Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR BRAIN W CONTRAST

Facility

$2,854.00

Service Code	CPT 70552
Hospital Charge Code	5300081
Hospital Revenue Code	611
Min. Negotiated Rate	$1,997.80
Max. Negotiated Rate	$2,854.00
Rate for Payer: Aetna Commercial	$2,711.30
Rate for Payer: Aetna Medicare	$2,568.60
Rate for Payer: BCBS MT CHIP	$2,568.60
Rate for Payer: BCBS MT Closed Plan Network	$2,711.30
Rate for Payer: BCBS MT HealthLink	$2,568.60
Rate for Payer: BCBS MT Medicare	$2,568.60
Rate for Payer: BCBS MT POS	$2,711.30
Rate for Payer: BCBS MT Traditional	$2,854.00
Rate for Payer: Cash Price	$2,568.60
Rate for Payer: Cigna Commercial	$2,711.30
Rate for Payer: Cigna Medicare	$2,568.60
Rate for Payer: Medicaid All Medicaid	$2,625.68
Rate for Payer: Medicare All Medicare	$1,997.80
Rate for Payer: Monida Allegiance	$2,711.30
Rate for Payer: Monida First Choice Health	$2,768.38
Rate for Payer: Monida Montana Health Co-op	$2,711.30
Rate for Payer: Monida PacificSource	$2,711.30

MR BRAIN W CONTRAST

Facility

$2,854.00

Service Code	CPT 70552
Hospital Charge Code	5300081
Hospital Revenue Code	611
Min. Negotiated Rate	$1,997.80
Max. Negotiated Rate	$2,854.00
Rate for Payer: Aetna Commercial	$2,711.30
Rate for Payer: Aetna Medicare	$2,568.60
Rate for Payer: BCBS MT CHIP	$2,568.60
Rate for Payer: BCBS MT Closed Plan Network	$2,711.30
Rate for Payer: BCBS MT HealthLink	$2,568.60
Rate for Payer: BCBS MT Medicare	$2,568.60
Rate for Payer: BCBS MT POS	$2,711.30
Rate for Payer: BCBS MT Traditional	$2,854.00
Rate for Payer: Cash Price	$2,568.60
Rate for Payer: Cigna Commercial	$2,711.30
Rate for Payer: Cigna Medicare	$2,568.60
Rate for Payer: Medicaid All Medicaid	$2,625.68
Rate for Payer: Medicare All Medicare	$1,997.80
Rate for Payer: Monida Allegiance	$2,711.30
Rate for Payer: Monida First Choice Health	$2,768.38
Rate for Payer: Monida Montana Health Co-op	$2,711.30
Rate for Payer: Monida PacificSource	$2,711.30

MR BRAIN WO CONTRAST

Facility

$2,460.00

Service Code	CPT 70551
Hospital Charge Code	5300082
Hospital Revenue Code	611
Min. Negotiated Rate	$1,722.00
Max. Negotiated Rate	$2,460.00
Rate for Payer: Aetna Commercial	$2,337.00
Rate for Payer: Aetna Medicare	$2,214.00
Rate for Payer: BCBS MT CHIP	$2,214.00
Rate for Payer: BCBS MT Closed Plan Network	$2,337.00
Rate for Payer: BCBS MT HealthLink	$2,214.00
Rate for Payer: BCBS MT Medicare	$2,214.00
Rate for Payer: BCBS MT POS	$2,337.00
Rate for Payer: BCBS MT Traditional	$2,460.00
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Cigna Commercial	$2,337.00
Rate for Payer: Cigna Medicare	$2,214.00
Rate for Payer: Medicaid All Medicaid	$2,263.20
Rate for Payer: Medicare All Medicare	$1,722.00
Rate for Payer: Monida Allegiance	$2,337.00
Rate for Payer: Monida First Choice Health	$2,386.20
Rate for Payer: Monida Montana Health Co-op	$2,337.00
Rate for Payer: Monida PacificSource	$2,337.00

MR BRAIN WO CONTRAST

Facility

$2,460.00

Service Code	CPT 70551
Hospital Charge Code	5300082
Hospital Revenue Code	611
Min. Negotiated Rate	$1,722.00
Max. Negotiated Rate	$2,460.00
Rate for Payer: Aetna Commercial	$2,337.00
Rate for Payer: Aetna Medicare	$2,214.00
Rate for Payer: BCBS MT CHIP	$2,214.00
Rate for Payer: BCBS MT Closed Plan Network	$2,337.00
Rate for Payer: BCBS MT HealthLink	$2,214.00
Rate for Payer: BCBS MT Medicare	$2,214.00
Rate for Payer: BCBS MT POS	$2,337.00
Rate for Payer: BCBS MT Traditional	$2,460.00
Rate for Payer: Cash Price	$2,214.00
Rate for Payer: Cigna Commercial	$2,337.00
Rate for Payer: Cigna Medicare	$2,214.00
Rate for Payer: Medicaid All Medicaid	$2,263.20
Rate for Payer: Medicare All Medicare	$1,722.00
Rate for Payer: Monida Allegiance	$2,337.00
Rate for Payer: Monida First Choice Health	$2,386.20
Rate for Payer: Monida Montana Health Co-op	$2,337.00
Rate for Payer: Monida PacificSource	$2,337.00

MR BRAIN W WO CONTRAST

Facility

$3,657.00

Service Code	CPT 70553
Hospital Charge Code	5300083
Hospital Revenue Code	611
Min. Negotiated Rate	$2,559.90
Max. Negotiated Rate	$3,657.00
Rate for Payer: Aetna Commercial	$3,474.15
Rate for Payer: Aetna Medicare	$3,291.30
Rate for Payer: BCBS MT CHIP	$3,291.30
Rate for Payer: BCBS MT Closed Plan Network	$3,474.15
Rate for Payer: BCBS MT HealthLink	$3,291.30
Rate for Payer: BCBS MT Medicare	$3,291.30
Rate for Payer: BCBS MT POS	$3,474.15
Rate for Payer: BCBS MT Traditional	$3,657.00
Rate for Payer: Cash Price	$3,291.30
Rate for Payer: Cigna Commercial	$3,474.15
Rate for Payer: Cigna Medicare	$3,291.30
Rate for Payer: Medicaid All Medicaid	$3,364.44
Rate for Payer: Medicare All Medicare	$2,559.90
Rate for Payer: Monida Allegiance	$3,474.15
Rate for Payer: Monida First Choice Health	$3,547.29
Rate for Payer: Monida Montana Health Co-op	$3,474.15
Rate for Payer: Monida PacificSource	$3,474.15

MR BRAIN W WO CONTRAST

Facility

$3,657.00

Service Code	CPT 70553
Hospital Charge Code	5300083
Hospital Revenue Code	611
Min. Negotiated Rate	$2,559.90
Max. Negotiated Rate	$3,657.00
Rate for Payer: Aetna Commercial	$3,474.15
Rate for Payer: Aetna Medicare	$3,291.30
Rate for Payer: BCBS MT CHIP	$3,291.30
Rate for Payer: BCBS MT Closed Plan Network	$3,474.15
Rate for Payer: BCBS MT HealthLink	$3,291.30
Rate for Payer: BCBS MT Medicare	$3,291.30
Rate for Payer: BCBS MT POS	$3,474.15
Rate for Payer: BCBS MT Traditional	$3,657.00
Rate for Payer: Cash Price	$3,291.30
Rate for Payer: Cigna Commercial	$3,474.15
Rate for Payer: Cigna Medicare	$3,291.30
Rate for Payer: Medicaid All Medicaid	$3,364.44
Rate for Payer: Medicare All Medicare	$2,559.90
Rate for Payer: Monida Allegiance	$3,474.15
Rate for Payer: Monida First Choice Health	$3,547.29
Rate for Payer: Monida Montana Health Co-op	$3,474.15
Rate for Payer: Monida PacificSource	$3,474.15

MR CERVICAL SPINE W CONTRAST

Facility

$2,922.00

Service Code	CPT 72142
Hospital Charge Code	5300084
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 CERVICAL SPINE W CONTRAST

Facility

$2,922.00

Service Code	CPT 72142
Hospital Charge Code	5300084
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 CERVICAL SPINE WO CONTRAST

Facility

$2,375.00

Service Code	CPT 72141
Hospital Charge Code	5300085
Hospital Revenue Code	612
Min. Negotiated Rate	$1,662.50
Max. Negotiated Rate	$2,375.00
Rate for Payer: Aetna Commercial	$2,256.25
Rate for Payer: Aetna Medicare	$2,137.50
Rate for Payer: BCBS MT CHIP	$2,137.50
Rate for Payer: BCBS MT Closed Plan Network	$2,256.25
Rate for Payer: BCBS MT HealthLink	$2,137.50
Rate for Payer: BCBS MT Medicare	$2,137.50
Rate for Payer: BCBS MT POS	$2,256.25
Rate for Payer: BCBS MT Traditional	$2,375.00
Rate for Payer: Cash Price	$2,137.50
Rate for Payer: Cigna Commercial	$2,256.25
Rate for Payer: Cigna Medicare	$2,137.50
Rate for Payer: Medicaid All Medicaid	$2,185.00
Rate for Payer: Medicare All Medicare	$1,662.50
Rate for Payer: Monida Allegiance	$2,256.25
Rate for Payer: Monida First Choice Health	$2,303.75
Rate for Payer: Monida Montana Health Co-op	$2,256.25
Rate for Payer: Monida PacificSource	$2,256.25

MR CERVICAL SPINE WO CONTRAST

Facility

$2,375.00

Service Code	CPT 72141
Hospital Charge Code	5300085
Hospital Revenue Code	612
Min. Negotiated Rate	$1,662.50
Max. Negotiated Rate	$2,375.00
Rate for Payer: Aetna Commercial	$2,256.25
Rate for Payer: Aetna Medicare	$2,137.50
Rate for Payer: BCBS MT CHIP	$2,137.50
Rate for Payer: BCBS MT Closed Plan Network	$2,256.25
Rate for Payer: BCBS MT HealthLink	$2,137.50
Rate for Payer: BCBS MT Medicare	$2,137.50
Rate for Payer: BCBS MT POS	$2,256.25
Rate for Payer: BCBS MT Traditional	$2,375.00
Rate for Payer: Cash Price	$2,137.50
Rate for Payer: Cigna Commercial	$2,256.25
Rate for Payer: Cigna Medicare	$2,137.50
Rate for Payer: Medicaid All Medicaid	$2,185.00
Rate for Payer: Medicare All Medicare	$1,662.50
Rate for Payer: Monida Allegiance	$2,256.25
Rate for Payer: Monida First Choice Health	$2,303.75
Rate for Payer: Monida Montana Health Co-op	$2,256.25
Rate for Payer: Monida PacificSource	$2,256.25

MR CERVICAL SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	CPT 72156
Hospital Charge Code	5300086
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 CERVICAL SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	CPT 72156
Hospital Charge Code	5300086
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 CHEST W CONTRAST

Facility

$2,732.00

Service Code	CPT 71551
Hospital Charge Code	5300087
Hospital Revenue Code	614
Min. Negotiated Rate	$1,912.40
Max. Negotiated Rate	$2,732.00
Rate for Payer: Aetna Commercial	$2,595.40
Rate for Payer: Aetna Medicare	$2,458.80
Rate for Payer: BCBS MT CHIP	$2,458.80
Rate for Payer: BCBS MT Closed Plan Network	$2,595.40
Rate for Payer: BCBS MT HealthLink	$2,458.80
Rate for Payer: BCBS MT Medicare	$2,458.80
Rate for Payer: BCBS MT POS	$2,595.40
Rate for Payer: BCBS MT Traditional	$2,732.00
Rate for Payer: Cash Price	$2,458.80
Rate for Payer: Cigna Commercial	$2,595.40
Rate for Payer: Cigna Medicare	$2,458.80
Rate for Payer: Medicaid All Medicaid	$2,513.44
Rate for Payer: Medicare All Medicare	$1,912.40
Rate for Payer: Monida Allegiance	$2,595.40
Rate for Payer: Monida First Choice Health	$2,650.04
Rate for Payer: Monida Montana Health Co-op	$2,595.40
Rate for Payer: Monida PacificSource	$2,595.40

MR CHEST W CONTRAST

Facility

$2,732.00

Service Code	CPT 71551
Hospital Charge Code	5300087
Hospital Revenue Code	614
Min. Negotiated Rate	$1,912.40
Max. Negotiated Rate	$2,732.00
Rate for Payer: Aetna Commercial	$2,595.40
Rate for Payer: Aetna Medicare	$2,458.80
Rate for Payer: BCBS MT CHIP	$2,458.80
Rate for Payer: BCBS MT Closed Plan Network	$2,595.40
Rate for Payer: BCBS MT HealthLink	$2,458.80
Rate for Payer: BCBS MT Medicare	$2,458.80
Rate for Payer: BCBS MT POS	$2,595.40
Rate for Payer: BCBS MT Traditional	$2,732.00
Rate for Payer: Cash Price	$2,458.80
Rate for Payer: Cigna Commercial	$2,595.40
Rate for Payer: Cigna Medicare	$2,458.80
Rate for Payer: Medicaid All Medicaid	$2,513.44
Rate for Payer: Medicare All Medicare	$1,912.40
Rate for Payer: Monida Allegiance	$2,595.40
Rate for Payer: Monida First Choice Health	$2,650.04
Rate for Payer: Monida Montana Health Co-op	$2,595.40
Rate for Payer: Monida PacificSource	$2,595.40

MR CHEST WO CONTRAST

Facility

$2,276.00

Service Code	CPT 71550
Hospital Charge Code	5300088
Hospital Revenue Code	614
Min. Negotiated Rate	$1,593.20
Max. Negotiated Rate	$2,276.00
Rate for Payer: Aetna Commercial	$2,162.20
Rate for Payer: Aetna Medicare	$2,048.40
Rate for Payer: BCBS MT CHIP	$2,048.40
Rate for Payer: BCBS MT Closed Plan Network	$2,162.20
Rate for Payer: BCBS MT HealthLink	$2,048.40
Rate for Payer: BCBS MT Medicare	$2,048.40
Rate for Payer: BCBS MT POS	$2,162.20
Rate for Payer: BCBS MT Traditional	$2,276.00
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Cigna Commercial	$2,162.20
Rate for Payer: Cigna Medicare	$2,048.40
Rate for Payer: Medicaid All Medicaid	$2,093.92
Rate for Payer: Medicare All Medicare	$1,593.20
Rate for Payer: Monida Allegiance	$2,162.20
Rate for Payer: Monida First Choice Health	$2,207.72
Rate for Payer: Monida Montana Health Co-op	$2,162.20
Rate for Payer: Monida PacificSource	$2,162.20

MR CHEST WO CONTRAST

Facility

$2,276.00

Service Code	CPT 71550
Hospital Charge Code	5300088
Hospital Revenue Code	614
Min. Negotiated Rate	$1,593.20
Max. Negotiated Rate	$2,276.00
Rate for Payer: Aetna Commercial	$2,162.20
Rate for Payer: Aetna Medicare	$2,048.40
Rate for Payer: BCBS MT CHIP	$2,048.40
Rate for Payer: BCBS MT Closed Plan Network	$2,162.20
Rate for Payer: BCBS MT HealthLink	$2,048.40
Rate for Payer: BCBS MT Medicare	$2,048.40
Rate for Payer: BCBS MT POS	$2,162.20
Rate for Payer: BCBS MT Traditional	$2,276.00
Rate for Payer: Cash Price	$2,048.40
Rate for Payer: Cigna Commercial	$2,162.20
Rate for Payer: Cigna Medicare	$2,048.40
Rate for Payer: Medicaid All Medicaid	$2,093.92
Rate for Payer: Medicare All Medicare	$1,593.20
Rate for Payer: Monida Allegiance	$2,162.20
Rate for Payer: Monida First Choice Health	$2,207.72
Rate for Payer: Monida Montana Health Co-op	$2,162.20
Rate for Payer: Monida PacificSource	$2,162.20

MR CHEST W WO CONTRAST

Facility

$3,347.00

Service Code	CPT 71552
Hospital Charge Code	5300089
Hospital Revenue Code	614
Min. Negotiated Rate	$2,342.90
Max. Negotiated Rate	$3,347.00
Rate for Payer: Aetna Commercial	$3,179.65
Rate for Payer: Aetna Medicare	$3,012.30
Rate for Payer: BCBS MT CHIP	$3,012.30
Rate for Payer: BCBS MT Closed Plan Network	$3,179.65
Rate for Payer: BCBS MT HealthLink	$3,012.30
Rate for Payer: BCBS MT Medicare	$3,012.30
Rate for Payer: BCBS MT POS	$3,179.65
Rate for Payer: BCBS MT Traditional	$3,347.00
Rate for Payer: Cash Price	$3,012.30
Rate for Payer: Cigna Commercial	$3,179.65
Rate for Payer: Cigna Medicare	$3,012.30
Rate for Payer: Medicaid All Medicaid	$3,079.24
Rate for Payer: Medicare All Medicare	$2,342.90
Rate for Payer: Monida Allegiance	$3,179.65
Rate for Payer: Monida First Choice Health	$3,246.59
Rate for Payer: Monida Montana Health Co-op	$3,179.65
Rate for Payer: Monida PacificSource	$3,179.65

MR CHEST W WO CONTRAST

Facility

$3,347.00

Service Code	CPT 71552
Hospital Charge Code	5300089
Hospital Revenue Code	614
Min. Negotiated Rate	$2,342.90
Max. Negotiated Rate	$3,347.00
Rate for Payer: Aetna Commercial	$3,179.65
Rate for Payer: Aetna Medicare	$3,012.30
Rate for Payer: BCBS MT CHIP	$3,012.30
Rate for Payer: BCBS MT Closed Plan Network	$3,179.65
Rate for Payer: BCBS MT HealthLink	$3,012.30
Rate for Payer: BCBS MT Medicare	$3,012.30
Rate for Payer: BCBS MT POS	$3,179.65
Rate for Payer: BCBS MT Traditional	$3,347.00
Rate for Payer: Cash Price	$3,012.30
Rate for Payer: Cigna Commercial	$3,179.65
Rate for Payer: Cigna Medicare	$3,012.30
Rate for Payer: Medicaid All Medicaid	$3,079.24
Rate for Payer: Medicare All Medicare	$2,342.90
Rate for Payer: Monida Allegiance	$3,179.65
Rate for Payer: Monida First Choice Health	$3,246.59
Rate for Payer: Monida Montana Health Co-op	$3,179.65
Rate for Payer: Monida PacificSource	$3,179.65

MRCP WO CONTRAST

Facility

$2,331.00

Service Code	CPT 74181
Hospital Charge Code	5300137
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

MRCP WO CONTRAST

Facility

$2,331.00

Service Code	CPT 74181
Hospital Charge Code	5300137
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 ELBOW LT W CONTRAST

Facility

$2,709.00

Service Code	CPT 73222
Hospital Charge Code	5300020
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 ELBOW LT W CONTRAST

Facility

$2,709.00

Service Code	CPT 73222
Hospital Charge Code	5300020
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 ELBOW LT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300026
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 ELBOW LT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300026
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 ELBOW LT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300032
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

Know your out-of-pocket cost for care.

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