Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MPL EXON 10 MUTATION CODE

Facility

$950.00

Service Code	CPT 81339
Hospital Charge Code	4087910
Hospital Revenue Code	300
Min. Negotiated Rate	$665.00
Max. Negotiated Rate	$950.00
Rate for Payer: Aetna Commercial	$902.50
Rate for Payer: Aetna Medicare	$855.00
Rate for Payer: BCBS MT CHIP	$855.00
Rate for Payer: BCBS MT Closed Plan Network	$902.50
Rate for Payer: BCBS MT HealthLink	$855.00
Rate for Payer: BCBS MT Medicare	$855.00
Rate for Payer: BCBS MT POS	$902.50
Rate for Payer: BCBS MT Traditional	$950.00
Rate for Payer: Cash Price	$855.00
Rate for Payer: Cigna Commercial	$902.50
Rate for Payer: Cigna Medicare	$855.00
Rate for Payer: Medicaid All Medicaid	$874.00
Rate for Payer: Medicare All Medicare	$665.00
Rate for Payer: Monida Allegiance	$902.50
Rate for Payer: Monida First Choice Health	$921.50
Rate for Payer: Monida Montana Health Co-op	$902.50
Rate for Payer: Monida PacificSource	$902.50

MPL EXON 10 MUTATION CODE

Facility

$950.00

Service Code	CPT 81339
Hospital Charge Code	4087910
Hospital Revenue Code	300
Min. Negotiated Rate	$665.00
Max. Negotiated Rate	$950.00
Rate for Payer: Aetna Commercial	$902.50
Rate for Payer: Aetna Medicare	$855.00
Rate for Payer: BCBS MT CHIP	$855.00
Rate for Payer: BCBS MT Closed Plan Network	$902.50
Rate for Payer: BCBS MT HealthLink	$855.00
Rate for Payer: BCBS MT Medicare	$855.00
Rate for Payer: BCBS MT POS	$902.50
Rate for Payer: BCBS MT Traditional	$950.00
Rate for Payer: Cash Price	$855.00
Rate for Payer: Cigna Commercial	$902.50
Rate for Payer: Cigna Medicare	$855.00
Rate for Payer: Medicaid All Medicaid	$874.00
Rate for Payer: Medicare All Medicare	$665.00
Rate for Payer: Monida Allegiance	$902.50
Rate for Payer: Monida First Choice Health	$921.50
Rate for Payer: Monida Montana Health Co-op	$902.50
Rate for Payer: Monida PacificSource	$902.50

MPO/PR3 ANCA ANTIBODIES

Facility

$96.00

Service Code	CPT 83516
Hospital Charge Code	4088100
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

MPO/PR3 ANCA ANTIBODIES

Facility

$96.00

Service Code	CPT 83516
Hospital Charge Code	4088100
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

MRA ABDOMEN W WO CONTRAST

Facility

$2,610.00

Service Code	CPT 74185
Hospital Charge Code	5300065
Hospital Revenue Code	618
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MRA ABDOMEN W WO CONTRAST

Facility

$2,610.00

Service Code	CPT 74185
Hospital Charge Code	5300065
Hospital Revenue Code	618
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MR ABDOMEN W CONTRAST

Facility

$2,610.00

Service Code	CPT 74182
Hospital Charge Code	5300078
Hospital Revenue Code	614
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MR ABDOMEN W CONTRAST

Facility

$2,610.00

Service Code	CPT 74182
Hospital Charge Code	5300078
Hospital Revenue Code	614
Min. Negotiated Rate	$1,827.00
Max. Negotiated Rate	$2,610.00
Rate for Payer: Aetna Commercial	$2,479.50
Rate for Payer: Aetna Medicare	$2,349.00
Rate for Payer: BCBS MT CHIP	$2,349.00
Rate for Payer: BCBS MT Closed Plan Network	$2,479.50
Rate for Payer: BCBS MT HealthLink	$2,349.00
Rate for Payer: BCBS MT Medicare	$2,349.00
Rate for Payer: BCBS MT POS	$2,479.50
Rate for Payer: BCBS MT Traditional	$2,610.00
Rate for Payer: Cash Price	$2,349.00
Rate for Payer: Cigna Commercial	$2,479.50
Rate for Payer: Cigna Medicare	$2,349.00
Rate for Payer: Medicaid All Medicaid	$2,401.20
Rate for Payer: Medicare All Medicare	$1,827.00
Rate for Payer: Monida Allegiance	$2,479.50
Rate for Payer: Monida First Choice Health	$2,531.70
Rate for Payer: Monida Montana Health Co-op	$2,479.50
Rate for Payer: Monida PacificSource	$2,479.50

MR ABDOMEN WO CONTRAST

Facility

$2,331.00

Service Code	CPT 74181
Hospital Charge Code	5300079
Hospital Revenue Code	614
Min. Negotiated Rate	$1,631.70
Max. Negotiated Rate	$2,331.00
Rate for Payer: Aetna Commercial	$2,214.45
Rate for Payer: Aetna Medicare	$2,097.90
Rate for Payer: BCBS MT CHIP	$2,097.90
Rate for Payer: BCBS MT Closed Plan Network	$2,214.45
Rate for Payer: BCBS MT HealthLink	$2,097.90
Rate for Payer: BCBS MT Medicare	$2,097.90
Rate for Payer: BCBS MT POS	$2,214.45
Rate for Payer: BCBS MT Traditional	$2,331.00
Rate for Payer: Cash Price	$2,097.90
Rate for Payer: Cigna Commercial	$2,214.45
Rate for Payer: Cigna Medicare	$2,097.90
Rate for Payer: Medicaid All Medicaid	$2,144.52
Rate for Payer: Medicare All Medicare	$1,631.70
Rate for Payer: Monida Allegiance	$2,214.45
Rate for Payer: Monida First Choice Health	$2,261.07
Rate for Payer: Monida Montana Health Co-op	$2,214.45
Rate for Payer: Monida PacificSource	$2,214.45

MR ABDOMEN WO CONTRAST

Facility

$2,331.00

Service Code	CPT 74181
Hospital Charge Code	5300079
Hospital Revenue Code	614
Min. Negotiated Rate	$1,631.70
Max. Negotiated Rate	$2,331.00
Rate for Payer: Aetna Commercial	$2,214.45
Rate for Payer: Aetna Medicare	$2,097.90
Rate for Payer: BCBS MT CHIP	$2,097.90
Rate for Payer: BCBS MT Closed Plan Network	$2,214.45
Rate for Payer: BCBS MT HealthLink	$2,097.90
Rate for Payer: BCBS MT Medicare	$2,097.90
Rate for Payer: BCBS MT POS	$2,214.45
Rate for Payer: BCBS MT Traditional	$2,331.00
Rate for Payer: Cash Price	$2,097.90
Rate for Payer: Cigna Commercial	$2,214.45
Rate for Payer: Cigna Medicare	$2,097.90
Rate for Payer: Medicaid All Medicaid	$2,144.52
Rate for Payer: Medicare All Medicare	$1,631.70
Rate for Payer: Monida Allegiance	$2,214.45
Rate for Payer: Monida First Choice Health	$2,261.07
Rate for Payer: Monida Montana Health Co-op	$2,214.45
Rate for Payer: Monida PacificSource	$2,214.45

MR ABDOMEN W WO CONTRAST

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300080
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300080
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - ADRENAL

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300136
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - ADRENAL

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300136
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - LIVER

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300133
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - LIVER

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300133
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - PANCREAS

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300134
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - PANCREAS

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300134
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - RENAL

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300135
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MR ABDOMEN W WO CONTRAST - RENAL

Facility

$3,519.00

Service Code	CPT 74183
Hospital Charge Code	5300135
Hospital Revenue Code	614
Min. Negotiated Rate	$2,463.30
Max. Negotiated Rate	$3,519.00
Rate for Payer: Aetna Commercial	$3,343.05
Rate for Payer: Aetna Medicare	$3,167.10
Rate for Payer: BCBS MT CHIP	$3,167.10
Rate for Payer: BCBS MT Closed Plan Network	$3,343.05
Rate for Payer: BCBS MT HealthLink	$3,167.10
Rate for Payer: BCBS MT Medicare	$3,167.10
Rate for Payer: BCBS MT POS	$3,343.05
Rate for Payer: BCBS MT Traditional	$3,519.00
Rate for Payer: Cash Price	$3,167.10
Rate for Payer: Cigna Commercial	$3,343.05
Rate for Payer: Cigna Medicare	$3,167.10
Rate for Payer: Medicaid All Medicaid	$3,237.48
Rate for Payer: Medicare All Medicare	$2,463.30
Rate for Payer: Monida Allegiance	$3,343.05
Rate for Payer: Monida First Choice Health	$3,413.43
Rate for Payer: Monida Montana Health Co-op	$3,343.05
Rate for Payer: Monida PacificSource	$3,343.05

MRA CHEST W WO CONTRAST

Facility

$1,812.00

Service Code	CPT 71555
Hospital Charge Code	5300066
Hospital Revenue Code	618
Min. Negotiated Rate	$1,268.40
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna Commercial	$1,721.40
Rate for Payer: Aetna Medicare	$1,630.80
Rate for Payer: BCBS MT CHIP	$1,630.80
Rate for Payer: BCBS MT Closed Plan Network	$1,721.40
Rate for Payer: BCBS MT HealthLink	$1,630.80
Rate for Payer: BCBS MT Medicare	$1,630.80
Rate for Payer: BCBS MT POS	$1,721.40
Rate for Payer: BCBS MT Traditional	$1,812.00
Rate for Payer: Cash Price	$1,630.80
Rate for Payer: Cigna Commercial	$1,721.40
Rate for Payer: Cigna Medicare	$1,630.80
Rate for Payer: Medicaid All Medicaid	$1,667.04
Rate for Payer: Medicare All Medicare	$1,268.40
Rate for Payer: Monida Allegiance	$1,721.40
Rate for Payer: Monida First Choice Health	$1,757.64
Rate for Payer: Monida Montana Health Co-op	$1,721.40
Rate for Payer: Monida PacificSource	$1,721.40

MRA CHEST W WO CONTRAST

Facility

$1,812.00

Service Code	CPT 71555
Hospital Charge Code	5300066
Hospital Revenue Code	618
Min. Negotiated Rate	$1,268.40
Max. Negotiated Rate	$1,812.00
Rate for Payer: Aetna Commercial	$1,721.40
Rate for Payer: Aetna Medicare	$1,630.80
Rate for Payer: BCBS MT CHIP	$1,630.80
Rate for Payer: BCBS MT Closed Plan Network	$1,721.40
Rate for Payer: BCBS MT HealthLink	$1,630.80
Rate for Payer: BCBS MT Medicare	$1,630.80
Rate for Payer: BCBS MT POS	$1,721.40
Rate for Payer: BCBS MT Traditional	$1,812.00
Rate for Payer: Cash Price	$1,630.80
Rate for Payer: Cigna Commercial	$1,721.40
Rate for Payer: Cigna Medicare	$1,630.80
Rate for Payer: Medicaid All Medicaid	$1,667.04
Rate for Payer: Medicare All Medicare	$1,268.40
Rate for Payer: Monida Allegiance	$1,721.40
Rate for Payer: Monida First Choice Health	$1,757.64
Rate for Payer: Monida Montana Health Co-op	$1,721.40
Rate for Payer: Monida PacificSource	$1,721.40

MRA HEAD W CONTRAST

Facility

$2,489.00

Service Code	CPT 70545
Hospital Charge Code	5300067
Hospital Revenue Code	615
Min. Negotiated Rate	$1,742.30
Max. Negotiated Rate	$2,489.00
Rate for Payer: Aetna Commercial	$2,364.55
Rate for Payer: Aetna Medicare	$2,240.10
Rate for Payer: BCBS MT CHIP	$2,240.10
Rate for Payer: BCBS MT Closed Plan Network	$2,364.55
Rate for Payer: BCBS MT HealthLink	$2,240.10
Rate for Payer: BCBS MT Medicare	$2,240.10
Rate for Payer: BCBS MT POS	$2,364.55
Rate for Payer: BCBS MT Traditional	$2,489.00
Rate for Payer: Cash Price	$2,240.10
Rate for Payer: Cigna Commercial	$2,364.55
Rate for Payer: Cigna Medicare	$2,240.10
Rate for Payer: Medicaid All Medicaid	$2,289.88
Rate for Payer: Medicare All Medicare	$1,742.30
Rate for Payer: Monida Allegiance	$2,364.55
Rate for Payer: Monida First Choice Health	$2,414.33
Rate for Payer: Monida Montana Health Co-op	$2,364.55
Rate for Payer: Monida PacificSource	$2,364.55

MRA HEAD W CONTRAST

Facility

$2,489.00

Service Code	CPT 70545
Hospital Charge Code	5300067
Hospital Revenue Code	615
Min. Negotiated Rate	$1,742.30
Max. Negotiated Rate	$2,489.00
Rate for Payer: Aetna Commercial	$2,364.55
Rate for Payer: Aetna Medicare	$2,240.10
Rate for Payer: BCBS MT CHIP	$2,240.10
Rate for Payer: BCBS MT Closed Plan Network	$2,364.55
Rate for Payer: BCBS MT HealthLink	$2,240.10
Rate for Payer: BCBS MT Medicare	$2,240.10
Rate for Payer: BCBS MT POS	$2,364.55
Rate for Payer: BCBS MT Traditional	$2,489.00
Rate for Payer: Cash Price	$2,240.10
Rate for Payer: Cigna Commercial	$2,364.55
Rate for Payer: Cigna Medicare	$2,240.10
Rate for Payer: Medicaid All Medicaid	$2,289.88
Rate for Payer: Medicare All Medicare	$1,742.30
Rate for Payer: Monida Allegiance	$2,364.55
Rate for Payer: Monida First Choice Health	$2,414.33
Rate for Payer: Monida Montana Health Co-op	$2,364.55
Rate for Payer: Monida PacificSource	$2,364.55

MRA HEAD WO CONTRAST

Facility

$2,292.00

Service Code	CPT 70544
Hospital Charge Code	5300069
Hospital Revenue Code	615
Min. Negotiated Rate	$1,604.40
Max. Negotiated Rate	$2,292.00
Rate for Payer: Aetna Commercial	$2,177.40
Rate for Payer: Aetna Medicare	$2,062.80
Rate for Payer: BCBS MT CHIP	$2,062.80
Rate for Payer: BCBS MT Closed Plan Network	$2,177.40
Rate for Payer: BCBS MT HealthLink	$2,062.80
Rate for Payer: BCBS MT Medicare	$2,062.80
Rate for Payer: BCBS MT POS	$2,177.40
Rate for Payer: BCBS MT Traditional	$2,292.00
Rate for Payer: Cash Price	$2,062.80
Rate for Payer: Cigna Commercial	$2,177.40
Rate for Payer: Cigna Medicare	$2,062.80
Rate for Payer: Medicaid All Medicaid	$2,108.64
Rate for Payer: Medicare All Medicare	$1,604.40
Rate for Payer: Monida Allegiance	$2,177.40
Rate for Payer: Monida First Choice Health	$2,223.24
Rate for Payer: Monida Montana Health Co-op	$2,177.40
Rate for Payer: Monida PacificSource	$2,177.40

Know your out-of-pocket cost for care.

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