Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MRSA, NAA SEND OUT(182956)

Facility

$184.00

Service Code	HCPCS 87641
Hospital Charge Code	4087641
Hospital Revenue Code	300
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$184.00
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: BCBS MT CHIP	$165.60
Rate for Payer: BCBS MT Closed Plan Network	$174.80
Rate for Payer: BCBS MT HealthLink	$165.60
Rate for Payer: BCBS MT Medicare	$165.60
Rate for Payer: BCBS MT POS	$174.80
Rate for Payer: BCBS MT Traditional	$184.00
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial	$174.80
Rate for Payer: Cigna Medicare	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

MRSA, NAA SEND OUT(182956)

Facility

$184.00

Service Code	HCPCS 87641
Hospital Charge Code	4087641
Hospital Revenue Code	300
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$184.00
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: BCBS MT CHIP	$165.60
Rate for Payer: BCBS MT Closed Plan Network	$174.80
Rate for Payer: BCBS MT HealthLink	$165.60
Rate for Payer: BCBS MT Medicare	$165.60
Rate for Payer: BCBS MT POS	$174.80
Rate for Payer: BCBS MT Traditional	$184.00
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial	$174.80
Rate for Payer: Cigna Medicare	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

MR SHOULDER LT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300019
Hospital Revenue Code	614
Min. Negotiated Rate	$1,896.30
Max. Negotiated Rate	$2,709.00
Rate for Payer: Aetna Commercial	$2,573.55
Rate for Payer: Aetna Medicare	$2,438.10
Rate for Payer: BCBS MT CHIP	$2,438.10
Rate for Payer: BCBS MT Closed Plan Network	$2,573.55
Rate for Payer: BCBS MT HealthLink	$2,438.10
Rate for Payer: BCBS MT Medicare	$2,438.10
Rate for Payer: BCBS MT POS	$2,573.55
Rate for Payer: BCBS MT Traditional	$2,709.00
Rate for Payer: Cash Price	$2,438.10
Rate for Payer: Cigna Commercial	$2,573.55
Rate for Payer: Cigna Medicare	$2,438.10
Rate for Payer: Medicaid All Medicaid	$2,492.28
Rate for Payer: Medicare All Medicare	$1,896.30
Rate for Payer: Monida Allegiance	$2,573.55
Rate for Payer: Monida First Choice Health	$2,627.73
Rate for Payer: Monida Montana Health Co-op	$2,573.55
Rate for Payer: Monida PacificSource	$2,573.55

MR SHOULDER LT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300019
Hospital Revenue Code	614
Min. Negotiated Rate	$1,896.30
Max. Negotiated Rate	$2,709.00
Rate for Payer: Aetna Commercial	$2,573.55
Rate for Payer: Aetna Medicare	$2,438.10
Rate for Payer: BCBS MT CHIP	$2,438.10
Rate for Payer: BCBS MT Closed Plan Network	$2,573.55
Rate for Payer: BCBS MT HealthLink	$2,438.10
Rate for Payer: BCBS MT Medicare	$2,438.10
Rate for Payer: BCBS MT POS	$2,573.55
Rate for Payer: BCBS MT Traditional	$2,709.00
Rate for Payer: Cash Price	$2,438.10
Rate for Payer: Cigna Commercial	$2,573.55
Rate for Payer: Cigna Medicare	$2,438.10
Rate for Payer: Medicaid All Medicaid	$2,492.28
Rate for Payer: Medicare All Medicare	$1,896.30
Rate for Payer: Monida Allegiance	$2,573.55
Rate for Payer: Monida First Choice Health	$2,627.73
Rate for Payer: Monida Montana Health Co-op	$2,573.55
Rate for Payer: Monida PacificSource	$2,573.55

MR SHOULDER LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300025
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 SHOULDER LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300025
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 SHOULDER LT W WO CONTRAST

Facility

$3,397.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300031
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 SHOULDER LT W WO CONTRAST

Facility

$3,397.00

Service Code	HCPCS 73223 TC,LT
Hospital Charge Code	5300031
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 SHOULDER RT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300022
Hospital Revenue Code	614
Min. Negotiated Rate	$1,896.30
Max. Negotiated Rate	$2,709.00
Rate for Payer: Aetna Commercial	$2,573.55
Rate for Payer: Aetna Medicare	$2,438.10
Rate for Payer: BCBS MT CHIP	$2,438.10
Rate for Payer: BCBS MT Closed Plan Network	$2,573.55
Rate for Payer: BCBS MT HealthLink	$2,438.10
Rate for Payer: BCBS MT Medicare	$2,438.10
Rate for Payer: BCBS MT POS	$2,573.55
Rate for Payer: BCBS MT Traditional	$2,709.00
Rate for Payer: Cash Price	$2,438.10
Rate for Payer: Cigna Commercial	$2,573.55
Rate for Payer: Cigna Medicare	$2,438.10
Rate for Payer: Medicaid All Medicaid	$2,492.28
Rate for Payer: Medicare All Medicare	$1,896.30
Rate for Payer: Monida Allegiance	$2,573.55
Rate for Payer: Monida First Choice Health	$2,627.73
Rate for Payer: Monida Montana Health Co-op	$2,573.55
Rate for Payer: Monida PacificSource	$2,573.55

MR SHOULDER RT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,RT
Hospital Charge Code	5300022
Hospital Revenue Code	614
Min. Negotiated Rate	$1,896.30
Max. Negotiated Rate	$2,709.00
Rate for Payer: Aetna Commercial	$2,573.55
Rate for Payer: Aetna Medicare	$2,438.10
Rate for Payer: BCBS MT CHIP	$2,438.10
Rate for Payer: BCBS MT Closed Plan Network	$2,573.55
Rate for Payer: BCBS MT HealthLink	$2,438.10
Rate for Payer: BCBS MT Medicare	$2,438.10
Rate for Payer: BCBS MT POS	$2,573.55
Rate for Payer: BCBS MT Traditional	$2,709.00
Rate for Payer: Cash Price	$2,438.10
Rate for Payer: Cigna Commercial	$2,573.55
Rate for Payer: Cigna Medicare	$2,438.10
Rate for Payer: Medicaid All Medicaid	$2,492.28
Rate for Payer: Medicare All Medicare	$1,896.30
Rate for Payer: Monida Allegiance	$2,573.55
Rate for Payer: Monida First Choice Health	$2,627.73
Rate for Payer: Monida Montana Health Co-op	$2,573.55
Rate for Payer: Monida PacificSource	$2,573.55

MR SHOULDER RT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300028
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 SHOULDER RT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,RT
Hospital Charge Code	5300028
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 SHOULDER RT W WO CONTRAST

Facility

$3,397.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300034
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 SHOULDER RT W WO CONTRAST

Facility

$3,397.00

Service Code	HCPCS 73223 TC,RT
Hospital Charge Code	5300034
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 THORACIC SPINE W CONTRAST

Facility

$2,922.00

Service Code	HCPCS 72147 TC
Hospital Charge Code	5300118
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 THORACIC SPINE W CONTRAST

Facility

$2,922.00

Service Code	HCPCS 72147 TC
Hospital Charge Code	5300118
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 THORACIC SPINE WO CONTRAST

Facility

$2,518.00

Service Code	HCPCS 72146 TC
Hospital Charge Code	5300119
Hospital Revenue Code	612
Min. Negotiated Rate	$1,762.60
Max. Negotiated Rate	$2,518.00
Rate for Payer: Aetna Commercial	$2,392.10
Rate for Payer: Aetna Medicare	$2,266.20
Rate for Payer: BCBS MT CHIP	$2,266.20
Rate for Payer: BCBS MT Closed Plan Network	$2,392.10
Rate for Payer: BCBS MT HealthLink	$2,266.20
Rate for Payer: BCBS MT Medicare	$2,266.20
Rate for Payer: BCBS MT POS	$2,392.10
Rate for Payer: BCBS MT Traditional	$2,518.00
Rate for Payer: Cash Price	$2,266.20
Rate for Payer: Cigna Commercial	$2,392.10
Rate for Payer: Cigna Medicare	$2,266.20
Rate for Payer: Medicaid All Medicaid	$2,316.56
Rate for Payer: Medicare All Medicare	$1,762.60
Rate for Payer: Monida Allegiance	$2,392.10
Rate for Payer: Monida First Choice Health	$2,442.46
Rate for Payer: Monida Montana Health Co-op	$2,392.10
Rate for Payer: Monida PacificSource	$2,392.10

MR THORACIC SPINE WO CONTRAST

Facility

$2,518.00

Service Code	HCPCS 72146 TC
Hospital Charge Code	5300119
Hospital Revenue Code	612
Min. Negotiated Rate	$1,762.60
Max. Negotiated Rate	$2,518.00
Rate for Payer: Aetna Commercial	$2,392.10
Rate for Payer: Aetna Medicare	$2,266.20
Rate for Payer: BCBS MT CHIP	$2,266.20
Rate for Payer: BCBS MT Closed Plan Network	$2,392.10
Rate for Payer: BCBS MT HealthLink	$2,266.20
Rate for Payer: BCBS MT Medicare	$2,266.20
Rate for Payer: BCBS MT POS	$2,392.10
Rate for Payer: BCBS MT Traditional	$2,518.00
Rate for Payer: Cash Price	$2,266.20
Rate for Payer: Cigna Commercial	$2,392.10
Rate for Payer: Cigna Medicare	$2,266.20
Rate for Payer: Medicaid All Medicaid	$2,316.56
Rate for Payer: Medicare All Medicare	$1,762.60
Rate for Payer: Monida Allegiance	$2,392.10
Rate for Payer: Monida First Choice Health	$2,442.46
Rate for Payer: Monida Montana Health Co-op	$2,392.10
Rate for Payer: Monida PacificSource	$2,392.10

MR THORACIC SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	HCPCS 72157 TC
Hospital Charge Code	5300120
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 THORACIC SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	HCPCS 72157 TC
Hospital Charge Code	5300120
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 TIBIA FIBULA LT W CONTRAST

Facility

$2,645.00

Service Code	HCPCS 73719 TC,LT
Hospital Charge Code	5300038
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 TIBIA FIBULA LT W CONTRAST

Facility

$2,645.00

Service Code	HCPCS 73719 TC,LT
Hospital Charge Code	5300038
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 TIBIA FIBULA LT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,LT
Hospital Charge Code	5300044
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 TIBIA FIBULA LT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,LT
Hospital Charge Code	5300044
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 TIBIA FIBULA LT W WO CONTRAST

Facility

$3,167.00

Service Code	HCPCS 73720 TC,LT
Hospital Charge Code	5300050
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

Know your out-of-pocket cost for care.

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