Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR LUMBAR SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	CPT 72158
Hospital Charge Code	5300105
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 LUMBAR SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	CPT 72158
Hospital Charge Code	5300105
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 LWR EXT W CON LT

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300106
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR LWR EXT W CON LT

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300106
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR LWR EXT W CON RT

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300107
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR LWR EXT W CON RT

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300107
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR LWR XT WO CON LT

Facility

$2,255.00

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

MR LWR XT WO CON LT

Facility

$2,255.00

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

MR LWR XT WO CON RT

Facility

$2,255.00

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

MR LWR XT WO CON RT

Facility

$2,255.00

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

MR LWR XT WO&W CON LT

Facility

$3,167.00

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

MR LWR XT WO&W CON LT

Facility

$3,167.00

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

MR LWR XT WO&W CON RT

Facility

$3,167.00

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

MR LWR XT WO&W CON RT

Facility

$3,167.00

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

MR ORBIT FACE NECK W CONTRAST

Facility

$2,651.00

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

MR ORBIT FACE NECK W CONTRAST

Facility

$2,651.00

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

MR ORBIT FACE NECK WO CONTRAST

Facility

$2,298.00

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

MR ORBIT FACE NECK WO CONTRAST

Facility

$2,298.00

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

MR ORBIT FACE NECK W WO CONTRAST

Facility

$3,281.00

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

MR ORBIT FACE NECK W WO CONTRAST

Facility

$3,281.00

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

MR ORBITS W WO CONTRAST

Facility

$3,281.00

Service Code	CPT 70543
Hospital Charge Code	5300138
Hospital Revenue Code	614
Min. Negotiated Rate	$2,296.70
Max. Negotiated Rate	$3,281.00
Rate for Payer: Aetna Commercial	$3,116.95
Rate for Payer: Aetna Medicare	$2,952.90
Rate for Payer: BCBS MT CHIP	$2,952.90
Rate for Payer: BCBS MT Closed Plan Network	$3,116.95
Rate for Payer: BCBS MT HealthLink	$2,952.90
Rate for Payer: BCBS MT Medicare	$2,952.90
Rate for Payer: BCBS MT POS	$3,116.95
Rate for Payer: BCBS MT Traditional	$3,281.00
Rate for Payer: Cash Price	$2,952.90
Rate for Payer: Cigna Commercial	$3,116.95
Rate for Payer: Cigna Medicare	$2,952.90
Rate for Payer: Medicaid All Medicaid	$3,018.52
Rate for Payer: Medicare All Medicare	$2,296.70
Rate for Payer: Monida Allegiance	$3,116.95
Rate for Payer: Monida First Choice Health	$3,182.57
Rate for Payer: Monida Montana Health Co-op	$3,116.95
Rate for Payer: Monida PacificSource	$3,116.95

MR ORBITS W WO CONTRAST

Facility

$3,281.00

Service Code	CPT 70543
Hospital Charge Code	5300138
Hospital Revenue Code	614
Min. Negotiated Rate	$2,296.70
Max. Negotiated Rate	$3,281.00
Rate for Payer: Aetna Commercial	$3,116.95
Rate for Payer: Aetna Medicare	$2,952.90
Rate for Payer: BCBS MT CHIP	$2,952.90
Rate for Payer: BCBS MT Closed Plan Network	$3,116.95
Rate for Payer: BCBS MT HealthLink	$2,952.90
Rate for Payer: BCBS MT Medicare	$2,952.90
Rate for Payer: BCBS MT POS	$3,116.95
Rate for Payer: BCBS MT Traditional	$3,281.00
Rate for Payer: Cash Price	$2,952.90
Rate for Payer: Cigna Commercial	$3,116.95
Rate for Payer: Cigna Medicare	$2,952.90
Rate for Payer: Medicaid All Medicaid	$3,018.52
Rate for Payer: Medicare All Medicare	$2,296.70
Rate for Payer: Monida Allegiance	$3,116.95
Rate for Payer: Monida First Choice Health	$3,182.57
Rate for Payer: Monida Montana Health Co-op	$3,116.95
Rate for Payer: Monida PacificSource	$3,116.95

MR ORBIT W CONTRAST

Facility

$2,651.00

Service Code	CPT 70542
Hospital Charge Code	5300144
Hospital Revenue Code	614
Min. Negotiated Rate	$1,855.70
Max. Negotiated Rate	$2,651.00
Rate for Payer: Aetna Commercial	$2,518.45
Rate for Payer: Aetna Medicare	$2,385.90
Rate for Payer: BCBS MT CHIP	$2,385.90
Rate for Payer: BCBS MT Closed Plan Network	$2,518.45
Rate for Payer: BCBS MT HealthLink	$2,385.90
Rate for Payer: BCBS MT Medicare	$2,385.90
Rate for Payer: BCBS MT POS	$2,518.45
Rate for Payer: BCBS MT Traditional	$2,651.00
Rate for Payer: Cash Price	$2,385.90
Rate for Payer: Cigna Commercial	$2,518.45
Rate for Payer: Cigna Medicare	$2,385.90
Rate for Payer: Medicaid All Medicaid	$2,438.92
Rate for Payer: Medicare All Medicare	$1,855.70
Rate for Payer: Monida Allegiance	$2,518.45
Rate for Payer: Monida First Choice Health	$2,571.47
Rate for Payer: Monida Montana Health Co-op	$2,518.45
Rate for Payer: Monida PacificSource	$2,518.45

MR ORBIT W CONTRAST

Facility

$2,651.00

Service Code	CPT 70542
Hospital Charge Code	5300144
Hospital Revenue Code	614
Min. Negotiated Rate	$1,855.70
Max. Negotiated Rate	$2,651.00
Rate for Payer: Aetna Commercial	$2,518.45
Rate for Payer: Aetna Medicare	$2,385.90
Rate for Payer: BCBS MT CHIP	$2,385.90
Rate for Payer: BCBS MT Closed Plan Network	$2,518.45
Rate for Payer: BCBS MT HealthLink	$2,385.90
Rate for Payer: BCBS MT Medicare	$2,385.90
Rate for Payer: BCBS MT POS	$2,518.45
Rate for Payer: BCBS MT Traditional	$2,651.00
Rate for Payer: Cash Price	$2,385.90
Rate for Payer: Cigna Commercial	$2,518.45
Rate for Payer: Cigna Medicare	$2,385.90
Rate for Payer: Medicaid All Medicaid	$2,438.92
Rate for Payer: Medicare All Medicare	$1,855.70
Rate for Payer: Monida Allegiance	$2,518.45
Rate for Payer: Monida First Choice Health	$2,571.47
Rate for Payer: Monida Montana Health Co-op	$2,518.45
Rate for Payer: Monida PacificSource	$2,518.45

MR ORBIT WO CONTRAST

Facility

$2,298.00

Service Code	CPT 70540
Hospital Charge Code	5300141
Hospital Revenue Code	614
Min. Negotiated Rate	$1,608.60
Max. Negotiated Rate	$2,298.00
Rate for Payer: Aetna Commercial	$2,183.10
Rate for Payer: Aetna Medicare	$2,068.20
Rate for Payer: BCBS MT CHIP	$2,068.20
Rate for Payer: BCBS MT Closed Plan Network	$2,183.10
Rate for Payer: BCBS MT HealthLink	$2,068.20
Rate for Payer: BCBS MT Medicare	$2,068.20
Rate for Payer: BCBS MT POS	$2,183.10
Rate for Payer: BCBS MT Traditional	$2,298.00
Rate for Payer: Cash Price	$2,068.20
Rate for Payer: Cigna Commercial	$2,183.10
Rate for Payer: Cigna Medicare	$2,068.20
Rate for Payer: Medicaid All Medicaid	$2,114.16
Rate for Payer: Medicare All Medicare	$1,608.60
Rate for Payer: Monida Allegiance	$2,183.10
Rate for Payer: Monida First Choice Health	$2,229.06
Rate for Payer: Monida Montana Health Co-op	$2,183.10
Rate for Payer: Monida PacificSource	$2,183.10

Know your out-of-pocket cost for care.

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