Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MR PELVIS W CONTRAST

Facility

$2,697.00

Service Code	CPT 72196
Hospital Charge Code	5300114
Hospital Revenue Code	614
Min. Negotiated Rate	$1,887.90
Max. Negotiated Rate	$2,697.00
Rate for Payer: Aetna Commercial	$2,562.15
Rate for Payer: Aetna Medicare	$2,427.30
Rate for Payer: BCBS MT CHIP	$2,427.30
Rate for Payer: BCBS MT Closed Plan Network	$2,562.15
Rate for Payer: BCBS MT HealthLink	$2,427.30
Rate for Payer: BCBS MT Medicare	$2,427.30
Rate for Payer: BCBS MT POS	$2,562.15
Rate for Payer: BCBS MT Traditional	$2,697.00
Rate for Payer: Cash Price	$2,427.30
Rate for Payer: Cigna Commercial	$2,562.15
Rate for Payer: Cigna Medicare	$2,427.30
Rate for Payer: Medicaid All Medicaid	$2,481.24
Rate for Payer: Medicare All Medicare	$1,887.90
Rate for Payer: Monida Allegiance	$2,562.15
Rate for Payer: Monida First Choice Health	$2,616.09
Rate for Payer: Monida Montana Health Co-op	$2,562.15
Rate for Payer: Monida PacificSource	$2,562.15

MR PELVIS W CONTRAST

Facility

$2,697.00

Service Code	CPT 72196
Hospital Charge Code	5300114
Hospital Revenue Code	614
Min. Negotiated Rate	$1,887.90
Max. Negotiated Rate	$2,697.00
Rate for Payer: Aetna Commercial	$2,562.15
Rate for Payer: Aetna Medicare	$2,427.30
Rate for Payer: BCBS MT CHIP	$2,427.30
Rate for Payer: BCBS MT Closed Plan Network	$2,562.15
Rate for Payer: BCBS MT HealthLink	$2,427.30
Rate for Payer: BCBS MT Medicare	$2,427.30
Rate for Payer: BCBS MT POS	$2,562.15
Rate for Payer: BCBS MT Traditional	$2,697.00
Rate for Payer: Cash Price	$2,427.30
Rate for Payer: Cigna Commercial	$2,562.15
Rate for Payer: Cigna Medicare	$2,427.30
Rate for Payer: Medicaid All Medicaid	$2,481.24
Rate for Payer: Medicare All Medicare	$1,887.90
Rate for Payer: Monida Allegiance	$2,562.15
Rate for Payer: Monida First Choice Health	$2,616.09
Rate for Payer: Monida Montana Health Co-op	$2,562.15
Rate for Payer: Monida PacificSource	$2,562.15

MR PELVIS WO CONTRAST

Facility

$2,425.00

Service Code	CPT 72195
Hospital Charge Code	5300115
Hospital Revenue Code	614
Min. Negotiated Rate	$1,697.50
Max. Negotiated Rate	$2,425.00
Rate for Payer: Aetna Commercial	$2,303.75
Rate for Payer: Aetna Medicare	$2,182.50
Rate for Payer: BCBS MT CHIP	$2,182.50
Rate for Payer: BCBS MT Closed Plan Network	$2,303.75
Rate for Payer: BCBS MT HealthLink	$2,182.50
Rate for Payer: BCBS MT Medicare	$2,182.50
Rate for Payer: BCBS MT POS	$2,303.75
Rate for Payer: BCBS MT Traditional	$2,425.00
Rate for Payer: Cash Price	$2,182.50
Rate for Payer: Cigna Commercial	$2,303.75
Rate for Payer: Cigna Medicare	$2,182.50
Rate for Payer: Medicaid All Medicaid	$2,231.00
Rate for Payer: Medicare All Medicare	$1,697.50
Rate for Payer: Monida Allegiance	$2,303.75
Rate for Payer: Monida First Choice Health	$2,352.25
Rate for Payer: Monida Montana Health Co-op	$2,303.75
Rate for Payer: Monida PacificSource	$2,303.75

MR PELVIS WO CONTRAST

Facility

$2,425.00

Service Code	CPT 72195
Hospital Charge Code	5300115
Hospital Revenue Code	614
Min. Negotiated Rate	$1,697.50
Max. Negotiated Rate	$2,425.00
Rate for Payer: Aetna Commercial	$2,303.75
Rate for Payer: Aetna Medicare	$2,182.50
Rate for Payer: BCBS MT CHIP	$2,182.50
Rate for Payer: BCBS MT Closed Plan Network	$2,303.75
Rate for Payer: BCBS MT HealthLink	$2,182.50
Rate for Payer: BCBS MT Medicare	$2,182.50
Rate for Payer: BCBS MT POS	$2,303.75
Rate for Payer: BCBS MT Traditional	$2,425.00
Rate for Payer: Cash Price	$2,182.50
Rate for Payer: Cigna Commercial	$2,303.75
Rate for Payer: Cigna Medicare	$2,182.50
Rate for Payer: Medicaid All Medicaid	$2,231.00
Rate for Payer: Medicare All Medicare	$1,697.50
Rate for Payer: Monida Allegiance	$2,303.75
Rate for Payer: Monida First Choice Health	$2,352.25
Rate for Payer: Monida Montana Health Co-op	$2,303.75
Rate for Payer: Monida PacificSource	$2,303.75

MR PELVIS W WO CONTRAST

Facility

$3,426.00

Service Code	CPT 72197
Hospital Charge Code	5300116
Hospital Revenue Code	614
Min. Negotiated Rate	$2,398.20
Max. Negotiated Rate	$3,426.00
Rate for Payer: Aetna Commercial	$3,254.70
Rate for Payer: Aetna Medicare	$3,083.40
Rate for Payer: BCBS MT CHIP	$3,083.40
Rate for Payer: BCBS MT Closed Plan Network	$3,254.70
Rate for Payer: BCBS MT HealthLink	$3,083.40
Rate for Payer: BCBS MT Medicare	$3,083.40
Rate for Payer: BCBS MT POS	$3,254.70
Rate for Payer: BCBS MT Traditional	$3,426.00
Rate for Payer: Cash Price	$3,083.40
Rate for Payer: Cigna Commercial	$3,254.70
Rate for Payer: Cigna Medicare	$3,083.40
Rate for Payer: Medicaid All Medicaid	$3,151.92
Rate for Payer: Medicare All Medicare	$2,398.20
Rate for Payer: Monida Allegiance	$3,254.70
Rate for Payer: Monida First Choice Health	$3,323.22
Rate for Payer: Monida Montana Health Co-op	$3,254.70
Rate for Payer: Monida PacificSource	$3,254.70

MR PELVIS W WO CONTRAST

Facility

$3,426.00

Service Code	CPT 72197
Hospital Charge Code	5300116
Hospital Revenue Code	614
Min. Negotiated Rate	$2,398.20
Max. Negotiated Rate	$3,426.00
Rate for Payer: Aetna Commercial	$3,254.70
Rate for Payer: Aetna Medicare	$3,083.40
Rate for Payer: BCBS MT CHIP	$3,083.40
Rate for Payer: BCBS MT Closed Plan Network	$3,254.70
Rate for Payer: BCBS MT HealthLink	$3,083.40
Rate for Payer: BCBS MT Medicare	$3,083.40
Rate for Payer: BCBS MT POS	$3,254.70
Rate for Payer: BCBS MT Traditional	$3,426.00
Rate for Payer: Cash Price	$3,083.40
Rate for Payer: Cigna Commercial	$3,254.70
Rate for Payer: Cigna Medicare	$3,083.40
Rate for Payer: Medicaid All Medicaid	$3,151.92
Rate for Payer: Medicare All Medicare	$2,398.20
Rate for Payer: Monida Allegiance	$3,254.70
Rate for Payer: Monida First Choice Health	$3,323.22
Rate for Payer: Monida Montana Health Co-op	$3,254.70
Rate for Payer: Monida PacificSource	$3,254.70

MRSA/MSSA NAAT RVMC

Facility

$195.00

Service Code	CPT 87641
Hospital Charge Code	4087882
Hospital Revenue Code	300
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

MRSA/MSSA NAAT RVMC

Facility

$195.00

Service Code	CPT 87641
Hospital Charge Code	4087882
Hospital Revenue Code	300
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$185.25
Rate for Payer: Aetna Medicare	$175.50
Rate for Payer: BCBS MT CHIP	$175.50
Rate for Payer: BCBS MT Closed Plan Network	$185.25
Rate for Payer: BCBS MT HealthLink	$175.50
Rate for Payer: BCBS MT Medicare	$175.50
Rate for Payer: BCBS MT POS	$185.25
Rate for Payer: BCBS MT Traditional	$195.00
Rate for Payer: Cash Price	$175.50
Rate for Payer: Cigna Commercial	$185.25
Rate for Payer: Cigna Medicare	$175.50
Rate for Payer: Medicaid All Medicaid	$179.40
Rate for Payer: Medicare All Medicare	$136.50
Rate for Payer: Monida Allegiance	$185.25
Rate for Payer: Monida First Choice Health	$189.15
Rate for Payer: Monida Montana Health Co-op	$185.25
Rate for Payer: Monida PacificSource	$185.25

MRSA, NAA SEND OUT(182956)

Facility

$184.00

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

MRSA, NAA SEND OUT(182956)

Facility

$184.00

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

MR SHOULDER LT W CONTRAST

Facility

$2,709.00

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

MR SHOULDER LT W CONTRAST

Facility

$2,709.00

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

MR SHOULDER LT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300025
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR SHOULDER LT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300025
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR SHOULDER LT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300031
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR SHOULDER LT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300031
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR SHOULDER RT W CONTRAST

Facility

$2,709.00

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

MR SHOULDER RT W CONTRAST

Facility

$2,709.00

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

MR SHOULDER RT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300028
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR SHOULDER RT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300028
Hospital Revenue Code	614
Min. Negotiated Rate	$1,574.30
Max. Negotiated Rate	$2,249.00
Rate for Payer: Aetna Commercial	$2,136.55
Rate for Payer: Aetna Medicare	$2,024.10
Rate for Payer: BCBS MT CHIP	$2,024.10
Rate for Payer: BCBS MT Closed Plan Network	$2,136.55
Rate for Payer: BCBS MT HealthLink	$2,024.10
Rate for Payer: BCBS MT Medicare	$2,024.10
Rate for Payer: BCBS MT POS	$2,136.55
Rate for Payer: BCBS MT Traditional	$2,249.00
Rate for Payer: Cash Price	$2,024.10
Rate for Payer: Cigna Commercial	$2,136.55
Rate for Payer: Cigna Medicare	$2,024.10
Rate for Payer: Medicaid All Medicaid	$2,069.08
Rate for Payer: Medicare All Medicare	$1,574.30
Rate for Payer: Monida Allegiance	$2,136.55
Rate for Payer: Monida First Choice Health	$2,181.53
Rate for Payer: Monida Montana Health Co-op	$2,136.55
Rate for Payer: Monida PacificSource	$2,136.55

MR SHOULDER RT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300034
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR SHOULDER RT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300034
Hospital Revenue Code	614
Min. Negotiated Rate	$2,377.90
Max. Negotiated Rate	$3,397.00
Rate for Payer: Aetna Commercial	$3,227.15
Rate for Payer: Aetna Medicare	$3,057.30
Rate for Payer: BCBS MT CHIP	$3,057.30
Rate for Payer: BCBS MT Closed Plan Network	$3,227.15
Rate for Payer: BCBS MT HealthLink	$3,057.30
Rate for Payer: BCBS MT Medicare	$3,057.30
Rate for Payer: BCBS MT POS	$3,227.15
Rate for Payer: BCBS MT Traditional	$3,397.00
Rate for Payer: Cash Price	$3,057.30
Rate for Payer: Cigna Commercial	$3,227.15
Rate for Payer: Cigna Medicare	$3,057.30
Rate for Payer: Medicaid All Medicaid	$3,125.24
Rate for Payer: Medicare All Medicare	$2,377.90
Rate for Payer: Monida Allegiance	$3,227.15
Rate for Payer: Monida First Choice Health	$3,295.09
Rate for Payer: Monida Montana Health Co-op	$3,227.15
Rate for Payer: Monida PacificSource	$3,227.15

MR SOFT TISSUE NECK W CONTRAST

Facility

$2,651.00

Service Code	CPT 70542
Hospital Charge Code	5300146
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 SOFT TISSUE NECK W CONTRAST

Facility

$2,651.00

Service Code	CPT 70542
Hospital Charge Code	5300146
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

Know your out-of-pocket cost for care.

All Charges