Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MR TIBIA FIBULA RT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,RT
Hospital Charge Code	5300047
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 RT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,RT
Hospital Charge Code	5300047
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 RT W WO CONTRAST

Facility

$3,167.00

Service Code	HCPCS 73720 TC,RT
Hospital Charge Code	5300053
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 WO CONTRAST

Facility

$3,167.00

Service Code	HCPCS 73720 TC,RT
Hospital Charge Code	5300053
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 TMJ

Facility

$2,113.00

Service Code	HCPCS 70336 TC
Hospital Charge Code	5300117
Hospital Revenue Code	614
Min. Negotiated Rate	$1,479.10
Max. Negotiated Rate	$2,113.00
Rate for Payer: Aetna Commercial	$2,007.35
Rate for Payer: Aetna Medicare	$1,901.70
Rate for Payer: BCBS MT CHIP	$1,901.70
Rate for Payer: BCBS MT Closed Plan Network	$2,007.35
Rate for Payer: BCBS MT HealthLink	$1,901.70
Rate for Payer: BCBS MT Medicare	$1,901.70
Rate for Payer: BCBS MT POS	$2,007.35
Rate for Payer: BCBS MT Traditional	$2,113.00
Rate for Payer: Cash Price	$1,901.70
Rate for Payer: Cigna Commercial	$2,007.35
Rate for Payer: Cigna Medicare	$1,901.70
Rate for Payer: Medicaid All Medicaid	$1,943.96
Rate for Payer: Medicare All Medicare	$1,479.10
Rate for Payer: Monida Allegiance	$2,007.35
Rate for Payer: Monida First Choice Health	$2,049.61
Rate for Payer: Monida Montana Health Co-op	$2,007.35
Rate for Payer: Monida PacificSource	$2,007.35

MR TMJ

Facility

$2,113.00

Service Code	HCPCS 70336 TC
Hospital Charge Code	5300117
Hospital Revenue Code	614
Min. Negotiated Rate	$1,479.10
Max. Negotiated Rate	$2,113.00
Rate for Payer: Aetna Commercial	$2,007.35
Rate for Payer: Aetna Medicare	$1,901.70
Rate for Payer: BCBS MT CHIP	$1,901.70
Rate for Payer: BCBS MT Closed Plan Network	$2,007.35
Rate for Payer: BCBS MT HealthLink	$1,901.70
Rate for Payer: BCBS MT Medicare	$1,901.70
Rate for Payer: BCBS MT POS	$2,007.35
Rate for Payer: BCBS MT Traditional	$2,113.00
Rate for Payer: Cash Price	$1,901.70
Rate for Payer: Cigna Commercial	$2,007.35
Rate for Payer: Cigna Medicare	$1,901.70
Rate for Payer: Medicaid All Medicaid	$1,943.96
Rate for Payer: Medicare All Medicare	$1,479.10
Rate for Payer: Monida Allegiance	$2,007.35
Rate for Payer: Monida First Choice Health	$2,049.61
Rate for Payer: Monida Montana Health Co-op	$2,007.35
Rate for Payer: Monida PacificSource	$2,007.35

MR UPPR XT W CON LT

Facility

$2,752.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300121
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 UPPR XT W CON LT

Facility

$2,752.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300121
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 UPPR XT W CON RT

Facility

$2,752.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300122
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 UPPR XT W CON RT

Facility

$2,752.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300122
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 UPPR XT WO CON LT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300123
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 UPPR XT WO CON LT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300123
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 UPPR XT WO CON RT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300124
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 UPPR XT WO CON RT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300124
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 UPPR XT WO&W CON LT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300125
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 UPPR XT WO&W CON LT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300125
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 UPPR XT WO&W CON RT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300126
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 UPPR XT WO&W CON RT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300126
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 WRIST LT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300021
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 WRIST LT W CONTRAST

Facility

$2,556.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300021
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 WRIST LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300027
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 WRIST LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300027
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 WRIST LT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300033
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 WRIST LT W WO CONTRAST

Facility

$3,205.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300033
Hospital Revenue Code	614
Min. Negotiated Rate	$2,243.50
Max. Negotiated Rate	$3,205.00
Rate for Payer: Aetna Commercial	$3,044.75
Rate for Payer: Aetna Medicare	$2,884.50
Rate for Payer: BCBS MT CHIP	$2,884.50
Rate for Payer: BCBS MT Closed Plan Network	$3,044.75
Rate for Payer: BCBS MT HealthLink	$2,884.50
Rate for Payer: BCBS MT Medicare	$2,884.50
Rate for Payer: BCBS MT POS	$3,044.75
Rate for Payer: BCBS MT Traditional	$3,205.00
Rate for Payer: Cash Price	$2,884.50
Rate for Payer: Cigna Commercial	$3,044.75
Rate for Payer: Cigna Medicare	$2,884.50
Rate for Payer: Medicaid All Medicaid	$2,948.60
Rate for Payer: Medicare All Medicare	$2,243.50
Rate for Payer: Monida Allegiance	$3,044.75
Rate for Payer: Monida First Choice Health	$3,108.85
Rate for Payer: Monida Montana Health Co-op	$3,044.75
Rate for Payer: Monida PacificSource	$3,044.75

Know your out-of-pocket cost for care.

All Charges