Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MRA CHEST W WO CONTRAST

Facility

$1,709.00

Service Code	HCPCS 71555 TC
Hospital Charge Code	5300066
Hospital Revenue Code	618
Min. Negotiated Rate	$1,196.30
Max. Negotiated Rate	$1,709.00
Rate for Payer: Aetna Commercial	$1,623.55
Rate for Payer: Aetna Medicare	$1,538.10
Rate for Payer: BCBS MT CHIP	$1,538.10
Rate for Payer: BCBS MT Closed Plan Network	$1,623.55
Rate for Payer: BCBS MT HealthLink	$1,538.10
Rate for Payer: BCBS MT Medicare	$1,538.10
Rate for Payer: BCBS MT POS	$1,623.55
Rate for Payer: BCBS MT Traditional	$1,709.00
Rate for Payer: Cash Price	$1,538.10
Rate for Payer: Cigna Commercial	$1,623.55
Rate for Payer: Cigna Medicare	$1,538.10
Rate for Payer: Medicaid All Medicaid	$1,572.28
Rate for Payer: Medicare All Medicare	$1,196.30
Rate for Payer: Monida Allegiance	$1,623.55
Rate for Payer: Monida First Choice Health	$1,657.73
Rate for Payer: Monida Montana Health Co-op	$1,623.55
Rate for Payer: Monida PacificSource	$1,623.55

MRA CHEST W WO CONTRAST

Facility

$1,709.00

Service Code	HCPCS 71555 TC
Hospital Charge Code	5300066
Hospital Revenue Code	618
Min. Negotiated Rate	$1,196.30
Max. Negotiated Rate	$1,709.00
Rate for Payer: Aetna Commercial	$1,623.55
Rate for Payer: Aetna Medicare	$1,538.10
Rate for Payer: BCBS MT CHIP	$1,538.10
Rate for Payer: BCBS MT Closed Plan Network	$1,623.55
Rate for Payer: BCBS MT HealthLink	$1,538.10
Rate for Payer: BCBS MT Medicare	$1,538.10
Rate for Payer: BCBS MT POS	$1,623.55
Rate for Payer: BCBS MT Traditional	$1,709.00
Rate for Payer: Cash Price	$1,538.10
Rate for Payer: Cigna Commercial	$1,623.55
Rate for Payer: Cigna Medicare	$1,538.10
Rate for Payer: Medicaid All Medicaid	$1,572.28
Rate for Payer: Medicare All Medicare	$1,196.30
Rate for Payer: Monida Allegiance	$1,623.55
Rate for Payer: Monida First Choice Health	$1,657.73
Rate for Payer: Monida Montana Health Co-op	$1,623.55
Rate for Payer: Monida PacificSource	$1,623.55

MRA HEAD W CONTRAST

Facility

$2,348.00

Service Code	HCPCS 70545 TC
Hospital Charge Code	5300067
Hospital Revenue Code	615
Min. Negotiated Rate	$1,643.60
Max. Negotiated Rate	$2,348.00
Rate for Payer: Aetna Commercial	$2,230.60
Rate for Payer: Aetna Medicare	$2,113.20
Rate for Payer: BCBS MT CHIP	$2,113.20
Rate for Payer: BCBS MT Closed Plan Network	$2,230.60
Rate for Payer: BCBS MT HealthLink	$2,113.20
Rate for Payer: BCBS MT Medicare	$2,113.20
Rate for Payer: BCBS MT POS	$2,230.60
Rate for Payer: BCBS MT Traditional	$2,348.00
Rate for Payer: Cash Price	$2,113.20
Rate for Payer: Cigna Commercial	$2,230.60
Rate for Payer: Cigna Medicare	$2,113.20
Rate for Payer: Medicaid All Medicaid	$2,160.16
Rate for Payer: Medicare All Medicare	$1,643.60
Rate for Payer: Monida Allegiance	$2,230.60
Rate for Payer: Monida First Choice Health	$2,277.56
Rate for Payer: Monida Montana Health Co-op	$2,230.60
Rate for Payer: Monida PacificSource	$2,230.60

MRA HEAD W CONTRAST

Facility

$2,348.00

Service Code	HCPCS 70545 TC
Hospital Charge Code	5300067
Hospital Revenue Code	615
Min. Negotiated Rate	$1,643.60
Max. Negotiated Rate	$2,348.00
Rate for Payer: Aetna Commercial	$2,230.60
Rate for Payer: Aetna Medicare	$2,113.20
Rate for Payer: BCBS MT CHIP	$2,113.20
Rate for Payer: BCBS MT Closed Plan Network	$2,230.60
Rate for Payer: BCBS MT HealthLink	$2,113.20
Rate for Payer: BCBS MT Medicare	$2,113.20
Rate for Payer: BCBS MT POS	$2,230.60
Rate for Payer: BCBS MT Traditional	$2,348.00
Rate for Payer: Cash Price	$2,113.20
Rate for Payer: Cigna Commercial	$2,230.60
Rate for Payer: Cigna Medicare	$2,113.20
Rate for Payer: Medicaid All Medicaid	$2,160.16
Rate for Payer: Medicare All Medicare	$1,643.60
Rate for Payer: Monida Allegiance	$2,230.60
Rate for Payer: Monida First Choice Health	$2,277.56
Rate for Payer: Monida Montana Health Co-op	$2,230.60
Rate for Payer: Monida PacificSource	$2,230.60

MRA HEAD WO CONTRAST

Facility

$2,162.00

Service Code	HCPCS 70544 TC
Hospital Charge Code	5300069
Hospital Revenue Code	615
Min. Negotiated Rate	$1,513.40
Max. Negotiated Rate	$2,162.00
Rate for Payer: Aetna Commercial	$2,053.90
Rate for Payer: Aetna Medicare	$1,945.80
Rate for Payer: BCBS MT CHIP	$1,945.80
Rate for Payer: BCBS MT Closed Plan Network	$2,053.90
Rate for Payer: BCBS MT HealthLink	$1,945.80
Rate for Payer: BCBS MT Medicare	$1,945.80
Rate for Payer: BCBS MT POS	$2,053.90
Rate for Payer: BCBS MT Traditional	$2,162.00
Rate for Payer: Cash Price	$1,945.80
Rate for Payer: Cigna Commercial	$2,053.90
Rate for Payer: Cigna Medicare	$1,945.80
Rate for Payer: Medicaid All Medicaid	$1,989.04
Rate for Payer: Medicare All Medicare	$1,513.40
Rate for Payer: Monida Allegiance	$2,053.90
Rate for Payer: Monida First Choice Health	$2,097.14
Rate for Payer: Monida Montana Health Co-op	$2,053.90
Rate for Payer: Monida PacificSource	$2,053.90

MRA HEAD WO CONTRAST

Facility

$2,162.00

Service Code	HCPCS 70544 TC
Hospital Charge Code	5300069
Hospital Revenue Code	615
Min. Negotiated Rate	$1,513.40
Max. Negotiated Rate	$2,162.00
Rate for Payer: Aetna Commercial	$2,053.90
Rate for Payer: Aetna Medicare	$1,945.80
Rate for Payer: BCBS MT CHIP	$1,945.80
Rate for Payer: BCBS MT Closed Plan Network	$2,053.90
Rate for Payer: BCBS MT HealthLink	$1,945.80
Rate for Payer: BCBS MT Medicare	$1,945.80
Rate for Payer: BCBS MT POS	$2,053.90
Rate for Payer: BCBS MT Traditional	$2,162.00
Rate for Payer: Cash Price	$1,945.80
Rate for Payer: Cigna Commercial	$2,053.90
Rate for Payer: Cigna Medicare	$1,945.80
Rate for Payer: Medicaid All Medicaid	$1,989.04
Rate for Payer: Medicare All Medicare	$1,513.40
Rate for Payer: Monida Allegiance	$2,053.90
Rate for Payer: Monida First Choice Health	$2,097.14
Rate for Payer: Monida Montana Health Co-op	$2,053.90
Rate for Payer: Monida PacificSource	$2,053.90

MRA HEAD W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70546 TC
Hospital Charge Code	5300068
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MRA HEAD W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70546 TC
Hospital Charge Code	5300068
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MRA NECK W CONTRAST

Facility

$2,413.00

Service Code	HCPCS 70548 TC
Hospital Charge Code	5300071
Hospital Revenue Code	615
Min. Negotiated Rate	$1,689.10
Max. Negotiated Rate	$2,413.00
Rate for Payer: Aetna Commercial	$2,292.35
Rate for Payer: Aetna Medicare	$2,171.70
Rate for Payer: BCBS MT CHIP	$2,171.70
Rate for Payer: BCBS MT Closed Plan Network	$2,292.35
Rate for Payer: BCBS MT HealthLink	$2,171.70
Rate for Payer: BCBS MT Medicare	$2,171.70
Rate for Payer: BCBS MT POS	$2,292.35
Rate for Payer: BCBS MT Traditional	$2,413.00
Rate for Payer: Cash Price	$2,171.70
Rate for Payer: Cigna Commercial	$2,292.35
Rate for Payer: Cigna Medicare	$2,171.70
Rate for Payer: Medicaid All Medicaid	$2,219.96
Rate for Payer: Medicare All Medicare	$1,689.10
Rate for Payer: Monida Allegiance	$2,292.35
Rate for Payer: Monida First Choice Health	$2,340.61
Rate for Payer: Monida Montana Health Co-op	$2,292.35
Rate for Payer: Monida PacificSource	$2,292.35

MRA NECK W CONTRAST

Facility

$2,413.00

Service Code	HCPCS 70548 TC
Hospital Charge Code	5300071
Hospital Revenue Code	615
Min. Negotiated Rate	$1,689.10
Max. Negotiated Rate	$2,413.00
Rate for Payer: Aetna Commercial	$2,292.35
Rate for Payer: Aetna Medicare	$2,171.70
Rate for Payer: BCBS MT CHIP	$2,171.70
Rate for Payer: BCBS MT Closed Plan Network	$2,292.35
Rate for Payer: BCBS MT HealthLink	$2,171.70
Rate for Payer: BCBS MT Medicare	$2,171.70
Rate for Payer: BCBS MT POS	$2,292.35
Rate for Payer: BCBS MT Traditional	$2,413.00
Rate for Payer: Cash Price	$2,171.70
Rate for Payer: Cigna Commercial	$2,292.35
Rate for Payer: Cigna Medicare	$2,171.70
Rate for Payer: Medicaid All Medicaid	$2,219.96
Rate for Payer: Medicare All Medicare	$1,689.10
Rate for Payer: Monida Allegiance	$2,292.35
Rate for Payer: Monida First Choice Health	$2,340.61
Rate for Payer: Monida Montana Health Co-op	$2,292.35
Rate for Payer: Monida PacificSource	$2,292.35

MRA NECK WO CONTRAST

Facility

$2,146.00

Service Code	HCPCS 70547 TC
Hospital Charge Code	5300072
Hospital Revenue Code	615
Min. Negotiated Rate	$1,502.20
Max. Negotiated Rate	$2,146.00
Rate for Payer: Aetna Commercial	$2,038.70
Rate for Payer: Aetna Medicare	$1,931.40
Rate for Payer: BCBS MT CHIP	$1,931.40
Rate for Payer: BCBS MT Closed Plan Network	$2,038.70
Rate for Payer: BCBS MT HealthLink	$1,931.40
Rate for Payer: BCBS MT Medicare	$1,931.40
Rate for Payer: BCBS MT POS	$2,038.70
Rate for Payer: BCBS MT Traditional	$2,146.00
Rate for Payer: Cash Price	$1,931.40
Rate for Payer: Cigna Commercial	$2,038.70
Rate for Payer: Cigna Medicare	$1,931.40
Rate for Payer: Medicaid All Medicaid	$1,974.32
Rate for Payer: Medicare All Medicare	$1,502.20
Rate for Payer: Monida Allegiance	$2,038.70
Rate for Payer: Monida First Choice Health	$2,081.62
Rate for Payer: Monida Montana Health Co-op	$2,038.70
Rate for Payer: Monida PacificSource	$2,038.70

MRA NECK WO CONTRAST

Facility

$2,146.00

Service Code	HCPCS 70547 TC
Hospital Charge Code	5300072
Hospital Revenue Code	615
Min. Negotiated Rate	$1,502.20
Max. Negotiated Rate	$2,146.00
Rate for Payer: Aetna Commercial	$2,038.70
Rate for Payer: Aetna Medicare	$1,931.40
Rate for Payer: BCBS MT CHIP	$1,931.40
Rate for Payer: BCBS MT Closed Plan Network	$2,038.70
Rate for Payer: BCBS MT HealthLink	$1,931.40
Rate for Payer: BCBS MT Medicare	$1,931.40
Rate for Payer: BCBS MT POS	$2,038.70
Rate for Payer: BCBS MT Traditional	$2,146.00
Rate for Payer: Cash Price	$1,931.40
Rate for Payer: Cigna Commercial	$2,038.70
Rate for Payer: Cigna Medicare	$1,931.40
Rate for Payer: Medicaid All Medicaid	$1,974.32
Rate for Payer: Medicare All Medicare	$1,502.20
Rate for Payer: Monida Allegiance	$2,038.70
Rate for Payer: Monida First Choice Health	$2,081.62
Rate for Payer: Monida Montana Health Co-op	$2,038.70
Rate for Payer: Monida PacificSource	$2,038.70

MRA NECK W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70549 TC
Hospital Charge Code	5300073
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MRA NECK W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70549 TC
Hospital Charge Code	5300073
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MR ANKLE LT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300003
Hospital Revenue Code	614
Min. Negotiated Rate	$1,799.70
Max. Negotiated Rate	$2,571.00
Rate for Payer: Aetna Commercial	$2,442.45
Rate for Payer: Aetna Medicare	$2,313.90
Rate for Payer: BCBS MT CHIP	$2,313.90
Rate for Payer: BCBS MT Closed Plan Network	$2,442.45
Rate for Payer: BCBS MT HealthLink	$2,313.90
Rate for Payer: BCBS MT Medicare	$2,313.90
Rate for Payer: BCBS MT POS	$2,442.45
Rate for Payer: BCBS MT Traditional	$2,571.00
Rate for Payer: Cash Price	$2,313.90
Rate for Payer: Cigna Commercial	$2,442.45
Rate for Payer: Cigna Medicare	$2,313.90
Rate for Payer: Medicaid All Medicaid	$2,365.32
Rate for Payer: Medicare All Medicare	$1,799.70
Rate for Payer: Monida Allegiance	$2,442.45
Rate for Payer: Monida First Choice Health	$2,493.87
Rate for Payer: Monida Montana Health Co-op	$2,442.45
Rate for Payer: Monida PacificSource	$2,442.45

MR ANKLE LT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300003
Hospital Revenue Code	614
Min. Negotiated Rate	$1,799.70
Max. Negotiated Rate	$2,571.00
Rate for Payer: Aetna Commercial	$2,442.45
Rate for Payer: Aetna Medicare	$2,313.90
Rate for Payer: BCBS MT CHIP	$2,313.90
Rate for Payer: BCBS MT Closed Plan Network	$2,442.45
Rate for Payer: BCBS MT HealthLink	$2,313.90
Rate for Payer: BCBS MT Medicare	$2,313.90
Rate for Payer: BCBS MT POS	$2,442.45
Rate for Payer: BCBS MT Traditional	$2,571.00
Rate for Payer: Cash Price	$2,313.90
Rate for Payer: Cigna Commercial	$2,442.45
Rate for Payer: Cigna Medicare	$2,313.90
Rate for Payer: Medicaid All Medicaid	$2,365.32
Rate for Payer: Medicare All Medicare	$1,799.70
Rate for Payer: Monida Allegiance	$2,442.45
Rate for Payer: Monida First Choice Health	$2,493.87
Rate for Payer: Monida Montana Health Co-op	$2,442.45
Rate for Payer: Monida PacificSource	$2,442.45

MR ANKLE LT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300009
Hospital Revenue Code	614
Min. Negotiated Rate	$1,593.20
Max. Negotiated Rate	$2,276.00
Rate for Payer: Aetna Commercial	$2,162.20
Rate for Payer: Aetna Medicare	$2,048.40
Rate for Payer: BCBS MT CHIP	$2,048.40
Rate for Payer: BCBS MT Closed Plan Network	$2,162.20
Rate for Payer: BCBS MT HealthLink	$2,048.40
Rate for Payer: BCBS MT Medicare	$2,048.40
Rate for Payer: BCBS MT POS	$2,162.20
Rate for Payer: BCBS MT Traditional	$2,276.00
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Cigna Commercial	$2,162.20
Rate for Payer: Cigna Medicare	$2,048.40
Rate for Payer: Medicaid All Medicaid	$2,093.92
Rate for Payer: Medicare All Medicare	$1,593.20
Rate for Payer: Monida Allegiance	$2,162.20
Rate for Payer: Monida First Choice Health	$2,207.72
Rate for Payer: Monida Montana Health Co-op	$2,162.20
Rate for Payer: Monida PacificSource	$2,162.20

MR ANKLE LT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300009
Hospital Revenue Code	614
Min. Negotiated Rate	$1,593.20
Max. Negotiated Rate	$2,276.00
Rate for Payer: Aetna Commercial	$2,162.20
Rate for Payer: Aetna Medicare	$2,048.40
Rate for Payer: BCBS MT CHIP	$2,048.40
Rate for Payer: BCBS MT Closed Plan Network	$2,162.20
Rate for Payer: BCBS MT HealthLink	$2,048.40
Rate for Payer: BCBS MT Medicare	$2,048.40
Rate for Payer: BCBS MT POS	$2,162.20
Rate for Payer: BCBS MT Traditional	$2,276.00
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Cigna Commercial	$2,162.20
Rate for Payer: Cigna Medicare	$2,048.40
Rate for Payer: Medicaid All Medicaid	$2,093.92
Rate for Payer: Medicare All Medicare	$1,593.20
Rate for Payer: Monida Allegiance	$2,162.20
Rate for Payer: Monida First Choice Health	$2,207.72
Rate for Payer: Monida Montana Health Co-op	$2,162.20
Rate for Payer: Monida PacificSource	$2,162.20

MR ANKLE LT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300015
Hospital Revenue Code	614
Min. Negotiated Rate	$2,296.70
Max. Negotiated Rate	$3,281.00
Rate for Payer: Aetna Commercial	$3,116.95
Rate for Payer: Aetna Medicare	$2,952.90
Rate for Payer: BCBS MT CHIP	$2,952.90
Rate for Payer: BCBS MT Closed Plan Network	$3,116.95
Rate for Payer: BCBS MT HealthLink	$2,952.90
Rate for Payer: BCBS MT Medicare	$2,952.90
Rate for Payer: BCBS MT POS	$3,116.95
Rate for Payer: BCBS MT Traditional	$3,281.00
Rate for Payer: Cash Price	$2,952.90
Rate for Payer: Cigna Commercial	$3,116.95
Rate for Payer: Cigna Medicare	$2,952.90
Rate for Payer: Medicaid All Medicaid	$3,018.52
Rate for Payer: Medicare All Medicare	$2,296.70
Rate for Payer: Monida Allegiance	$3,116.95
Rate for Payer: Monida First Choice Health	$3,182.57
Rate for Payer: Monida Montana Health Co-op	$3,116.95
Rate for Payer: Monida PacificSource	$3,116.95

MR ANKLE LT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300015
Hospital Revenue Code	614
Min. Negotiated Rate	$2,296.70
Max. Negotiated Rate	$3,281.00
Rate for Payer: Aetna Commercial	$3,116.95
Rate for Payer: Aetna Medicare	$2,952.90
Rate for Payer: BCBS MT CHIP	$2,952.90
Rate for Payer: BCBS MT Closed Plan Network	$3,116.95
Rate for Payer: BCBS MT HealthLink	$2,952.90
Rate for Payer: BCBS MT Medicare	$2,952.90
Rate for Payer: BCBS MT POS	$3,116.95
Rate for Payer: BCBS MT Traditional	$3,281.00
Rate for Payer: Cash Price	$2,952.90
Rate for Payer: Cigna Commercial	$3,116.95
Rate for Payer: Cigna Medicare	$2,952.90
Rate for Payer: Medicaid All Medicaid	$3,018.52
Rate for Payer: Medicare All Medicare	$2,296.70
Rate for Payer: Monida Allegiance	$3,116.95
Rate for Payer: Monida First Choice Health	$3,182.57
Rate for Payer: Monida Montana Health Co-op	$3,116.95
Rate for Payer: Monida PacificSource	$3,116.95

MR ANKLE RT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300006
Hospital Revenue Code	614
Min. Negotiated Rate	$1,799.70
Max. Negotiated Rate	$2,571.00
Rate for Payer: Aetna Commercial	$2,442.45
Rate for Payer: Aetna Medicare	$2,313.90
Rate for Payer: BCBS MT CHIP	$2,313.90
Rate for Payer: BCBS MT Closed Plan Network	$2,442.45
Rate for Payer: BCBS MT HealthLink	$2,313.90
Rate for Payer: BCBS MT Medicare	$2,313.90
Rate for Payer: BCBS MT POS	$2,442.45
Rate for Payer: BCBS MT Traditional	$2,571.00
Rate for Payer: Cash Price	$2,313.90
Rate for Payer: Cigna Commercial	$2,442.45
Rate for Payer: Cigna Medicare	$2,313.90
Rate for Payer: Medicaid All Medicaid	$2,365.32
Rate for Payer: Medicare All Medicare	$1,799.70
Rate for Payer: Monida Allegiance	$2,442.45
Rate for Payer: Monida First Choice Health	$2,493.87
Rate for Payer: Monida Montana Health Co-op	$2,442.45
Rate for Payer: Monida PacificSource	$2,442.45

MR ANKLE RT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300006
Hospital Revenue Code	614
Min. Negotiated Rate	$1,799.70
Max. Negotiated Rate	$2,571.00
Rate for Payer: Aetna Commercial	$2,442.45
Rate for Payer: Aetna Medicare	$2,313.90
Rate for Payer: BCBS MT CHIP	$2,313.90
Rate for Payer: BCBS MT Closed Plan Network	$2,442.45
Rate for Payer: BCBS MT HealthLink	$2,313.90
Rate for Payer: BCBS MT Medicare	$2,313.90
Rate for Payer: BCBS MT POS	$2,442.45
Rate for Payer: BCBS MT Traditional	$2,571.00
Rate for Payer: Cash Price	$2,313.90
Rate for Payer: Cigna Commercial	$2,442.45
Rate for Payer: Cigna Medicare	$2,313.90
Rate for Payer: Medicaid All Medicaid	$2,365.32
Rate for Payer: Medicare All Medicare	$1,799.70
Rate for Payer: Monida Allegiance	$2,442.45
Rate for Payer: Monida First Choice Health	$2,493.87
Rate for Payer: Monida Montana Health Co-op	$2,442.45
Rate for Payer: Monida PacificSource	$2,442.45

MR ANKLE RT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300012
Hospital Revenue Code	614
Min. Negotiated Rate	$1,593.20
Max. Negotiated Rate	$2,276.00
Rate for Payer: Aetna Commercial	$2,162.20
Rate for Payer: Aetna Medicare	$2,048.40
Rate for Payer: BCBS MT CHIP	$2,048.40
Rate for Payer: BCBS MT Closed Plan Network	$2,162.20
Rate for Payer: BCBS MT HealthLink	$2,048.40
Rate for Payer: BCBS MT Medicare	$2,048.40
Rate for Payer: BCBS MT POS	$2,162.20
Rate for Payer: BCBS MT Traditional	$2,276.00
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Cigna Commercial	$2,162.20
Rate for Payer: Cigna Medicare	$2,048.40
Rate for Payer: Medicaid All Medicaid	$2,093.92
Rate for Payer: Medicare All Medicare	$1,593.20
Rate for Payer: Monida Allegiance	$2,162.20
Rate for Payer: Monida First Choice Health	$2,207.72
Rate for Payer: Monida Montana Health Co-op	$2,162.20
Rate for Payer: Monida PacificSource	$2,162.20

MR ANKLE RT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300012
Hospital Revenue Code	614
Min. Negotiated Rate	$1,593.20
Max. Negotiated Rate	$2,276.00
Rate for Payer: Aetna Commercial	$2,162.20
Rate for Payer: Aetna Medicare	$2,048.40
Rate for Payer: BCBS MT CHIP	$2,048.40
Rate for Payer: BCBS MT Closed Plan Network	$2,162.20
Rate for Payer: BCBS MT HealthLink	$2,048.40
Rate for Payer: BCBS MT Medicare	$2,048.40
Rate for Payer: BCBS MT POS	$2,162.20
Rate for Payer: BCBS MT Traditional	$2,276.00
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Cigna Commercial	$2,162.20
Rate for Payer: Cigna Medicare	$2,048.40
Rate for Payer: Medicaid All Medicaid	$2,093.92
Rate for Payer: Medicare All Medicare	$1,593.20
Rate for Payer: Monida Allegiance	$2,162.20
Rate for Payer: Monida First Choice Health	$2,207.72
Rate for Payer: Monida Montana Health Co-op	$2,162.20
Rate for Payer: Monida PacificSource	$2,162.20

MR ANKLE RT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300018
Hospital Revenue Code	614
Min. Negotiated Rate	$2,296.70
Max. Negotiated Rate	$3,281.00
Rate for Payer: Aetna Commercial	$3,116.95
Rate for Payer: Aetna Medicare	$2,952.90
Rate for Payer: BCBS MT CHIP	$2,952.90
Rate for Payer: BCBS MT Closed Plan Network	$3,116.95
Rate for Payer: BCBS MT HealthLink	$2,952.90
Rate for Payer: BCBS MT Medicare	$2,952.90
Rate for Payer: BCBS MT POS	$3,116.95
Rate for Payer: BCBS MT Traditional	$3,281.00
Rate for Payer: Cash Price	$2,952.90
Rate for Payer: Cigna Commercial	$3,116.95
Rate for Payer: Cigna Medicare	$2,952.90
Rate for Payer: Medicaid All Medicaid	$3,018.52
Rate for Payer: Medicare All Medicare	$2,296.70
Rate for Payer: Monida Allegiance	$3,116.95
Rate for Payer: Monida First Choice Health	$3,182.57
Rate for Payer: Monida Montana Health Co-op	$3,116.95
Rate for Payer: Monida PacificSource	$3,116.95

Know your out-of-pocket cost for care.

All Charges