Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

ECHO EXAM OF FETAL HEART

Facility

$1,451.00

Service Code	HCPCS 76825 TC
Hospital Charge Code	5176825
Hospital Revenue Code	402
Min. Negotiated Rate	$1,015.70
Max. Negotiated Rate	$1,451.00
Rate for Payer: Aetna Commercial	$1,378.45
Rate for Payer: Aetna Medicare	$1,305.90
Rate for Payer: BCBS MT CHIP	$1,305.90
Rate for Payer: BCBS MT Closed Plan Network	$1,378.45
Rate for Payer: BCBS MT HealthLink	$1,305.90
Rate for Payer: BCBS MT Medicare	$1,305.90
Rate for Payer: BCBS MT POS	$1,378.45
Rate for Payer: BCBS MT Traditional	$1,451.00
Rate for Payer: Cash Price	$1,305.90
Rate for Payer: Cigna Commercial	$1,378.45
Rate for Payer: Cigna Medicare	$1,305.90
Rate for Payer: Medicaid All Medicaid	$1,334.92
Rate for Payer: Medicare All Medicare	$1,015.70
Rate for Payer: Monida Allegiance	$1,378.45
Rate for Payer: Monida First Choice Health	$1,407.47
Rate for Payer: Monida Montana Health Co-op	$1,378.45
Rate for Payer: Monida PacificSource	$1,378.45

ECHO EXAM OF FETAL HEART

Facility

$1,451.00

Service Code	HCPCS 76825 TC
Hospital Charge Code	5176825
Hospital Revenue Code	402
Min. Negotiated Rate	$1,015.70
Max. Negotiated Rate	$1,451.00
Rate for Payer: Aetna Commercial	$1,378.45
Rate for Payer: Aetna Medicare	$1,305.90
Rate for Payer: BCBS MT CHIP	$1,305.90
Rate for Payer: BCBS MT Closed Plan Network	$1,378.45
Rate for Payer: BCBS MT HealthLink	$1,305.90
Rate for Payer: BCBS MT Medicare	$1,305.90
Rate for Payer: BCBS MT POS	$1,378.45
Rate for Payer: BCBS MT Traditional	$1,451.00
Rate for Payer: Cash Price	$1,305.90
Rate for Payer: Cigna Commercial	$1,378.45
Rate for Payer: Cigna Medicare	$1,305.90
Rate for Payer: Medicaid All Medicaid	$1,334.92
Rate for Payer: Medicare All Medicare	$1,015.70
Rate for Payer: Monida Allegiance	$1,378.45
Rate for Payer: Monida First Choice Health	$1,407.47
Rate for Payer: Monida Montana Health Co-op	$1,378.45
Rate for Payer: Monida PacificSource	$1,378.45

ECHO EXAM UTERUS

Facility

$579.00

Service Code	HCPCS 76831 TC
Hospital Charge Code	5176831
Hospital Revenue Code	402
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$579.00
Rate for Payer: Aetna Commercial	$550.05
Rate for Payer: Aetna Medicare	$521.10
Rate for Payer: BCBS MT CHIP	$521.10
Rate for Payer: BCBS MT Closed Plan Network	$550.05
Rate for Payer: BCBS MT HealthLink	$521.10
Rate for Payer: BCBS MT Medicare	$521.10
Rate for Payer: BCBS MT POS	$550.05
Rate for Payer: BCBS MT Traditional	$579.00
Rate for Payer: Cash Price	$521.10
Rate for Payer: Cigna Commercial	$550.05
Rate for Payer: Cigna Medicare	$521.10
Rate for Payer: Medicaid All Medicaid	$532.68
Rate for Payer: Medicare All Medicare	$405.30
Rate for Payer: Monida Allegiance	$550.05
Rate for Payer: Monida First Choice Health	$561.63
Rate for Payer: Monida Montana Health Co-op	$550.05
Rate for Payer: Monida PacificSource	$550.05

ECHO EXAM UTERUS

Facility

$579.00

Service Code	HCPCS 76831 TC
Hospital Charge Code	5176831
Hospital Revenue Code	402
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$579.00
Rate for Payer: Aetna Commercial	$550.05
Rate for Payer: Aetna Medicare	$521.10
Rate for Payer: BCBS MT CHIP	$521.10
Rate for Payer: BCBS MT Closed Plan Network	$550.05
Rate for Payer: BCBS MT HealthLink	$521.10
Rate for Payer: BCBS MT Medicare	$521.10
Rate for Payer: BCBS MT POS	$550.05
Rate for Payer: BCBS MT Traditional	$579.00
Rate for Payer: Cash Price	$521.10
Rate for Payer: Cigna Commercial	$550.05
Rate for Payer: Cigna Medicare	$521.10
Rate for Payer: Medicaid All Medicaid	$532.68
Rate for Payer: Medicare All Medicare	$405.30
Rate for Payer: Monida Allegiance	$550.05
Rate for Payer: Monida First Choice Health	$561.63
Rate for Payer: Monida Montana Health Co-op	$550.05
Rate for Payer: Monida PacificSource	$550.05

ECHO LIMITED

Facility

$783.00

Service Code	HCPCS 93308 TC
Hospital Charge Code	5193308
Hospital Revenue Code	402
Min. Negotiated Rate	$548.10
Max. Negotiated Rate	$783.00
Rate for Payer: Aetna Commercial	$743.85
Rate for Payer: Aetna Medicare	$704.70
Rate for Payer: BCBS MT CHIP	$704.70
Rate for Payer: BCBS MT Closed Plan Network	$743.85
Rate for Payer: BCBS MT HealthLink	$704.70
Rate for Payer: BCBS MT Medicare	$704.70
Rate for Payer: BCBS MT POS	$743.85
Rate for Payer: BCBS MT Traditional	$783.00
Rate for Payer: Cash Price	$704.70
Rate for Payer: Cigna Commercial	$743.85
Rate for Payer: Cigna Medicare	$704.70
Rate for Payer: Medicaid All Medicaid	$720.36
Rate for Payer: Medicare All Medicare	$548.10
Rate for Payer: Monida Allegiance	$743.85
Rate for Payer: Monida First Choice Health	$759.51
Rate for Payer: Monida Montana Health Co-op	$743.85
Rate for Payer: Monida PacificSource	$743.85

ECHO LIMITED

Facility

$783.00

Service Code	HCPCS 93308 TC
Hospital Charge Code	5193308
Hospital Revenue Code	402
Min. Negotiated Rate	$548.10
Max. Negotiated Rate	$783.00
Rate for Payer: Aetna Commercial	$743.85
Rate for Payer: Aetna Medicare	$704.70
Rate for Payer: BCBS MT CHIP	$704.70
Rate for Payer: BCBS MT Closed Plan Network	$743.85
Rate for Payer: BCBS MT HealthLink	$704.70
Rate for Payer: BCBS MT Medicare	$704.70
Rate for Payer: BCBS MT POS	$743.85
Rate for Payer: BCBS MT Traditional	$783.00
Rate for Payer: Cash Price	$704.70
Rate for Payer: Cigna Commercial	$743.85
Rate for Payer: Cigna Medicare	$704.70
Rate for Payer: Medicaid All Medicaid	$720.36
Rate for Payer: Medicare All Medicare	$548.10
Rate for Payer: Monida Allegiance	$743.85
Rate for Payer: Monida First Choice Health	$759.51
Rate for Payer: Monida Montana Health Co-op	$743.85
Rate for Payer: Monida PacificSource	$743.85

ED MODERATE CONCIOUS SEDATION ADD ON 15M

Facility

$135.00

Service Code	HCPCS 99153
Hospital Charge Code	1099153
Hospital Revenue Code	450
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

ED MODERATE CONCIOUS SEDATION ADD ON 15M

Facility

$135.00

Service Code	HCPCS 99153
Hospital Charge Code	1099153
Hospital Revenue Code	450
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

EGD 43235

Facility

$2,843.00

Service Code	HCPCS 43235
Hospital Charge Code	5843235
Hospital Revenue Code	750
Min. Negotiated Rate	$1,990.10
Max. Negotiated Rate	$2,843.00
Rate for Payer: Aetna Commercial	$2,700.85
Rate for Payer: Aetna Medicare	$2,558.70
Rate for Payer: BCBS MT CHIP	$2,558.70
Rate for Payer: BCBS MT Closed Plan Network	$2,700.85
Rate for Payer: BCBS MT HealthLink	$2,558.70
Rate for Payer: BCBS MT Medicare	$2,558.70
Rate for Payer: BCBS MT POS	$2,700.85
Rate for Payer: BCBS MT Traditional	$2,843.00
Rate for Payer: Cash Price	$2,558.70
Rate for Payer: Cigna Commercial	$2,700.85
Rate for Payer: Cigna Medicare	$2,558.70
Rate for Payer: Medicaid All Medicaid	$2,615.56
Rate for Payer: Medicare All Medicare	$1,990.10
Rate for Payer: Monida Allegiance	$2,700.85
Rate for Payer: Monida First Choice Health	$2,757.71
Rate for Payer: Monida Montana Health Co-op	$2,700.85
Rate for Payer: Monida PacificSource	$2,700.85

EGD 43235

Facility

$2,843.00

Service Code	HCPCS 43235
Hospital Charge Code	5843235
Hospital Revenue Code	750
Min. Negotiated Rate	$1,990.10
Max. Negotiated Rate	$2,843.00
Rate for Payer: Aetna Commercial	$2,700.85
Rate for Payer: Aetna Medicare	$2,558.70
Rate for Payer: BCBS MT CHIP	$2,558.70
Rate for Payer: BCBS MT Closed Plan Network	$2,700.85
Rate for Payer: BCBS MT HealthLink	$2,558.70
Rate for Payer: BCBS MT Medicare	$2,558.70
Rate for Payer: BCBS MT POS	$2,700.85
Rate for Payer: BCBS MT Traditional	$2,843.00
Rate for Payer: Cash Price	$2,558.70
Rate for Payer: Cigna Commercial	$2,700.85
Rate for Payer: Cigna Medicare	$2,558.70
Rate for Payer: Medicaid All Medicaid	$2,615.56
Rate for Payer: Medicare All Medicare	$1,990.10
Rate for Payer: Monida Allegiance	$2,700.85
Rate for Payer: Monida First Choice Health	$2,757.71
Rate for Payer: Monida Montana Health Co-op	$2,700.85
Rate for Payer: Monida PacificSource	$2,700.85

EGD W/ BIOPSY 43239

Facility

$2,921.00

Service Code	HCPCS 43239
Hospital Charge Code	5843239
Hospital Revenue Code	750
Min. Negotiated Rate	$2,044.70
Max. Negotiated Rate	$2,921.00
Rate for Payer: Aetna Commercial	$2,774.95
Rate for Payer: Aetna Medicare	$2,628.90
Rate for Payer: BCBS MT CHIP	$2,628.90
Rate for Payer: BCBS MT Closed Plan Network	$2,774.95
Rate for Payer: BCBS MT HealthLink	$2,628.90
Rate for Payer: BCBS MT Medicare	$2,628.90
Rate for Payer: BCBS MT POS	$2,774.95
Rate for Payer: BCBS MT Traditional	$2,921.00
Rate for Payer: Cash Price	$2,628.90
Rate for Payer: Cigna Commercial	$2,774.95
Rate for Payer: Cigna Medicare	$2,628.90
Rate for Payer: Medicaid All Medicaid	$2,687.32
Rate for Payer: Medicare All Medicare	$2,044.70
Rate for Payer: Monida Allegiance	$2,774.95
Rate for Payer: Monida First Choice Health	$2,833.37
Rate for Payer: Monida Montana Health Co-op	$2,774.95
Rate for Payer: Monida PacificSource	$2,774.95

EGD W/ BIOPSY 43239

Facility

$2,921.00

Service Code	HCPCS 43239
Hospital Charge Code	5843239
Hospital Revenue Code	750
Min. Negotiated Rate	$2,044.70
Max. Negotiated Rate	$2,921.00
Rate for Payer: Aetna Commercial	$2,774.95
Rate for Payer: Aetna Medicare	$2,628.90
Rate for Payer: BCBS MT CHIP	$2,628.90
Rate for Payer: BCBS MT Closed Plan Network	$2,774.95
Rate for Payer: BCBS MT HealthLink	$2,628.90
Rate for Payer: BCBS MT Medicare	$2,628.90
Rate for Payer: BCBS MT POS	$2,774.95
Rate for Payer: BCBS MT Traditional	$2,921.00
Rate for Payer: Cash Price	$2,628.90
Rate for Payer: Cigna Commercial	$2,774.95
Rate for Payer: Cigna Medicare	$2,628.90
Rate for Payer: Medicaid All Medicaid	$2,687.32
Rate for Payer: Medicare All Medicare	$2,044.70
Rate for Payer: Monida Allegiance	$2,774.95
Rate for Payer: Monida First Choice Health	$2,833.37
Rate for Payer: Monida Montana Health Co-op	$2,774.95
Rate for Payer: Monida PacificSource	$2,774.95

EGD W/ DILITATION 43248

Facility

$2,756.00

Service Code	HCPCS 43248
Hospital Charge Code	5843248
Hospital Revenue Code	750
Min. Negotiated Rate	$1,929.20
Max. Negotiated Rate	$2,756.00
Rate for Payer: Aetna Commercial	$2,618.20
Rate for Payer: Aetna Medicare	$2,480.40
Rate for Payer: BCBS MT CHIP	$2,480.40
Rate for Payer: BCBS MT Closed Plan Network	$2,618.20
Rate for Payer: BCBS MT HealthLink	$2,480.40
Rate for Payer: BCBS MT Medicare	$2,480.40
Rate for Payer: BCBS MT POS	$2,618.20
Rate for Payer: BCBS MT Traditional	$2,756.00
Rate for Payer: Cash Price	$2,480.40
Rate for Payer: Cigna Commercial	$2,618.20
Rate for Payer: Cigna Medicare	$2,480.40
Rate for Payer: Medicaid All Medicaid	$2,535.52
Rate for Payer: Medicare All Medicare	$1,929.20
Rate for Payer: Monida Allegiance	$2,618.20
Rate for Payer: Monida First Choice Health	$2,673.32
Rate for Payer: Monida Montana Health Co-op	$2,618.20
Rate for Payer: Monida PacificSource	$2,618.20

EGD W/ DILITATION 43248

Facility

$2,756.00

Service Code	HCPCS 43248
Hospital Charge Code	5843248
Hospital Revenue Code	750
Min. Negotiated Rate	$1,929.20
Max. Negotiated Rate	$2,756.00
Rate for Payer: Aetna Commercial	$2,618.20
Rate for Payer: Aetna Medicare	$2,480.40
Rate for Payer: BCBS MT CHIP	$2,480.40
Rate for Payer: BCBS MT Closed Plan Network	$2,618.20
Rate for Payer: BCBS MT HealthLink	$2,480.40
Rate for Payer: BCBS MT Medicare	$2,480.40
Rate for Payer: BCBS MT POS	$2,618.20
Rate for Payer: BCBS MT Traditional	$2,756.00
Rate for Payer: Cash Price	$2,480.40
Rate for Payer: Cigna Commercial	$2,618.20
Rate for Payer: Cigna Medicare	$2,480.40
Rate for Payer: Medicaid All Medicaid	$2,535.52
Rate for Payer: Medicare All Medicare	$1,929.20
Rate for Payer: Monida Allegiance	$2,618.20
Rate for Payer: Monida First Choice Health	$2,673.32
Rate for Payer: Monida Montana Health Co-op	$2,618.20
Rate for Payer: Monida PacificSource	$2,618.20

EKG - AMBULANCE

Facility

$179.00

Service Code	HCPCS 93005 QN
Hospital Charge Code	693005
Hospital Revenue Code	730
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

EKG - AMBULANCE

Facility

$179.00

Service Code	HCPCS 93005 QN
Hospital Charge Code	693005
Hospital Revenue Code	730
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$179.00
Rate for Payer: Aetna Commercial	$170.05
Rate for Payer: Aetna Medicare	$161.10
Rate for Payer: BCBS MT CHIP	$161.10
Rate for Payer: BCBS MT Closed Plan Network	$170.05
Rate for Payer: BCBS MT HealthLink	$161.10
Rate for Payer: BCBS MT Medicare	$161.10
Rate for Payer: BCBS MT POS	$170.05
Rate for Payer: BCBS MT Traditional	$179.00
Rate for Payer: Cash Price	$161.10
Rate for Payer: Cigna Commercial	$170.05
Rate for Payer: Cigna Medicare	$161.10
Rate for Payer: Medicaid All Medicaid	$164.68
Rate for Payer: Medicare All Medicare	$125.30
Rate for Payer: Monida Allegiance	$170.05
Rate for Payer: Monida First Choice Health	$173.63
Rate for Payer: Monida Montana Health Co-op	$170.05
Rate for Payer: Monida PacificSource	$170.05

EKG - OP/HOSPITAL

Facility

$186.00

Service Code	HCPCS 93005
Hospital Charge Code	114001
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

EKG - OP/HOSPITAL

Facility

$186.00

Service Code	HCPCS 93005
Hospital Charge Code	114001
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

EKG WELCOME TO MEDICARE

Facility

$186.00

Service Code	HCPCS G0404
Hospital Charge Code	114003
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

EKG WELCOME TO MEDICARE

Facility

$186.00

Service Code	HCPCS G0404
Hospital Charge Code	114003
Hospital Revenue Code	730
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

ELASTIC SHLDR IMMOB

Facility

$121.00

Service Code	HCPCS L3650
Hospital Charge Code	8003650
Hospital Revenue Code	290
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

ELASTIC SHLDR IMMOB

Facility

$121.00

Service Code	HCPCS L3650
Hospital Charge Code	8003650
Hospital Revenue Code	290
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$121.00
Rate for Payer: Aetna Commercial	$114.95
Rate for Payer: Aetna Medicare	$108.90
Rate for Payer: BCBS MT CHIP	$108.90
Rate for Payer: BCBS MT Closed Plan Network	$114.95
Rate for Payer: BCBS MT HealthLink	$108.90
Rate for Payer: BCBS MT Medicare	$108.90
Rate for Payer: BCBS MT POS	$114.95
Rate for Payer: BCBS MT Traditional	$121.00
Rate for Payer: Cash Price	$108.90
Rate for Payer: Cigna Commercial	$114.95
Rate for Payer: Cigna Medicare	$108.90
Rate for Payer: Medicaid All Medicaid	$111.32
Rate for Payer: Medicare All Medicare	$84.70
Rate for Payer: Monida Allegiance	$114.95
Rate for Payer: Monida First Choice Health	$117.37
Rate for Payer: Monida Montana Health Co-op	$114.95
Rate for Payer: Monida PacificSource	$114.95

ELBOW ORTHOTIC W/O JOINTS

Facility

$301.00

Service Code	HCPCS L3702
Hospital Charge Code	8003702
Hospital Revenue Code	290
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

ELBOW ORTHOTIC W/O JOINTS

Facility

$301.00

Service Code	HCPCS L3702
Hospital Charge Code	8003702
Hospital Revenue Code	290
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

Know your out-of-pocket cost for care.

All Charges