Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

EBV AB TO VCA, IGM (096735)

Facility

$41.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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 EPPSTEIN BARR QUANTITATIVE NAAT

Facility

$260.00

Service Code	CPT 87799
Hospital Charge Code	4088093
Hospital Revenue Code	302
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

EBV EPPSTEIN BARR QUANTITATIVE NAAT

Facility

$260.00

Service Code	CPT 87799
Hospital Charge Code	4088093
Hospital Revenue Code	302
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

EBV NUCLEAR ANTIGEN AB, IGG (010272)

Facility

$42.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 93306
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	CPT 93306
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	CPT 93306
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	CPT 93306
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	CPT 76506
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

ECHOENCEPHALOGRAPHY REAL TIME IMAGING

Facility

$668.00

Service Code	CPT 76506
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	CPT 76825
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	CPT 76825
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	CPT 76831
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	CPT 76831
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	CPT 93308
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

Know your out-of-pocket cost for care.

All Charges