Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

US/MONITORING OF HEART OF FETUS BIOPHYPR

Facility

$369.00

Service Code	CPT 76818
Hospital Charge Code	5176818
Hospital Revenue Code	402
Min. Negotiated Rate	$258.30
Max. Negotiated Rate	$369.00
Rate for Payer: Aetna Commercial	$350.55
Rate for Payer: Aetna Medicare	$332.10
Rate for Payer: BCBS MT CHIP	$332.10
Rate for Payer: BCBS MT Closed Plan Network	$350.55
Rate for Payer: BCBS MT HealthLink	$332.10
Rate for Payer: BCBS MT Medicare	$332.10
Rate for Payer: BCBS MT POS	$350.55
Rate for Payer: BCBS MT Traditional	$369.00
Rate for Payer: Cash Price	$332.10
Rate for Payer: Cigna Commercial	$350.55
Rate for Payer: Cigna Medicare	$332.10
Rate for Payer: Medicaid All Medicaid	$339.48
Rate for Payer: Medicare All Medicare	$258.30
Rate for Payer: Monida Allegiance	$350.55
Rate for Payer: Monida First Choice Health	$357.93
Rate for Payer: Monida Montana Health Co-op	$350.55
Rate for Payer: Monida PacificSource	$350.55

US/MONITORING OF HEART OF FETUS BIOPHYPR

Facility

$369.00

Service Code	CPT 76818
Hospital Charge Code	5176818
Hospital Revenue Code	402
Min. Negotiated Rate	$258.30
Max. Negotiated Rate	$369.00
Rate for Payer: Aetna Commercial	$350.55
Rate for Payer: Aetna Medicare	$332.10
Rate for Payer: BCBS MT CHIP	$332.10
Rate for Payer: BCBS MT Closed Plan Network	$350.55
Rate for Payer: BCBS MT HealthLink	$332.10
Rate for Payer: BCBS MT Medicare	$332.10
Rate for Payer: BCBS MT POS	$350.55
Rate for Payer: BCBS MT Traditional	$369.00
Rate for Payer: Cash Price	$332.10
Rate for Payer: Cigna Commercial	$350.55
Rate for Payer: Cigna Medicare	$332.10
Rate for Payer: Medicaid All Medicaid	$339.48
Rate for Payer: Medicare All Medicare	$258.30
Rate for Payer: Monida Allegiance	$350.55
Rate for Payer: Monida First Choice Health	$357.93
Rate for Payer: Monida Montana Health Co-op	$350.55
Rate for Payer: Monida PacificSource	$350.55

US OF BONE DENSITY MEASUREMENT

Facility

$35.00

Service Code	CPT 76977
Hospital Charge Code	5176977
Hospital Revenue Code	402
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

US OF BONE DENSITY MEASUREMENT

Facility

$35.00

Service Code	CPT 76977
Hospital Charge Code	5176977
Hospital Revenue Code	402
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$35.00
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: BCBS MT CHIP	$31.50
Rate for Payer: BCBS MT Closed Plan Network	$33.25
Rate for Payer: BCBS MT HealthLink	$31.50
Rate for Payer: BCBS MT Medicare	$31.50
Rate for Payer: BCBS MT POS	$33.25
Rate for Payer: BCBS MT Traditional	$35.00
Rate for Payer: Cash Price	$31.50
Rate for Payer: Cigna Commercial	$33.25
Rate for Payer: Cigna Medicare	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

US OF CORNEAL STRUCTURE AND MEASUREMENT

Facility

$96.00

Service Code	CPT 76514
Hospital Charge Code	5176514
Hospital Revenue Code	402
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

US OF CORNEAL STRUCTURE AND MEASUREMENT

Facility

$96.00

Service Code	CPT 76514
Hospital Charge Code	5176514
Hospital Revenue Code	402
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

US OF EYE DISEASE, GROWTH, OR STRUCTURE

Facility

$474.00

Service Code	CPT 76512
Hospital Charge Code	5176512
Hospital Revenue Code	402
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

US OF EYE DISEASE, GROWTH, OR STRUCTURE

Facility

$474.00

Service Code	CPT 76512
Hospital Charge Code	5176512
Hospital Revenue Code	402
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

US OF EYE DISEASE OR GROWTH

Facility

$555.00

Service Code	CPT 76511
Hospital Charge Code	5176511
Hospital Revenue Code	402
Min. Negotiated Rate	$388.50
Max. Negotiated Rate	$555.00
Rate for Payer: Aetna Commercial	$527.25
Rate for Payer: Aetna Medicare	$499.50
Rate for Payer: BCBS MT CHIP	$499.50
Rate for Payer: BCBS MT Closed Plan Network	$527.25
Rate for Payer: BCBS MT HealthLink	$499.50
Rate for Payer: BCBS MT Medicare	$499.50
Rate for Payer: BCBS MT POS	$527.25
Rate for Payer: BCBS MT Traditional	$555.00
Rate for Payer: Cash Price	$499.50
Rate for Payer: Cigna Commercial	$527.25
Rate for Payer: Cigna Medicare	$499.50
Rate for Payer: Medicaid All Medicaid	$510.60
Rate for Payer: Medicare All Medicare	$388.50
Rate for Payer: Monida Allegiance	$527.25
Rate for Payer: Monida First Choice Health	$538.35
Rate for Payer: Monida Montana Health Co-op	$527.25
Rate for Payer: Monida PacificSource	$527.25

US OF EYE DISEASE OR GROWTH

Facility

$555.00

Service Code	CPT 76511
Hospital Charge Code	5176511
Hospital Revenue Code	402
Min. Negotiated Rate	$388.50
Max. Negotiated Rate	$555.00
Rate for Payer: Aetna Commercial	$527.25
Rate for Payer: Aetna Medicare	$499.50
Rate for Payer: BCBS MT CHIP	$499.50
Rate for Payer: BCBS MT Closed Plan Network	$527.25
Rate for Payer: BCBS MT HealthLink	$499.50
Rate for Payer: BCBS MT Medicare	$499.50
Rate for Payer: BCBS MT POS	$527.25
Rate for Payer: BCBS MT Traditional	$555.00
Rate for Payer: Cash Price	$499.50
Rate for Payer: Cigna Commercial	$527.25
Rate for Payer: Cigna Medicare	$499.50
Rate for Payer: Medicaid All Medicaid	$510.60
Rate for Payer: Medicare All Medicare	$388.50
Rate for Payer: Monida Allegiance	$527.25
Rate for Payer: Monida First Choice Health	$538.35
Rate for Payer: Monida Montana Health Co-op	$527.25
Rate for Payer: Monida PacificSource	$527.25

US OF EYE FOR DETERMINATION LENS POWER

Facility

$439.00

Service Code	CPT 76519
Hospital Charge Code	5176519
Hospital Revenue Code	402
Min. Negotiated Rate	$307.30
Max. Negotiated Rate	$439.00
Rate for Payer: Aetna Commercial	$417.05
Rate for Payer: Aetna Medicare	$395.10
Rate for Payer: BCBS MT CHIP	$395.10
Rate for Payer: BCBS MT Closed Plan Network	$417.05
Rate for Payer: BCBS MT HealthLink	$395.10
Rate for Payer: BCBS MT Medicare	$395.10
Rate for Payer: BCBS MT POS	$417.05
Rate for Payer: BCBS MT Traditional	$439.00
Rate for Payer: Cash Price	$395.10
Rate for Payer: Cigna Commercial	$417.05
Rate for Payer: Cigna Medicare	$395.10
Rate for Payer: Medicaid All Medicaid	$403.88
Rate for Payer: Medicare All Medicare	$307.30
Rate for Payer: Monida Allegiance	$417.05
Rate for Payer: Monida First Choice Health	$425.83
Rate for Payer: Monida Montana Health Co-op	$417.05
Rate for Payer: Monida PacificSource	$417.05

US OF EYE FOR DETERMINATION LENS POWER

Facility

$439.00

Service Code	CPT 76519
Hospital Charge Code	5176519
Hospital Revenue Code	402
Min. Negotiated Rate	$307.30
Max. Negotiated Rate	$439.00
Rate for Payer: Aetna Commercial	$417.05
Rate for Payer: Aetna Medicare	$395.10
Rate for Payer: BCBS MT CHIP	$395.10
Rate for Payer: BCBS MT Closed Plan Network	$417.05
Rate for Payer: BCBS MT HealthLink	$395.10
Rate for Payer: BCBS MT Medicare	$395.10
Rate for Payer: BCBS MT POS	$417.05
Rate for Payer: BCBS MT Traditional	$439.00
Rate for Payer: Cash Price	$395.10
Rate for Payer: Cigna Commercial	$417.05
Rate for Payer: Cigna Medicare	$395.10
Rate for Payer: Medicaid All Medicaid	$403.88
Rate for Payer: Medicare All Medicare	$307.30
Rate for Payer: Monida Allegiance	$417.05
Rate for Payer: Monida First Choice Health	$425.83
Rate for Payer: Monida Montana Health Co-op	$417.05
Rate for Payer: Monida PacificSource	$417.05

US OF EYE FOREIGN BODY LOCALIZATION

Facility

$89.00

Service Code	CPT 76529
Hospital Charge Code	5176529
Hospital Revenue Code	402
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

US OF EYE FOREIGN BODY LOCALIZATION

Facility

$89.00

Service Code	CPT 76529
Hospital Charge Code	5176529
Hospital Revenue Code	402
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$89.00
Rate for Payer: Aetna Commercial	$84.55
Rate for Payer: Aetna Medicare	$80.10
Rate for Payer: BCBS MT CHIP	$80.10
Rate for Payer: BCBS MT Closed Plan Network	$84.55
Rate for Payer: BCBS MT HealthLink	$80.10
Rate for Payer: BCBS MT Medicare	$80.10
Rate for Payer: BCBS MT POS	$84.55
Rate for Payer: BCBS MT Traditional	$89.00
Rate for Payer: Cash Price	$80.10
Rate for Payer: Cigna Commercial	$84.55
Rate for Payer: Cigna Medicare	$80.10
Rate for Payer: Medicaid All Medicaid	$81.88
Rate for Payer: Medicare All Medicare	$62.30
Rate for Payer: Monida Allegiance	$84.55
Rate for Payer: Monida First Choice Health	$86.33
Rate for Payer: Monida Montana Health Co-op	$84.55
Rate for Payer: Monida PacificSource	$84.55

US OF EYE TISSUE AND STRUCTURES

Facility

$831.00

Service Code	CPT 76516
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 TISSUE AND STRUCTURES

Facility

$831.00

Service Code	CPT 76516
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	CPT 76513
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	CPT 76513
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	CPT 76821
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	CPT 76821
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	CPT 76820
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	CPT 76820
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	CPT 76886
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	CPT 76886
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	CPT 76856
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

Know your out-of-pocket cost for care.

All Charges