Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

MR SOFT TISSUE NECK WO CONTRAST

Facility

$2,298.00

Service Code	CPT 70540
Hospital Charge Code	5300143
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 SOFT TISSUE NECK WO CONTRAST

Facility

$2,298.00

Service Code	CPT 70540
Hospital Charge Code	5300143
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 SOFT TISSUE NECK W WO CONTRAST

Facility

$3,281.00

Service Code	CPT 70543
Hospital Charge Code	5300139
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 SOFT TISSUE NECK W WO CONTRAST

Facility

$3,281.00

Service Code	CPT 70543
Hospital Charge Code	5300139
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 THORACIC SPINE W CONTRAST

Facility

$2,922.00

Service Code	CPT 72147
Hospital Charge Code	5300118
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 THORACIC SPINE W CONTRAST

Facility

$2,922.00

Service Code	CPT 72147
Hospital Charge Code	5300118
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 THORACIC SPINE WO CONTRAST

Facility

$2,518.00

Service Code	CPT 72146
Hospital Charge Code	5300119
Hospital Revenue Code	612
Min. Negotiated Rate	$1,762.60
Max. Negotiated Rate	$2,518.00
Rate for Payer: Aetna Commercial	$2,392.10
Rate for Payer: Aetna Medicare	$2,266.20
Rate for Payer: BCBS MT CHIP	$2,266.20
Rate for Payer: BCBS MT Closed Plan Network	$2,392.10
Rate for Payer: BCBS MT HealthLink	$2,266.20
Rate for Payer: BCBS MT Medicare	$2,266.20
Rate for Payer: BCBS MT POS	$2,392.10
Rate for Payer: BCBS MT Traditional	$2,518.00
Rate for Payer: Cash Price	$2,266.20
Rate for Payer: Cigna Commercial	$2,392.10
Rate for Payer: Cigna Medicare	$2,266.20
Rate for Payer: Medicaid All Medicaid	$2,316.56
Rate for Payer: Medicare All Medicare	$1,762.60
Rate for Payer: Monida Allegiance	$2,392.10
Rate for Payer: Monida First Choice Health	$2,442.46
Rate for Payer: Monida Montana Health Co-op	$2,392.10
Rate for Payer: Monida PacificSource	$2,392.10

MR THORACIC SPINE WO CONTRAST

Facility

$2,518.00

Service Code	CPT 72146
Hospital Charge Code	5300119
Hospital Revenue Code	612
Min. Negotiated Rate	$1,762.60
Max. Negotiated Rate	$2,518.00
Rate for Payer: Aetna Commercial	$2,392.10
Rate for Payer: Aetna Medicare	$2,266.20
Rate for Payer: BCBS MT CHIP	$2,266.20
Rate for Payer: BCBS MT Closed Plan Network	$2,392.10
Rate for Payer: BCBS MT HealthLink	$2,266.20
Rate for Payer: BCBS MT Medicare	$2,266.20
Rate for Payer: BCBS MT POS	$2,392.10
Rate for Payer: BCBS MT Traditional	$2,518.00
Rate for Payer: Cash Price	$2,266.20
Rate for Payer: Cigna Commercial	$2,392.10
Rate for Payer: Cigna Medicare	$2,266.20
Rate for Payer: Medicaid All Medicaid	$2,316.56
Rate for Payer: Medicare All Medicare	$1,762.60
Rate for Payer: Monida Allegiance	$2,392.10
Rate for Payer: Monida First Choice Health	$2,442.46
Rate for Payer: Monida Montana Health Co-op	$2,392.10
Rate for Payer: Monida PacificSource	$2,392.10

MR THORACIC SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	CPT 72157
Hospital Charge Code	5300120
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 THORACIC SPINE W WO CONTRAST

Facility

$3,680.00

Service Code	CPT 72157
Hospital Charge Code	5300120
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 TIBIA FIBULA LT W CONTRAST

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300038
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR TIBIA FIBULA LT W CONTRAST

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300038
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR TIBIA FIBULA LT WO CONTRAST

Facility

$2,255.00

Service Code	CPT 73718
Hospital Charge Code	5300044
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR TIBIA FIBULA LT WO CONTRAST

Facility

$2,255.00

Service Code	CPT 73718
Hospital Charge Code	5300044
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR TIBIA FIBULA LT W WO CONTRAST

Facility

$3,167.00

Service Code	CPT 73720
Hospital Charge Code	5300050
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR TIBIA FIBULA LT W WO CONTRAST

Facility

$3,167.00

Service Code	CPT 73720
Hospital Charge Code	5300050
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR TIBIA FIBULA RT W CONTRAST

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300041
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR TIBIA FIBULA RT W CONTRAST

Facility

$2,645.00

Service Code	CPT 73719
Hospital Charge Code	5300041
Hospital Revenue Code	614
Min. Negotiated Rate	$1,851.50
Max. Negotiated Rate	$2,645.00
Rate for Payer: Aetna Commercial	$2,512.75
Rate for Payer: Aetna Medicare	$2,380.50
Rate for Payer: BCBS MT CHIP	$2,380.50
Rate for Payer: BCBS MT Closed Plan Network	$2,512.75
Rate for Payer: BCBS MT HealthLink	$2,380.50
Rate for Payer: BCBS MT Medicare	$2,380.50
Rate for Payer: BCBS MT POS	$2,512.75
Rate for Payer: BCBS MT Traditional	$2,645.00
Rate for Payer: Cash Price	$2,380.50
Rate for Payer: Cigna Commercial	$2,512.75
Rate for Payer: Cigna Medicare	$2,380.50
Rate for Payer: Medicaid All Medicaid	$2,433.40
Rate for Payer: Medicare All Medicare	$1,851.50
Rate for Payer: Monida Allegiance	$2,512.75
Rate for Payer: Monida First Choice Health	$2,565.65
Rate for Payer: Monida Montana Health Co-op	$2,512.75
Rate for Payer: Monida PacificSource	$2,512.75

MR TIBIA FIBULA RT WO CONTRAST

Facility

$2,255.00

Service Code	CPT 73718
Hospital Charge Code	5300047
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR TIBIA FIBULA RT WO CONTRAST

Facility

$2,255.00

Service Code	CPT 73718
Hospital Charge Code	5300047
Hospital Revenue Code	614
Min. Negotiated Rate	$1,578.50
Max. Negotiated Rate	$2,255.00
Rate for Payer: Aetna Commercial	$2,142.25
Rate for Payer: Aetna Medicare	$2,029.50
Rate for Payer: BCBS MT CHIP	$2,029.50
Rate for Payer: BCBS MT Closed Plan Network	$2,142.25
Rate for Payer: BCBS MT HealthLink	$2,029.50
Rate for Payer: BCBS MT Medicare	$2,029.50
Rate for Payer: BCBS MT POS	$2,142.25
Rate for Payer: BCBS MT Traditional	$2,255.00
Rate for Payer: Cash Price	$2,029.50
Rate for Payer: Cigna Commercial	$2,142.25
Rate for Payer: Cigna Medicare	$2,029.50
Rate for Payer: Medicaid All Medicaid	$2,074.60
Rate for Payer: Medicare All Medicare	$1,578.50
Rate for Payer: Monida Allegiance	$2,142.25
Rate for Payer: Monida First Choice Health	$2,187.35
Rate for Payer: Monida Montana Health Co-op	$2,142.25
Rate for Payer: Monida PacificSource	$2,142.25

MR TIBIA FIBULA RT W WO CONTRAST

Facility

$3,167.00

Service Code	CPT 73720
Hospital Charge Code	5300053
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR TIBIA FIBULA RT W WO CONTRAST

Facility

$3,167.00

Service Code	CPT 73720
Hospital Charge Code	5300053
Hospital Revenue Code	614
Min. Negotiated Rate	$2,216.90
Max. Negotiated Rate	$3,167.00
Rate for Payer: Aetna Commercial	$3,008.65
Rate for Payer: Aetna Medicare	$2,850.30
Rate for Payer: BCBS MT CHIP	$2,850.30
Rate for Payer: BCBS MT Closed Plan Network	$3,008.65
Rate for Payer: BCBS MT HealthLink	$2,850.30
Rate for Payer: BCBS MT Medicare	$2,850.30
Rate for Payer: BCBS MT POS	$3,008.65
Rate for Payer: BCBS MT Traditional	$3,167.00
Rate for Payer: Cash Price	$2,850.30
Rate for Payer: Cigna Commercial	$3,008.65
Rate for Payer: Cigna Medicare	$2,850.30
Rate for Payer: Medicaid All Medicaid	$2,913.64
Rate for Payer: Medicare All Medicare	$2,216.90
Rate for Payer: Monida Allegiance	$3,008.65
Rate for Payer: Monida First Choice Health	$3,071.99
Rate for Payer: Monida Montana Health Co-op	$3,008.65
Rate for Payer: Monida PacificSource	$3,008.65

MR TMJ

Facility

$2,113.00

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

MR TMJ

Facility

$2,113.00

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

MR UPPR XT W CON LT

Facility

$2,917.00

Service Code	CPT 73219
Hospital Charge Code	5300121
Hospital Revenue Code	614
Min. Negotiated Rate	$2,041.90
Max. Negotiated Rate	$2,917.00
Rate for Payer: Aetna Commercial	$2,771.15
Rate for Payer: Aetna Medicare	$2,625.30
Rate for Payer: BCBS MT CHIP	$2,625.30
Rate for Payer: BCBS MT Closed Plan Network	$2,771.15
Rate for Payer: BCBS MT HealthLink	$2,625.30
Rate for Payer: BCBS MT Medicare	$2,625.30
Rate for Payer: BCBS MT POS	$2,771.15
Rate for Payer: BCBS MT Traditional	$2,917.00
Rate for Payer: Cash Price	$2,625.30
Rate for Payer: Cigna Commercial	$2,771.15
Rate for Payer: Cigna Medicare	$2,625.30
Rate for Payer: Medicaid All Medicaid	$2,683.64
Rate for Payer: Medicare All Medicare	$2,041.90
Rate for Payer: Monida Allegiance	$2,771.15
Rate for Payer: Monida First Choice Health	$2,829.49
Rate for Payer: Monida Montana Health Co-op	$2,771.15
Rate for Payer: Monida PacificSource	$2,771.15

Know your out-of-pocket cost for care.

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