Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MR LWR EXT W CON RT

Facility

$2,645.00

Service Code	HCPCS 73719 TC,RT
Hospital Charge Code	5300107
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

MR LWR EXT W CON RT

Facility

$2,645.00

Service Code	HCPCS 73719 TC,RT
Hospital Charge Code	5300107
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

MR LWR XT WO CON LT

Facility

$2,255.00

Service Code	HCPCS 73718 TC,LT
Hospital Charge Code	5300108
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR LWR XT WO CON LT

Facility

$2,255.00

Service Code	HCPCS 73718 TC,LT
Hospital Charge Code	5300108
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR LWR XT WO CON RT

Facility

$2,255.00

Service Code	HCPCS 73718 TC,RT
Hospital Charge Code	5300109
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR LWR XT WO CON RT

Facility

$2,255.00

Service Code	HCPCS 73718 TC,RT
Hospital Charge Code	5300109
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR LWR XT WO&W CON LT

Facility

$3,167.00

Service Code	HCPCS 73720 TC,LT
Hospital Charge Code	5300110
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR LWR XT WO&W CON LT

Facility

$3,167.00

Service Code	HCPCS 73720 TC,LT
Hospital Charge Code	5300110
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR LWR XT WO&W CON RT

Facility

$3,167.00

Service Code	HCPCS 73720 TC,RT
Hospital Charge Code	5300111
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR LWR XT WO&W CON RT

Facility

$3,167.00

Service Code	HCPCS 73720 TC,RT
Hospital Charge Code	5300111
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR ORBIT FACE NECK W CONTRAST

Facility

$2,651.00

Service Code	HCPCS 70542 TC
Hospital Charge Code	5300077
Hospital Revenue Code	614
Min. Negotiated Rate	$1,855.70
Max. Negotiated Rate	$2,651.00
Rate for Payer: Aetna Commercial	$2,518.45
Rate for Payer: Aetna Medicare	$2,385.90
Rate for Payer: BCBS MT CHIP	$2,385.90
Rate for Payer: BCBS MT Closed Plan Network	$2,518.45
Rate for Payer: BCBS MT HealthLink	$2,385.90
Rate for Payer: BCBS MT Medicare	$2,385.90
Rate for Payer: BCBS MT POS	$2,518.45
Rate for Payer: BCBS MT Traditional	$2,651.00
Rate for Payer: Cash Price	$2,385.90
Rate for Payer: Cigna Commercial	$2,518.45
Rate for Payer: Cigna Medicare	$2,385.90
Rate for Payer: Medicaid All Medicaid	$2,438.92
Rate for Payer: Medicare All Medicare	$1,855.70
Rate for Payer: Monida Allegiance	$2,518.45
Rate for Payer: Monida First Choice Health	$2,571.47
Rate for Payer: Monida Montana Health Co-op	$2,518.45
Rate for Payer: Monida PacificSource	$2,518.45

MR ORBIT FACE NECK W CONTRAST

Facility

$2,651.00

Service Code	HCPCS 70542 TC
Hospital Charge Code	5300077
Hospital Revenue Code	614
Min. Negotiated Rate	$1,855.70
Max. Negotiated Rate	$2,651.00
Rate for Payer: Aetna Commercial	$2,518.45
Rate for Payer: Aetna Medicare	$2,385.90
Rate for Payer: BCBS MT CHIP	$2,385.90
Rate for Payer: BCBS MT Closed Plan Network	$2,518.45
Rate for Payer: BCBS MT HealthLink	$2,385.90
Rate for Payer: BCBS MT Medicare	$2,385.90
Rate for Payer: BCBS MT POS	$2,518.45
Rate for Payer: BCBS MT Traditional	$2,651.00
Rate for Payer: Cash Price	$2,385.90
Rate for Payer: Cigna Commercial	$2,518.45
Rate for Payer: Cigna Medicare	$2,385.90
Rate for Payer: Medicaid All Medicaid	$2,438.92
Rate for Payer: Medicare All Medicare	$1,855.70
Rate for Payer: Monida Allegiance	$2,518.45
Rate for Payer: Monida First Choice Health	$2,571.47
Rate for Payer: Monida Montana Health Co-op	$2,518.45
Rate for Payer: Monida PacificSource	$2,518.45

MR ORBIT FACE NECK WO CONTRAST

Facility

$2,298.00

Service Code	HCPCS 70540 TC
Hospital Charge Code	5300113
Hospital Revenue Code	614
Min. Negotiated Rate	$1,608.60
Max. Negotiated Rate	$2,298.00
Rate for Payer: Aetna Commercial	$2,183.10
Rate for Payer: Aetna Medicare	$2,068.20
Rate for Payer: BCBS MT CHIP	$2,068.20
Rate for Payer: BCBS MT Closed Plan Network	$2,183.10
Rate for Payer: BCBS MT HealthLink	$2,068.20
Rate for Payer: BCBS MT Medicare	$2,068.20
Rate for Payer: BCBS MT POS	$2,183.10
Rate for Payer: BCBS MT Traditional	$2,298.00
Rate for Payer: Cash Price	$2,068.20
Rate for Payer: Cigna Commercial	$2,183.10
Rate for Payer: Cigna Medicare	$2,068.20
Rate for Payer: Medicaid All Medicaid	$2,114.16
Rate for Payer: Medicare All Medicare	$1,608.60
Rate for Payer: Monida Allegiance	$2,183.10
Rate for Payer: Monida First Choice Health	$2,229.06
Rate for Payer: Monida Montana Health Co-op	$2,183.10
Rate for Payer: Monida PacificSource	$2,183.10

MR ORBIT FACE NECK WO CONTRAST

Facility

$2,298.00

Service Code	HCPCS 70540 TC
Hospital Charge Code	5300113
Hospital Revenue Code	614
Min. Negotiated Rate	$1,608.60
Max. Negotiated Rate	$2,298.00
Rate for Payer: Aetna Commercial	$2,183.10
Rate for Payer: Aetna Medicare	$2,068.20
Rate for Payer: BCBS MT CHIP	$2,068.20
Rate for Payer: BCBS MT Closed Plan Network	$2,183.10
Rate for Payer: BCBS MT HealthLink	$2,068.20
Rate for Payer: BCBS MT Medicare	$2,068.20
Rate for Payer: BCBS MT POS	$2,183.10
Rate for Payer: BCBS MT Traditional	$2,298.00
Rate for Payer: Cash Price	$2,068.20
Rate for Payer: Cigna Commercial	$2,183.10
Rate for Payer: Cigna Medicare	$2,068.20
Rate for Payer: Medicaid All Medicaid	$2,114.16
Rate for Payer: Medicare All Medicare	$1,608.60
Rate for Payer: Monida Allegiance	$2,183.10
Rate for Payer: Monida First Choice Health	$2,229.06
Rate for Payer: Monida Montana Health Co-op	$2,183.10
Rate for Payer: Monida PacificSource	$2,183.10

MR ORBIT FACE NECK W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 70543 TC
Hospital Charge Code	5300112
Hospital Revenue Code	614
Min. Negotiated Rate	$2,296.70
Max. Negotiated Rate	$3,281.00
Rate for Payer: Aetna Commercial	$3,116.95
Rate for Payer: Aetna Medicare	$2,952.90
Rate for Payer: BCBS MT CHIP	$2,952.90
Rate for Payer: BCBS MT Closed Plan Network	$3,116.95
Rate for Payer: BCBS MT HealthLink	$2,952.90
Rate for Payer: BCBS MT Medicare	$2,952.90
Rate for Payer: BCBS MT POS	$3,116.95
Rate for Payer: BCBS MT Traditional	$3,281.00
Rate for Payer: Cash Price	$2,952.90
Rate for Payer: Cigna Commercial	$3,116.95
Rate for Payer: Cigna Medicare	$2,952.90
Rate for Payer: Medicaid All Medicaid	$3,018.52
Rate for Payer: Medicare All Medicare	$2,296.70
Rate for Payer: Monida Allegiance	$3,116.95
Rate for Payer: Monida First Choice Health	$3,182.57
Rate for Payer: Monida Montana Health Co-op	$3,116.95
Rate for Payer: Monida PacificSource	$3,116.95

MR ORBIT FACE NECK W WO CONTRAST

Facility

$3,281.00

Service Code	HCPCS 70543 TC
Hospital Charge Code	5300112
Hospital Revenue Code	614
Min. Negotiated Rate	$2,296.70
Max. Negotiated Rate	$3,281.00
Rate for Payer: Aetna Commercial	$3,116.95
Rate for Payer: Aetna Medicare	$2,952.90
Rate for Payer: BCBS MT CHIP	$2,952.90
Rate for Payer: BCBS MT Closed Plan Network	$3,116.95
Rate for Payer: BCBS MT HealthLink	$2,952.90
Rate for Payer: BCBS MT Medicare	$2,952.90
Rate for Payer: BCBS MT POS	$3,116.95
Rate for Payer: BCBS MT Traditional	$3,281.00
Rate for Payer: Cash Price	$2,952.90
Rate for Payer: Cigna Commercial	$3,116.95
Rate for Payer: Cigna Medicare	$2,952.90
Rate for Payer: Medicaid All Medicaid	$3,018.52
Rate for Payer: Medicare All Medicare	$2,296.70
Rate for Payer: Monida Allegiance	$3,116.95
Rate for Payer: Monida First Choice Health	$3,182.57
Rate for Payer: Monida Montana Health Co-op	$3,116.95
Rate for Payer: Monida PacificSource	$3,116.95

MR PELVIS W CONTRAST

Facility

$2,697.00

Service Code	HCPCS 72196 TC
Hospital Charge Code	5300114
Hospital Revenue Code	614
Min. Negotiated Rate	$1,887.90
Max. Negotiated Rate	$2,697.00
Rate for Payer: Aetna Commercial	$2,562.15
Rate for Payer: Aetna Medicare	$2,427.30
Rate for Payer: BCBS MT CHIP	$2,427.30
Rate for Payer: BCBS MT Closed Plan Network	$2,562.15
Rate for Payer: BCBS MT HealthLink	$2,427.30
Rate for Payer: BCBS MT Medicare	$2,427.30
Rate for Payer: BCBS MT POS	$2,562.15
Rate for Payer: BCBS MT Traditional	$2,697.00
Rate for Payer: Cash Price	$2,427.30
Rate for Payer: Cigna Commercial	$2,562.15
Rate for Payer: Cigna Medicare	$2,427.30
Rate for Payer: Medicaid All Medicaid	$2,481.24
Rate for Payer: Medicare All Medicare	$1,887.90
Rate for Payer: Monida Allegiance	$2,562.15
Rate for Payer: Monida First Choice Health	$2,616.09
Rate for Payer: Monida Montana Health Co-op	$2,562.15
Rate for Payer: Monida PacificSource	$2,562.15

MR PELVIS W CONTRAST

Facility

$2,697.00

Service Code	HCPCS 72196 TC
Hospital Charge Code	5300114
Hospital Revenue Code	614
Min. Negotiated Rate	$1,887.90
Max. Negotiated Rate	$2,697.00
Rate for Payer: Aetna Commercial	$2,562.15
Rate for Payer: Aetna Medicare	$2,427.30
Rate for Payer: BCBS MT CHIP	$2,427.30
Rate for Payer: BCBS MT Closed Plan Network	$2,562.15
Rate for Payer: BCBS MT HealthLink	$2,427.30
Rate for Payer: BCBS MT Medicare	$2,427.30
Rate for Payer: BCBS MT POS	$2,562.15
Rate for Payer: BCBS MT Traditional	$2,697.00
Rate for Payer: Cash Price	$2,427.30
Rate for Payer: Cigna Commercial	$2,562.15
Rate for Payer: Cigna Medicare	$2,427.30
Rate for Payer: Medicaid All Medicaid	$2,481.24
Rate for Payer: Medicare All Medicare	$1,887.90
Rate for Payer: Monida Allegiance	$2,562.15
Rate for Payer: Monida First Choice Health	$2,616.09
Rate for Payer: Monida Montana Health Co-op	$2,562.15
Rate for Payer: Monida PacificSource	$2,562.15

MR PELVIS WO CONTRAST

Facility

$2,425.00

Service Code	HCPCS 72195 TC
Hospital Charge Code	5300115
Hospital Revenue Code	614
Min. Negotiated Rate	$1,697.50
Max. Negotiated Rate	$2,425.00
Rate for Payer: Aetna Commercial	$2,303.75
Rate for Payer: Aetna Medicare	$2,182.50
Rate for Payer: BCBS MT CHIP	$2,182.50
Rate for Payer: BCBS MT Closed Plan Network	$2,303.75
Rate for Payer: BCBS MT HealthLink	$2,182.50
Rate for Payer: BCBS MT Medicare	$2,182.50
Rate for Payer: BCBS MT POS	$2,303.75
Rate for Payer: BCBS MT Traditional	$2,425.00
Rate for Payer: Cash Price	$2,182.50
Rate for Payer: Cigna Commercial	$2,303.75
Rate for Payer: Cigna Medicare	$2,182.50
Rate for Payer: Medicaid All Medicaid	$2,231.00
Rate for Payer: Medicare All Medicare	$1,697.50
Rate for Payer: Monida Allegiance	$2,303.75
Rate for Payer: Monida First Choice Health	$2,352.25
Rate for Payer: Monida Montana Health Co-op	$2,303.75
Rate for Payer: Monida PacificSource	$2,303.75

MR PELVIS WO CONTRAST

Facility

$2,425.00

Service Code	HCPCS 72195 TC
Hospital Charge Code	5300115
Hospital Revenue Code	614
Min. Negotiated Rate	$1,697.50
Max. Negotiated Rate	$2,425.00
Rate for Payer: Aetna Commercial	$2,303.75
Rate for Payer: Aetna Medicare	$2,182.50
Rate for Payer: BCBS MT CHIP	$2,182.50
Rate for Payer: BCBS MT Closed Plan Network	$2,303.75
Rate for Payer: BCBS MT HealthLink	$2,182.50
Rate for Payer: BCBS MT Medicare	$2,182.50
Rate for Payer: BCBS MT POS	$2,303.75
Rate for Payer: BCBS MT Traditional	$2,425.00
Rate for Payer: Cash Price	$2,182.50
Rate for Payer: Cigna Commercial	$2,303.75
Rate for Payer: Cigna Medicare	$2,182.50
Rate for Payer: Medicaid All Medicaid	$2,231.00
Rate for Payer: Medicare All Medicare	$1,697.50
Rate for Payer: Monida Allegiance	$2,303.75
Rate for Payer: Monida First Choice Health	$2,352.25
Rate for Payer: Monida Montana Health Co-op	$2,303.75
Rate for Payer: Monida PacificSource	$2,303.75

MR PELVIS W WO CONTRAST

Facility

$3,426.00

Service Code	HCPCS 72197 TC
Hospital Charge Code	5300116
Hospital Revenue Code	614
Min. Negotiated Rate	$2,398.20
Max. Negotiated Rate	$3,426.00
Rate for Payer: Aetna Commercial	$3,254.70
Rate for Payer: Aetna Medicare	$3,083.40
Rate for Payer: BCBS MT CHIP	$3,083.40
Rate for Payer: BCBS MT Closed Plan Network	$3,254.70
Rate for Payer: BCBS MT HealthLink	$3,083.40
Rate for Payer: BCBS MT Medicare	$3,083.40
Rate for Payer: BCBS MT POS	$3,254.70
Rate for Payer: BCBS MT Traditional	$3,426.00
Rate for Payer: Cash Price	$3,083.40
Rate for Payer: Cigna Commercial	$3,254.70
Rate for Payer: Cigna Medicare	$3,083.40
Rate for Payer: Medicaid All Medicaid	$3,151.92
Rate for Payer: Medicare All Medicare	$2,398.20
Rate for Payer: Monida Allegiance	$3,254.70
Rate for Payer: Monida First Choice Health	$3,323.22
Rate for Payer: Monida Montana Health Co-op	$3,254.70
Rate for Payer: Monida PacificSource	$3,254.70

MR PELVIS W WO CONTRAST

Facility

$3,426.00

Service Code	HCPCS 72197 TC
Hospital Charge Code	5300116
Hospital Revenue Code	614
Min. Negotiated Rate	$2,398.20
Max. Negotiated Rate	$3,426.00
Rate for Payer: Aetna Commercial	$3,254.70
Rate for Payer: Aetna Medicare	$3,083.40
Rate for Payer: BCBS MT CHIP	$3,083.40
Rate for Payer: BCBS MT Closed Plan Network	$3,254.70
Rate for Payer: BCBS MT HealthLink	$3,083.40
Rate for Payer: BCBS MT Medicare	$3,083.40
Rate for Payer: BCBS MT POS	$3,254.70
Rate for Payer: BCBS MT Traditional	$3,426.00
Rate for Payer: Cash Price	$3,083.40
Rate for Payer: Cigna Commercial	$3,254.70
Rate for Payer: Cigna Medicare	$3,083.40
Rate for Payer: Medicaid All Medicaid	$3,151.92
Rate for Payer: Medicare All Medicare	$2,398.20
Rate for Payer: Monida Allegiance	$3,254.70
Rate for Payer: Monida First Choice Health	$3,323.22
Rate for Payer: Monida Montana Health Co-op	$3,254.70
Rate for Payer: Monida PacificSource	$3,254.70

MRSA/MSSA NAAT RVMC

Facility

$195.00

Service Code	HCPCS 87641
Hospital Charge Code	4087882
Hospital Revenue Code	300
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

MRSA/MSSA NAAT RVMC

Facility

$195.00

Service Code	HCPCS 87641
Hospital Charge Code	4087882
Hospital Revenue Code	300
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

Know your out-of-pocket cost for care.

All Charges