Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR SHOULDER LT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300019
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 SHOULDER LT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300019
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 SHOULDER LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300025
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 SHOULDER LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300025
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 SHOULDER LT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300031
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 SHOULDER LT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300031
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 SHOULDER RT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300022
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 SHOULDER RT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300022
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 SHOULDER RT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300028
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 SHOULDER RT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300028
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 SHOULDER RT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300034
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 SHOULDER RT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300034
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 THORACIC SPINE W CONTRAST

Facility

$2,757.00

Service Code	HCPCS 72147 TC
Hospital Charge Code	5300118
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 THORACIC SPINE W CONTRAST

Facility

$2,757.00

Service Code	HCPCS 72147 TC
Hospital Charge Code	5300118
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 THORACIC SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72146 TC
Hospital Charge Code	5300119
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 THORACIC SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72146 TC
Hospital Charge Code	5300119
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 THORACIC SPINE W WO CONTRAST

Facility

$3,472.00

Service Code	HCPCS 72157 TC
Hospital Charge Code	5300120
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 THORACIC SPINE W WO CONTRAST

Facility

$3,472.00

Service Code	HCPCS 72157 TC
Hospital Charge Code	5300120
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 TIBIA FIBULA LT W CONTRAST

Facility

$2,495.00

Service Code	HCPCS 73719 TC,LT
Hospital Charge Code	5300038
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 TIBIA FIBULA LT W CONTRAST

Facility

$2,495.00

Service Code	HCPCS 73719 TC,LT
Hospital Charge Code	5300038
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 TIBIA FIBULA LT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,LT
Hospital Charge Code	5300044
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR TIBIA FIBULA LT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,LT
Hospital Charge Code	5300044
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR TIBIA FIBULA LT W WO CONTRAST

Facility

$3,167.00

Service Code	HCPCS 73720 TC,LT
Hospital Charge Code	5300050
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR TIBIA FIBULA LT W WO CONTRAST

Facility

$3,167.00

Service Code	HCPCS 73720 TC,LT
Hospital Charge Code	5300050
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR TIBIA FIBULA RT W CONTRAST

Facility

$2,495.00

Service Code	HCPCS 73719 TC,RT
Hospital Charge Code	5300041
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.

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