	$567.90
Rate for Payer: BCBS MT Closed Plan Network	$599.45
Rate for Payer: BCBS MT HealthLink	$567.90
Rate for Payer: BCBS MT Medicare	$567.90
Rate for Payer: BCBS MT POS	$599.45
Rate for Payer: BCBS MT Traditional	$631.00
Rate for Payer: Cash Price	$567.90
Rate for Payer: Cigna Commercial	$599.45
Rate for Payer: Cigna Medicare	$567.90
Rate for Payer: Medicaid All Medicaid	$580.52
Rate for Payer: Medicare All Medicare	$441.70
Rate for Payer: Monida Allegiance	$599.45
Rate for Payer: Monida First Choice Health	$612.07
Rate for Payer: Monida Montana Health Co-op	$599.45
Rate for Payer: Monida PacificSource	$599.45

US DOP ECHOCARD PULSE WAVE W/SPECT F-UP/

Facility

$220.00

Service Code	CPT 93321
Hospital Charge Code	5193321
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 DOP ECHOCARD PULSE WAVE W/SPECT F-UP/

Facility

$220.00

Service Code	CPT 93321
Hospital Charge Code	5193321
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 DOPPLER COLOR FLOW ADD-ON

Facility

$941.00

Service Code	CPT 93325
Hospital Charge Code	5193325
Hospital Revenue Code	402
Min. Negotiated Rate	$658.70
Max. Negotiated Rate	$941.00
Rate for Payer: Aetna Commercial	$893.95
Rate for Payer: Aetna Medicare	$846.90
Rate for Payer: BCBS MT CHIP	$846.90
Rate for Payer: BCBS MT Closed Plan Network	$893.95
Rate for Payer: BCBS MT HealthLink	$846.90
Rate for Payer: BCBS MT Medicare	$846.90
Rate for Payer: BCBS MT POS	$893.95
Rate for Payer: BCBS MT Traditional	$941.00
Rate for Payer: Cash Price	$846.90
Rate for Payer: Cigna Commercial	$893.95
Rate for Payer: Cigna Medicare	$846.90
Rate for Payer: Medicaid All Medicaid	$865.72
Rate for Payer: Medicare All Medicare	$658.70
Rate for Payer: Monida Allegiance	$893.95
Rate for Payer: Monida First Choice Health	$912.77
Rate for Payer: Monida Montana Health Co-op	$893.95
Rate for Payer: Monida PacificSource	$893.95

US DOPPLER COLOR FLOW ADD-ON

Facility

$941.00

Service Code	CPT 93325
Hospital Charge Code	5193325
Hospital Revenue Code	402
Min. Negotiated Rate	$658.70
Max. Negotiated Rate	$941.00
Rate for Payer: Aetna Commercial	$893.95
Rate for Payer: Aetna Medicare	$846.90
Rate for Payer: BCBS MT CHIP	$846.90
Rate for Payer: BCBS MT Closed Plan Network	$893.95
Rate for Payer: BCBS MT HealthLink	$846.90
Rate for Payer: BCBS MT Medicare	$846.90
Rate for Payer: BCBS MT POS	$893.95
Rate for Payer: BCBS MT Traditional	$941.00
Rate for Payer: Cash Price	$846.90
Rate for Payer: Cigna Commercial	$893.95
Rate for Payer: Cigna Medicare	$846.90
Rate for Payer: Medicaid All Medicaid	$865.72
Rate for Payer: Medicare All Medicare	$658.70
Rate for Payer: Monida Allegiance	$893.95
Rate for Payer: Monida First Choice Health	$912.77
Rate for Payer: Monida Montana Health Co-op	$893.95
Rate for Payer: Monida PacificSource	$893.95

US ELASTOGRAPHY EA ADDL TAGET LE

Facility

$275.00

Service Code	CPT 76983
Hospital Charge Code	5176983
Hospital Revenue Code	402
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$275.00
Rate for Payer: Aetna Commercial	$261.25
Rate for Payer: Aetna Medicare	$247.50
Rate for Payer: BCBS MT CHIP	$247.50
Rate for Payer: BCBS MT Closed Plan Network	$261.25
Rate for Payer: BCBS MT HealthLink	$247.50
Rate for Payer: BCBS MT Medicare	$247.50
Rate for Payer: BCBS MT POS	$261.25
Rate for Payer: BCBS MT Traditional	$275.00
Rate for Payer: Cash Price	$247.50
Rate for Payer: Cigna Commercial	$261.25
Rate for Payer: Cigna Medicare	$247.50
Rate for Payer: Medicaid All Medicaid	$253.00
Rate for Payer: Medicare All Medicare	$192.50
Rate for Payer: Monida Allegiance	$261.25
Rate for Payer: Monida First Choice Health	$266.75
Rate for Payer: Monida Montana Health Co-op	$261.25
Rate for Payer: Monida PacificSource	$261.25

US ELASTOGRAPHY EA ADDL TAGET LE

Facility

$275.00

Service Code	CPT 76983
Hospital Charge Code	5176983
Hospital Revenue Code	402
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$275.00
Rate for Payer: Aetna Commercial	$261.25
Rate for Payer: Aetna Medicare	$247.50
Rate for Payer: BCBS MT CHIP	$247.50
Rate for Payer: BCBS MT Closed Plan Network	$261.25
Rate for Payer: BCBS MT HealthLink	$247.50
Rate for Payer: BCBS MT Medicare	$247.50
Rate for Payer: BCBS MT POS	$261.25
Rate for Payer: BCBS MT Traditional	$275.00
Rate for Payer: Cash Price	$247.50
Rate for Payer: Cigna Commercial	$261.25
Rate for Payer: Cigna Medicare	$247.50
Rate for Payer: Medicaid All Medicaid	$253.00
Rate for Payer: Medicare All Medicare	$192.50
Rate for Payer: Monida Allegiance	$261.25
Rate for Payer: Monida First Choice Health	$266.75
Rate for Payer: Monida Montana Health Co-op	$261.25
Rate for Payer: Monida PacificSource	$261.25

US ELASTOGRAPHY FIRST TARGET LESION

Facility

$361.00

Service Code	CPT 76982
Hospital Charge Code	5176982
Hospital Revenue Code	402
Min. Negotiated Rate	$252.70
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.95
Rate for Payer: Aetna Medicare	$324.90
Rate for Payer: BCBS MT CHIP	$324.90
Rate for Payer: BCBS MT Closed Plan Network	$342.95
Rate for Payer: BCBS MT HealthLink	$324.90
Rate for Payer: BCBS MT Medicare	$324.90
Rate for Payer: BCBS MT POS	$342.95
Rate for Payer: BCBS MT Traditional	$361.00
Rate for Payer: Cash Price	$324.90
Rate for Payer: Cigna Commercial	$342.95
Rate for Payer: Cigna Medicare	$324.90
Rate for Payer: Medicaid All Medicaid	$332.12
Rate for Payer: Medicare All Medicare	$252.70
Rate for Payer: Monida Allegiance	$342.95
Rate for Payer: Monida First Choice Health	$350.17
Rate for Payer: Monida Montana Health Co-op	$342.95
Rate for Payer: Monida PacificSource	$342.95

US ELASTOGRAPHY FIRST TARGET LESION

Facility

$361.00

Service Code	CPT 76982
Hospital Charge Code	5176982
Hospital Revenue Code	402
Min. Negotiated Rate	$252.70
Max. Negotiated Rate	$361.00
Rate for Payer: Aetna Commercial	$342.95
Rate for Payer: Aetna Medicare	$324.90
Rate for Payer: BCBS MT CHIP	$324.90
Rate for Payer: BCBS MT Closed Plan Network	$342.95
Rate for Payer: BCBS MT HealthLink	$324.90
Rate for Payer: BCBS MT Medicare	$324.90
Rate for Payer: BCBS MT POS	$342.95
Rate for Payer: BCBS MT Traditional	$361.00
Rate for Payer: Cash Price	$324.90
Rate for Payer: Cigna Commercial	$342.95
Rate for Payer: Cigna Medicare	$324.90
Rate for Payer: Medicaid All Medicaid	$332.12
Rate for Payer: Medicare All Medicare	$252.70
Rate for Payer: Monida Allegiance	$342.95
Rate for Payer: Monida First Choice Health	$350.17
Rate for Payer: Monida Montana Health Co-op	$342.95
Rate for Payer: Monida PacificSource	$342.95

US ELASTOGRAPHY OF ORGAN TISSUE

Facility

$427.00

Service Code	CPT 76981
Hospital Charge Code	5176981
Hospital Revenue Code	402
Min. Negotiated Rate	$298.90
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$405.65
Rate for Payer: Aetna Medicare	$384.30
Rate for Payer: BCBS MT CHIP	$384.30
Rate for Payer: BCBS MT Closed Plan Network	$405.65
Rate for Payer: BCBS MT HealthLink	$384.30
Rate for Payer: BCBS MT Medicare	$384.30
Rate for Payer: BCBS MT POS	$405.65
Rate for Payer: BCBS MT Traditional	$427.00
Rate for Payer: Cash Price	$384.30
Rate for Payer: Cigna Commercial	$405.65
Rate for Payer: Cigna Medicare	$384.30
Rate for Payer: Medicaid All Medicaid	$392.84
Rate for Payer: Medicare All Medicare	$298.90
Rate for Payer: Monida Allegiance	$405.65
Rate for Payer: Monida First Choice Health	$414.19
Rate for Payer: Monida Montana Health Co-op	$405.65
Rate for Payer: Monida PacificSource	$405.65

US ELASTOGRAPHY OF ORGAN TISSUE

Facility

$427.00

Service Code	CPT 76981
Hospital Charge Code	5176981
Hospital Revenue Code	402
Min. Negotiated Rate	$298.90
Max. Negotiated Rate	$427.00
Rate for Payer: Aetna Commercial	$405.65
Rate for Payer: Aetna Medicare	$384.30
Rate for Payer: BCBS MT CHIP	$384.30
Rate for Payer: BCBS MT Closed Plan Network	$405.65
Rate for Payer: BCBS MT HealthLink	$384.30
Rate for Payer: BCBS MT Medicare	$384.30
Rate for Payer: BCBS MT POS	$405.65
Rate for Payer: BCBS MT Traditional	$427.00
Rate for Payer: Cash Price	$384.30
Rate for Payer: Cigna Commercial	$405.65
Rate for Payer: Cigna Medicare	$384.30
Rate for Payer: Medicaid All Medicaid	$392.84
Rate for Payer: Medicare All Medicare	$298.90
Rate for Payer: Monida Allegiance	$405.65
Rate for Payer: Monida First Choice Health	$414.19
Rate for Payer: Monida Montana Health Co-op	$405.65
Rate for Payer: Monida PacificSource	$405.65

US EXTREMITY NON-VASCULAR UNILATERAL

Facility

$375.00

Service Code	CPT 76881
Hospital Charge Code	5176881
Hospital Revenue Code	402
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

US EXTREMITY NON-VASCULAR UNILATERAL

Facility

$375.00

Service Code	CPT 76881
Hospital Charge Code	5176881
Hospital Revenue Code	402
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

US FETAL BIOPHYS PROF W/O NON STRESS TES

Facility

$673.00

Service Code	CPT 76819
Hospital Charge Code	5176819
Hospital Revenue Code	402
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

US FETAL BIOPHYS PROF W/O NON STRESS TES

Facility

$673.00

Service Code	CPT 76819
Hospital Charge Code	5176819
Hospital Revenue Code	402
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

US FETAL UMBILICAL CORD OCCLUSION W/US

Facility

$306.00

Service Code	CPT 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	CPT 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 GUIDE VASCULAR ACCESS

Facility

$175.00

Service Code	CPT 76937
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	CPT 76937
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 ILIAC VEIN DUPLEX BILATERAL

Facility

$374.00

Service Code	CPT 93978
Hospital Charge Code	5193934
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

US ILIAC VEIN DUPLEX BILATERAL

Facility

$374.00

Service Code	CPT 93978
Hospital Charge Code	5193934
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

US ILIAC VEIN DUPLEX UNILATERAL

Facility

$374.00

Service Code	CPT 93979
Hospital Charge Code	5193979
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

US ILIAC VEIN DUPLEX UNILATERAL

Facility

$374.00

Service Code	CPT 93979
Hospital Charge Code	5193979
Hospital Revenue Code	402
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

Know your out-of-pocket cost for care.

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