Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

MR UPPR XT W CON RT

Facility

$2,917.00

Service Code	CPT 73219
Hospital Charge Code	5300122
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

MR UPPR XT W CON RT

Facility

$2,917.00

Service Code	CPT 73219
Hospital Charge Code	5300122
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

MR UPPR XT WO CON LT

Facility

$2,222.00

Service Code	CPT 73218
Hospital Charge Code	5300123
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR UPPR XT WO CON LT

Facility

$2,222.00

Service Code	CPT 73218
Hospital Charge Code	5300123
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR UPPR XT WO CON RT

Facility

$2,222.00

Service Code	CPT 73218
Hospital Charge Code	5300124
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR UPPR XT WO CON RT

Facility

$2,222.00

Service Code	CPT 73218
Hospital Charge Code	5300124
Hospital Revenue Code	614
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

MR UPPR XT WO&W CON LT

Facility

$3,172.00

Service Code	CPT 73220
Hospital Charge Code	5300125
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MR UPPR XT WO&W CON LT

Facility

$3,172.00

Service Code	CPT 73220
Hospital Charge Code	5300125
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MR UPPR XT WO&W CON RT

Facility

$3,172.00

Service Code	CPT 73220
Hospital Charge Code	5300126
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MR UPPR XT WO&W CON RT

Facility

$3,172.00

Service Code	CPT 73220
Hospital Charge Code	5300126
Hospital Revenue Code	614
Min. Negotiated Rate	$2,220.40
Max. Negotiated Rate	$3,172.00
Rate for Payer: Aetna Commercial	$3,013.40
Rate for Payer: Aetna Medicare	$2,854.80
Rate for Payer: BCBS MT CHIP	$2,854.80
Rate for Payer: BCBS MT Closed Plan Network	$3,013.40
Rate for Payer: BCBS MT HealthLink	$2,854.80
Rate for Payer: BCBS MT Medicare	$2,854.80
Rate for Payer: BCBS MT POS	$3,013.40
Rate for Payer: BCBS MT Traditional	$3,172.00
Rate for Payer: Cash Price	$2,854.80
Rate for Payer: Cigna Commercial	$3,013.40
Rate for Payer: Cigna Medicare	$2,854.80
Rate for Payer: Medicaid All Medicaid	$2,918.24
Rate for Payer: Medicare All Medicare	$2,220.40
Rate for Payer: Monida Allegiance	$3,013.40
Rate for Payer: Monida First Choice Health	$3,076.84
Rate for Payer: Monida Montana Health Co-op	$3,013.40
Rate for Payer: Monida PacificSource	$3,013.40

MRV BRAIN W WO CONTRAST

Facility

$3,657.00

Service Code	CPT 70546
Hospital Charge Code	5300147
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

MRV BRAIN W WO CONTRAST

Facility

$3,657.00

Service Code	CPT 70546
Hospital Charge Code	5300147
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 WRIST LT W CONTRAST

Facility

$2,709.00

Service Code	CPT 73222
Hospital Charge Code	5300021
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 WRIST LT W CONTRAST

Facility

$2,709.00

Service Code	CPT 73222
Hospital Charge Code	5300021
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 WRIST LT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300027
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 WRIST LT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300027
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 WRIST LT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300033
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 WRIST LT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300033
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 WRIST RT W CONTRAST

Facility

$2,709.00

Service Code	CPT 73222
Hospital Charge Code	5300024
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 WRIST RT W CONTRAST

Facility

$2,709.00

Service Code	CPT 73222
Hospital Charge Code	5300024
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 WRIST RT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300030
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 WRIST RT WO CONTRAST

Facility

$2,249.00

Service Code	CPT 73221
Hospital Charge Code	5300030
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 WRIST RT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300036
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 WRIST RT W WO CONTRAST

Facility

$3,397.00

Service Code	CPT 73223
Hospital Charge Code	5300036
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.

All Charges