Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

DX LEVOFLOXACIN TAB [500 MG]

Facility

$64.00

Service Code	HCPCS J3490
Hospital Charge Code	3000273
Hospital Revenue Code	250
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

DX LEVOFLOXACIN TAB [500 MG]

Facility

$64.00

Service Code	HCPCS J3490
Hospital Charge Code	3000273
Hospital Revenue Code	250
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

DX Triamterene/Hctz Tab 37.5mg/25mg

Facility

$8.00

Service Code	NDC 68084075025
Hospital Charge Code	3007375
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

DX Triamterene/Hctz Tab 37.5mg/25mg

Facility

$8.00

Service Code	NDC 68084075025
Hospital Charge Code	3007375
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

EASYDROP FLOW CONTROLLER

Facility

$64.00

Hospital Charge Code	80040122
Hospital Revenue Code	270
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

EASYDROP FLOW CONTROLLER

Facility

$64.00

Hospital Charge Code	80040122
Hospital Revenue Code	270
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

EBV AB TO VCA, IGG (096230)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4086665
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV AB TO VCA, IGG (096230)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4086665
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV AB TO VCA, IGM (096735)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4000054
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV AB TO VCA, IGM (096735)

Facility

$41.00

Service Code	HCPCS 86665
Hospital Charge Code	4000054
Hospital Revenue Code	302
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$41.00
Rate for Payer: Aetna Commercial	$38.95
Rate for Payer: Aetna Medicare	$36.90
Rate for Payer: BCBS MT CHIP	$36.90
Rate for Payer: BCBS MT Closed Plan Network	$38.95
Rate for Payer: BCBS MT HealthLink	$36.90
Rate for Payer: BCBS MT Medicare	$36.90
Rate for Payer: BCBS MT POS	$38.95
Rate for Payer: BCBS MT Traditional	$41.00
Rate for Payer: Cash Price	$36.90
Rate for Payer: Cigna Commercial	$38.95
Rate for Payer: Cigna Medicare	$36.90
Rate for Payer: Medicaid All Medicaid	$37.72
Rate for Payer: Medicare All Medicare	$28.70
Rate for Payer: Monida Allegiance	$38.95
Rate for Payer: Monida First Choice Health	$39.77
Rate for Payer: Monida Montana Health Co-op	$38.95
Rate for Payer: Monida PacificSource	$38.95

EBV ANTIBODY PROFILE (240610)

Facility

$124.00

Service Code	HCPCS 86664
Hospital Charge Code	4066641
Hospital Revenue Code	302
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

EBV ANTIBODY PROFILE (240610)

Facility

$124.00

Service Code	HCPCS 86664
Hospital Charge Code	4066641
Hospital Revenue Code	302
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$124.00
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: BCBS MT CHIP	$111.60
Rate for Payer: BCBS MT Closed Plan Network	$117.80
Rate for Payer: BCBS MT HealthLink	$111.60
Rate for Payer: BCBS MT Medicare	$111.60
Rate for Payer: BCBS MT POS	$117.80
Rate for Payer: BCBS MT Traditional	$124.00
Rate for Payer: Cash Price	$111.60
Rate for Payer: Cigna Commercial	$117.80
Rate for Payer: Cigna Medicare	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

EBV NUCLEAR ANTIGEN AB, IGG (010272)

Facility

$42.00

Service Code	HCPCS 86664
Hospital Charge Code	4086664
Hospital Revenue Code	302
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

EBV NUCLEAR ANTIGEN AB, IGG (010272)

Facility

$42.00

Service Code	HCPCS 86664
Hospital Charge Code	4086664
Hospital Revenue Code	302
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$42.00
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: BCBS MT CHIP	$37.80
Rate for Payer: BCBS MT Closed Plan Network	$39.90
Rate for Payer: BCBS MT HealthLink	$37.80
Rate for Payer: BCBS MT Medicare	$37.80
Rate for Payer: BCBS MT POS	$39.90
Rate for Payer: BCBS MT Traditional	$42.00
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cigna Commercial	$39.90
Rate for Payer: Cigna Medicare	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

EBV, QUALITATIVE, PCR (138289)

Facility

$659.00

Service Code	HCPCS 87798
Hospital Charge Code	4087799
Hospital Revenue Code	300
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

EBV, QUALITATIVE, PCR (138289)

Facility

$659.00

Service Code	HCPCS 87798
Hospital Charge Code	4087799
Hospital Revenue Code	300
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$659.00
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: BCBS MT CHIP	$593.10
Rate for Payer: BCBS MT Closed Plan Network	$626.05
Rate for Payer: BCBS MT HealthLink	$593.10
Rate for Payer: BCBS MT Medicare	$593.10
Rate for Payer: BCBS MT POS	$626.05
Rate for Payer: BCBS MT Traditional	$659.00
Rate for Payer: Cash Price	$593.10
Rate for Payer: Cigna Commercial	$626.05
Rate for Payer: Cigna Medicare	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

EBV, QUANTITATIVE, PCR (138230)

Facility

$630.00

Service Code	HCPCS 87799
Hospital Charge Code	4077991
Hospital Revenue Code	300
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

EBV, QUANTITATIVE, PCR (138230)

Facility

$630.00

Service Code	HCPCS 87799
Hospital Charge Code	4077991
Hospital Revenue Code	300
Min. Negotiated Rate	$441.00
Max. Negotiated Rate	$630.00
Rate for Payer: Aetna Commercial	$598.50
Rate for Payer: Aetna Medicare	$567.00
Rate for Payer: BCBS MT CHIP	$567.00
Rate for Payer: BCBS MT Closed Plan Network	$598.50
Rate for Payer: BCBS MT HealthLink	$567.00
Rate for Payer: BCBS MT Medicare	$567.00
Rate for Payer: BCBS MT POS	$598.50
Rate for Payer: BCBS MT Traditional	$630.00
Rate for Payer: Cash Price	$567.00
Rate for Payer: Cigna Commercial	$598.50
Rate for Payer: Cigna Medicare	$567.00
Rate for Payer: Medicaid All Medicaid	$579.60
Rate for Payer: Medicare All Medicare	$441.00
Rate for Payer: Monida Allegiance	$598.50
Rate for Payer: Monida First Choice Health	$611.10
Rate for Payer: Monida Montana Health Co-op	$598.50
Rate for Payer: Monida PacificSource	$598.50

E-CHECK XS LOW LEVEL 5 X 1.5

Facility

$150.34

Hospital Charge Code	90195075
Hospital Revenue Code	270
Min. Negotiated Rate	$105.24
Max. Negotiated Rate	$150.34
Rate for Payer: Aetna Commercial	$142.82
Rate for Payer: Aetna Medicare	$135.31
Rate for Payer: BCBS MT CHIP	$135.31
Rate for Payer: BCBS MT Closed Plan Network	$142.82
Rate for Payer: BCBS MT HealthLink	$135.31
Rate for Payer: BCBS MT Medicare	$135.31
Rate for Payer: BCBS MT POS	$142.82
Rate for Payer: BCBS MT Traditional	$150.34
Rate for Payer: Cash Price	$135.31
Rate for Payer: Cigna Commercial	$142.82
Rate for Payer: Cigna Medicare	$135.31
Rate for Payer: Medicaid All Medicaid	$138.31
Rate for Payer: Medicare All Medicare	$105.24
Rate for Payer: Monida Allegiance	$142.82
Rate for Payer: Monida First Choice Health	$145.83
Rate for Payer: Monida Montana Health Co-op	$142.82
Rate for Payer: Monida PacificSource	$142.82

E-CHECK XS LOW LEVEL 5 X 1.5

Facility

$150.34

Hospital Charge Code	90195075
Hospital Revenue Code	270
Min. Negotiated Rate	$105.24
Max. Negotiated Rate	$150.34
Rate for Payer: Aetna Commercial	$142.82
Rate for Payer: Aetna Medicare	$135.31
Rate for Payer: BCBS MT CHIP	$135.31
Rate for Payer: BCBS MT Closed Plan Network	$142.82
Rate for Payer: BCBS MT HealthLink	$135.31
Rate for Payer: BCBS MT Medicare	$135.31
Rate for Payer: BCBS MT POS	$142.82
Rate for Payer: BCBS MT Traditional	$150.34
Rate for Payer: Cash Price	$135.31
Rate for Payer: Cigna Commercial	$142.82
Rate for Payer: Cigna Medicare	$135.31
Rate for Payer: Medicaid All Medicaid	$138.31
Rate for Payer: Medicare All Medicare	$105.24
Rate for Payer: Monida Allegiance	$142.82
Rate for Payer: Monida First Choice Health	$145.83
Rate for Payer: Monida Montana Health Co-op	$142.82
Rate for Payer: Monida PacificSource	$142.82

ECHO BUBBLE STUDY

Facility

$1,906.00

Service Code	HCPCS 93306 TC
Hospital Charge Code	5193307
Hospital Revenue Code	483
Min. Negotiated Rate	$1,334.20
Max. Negotiated Rate	$1,906.00
Rate for Payer: Aetna Commercial	$1,810.70
Rate for Payer: Aetna Medicare	$1,715.40
Rate for Payer: BCBS MT CHIP	$1,715.40
Rate for Payer: BCBS MT Closed Plan Network	$1,810.70
Rate for Payer: BCBS MT HealthLink	$1,715.40
Rate for Payer: BCBS MT Medicare	$1,715.40
Rate for Payer: BCBS MT POS	$1,810.70
Rate for Payer: BCBS MT Traditional	$1,906.00
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Cigna Commercial	$1,810.70
Rate for Payer: Cigna Medicare	$1,715.40
Rate for Payer: Medicaid All Medicaid	$1,753.52
Rate for Payer: Medicare All Medicare	$1,334.20
Rate for Payer: Monida Allegiance	$1,810.70
Rate for Payer: Monida First Choice Health	$1,848.82
Rate for Payer: Monida Montana Health Co-op	$1,810.70
Rate for Payer: Monida PacificSource	$1,810.70

ECHO BUBBLE STUDY

Facility

$1,906.00

Service Code	HCPCS 93306 TC
Hospital Charge Code	5193307
Hospital Revenue Code	483
Min. Negotiated Rate	$1,334.20
Max. Negotiated Rate	$1,906.00
Rate for Payer: Aetna Commercial	$1,810.70
Rate for Payer: Aetna Medicare	$1,715.40
Rate for Payer: BCBS MT CHIP	$1,715.40
Rate for Payer: BCBS MT Closed Plan Network	$1,810.70
Rate for Payer: BCBS MT HealthLink	$1,715.40
Rate for Payer: BCBS MT Medicare	$1,715.40
Rate for Payer: BCBS MT POS	$1,810.70
Rate for Payer: BCBS MT Traditional	$1,906.00
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Cigna Commercial	$1,810.70
Rate for Payer: Cigna Medicare	$1,715.40
Rate for Payer: Medicaid All Medicaid	$1,753.52
Rate for Payer: Medicare All Medicare	$1,334.20
Rate for Payer: Monida Allegiance	$1,810.70
Rate for Payer: Monida First Choice Health	$1,848.82
Rate for Payer: Monida Montana Health Co-op	$1,810.70
Rate for Payer: Monida PacificSource	$1,810.70

ECHO COMPLETE

Facility

$1,906.00

Service Code	HCPCS 93306 TC
Hospital Charge Code	5193306
Hospital Revenue Code	483
Min. Negotiated Rate	$1,334.20
Max. Negotiated Rate	$1,906.00
Rate for Payer: Aetna Commercial	$1,810.70
Rate for Payer: Aetna Medicare	$1,715.40
Rate for Payer: BCBS MT CHIP	$1,715.40
Rate for Payer: BCBS MT Closed Plan Network	$1,810.70
Rate for Payer: BCBS MT HealthLink	$1,715.40
Rate for Payer: BCBS MT Medicare	$1,715.40
Rate for Payer: BCBS MT POS	$1,810.70
Rate for Payer: BCBS MT Traditional	$1,906.00
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Cigna Commercial	$1,810.70
Rate for Payer: Cigna Medicare	$1,715.40
Rate for Payer: Medicaid All Medicaid	$1,753.52
Rate for Payer: Medicare All Medicare	$1,334.20
Rate for Payer: Monida Allegiance	$1,810.70
Rate for Payer: Monida First Choice Health	$1,848.82
Rate for Payer: Monida Montana Health Co-op	$1,810.70
Rate for Payer: Monida PacificSource	$1,810.70

ECHO COMPLETE

Facility

$1,906.00

Service Code	HCPCS 93306 TC
Hospital Charge Code	5193306
Hospital Revenue Code	483
Min. Negotiated Rate	$1,334.20
Max. Negotiated Rate	$1,906.00
Rate for Payer: Aetna Commercial	$1,810.70
Rate for Payer: Aetna Medicare	$1,715.40
Rate for Payer: BCBS MT CHIP	$1,715.40
Rate for Payer: BCBS MT Closed Plan Network	$1,810.70
Rate for Payer: BCBS MT HealthLink	$1,715.40
Rate for Payer: BCBS MT Medicare	$1,715.40
Rate for Payer: BCBS MT POS	$1,810.70
Rate for Payer: BCBS MT Traditional	$1,906.00
Rate for Payer: Cash Price	$1,715.40
Rate for Payer: Cigna Commercial	$1,810.70
Rate for Payer: Cigna Medicare	$1,715.40
Rate for Payer: Medicaid All Medicaid	$1,753.52
Rate for Payer: Medicare All Medicare	$1,334.20
Rate for Payer: Monida Allegiance	$1,810.70
Rate for Payer: Monida First Choice Health	$1,848.82
Rate for Payer: Monida Montana Health Co-op	$1,810.70
Rate for Payer: Monida PacificSource	$1,810.70

ECHOENCEPHALOGRAPHY REAL TIME IMAGING

Facility

$668.00

Service Code	HCPCS 76506 TC
Hospital Charge Code	5176506
Hospital Revenue Code	402
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$668.00
Rate for Payer: Aetna Commercial	$634.60
Rate for Payer: Aetna Medicare	$601.20
Rate for Payer: BCBS MT CHIP	$601.20
Rate for Payer: BCBS MT Closed Plan Network	$634.60
Rate for Payer: BCBS MT HealthLink	$601.20
Rate for Payer: BCBS MT Medicare	$601.20
Rate for Payer: BCBS MT POS	$634.60
Rate for Payer: BCBS MT Traditional	$668.00
Rate for Payer: Cash Price	$601.20
Rate for Payer: Cigna Commercial	$634.60
Rate for Payer: Cigna Medicare	$601.20
Rate for Payer: Medicaid All Medicaid	$614.56
Rate for Payer: Medicare All Medicare	$467.60
Rate for Payer: Monida Allegiance	$634.60
Rate for Payer: Monida First Choice Health	$647.96
Rate for Payer: Monida Montana Health Co-op	$634.60
Rate for Payer: Monida PacificSource	$634.60

Know your out-of-pocket cost for care.

All Charges