Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR JNT UPPR EXT WO&W CN LT

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300101
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 JNT UPPR EXT WO&W CN LT

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300101
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 JNT UPPR EXT WO&W CN RT

Facility

$3,205.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300102
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 JNT UPPR EXT WO&W CN RT

Facility

$3,205.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300102
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 KNEE LT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300002
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 KNEE LT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300002
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 KNEE LT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300008
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 KNEE LT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300008
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 KNEE LT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300014
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 KNEE LT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300014
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 KNEE RT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300005
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 KNEE RT W CONTRAST

Facility

$2,571.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300005
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 KNEE RT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300011
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 KNEE RT WO CONTRAST

Facility

$2,276.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300011
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 KNEE RT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300017
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 KNEE RT W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300017
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 LUMBAR SPINE W CONTRAST

Facility

$2,757.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	5300103
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 LUMBAR SPINE W CONTRAST

Facility

$2,757.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	5300103
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 LUMBAR SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	5300104
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 LUMBAR SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	5300104
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 LUMBAR SPINE W WO CONTRAST

Facility

$3,472.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	5300105
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 LUMBAR SPINE W WO CONTRAST

Facility

$3,472.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	5300105
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 LWR EXT W CON LT

Facility

$2,495.00

Service Code	HCPCS 73719 TC,LT
Hospital Charge Code	5300106
Hospital Revenue Code	614
Min. Negotiated Rate	$1,746.50
Max. Negotiated Rate	$2,495.00
Rate for Payer: Aetna Commercial	$2,370.25
Rate for Payer: Aetna Medicare	$2,245.50
Rate for Payer: BCBS MT CHIP	$2,245.50
Rate for Payer: BCBS MT Closed Plan Network	$2,370.25
Rate for Payer: BCBS MT HealthLink	$2,245.50
Rate for Payer: BCBS MT Medicare	$2,245.50
Rate for Payer: BCBS MT POS	$2,370.25
Rate for Payer: BCBS MT Traditional	$2,495.00
Rate for Payer: Cash Price	$2,245.50
Rate for Payer: Cigna Commercial	$2,370.25
Rate for Payer: Cigna Medicare	$2,245.50
Rate for Payer: Medicaid All Medicaid	$2,295.40
Rate for Payer: Medicare All Medicare	$1,746.50
Rate for Payer: Monida Allegiance	$2,370.25
Rate for Payer: Monida First Choice Health	$2,420.15
Rate for Payer: Monida Montana Health Co-op	$2,370.25
Rate for Payer: Monida PacificSource	$2,370.25

MR LWR EXT W CON LT

Facility

$2,495.00

Service Code	HCPCS 73719 TC,LT
Hospital Charge Code	5300106
Hospital Revenue Code	614
Min. Negotiated Rate	$1,746.50
Max. Negotiated Rate	$2,495.00
Rate for Payer: Aetna Commercial	$2,370.25
Rate for Payer: Aetna Medicare	$2,245.50
Rate for Payer: BCBS MT CHIP	$2,245.50
Rate for Payer: BCBS MT Closed Plan Network	$2,370.25
Rate for Payer: BCBS MT HealthLink	$2,245.50
Rate for Payer: BCBS MT Medicare	$2,245.50
Rate for Payer: BCBS MT POS	$2,370.25
Rate for Payer: BCBS MT Traditional	$2,495.00
Rate for Payer: Cash Price	$2,245.50
Rate for Payer: Cigna Commercial	$2,370.25
Rate for Payer: Cigna Medicare	$2,245.50
Rate for Payer: Medicaid All Medicaid	$2,295.40
Rate for Payer: Medicare All Medicare	$1,746.50
Rate for Payer: Monida Allegiance	$2,370.25
Rate for Payer: Monida First Choice Health	$2,420.15
Rate for Payer: Monida Montana Health Co-op	$2,370.25
Rate for Payer: Monida PacificSource	$2,370.25

MR LWR EXT W CON RT

Facility

$2,495.00

Service Code	HCPCS 73719 TC,RT
Hospital Charge Code	5300107
Hospital Revenue Code	614
Min. Negotiated Rate	$1,746.50
Max. Negotiated Rate	$2,495.00
Rate for Payer: Aetna Commercial	$2,370.25
Rate for Payer: Aetna Medicare	$2,245.50
Rate for Payer: BCBS MT CHIP	$2,245.50
Rate for Payer: BCBS MT Closed Plan Network	$2,370.25
Rate for Payer: BCBS MT HealthLink	$2,245.50
Rate for Payer: BCBS MT Medicare	$2,245.50
Rate for Payer: BCBS MT POS	$2,370.25
Rate for Payer: BCBS MT Traditional	$2,495.00
Rate for Payer: Cash Price	$2,245.50
Rate for Payer: Cigna Commercial	$2,370.25
Rate for Payer: Cigna Medicare	$2,245.50
Rate for Payer: Medicaid All Medicaid	$2,295.40
Rate for Payer: Medicare All Medicare	$1,746.50
Rate for Payer: Monida Allegiance	$2,370.25
Rate for Payer: Monida First Choice Health	$2,420.15
Rate for Payer: Monida Montana Health Co-op	$2,370.25
Rate for Payer: Monida PacificSource	$2,370.25

Know your out-of-pocket cost for care.

All Charges