Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

USTEKINUMAB QUAN W/AB

Facility

$399.00

Service Code	CPT 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 W/AB

Facility

$399.00

Service Code	CPT 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 TEMPORAL ARTERY DUPLEX

Facility

$694.00

Service Code	CPT 93880
Hospital Charge Code	5193980
Hospital Revenue Code	402
Min. Negotiated Rate	$485.80
Max. Negotiated Rate	$694.00
Rate for Payer: Aetna Commercial	$659.30
Rate for Payer: Aetna Medicare	$624.60
Rate for Payer: BCBS MT CHIP	$624.60
Rate for Payer: BCBS MT Closed Plan Network	$659.30
Rate for Payer: BCBS MT HealthLink	$624.60
Rate for Payer: BCBS MT Medicare	$624.60
Rate for Payer: BCBS MT POS	$659.30
Rate for Payer: BCBS MT Traditional	$694.00
Rate for Payer: Cash Price	$624.60
Rate for Payer: Cigna Commercial	$659.30
Rate for Payer: Cigna Medicare	$624.60
Rate for Payer: Medicaid All Medicaid	$638.48
Rate for Payer: Medicare All Medicare	$485.80
Rate for Payer: Monida Allegiance	$659.30
Rate for Payer: Monida First Choice Health	$673.18
Rate for Payer: Monida Montana Health Co-op	$659.30
Rate for Payer: Monida PacificSource	$659.30

US TEMPORAL ARTERY DUPLEX

Facility

$694.00

Service Code	CPT 93880
Hospital Charge Code	5193980
Hospital Revenue Code	402
Min. Negotiated Rate	$485.80
Max. Negotiated Rate	$694.00
Rate for Payer: Aetna Commercial	$659.30
Rate for Payer: Aetna Medicare	$624.60
Rate for Payer: BCBS MT CHIP	$624.60
Rate for Payer: BCBS MT Closed Plan Network	$659.30
Rate for Payer: BCBS MT HealthLink	$624.60
Rate for Payer: BCBS MT Medicare	$624.60
Rate for Payer: BCBS MT POS	$659.30
Rate for Payer: BCBS MT Traditional	$694.00
Rate for Payer: Cash Price	$624.60
Rate for Payer: Cigna Commercial	$659.30
Rate for Payer: Cigna Medicare	$624.60
Rate for Payer: Medicaid All Medicaid	$638.48
Rate for Payer: Medicare All Medicare	$485.80
Rate for Payer: Monida Allegiance	$659.30
Rate for Payer: Monida First Choice Health	$673.18
Rate for Payer: Monida Montana Health Co-op	$659.30
Rate for Payer: Monida PacificSource	$659.30

US TESTICULAR SCROTUM

Facility

$451.00

Service Code	CPT 76870
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	CPT 76870
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	CPT 76536
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	CPT 76536
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	CPT 76516
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	CPT 76516
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	CPT 93893
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	CPT 93893
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	CPT 93886
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	CPT 93886
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	CPT 93888
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	CPT 93888
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	CPT 93892
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	CPT 93892
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	CPT 76830
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

US TRANSVAGINAL US NON-OB

Facility

$431.00

Service Code	CPT 76830
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

US TRANSVAGINAL US OBSTETRIC

Facility

$348.00

Service Code	CPT 76817
Hospital Charge Code	5176817
Hospital Revenue Code	402
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

US TRANSVAGINAL US OBSTETRIC

Facility

$348.00

Service Code	CPT 76817
Hospital Charge Code	5176817
Hospital Revenue Code	402
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

US TRANS VAG LMT

Facility

$230.00

Service Code	CPT 76857
Hospital Charge Code	5100003
Hospital Revenue Code	402
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

US TRANS VAG LMT

Facility

$230.00

Service Code	CPT 76857
Hospital Charge Code	5100003
Hospital Revenue Code	402
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$230.00
Rate for Payer: Aetna Commercial	$218.50
Rate for Payer: Aetna Medicare	$207.00
Rate for Payer: BCBS MT CHIP	$207.00
Rate for Payer: BCBS MT Closed Plan Network	$218.50
Rate for Payer: BCBS MT HealthLink	$207.00
Rate for Payer: BCBS MT Medicare	$207.00
Rate for Payer: BCBS MT POS	$218.50
Rate for Payer: BCBS MT Traditional	$230.00
Rate for Payer: Cash Price	$207.00
Rate for Payer: Cigna Commercial	$218.50
Rate for Payer: Cigna Medicare	$207.00
Rate for Payer: Medicaid All Medicaid	$211.60
Rate for Payer: Medicare All Medicare	$161.00
Rate for Payer: Monida Allegiance	$218.50
Rate for Payer: Monida First Choice Health	$223.10
Rate for Payer: Monida Montana Health Co-op	$218.50
Rate for Payer: Monida PacificSource	$218.50

US TRNSPLNT KIDNEY REAL TIME W/IMAGE DOC

Facility

$847.00

Service Code	CPT 76776
Hospital Charge Code	5176776
Hospital Revenue Code	402
Min. Negotiated Rate	$592.90
Max. Negotiated Rate	$847.00
Rate for Payer: Aetna Commercial	$804.65
Rate for Payer: Aetna Medicare	$762.30
Rate for Payer: BCBS MT CHIP	$762.30
Rate for Payer: BCBS MT Closed Plan Network	$804.65
Rate for Payer: BCBS MT HealthLink	$762.30
Rate for Payer: BCBS MT Medicare	$762.30
Rate for Payer: BCBS MT POS	$804.65
Rate for Payer: BCBS MT Traditional	$847.00
Rate for Payer: Cash Price	$762.30
Rate for Payer: Cigna Commercial	$804.65
Rate for Payer: Cigna Medicare	$762.30
Rate for Payer: Medicaid All Medicaid	$779.24
Rate for Payer: Medicare All Medicare	$592.90
Rate for Payer: Monida Allegiance	$804.65
Rate for Payer: Monida First Choice Health	$821.59
Rate for Payer: Monida Montana Health Co-op	$804.65
Rate for Payer: Monida PacificSource	$804.65

Know your out-of-pocket cost for care.

All Charges