Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR HAND RT W CONTRAST

Facility

$2,917.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300060
Hospital Revenue Code	614
Min. Negotiated Rate	$2,041.90
Max. Negotiated Rate	$2,917.00
Rate for Payer: Aetna Commercial	$2,771.15
Rate for Payer: Aetna Medicare	$2,625.30
Rate for Payer: BCBS MT CHIP	$2,625.30
Rate for Payer: BCBS MT Closed Plan Network	$2,771.15
Rate for Payer: BCBS MT HealthLink	$2,625.30
Rate for Payer: BCBS MT Medicare	$2,625.30
Rate for Payer: BCBS MT POS	$2,771.15
Rate for Payer: BCBS MT Traditional	$2,917.00
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna Commercial	$2,771.15
Rate for Payer: Cigna Medicare	$2,625.30
Rate for Payer: Medicaid All Medicaid	$2,683.64
Rate for Payer: Medicare All Medicare	$2,041.90
Rate for Payer: Monida Allegiance	$2,771.15
Rate for Payer: Monida First Choice Health	$2,829.49
Rate for Payer: Monida Montana Health Co-op	$2,771.15
Rate for Payer: Monida PacificSource	$2,771.15

MR HAND RT W CONTRAST

Facility

$2,917.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300060
Hospital Revenue Code	614
Min. Negotiated Rate	$2,041.90
Max. Negotiated Rate	$2,917.00
Rate for Payer: Aetna Commercial	$2,771.15
Rate for Payer: Aetna Medicare	$2,625.30
Rate for Payer: BCBS MT CHIP	$2,625.30
Rate for Payer: BCBS MT Closed Plan Network	$2,771.15
Rate for Payer: BCBS MT HealthLink	$2,625.30
Rate for Payer: BCBS MT Medicare	$2,625.30
Rate for Payer: BCBS MT POS	$2,771.15
Rate for Payer: BCBS MT Traditional	$2,917.00
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna Commercial	$2,771.15
Rate for Payer: Cigna Medicare	$2,625.30
Rate for Payer: Medicaid All Medicaid	$2,683.64
Rate for Payer: Medicare All Medicare	$2,041.90
Rate for Payer: Monida Allegiance	$2,771.15
Rate for Payer: Monida First Choice Health	$2,829.49
Rate for Payer: Monida Montana Health Co-op	$2,771.15
Rate for Payer: Monida PacificSource	$2,771.15

MR HAND RT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300074
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 HAND RT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300074
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 HAND RT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300130
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 HAND RT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300130
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 HIP LT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300001
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 HIP LT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300001
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 HIP LT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300007
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 HIP LT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300007
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 HIP LT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300013
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 HIP LT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300013
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 HIP RT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300004
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 HIP RT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300004
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 HIP RT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300010
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 HIP RT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300010
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 HIP RT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300016
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 HIP RT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300016
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 HUMERUS LT W CONTRAST

Facility

$2,917.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300055
Hospital Revenue Code	614
Min. Negotiated Rate	$2,041.90
Max. Negotiated Rate	$2,917.00
Rate for Payer: Aetna Commercial	$2,771.15
Rate for Payer: Aetna Medicare	$2,625.30
Rate for Payer: BCBS MT CHIP	$2,625.30
Rate for Payer: BCBS MT Closed Plan Network	$2,771.15
Rate for Payer: BCBS MT HealthLink	$2,625.30
Rate for Payer: BCBS MT Medicare	$2,625.30
Rate for Payer: BCBS MT POS	$2,771.15
Rate for Payer: BCBS MT Traditional	$2,917.00
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna Commercial	$2,771.15
Rate for Payer: Cigna Medicare	$2,625.30
Rate for Payer: Medicaid All Medicaid	$2,683.64
Rate for Payer: Medicare All Medicare	$2,041.90
Rate for Payer: Monida Allegiance	$2,771.15
Rate for Payer: Monida First Choice Health	$2,829.49
Rate for Payer: Monida Montana Health Co-op	$2,771.15
Rate for Payer: Monida PacificSource	$2,771.15

MR HUMERUS LT W CONTRAST

Facility

$2,917.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300055
Hospital Revenue Code	614
Min. Negotiated Rate	$2,041.90
Max. Negotiated Rate	$2,917.00
Rate for Payer: Aetna Commercial	$2,771.15
Rate for Payer: Aetna Medicare	$2,625.30
Rate for Payer: BCBS MT CHIP	$2,625.30
Rate for Payer: BCBS MT Closed Plan Network	$2,771.15
Rate for Payer: BCBS MT HealthLink	$2,625.30
Rate for Payer: BCBS MT Medicare	$2,625.30
Rate for Payer: BCBS MT POS	$2,771.15
Rate for Payer: BCBS MT Traditional	$2,917.00
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna Commercial	$2,771.15
Rate for Payer: Cigna Medicare	$2,625.30
Rate for Payer: Medicaid All Medicaid	$2,683.64
Rate for Payer: Medicare All Medicare	$2,041.90
Rate for Payer: Monida Allegiance	$2,771.15
Rate for Payer: Monida First Choice Health	$2,829.49
Rate for Payer: Monida Montana Health Co-op	$2,771.15
Rate for Payer: Monida PacificSource	$2,771.15

MR HUMERUS LT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300061
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 HUMERUS LT WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300061
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 HUMERUS LT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300076
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 HUMERUS LT W WO CONTRAST

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300076
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 HUMERUS RT W CONTRAST

Facility

$2,917.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300058
Hospital Revenue Code	614
Min. Negotiated Rate	$2,041.90
Max. Negotiated Rate	$2,917.00
Rate for Payer: Aetna Commercial	$2,771.15
Rate for Payer: Aetna Medicare	$2,625.30
Rate for Payer: BCBS MT CHIP	$2,625.30
Rate for Payer: BCBS MT Closed Plan Network	$2,771.15
Rate for Payer: BCBS MT HealthLink	$2,625.30
Rate for Payer: BCBS MT Medicare	$2,625.30
Rate for Payer: BCBS MT POS	$2,771.15
Rate for Payer: BCBS MT Traditional	$2,917.00
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna Commercial	$2,771.15
Rate for Payer: Cigna Medicare	$2,625.30
Rate for Payer: Medicaid All Medicaid	$2,683.64
Rate for Payer: Medicare All Medicare	$2,041.90
Rate for Payer: Monida Allegiance	$2,771.15
Rate for Payer: Monida First Choice Health	$2,829.49
Rate for Payer: Monida Montana Health Co-op	$2,771.15
Rate for Payer: Monida PacificSource	$2,771.15

Know your out-of-pocket cost for care.

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