Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

CT CERVICAL SPINE WO CONTRAST

Facility

$1,611.00

Service Code	HCPCS 72125 TC
Hospital Charge Code	5200019
Hospital Revenue Code	350
Min. Negotiated Rate	$1,127.70
Max. Negotiated Rate	$1,611.00
Rate for Payer: Aetna Commercial	$1,530.45
Rate for Payer: Aetna Medicare	$1,449.90
Rate for Payer: BCBS MT CHIP	$1,449.90
Rate for Payer: BCBS MT Closed Plan Network	$1,530.45
Rate for Payer: BCBS MT HealthLink	$1,449.90
Rate for Payer: BCBS MT Medicare	$1,449.90
Rate for Payer: BCBS MT POS	$1,530.45
Rate for Payer: BCBS MT Traditional	$1,611.00
Rate for Payer: Cash Price	$1,449.90
Rate for Payer: Cigna Commercial	$1,530.45
Rate for Payer: Cigna Medicare	$1,449.90
Rate for Payer: Medicaid All Medicaid	$1,482.12
Rate for Payer: Medicare All Medicare	$1,127.70
Rate for Payer: Monida Allegiance	$1,530.45
Rate for Payer: Monida First Choice Health	$1,562.67
Rate for Payer: Monida Montana Health Co-op	$1,530.45
Rate for Payer: Monida PacificSource	$1,530.45

CT CERVICAL SPINE WO CONTRAST

Facility

$1,611.00

Service Code	HCPCS 72125 TC
Hospital Charge Code	5200019
Hospital Revenue Code	350
Min. Negotiated Rate	$1,127.70
Max. Negotiated Rate	$1,611.00
Rate for Payer: Aetna Commercial	$1,530.45
Rate for Payer: Aetna Medicare	$1,449.90
Rate for Payer: BCBS MT CHIP	$1,449.90
Rate for Payer: BCBS MT Closed Plan Network	$1,530.45
Rate for Payer: BCBS MT HealthLink	$1,449.90
Rate for Payer: BCBS MT Medicare	$1,449.90
Rate for Payer: BCBS MT POS	$1,530.45
Rate for Payer: BCBS MT Traditional	$1,611.00
Rate for Payer: Cash Price	$1,449.90
Rate for Payer: Cigna Commercial	$1,530.45
Rate for Payer: Cigna Medicare	$1,449.90
Rate for Payer: Medicaid All Medicaid	$1,482.12
Rate for Payer: Medicare All Medicare	$1,127.70
Rate for Payer: Monida Allegiance	$1,530.45
Rate for Payer: Monida First Choice Health	$1,562.67
Rate for Payer: Monida Montana Health Co-op	$1,530.45
Rate for Payer: Monida PacificSource	$1,530.45

CT CERVICAL SPINE W WO CONTRAST

Facility

$2,261.00

Service Code	HCPCS 72127 TC
Hospital Charge Code	5200020
Hospital Revenue Code	350
Min. Negotiated Rate	$1,582.70
Max. Negotiated Rate	$2,261.00
Rate for Payer: Aetna Commercial	$2,147.95
Rate for Payer: Aetna Medicare	$2,034.90
Rate for Payer: BCBS MT CHIP	$2,034.90
Rate for Payer: BCBS MT Closed Plan Network	$2,147.95
Rate for Payer: BCBS MT HealthLink	$2,034.90
Rate for Payer: BCBS MT Medicare	$2,034.90
Rate for Payer: BCBS MT POS	$2,147.95
Rate for Payer: BCBS MT Traditional	$2,261.00
Rate for Payer: Cash Price	$2,034.90
Rate for Payer: Cigna Commercial	$2,147.95
Rate for Payer: Cigna Medicare	$2,034.90
Rate for Payer: Medicaid All Medicaid	$2,080.12
Rate for Payer: Medicare All Medicare	$1,582.70
Rate for Payer: Monida Allegiance	$2,147.95
Rate for Payer: Monida First Choice Health	$2,193.17
Rate for Payer: Monida Montana Health Co-op	$2,147.95
Rate for Payer: Monida PacificSource	$2,147.95

CT CERVICAL SPINE W WO CONTRAST

Facility

$2,261.00

Service Code	HCPCS 72127 TC
Hospital Charge Code	5200020
Hospital Revenue Code	350
Min. Negotiated Rate	$1,582.70
Max. Negotiated Rate	$2,261.00
Rate for Payer: Aetna Commercial	$2,147.95
Rate for Payer: Aetna Medicare	$2,034.90
Rate for Payer: BCBS MT CHIP	$2,034.90
Rate for Payer: BCBS MT Closed Plan Network	$2,147.95
Rate for Payer: BCBS MT HealthLink	$2,034.90
Rate for Payer: BCBS MT Medicare	$2,034.90
Rate for Payer: BCBS MT POS	$2,147.95
Rate for Payer: BCBS MT Traditional	$2,261.00
Rate for Payer: Cash Price	$2,034.90
Rate for Payer: Cigna Commercial	$2,147.95
Rate for Payer: Cigna Medicare	$2,034.90
Rate for Payer: Medicaid All Medicaid	$2,080.12
Rate for Payer: Medicare All Medicare	$1,582.70
Rate for Payer: Monida Allegiance	$2,147.95
Rate for Payer: Monida First Choice Health	$2,193.17
Rate for Payer: Monida Montana Health Co-op	$2,147.95
Rate for Payer: Monida PacificSource	$2,147.95

CT CHEST W CONTRAST

Facility

$1,988.00

Service Code	HCPCS 71260
Hospital Charge Code	5200014
Hospital Revenue Code	350
Min. Negotiated Rate	$1,391.60
Max. Negotiated Rate	$1,988.00
Rate for Payer: Aetna Commercial	$1,888.60
Rate for Payer: Aetna Medicare	$1,789.20
Rate for Payer: BCBS MT CHIP	$1,789.20
Rate for Payer: BCBS MT Closed Plan Network	$1,888.60
Rate for Payer: BCBS MT HealthLink	$1,789.20
Rate for Payer: BCBS MT Medicare	$1,789.20
Rate for Payer: BCBS MT POS	$1,888.60
Rate for Payer: BCBS MT Traditional	$1,988.00
Rate for Payer: Cash Price	$1,789.20
Rate for Payer: Cigna Commercial	$1,888.60
Rate for Payer: Cigna Medicare	$1,789.20
Rate for Payer: Medicaid All Medicaid	$1,828.96
Rate for Payer: Medicare All Medicare	$1,391.60
Rate for Payer: Monida Allegiance	$1,888.60
Rate for Payer: Monida First Choice Health	$1,928.36
Rate for Payer: Monida Montana Health Co-op	$1,888.60
Rate for Payer: Monida PacificSource	$1,888.60

CT CHEST W CONTRAST

Facility

$1,988.00

Service Code	HCPCS 71260
Hospital Charge Code	5200014
Hospital Revenue Code	350
Min. Negotiated Rate	$1,391.60
Max. Negotiated Rate	$1,988.00
Rate for Payer: Aetna Commercial	$1,888.60
Rate for Payer: Aetna Medicare	$1,789.20
Rate for Payer: BCBS MT CHIP	$1,789.20
Rate for Payer: BCBS MT Closed Plan Network	$1,888.60
Rate for Payer: BCBS MT HealthLink	$1,789.20
Rate for Payer: BCBS MT Medicare	$1,789.20
Rate for Payer: BCBS MT POS	$1,888.60
Rate for Payer: BCBS MT Traditional	$1,988.00
Rate for Payer: Cash Price	$1,789.20
Rate for Payer: Cigna Commercial	$1,888.60
Rate for Payer: Cigna Medicare	$1,789.20
Rate for Payer: Medicaid All Medicaid	$1,828.96
Rate for Payer: Medicare All Medicare	$1,391.60
Rate for Payer: Monida Allegiance	$1,888.60
Rate for Payer: Monida First Choice Health	$1,928.36
Rate for Payer: Monida Montana Health Co-op	$1,888.60
Rate for Payer: Monida PacificSource	$1,888.60

CT CHEST WO CONTRAST

Facility

$1,507.00

Service Code	HCPCS 71250
Hospital Charge Code	5200015
Hospital Revenue Code	350
Min. Negotiated Rate	$1,054.90
Max. Negotiated Rate	$1,507.00
Rate for Payer: Aetna Commercial	$1,431.65
Rate for Payer: Aetna Medicare	$1,356.30
Rate for Payer: BCBS MT CHIP	$1,356.30
Rate for Payer: BCBS MT Closed Plan Network	$1,431.65
Rate for Payer: BCBS MT HealthLink	$1,356.30
Rate for Payer: BCBS MT Medicare	$1,356.30
Rate for Payer: BCBS MT POS	$1,431.65
Rate for Payer: BCBS MT Traditional	$1,507.00
Rate for Payer: Cash Price	$1,356.30
Rate for Payer: Cigna Commercial	$1,431.65
Rate for Payer: Cigna Medicare	$1,356.30
Rate for Payer: Medicaid All Medicaid	$1,386.44
Rate for Payer: Medicare All Medicare	$1,054.90
Rate for Payer: Monida Allegiance	$1,431.65
Rate for Payer: Monida First Choice Health	$1,461.79
Rate for Payer: Monida Montana Health Co-op	$1,431.65
Rate for Payer: Monida PacificSource	$1,431.65

CT CHEST WO CONTRAST

Facility

$1,507.00

Service Code	HCPCS 71250
Hospital Charge Code	5200015
Hospital Revenue Code	350
Min. Negotiated Rate	$1,054.90
Max. Negotiated Rate	$1,507.00
Rate for Payer: Aetna Commercial	$1,431.65
Rate for Payer: Aetna Medicare	$1,356.30
Rate for Payer: BCBS MT CHIP	$1,356.30
Rate for Payer: BCBS MT Closed Plan Network	$1,431.65
Rate for Payer: BCBS MT HealthLink	$1,356.30
Rate for Payer: BCBS MT Medicare	$1,356.30
Rate for Payer: BCBS MT POS	$1,431.65
Rate for Payer: BCBS MT Traditional	$1,507.00
Rate for Payer: Cash Price	$1,356.30
Rate for Payer: Cigna Commercial	$1,431.65
Rate for Payer: Cigna Medicare	$1,356.30
Rate for Payer: Medicaid All Medicaid	$1,386.44
Rate for Payer: Medicare All Medicare	$1,054.90
Rate for Payer: Monida Allegiance	$1,431.65
Rate for Payer: Monida First Choice Health	$1,461.79
Rate for Payer: Monida Montana Health Co-op	$1,431.65
Rate for Payer: Monida PacificSource	$1,431.65

CT CHEST W WO CONTRAST

Facility

$2,321.00

Service Code	HCPCS 71270 TC
Hospital Charge Code	5200016
Hospital Revenue Code	350
Min. Negotiated Rate	$1,624.70
Max. Negotiated Rate	$2,321.00
Rate for Payer: Aetna Commercial	$2,204.95
Rate for Payer: Aetna Medicare	$2,088.90
Rate for Payer: BCBS MT CHIP	$2,088.90
Rate for Payer: BCBS MT Closed Plan Network	$2,204.95
Rate for Payer: BCBS MT HealthLink	$2,088.90
Rate for Payer: BCBS MT Medicare	$2,088.90
Rate for Payer: BCBS MT POS	$2,204.95
Rate for Payer: BCBS MT Traditional	$2,321.00
Rate for Payer: Cash Price	$2,088.90
Rate for Payer: Cigna Commercial	$2,204.95
Rate for Payer: Cigna Medicare	$2,088.90
Rate for Payer: Medicaid All Medicaid	$2,135.32
Rate for Payer: Medicare All Medicare	$1,624.70
Rate for Payer: Monida Allegiance	$2,204.95
Rate for Payer: Monida First Choice Health	$2,251.37
Rate for Payer: Monida Montana Health Co-op	$2,204.95
Rate for Payer: Monida PacificSource	$2,204.95

CT CHEST W WO CONTRAST

Facility

$2,321.00

Service Code	HCPCS 71270 TC
Hospital Charge Code	5200016
Hospital Revenue Code	350
Min. Negotiated Rate	$1,624.70
Max. Negotiated Rate	$2,321.00
Rate for Payer: Aetna Commercial	$2,204.95
Rate for Payer: Aetna Medicare	$2,088.90
Rate for Payer: BCBS MT CHIP	$2,088.90
Rate for Payer: BCBS MT Closed Plan Network	$2,204.95
Rate for Payer: BCBS MT HealthLink	$2,088.90
Rate for Payer: BCBS MT Medicare	$2,088.90
Rate for Payer: BCBS MT POS	$2,204.95
Rate for Payer: BCBS MT Traditional	$2,321.00
Rate for Payer: Cash Price	$2,088.90
Rate for Payer: Cigna Commercial	$2,204.95
Rate for Payer: Cigna Medicare	$2,088.90
Rate for Payer: Medicaid All Medicaid	$2,135.32
Rate for Payer: Medicare All Medicare	$1,624.70
Rate for Payer: Monida Allegiance	$2,204.95
Rate for Payer: Monida First Choice Health	$2,251.37
Rate for Payer: Monida Montana Health Co-op	$2,204.95
Rate for Payer: Monida PacificSource	$2,204.95

CT CONTRAST BOTTLE ISOVUE 250 200ML

Facility

$181.00

Service Code	HCPCS Q9967 TC
Hospital Charge Code	5200251
Hospital Revenue Code	255
Min. Negotiated Rate	$126.70
Max. Negotiated Rate	$181.00
Rate for Payer: Aetna Commercial	$171.95
Rate for Payer: Aetna Medicare	$162.90
Rate for Payer: BCBS MT CHIP	$162.90
Rate for Payer: BCBS MT Closed Plan Network	$171.95
Rate for Payer: BCBS MT HealthLink	$162.90
Rate for Payer: BCBS MT Medicare	$162.90
Rate for Payer: BCBS MT POS	$171.95
Rate for Payer: BCBS MT Traditional	$181.00
Rate for Payer: Cash Price	$162.90
Rate for Payer: Cigna Commercial	$171.95
Rate for Payer: Cigna Medicare	$162.90
Rate for Payer: Medicaid All Medicaid	$166.52
Rate for Payer: Medicare All Medicare	$126.70
Rate for Payer: Monida Allegiance	$171.95
Rate for Payer: Monida First Choice Health	$175.57
Rate for Payer: Monida Montana Health Co-op	$171.95
Rate for Payer: Monida PacificSource	$171.95

CT CONTRAST BOTTLE ISOVUE 250 200ML

Facility

$181.00

Service Code	HCPCS Q9967 TC
Hospital Charge Code	5200251
Hospital Revenue Code	255
Min. Negotiated Rate	$126.70
Max. Negotiated Rate	$181.00
Rate for Payer: Aetna Commercial	$171.95
Rate for Payer: Aetna Medicare	$162.90
Rate for Payer: BCBS MT CHIP	$162.90
Rate for Payer: BCBS MT Closed Plan Network	$171.95
Rate for Payer: BCBS MT HealthLink	$162.90
Rate for Payer: BCBS MT Medicare	$162.90
Rate for Payer: BCBS MT POS	$171.95
Rate for Payer: BCBS MT Traditional	$181.00
Rate for Payer: Cash Price	$162.90
Rate for Payer: Cigna Commercial	$171.95
Rate for Payer: Cigna Medicare	$162.90
Rate for Payer: Medicaid All Medicaid	$166.52
Rate for Payer: Medicare All Medicare	$126.70
Rate for Payer: Monida Allegiance	$171.95
Rate for Payer: Monida First Choice Health	$175.57
Rate for Payer: Monida Montana Health Co-op	$171.95
Rate for Payer: Monida PacificSource	$171.95

CT CONTRAST BOTTLE ISOVUE 370 125ML

Facility

$226.00

Service Code	HCPCS Q9967 TC
Hospital Charge Code	5200018
Hospital Revenue Code	255
Min. Negotiated Rate	$158.20
Max. Negotiated Rate	$226.00
Rate for Payer: Aetna Commercial	$214.70
Rate for Payer: Aetna Medicare	$203.40
Rate for Payer: BCBS MT CHIP	$203.40
Rate for Payer: BCBS MT Closed Plan Network	$214.70
Rate for Payer: BCBS MT HealthLink	$203.40
Rate for Payer: BCBS MT Medicare	$203.40
Rate for Payer: BCBS MT POS	$214.70
Rate for Payer: BCBS MT Traditional	$226.00
Rate for Payer: Cash Price	$203.40
Rate for Payer: Cigna Commercial	$214.70
Rate for Payer: Cigna Medicare	$203.40
Rate for Payer: Medicaid All Medicaid	$207.92
Rate for Payer: Medicare All Medicare	$158.20
Rate for Payer: Monida Allegiance	$214.70
Rate for Payer: Monida First Choice Health	$219.22
Rate for Payer: Monida Montana Health Co-op	$214.70
Rate for Payer: Monida PacificSource	$214.70

CT CONTRAST BOTTLE ISOVUE 370 125ML

Facility

$226.00

Service Code	HCPCS Q9967 TC
Hospital Charge Code	5200018
Hospital Revenue Code	255
Min. Negotiated Rate	$158.20
Max. Negotiated Rate	$226.00
Rate for Payer: Aetna Commercial	$214.70
Rate for Payer: Aetna Medicare	$203.40
Rate for Payer: BCBS MT CHIP	$203.40
Rate for Payer: BCBS MT Closed Plan Network	$214.70
Rate for Payer: BCBS MT HealthLink	$203.40
Rate for Payer: BCBS MT Medicare	$203.40
Rate for Payer: BCBS MT POS	$214.70
Rate for Payer: BCBS MT Traditional	$226.00
Rate for Payer: Cash Price	$203.40
Rate for Payer: Cigna Commercial	$214.70
Rate for Payer: Cigna Medicare	$203.40
Rate for Payer: Medicaid All Medicaid	$207.92
Rate for Payer: Medicare All Medicare	$158.20
Rate for Payer: Monida Allegiance	$214.70
Rate for Payer: Monida First Choice Health	$219.22
Rate for Payer: Monida Montana Health Co-op	$214.70
Rate for Payer: Monida PacificSource	$214.70

CT FACIAL BONES W CONTRAST

Facility

$1,846.00

Service Code	HCPCS 70487 TC
Hospital Charge Code	5200024
Hospital Revenue Code	350
Min. Negotiated Rate	$1,292.20
Max. Negotiated Rate	$1,846.00
Rate for Payer: Aetna Commercial	$1,753.70
Rate for Payer: Aetna Medicare	$1,661.40
Rate for Payer: BCBS MT CHIP	$1,661.40
Rate for Payer: BCBS MT Closed Plan Network	$1,753.70
Rate for Payer: BCBS MT HealthLink	$1,661.40
Rate for Payer: BCBS MT Medicare	$1,661.40
Rate for Payer: BCBS MT POS	$1,753.70
Rate for Payer: BCBS MT Traditional	$1,846.00
Rate for Payer: Cash Price	$1,661.40
Rate for Payer: Cigna Commercial	$1,753.70
Rate for Payer: Cigna Medicare	$1,661.40
Rate for Payer: Medicaid All Medicaid	$1,698.32
Rate for Payer: Medicare All Medicare	$1,292.20
Rate for Payer: Monida Allegiance	$1,753.70
Rate for Payer: Monida First Choice Health	$1,790.62
Rate for Payer: Monida Montana Health Co-op	$1,753.70
Rate for Payer: Monida PacificSource	$1,753.70

CT FACIAL BONES W CONTRAST

Facility

$1,846.00

Service Code	HCPCS 70487 TC
Hospital Charge Code	5200024
Hospital Revenue Code	350
Min. Negotiated Rate	$1,292.20
Max. Negotiated Rate	$1,846.00
Rate for Payer: Aetna Commercial	$1,753.70
Rate for Payer: Aetna Medicare	$1,661.40
Rate for Payer: BCBS MT CHIP	$1,661.40
Rate for Payer: BCBS MT Closed Plan Network	$1,753.70
Rate for Payer: BCBS MT HealthLink	$1,661.40
Rate for Payer: BCBS MT Medicare	$1,661.40
Rate for Payer: BCBS MT POS	$1,753.70
Rate for Payer: BCBS MT Traditional	$1,846.00
Rate for Payer: Cash Price	$1,661.40
Rate for Payer: Cigna Commercial	$1,753.70
Rate for Payer: Cigna Medicare	$1,661.40
Rate for Payer: Medicaid All Medicaid	$1,698.32
Rate for Payer: Medicare All Medicare	$1,292.20
Rate for Payer: Monida Allegiance	$1,753.70
Rate for Payer: Monida First Choice Health	$1,790.62
Rate for Payer: Monida Montana Health Co-op	$1,753.70
Rate for Payer: Monida PacificSource	$1,753.70

CT FACIAL BONES WO CONTRAST

Facility

$1,436.00

Service Code	HCPCS 70486 TC
Hospital Charge Code	5200022
Hospital Revenue Code	350
Min. Negotiated Rate	$1,005.20
Max. Negotiated Rate	$1,436.00
Rate for Payer: Aetna Commercial	$1,364.20
Rate for Payer: Aetna Medicare	$1,292.40
Rate for Payer: BCBS MT CHIP	$1,292.40
Rate for Payer: BCBS MT Closed Plan Network	$1,364.20
Rate for Payer: BCBS MT HealthLink	$1,292.40
Rate for Payer: BCBS MT Medicare	$1,292.40
Rate for Payer: BCBS MT POS	$1,364.20
Rate for Payer: BCBS MT Traditional	$1,436.00
Rate for Payer: Cash Price	$1,292.40
Rate for Payer: Cigna Commercial	$1,364.20
Rate for Payer: Cigna Medicare	$1,292.40
Rate for Payer: Medicaid All Medicaid	$1,321.12
Rate for Payer: Medicare All Medicare	$1,005.20
Rate for Payer: Monida Allegiance	$1,364.20
Rate for Payer: Monida First Choice Health	$1,392.92
Rate for Payer: Monida Montana Health Co-op	$1,364.20
Rate for Payer: Monida PacificSource	$1,364.20

CT FACIAL BONES WO CONTRAST

Facility

$1,436.00

Service Code	HCPCS 70486 TC
Hospital Charge Code	5200022
Hospital Revenue Code	350
Min. Negotiated Rate	$1,005.20
Max. Negotiated Rate	$1,436.00
Rate for Payer: Aetna Commercial	$1,364.20
Rate for Payer: Aetna Medicare	$1,292.40
Rate for Payer: BCBS MT CHIP	$1,292.40
Rate for Payer: BCBS MT Closed Plan Network	$1,364.20
Rate for Payer: BCBS MT HealthLink	$1,292.40
Rate for Payer: BCBS MT Medicare	$1,292.40
Rate for Payer: BCBS MT POS	$1,364.20
Rate for Payer: BCBS MT Traditional	$1,436.00
Rate for Payer: Cash Price	$1,292.40
Rate for Payer: Cigna Commercial	$1,364.20
Rate for Payer: Cigna Medicare	$1,292.40
Rate for Payer: Medicaid All Medicaid	$1,321.12
Rate for Payer: Medicare All Medicare	$1,005.20
Rate for Payer: Monida Allegiance	$1,364.20
Rate for Payer: Monida First Choice Health	$1,392.92
Rate for Payer: Monida Montana Health Co-op	$1,364.20
Rate for Payer: Monida PacificSource	$1,364.20

CT FACIAL BONES W WO CONTRAST

Facility

$2,124.00

Service Code	HCPCS 70488 TC
Hospital Charge Code	5200023
Hospital Revenue Code	350
Min. Negotiated Rate	$1,486.80
Max. Negotiated Rate	$2,124.00
Rate for Payer: Aetna Commercial	$2,017.80
Rate for Payer: Aetna Medicare	$1,911.60
Rate for Payer: BCBS MT CHIP	$1,911.60
Rate for Payer: BCBS MT Closed Plan Network	$2,017.80
Rate for Payer: BCBS MT HealthLink	$1,911.60
Rate for Payer: BCBS MT Medicare	$1,911.60
Rate for Payer: BCBS MT POS	$2,017.80
Rate for Payer: BCBS MT Traditional	$2,124.00
Rate for Payer: Cash Price	$1,911.60
Rate for Payer: Cigna Commercial	$2,017.80
Rate for Payer: Cigna Medicare	$1,911.60
Rate for Payer: Medicaid All Medicaid	$1,954.08
Rate for Payer: Medicare All Medicare	$1,486.80
Rate for Payer: Monida Allegiance	$2,017.80
Rate for Payer: Monida First Choice Health	$2,060.28
Rate for Payer: Monida Montana Health Co-op	$2,017.80
Rate for Payer: Monida PacificSource	$2,017.80

CT FACIAL BONES W WO CONTRAST

Facility

$2,124.00

Service Code	HCPCS 70488 TC
Hospital Charge Code	5200023
Hospital Revenue Code	350
Min. Negotiated Rate	$1,486.80
Max. Negotiated Rate	$2,124.00
Rate for Payer: Aetna Commercial	$2,017.80
Rate for Payer: Aetna Medicare	$1,911.60
Rate for Payer: BCBS MT CHIP	$1,911.60
Rate for Payer: BCBS MT Closed Plan Network	$2,017.80
Rate for Payer: BCBS MT HealthLink	$1,911.60
Rate for Payer: BCBS MT Medicare	$1,911.60
Rate for Payer: BCBS MT POS	$2,017.80
Rate for Payer: BCBS MT Traditional	$2,124.00
Rate for Payer: Cash Price	$1,911.60
Rate for Payer: Cigna Commercial	$2,017.80
Rate for Payer: Cigna Medicare	$1,911.60
Rate for Payer: Medicaid All Medicaid	$1,954.08
Rate for Payer: Medicare All Medicare	$1,486.80
Rate for Payer: Monida Allegiance	$2,017.80
Rate for Payer: Monida First Choice Health	$2,060.28
Rate for Payer: Monida Montana Health Co-op	$2,017.80
Rate for Payer: Monida PacificSource	$2,017.80

CT HEAD W CONTRAST

Facility

$1,769.00

Service Code	HCPCS 70460 TC
Hospital Charge Code	5200027
Hospital Revenue Code	350
Min. Negotiated Rate	$1,238.30
Max. Negotiated Rate	$1,769.00
Rate for Payer: Aetna Commercial	$1,680.55
Rate for Payer: Aetna Medicare	$1,592.10
Rate for Payer: BCBS MT CHIP	$1,592.10
Rate for Payer: BCBS MT Closed Plan Network	$1,680.55
Rate for Payer: BCBS MT HealthLink	$1,592.10
Rate for Payer: BCBS MT Medicare	$1,592.10
Rate for Payer: BCBS MT POS	$1,680.55
Rate for Payer: BCBS MT Traditional	$1,769.00
Rate for Payer: Cash Price	$1,592.10
Rate for Payer: Cigna Commercial	$1,680.55
Rate for Payer: Cigna Medicare	$1,592.10
Rate for Payer: Medicaid All Medicaid	$1,627.48
Rate for Payer: Medicare All Medicare	$1,238.30
Rate for Payer: Monida Allegiance	$1,680.55
Rate for Payer: Monida First Choice Health	$1,715.93
Rate for Payer: Monida Montana Health Co-op	$1,680.55
Rate for Payer: Monida PacificSource	$1,680.55

CT HEAD W CONTRAST

Facility

$1,769.00

Service Code	HCPCS 70460 TC
Hospital Charge Code	5200027
Hospital Revenue Code	350
Min. Negotiated Rate	$1,238.30
Max. Negotiated Rate	$1,769.00
Rate for Payer: Aetna Commercial	$1,680.55
Rate for Payer: Aetna Medicare	$1,592.10
Rate for Payer: BCBS MT CHIP	$1,592.10
Rate for Payer: BCBS MT Closed Plan Network	$1,680.55
Rate for Payer: BCBS MT HealthLink	$1,592.10
Rate for Payer: BCBS MT Medicare	$1,592.10
Rate for Payer: BCBS MT POS	$1,680.55
Rate for Payer: BCBS MT Traditional	$1,769.00
Rate for Payer: Cash Price	$1,592.10
Rate for Payer: Cigna Commercial	$1,680.55
Rate for Payer: Cigna Medicare	$1,592.10
Rate for Payer: Medicaid All Medicaid	$1,627.48
Rate for Payer: Medicare All Medicare	$1,238.30
Rate for Payer: Monida Allegiance	$1,680.55
Rate for Payer: Monida First Choice Health	$1,715.93
Rate for Payer: Monida Montana Health Co-op	$1,680.55
Rate for Payer: Monida PacificSource	$1,680.55

CT HEAD WO CONTRAST

Facility

$1,432.00

Service Code	HCPCS 70450 TC
Hospital Charge Code	5200025
Hospital Revenue Code	350
Min. Negotiated Rate	$1,002.40
Max. Negotiated Rate	$1,432.00
Rate for Payer: Aetna Commercial	$1,360.40
Rate for Payer: Aetna Medicare	$1,288.80
Rate for Payer: BCBS MT CHIP	$1,288.80
Rate for Payer: BCBS MT Closed Plan Network	$1,360.40
Rate for Payer: BCBS MT HealthLink	$1,288.80
Rate for Payer: BCBS MT Medicare	$1,288.80
Rate for Payer: BCBS MT POS	$1,360.40
Rate for Payer: BCBS MT Traditional	$1,432.00
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Cigna Commercial	$1,360.40
Rate for Payer: Cigna Medicare	$1,288.80
Rate for Payer: Medicaid All Medicaid	$1,317.44
Rate for Payer: Medicare All Medicare	$1,002.40
Rate for Payer: Monida Allegiance	$1,360.40
Rate for Payer: Monida First Choice Health	$1,389.04
Rate for Payer: Monida Montana Health Co-op	$1,360.40
Rate for Payer: Monida PacificSource	$1,360.40

CT HEAD WO CONTRAST

Facility

$1,432.00

Service Code	HCPCS 70450 TC
Hospital Charge Code	5200025
Hospital Revenue Code	350
Min. Negotiated Rate	$1,002.40
Max. Negotiated Rate	$1,432.00
Rate for Payer: Aetna Commercial	$1,360.40
Rate for Payer: Aetna Medicare	$1,288.80
Rate for Payer: BCBS MT CHIP	$1,288.80
Rate for Payer: BCBS MT Closed Plan Network	$1,360.40
Rate for Payer: BCBS MT HealthLink	$1,288.80
Rate for Payer: BCBS MT Medicare	$1,288.80
Rate for Payer: BCBS MT POS	$1,360.40
Rate for Payer: BCBS MT Traditional	$1,432.00
Rate for Payer: Cash Price	$1,288.80
Rate for Payer: Cigna Commercial	$1,360.40
Rate for Payer: Cigna Medicare	$1,288.80
Rate for Payer: Medicaid All Medicaid	$1,317.44
Rate for Payer: Medicare All Medicare	$1,002.40
Rate for Payer: Monida Allegiance	$1,360.40
Rate for Payer: Monida First Choice Health	$1,389.04
Rate for Payer: Monida Montana Health Co-op	$1,360.40
Rate for Payer: Monida PacificSource	$1,360.40

Know your out-of-pocket cost for care.

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