Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MRA HEAD W CONTRAST

Facility

$2,489.00

Service Code	HCPCS 70545 TC
Hospital Charge Code	5300067
Hospital Revenue Code	615
Min. Negotiated Rate	$1,742.30
Max. Negotiated Rate	$2,489.00
Rate for Payer: Aetna Commercial	$2,364.55
Rate for Payer: Aetna Medicare	$2,240.10
Rate for Payer: BCBS MT CHIP	$2,240.10
Rate for Payer: BCBS MT Closed Plan Network	$2,364.55
Rate for Payer: BCBS MT HealthLink	$2,240.10
Rate for Payer: BCBS MT Medicare	$2,240.10
Rate for Payer: BCBS MT POS	$2,364.55
Rate for Payer: BCBS MT Traditional	$2,489.00
Rate for Payer: Cash Price	$2,240.10
Rate for Payer: Cigna Commercial	$2,364.55
Rate for Payer: Cigna Medicare	$2,240.10
Rate for Payer: Medicaid All Medicaid	$2,289.88
Rate for Payer: Medicare All Medicare	$1,742.30
Rate for Payer: Monida Allegiance	$2,364.55
Rate for Payer: Monida First Choice Health	$2,414.33
Rate for Payer: Monida Montana Health Co-op	$2,364.55
Rate for Payer: Monida PacificSource	$2,364.55

MRA HEAD W CONTRAST

Facility

$2,489.00

Service Code	HCPCS 70545 TC
Hospital Charge Code	5300067
Hospital Revenue Code	615
Min. Negotiated Rate	$1,742.30
Max. Negotiated Rate	$2,489.00
Rate for Payer: Aetna Commercial	$2,364.55
Rate for Payer: Aetna Medicare	$2,240.10
Rate for Payer: BCBS MT CHIP	$2,240.10
Rate for Payer: BCBS MT Closed Plan Network	$2,364.55
Rate for Payer: BCBS MT HealthLink	$2,240.10
Rate for Payer: BCBS MT Medicare	$2,240.10
Rate for Payer: BCBS MT POS	$2,364.55
Rate for Payer: BCBS MT Traditional	$2,489.00
Rate for Payer: Cash Price	$2,240.10
Rate for Payer: Cigna Commercial	$2,364.55
Rate for Payer: Cigna Medicare	$2,240.10
Rate for Payer: Medicaid All Medicaid	$2,289.88
Rate for Payer: Medicare All Medicare	$1,742.30
Rate for Payer: Monida Allegiance	$2,364.55
Rate for Payer: Monida First Choice Health	$2,414.33
Rate for Payer: Monida Montana Health Co-op	$2,364.55
Rate for Payer: Monida PacificSource	$2,364.55

MRA HEAD WO CONTRAST

Facility

$2,292.00

Service Code	HCPCS 70544 TC
Hospital Charge Code	5300069
Hospital Revenue Code	615
Min. Negotiated Rate	$1,604.40
Max. Negotiated Rate	$2,292.00
Rate for Payer: Aetna Commercial	$2,177.40
Rate for Payer: Aetna Medicare	$2,062.80
Rate for Payer: BCBS MT CHIP	$2,062.80
Rate for Payer: BCBS MT Closed Plan Network	$2,177.40
Rate for Payer: BCBS MT HealthLink	$2,062.80
Rate for Payer: BCBS MT Medicare	$2,062.80
Rate for Payer: BCBS MT POS	$2,177.40
Rate for Payer: BCBS MT Traditional	$2,292.00
Rate for Payer: Cash Price	$2,062.80
Rate for Payer: Cigna Commercial	$2,177.40
Rate for Payer: Cigna Medicare	$2,062.80
Rate for Payer: Medicaid All Medicaid	$2,108.64
Rate for Payer: Medicare All Medicare	$1,604.40
Rate for Payer: Monida Allegiance	$2,177.40
Rate for Payer: Monida First Choice Health	$2,223.24
Rate for Payer: Monida Montana Health Co-op	$2,177.40
Rate for Payer: Monida PacificSource	$2,177.40

MRA HEAD WO CONTRAST

Facility

$2,292.00

Service Code	HCPCS 70544 TC
Hospital Charge Code	5300069
Hospital Revenue Code	615
Min. Negotiated Rate	$1,604.40
Max. Negotiated Rate	$2,292.00
Rate for Payer: Aetna Commercial	$2,177.40
Rate for Payer: Aetna Medicare	$2,062.80
Rate for Payer: BCBS MT CHIP	$2,062.80
Rate for Payer: BCBS MT Closed Plan Network	$2,177.40
Rate for Payer: BCBS MT HealthLink	$2,062.80
Rate for Payer: BCBS MT Medicare	$2,062.80
Rate for Payer: BCBS MT POS	$2,177.40
Rate for Payer: BCBS MT Traditional	$2,292.00
Rate for Payer: Cash Price	$2,062.80
Rate for Payer: Cigna Commercial	$2,177.40
Rate for Payer: Cigna Medicare	$2,062.80
Rate for Payer: Medicaid All Medicaid	$2,108.64
Rate for Payer: Medicare All Medicare	$1,604.40
Rate for Payer: Monida Allegiance	$2,177.40
Rate for Payer: Monida First Choice Health	$2,223.24
Rate for Payer: Monida Montana Health Co-op	$2,177.40
Rate for Payer: Monida PacificSource	$2,177.40

MRA HEAD W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70546 TC
Hospital Charge Code	5300068
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MRA HEAD W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70546 TC
Hospital Charge Code	5300068
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MRA NECK W CONTRAST

Facility

$2,558.00

Service Code	HCPCS 70548 TC
Hospital Charge Code	5300071
Hospital Revenue Code	615
Min. Negotiated Rate	$1,790.60
Max. Negotiated Rate	$2,558.00
Rate for Payer: Aetna Commercial	$2,430.10
Rate for Payer: Aetna Medicare	$2,302.20
Rate for Payer: BCBS MT CHIP	$2,302.20
Rate for Payer: BCBS MT Closed Plan Network	$2,430.10
Rate for Payer: BCBS MT HealthLink	$2,302.20
Rate for Payer: BCBS MT Medicare	$2,302.20
Rate for Payer: BCBS MT POS	$2,430.10
Rate for Payer: BCBS MT Traditional	$2,558.00
Rate for Payer: Cash Price	$2,302.20
Rate for Payer: Cigna Commercial	$2,430.10
Rate for Payer: Cigna Medicare	$2,302.20
Rate for Payer: Medicaid All Medicaid	$2,353.36
Rate for Payer: Medicare All Medicare	$1,790.60
Rate for Payer: Monida Allegiance	$2,430.10
Rate for Payer: Monida First Choice Health	$2,481.26
Rate for Payer: Monida Montana Health Co-op	$2,430.10
Rate for Payer: Monida PacificSource	$2,430.10

MRA NECK W CONTRAST

Facility

$2,558.00

Service Code	HCPCS 70548 TC
Hospital Charge Code	5300071
Hospital Revenue Code	615
Min. Negotiated Rate	$1,790.60
Max. Negotiated Rate	$2,558.00
Rate for Payer: Aetna Commercial	$2,430.10
Rate for Payer: Aetna Medicare	$2,302.20
Rate for Payer: BCBS MT CHIP	$2,302.20
Rate for Payer: BCBS MT Closed Plan Network	$2,430.10
Rate for Payer: BCBS MT HealthLink	$2,302.20
Rate for Payer: BCBS MT Medicare	$2,302.20
Rate for Payer: BCBS MT POS	$2,430.10
Rate for Payer: BCBS MT Traditional	$2,558.00
Rate for Payer: Cash Price	$2,302.20
Rate for Payer: Cigna Commercial	$2,430.10
Rate for Payer: Cigna Medicare	$2,302.20
Rate for Payer: Medicaid All Medicaid	$2,353.36
Rate for Payer: Medicare All Medicare	$1,790.60
Rate for Payer: Monida Allegiance	$2,430.10
Rate for Payer: Monida First Choice Health	$2,481.26
Rate for Payer: Monida Montana Health Co-op	$2,430.10
Rate for Payer: Monida PacificSource	$2,430.10

MRA NECK WO CONTRAST

Facility

$2,146.00

Service Code	HCPCS 70547 TC
Hospital Charge Code	5300072
Hospital Revenue Code	615
Min. Negotiated Rate	$1,502.20
Max. Negotiated Rate	$2,146.00
Rate for Payer: Aetna Commercial	$2,038.70
Rate for Payer: Aetna Medicare	$1,931.40
Rate for Payer: BCBS MT CHIP	$1,931.40
Rate for Payer: BCBS MT Closed Plan Network	$2,038.70
Rate for Payer: BCBS MT HealthLink	$1,931.40
Rate for Payer: BCBS MT Medicare	$1,931.40
Rate for Payer: BCBS MT POS	$2,038.70
Rate for Payer: BCBS MT Traditional	$2,146.00
Rate for Payer: Cash Price	$1,931.40
Rate for Payer: Cigna Commercial	$2,038.70
Rate for Payer: Cigna Medicare	$1,931.40
Rate for Payer: Medicaid All Medicaid	$1,974.32
Rate for Payer: Medicare All Medicare	$1,502.20
Rate for Payer: Monida Allegiance	$2,038.70
Rate for Payer: Monida First Choice Health	$2,081.62
Rate for Payer: Monida Montana Health Co-op	$2,038.70
Rate for Payer: Monida PacificSource	$2,038.70

MRA NECK WO CONTRAST

Facility

$2,146.00

Service Code	HCPCS 70547 TC
Hospital Charge Code	5300072
Hospital Revenue Code	615
Min. Negotiated Rate	$1,502.20
Max. Negotiated Rate	$2,146.00
Rate for Payer: Aetna Commercial	$2,038.70
Rate for Payer: Aetna Medicare	$1,931.40
Rate for Payer: BCBS MT CHIP	$1,931.40
Rate for Payer: BCBS MT Closed Plan Network	$2,038.70
Rate for Payer: BCBS MT HealthLink	$1,931.40
Rate for Payer: BCBS MT Medicare	$1,931.40
Rate for Payer: BCBS MT POS	$2,038.70
Rate for Payer: BCBS MT Traditional	$2,146.00
Rate for Payer: Cash Price	$1,931.40
Rate for Payer: Cigna Commercial	$2,038.70
Rate for Payer: Cigna Medicare	$1,931.40
Rate for Payer: Medicaid All Medicaid	$1,974.32
Rate for Payer: Medicare All Medicare	$1,502.20
Rate for Payer: Monida Allegiance	$2,038.70
Rate for Payer: Monida First Choice Health	$2,081.62
Rate for Payer: Monida Montana Health Co-op	$2,038.70
Rate for Payer: Monida PacificSource	$2,038.70

MRA NECK W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70549 TC
Hospital Charge Code	5300073
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MRA NECK W WO CONTRAST

Facility

$3,047.00

Service Code	HCPCS 70549 TC
Hospital Charge Code	5300073
Hospital Revenue Code	615
Min. Negotiated Rate	$2,132.90
Max. Negotiated Rate	$3,047.00
Rate for Payer: Aetna Commercial	$2,894.65
Rate for Payer: Aetna Medicare	$2,742.30
Rate for Payer: BCBS MT CHIP	$2,742.30
Rate for Payer: BCBS MT Closed Plan Network	$2,894.65
Rate for Payer: BCBS MT HealthLink	$2,742.30
Rate for Payer: BCBS MT Medicare	$2,742.30
Rate for Payer: BCBS MT POS	$2,894.65
Rate for Payer: BCBS MT Traditional	$3,047.00
Rate for Payer: Cash Price	$2,742.30
Rate for Payer: Cigna Commercial	$2,894.65
Rate for Payer: Cigna Medicare	$2,742.30
Rate for Payer: Medicaid All Medicaid	$2,803.24
Rate for Payer: Medicare All Medicare	$2,132.90
Rate for Payer: Monida Allegiance	$2,894.65
Rate for Payer: Monida First Choice Health	$2,955.59
Rate for Payer: Monida Montana Health Co-op	$2,894.65
Rate for Payer: Monida PacificSource	$2,894.65

MR ANKLE LT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300003
Hospital Revenue Code	614
Min. Negotiated Rate	$1,907.50
Max. Negotiated Rate	$2,725.00
Rate for Payer: Aetna Commercial	$2,588.75
Rate for Payer: Aetna Medicare	$2,452.50
Rate for Payer: BCBS MT CHIP	$2,452.50
Rate for Payer: BCBS MT Closed Plan Network	$2,588.75
Rate for Payer: BCBS MT HealthLink	$2,452.50
Rate for Payer: BCBS MT Medicare	$2,452.50
Rate for Payer: BCBS MT POS	$2,588.75
Rate for Payer: BCBS MT Traditional	$2,725.00
Rate for Payer: Cash Price	$2,452.50
Rate for Payer: Cigna Commercial	$2,588.75
Rate for Payer: Cigna Medicare	$2,452.50
Rate for Payer: Medicaid All Medicaid	$2,507.00
Rate for Payer: Medicare All Medicare	$1,907.50
Rate for Payer: Monida Allegiance	$2,588.75
Rate for Payer: Monida First Choice Health	$2,643.25
Rate for Payer: Monida Montana Health Co-op	$2,588.75
Rate for Payer: Monida PacificSource	$2,588.75

MR ANKLE LT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300003
Hospital Revenue Code	614
Min. Negotiated Rate	$1,907.50
Max. Negotiated Rate	$2,725.00
Rate for Payer: Aetna Commercial	$2,588.75
Rate for Payer: Aetna Medicare	$2,452.50
Rate for Payer: BCBS MT CHIP	$2,452.50
Rate for Payer: BCBS MT Closed Plan Network	$2,588.75
Rate for Payer: BCBS MT HealthLink	$2,452.50
Rate for Payer: BCBS MT Medicare	$2,452.50
Rate for Payer: BCBS MT POS	$2,588.75
Rate for Payer: BCBS MT Traditional	$2,725.00
Rate for Payer: Cash Price	$2,452.50
Rate for Payer: Cigna Commercial	$2,588.75
Rate for Payer: Cigna Medicare	$2,452.50
Rate for Payer: Medicaid All Medicaid	$2,507.00
Rate for Payer: Medicare All Medicare	$1,907.50
Rate for Payer: Monida Allegiance	$2,588.75
Rate for Payer: Monida First Choice Health	$2,643.25
Rate for Payer: Monida Montana Health Co-op	$2,588.75
Rate for Payer: Monida PacificSource	$2,588.75

MR ANKLE LT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300009
Hospital Revenue Code	614
Min. Negotiated Rate	$1,689.10
Max. Negotiated Rate	$2,413.00
Rate for Payer: Aetna Commercial	$2,292.35
Rate for Payer: Aetna Medicare	$2,171.70
Rate for Payer: BCBS MT CHIP	$2,171.70
Rate for Payer: BCBS MT Closed Plan Network	$2,292.35
Rate for Payer: BCBS MT HealthLink	$2,171.70
Rate for Payer: BCBS MT Medicare	$2,171.70
Rate for Payer: BCBS MT POS	$2,292.35
Rate for Payer: BCBS MT Traditional	$2,413.00
Rate for Payer: Cash Price	$2,171.70
Rate for Payer: Cigna Commercial	$2,292.35
Rate for Payer: Cigna Medicare	$2,171.70
Rate for Payer: Medicaid All Medicaid	$2,219.96
Rate for Payer: Medicare All Medicare	$1,689.10
Rate for Payer: Monida Allegiance	$2,292.35
Rate for Payer: Monida First Choice Health	$2,340.61
Rate for Payer: Monida Montana Health Co-op	$2,292.35
Rate for Payer: Monida PacificSource	$2,292.35

MR ANKLE LT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300009
Hospital Revenue Code	614
Min. Negotiated Rate	$1,689.10
Max. Negotiated Rate	$2,413.00
Rate for Payer: Aetna Commercial	$2,292.35
Rate for Payer: Aetna Medicare	$2,171.70
Rate for Payer: BCBS MT CHIP	$2,171.70
Rate for Payer: BCBS MT Closed Plan Network	$2,292.35
Rate for Payer: BCBS MT HealthLink	$2,171.70
Rate for Payer: BCBS MT Medicare	$2,171.70
Rate for Payer: BCBS MT POS	$2,292.35
Rate for Payer: BCBS MT Traditional	$2,413.00
Rate for Payer: Cash Price	$2,171.70
Rate for Payer: Cigna Commercial	$2,292.35
Rate for Payer: Cigna Medicare	$2,171.70
Rate for Payer: Medicaid All Medicaid	$2,219.96
Rate for Payer: Medicare All Medicare	$1,689.10
Rate for Payer: Monida Allegiance	$2,292.35
Rate for Payer: Monida First Choice Health	$2,340.61
Rate for Payer: Monida Montana Health Co-op	$2,292.35
Rate for Payer: Monida PacificSource	$2,292.35

MR ANKLE LT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300015
Hospital Revenue Code	614
Min. Negotiated Rate	$2,434.60
Max. Negotiated Rate	$3,478.00
Rate for Payer: Aetna Commercial	$3,304.10
Rate for Payer: Aetna Medicare	$3,130.20
Rate for Payer: BCBS MT CHIP	$3,130.20
Rate for Payer: BCBS MT Closed Plan Network	$3,304.10
Rate for Payer: BCBS MT HealthLink	$3,130.20
Rate for Payer: BCBS MT Medicare	$3,130.20
Rate for Payer: BCBS MT POS	$3,304.10
Rate for Payer: BCBS MT Traditional	$3,478.00
Rate for Payer: Cash Price	$3,130.20
Rate for Payer: Cigna Commercial	$3,304.10
Rate for Payer: Cigna Medicare	$3,130.20
Rate for Payer: Medicaid All Medicaid	$3,199.76
Rate for Payer: Medicare All Medicare	$2,434.60
Rate for Payer: Monida Allegiance	$3,304.10
Rate for Payer: Monida First Choice Health	$3,373.66
Rate for Payer: Monida Montana Health Co-op	$3,304.10
Rate for Payer: Monida PacificSource	$3,304.10

MR ANKLE LT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300015
Hospital Revenue Code	614
Min. Negotiated Rate	$2,434.60
Max. Negotiated Rate	$3,478.00
Rate for Payer: Aetna Commercial	$3,304.10
Rate for Payer: Aetna Medicare	$3,130.20
Rate for Payer: BCBS MT CHIP	$3,130.20
Rate for Payer: BCBS MT Closed Plan Network	$3,304.10
Rate for Payer: BCBS MT HealthLink	$3,130.20
Rate for Payer: BCBS MT Medicare	$3,130.20
Rate for Payer: BCBS MT POS	$3,304.10
Rate for Payer: BCBS MT Traditional	$3,478.00
Rate for Payer: Cash Price	$3,130.20
Rate for Payer: Cigna Commercial	$3,304.10
Rate for Payer: Cigna Medicare	$3,130.20
Rate for Payer: Medicaid All Medicaid	$3,199.76
Rate for Payer: Medicare All Medicare	$2,434.60
Rate for Payer: Monida Allegiance	$3,304.10
Rate for Payer: Monida First Choice Health	$3,373.66
Rate for Payer: Monida Montana Health Co-op	$3,304.10
Rate for Payer: Monida PacificSource	$3,304.10

MR ANKLE RT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300006
Hospital Revenue Code	614
Min. Negotiated Rate	$1,907.50
Max. Negotiated Rate	$2,725.00
Rate for Payer: Aetna Commercial	$2,588.75
Rate for Payer: Aetna Medicare	$2,452.50
Rate for Payer: BCBS MT CHIP	$2,452.50
Rate for Payer: BCBS MT Closed Plan Network	$2,588.75
Rate for Payer: BCBS MT HealthLink	$2,452.50
Rate for Payer: BCBS MT Medicare	$2,452.50
Rate for Payer: BCBS MT POS	$2,588.75
Rate for Payer: BCBS MT Traditional	$2,725.00
Rate for Payer: Cash Price	$2,452.50
Rate for Payer: Cigna Commercial	$2,588.75
Rate for Payer: Cigna Medicare	$2,452.50
Rate for Payer: Medicaid All Medicaid	$2,507.00
Rate for Payer: Medicare All Medicare	$1,907.50
Rate for Payer: Monida Allegiance	$2,588.75
Rate for Payer: Monida First Choice Health	$2,643.25
Rate for Payer: Monida Montana Health Co-op	$2,588.75
Rate for Payer: Monida PacificSource	$2,588.75

MR ANKLE RT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300006
Hospital Revenue Code	614
Min. Negotiated Rate	$1,907.50
Max. Negotiated Rate	$2,725.00
Rate for Payer: Aetna Commercial	$2,588.75
Rate for Payer: Aetna Medicare	$2,452.50
Rate for Payer: BCBS MT CHIP	$2,452.50
Rate for Payer: BCBS MT Closed Plan Network	$2,588.75
Rate for Payer: BCBS MT HealthLink	$2,452.50
Rate for Payer: BCBS MT Medicare	$2,452.50
Rate for Payer: BCBS MT POS	$2,588.75
Rate for Payer: BCBS MT Traditional	$2,725.00
Rate for Payer: Cash Price	$2,452.50
Rate for Payer: Cigna Commercial	$2,588.75
Rate for Payer: Cigna Medicare	$2,452.50
Rate for Payer: Medicaid All Medicaid	$2,507.00
Rate for Payer: Medicare All Medicare	$1,907.50
Rate for Payer: Monida Allegiance	$2,588.75
Rate for Payer: Monida First Choice Health	$2,643.25
Rate for Payer: Monida Montana Health Co-op	$2,588.75
Rate for Payer: Monida PacificSource	$2,588.75

MR ANKLE RT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300012
Hospital Revenue Code	614
Min. Negotiated Rate	$1,689.10
Max. Negotiated Rate	$2,413.00
Rate for Payer: Aetna Commercial	$2,292.35
Rate for Payer: Aetna Medicare	$2,171.70
Rate for Payer: BCBS MT CHIP	$2,171.70
Rate for Payer: BCBS MT Closed Plan Network	$2,292.35
Rate for Payer: BCBS MT HealthLink	$2,171.70
Rate for Payer: BCBS MT Medicare	$2,171.70
Rate for Payer: BCBS MT POS	$2,292.35
Rate for Payer: BCBS MT Traditional	$2,413.00
Rate for Payer: Cash Price	$2,171.70
Rate for Payer: Cigna Commercial	$2,292.35
Rate for Payer: Cigna Medicare	$2,171.70
Rate for Payer: Medicaid All Medicaid	$2,219.96
Rate for Payer: Medicare All Medicare	$1,689.10
Rate for Payer: Monida Allegiance	$2,292.35
Rate for Payer: Monida First Choice Health	$2,340.61
Rate for Payer: Monida Montana Health Co-op	$2,292.35
Rate for Payer: Monida PacificSource	$2,292.35

MR ANKLE RT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300012
Hospital Revenue Code	614
Min. Negotiated Rate	$1,689.10
Max. Negotiated Rate	$2,413.00
Rate for Payer: Aetna Commercial	$2,292.35
Rate for Payer: Aetna Medicare	$2,171.70
Rate for Payer: BCBS MT CHIP	$2,171.70
Rate for Payer: BCBS MT Closed Plan Network	$2,292.35
Rate for Payer: BCBS MT HealthLink	$2,171.70
Rate for Payer: BCBS MT Medicare	$2,171.70
Rate for Payer: BCBS MT POS	$2,292.35
Rate for Payer: BCBS MT Traditional	$2,413.00
Rate for Payer: Cash Price	$2,171.70
Rate for Payer: Cigna Commercial	$2,292.35
Rate for Payer: Cigna Medicare	$2,171.70
Rate for Payer: Medicaid All Medicaid	$2,219.96
Rate for Payer: Medicare All Medicare	$1,689.10
Rate for Payer: Monida Allegiance	$2,292.35
Rate for Payer: Monida First Choice Health	$2,340.61
Rate for Payer: Monida Montana Health Co-op	$2,292.35
Rate for Payer: Monida PacificSource	$2,292.35

MR ANKLE RT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300018
Hospital Revenue Code	614
Min. Negotiated Rate	$2,434.60
Max. Negotiated Rate	$3,478.00
Rate for Payer: Aetna Commercial	$3,304.10
Rate for Payer: Aetna Medicare	$3,130.20
Rate for Payer: BCBS MT CHIP	$3,130.20
Rate for Payer: BCBS MT Closed Plan Network	$3,304.10
Rate for Payer: BCBS MT HealthLink	$3,130.20
Rate for Payer: BCBS MT Medicare	$3,130.20
Rate for Payer: BCBS MT POS	$3,304.10
Rate for Payer: BCBS MT Traditional	$3,478.00
Rate for Payer: Cash Price	$3,130.20
Rate for Payer: Cigna Commercial	$3,304.10
Rate for Payer: Cigna Medicare	$3,130.20
Rate for Payer: Medicaid All Medicaid	$3,199.76
Rate for Payer: Medicare All Medicare	$2,434.60
Rate for Payer: Monida Allegiance	$3,304.10
Rate for Payer: Monida First Choice Health	$3,373.66
Rate for Payer: Monida Montana Health Co-op	$3,304.10
Rate for Payer: Monida PacificSource	$3,304.10

MR ANKLE RT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300018
Hospital Revenue Code	614
Min. Negotiated Rate	$2,434.60
Max. Negotiated Rate	$3,478.00
Rate for Payer: Aetna Commercial	$3,304.10
Rate for Payer: Aetna Medicare	$3,130.20
Rate for Payer: BCBS MT CHIP	$3,130.20
Rate for Payer: BCBS MT Closed Plan Network	$3,304.10
Rate for Payer: BCBS MT HealthLink	$3,130.20
Rate for Payer: BCBS MT Medicare	$3,130.20
Rate for Payer: BCBS MT POS	$3,304.10
Rate for Payer: BCBS MT Traditional	$3,478.00
Rate for Payer: Cash Price	$3,130.20
Rate for Payer: Cigna Commercial	$3,304.10
Rate for Payer: Cigna Medicare	$3,130.20
Rate for Payer: Medicaid All Medicaid	$3,199.76
Rate for Payer: Medicare All Medicare	$2,434.60
Rate for Payer: Monida Allegiance	$3,304.10
Rate for Payer: Monida First Choice Health	$3,373.66
Rate for Payer: Monida Montana Health Co-op	$3,304.10
Rate for Payer: Monida PacificSource	$3,304.10

MR BRAIN AND IAC W WO CONTRAST

Facility

$2,854.00

Service Code	HCPCS 70553 TC
Hospital Charge Code	5370553
Hospital Revenue Code	611
Min. Negotiated Rate	$1,997.80
Max. Negotiated Rate	$2,854.00
Rate for Payer: Aetna Commercial	$2,711.30
Rate for Payer: Aetna Medicare	$2,568.60
Rate for Payer: BCBS MT CHIP	$2,568.60
Rate for Payer: BCBS MT Closed Plan Network	$2,711.30
Rate for Payer: BCBS MT HealthLink	$2,568.60
Rate for Payer: BCBS MT Medicare	$2,568.60
Rate for Payer: BCBS MT POS	$2,711.30
Rate for Payer: BCBS MT Traditional	$2,854.00
Rate for Payer: Cash Price	$2,568.60
Rate for Payer: Cigna Commercial	$2,711.30
Rate for Payer: Cigna Medicare	$2,568.60
Rate for Payer: Medicaid All Medicaid	$2,625.68
Rate for Payer: Medicare All Medicare	$1,997.80
Rate for Payer: Monida Allegiance	$2,711.30
Rate for Payer: Monida First Choice Health	$2,768.38
Rate for Payer: Monida Montana Health Co-op	$2,711.30
Rate for Payer: Monida PacificSource	$2,711.30

Know your out-of-pocket cost for care.

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