Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR HAND RT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300074
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR HAND RT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300074
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR HAND RT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300130
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MR HAND RT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300130
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MR HIP LT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300001
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 HIP LT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300001
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 HIP LT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300007
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 HIP LT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300007
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 HIP LT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300013
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 HIP LT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300013
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 HIP RT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300004
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 HIP RT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300004
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 HIP RT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300010
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 HIP RT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300010
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 HIP RT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300016
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 HIP RT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300016
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 HUMERUS LT W CONTRAST

Facility

$2,752.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300055
Hospital Revenue Code	614
Min. Negotiated Rate	$1,926.40
Max. Negotiated Rate	$2,752.00
Rate for Payer: Aetna Commercial	$2,614.40
Rate for Payer: Aetna Medicare	$2,476.80
Rate for Payer: BCBS MT CHIP	$2,476.80
Rate for Payer: BCBS MT Closed Plan Network	$2,614.40
Rate for Payer: BCBS MT HealthLink	$2,476.80
Rate for Payer: BCBS MT Medicare	$2,476.80
Rate for Payer: BCBS MT POS	$2,614.40
Rate for Payer: BCBS MT Traditional	$2,752.00
Rate for Payer: Cash Price	$2,476.80
Rate for Payer: Cigna Commercial	$2,614.40
Rate for Payer: Cigna Medicare	$2,476.80
Rate for Payer: Medicaid All Medicaid	$2,531.84
Rate for Payer: Medicare All Medicare	$1,926.40
Rate for Payer: Monida Allegiance	$2,614.40
Rate for Payer: Monida First Choice Health	$2,669.44
Rate for Payer: Monida Montana Health Co-op	$2,614.40
Rate for Payer: Monida PacificSource	$2,614.40

MR HUMERUS LT W CONTRAST

Facility

$2,752.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300055
Hospital Revenue Code	614
Min. Negotiated Rate	$1,926.40
Max. Negotiated Rate	$2,752.00
Rate for Payer: Aetna Commercial	$2,614.40
Rate for Payer: Aetna Medicare	$2,476.80
Rate for Payer: BCBS MT CHIP	$2,476.80
Rate for Payer: BCBS MT Closed Plan Network	$2,614.40
Rate for Payer: BCBS MT HealthLink	$2,476.80
Rate for Payer: BCBS MT Medicare	$2,476.80
Rate for Payer: BCBS MT POS	$2,614.40
Rate for Payer: BCBS MT Traditional	$2,752.00
Rate for Payer: Cash Price	$2,476.80
Rate for Payer: Cigna Commercial	$2,614.40
Rate for Payer: Cigna Medicare	$2,476.80
Rate for Payer: Medicaid All Medicaid	$2,531.84
Rate for Payer: Medicare All Medicare	$1,926.40
Rate for Payer: Monida Allegiance	$2,614.40
Rate for Payer: Monida First Choice Health	$2,669.44
Rate for Payer: Monida Montana Health Co-op	$2,614.40
Rate for Payer: Monida PacificSource	$2,614.40

MR HUMERUS LT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300061
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR HUMERUS LT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300061
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR HUMERUS LT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300076
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MR HUMERUS LT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300076
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MR HUMERUS RT W CONTRAST

Facility

$2,752.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300058
Hospital Revenue Code	614
Min. Negotiated Rate	$1,926.40
Max. Negotiated Rate	$2,752.00
Rate for Payer: Aetna Commercial	$2,614.40
Rate for Payer: Aetna Medicare	$2,476.80
Rate for Payer: BCBS MT CHIP	$2,476.80
Rate for Payer: BCBS MT Closed Plan Network	$2,614.40
Rate for Payer: BCBS MT HealthLink	$2,476.80
Rate for Payer: BCBS MT Medicare	$2,476.80
Rate for Payer: BCBS MT POS	$2,614.40
Rate for Payer: BCBS MT Traditional	$2,752.00
Rate for Payer: Cash Price	$2,476.80
Rate for Payer: Cigna Commercial	$2,614.40
Rate for Payer: Cigna Medicare	$2,476.80
Rate for Payer: Medicaid All Medicaid	$2,531.84
Rate for Payer: Medicare All Medicare	$1,926.40
Rate for Payer: Monida Allegiance	$2,614.40
Rate for Payer: Monida First Choice Health	$2,669.44
Rate for Payer: Monida Montana Health Co-op	$2,614.40
Rate for Payer: Monida PacificSource	$2,614.40

MR HUMERUS RT W CONTRAST

Facility

$2,752.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300058
Hospital Revenue Code	614
Min. Negotiated Rate	$1,926.40
Max. Negotiated Rate	$2,752.00
Rate for Payer: Aetna Commercial	$2,614.40
Rate for Payer: Aetna Medicare	$2,476.80
Rate for Payer: BCBS MT CHIP	$2,476.80
Rate for Payer: BCBS MT Closed Plan Network	$2,614.40
Rate for Payer: BCBS MT HealthLink	$2,476.80
Rate for Payer: BCBS MT Medicare	$2,476.80
Rate for Payer: BCBS MT POS	$2,614.40
Rate for Payer: BCBS MT Traditional	$2,752.00
Rate for Payer: Cash Price	$2,476.80
Rate for Payer: Cigna Commercial	$2,614.40
Rate for Payer: Cigna Medicare	$2,476.80
Rate for Payer: Medicaid All Medicaid	$2,531.84
Rate for Payer: Medicare All Medicare	$1,926.40
Rate for Payer: Monida Allegiance	$2,614.40
Rate for Payer: Monida First Choice Health	$2,669.44
Rate for Payer: Monida Montana Health Co-op	$2,614.40
Rate for Payer: Monida PacificSource	$2,614.40

MR HUMERUS RT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300064
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

Know your out-of-pocket cost for care.

All Charges