Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR JNT UPPR EXT WO CON R

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300100
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 JNT UPPR EXT WO CON R

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300100
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 JNT UPPR EXT WO&W CN LT

Facility

$3,397.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300101
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR JNT UPPR EXT WO&W CN LT

Facility

$3,397.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300101
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR JNT UPPR EXT WO&W CN RT

Facility

$3,397.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300102
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR JNT UPPR EXT WO&W CN RT

Facility

$3,397.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300102
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR KNEE LT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300002
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 KNEE LT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,LT
Hospital Charge Code	5300002
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 KNEE LT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300008
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 KNEE LT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,LT
Hospital Charge Code	5300008
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 KNEE LT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300014
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 KNEE LT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,LT
Hospital Charge Code	5300014
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 KNEE RT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300005
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 KNEE RT W CONTRAST

Facility

$2,725.00

Service Code	HCPCS 73722 TC,RT
Hospital Charge Code	5300005
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 KNEE RT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300011
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 KNEE RT WO CONTRAST

Facility

$2,413.00

Service Code	HCPCS 73721 TC,RT
Hospital Charge Code	5300011
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 KNEE RT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300017
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 KNEE RT W WO CONTRAST

Facility

$3,478.00

Service Code	HCPCS 73723 TC,RT
Hospital Charge Code	5300017
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 LUMBAR SPINE W CONTRAST

Facility

$2,922.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	5300103
Hospital Revenue Code	612
Min. Negotiated Rate	$2,045.40
Max. Negotiated Rate	$2,922.00
Rate for Payer: Aetna Commercial	$2,775.90
Rate for Payer: Aetna Medicare	$2,629.80
Rate for Payer: BCBS MT CHIP	$2,629.80
Rate for Payer: BCBS MT Closed Plan Network	$2,775.90
Rate for Payer: BCBS MT HealthLink	$2,629.80
Rate for Payer: BCBS MT Medicare	$2,629.80
Rate for Payer: BCBS MT POS	$2,775.90
Rate for Payer: BCBS MT Traditional	$2,922.00
Rate for Payer: Cash Price	$2,629.80
Rate for Payer: Cigna Commercial	$2,775.90
Rate for Payer: Cigna Medicare	$2,629.80
Rate for Payer: Medicaid All Medicaid	$2,688.24
Rate for Payer: Medicare All Medicare	$2,045.40
Rate for Payer: Monida Allegiance	$2,775.90
Rate for Payer: Monida First Choice Health	$2,834.34
Rate for Payer: Monida Montana Health Co-op	$2,775.90
Rate for Payer: Monida PacificSource	$2,775.90

MR LUMBAR SPINE W CONTRAST

Facility

$2,922.00

Service Code	HCPCS 72149 TC
Hospital Charge Code	5300103
Hospital Revenue Code	612
Min. Negotiated Rate	$2,045.40
Max. Negotiated Rate	$2,922.00
Rate for Payer: Aetna Commercial	$2,775.90
Rate for Payer: Aetna Medicare	$2,629.80
Rate for Payer: BCBS MT CHIP	$2,629.80
Rate for Payer: BCBS MT Closed Plan Network	$2,775.90
Rate for Payer: BCBS MT HealthLink	$2,629.80
Rate for Payer: BCBS MT Medicare	$2,629.80
Rate for Payer: BCBS MT POS	$2,775.90
Rate for Payer: BCBS MT Traditional	$2,922.00
Rate for Payer: Cash Price	$2,629.80
Rate for Payer: Cigna Commercial	$2,775.90
Rate for Payer: Cigna Medicare	$2,629.80
Rate for Payer: Medicaid All Medicaid	$2,688.24
Rate for Payer: Medicare All Medicare	$2,045.40
Rate for Payer: Monida Allegiance	$2,775.90
Rate for Payer: Monida First Choice Health	$2,834.34
Rate for Payer: Monida Montana Health Co-op	$2,775.90
Rate for Payer: Monida PacificSource	$2,775.90

MR LUMBAR SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	5300104
Hospital Revenue Code	612
Min. Negotiated Rate	$1,662.50
Max. Negotiated Rate	$2,375.00
Rate for Payer: Aetna Commercial	$2,256.25
Rate for Payer: Aetna Medicare	$2,137.50
Rate for Payer: BCBS MT CHIP	$2,137.50
Rate for Payer: BCBS MT Closed Plan Network	$2,256.25
Rate for Payer: BCBS MT HealthLink	$2,137.50
Rate for Payer: BCBS MT Medicare	$2,137.50
Rate for Payer: BCBS MT POS	$2,256.25
Rate for Payer: BCBS MT Traditional	$2,375.00
Rate for Payer: Cash Price	$2,137.50
Rate for Payer: Cigna Commercial	$2,256.25
Rate for Payer: Cigna Medicare	$2,137.50
Rate for Payer: Medicaid All Medicaid	$2,185.00
Rate for Payer: Medicare All Medicare	$1,662.50
Rate for Payer: Monida Allegiance	$2,256.25
Rate for Payer: Monida First Choice Health	$2,303.75
Rate for Payer: Monida Montana Health Co-op	$2,256.25
Rate for Payer: Monida PacificSource	$2,256.25

MR LUMBAR SPINE WO CONTRAST

Facility

$2,375.00

Service Code	HCPCS 72148 TC
Hospital Charge Code	5300104
Hospital Revenue Code	612
Min. Negotiated Rate	$1,662.50
Max. Negotiated Rate	$2,375.00
Rate for Payer: Aetna Commercial	$2,256.25
Rate for Payer: Aetna Medicare	$2,137.50
Rate for Payer: BCBS MT CHIP	$2,137.50
Rate for Payer: BCBS MT Closed Plan Network	$2,256.25
Rate for Payer: BCBS MT HealthLink	$2,137.50
Rate for Payer: BCBS MT Medicare	$2,137.50
Rate for Payer: BCBS MT POS	$2,256.25
Rate for Payer: BCBS MT Traditional	$2,375.00
Rate for Payer: Cash Price	$2,137.50
Rate for Payer: Cigna Commercial	$2,256.25
Rate for Payer: Cigna Medicare	$2,137.50
Rate for Payer: Medicaid All Medicaid	$2,185.00
Rate for Payer: Medicare All Medicare	$1,662.50
Rate for Payer: Monida Allegiance	$2,256.25
Rate for Payer: Monida First Choice Health	$2,303.75
Rate for Payer: Monida Montana Health Co-op	$2,256.25
Rate for Payer: Monida PacificSource	$2,256.25

MR LUMBAR SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	5300105
Hospital Revenue Code	612
Min. Negotiated Rate	$2,576.00
Max. Negotiated Rate	$3,680.00
Rate for Payer: Aetna Commercial	$3,496.00
Rate for Payer: Aetna Medicare	$3,312.00
Rate for Payer: BCBS MT CHIP	$3,312.00
Rate for Payer: BCBS MT Closed Plan Network	$3,496.00
Rate for Payer: BCBS MT HealthLink	$3,312.00
Rate for Payer: BCBS MT Medicare	$3,312.00
Rate for Payer: BCBS MT POS	$3,496.00
Rate for Payer: BCBS MT Traditional	$3,680.00
Rate for Payer: Cash Price	$3,312.00
Rate for Payer: Cigna Commercial	$3,496.00
Rate for Payer: Cigna Medicare	$3,312.00
Rate for Payer: Medicaid All Medicaid	$3,385.60
Rate for Payer: Medicare All Medicare	$2,576.00
Rate for Payer: Monida Allegiance	$3,496.00
Rate for Payer: Monida First Choice Health	$3,569.60
Rate for Payer: Monida Montana Health Co-op	$3,496.00
Rate for Payer: Monida PacificSource	$3,496.00

MR LUMBAR SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	HCPCS 72158 TC
Hospital Charge Code	5300105
Hospital Revenue Code	612
Min. Negotiated Rate	$2,576.00
Max. Negotiated Rate	$3,680.00
Rate for Payer: Aetna Commercial	$3,496.00
Rate for Payer: Aetna Medicare	$3,312.00
Rate for Payer: BCBS MT CHIP	$3,312.00
Rate for Payer: BCBS MT Closed Plan Network	$3,496.00
Rate for Payer: BCBS MT HealthLink	$3,312.00
Rate for Payer: BCBS MT Medicare	$3,312.00
Rate for Payer: BCBS MT POS	$3,496.00
Rate for Payer: BCBS MT Traditional	$3,680.00
Rate for Payer: Cash Price	$3,312.00
Rate for Payer: Cigna Commercial	$3,496.00
Rate for Payer: Cigna Medicare	$3,312.00
Rate for Payer: Medicaid All Medicaid	$3,385.60
Rate for Payer: Medicare All Medicare	$2,576.00
Rate for Payer: Monida Allegiance	$3,496.00
Rate for Payer: Monida First Choice Health	$3,569.60
Rate for Payer: Monida Montana Health Co-op	$3,496.00
Rate for Payer: Monida PacificSource	$3,496.00

MR LWR EXT W CON LT

Facility

$2,645.00

Service Code	HCPCS 73719 TC,LT
Hospital Charge Code	5300106
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

Know your out-of-pocket cost for care.

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