Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CT ABDOMEN W WO CONTRAST

Facility

$2,315.00

Service Code	HCPCS 74170 TC
Hospital Charge Code	5200007
Hospital Revenue Code	350
Min. Negotiated Rate	$1,620.50
Max. Negotiated Rate	$2,315.00
Rate for Payer: Aetna Commercial	$2,199.25
Rate for Payer: Aetna Medicare	$2,083.50
Rate for Payer: BCBS MT CHIP	$2,083.50
Rate for Payer: BCBS MT Closed Plan Network	$2,199.25
Rate for Payer: BCBS MT HealthLink	$2,083.50
Rate for Payer: BCBS MT Medicare	$2,083.50
Rate for Payer: BCBS MT POS	$2,199.25
Rate for Payer: BCBS MT Traditional	$2,315.00
Rate for Payer: Cash Price	$2,083.50
Rate for Payer: Cigna Commercial	$2,199.25
Rate for Payer: Cigna Medicare	$2,083.50
Rate for Payer: Medicaid All Medicaid	$2,129.80
Rate for Payer: Medicare All Medicare	$1,620.50
Rate for Payer: Monida Allegiance	$2,199.25
Rate for Payer: Monida First Choice Health	$2,245.55
Rate for Payer: Monida Montana Health Co-op	$2,199.25
Rate for Payer: Monida PacificSource	$2,199.25

CT ABDOMEN W WO CONTRAST

Facility

$2,315.00

Service Code	HCPCS 74170 TC
Hospital Charge Code	5200007
Hospital Revenue Code	350
Min. Negotiated Rate	$1,620.50
Max. Negotiated Rate	$2,315.00
Rate for Payer: Aetna Commercial	$2,199.25
Rate for Payer: Aetna Medicare	$2,083.50
Rate for Payer: BCBS MT CHIP	$2,083.50
Rate for Payer: BCBS MT Closed Plan Network	$2,199.25
Rate for Payer: BCBS MT HealthLink	$2,083.50
Rate for Payer: BCBS MT Medicare	$2,083.50
Rate for Payer: BCBS MT POS	$2,199.25
Rate for Payer: BCBS MT Traditional	$2,315.00
Rate for Payer: Cash Price	$2,083.50
Rate for Payer: Cigna Commercial	$2,199.25
Rate for Payer: Cigna Medicare	$2,083.50
Rate for Payer: Medicaid All Medicaid	$2,129.80
Rate for Payer: Medicare All Medicare	$1,620.50
Rate for Payer: Monida Allegiance	$2,199.25
Rate for Payer: Monida First Choice Health	$2,245.55
Rate for Payer: Monida Montana Health Co-op	$2,199.25
Rate for Payer: Monida PacificSource	$2,199.25

CTA CAROTID ARTERIES

Facility

$2,167.00

Service Code	HCPCS 70498 TC
Hospital Charge Code	5200055
Hospital Revenue Code	350
Min. Negotiated Rate	$1,516.90
Max. Negotiated Rate	$2,167.00
Rate for Payer: Aetna Commercial	$2,058.65
Rate for Payer: Aetna Medicare	$1,950.30
Rate for Payer: BCBS MT CHIP	$1,950.30
Rate for Payer: BCBS MT Closed Plan Network	$2,058.65
Rate for Payer: BCBS MT HealthLink	$1,950.30
Rate for Payer: BCBS MT Medicare	$1,950.30
Rate for Payer: BCBS MT POS	$2,058.65
Rate for Payer: BCBS MT Traditional	$2,167.00
Rate for Payer: Cash Price	$1,950.30
Rate for Payer: Cigna Commercial	$2,058.65
Rate for Payer: Cigna Medicare	$1,950.30
Rate for Payer: Medicaid All Medicaid	$1,993.64
Rate for Payer: Medicare All Medicare	$1,516.90
Rate for Payer: Monida Allegiance	$2,058.65
Rate for Payer: Monida First Choice Health	$2,101.99
Rate for Payer: Monida Montana Health Co-op	$2,058.65
Rate for Payer: Monida PacificSource	$2,058.65

CTA CAROTID ARTERIES

Facility

$2,167.00

Service Code	HCPCS 70498 TC
Hospital Charge Code	5200055
Hospital Revenue Code	350
Min. Negotiated Rate	$1,516.90
Max. Negotiated Rate	$2,167.00
Rate for Payer: Aetna Commercial	$2,058.65
Rate for Payer: Aetna Medicare	$1,950.30
Rate for Payer: BCBS MT CHIP	$1,950.30
Rate for Payer: BCBS MT Closed Plan Network	$2,058.65
Rate for Payer: BCBS MT HealthLink	$1,950.30
Rate for Payer: BCBS MT Medicare	$1,950.30
Rate for Payer: BCBS MT POS	$2,058.65
Rate for Payer: BCBS MT Traditional	$2,167.00
Rate for Payer: Cash Price	$1,950.30
Rate for Payer: Cigna Commercial	$2,058.65
Rate for Payer: Cigna Medicare	$1,950.30
Rate for Payer: Medicaid All Medicaid	$1,993.64
Rate for Payer: Medicare All Medicare	$1,516.90
Rate for Payer: Monida Allegiance	$2,058.65
Rate for Payer: Monida First Choice Health	$2,101.99
Rate for Payer: Monida Montana Health Co-op	$2,058.65
Rate for Payer: Monida PacificSource	$2,058.65

CTA HEAD CIRCLE OF WILLIS

Facility

$2,184.00

Service Code	HCPCS 70496 XU
Hospital Charge Code	5200056
Hospital Revenue Code	350
Min. Negotiated Rate	$1,528.80
Max. Negotiated Rate	$2,184.00
Rate for Payer: Aetna Commercial	$2,074.80
Rate for Payer: Aetna Medicare	$1,965.60
Rate for Payer: BCBS MT CHIP	$1,965.60
Rate for Payer: BCBS MT Closed Plan Network	$2,074.80
Rate for Payer: BCBS MT HealthLink	$1,965.60
Rate for Payer: BCBS MT Medicare	$1,965.60
Rate for Payer: BCBS MT POS	$2,074.80
Rate for Payer: BCBS MT Traditional	$2,184.00
Rate for Payer: Cash Price	$1,965.60
Rate for Payer: Cigna Commercial	$2,074.80
Rate for Payer: Cigna Medicare	$1,965.60
Rate for Payer: Medicaid All Medicaid	$2,009.28
Rate for Payer: Medicare All Medicare	$1,528.80
Rate for Payer: Monida Allegiance	$2,074.80
Rate for Payer: Monida First Choice Health	$2,118.48
Rate for Payer: Monida Montana Health Co-op	$2,074.80
Rate for Payer: Monida PacificSource	$2,074.80

CTA HEAD CIRCLE OF WILLIS

Facility

$2,184.00

Service Code	HCPCS 70496 XU
Hospital Charge Code	5200056
Hospital Revenue Code	350
Min. Negotiated Rate	$1,528.80
Max. Negotiated Rate	$2,184.00
Rate for Payer: Aetna Commercial	$2,074.80
Rate for Payer: Aetna Medicare	$1,965.60
Rate for Payer: BCBS MT CHIP	$1,965.60
Rate for Payer: BCBS MT Closed Plan Network	$2,074.80
Rate for Payer: BCBS MT HealthLink	$1,965.60
Rate for Payer: BCBS MT Medicare	$1,965.60
Rate for Payer: BCBS MT POS	$2,074.80
Rate for Payer: BCBS MT Traditional	$2,184.00
Rate for Payer: Cash Price	$1,965.60
Rate for Payer: Cigna Commercial	$2,074.80
Rate for Payer: Cigna Medicare	$1,965.60
Rate for Payer: Medicaid All Medicaid	$2,009.28
Rate for Payer: Medicare All Medicare	$1,528.80
Rate for Payer: Monida Allegiance	$2,074.80
Rate for Payer: Monida First Choice Health	$2,118.48
Rate for Payer: Monida Montana Health Co-op	$2,074.80
Rate for Payer: Monida PacificSource	$2,074.80

CTA LOWER EXTREMITY BILAT W WO CONTRAST

Facility

$2,092.00

Service Code	HCPCS 73706 TC
Hospital Charge Code	5200028
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CTA LOWER EXTREMITY BILAT W WO CONTRAST

Facility

$2,092.00

Service Code	HCPCS 73706 TC
Hospital Charge Code	5200028
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CTA ORBIT EAR FOSSA W CONTRAST

Facility

$1,878.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	5200063
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CTA ORBIT EAR FOSSA W CONTRAST

Facility

$1,878.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	5200063
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CTA PELVIS

Facility

$2,031.00

Service Code	HCPCS 72191 TC
Hospital Charge Code	5200057
Hospital Revenue Code	350
Min. Negotiated Rate	$1,421.70
Max. Negotiated Rate	$2,031.00
Rate for Payer: Aetna Commercial	$1,929.45
Rate for Payer: Aetna Medicare	$1,827.90
Rate for Payer: BCBS MT CHIP	$1,827.90
Rate for Payer: BCBS MT Closed Plan Network	$1,929.45
Rate for Payer: BCBS MT HealthLink	$1,827.90
Rate for Payer: BCBS MT Medicare	$1,827.90
Rate for Payer: BCBS MT POS	$1,929.45
Rate for Payer: BCBS MT Traditional	$2,031.00
Rate for Payer: Cash Price	$1,827.90
Rate for Payer: Cigna Commercial	$1,929.45
Rate for Payer: Cigna Medicare	$1,827.90
Rate for Payer: Medicaid All Medicaid	$1,868.52
Rate for Payer: Medicare All Medicare	$1,421.70
Rate for Payer: Monida Allegiance	$1,929.45
Rate for Payer: Monida First Choice Health	$1,970.07
Rate for Payer: Monida Montana Health Co-op	$1,929.45
Rate for Payer: Monida PacificSource	$1,929.45

CTA PELVIS

Facility

$2,031.00

Service Code	HCPCS 72191 TC
Hospital Charge Code	5200057
Hospital Revenue Code	350
Min. Negotiated Rate	$1,421.70
Max. Negotiated Rate	$2,031.00
Rate for Payer: Aetna Commercial	$1,929.45
Rate for Payer: Aetna Medicare	$1,827.90
Rate for Payer: BCBS MT CHIP	$1,827.90
Rate for Payer: BCBS MT Closed Plan Network	$1,929.45
Rate for Payer: BCBS MT HealthLink	$1,827.90
Rate for Payer: BCBS MT Medicare	$1,827.90
Rate for Payer: BCBS MT POS	$1,929.45
Rate for Payer: BCBS MT Traditional	$2,031.00
Rate for Payer: Cash Price	$1,827.90
Rate for Payer: Cigna Commercial	$1,929.45
Rate for Payer: Cigna Medicare	$1,827.90
Rate for Payer: Medicaid All Medicaid	$1,868.52
Rate for Payer: Medicare All Medicare	$1,421.70
Rate for Payer: Monida Allegiance	$1,929.45
Rate for Payer: Monida First Choice Health	$1,970.07
Rate for Payer: Monida Montana Health Co-op	$1,929.45
Rate for Payer: Monida PacificSource	$1,929.45

CTA THORACIC AORTA

Facility

$2,283.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	5200068
Hospital Revenue Code	350
Min. Negotiated Rate	$1,598.10
Max. Negotiated Rate	$2,283.00
Rate for Payer: Aetna Commercial	$2,168.85
Rate for Payer: Aetna Medicare	$2,054.70
Rate for Payer: BCBS MT CHIP	$2,054.70
Rate for Payer: BCBS MT Closed Plan Network	$2,168.85
Rate for Payer: BCBS MT HealthLink	$2,054.70
Rate for Payer: BCBS MT Medicare	$2,054.70
Rate for Payer: BCBS MT POS	$2,168.85
Rate for Payer: BCBS MT Traditional	$2,283.00
Rate for Payer: Cash Price	$2,054.70
Rate for Payer: Cigna Commercial	$2,168.85
Rate for Payer: Cigna Medicare	$2,054.70
Rate for Payer: Medicaid All Medicaid	$2,100.36
Rate for Payer: Medicare All Medicare	$1,598.10
Rate for Payer: Monida Allegiance	$2,168.85
Rate for Payer: Monida First Choice Health	$2,214.51
Rate for Payer: Monida Montana Health Co-op	$2,168.85
Rate for Payer: Monida PacificSource	$2,168.85

CTA THORACIC AORTA

Facility

$2,283.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	5200068
Hospital Revenue Code	350
Min. Negotiated Rate	$1,598.10
Max. Negotiated Rate	$2,283.00
Rate for Payer: Aetna Commercial	$2,168.85
Rate for Payer: Aetna Medicare	$2,054.70
Rate for Payer: BCBS MT CHIP	$2,054.70
Rate for Payer: BCBS MT Closed Plan Network	$2,168.85
Rate for Payer: BCBS MT HealthLink	$2,054.70
Rate for Payer: BCBS MT Medicare	$2,054.70
Rate for Payer: BCBS MT POS	$2,168.85
Rate for Payer: BCBS MT Traditional	$2,283.00
Rate for Payer: Cash Price	$2,054.70
Rate for Payer: Cigna Commercial	$2,168.85
Rate for Payer: Cigna Medicare	$2,054.70
Rate for Payer: Medicaid All Medicaid	$2,100.36
Rate for Payer: Medicare All Medicare	$1,598.10
Rate for Payer: Monida Allegiance	$2,168.85
Rate for Payer: Monida First Choice Health	$2,214.51
Rate for Payer: Monida Montana Health Co-op	$2,168.85
Rate for Payer: Monida PacificSource	$2,168.85

CTA THORACIC PE STUDY

Facility

$2,283.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	5200064
Hospital Revenue Code	350
Min. Negotiated Rate	$1,598.10
Max. Negotiated Rate	$2,283.00
Rate for Payer: Aetna Commercial	$2,168.85
Rate for Payer: Aetna Medicare	$2,054.70
Rate for Payer: BCBS MT CHIP	$2,054.70
Rate for Payer: BCBS MT Closed Plan Network	$2,168.85
Rate for Payer: BCBS MT HealthLink	$2,054.70
Rate for Payer: BCBS MT Medicare	$2,054.70
Rate for Payer: BCBS MT POS	$2,168.85
Rate for Payer: BCBS MT Traditional	$2,283.00
Rate for Payer: Cash Price	$2,054.70
Rate for Payer: Cigna Commercial	$2,168.85
Rate for Payer: Cigna Medicare	$2,054.70
Rate for Payer: Medicaid All Medicaid	$2,100.36
Rate for Payer: Medicare All Medicare	$1,598.10
Rate for Payer: Monida Allegiance	$2,168.85
Rate for Payer: Monida First Choice Health	$2,214.51
Rate for Payer: Monida Montana Health Co-op	$2,168.85
Rate for Payer: Monida PacificSource	$2,168.85

CTA THORACIC PE STUDY

Facility

$2,283.00

Service Code	HCPCS 71275 TC
Hospital Charge Code	5200064
Hospital Revenue Code	350
Min. Negotiated Rate	$1,598.10
Max. Negotiated Rate	$2,283.00
Rate for Payer: Aetna Commercial	$2,168.85
Rate for Payer: Aetna Medicare	$2,054.70
Rate for Payer: BCBS MT CHIP	$2,054.70
Rate for Payer: BCBS MT Closed Plan Network	$2,168.85
Rate for Payer: BCBS MT HealthLink	$2,054.70
Rate for Payer: BCBS MT Medicare	$2,054.70
Rate for Payer: BCBS MT POS	$2,168.85
Rate for Payer: BCBS MT Traditional	$2,283.00
Rate for Payer: Cash Price	$2,054.70
Rate for Payer: Cigna Commercial	$2,168.85
Rate for Payer: Cigna Medicare	$2,054.70
Rate for Payer: Medicaid All Medicaid	$2,100.36
Rate for Payer: Medicare All Medicare	$1,598.10
Rate for Payer: Monida Allegiance	$2,168.85
Rate for Payer: Monida First Choice Health	$2,214.51
Rate for Payer: Monida Montana Health Co-op	$2,168.85
Rate for Payer: Monida PacificSource	$2,168.85

CTA UPPER EXTREMITY LT W WO

Facility

$2,025.00

Service Code	HCPCS 73206 TC
Hospital Charge Code	5200128
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY LT W WO

Facility

$2,025.00

Service Code	HCPCS 73206 TC
Hospital Charge Code	5200128
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY RT W WO

Facility

$2,025.00

Service Code	HCPCS 73206 TC,RT
Hospital Charge Code	5200069
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY RT W WO

Facility

$2,025.00

Service Code	HCPCS 73206 TC,RT
Hospital Charge Code	5200069
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CT BONE DENSITY

Facility

$350.00

Service Code	HCPCS 77078 TC
Hospital Charge Code	5200012
Hospital Revenue Code	350
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

CT BONE DENSITY

Facility

$350.00

Service Code	HCPCS 77078 TC
Hospital Charge Code	5200012
Hospital Revenue Code	350
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

CT BONE LENGTH STUDY SCANOGRAM

Facility

$617.00

Service Code	HCPCS 77073
Hospital Charge Code	5277173
Hospital Revenue Code	350
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

CT BONE LENGTH STUDY SCANOGRAM

Facility

$617.00

Service Code	HCPCS 77073
Hospital Charge Code	5277173
Hospital Revenue Code	350
Min. Negotiated Rate	$431.90
Max. Negotiated Rate	$617.00
Rate for Payer: Aetna Commercial	$586.15
Rate for Payer: Aetna Medicare	$555.30
Rate for Payer: BCBS MT CHIP	$555.30
Rate for Payer: BCBS MT Closed Plan Network	$586.15
Rate for Payer: BCBS MT HealthLink	$555.30
Rate for Payer: BCBS MT Medicare	$555.30
Rate for Payer: BCBS MT POS	$586.15
Rate for Payer: BCBS MT Traditional	$617.00
Rate for Payer: Cash Price	$555.30
Rate for Payer: Cigna Commercial	$586.15
Rate for Payer: Cigna Medicare	$555.30
Rate for Payer: Medicaid All Medicaid	$567.64
Rate for Payer: Medicare All Medicare	$431.90
Rate for Payer: Monida Allegiance	$586.15
Rate for Payer: Monida First Choice Health	$598.49
Rate for Payer: Monida Montana Health Co-op	$586.15
Rate for Payer: Monida PacificSource	$586.15

CT CERVICAL SPINE W CONTRAST

Facility

$2,020.00

Service Code	HCPCS 72126 TC
Hospital Charge Code	5200021
Hospital Revenue Code	350
Min. Negotiated Rate	$1,414.00
Max. Negotiated Rate	$2,020.00
Rate for Payer: Aetna Commercial	$1,919.00
Rate for Payer: Aetna Medicare	$1,818.00
Rate for Payer: BCBS MT CHIP	$1,818.00
Rate for Payer: BCBS MT Closed Plan Network	$1,919.00
Rate for Payer: BCBS MT HealthLink	$1,818.00
Rate for Payer: BCBS MT Medicare	$1,818.00
Rate for Payer: BCBS MT POS	$1,919.00
Rate for Payer: BCBS MT Traditional	$2,020.00
Rate for Payer: Cash Price	$1,818.00
Rate for Payer: Cigna Commercial	$1,919.00
Rate for Payer: Cigna Medicare	$1,818.00
Rate for Payer: Medicaid All Medicaid	$1,858.40
Rate for Payer: Medicare All Medicare	$1,414.00
Rate for Payer: Monida Allegiance	$1,919.00
Rate for Payer: Monida First Choice Health	$1,959.40
Rate for Payer: Monida Montana Health Co-op	$1,919.00
Rate for Payer: Monida PacificSource	$1,919.00

Know your out-of-pocket cost for care.

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