Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MR BRAIN W CONTRAST

Facility

$2,692.00

Service Code	HCPCS 70552 TC
Hospital Charge Code	5300081
Hospital Revenue Code	611
Min. Negotiated Rate	$1,884.40
Max. Negotiated Rate	$2,692.00
Rate for Payer: Aetna Commercial	$2,557.40
Rate for Payer: Aetna Medicare	$2,422.80
Rate for Payer: BCBS MT CHIP	$2,422.80
Rate for Payer: BCBS MT Closed Plan Network	$2,557.40
Rate for Payer: BCBS MT HealthLink	$2,422.80
Rate for Payer: BCBS MT Medicare	$2,422.80
Rate for Payer: BCBS MT POS	$2,557.40
Rate for Payer: BCBS MT Traditional	$2,692.00
Rate for Payer: Cash Price	$2,422.80
Rate for Payer: Cigna Commercial	$2,557.40
Rate for Payer: Cigna Medicare	$2,422.80
Rate for Payer: Medicaid All Medicaid	$2,476.64
Rate for Payer: Medicare All Medicare	$1,884.40
Rate for Payer: Monida Allegiance	$2,557.40
Rate for Payer: Monida First Choice Health	$2,611.24
Rate for Payer: Monida Montana Health Co-op	$2,557.40
Rate for Payer: Monida PacificSource	$2,557.40

MR BRAIN W CONTRAST

Facility

$2,692.00

Service Code	HCPCS 70552 TC
Hospital Charge Code	5300081
Hospital Revenue Code	611
Min. Negotiated Rate	$1,884.40
Max. Negotiated Rate	$2,692.00
Rate for Payer: Aetna Commercial	$2,557.40
Rate for Payer: Aetna Medicare	$2,422.80
Rate for Payer: BCBS MT CHIP	$2,422.80
Rate for Payer: BCBS MT Closed Plan Network	$2,557.40
Rate for Payer: BCBS MT HealthLink	$2,422.80
Rate for Payer: BCBS MT Medicare	$2,422.80
Rate for Payer: BCBS MT POS	$2,557.40
Rate for Payer: BCBS MT Traditional	$2,692.00
Rate for Payer: Cash Price	$2,422.80
Rate for Payer: Cigna Commercial	$2,557.40
Rate for Payer: Cigna Medicare	$2,422.80
Rate for Payer: Medicaid All Medicaid	$2,476.64
Rate for Payer: Medicare All Medicare	$1,884.40
Rate for Payer: Monida Allegiance	$2,557.40
Rate for Payer: Monida First Choice Health	$2,611.24
Rate for Payer: Monida Montana Health Co-op	$2,557.40
Rate for Payer: Monida PacificSource	$2,557.40

MR BRAIN WO CONTRAST

Facility

$2,321.00

Service Code	HCPCS 70551 TC
Hospital Charge Code	5300082
Hospital Revenue Code	611
Min. Negotiated Rate	$1,624.70
Max. Negotiated Rate	$2,321.00
Rate for Payer: Aetna Commercial	$2,204.95
Rate for Payer: Aetna Medicare	$2,088.90
Rate for Payer: BCBS MT CHIP	$2,088.90
Rate for Payer: BCBS MT Closed Plan Network	$2,204.95
Rate for Payer: BCBS MT HealthLink	$2,088.90
Rate for Payer: BCBS MT Medicare	$2,088.90
Rate for Payer: BCBS MT POS	$2,204.95
Rate for Payer: BCBS MT Traditional	$2,321.00
Rate for Payer: Cash Price	$2,088.90
Rate for Payer: Cigna Commercial	$2,204.95
Rate for Payer: Cigna Medicare	$2,088.90
Rate for Payer: Medicaid All Medicaid	$2,135.32
Rate for Payer: Medicare All Medicare	$1,624.70
Rate for Payer: Monida Allegiance	$2,204.95
Rate for Payer: Monida First Choice Health	$2,251.37
Rate for Payer: Monida Montana Health Co-op	$2,204.95
Rate for Payer: Monida PacificSource	$2,204.95

MR BRAIN WO CONTRAST

Facility

$2,321.00

Service Code	HCPCS 70551 TC
Hospital Charge Code	5300082
Hospital Revenue Code	611
Min. Negotiated Rate	$1,624.70
Max. Negotiated Rate	$2,321.00
Rate for Payer: Aetna Commercial	$2,204.95
Rate for Payer: Aetna Medicare	$2,088.90
Rate for Payer: BCBS MT CHIP	$2,088.90
Rate for Payer: BCBS MT Closed Plan Network	$2,204.95
Rate for Payer: BCBS MT HealthLink	$2,088.90
Rate for Payer: BCBS MT Medicare	$2,088.90
Rate for Payer: BCBS MT POS	$2,204.95
Rate for Payer: BCBS MT Traditional	$2,321.00
Rate for Payer: Cash Price	$2,088.90
Rate for Payer: Cigna Commercial	$2,204.95
Rate for Payer: Cigna Medicare	$2,088.90
Rate for Payer: Medicaid All Medicaid	$2,135.32
Rate for Payer: Medicare All Medicare	$1,624.70
Rate for Payer: Monida Allegiance	$2,204.95
Rate for Payer: Monida First Choice Health	$2,251.37
Rate for Payer: Monida Montana Health Co-op	$2,204.95
Rate for Payer: Monida PacificSource	$2,204.95

MR BRAIN W WO CONTRAST

Facility

$3,450.00

Service Code	HCPCS 70553 TC
Hospital Charge Code	5300083
Hospital Revenue Code	611
Min. Negotiated Rate	$2,415.00
Max. Negotiated Rate	$3,450.00
Rate for Payer: Aetna Commercial	$3,277.50
Rate for Payer: Aetna Medicare	$3,105.00
Rate for Payer: BCBS MT CHIP	$3,105.00
Rate for Payer: BCBS MT Closed Plan Network	$3,277.50
Rate for Payer: BCBS MT HealthLink	$3,105.00
Rate for Payer: BCBS MT Medicare	$3,105.00
Rate for Payer: BCBS MT POS	$3,277.50
Rate for Payer: BCBS MT Traditional	$3,450.00
Rate for Payer: Cash Price	$3,105.00
Rate for Payer: Cigna Commercial	$3,277.50
Rate for Payer: Cigna Medicare	$3,105.00
Rate for Payer: Medicaid All Medicaid	$3,174.00
Rate for Payer: Medicare All Medicare	$2,415.00
Rate for Payer: Monida Allegiance	$3,277.50
Rate for Payer: Monida First Choice Health	$3,346.50
Rate for Payer: Monida Montana Health Co-op	$3,277.50
Rate for Payer: Monida PacificSource	$3,277.50

MR BRAIN W WO CONTRAST

Facility

$3,450.00

Service Code	HCPCS 70553 TC
Hospital Charge Code	5300083
Hospital Revenue Code	611
Min. Negotiated Rate	$2,415.00
Max. Negotiated Rate	$3,450.00
Rate for Payer: Aetna Commercial	$3,277.50
Rate for Payer: Aetna Medicare	$3,105.00
Rate for Payer: BCBS MT CHIP	$3,105.00
Rate for Payer: BCBS MT Closed Plan Network	$3,277.50
Rate for Payer: BCBS MT HealthLink	$3,105.00
Rate for Payer: BCBS MT Medicare	$3,105.00
Rate for Payer: BCBS MT POS	$3,277.50
Rate for Payer: BCBS MT Traditional	$3,450.00
Rate for Payer: Cash Price	$3,105.00
Rate for Payer: Cigna Commercial	$3,277.50
Rate for Payer: Cigna Medicare	$3,105.00
Rate for Payer: Medicaid All Medicaid	$3,174.00
Rate for Payer: Medicare All Medicare	$2,415.00
Rate for Payer: Monida Allegiance	$3,277.50
Rate for Payer: Monida First Choice Health	$3,346.50
Rate for Payer: Monida Montana Health Co-op	$3,277.50
Rate for Payer: Monida PacificSource	$3,277.50

MR CERVICAL SPINE W CONTRAST

Facility

$2,757.00

Service Code	HCPCS 72142 TC
Hospital Charge Code	5300084
Hospital Revenue Code	612
Min. Negotiated Rate	$1,929.90
Max. Negotiated Rate	$2,757.00
Rate for Payer: Aetna Commercial	$2,619.15
Rate for Payer: Aetna Medicare	$2,481.30
Rate for Payer: BCBS MT CHIP	$2,481.30
Rate for Payer: BCBS MT Closed Plan Network	$2,619.15
Rate for Payer: BCBS MT HealthLink	$2,481.30
Rate for Payer: BCBS MT Medicare	$2,481.30
Rate for Payer: BCBS MT POS	$2,619.15
Rate for Payer: BCBS MT Traditional	$2,757.00
Rate for Payer: Cash Price	$2,481.30
Rate for Payer: Cigna Commercial	$2,619.15
Rate for Payer: Cigna Medicare	$2,481.30
Rate for Payer: Medicaid All Medicaid	$2,536.44
Rate for Payer: Medicare All Medicare	$1,929.90
Rate for Payer: Monida Allegiance	$2,619.15
Rate for Payer: Monida First Choice Health	$2,674.29
Rate for Payer: Monida Montana Health Co-op	$2,619.15
Rate for Payer: Monida PacificSource	$2,619.15

MR CERVICAL SPINE W CONTRAST

Facility

$2,757.00

Service Code	HCPCS 72142 TC
Hospital Charge Code	5300084
Hospital Revenue Code	612
Min. Negotiated Rate	$1,929.90
Max. Negotiated Rate	$2,757.00
Rate for Payer: Aetna Commercial	$2,619.15
Rate for Payer: Aetna Medicare	$2,481.30
Rate for Payer: BCBS MT CHIP	$2,481.30
Rate for Payer: BCBS MT Closed Plan Network	$2,619.15
Rate for Payer: BCBS MT HealthLink	$2,481.30
Rate for Payer: BCBS MT Medicare	$2,481.30
Rate for Payer: BCBS MT POS	$2,619.15
Rate for Payer: BCBS MT Traditional	$2,757.00
Rate for Payer: Cash Price	$2,481.30
Rate for Payer: Cigna Commercial	$2,619.15
Rate for Payer: Cigna Medicare	$2,481.30
Rate for Payer: Medicaid All Medicaid	$2,536.44
Rate for Payer: Medicare All Medicare	$1,929.90
Rate for Payer: Monida Allegiance	$2,619.15
Rate for Payer: Monida First Choice Health	$2,674.29
Rate for Payer: Monida Montana Health Co-op	$2,619.15
Rate for Payer: Monida PacificSource	$2,619.15

MR CERVICAL SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72141 TC
Hospital Charge Code	5300085
Hospital Revenue Code	612
Min. Negotiated Rate	$1,662.50
Max. Negotiated Rate	$2,375.00
Rate for Payer: Aetna Commercial	$2,256.25
Rate for Payer: Aetna Medicare	$2,137.50
Rate for Payer: BCBS MT CHIP	$2,137.50
Rate for Payer: BCBS MT Closed Plan Network	$2,256.25
Rate for Payer: BCBS MT HealthLink	$2,137.50
Rate for Payer: BCBS MT Medicare	$2,137.50
Rate for Payer: BCBS MT POS	$2,256.25
Rate for Payer: BCBS MT Traditional	$2,375.00
Rate for Payer: Cash Price	$2,137.50
Rate for Payer: Cigna Commercial	$2,256.25
Rate for Payer: Cigna Medicare	$2,137.50
Rate for Payer: Medicaid All Medicaid	$2,185.00
Rate for Payer: Medicare All Medicare	$1,662.50
Rate for Payer: Monida Allegiance	$2,256.25
Rate for Payer: Monida First Choice Health	$2,303.75
Rate for Payer: Monida Montana Health Co-op	$2,256.25
Rate for Payer: Monida PacificSource	$2,256.25

MR CERVICAL SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72141 TC
Hospital Charge Code	5300085
Hospital Revenue Code	612
Min. Negotiated Rate	$1,662.50
Max. Negotiated Rate	$2,375.00
Rate for Payer: Aetna Commercial	$2,256.25
Rate for Payer: Aetna Medicare	$2,137.50
Rate for Payer: BCBS MT CHIP	$2,137.50
Rate for Payer: BCBS MT Closed Plan Network	$2,256.25
Rate for Payer: BCBS MT HealthLink	$2,137.50
Rate for Payer: BCBS MT Medicare	$2,137.50
Rate for Payer: BCBS MT POS	$2,256.25
Rate for Payer: BCBS MT Traditional	$2,375.00
Rate for Payer: Cash Price	$2,137.50
Rate for Payer: Cigna Commercial	$2,256.25
Rate for Payer: Cigna Medicare	$2,137.50
Rate for Payer: Medicaid All Medicaid	$2,185.00
Rate for Payer: Medicare All Medicare	$1,662.50
Rate for Payer: Monida Allegiance	$2,256.25
Rate for Payer: Monida First Choice Health	$2,303.75
Rate for Payer: Monida Montana Health Co-op	$2,256.25
Rate for Payer: Monida PacificSource	$2,256.25

MR CERVICAL SPINE W WO CONTRAST

Facility

$3,472.00

Service Code	HCPCS 72156 TC
Hospital Charge Code	5300086
Hospital Revenue Code	612
Min. Negotiated Rate	$2,430.40
Max. Negotiated Rate	$3,472.00
Rate for Payer: Aetna Commercial	$3,298.40
Rate for Payer: Aetna Medicare	$3,124.80
Rate for Payer: BCBS MT CHIP	$3,124.80
Rate for Payer: BCBS MT Closed Plan Network	$3,298.40
Rate for Payer: BCBS MT HealthLink	$3,124.80
Rate for Payer: BCBS MT Medicare	$3,124.80
Rate for Payer: BCBS MT POS	$3,298.40
Rate for Payer: BCBS MT Traditional	$3,472.00
Rate for Payer: Cash Price	$3,124.80
Rate for Payer: Cigna Commercial	$3,298.40
Rate for Payer: Cigna Medicare	$3,124.80
Rate for Payer: Medicaid All Medicaid	$3,194.24
Rate for Payer: Medicare All Medicare	$2,430.40
Rate for Payer: Monida Allegiance	$3,298.40
Rate for Payer: Monida First Choice Health	$3,367.84
Rate for Payer: Monida Montana Health Co-op	$3,298.40
Rate for Payer: Monida PacificSource	$3,298.40

MR CERVICAL SPINE W WO CONTRAST

Facility

$3,472.00

Service Code	HCPCS 72156 TC
Hospital Charge Code	5300086
Hospital Revenue Code	612
Min. Negotiated Rate	$2,430.40
Max. Negotiated Rate	$3,472.00
Rate for Payer: Aetna Commercial	$3,298.40
Rate for Payer: Aetna Medicare	$3,124.80
Rate for Payer: BCBS MT CHIP	$3,124.80
Rate for Payer: BCBS MT Closed Plan Network	$3,298.40
Rate for Payer: BCBS MT HealthLink	$3,124.80
Rate for Payer: BCBS MT Medicare	$3,124.80
Rate for Payer: BCBS MT POS	$3,298.40
Rate for Payer: BCBS MT Traditional	$3,472.00
Rate for Payer: Cash Price	$3,124.80
Rate for Payer: Cigna Commercial	$3,298.40
Rate for Payer: Cigna Medicare	$3,124.80
Rate for Payer: Medicaid All Medicaid	$3,194.24
Rate for Payer: Medicare All Medicare	$2,430.40
Rate for Payer: Monida Allegiance	$3,298.40
Rate for Payer: Monida First Choice Health	$3,367.84
Rate for Payer: Monida Montana Health Co-op	$3,298.40
Rate for Payer: Monida PacificSource	$3,298.40

MR CHEST W CONTRAST

Facility

$2,577.00

Service Code	HCPCS 71551 TC
Hospital Charge Code	5300087
Hospital Revenue Code	614
Min. Negotiated Rate	$1,803.90
Max. Negotiated Rate	$2,577.00
Rate for Payer: Aetna Commercial	$2,448.15
Rate for Payer: Aetna Medicare	$2,319.30
Rate for Payer: BCBS MT CHIP	$2,319.30
Rate for Payer: BCBS MT Closed Plan Network	$2,448.15
Rate for Payer: BCBS MT HealthLink	$2,319.30
Rate for Payer: BCBS MT Medicare	$2,319.30
Rate for Payer: BCBS MT POS	$2,448.15
Rate for Payer: BCBS MT Traditional	$2,577.00
Rate for Payer: Cash Price	$2,319.30
Rate for Payer: Cigna Commercial	$2,448.15
Rate for Payer: Cigna Medicare	$2,319.30
Rate for Payer: Medicaid All Medicaid	$2,370.84
Rate for Payer: Medicare All Medicare	$1,803.90
Rate for Payer: Monida Allegiance	$2,448.15
Rate for Payer: Monida First Choice Health	$2,499.69
Rate for Payer: Monida Montana Health Co-op	$2,448.15
Rate for Payer: Monida PacificSource	$2,448.15

MR CHEST W CONTRAST

Facility

$2,577.00

Service Code	HCPCS 71551 TC
Hospital Charge Code	5300087
Hospital Revenue Code	614
Min. Negotiated Rate	$1,803.90
Max. Negotiated Rate	$2,577.00
Rate for Payer: Aetna Commercial	$2,448.15
Rate for Payer: Aetna Medicare	$2,319.30
Rate for Payer: BCBS MT CHIP	$2,319.30
Rate for Payer: BCBS MT Closed Plan Network	$2,448.15
Rate for Payer: BCBS MT HealthLink	$2,319.30
Rate for Payer: BCBS MT Medicare	$2,319.30
Rate for Payer: BCBS MT POS	$2,448.15
Rate for Payer: BCBS MT Traditional	$2,577.00
Rate for Payer: Cash Price	$2,319.30
Rate for Payer: Cigna Commercial	$2,448.15
Rate for Payer: Cigna Medicare	$2,319.30
Rate for Payer: Medicaid All Medicaid	$2,370.84
Rate for Payer: Medicare All Medicare	$1,803.90
Rate for Payer: Monida Allegiance	$2,448.15
Rate for Payer: Monida First Choice Health	$2,499.69
Rate for Payer: Monida Montana Health Co-op	$2,448.15
Rate for Payer: Monida PacificSource	$2,448.15

MR CHEST WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 71550 TC
Hospital Charge Code	5300088
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 CHEST WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 71550 TC
Hospital Charge Code	5300088
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 CHEST W WO CONTRAST

Facility

$3,347.00

Service Code	HCPCS 71552 TC
Hospital Charge Code	5300089
Hospital Revenue Code	614
Min. Negotiated Rate	$2,342.90
Max. Negotiated Rate	$3,347.00
Rate for Payer: Aetna Commercial	$3,179.65
Rate for Payer: Aetna Medicare	$3,012.30
Rate for Payer: BCBS MT CHIP	$3,012.30
Rate for Payer: BCBS MT Closed Plan Network	$3,179.65
Rate for Payer: BCBS MT HealthLink	$3,012.30
Rate for Payer: BCBS MT Medicare	$3,012.30
Rate for Payer: BCBS MT POS	$3,179.65
Rate for Payer: BCBS MT Traditional	$3,347.00
Rate for Payer: Cash Price	$3,012.30
Rate for Payer: Cigna Commercial	$3,179.65
Rate for Payer: Cigna Medicare	$3,012.30
Rate for Payer: Medicaid All Medicaid	$3,079.24
Rate for Payer: Medicare All Medicare	$2,342.90
Rate for Payer: Monida Allegiance	$3,179.65
Rate for Payer: Monida First Choice Health	$3,246.59
Rate for Payer: Monida Montana Health Co-op	$3,179.65
Rate for Payer: Monida PacificSource	$3,179.65

MR CHEST W WO CONTRAST

Facility

$3,347.00

Service Code	HCPCS 71552 TC
Hospital Charge Code	5300089
Hospital Revenue Code	614
Min. Negotiated Rate	$2,342.90
Max. Negotiated Rate	$3,347.00
Rate for Payer: Aetna Commercial	$3,179.65
Rate for Payer: Aetna Medicare	$3,012.30
Rate for Payer: BCBS MT CHIP	$3,012.30
Rate for Payer: BCBS MT Closed Plan Network	$3,179.65
Rate for Payer: BCBS MT HealthLink	$3,012.30
Rate for Payer: BCBS MT Medicare	$3,012.30
Rate for Payer: BCBS MT POS	$3,179.65
Rate for Payer: BCBS MT Traditional	$3,347.00
Rate for Payer: Cash Price	$3,012.30
Rate for Payer: Cigna Commercial	$3,179.65
Rate for Payer: Cigna Medicare	$3,012.30
Rate for Payer: Medicaid All Medicaid	$3,079.24
Rate for Payer: Medicare All Medicare	$2,342.90
Rate for Payer: Monida Allegiance	$3,179.65
Rate for Payer: Monida First Choice Health	$3,246.59
Rate for Payer: Monida Montana Health Co-op	$3,179.65
Rate for Payer: Monida PacificSource	$3,179.65

MR ELBOW LT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300020
Hospital Revenue Code	614
Min. Negotiated Rate	$1,789.20
Max. Negotiated Rate	$2,556.00
Rate for Payer: Aetna Commercial	$2,428.20
Rate for Payer: Aetna Medicare	$2,300.40
Rate for Payer: BCBS MT CHIP	$2,300.40
Rate for Payer: BCBS MT Closed Plan Network	$2,428.20
Rate for Payer: BCBS MT HealthLink	$2,300.40
Rate for Payer: BCBS MT Medicare	$2,300.40
Rate for Payer: BCBS MT POS	$2,428.20
Rate for Payer: BCBS MT Traditional	$2,556.00
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Cigna Commercial	$2,428.20
Rate for Payer: Cigna Medicare	$2,300.40
Rate for Payer: Medicaid All Medicaid	$2,351.52
Rate for Payer: Medicare All Medicare	$1,789.20
Rate for Payer: Monida Allegiance	$2,428.20
Rate for Payer: Monida First Choice Health	$2,479.32
Rate for Payer: Monida Montana Health Co-op	$2,428.20
Rate for Payer: Monida PacificSource	$2,428.20

MR ELBOW LT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300020
Hospital Revenue Code	614
Min. Negotiated Rate	$1,789.20
Max. Negotiated Rate	$2,556.00
Rate for Payer: Aetna Commercial	$2,428.20
Rate for Payer: Aetna Medicare	$2,300.40
Rate for Payer: BCBS MT CHIP	$2,300.40
Rate for Payer: BCBS MT Closed Plan Network	$2,428.20
Rate for Payer: BCBS MT HealthLink	$2,300.40
Rate for Payer: BCBS MT Medicare	$2,300.40
Rate for Payer: BCBS MT POS	$2,428.20
Rate for Payer: BCBS MT Traditional	$2,556.00
Rate for Payer: Cash Price	$2,300.40
Rate for Payer: Cigna Commercial	$2,428.20
Rate for Payer: Cigna Medicare	$2,300.40
Rate for Payer: Medicaid All Medicaid	$2,351.52
Rate for Payer: Medicare All Medicare	$1,789.20
Rate for Payer: Monida Allegiance	$2,428.20
Rate for Payer: Monida First Choice Health	$2,479.32
Rate for Payer: Monida Montana Health Co-op	$2,428.20
Rate for Payer: Monida PacificSource	$2,428.20

MR ELBOW LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300026
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR ELBOW LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300026
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR ELBOW LT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300032
Hospital Revenue Code	614
Min. Negotiated Rate	$2,243.50
Max. Negotiated Rate	$3,205.00
Rate for Payer: Aetna Commercial	$3,044.75
Rate for Payer: Aetna Medicare	$2,884.50
Rate for Payer: BCBS MT CHIP	$2,884.50
Rate for Payer: BCBS MT Closed Plan Network	$3,044.75
Rate for Payer: BCBS MT HealthLink	$2,884.50
Rate for Payer: BCBS MT Medicare	$2,884.50
Rate for Payer: BCBS MT POS	$3,044.75
Rate for Payer: BCBS MT Traditional	$3,205.00
Rate for Payer: Cash Price	$2,884.50
Rate for Payer: Cigna Commercial	$3,044.75
Rate for Payer: Cigna Medicare	$2,884.50
Rate for Payer: Medicaid All Medicaid	$2,948.60
Rate for Payer: Medicare All Medicare	$2,243.50
Rate for Payer: Monida Allegiance	$3,044.75
Rate for Payer: Monida First Choice Health	$3,108.85
Rate for Payer: Monida Montana Health Co-op	$3,044.75
Rate for Payer: Monida PacificSource	$3,044.75

MR ELBOW LT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300032
Hospital Revenue Code	614
Min. Negotiated Rate	$2,243.50
Max. Negotiated Rate	$3,205.00
Rate for Payer: Aetna Commercial	$3,044.75
Rate for Payer: Aetna Medicare	$2,884.50
Rate for Payer: BCBS MT CHIP	$2,884.50
Rate for Payer: BCBS MT Closed Plan Network	$3,044.75
Rate for Payer: BCBS MT HealthLink	$2,884.50
Rate for Payer: BCBS MT Medicare	$2,884.50
Rate for Payer: BCBS MT POS	$3,044.75
Rate for Payer: BCBS MT Traditional	$3,205.00
Rate for Payer: Cash Price	$2,884.50
Rate for Payer: Cigna Commercial	$3,044.75
Rate for Payer: Cigna Medicare	$2,884.50
Rate for Payer: Medicaid All Medicaid	$2,948.60
Rate for Payer: Medicare All Medicare	$2,243.50
Rate for Payer: Monida Allegiance	$3,044.75
Rate for Payer: Monida First Choice Health	$3,108.85
Rate for Payer: Monida Montana Health Co-op	$3,044.75
Rate for Payer: Monida PacificSource	$3,044.75

Know your out-of-pocket cost for care.

All Charges