Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MR HUMERUS RT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300128
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 WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300128
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

MRI DOTAREM 20ML CONTRAST BOTTLE

Facility

$218.00

Service Code	HCPCS A9575
Hospital Charge Code	5300090
Hospital Revenue Code	636
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

MRI DOTAREM 20ML CONTRAST BOTTLE

Facility

$218.00

Service Code	HCPCS A9575
Hospital Charge Code	5300090
Hospital Revenue Code	636
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

MR JNT LWR EXT W CON LT

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300091
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 JNT LWR EXT W CON LT

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300091
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 JNT LWR EXT W CON RT

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300092
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 JNT LWR EXT W CON RT

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300092
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 JNT LWR EXT W/O CON LT

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300093
Hospital Revenue Code	610
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 JNT LWR EXT W/O CON LT

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300093
Hospital Revenue Code	610
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 JNT LWR XT WO CON RT

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300094
Hospital Revenue Code	610
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 JNT LWR XT WO CON RT

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300094
Hospital Revenue Code	610
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 JNT LWR XT WO&W CON L

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300095
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 JNT LWR XT WO&W CON L

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300095
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 JNT LWR XT WO&W CON R

Facility

$3,281.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300096
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 JNT LWR XT WO&W CON R

Facility

$3,281.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300096
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 JNT UPPR EXT W CON LT

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300097
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 JNT UPPR EXT W CON LT

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300097
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 JNT UPPR EXT W CON RT

Facility

$2,556.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300098
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 JNT UPPR EXT W CON RT

Facility

$2,556.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300098
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 JNT UPPR EXT WO CO LT

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300099
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 JNT UPPR EXT WO CO LT

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300099
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 JNT UPPR EXT WO CON R

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300100
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 JNT UPPR EXT WO CON R

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300100
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

Know your out-of-pocket cost for care.

All Charges