Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MR TIBIA FIBULA RT W CONTRAST

Facility

$2,645.00

Service Code	HCPCS 73719 TC,RT
Hospital Charge Code	5300041
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 RT W CONTRAST

Facility

$2,645.00

Service Code	HCPCS 73719 TC,RT
Hospital Charge Code	5300041
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 RT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,RT
Hospital Charge Code	5300047
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 RT WO CONTRAST

Facility

$2,255.00

Service Code	HCPCS 73718 TC,RT
Hospital Charge Code	5300047
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 RT W WO CONTRAST

Facility

$3,167.00

Service Code	HCPCS 73720 TC,RT
Hospital Charge Code	5300053
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 TIBIA FIBULA RT W WO CONTRAST

Facility

$3,167.00

Service Code	HCPCS 73720 TC,RT
Hospital Charge Code	5300053
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 TMJ

Facility

$2,113.00

Service Code	HCPCS 70336 TC
Hospital Charge Code	5300117
Hospital Revenue Code	614
Min. Negotiated Rate	$1,479.10
Max. Negotiated Rate	$2,113.00
Rate for Payer: Aetna Commercial	$2,007.35
Rate for Payer: Aetna Medicare	$1,901.70
Rate for Payer: BCBS MT CHIP	$1,901.70
Rate for Payer: BCBS MT Closed Plan Network	$2,007.35
Rate for Payer: BCBS MT HealthLink	$1,901.70
Rate for Payer: BCBS MT Medicare	$1,901.70
Rate for Payer: BCBS MT POS	$2,007.35
Rate for Payer: BCBS MT Traditional	$2,113.00
Rate for Payer: Cash Price	$1,901.70
Rate for Payer: Cigna Commercial	$2,007.35
Rate for Payer: Cigna Medicare	$1,901.70
Rate for Payer: Medicaid All Medicaid	$1,943.96
Rate for Payer: Medicare All Medicare	$1,479.10
Rate for Payer: Monida Allegiance	$2,007.35
Rate for Payer: Monida First Choice Health	$2,049.61
Rate for Payer: Monida Montana Health Co-op	$2,007.35
Rate for Payer: Monida PacificSource	$2,007.35

MR TMJ

Facility

$2,113.00

Service Code	HCPCS 70336 TC
Hospital Charge Code	5300117
Hospital Revenue Code	614
Min. Negotiated Rate	$1,479.10
Max. Negotiated Rate	$2,113.00
Rate for Payer: Aetna Commercial	$2,007.35
Rate for Payer: Aetna Medicare	$1,901.70
Rate for Payer: BCBS MT CHIP	$1,901.70
Rate for Payer: BCBS MT Closed Plan Network	$2,007.35
Rate for Payer: BCBS MT HealthLink	$1,901.70
Rate for Payer: BCBS MT Medicare	$1,901.70
Rate for Payer: BCBS MT POS	$2,007.35
Rate for Payer: BCBS MT Traditional	$2,113.00
Rate for Payer: Cash Price	$1,901.70
Rate for Payer: Cigna Commercial	$2,007.35
Rate for Payer: Cigna Medicare	$1,901.70
Rate for Payer: Medicaid All Medicaid	$1,943.96
Rate for Payer: Medicare All Medicare	$1,479.10
Rate for Payer: Monida Allegiance	$2,007.35
Rate for Payer: Monida First Choice Health	$2,049.61
Rate for Payer: Monida Montana Health Co-op	$2,007.35
Rate for Payer: Monida PacificSource	$2,007.35

MR UPPR XT W CON LT

Facility

$2,917.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300121
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 UPPR XT W CON LT

Facility

$2,917.00

Service Code	HCPCS 73219 TC,LT
Hospital Charge Code	5300121
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 UPPR XT W CON RT

Facility

$2,917.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300122
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 UPPR XT W CON RT

Facility

$2,917.00

Service Code	HCPCS 73219 TC,RT
Hospital Charge Code	5300122
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 UPPR XT WO CON LT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300123
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 UPPR XT WO CON LT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,LT
Hospital Charge Code	5300123
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 UPPR XT WO CON RT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300124
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 UPPR XT WO CON RT

Facility

$2,222.00

Service Code	HCPCS 73218 TC,RT
Hospital Charge Code	5300124
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 UPPR XT WO&W CON LT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300125
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 UPPR XT WO&W CON LT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,LT
Hospital Charge Code	5300125
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 UPPR XT WO&W CON RT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300126
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 UPPR XT WO&W CON RT

Facility

$3,172.00

Service Code	HCPCS 73220 TC,RT
Hospital Charge Code	5300126
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 WRIST LT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300021
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 WRIST LT W CONTRAST

Facility

$2,709.00

Service Code	HCPCS 73222 TC,LT
Hospital Charge Code	5300021
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 WRIST LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300027
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 WRIST LT WO CONTRAST

Facility

$2,249.00

Service Code	HCPCS 73221 TC,LT
Hospital Charge Code	5300027
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

Know your out-of-pocket cost for care.

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