Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CRUTCH ADULT TALL 5'10"

Facility

$95.00

Service Code	HCPCS E0116
Hospital Charge Code	2893282
Hospital Revenue Code	270
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

CRUTCH DRESSED CHILD

Facility

$54.00

Service Code	HCPCS E0116
Hospital Charge Code	2893284
Hospital Revenue Code	290
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

CRUTCH DRESSED CHILD

Facility

$54.00

Service Code	HCPCS E0116
Hospital Charge Code	2893284
Hospital Revenue Code	290
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

CRUTCH YOUTH 4'6 - 5'2

Facility

$66.00

Service Code	HCPCS E0116
Hospital Charge Code	2870012
Hospital Revenue Code	270
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

CRUTCH YOUTH 4'6 - 5'2

Facility

$66.00

Service Code	HCPCS E0116
Hospital Charge Code	2870012
Hospital Revenue Code	270
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$66.00
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: BCBS MT CHIP	$59.40
Rate for Payer: BCBS MT Closed Plan Network	$62.70
Rate for Payer: BCBS MT HealthLink	$59.40
Rate for Payer: BCBS MT Medicare	$59.40
Rate for Payer: BCBS MT POS	$62.70
Rate for Payer: BCBS MT Traditional	$66.00
Rate for Payer: Cash Price	$59.40
Rate for Payer: Cigna Commercial	$62.70
Rate for Payer: Cigna Medicare	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

CRYPTOSPORIDUM, EIA (183020)

Facility

$206.00

Service Code	HCPCS 87328
Hospital Charge Code	4087328
Hospital Revenue Code	301
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$206.00
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: BCBS MT CHIP	$185.40
Rate for Payer: BCBS MT Closed Plan Network	$195.70
Rate for Payer: BCBS MT HealthLink	$185.40
Rate for Payer: BCBS MT Medicare	$185.40
Rate for Payer: BCBS MT POS	$195.70
Rate for Payer: BCBS MT Traditional	$206.00
Rate for Payer: Cash Price	$185.40
Rate for Payer: Cigna Commercial	$195.70
Rate for Payer: Cigna Medicare	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

CRYPTOSPORIDUM, EIA (183020)

Facility

$206.00

Service Code	HCPCS 87328
Hospital Charge Code	4087328
Hospital Revenue Code	301
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$206.00
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: BCBS MT CHIP	$185.40
Rate for Payer: BCBS MT Closed Plan Network	$195.70
Rate for Payer: BCBS MT HealthLink	$185.40
Rate for Payer: BCBS MT Medicare	$185.40
Rate for Payer: BCBS MT POS	$195.70
Rate for Payer: BCBS MT Traditional	$206.00
Rate for Payer: Cash Price	$185.40
Rate for Payer: Cigna Commercial	$195.70
Rate for Payer: Cigna Medicare	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

CT 3D RECONSTRUCTION

Facility

$365.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5200005
Hospital Revenue Code	350
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

CT 3D RECONSTRUCTION

Facility

$365.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5200005
Hospital Revenue Code	350
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

CTA ABDOMEN GENERAL

Facility

$2,255.00

Service Code	HCPCS 74175 TC
Hospital Charge Code	5200053
Hospital Revenue Code	350
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

CTA ABDOMEN GENERAL

Facility

$2,255.00

Service Code	HCPCS 74175 TC
Hospital Charge Code	5200053
Hospital Revenue Code	350
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

CTA ABDOMEN PELVIS W WO CONTRAST

Facility

$2,807.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	5200250
Hospital Revenue Code	350
Min. Negotiated Rate	$1,964.90
Max. Negotiated Rate	$2,807.00
Rate for Payer: Aetna Commercial	$2,666.65
Rate for Payer: Aetna Medicare	$2,526.30
Rate for Payer: BCBS MT CHIP	$2,526.30
Rate for Payer: BCBS MT Closed Plan Network	$2,666.65
Rate for Payer: BCBS MT HealthLink	$2,526.30
Rate for Payer: BCBS MT Medicare	$2,526.30
Rate for Payer: BCBS MT POS	$2,666.65
Rate for Payer: BCBS MT Traditional	$2,807.00
Rate for Payer: Cash Price	$2,526.30
Rate for Payer: Cigna Commercial	$2,666.65
Rate for Payer: Cigna Medicare	$2,526.30
Rate for Payer: Medicaid All Medicaid	$2,582.44
Rate for Payer: Medicare All Medicare	$1,964.90
Rate for Payer: Monida Allegiance	$2,666.65
Rate for Payer: Monida First Choice Health	$2,722.79
Rate for Payer: Monida Montana Health Co-op	$2,666.65
Rate for Payer: Monida PacificSource	$2,666.65

CTA ABDOMEN PELVIS W WO CONTRAST

Facility

$2,807.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	5200250
Hospital Revenue Code	350
Min. Negotiated Rate	$1,964.90
Max. Negotiated Rate	$2,807.00
Rate for Payer: Aetna Commercial	$2,666.65
Rate for Payer: Aetna Medicare	$2,526.30
Rate for Payer: BCBS MT CHIP	$2,526.30
Rate for Payer: BCBS MT Closed Plan Network	$2,666.65
Rate for Payer: BCBS MT HealthLink	$2,526.30
Rate for Payer: BCBS MT Medicare	$2,526.30
Rate for Payer: BCBS MT POS	$2,666.65
Rate for Payer: BCBS MT Traditional	$2,807.00
Rate for Payer: Cash Price	$2,526.30
Rate for Payer: Cigna Commercial	$2,666.65
Rate for Payer: Cigna Medicare	$2,526.30
Rate for Payer: Medicaid All Medicaid	$2,582.44
Rate for Payer: Medicare All Medicare	$1,964.90
Rate for Payer: Monida Allegiance	$2,666.65
Rate for Payer: Monida First Choice Health	$2,722.79
Rate for Payer: Monida Montana Health Co-op	$2,666.65
Rate for Payer: Monida PacificSource	$2,666.65

CTA AORTA ILIAC RUNOFF

Facility

$2,228.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5200054
Hospital Revenue Code	350
Min. Negotiated Rate	$1,559.60
Max. Negotiated Rate	$2,228.00
Rate for Payer: Aetna Commercial	$2,116.60
Rate for Payer: Aetna Medicare	$2,005.20
Rate for Payer: BCBS MT CHIP	$2,005.20
Rate for Payer: BCBS MT Closed Plan Network	$2,116.60
Rate for Payer: BCBS MT HealthLink	$2,005.20
Rate for Payer: BCBS MT Medicare	$2,005.20
Rate for Payer: BCBS MT POS	$2,116.60
Rate for Payer: BCBS MT Traditional	$2,228.00
Rate for Payer: Cash Price	$2,005.20
Rate for Payer: Cigna Commercial	$2,116.60
Rate for Payer: Cigna Medicare	$2,005.20
Rate for Payer: Medicaid All Medicaid	$2,049.76
Rate for Payer: Medicare All Medicare	$1,559.60
Rate for Payer: Monida Allegiance	$2,116.60
Rate for Payer: Monida First Choice Health	$2,161.16
Rate for Payer: Monida Montana Health Co-op	$2,116.60
Rate for Payer: Monida PacificSource	$2,116.60

CTA AORTA ILIAC RUNOFF

Facility

$2,228.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5200054
Hospital Revenue Code	350
Min. Negotiated Rate	$1,559.60
Max. Negotiated Rate	$2,228.00
Rate for Payer: Aetna Commercial	$2,116.60
Rate for Payer: Aetna Medicare	$2,005.20
Rate for Payer: BCBS MT CHIP	$2,005.20
Rate for Payer: BCBS MT Closed Plan Network	$2,116.60
Rate for Payer: BCBS MT HealthLink	$2,005.20
Rate for Payer: BCBS MT Medicare	$2,005.20
Rate for Payer: BCBS MT POS	$2,116.60
Rate for Payer: BCBS MT Traditional	$2,228.00
Rate for Payer: Cash Price	$2,005.20
Rate for Payer: Cigna Commercial	$2,116.60
Rate for Payer: Cigna Medicare	$2,005.20
Rate for Payer: Medicaid All Medicaid	$2,049.76
Rate for Payer: Medicare All Medicare	$1,559.60
Rate for Payer: Monida Allegiance	$2,116.60
Rate for Payer: Monida First Choice Health	$2,161.16
Rate for Payer: Monida Montana Health Co-op	$2,116.60
Rate for Payer: Monida PacificSource	$2,116.60

CT ABDOMEN PELVIS W CONTRAST

Facility

$3,025.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	5200011
Hospital Revenue Code	350
Min. Negotiated Rate	$2,117.50
Max. Negotiated Rate	$3,025.00
Rate for Payer: Aetna Commercial	$2,873.75
Rate for Payer: Aetna Medicare	$2,722.50
Rate for Payer: BCBS MT CHIP	$2,722.50
Rate for Payer: BCBS MT Closed Plan Network	$2,873.75
Rate for Payer: BCBS MT HealthLink	$2,722.50
Rate for Payer: BCBS MT Medicare	$2,722.50
Rate for Payer: BCBS MT POS	$2,873.75
Rate for Payer: BCBS MT Traditional	$3,025.00
Rate for Payer: Cash Price	$2,722.50
Rate for Payer: Cigna Commercial	$2,873.75
Rate for Payer: Cigna Medicare	$2,722.50
Rate for Payer: Medicaid All Medicaid	$2,783.00
Rate for Payer: Medicare All Medicare	$2,117.50
Rate for Payer: Monida Allegiance	$2,873.75
Rate for Payer: Monida First Choice Health	$2,934.25
Rate for Payer: Monida Montana Health Co-op	$2,873.75
Rate for Payer: Monida PacificSource	$2,873.75

CT ABDOMEN PELVIS W CONTRAST

Facility

$3,025.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	5200011
Hospital Revenue Code	350
Min. Negotiated Rate	$2,117.50
Max. Negotiated Rate	$3,025.00
Rate for Payer: Aetna Commercial	$2,873.75
Rate for Payer: Aetna Medicare	$2,722.50
Rate for Payer: BCBS MT CHIP	$2,722.50
Rate for Payer: BCBS MT Closed Plan Network	$2,873.75
Rate for Payer: BCBS MT HealthLink	$2,722.50
Rate for Payer: BCBS MT Medicare	$2,722.50
Rate for Payer: BCBS MT POS	$2,873.75
Rate for Payer: BCBS MT Traditional	$3,025.00
Rate for Payer: Cash Price	$2,722.50
Rate for Payer: Cigna Commercial	$2,873.75
Rate for Payer: Cigna Medicare	$2,722.50
Rate for Payer: Medicaid All Medicaid	$2,783.00
Rate for Payer: Medicare All Medicare	$2,117.50
Rate for Payer: Monida Allegiance	$2,873.75
Rate for Payer: Monida First Choice Health	$2,934.25
Rate for Payer: Monida Montana Health Co-op	$2,873.75
Rate for Payer: Monida PacificSource	$2,873.75

CT ABDOMEN PELVIS WO CONTRAST

Facility

$2,376.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	5200009
Hospital Revenue Code	350
Min. Negotiated Rate	$1,663.20
Max. Negotiated Rate	$2,376.00
Rate for Payer: Aetna Commercial	$2,257.20
Rate for Payer: Aetna Medicare	$2,138.40
Rate for Payer: BCBS MT CHIP	$2,138.40
Rate for Payer: BCBS MT Closed Plan Network	$2,257.20
Rate for Payer: BCBS MT HealthLink	$2,138.40
Rate for Payer: BCBS MT Medicare	$2,138.40
Rate for Payer: BCBS MT POS	$2,257.20
Rate for Payer: BCBS MT Traditional	$2,376.00
Rate for Payer: Cash Price	$2,138.40
Rate for Payer: Cigna Commercial	$2,257.20
Rate for Payer: Cigna Medicare	$2,138.40
Rate for Payer: Medicaid All Medicaid	$2,185.92
Rate for Payer: Medicare All Medicare	$1,663.20
Rate for Payer: Monida Allegiance	$2,257.20
Rate for Payer: Monida First Choice Health	$2,304.72
Rate for Payer: Monida Montana Health Co-op	$2,257.20
Rate for Payer: Monida PacificSource	$2,257.20

CT ABDOMEN PELVIS WO CONTRAST

Facility

$2,376.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	5200009
Hospital Revenue Code	350
Min. Negotiated Rate	$1,663.20
Max. Negotiated Rate	$2,376.00
Rate for Payer: Aetna Commercial	$2,257.20
Rate for Payer: Aetna Medicare	$2,138.40
Rate for Payer: BCBS MT CHIP	$2,138.40
Rate for Payer: BCBS MT Closed Plan Network	$2,257.20
Rate for Payer: BCBS MT HealthLink	$2,138.40
Rate for Payer: BCBS MT Medicare	$2,138.40
Rate for Payer: BCBS MT POS	$2,257.20
Rate for Payer: BCBS MT Traditional	$2,376.00
Rate for Payer: Cash Price	$2,138.40
Rate for Payer: Cigna Commercial	$2,257.20
Rate for Payer: Cigna Medicare	$2,138.40
Rate for Payer: Medicaid All Medicaid	$2,185.92
Rate for Payer: Medicare All Medicare	$1,663.20
Rate for Payer: Monida Allegiance	$2,257.20
Rate for Payer: Monida First Choice Health	$2,304.72
Rate for Payer: Monida Montana Health Co-op	$2,257.20
Rate for Payer: Monida PacificSource	$2,257.20

CT ABDOMEN PELVIS W WO CONTRAST

Facility

$3,358.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	5200010
Hospital Revenue Code	350
Min. Negotiated Rate	$2,350.60
Max. Negotiated Rate	$3,358.00
Rate for Payer: Aetna Commercial	$3,190.10
Rate for Payer: Aetna Medicare	$3,022.20
Rate for Payer: BCBS MT CHIP	$3,022.20
Rate for Payer: BCBS MT Closed Plan Network	$3,190.10
Rate for Payer: BCBS MT HealthLink	$3,022.20
Rate for Payer: BCBS MT Medicare	$3,022.20
Rate for Payer: BCBS MT POS	$3,190.10
Rate for Payer: BCBS MT Traditional	$3,358.00
Rate for Payer: Cash Price	$3,022.20
Rate for Payer: Cigna Commercial	$3,190.10
Rate for Payer: Cigna Medicare	$3,022.20
Rate for Payer: Medicaid All Medicaid	$3,089.36
Rate for Payer: Medicare All Medicare	$2,350.60
Rate for Payer: Monida Allegiance	$3,190.10
Rate for Payer: Monida First Choice Health	$3,257.26
Rate for Payer: Monida Montana Health Co-op	$3,190.10
Rate for Payer: Monida PacificSource	$3,190.10

CT ABDOMEN PELVIS W WO CONTRAST

Facility

$3,358.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	5200010
Hospital Revenue Code	350
Min. Negotiated Rate	$2,350.60
Max. Negotiated Rate	$3,358.00
Rate for Payer: Aetna Commercial	$3,190.10
Rate for Payer: Aetna Medicare	$3,022.20
Rate for Payer: BCBS MT CHIP	$3,022.20
Rate for Payer: BCBS MT Closed Plan Network	$3,190.10
Rate for Payer: BCBS MT HealthLink	$3,022.20
Rate for Payer: BCBS MT Medicare	$3,022.20
Rate for Payer: BCBS MT POS	$3,190.10
Rate for Payer: BCBS MT Traditional	$3,358.00
Rate for Payer: Cash Price	$3,022.20
Rate for Payer: Cigna Commercial	$3,190.10
Rate for Payer: Cigna Medicare	$3,022.20
Rate for Payer: Medicaid All Medicaid	$3,089.36
Rate for Payer: Medicare All Medicare	$2,350.60
Rate for Payer: Monida Allegiance	$3,190.10
Rate for Payer: Monida First Choice Health	$3,257.26
Rate for Payer: Monida Montana Health Co-op	$3,190.10
Rate for Payer: Monida PacificSource	$3,190.10

CT ABDOMEN W CONTRAST

Facility

$1,966.00

Service Code	HCPCS 74160 TC
Hospital Charge Code	5200008
Hospital Revenue Code	350
Min. Negotiated Rate	$1,376.20
Max. Negotiated Rate	$1,966.00
Rate for Payer: Aetna Commercial	$1,867.70
Rate for Payer: Aetna Medicare	$1,769.40
Rate for Payer: BCBS MT CHIP	$1,769.40
Rate for Payer: BCBS MT Closed Plan Network	$1,867.70
Rate for Payer: BCBS MT HealthLink	$1,769.40
Rate for Payer: BCBS MT Medicare	$1,769.40
Rate for Payer: BCBS MT POS	$1,867.70
Rate for Payer: BCBS MT Traditional	$1,966.00
Rate for Payer: Cash Price	$1,769.40
Rate for Payer: Cigna Commercial	$1,867.70
Rate for Payer: Cigna Medicare	$1,769.40
Rate for Payer: Medicaid All Medicaid	$1,808.72
Rate for Payer: Medicare All Medicare	$1,376.20
Rate for Payer: Monida Allegiance	$1,867.70
Rate for Payer: Monida First Choice Health	$1,907.02
Rate for Payer: Monida Montana Health Co-op	$1,867.70
Rate for Payer: Monida PacificSource	$1,867.70

CT ABDOMEN W CONTRAST

Facility

$1,966.00

Service Code	HCPCS 74160 TC
Hospital Charge Code	5200008
Hospital Revenue Code	350
Min. Negotiated Rate	$1,376.20
Max. Negotiated Rate	$1,966.00
Rate for Payer: Aetna Commercial	$1,867.70
Rate for Payer: Aetna Medicare	$1,769.40
Rate for Payer: BCBS MT CHIP	$1,769.40
Rate for Payer: BCBS MT Closed Plan Network	$1,867.70
Rate for Payer: BCBS MT HealthLink	$1,769.40
Rate for Payer: BCBS MT Medicare	$1,769.40
Rate for Payer: BCBS MT POS	$1,867.70
Rate for Payer: BCBS MT Traditional	$1,966.00
Rate for Payer: Cash Price	$1,769.40
Rate for Payer: Cigna Commercial	$1,867.70
Rate for Payer: Cigna Medicare	$1,769.40
Rate for Payer: Medicaid All Medicaid	$1,808.72
Rate for Payer: Medicare All Medicare	$1,376.20
Rate for Payer: Monida Allegiance	$1,867.70
Rate for Payer: Monida First Choice Health	$1,907.02
Rate for Payer: Monida Montana Health Co-op	$1,867.70
Rate for Payer: Monida PacificSource	$1,867.70

CT ABDOMEN WO CONTRAST

Facility

$1,539.00

Service Code	HCPCS 74150 TC
Hospital Charge Code	5200006
Hospital Revenue Code	350
Min. Negotiated Rate	$1,077.30
Max. Negotiated Rate	$1,539.00
Rate for Payer: Aetna Commercial	$1,462.05
Rate for Payer: Aetna Medicare	$1,385.10
Rate for Payer: BCBS MT CHIP	$1,385.10
Rate for Payer: BCBS MT Closed Plan Network	$1,462.05
Rate for Payer: BCBS MT HealthLink	$1,385.10
Rate for Payer: BCBS MT Medicare	$1,385.10
Rate for Payer: BCBS MT POS	$1,462.05
Rate for Payer: BCBS MT Traditional	$1,539.00
Rate for Payer: Cash Price	$1,385.10
Rate for Payer: Cigna Commercial	$1,462.05
Rate for Payer: Cigna Medicare	$1,385.10
Rate for Payer: Medicaid All Medicaid	$1,415.88
Rate for Payer: Medicare All Medicare	$1,077.30
Rate for Payer: Monida Allegiance	$1,462.05
Rate for Payer: Monida First Choice Health	$1,492.83
Rate for Payer: Monida Montana Health Co-op	$1,462.05
Rate for Payer: Monida PacificSource	$1,462.05

CT ABDOMEN WO CONTRAST

Facility

$1,539.00

Service Code	HCPCS 74150 TC
Hospital Charge Code	5200006
Hospital Revenue Code	350
Min. Negotiated Rate	$1,077.30
Max. Negotiated Rate	$1,539.00
Rate for Payer: Aetna Commercial	$1,462.05
Rate for Payer: Aetna Medicare	$1,385.10
Rate for Payer: BCBS MT CHIP	$1,385.10
Rate for Payer: BCBS MT Closed Plan Network	$1,462.05
Rate for Payer: BCBS MT HealthLink	$1,385.10
Rate for Payer: BCBS MT Medicare	$1,385.10
Rate for Payer: BCBS MT POS	$1,462.05
Rate for Payer: BCBS MT Traditional	$1,539.00
Rate for Payer: Cash Price	$1,385.10
Rate for Payer: Cigna Commercial	$1,462.05
Rate for Payer: Cigna Medicare	$1,385.10
Rate for Payer: Medicaid All Medicaid	$1,415.88
Rate for Payer: Medicare All Medicare	$1,077.30
Rate for Payer: Monida Allegiance	$1,462.05
Rate for Payer: Monida First Choice Health	$1,492.83
Rate for Payer: Monida Montana Health Co-op	$1,462.05
Rate for Payer: Monida PacificSource	$1,462.05

Know your out-of-pocket cost for care.

All Charges