Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MITOCHONDRIAL ANTIBODY (006650)

Facility

$26.00

Service Code	HCPCS 86381
Hospital Charge Code	4000516
Hospital Revenue Code	301
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MOMETASONE FUROATE 100MCG/5MCG INH

Facility

$640.10

Service Code	NDC 78206012702
Hospital Charge Code	3007386
Hospital Revenue Code	250
Min. Negotiated Rate	$448.07
Max. Negotiated Rate	$640.10
Rate for Payer: Aetna Commercial	$608.10
Rate for Payer: Aetna Medicare	$576.09
Rate for Payer: BCBS MT CHIP	$576.09
Rate for Payer: BCBS MT Closed Plan Network	$608.10
Rate for Payer: BCBS MT HealthLink	$576.09
Rate for Payer: BCBS MT Medicare	$576.09
Rate for Payer: BCBS MT POS	$608.10
Rate for Payer: BCBS MT Traditional	$640.10
Rate for Payer: Cash Price	$576.09
Rate for Payer: Cigna Commercial	$608.10
Rate for Payer: Cigna Medicare	$576.09
Rate for Payer: Medicaid All Medicaid	$588.89
Rate for Payer: Medicare All Medicare	$448.07
Rate for Payer: Monida Allegiance	$608.10
Rate for Payer: Monida First Choice Health	$620.90
Rate for Payer: Monida Montana Health Co-op	$608.10
Rate for Payer: Monida PacificSource	$608.10

MOMETASONE FUROATE 100MCG/5MCG INH

Facility

$640.10

Service Code	NDC 78206012702
Hospital Charge Code	3007386
Hospital Revenue Code	250
Min. Negotiated Rate	$448.07
Max. Negotiated Rate	$640.10
Rate for Payer: Aetna Commercial	$608.10
Rate for Payer: Aetna Medicare	$576.09
Rate for Payer: BCBS MT CHIP	$576.09
Rate for Payer: BCBS MT Closed Plan Network	$608.10
Rate for Payer: BCBS MT HealthLink	$576.09
Rate for Payer: BCBS MT Medicare	$576.09
Rate for Payer: BCBS MT POS	$608.10
Rate for Payer: BCBS MT Traditional	$640.10
Rate for Payer: Cash Price	$576.09
Rate for Payer: Cigna Commercial	$608.10
Rate for Payer: Cigna Medicare	$576.09
Rate for Payer: Medicaid All Medicaid	$588.89
Rate for Payer: Medicare All Medicare	$448.07
Rate for Payer: Monida Allegiance	$608.10
Rate for Payer: Monida First Choice Health	$620.90
Rate for Payer: Monida Montana Health Co-op	$608.10
Rate for Payer: Monida PacificSource	$608.10

MONTELUKAST TAB [10 MG]

Facility

$18.00

Service Code	HCPCS J3490
Hospital Charge Code	3000335
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

MONTELUKAST TAB [10 MG]

Facility

$18.00

Service Code	HCPCS J3490
Hospital Charge Code	3000335
Hospital Revenue Code	250
Min. Negotiated Rate	$12.60
Max. Negotiated Rate	$18.00
Rate for Payer: Aetna Commercial	$17.10
Rate for Payer: Aetna Medicare	$16.20
Rate for Payer: BCBS MT CHIP	$16.20
Rate for Payer: BCBS MT Closed Plan Network	$17.10
Rate for Payer: BCBS MT HealthLink	$16.20
Rate for Payer: BCBS MT Medicare	$16.20
Rate for Payer: BCBS MT POS	$17.10
Rate for Payer: BCBS MT Traditional	$18.00
Rate for Payer: Cash Price	$16.20
Rate for Payer: Cigna Commercial	$17.10
Rate for Payer: Cigna Medicare	$16.20
Rate for Payer: Medicaid All Medicaid	$16.56
Rate for Payer: Medicare All Medicare	$12.60
Rate for Payer: Monida Allegiance	$17.10
Rate for Payer: Monida First Choice Health	$17.46
Rate for Payer: Monida Montana Health Co-op	$17.10
Rate for Payer: Monida PacificSource	$17.10

MORPHINE INJ [10 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000337
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MORPHINE INJ [10 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000337
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MORPHINE INJ [4 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000338
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MORPHINE INJ [4 MG/ML] VL

Facility

$26.00

Service Code	HCPCS J2270
Hospital Charge Code	3000338
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

MORPHINE ORAL SLN [20 MG/ML] 30ML BTL

Facility

$81.00

Service Code	HCPCS J3490
Hospital Charge Code	3000559
Hospital Revenue Code	250
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

MORPHINE ORAL SLN [20 MG/ML] 30ML BTL

Facility

$81.00

Service Code	HCPCS J3490
Hospital Charge Code	3000559
Hospital Revenue Code	250
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

MORPHINE SOLN (ROXANOL) 10MG/5ML UD CUP

Facility

$8.00

Service Code	NDC 68094000162
Hospital Charge Code	3007063
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

MORPHINE SOLN (ROXANOL) 10MG/5ML UD CUP

Facility

$8.00

Service Code	NDC 68094000162
Hospital Charge Code	3007063
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

MPL EXON 10 MUTATION CODE

Facility

$950.00

Service Code	HCPCS 81339
Hospital Charge Code	4087910
Hospital Revenue Code	300
Min. Negotiated Rate	$665.00
Max. Negotiated Rate	$950.00
Rate for Payer: Aetna Commercial	$902.50
Rate for Payer: Aetna Medicare	$855.00
Rate for Payer: BCBS MT CHIP	$855.00
Rate for Payer: BCBS MT Closed Plan Network	$902.50
Rate for Payer: BCBS MT HealthLink	$855.00
Rate for Payer: BCBS MT Medicare	$855.00
Rate for Payer: BCBS MT POS	$902.50
Rate for Payer: BCBS MT Traditional	$950.00
Rate for Payer: Cash Price	$855.00
Rate for Payer: Cigna Commercial	$902.50
Rate for Payer: Cigna Medicare	$855.00
Rate for Payer: Medicaid All Medicaid	$874.00
Rate for Payer: Medicare All Medicare	$665.00
Rate for Payer: Monida Allegiance	$902.50
Rate for Payer: Monida First Choice Health	$921.50
Rate for Payer: Monida Montana Health Co-op	$902.50
Rate for Payer: Monida PacificSource	$902.50

MPL EXON 10 MUTATION CODE

Facility

$950.00

Service Code	HCPCS 81339
Hospital Charge Code	4087910
Hospital Revenue Code	300
Min. Negotiated Rate	$665.00
Max. Negotiated Rate	$950.00
Rate for Payer: Aetna Commercial	$902.50
Rate for Payer: Aetna Medicare	$855.00
Rate for Payer: BCBS MT CHIP	$855.00
Rate for Payer: BCBS MT Closed Plan Network	$902.50
Rate for Payer: BCBS MT HealthLink	$855.00
Rate for Payer: BCBS MT Medicare	$855.00
Rate for Payer: BCBS MT POS	$902.50
Rate for Payer: BCBS MT Traditional	$950.00
Rate for Payer: Cash Price	$855.00
Rate for Payer: Cigna Commercial	$902.50
Rate for Payer: Cigna Medicare	$855.00
Rate for Payer: Medicaid All Medicaid	$874.00
Rate for Payer: Medicare All Medicare	$665.00
Rate for Payer: Monida Allegiance	$902.50
Rate for Payer: Monida First Choice Health	$921.50
Rate for Payer: Monida Montana Health Co-op	$902.50
Rate for Payer: Monida PacificSource	$902.50

MRA ABDOMEN W WO CONTRAST

Facility

$2,610.00

Service Code	HCPCS 74185 TC
Hospital Charge Code	5300065
Hospital Revenue Code	618
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MRA ABDOMEN W WO CONTRAST

Facility

$2,610.00

Service Code	HCPCS 74185 TC
Hospital Charge Code	5300065
Hospital Revenue Code	618
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MR ABDOMEN W CONTRAST

Facility

$2,610.00

Service Code	HCPCS 74182 TC
Hospital Charge Code	5300078
Hospital Revenue Code	614
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MR ABDOMEN W CONTRAST

Facility

$2,610.00

Service Code	HCPCS 74182 TC
Hospital Charge Code	5300078
Hospital Revenue Code	614
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MR ABDOMEN WO CONTRAST

Facility

$2,331.00

Service Code	HCPCS 74181 TC
Hospital Charge Code	5300079
Hospital Revenue Code	614
Min. Negotiated Rate	$1,631.70
Max. Negotiated Rate	$2,331.00
Rate for Payer: Aetna Commercial	$2,214.45
Rate for Payer: Aetna Medicare	$2,097.90
Rate for Payer: BCBS MT CHIP	$2,097.90
Rate for Payer: BCBS MT Closed Plan Network	$2,214.45
Rate for Payer: BCBS MT HealthLink	$2,097.90
Rate for Payer: BCBS MT Medicare	$2,097.90
Rate for Payer: BCBS MT POS	$2,214.45
Rate for Payer: BCBS MT Traditional	$2,331.00
Rate for Payer: Cash Price	$2,097.90
Rate for Payer: Cigna Commercial	$2,214.45
Rate for Payer: Cigna Medicare	$2,097.90
Rate for Payer: Medicaid All Medicaid	$2,144.52
Rate for Payer: Medicare All Medicare	$1,631.70
Rate for Payer: Monida Allegiance	$2,214.45
Rate for Payer: Monida First Choice Health	$2,261.07
Rate for Payer: Monida Montana Health Co-op	$2,214.45
Rate for Payer: Monida PacificSource	$2,214.45

MR ABDOMEN WO CONTRAST

Facility

$2,331.00

Service Code	HCPCS 74181 TC
Hospital Charge Code	5300079
Hospital Revenue Code	614
Min. Negotiated Rate	$1,631.70
Max. Negotiated Rate	$2,331.00
Rate for Payer: Aetna Commercial	$2,214.45
Rate for Payer: Aetna Medicare	$2,097.90
Rate for Payer: BCBS MT CHIP	$2,097.90
Rate for Payer: BCBS MT Closed Plan Network	$2,214.45
Rate for Payer: BCBS MT HealthLink	$2,097.90
Rate for Payer: BCBS MT Medicare	$2,097.90
Rate for Payer: BCBS MT POS	$2,214.45
Rate for Payer: BCBS MT Traditional	$2,331.00
Rate for Payer: Cash Price	$2,097.90
Rate for Payer: Cigna Commercial	$2,214.45
Rate for Payer: Cigna Medicare	$2,097.90
Rate for Payer: Medicaid All Medicaid	$2,144.52
Rate for Payer: Medicare All Medicare	$1,631.70
Rate for Payer: Monida Allegiance	$2,214.45
Rate for Payer: Monida First Choice Health	$2,261.07
Rate for Payer: Monida Montana Health Co-op	$2,214.45
Rate for Payer: Monida PacificSource	$2,214.45

MR ABDOMEN W WO CONTRAST

Facility

$3,519.00

Service Code	HCPCS 74183 TC
Hospital Charge Code	5300080
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST

Facility

$3,519.00

Service Code	HCPCS 74183 TC
Hospital Charge Code	5300080
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MRA CHEST W WO CONTRAST

Facility

$1,812.00

Service Code	HCPCS 71555 TC
Hospital Charge Code	5300066
Hospital Revenue Code	618
Min. Negotiated Rate	$1,268.40
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna Commercial	$1,721.40
Rate for Payer: Aetna Medicare	$1,630.80
Rate for Payer: BCBS MT CHIP	$1,630.80
Rate for Payer: BCBS MT Closed Plan Network	$1,721.40
Rate for Payer: BCBS MT HealthLink	$1,630.80
Rate for Payer: BCBS MT Medicare	$1,630.80
Rate for Payer: BCBS MT POS	$1,721.40
Rate for Payer: BCBS MT Traditional	$1,812.00
Rate for Payer: Cash Price	$1,630.80
Rate for Payer: Cigna Commercial	$1,721.40
Rate for Payer: Cigna Medicare	$1,630.80
Rate for Payer: Medicaid All Medicaid	$1,667.04
Rate for Payer: Medicare All Medicare	$1,268.40
Rate for Payer: Monida Allegiance	$1,721.40
Rate for Payer: Monida First Choice Health	$1,757.64
Rate for Payer: Monida Montana Health Co-op	$1,721.40
Rate for Payer: Monida PacificSource	$1,721.40

MRA CHEST W WO CONTRAST

Facility

$1,812.00

Service Code	HCPCS 71555 TC
Hospital Charge Code	5300066
Hospital Revenue Code	618
Min. Negotiated Rate	$1,268.40
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna Commercial	$1,721.40
Rate for Payer: Aetna Medicare	$1,630.80
Rate for Payer: BCBS MT CHIP	$1,630.80
Rate for Payer: BCBS MT Closed Plan Network	$1,721.40
Rate for Payer: BCBS MT HealthLink	$1,630.80
Rate for Payer: BCBS MT Medicare	$1,630.80
Rate for Payer: BCBS MT POS	$1,721.40
Rate for Payer: BCBS MT Traditional	$1,812.00
Rate for Payer: Cash Price	$1,630.80
Rate for Payer: Cigna Commercial	$1,721.40
Rate for Payer: Cigna Medicare	$1,630.80
Rate for Payer: Medicaid All Medicaid	$1,667.04
Rate for Payer: Medicare All Medicare	$1,268.40
Rate for Payer: Monida Allegiance	$1,721.40
Rate for Payer: Monida First Choice Health	$1,757.64
Rate for Payer: Monida Montana Health Co-op	$1,721.40
Rate for Payer: Monida PacificSource	$1,721.40

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