Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CT HEAD W WO CONTRAST

Facility

$2,107.00

Service Code	HCPCS 70470 TC
Hospital Charge Code	5200026
Hospital Revenue Code	350
Min. Negotiated Rate	$1,474.90
Max. Negotiated Rate	$2,107.00
Rate for Payer: Aetna Commercial	$2,001.65
Rate for Payer: Aetna Medicare	$1,896.30
Rate for Payer: BCBS MT CHIP	$1,896.30
Rate for Payer: BCBS MT Closed Plan Network	$2,001.65
Rate for Payer: BCBS MT HealthLink	$1,896.30
Rate for Payer: BCBS MT Medicare	$1,896.30
Rate for Payer: BCBS MT POS	$2,001.65
Rate for Payer: BCBS MT Traditional	$2,107.00
Rate for Payer: Cash Price	$1,896.30
Rate for Payer: Cigna Commercial	$2,001.65
Rate for Payer: Cigna Medicare	$1,896.30
Rate for Payer: Medicaid All Medicaid	$1,938.44
Rate for Payer: Medicare All Medicare	$1,474.90
Rate for Payer: Monida Allegiance	$2,001.65
Rate for Payer: Monida First Choice Health	$2,043.79
Rate for Payer: Monida Montana Health Co-op	$2,001.65
Rate for Payer: Monida PacificSource	$2,001.65

CT HEAD W WO CONTRAST

Facility

$2,107.00

Service Code	HCPCS 70470 TC
Hospital Charge Code	5200026
Hospital Revenue Code	350
Min. Negotiated Rate	$1,474.90
Max. Negotiated Rate	$2,107.00
Rate for Payer: Aetna Commercial	$2,001.65
Rate for Payer: Aetna Medicare	$1,896.30
Rate for Payer: BCBS MT CHIP	$1,896.30
Rate for Payer: BCBS MT Closed Plan Network	$2,001.65
Rate for Payer: BCBS MT HealthLink	$1,896.30
Rate for Payer: BCBS MT Medicare	$1,896.30
Rate for Payer: BCBS MT POS	$2,001.65
Rate for Payer: BCBS MT Traditional	$2,107.00
Rate for Payer: Cash Price	$1,896.30
Rate for Payer: Cigna Commercial	$2,001.65
Rate for Payer: Cigna Medicare	$1,896.30
Rate for Payer: Medicaid All Medicaid	$1,938.44
Rate for Payer: Medicare All Medicare	$1,474.90
Rate for Payer: Monida Allegiance	$2,001.65
Rate for Payer: Monida First Choice Health	$2,043.79
Rate for Payer: Monida Montana Health Co-op	$2,001.65
Rate for Payer: Monida PacificSource	$2,001.65

CT HIGH REZ CHEST

Facility

$1,507.00

Service Code	HCPCS 71250
Hospital Charge Code	5200075
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 HIGH REZ CHEST

Facility

$1,507.00

Service Code	HCPCS 71250
Hospital Charge Code	5200075
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 ISOVUE 370 100ML CONTRAST BOTTLE

Facility

$311.00

Service Code	HCPCS Q9967 TC
Hospital Charge Code	5200017
Hospital Revenue Code	255
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

CT ISOVUE 370 100ML CONTRAST BOTTLE

Facility

$311.00

Service Code	HCPCS Q9967 TC
Hospital Charge Code	5200017
Hospital Revenue Code	255
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

CT LIMITED FOLLOW-UP

Facility

$737.00

Service Code	HCPCS 76380 TC
Hospital Charge Code	5200029
Hospital Revenue Code	350
Min. Negotiated Rate	$515.90
Max. Negotiated Rate	$737.00
Rate for Payer: Aetna Commercial	$700.15
Rate for Payer: Aetna Medicare	$663.30
Rate for Payer: BCBS MT CHIP	$663.30
Rate for Payer: BCBS MT Closed Plan Network	$700.15
Rate for Payer: BCBS MT HealthLink	$663.30
Rate for Payer: BCBS MT Medicare	$663.30
Rate for Payer: BCBS MT POS	$700.15
Rate for Payer: BCBS MT Traditional	$737.00
Rate for Payer: Cash Price	$663.30
Rate for Payer: Cigna Commercial	$700.15
Rate for Payer: Cigna Medicare	$663.30
Rate for Payer: Medicaid All Medicaid	$678.04
Rate for Payer: Medicare All Medicare	$515.90
Rate for Payer: Monida Allegiance	$700.15
Rate for Payer: Monida First Choice Health	$714.89
Rate for Payer: Monida Montana Health Co-op	$700.15
Rate for Payer: Monida PacificSource	$700.15

CT LIMITED FOLLOW-UP

Facility

$737.00

Service Code	HCPCS 76380 TC
Hospital Charge Code	5200029
Hospital Revenue Code	350
Min. Negotiated Rate	$515.90
Max. Negotiated Rate	$737.00
Rate for Payer: Aetna Commercial	$700.15
Rate for Payer: Aetna Medicare	$663.30
Rate for Payer: BCBS MT CHIP	$663.30
Rate for Payer: BCBS MT Closed Plan Network	$700.15
Rate for Payer: BCBS MT HealthLink	$663.30
Rate for Payer: BCBS MT Medicare	$663.30
Rate for Payer: BCBS MT POS	$700.15
Rate for Payer: BCBS MT Traditional	$737.00
Rate for Payer: Cash Price	$663.30
Rate for Payer: Cigna Commercial	$700.15
Rate for Payer: Cigna Medicare	$663.30
Rate for Payer: Medicaid All Medicaid	$678.04
Rate for Payer: Medicare All Medicare	$515.90
Rate for Payer: Monida Allegiance	$700.15
Rate for Payer: Monida First Choice Health	$714.89
Rate for Payer: Monida Montana Health Co-op	$700.15
Rate for Payer: Monida PacificSource	$700.15

CT LIMITED ORBITS FOR MRI

Facility

$911.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	5200030
Hospital Revenue Code	350
Min. Negotiated Rate	$637.70
Max. Negotiated Rate	$911.00
Rate for Payer: Aetna Commercial	$865.45
Rate for Payer: Aetna Medicare	$819.90
Rate for Payer: BCBS MT CHIP	$819.90
Rate for Payer: BCBS MT Closed Plan Network	$865.45
Rate for Payer: BCBS MT HealthLink	$819.90
Rate for Payer: BCBS MT Medicare	$819.90
Rate for Payer: BCBS MT POS	$865.45
Rate for Payer: BCBS MT Traditional	$911.00
Rate for Payer: Cash Price	$819.90
Rate for Payer: Cigna Commercial	$865.45
Rate for Payer: Cigna Medicare	$819.90
Rate for Payer: Medicaid All Medicaid	$838.12
Rate for Payer: Medicare All Medicare	$637.70
Rate for Payer: Monida Allegiance	$865.45
Rate for Payer: Monida First Choice Health	$883.67
Rate for Payer: Monida Montana Health Co-op	$865.45
Rate for Payer: Monida PacificSource	$865.45

CT LIMITED ORBITS FOR MRI

Facility

$911.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	5200030
Hospital Revenue Code	350
Min. Negotiated Rate	$637.70
Max. Negotiated Rate	$911.00
Rate for Payer: Aetna Commercial	$865.45
Rate for Payer: Aetna Medicare	$819.90
Rate for Payer: BCBS MT CHIP	$819.90
Rate for Payer: BCBS MT Closed Plan Network	$865.45
Rate for Payer: BCBS MT HealthLink	$819.90
Rate for Payer: BCBS MT Medicare	$819.90
Rate for Payer: BCBS MT POS	$865.45
Rate for Payer: BCBS MT Traditional	$911.00
Rate for Payer: Cash Price	$819.90
Rate for Payer: Cigna Commercial	$865.45
Rate for Payer: Cigna Medicare	$819.90
Rate for Payer: Medicaid All Medicaid	$838.12
Rate for Payer: Medicare All Medicare	$637.70
Rate for Payer: Monida Allegiance	$865.45
Rate for Payer: Monida First Choice Health	$883.67
Rate for Payer: Monida Montana Health Co-op	$865.45
Rate for Payer: Monida PacificSource	$865.45

CT LOW DOSE LUNG SCREEN

Facility

$464.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	5070297
Hospital Revenue Code	350
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$464.00
Rate for Payer: Aetna Commercial	$440.80
Rate for Payer: Aetna Medicare	$417.60
Rate for Payer: BCBS MT CHIP	$417.60
Rate for Payer: BCBS MT Closed Plan Network	$440.80
Rate for Payer: BCBS MT HealthLink	$417.60
Rate for Payer: BCBS MT Medicare	$417.60
Rate for Payer: BCBS MT POS	$440.80
Rate for Payer: BCBS MT Traditional	$464.00
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cigna Commercial	$440.80
Rate for Payer: Cigna Medicare	$417.60
Rate for Payer: Medicaid All Medicaid	$426.88
Rate for Payer: Medicare All Medicare	$324.80
Rate for Payer: Monida Allegiance	$440.80
Rate for Payer: Monida First Choice Health	$450.08
Rate for Payer: Monida Montana Health Co-op	$440.80
Rate for Payer: Monida PacificSource	$440.80

CT LOW DOSE LUNG SCREEN

Facility

$464.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	5070297
Hospital Revenue Code	350
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$464.00
Rate for Payer: Aetna Commercial	$440.80
Rate for Payer: Aetna Medicare	$417.60
Rate for Payer: BCBS MT CHIP	$417.60
Rate for Payer: BCBS MT Closed Plan Network	$440.80
Rate for Payer: BCBS MT HealthLink	$417.60
Rate for Payer: BCBS MT Medicare	$417.60
Rate for Payer: BCBS MT POS	$440.80
Rate for Payer: BCBS MT Traditional	$464.00
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cigna Commercial	$440.80
Rate for Payer: Cigna Medicare	$417.60
Rate for Payer: Medicaid All Medicaid	$426.88
Rate for Payer: Medicare All Medicare	$324.80
Rate for Payer: Monida Allegiance	$440.80
Rate for Payer: Monida First Choice Health	$450.08
Rate for Payer: Monida Montana Health Co-op	$440.80
Rate for Payer: Monida PacificSource	$440.80

CT LOWER EXTREMITY LT W CONTRAST

Facility

$1,819.00

Service Code	HCPCS 73701 TC,LT
Hospital Charge Code	5200033
Hospital Revenue Code	350
Min. Negotiated Rate	$1,273.30
Max. Negotiated Rate	$1,819.00
Rate for Payer: Aetna Commercial	$1,728.05
Rate for Payer: Aetna Medicare	$1,637.10
Rate for Payer: BCBS MT CHIP	$1,637.10
Rate for Payer: BCBS MT Closed Plan Network	$1,728.05
Rate for Payer: BCBS MT HealthLink	$1,637.10
Rate for Payer: BCBS MT Medicare	$1,637.10
Rate for Payer: BCBS MT POS	$1,728.05
Rate for Payer: BCBS MT Traditional	$1,819.00
Rate for Payer: Cash Price	$1,637.10
Rate for Payer: Cigna Commercial	$1,728.05
Rate for Payer: Cigna Medicare	$1,637.10
Rate for Payer: Medicaid All Medicaid	$1,673.48
Rate for Payer: Medicare All Medicare	$1,273.30
Rate for Payer: Monida Allegiance	$1,728.05
Rate for Payer: Monida First Choice Health	$1,764.43
Rate for Payer: Monida Montana Health Co-op	$1,728.05
Rate for Payer: Monida PacificSource	$1,728.05

CT LOWER EXTREMITY LT W CONTRAST

Facility

$1,819.00

Service Code	HCPCS 73701 TC,LT
Hospital Charge Code	5200033
Hospital Revenue Code	350
Min. Negotiated Rate	$1,273.30
Max. Negotiated Rate	$1,819.00
Rate for Payer: Aetna Commercial	$1,728.05
Rate for Payer: Aetna Medicare	$1,637.10
Rate for Payer: BCBS MT CHIP	$1,637.10
Rate for Payer: BCBS MT Closed Plan Network	$1,728.05
Rate for Payer: BCBS MT HealthLink	$1,637.10
Rate for Payer: BCBS MT Medicare	$1,637.10
Rate for Payer: BCBS MT POS	$1,728.05
Rate for Payer: BCBS MT Traditional	$1,819.00
Rate for Payer: Cash Price	$1,637.10
Rate for Payer: Cigna Commercial	$1,728.05
Rate for Payer: Cigna Medicare	$1,637.10
Rate for Payer: Medicaid All Medicaid	$1,673.48
Rate for Payer: Medicare All Medicare	$1,273.30
Rate for Payer: Monida Allegiance	$1,728.05
Rate for Payer: Monida First Choice Health	$1,764.43
Rate for Payer: Monida Montana Health Co-op	$1,728.05
Rate for Payer: Monida PacificSource	$1,728.05

CT LOWER EXTREMITY LT WO CONTRAST

Facility

$1,474.00

Service Code	HCPCS 73700 TC,RT
Hospital Charge Code	5200032
Hospital Revenue Code	350
Min. Negotiated Rate	$1,031.80
Max. Negotiated Rate	$1,474.00
Rate for Payer: Aetna Commercial	$1,400.30
Rate for Payer: Aetna Medicare	$1,326.60
Rate for Payer: BCBS MT CHIP	$1,326.60
Rate for Payer: BCBS MT Closed Plan Network	$1,400.30
Rate for Payer: BCBS MT HealthLink	$1,326.60
Rate for Payer: BCBS MT Medicare	$1,326.60
Rate for Payer: BCBS MT POS	$1,400.30
Rate for Payer: BCBS MT Traditional	$1,474.00
Rate for Payer: Cash Price	$1,326.60
Rate for Payer: Cigna Commercial	$1,400.30
Rate for Payer: Cigna Medicare	$1,326.60
Rate for Payer: Medicaid All Medicaid	$1,356.08
Rate for Payer: Medicare All Medicare	$1,031.80
Rate for Payer: Monida Allegiance	$1,400.30
Rate for Payer: Monida First Choice Health	$1,429.78
Rate for Payer: Monida Montana Health Co-op	$1,400.30
Rate for Payer: Monida PacificSource	$1,400.30

CT LOWER EXTREMITY LT WO CONTRAST

Facility

$1,474.00

Service Code	HCPCS 73700 TC,RT
Hospital Charge Code	5200032
Hospital Revenue Code	350
Min. Negotiated Rate	$1,031.80
Max. Negotiated Rate	$1,474.00
Rate for Payer: Aetna Commercial	$1,400.30
Rate for Payer: Aetna Medicare	$1,326.60
Rate for Payer: BCBS MT CHIP	$1,326.60
Rate for Payer: BCBS MT Closed Plan Network	$1,400.30
Rate for Payer: BCBS MT HealthLink	$1,326.60
Rate for Payer: BCBS MT Medicare	$1,326.60
Rate for Payer: BCBS MT POS	$1,400.30
Rate for Payer: BCBS MT Traditional	$1,474.00
Rate for Payer: Cash Price	$1,326.60
Rate for Payer: Cigna Commercial	$1,400.30
Rate for Payer: Cigna Medicare	$1,326.60
Rate for Payer: Medicaid All Medicaid	$1,356.08
Rate for Payer: Medicare All Medicare	$1,031.80
Rate for Payer: Monida Allegiance	$1,400.30
Rate for Payer: Monida First Choice Health	$1,429.78
Rate for Payer: Monida Montana Health Co-op	$1,400.30
Rate for Payer: Monida PacificSource	$1,400.30

CT LOWER EXTREMITY LT W WO CONTRAST

Facility

$2,167.00

Service Code	HCPCS 73702 TC,LT
Hospital Charge Code	5200001
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

CT LOWER EXTREMITY LT W WO CONTRAST

Facility

$2,167.00

Service Code	HCPCS 73702 TC,LT
Hospital Charge Code	5200001
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

CT LOWER EXTREMITY RT W CONTRAST

Facility

$1,819.00

Service Code	HCPCS 73701 TC,RT
Hospital Charge Code	5200031
Hospital Revenue Code	350
Min. Negotiated Rate	$1,273.30
Max. Negotiated Rate	$1,819.00
Rate for Payer: Aetna Commercial	$1,728.05
Rate for Payer: Aetna Medicare	$1,637.10
Rate for Payer: BCBS MT CHIP	$1,637.10
Rate for Payer: BCBS MT Closed Plan Network	$1,728.05
Rate for Payer: BCBS MT HealthLink	$1,637.10
Rate for Payer: BCBS MT Medicare	$1,637.10
Rate for Payer: BCBS MT POS	$1,728.05
Rate for Payer: BCBS MT Traditional	$1,819.00
Rate for Payer: Cash Price	$1,637.10
Rate for Payer: Cigna Commercial	$1,728.05
Rate for Payer: Cigna Medicare	$1,637.10
Rate for Payer: Medicaid All Medicaid	$1,673.48
Rate for Payer: Medicare All Medicare	$1,273.30
Rate for Payer: Monida Allegiance	$1,728.05
Rate for Payer: Monida First Choice Health	$1,764.43
Rate for Payer: Monida Montana Health Co-op	$1,728.05
Rate for Payer: Monida PacificSource	$1,728.05

CT LOWER EXTREMITY RT W CONTRAST

Facility

$1,819.00

Service Code	HCPCS 73701 TC,RT
Hospital Charge Code	5200031
Hospital Revenue Code	350
Min. Negotiated Rate	$1,273.30
Max. Negotiated Rate	$1,819.00
Rate for Payer: Aetna Commercial	$1,728.05
Rate for Payer: Aetna Medicare	$1,637.10
Rate for Payer: BCBS MT CHIP	$1,637.10
Rate for Payer: BCBS MT Closed Plan Network	$1,728.05
Rate for Payer: BCBS MT HealthLink	$1,637.10
Rate for Payer: BCBS MT Medicare	$1,637.10
Rate for Payer: BCBS MT POS	$1,728.05
Rate for Payer: BCBS MT Traditional	$1,819.00
Rate for Payer: Cash Price	$1,637.10
Rate for Payer: Cigna Commercial	$1,728.05
Rate for Payer: Cigna Medicare	$1,637.10
Rate for Payer: Medicaid All Medicaid	$1,673.48
Rate for Payer: Medicare All Medicare	$1,273.30
Rate for Payer: Monida Allegiance	$1,728.05
Rate for Payer: Monida First Choice Health	$1,764.43
Rate for Payer: Monida Montana Health Co-op	$1,728.05
Rate for Payer: Monida PacificSource	$1,728.05

CT LOWER EXTREMITY RT WO CONTRAST

Facility

$1,474.00

Service Code	HCPCS 73700 TC,RT
Hospital Charge Code	5200034
Hospital Revenue Code	350
Min. Negotiated Rate	$1,031.80
Max. Negotiated Rate	$1,474.00
Rate for Payer: Aetna Commercial	$1,400.30
Rate for Payer: Aetna Medicare	$1,326.60
Rate for Payer: BCBS MT CHIP	$1,326.60
Rate for Payer: BCBS MT Closed Plan Network	$1,400.30
Rate for Payer: BCBS MT HealthLink	$1,326.60
Rate for Payer: BCBS MT Medicare	$1,326.60
Rate for Payer: BCBS MT POS	$1,400.30
Rate for Payer: BCBS MT Traditional	$1,474.00
Rate for Payer: Cash Price	$1,326.60
Rate for Payer: Cigna Commercial	$1,400.30
Rate for Payer: Cigna Medicare	$1,326.60
Rate for Payer: Medicaid All Medicaid	$1,356.08
Rate for Payer: Medicare All Medicare	$1,031.80
Rate for Payer: Monida Allegiance	$1,400.30
Rate for Payer: Monida First Choice Health	$1,429.78
Rate for Payer: Monida Montana Health Co-op	$1,400.30
Rate for Payer: Monida PacificSource	$1,400.30

CT LOWER EXTREMITY RT WO CONTRAST

Facility

$1,474.00

Service Code	HCPCS 73700 TC,RT
Hospital Charge Code	5200034
Hospital Revenue Code	350
Min. Negotiated Rate	$1,031.80
Max. Negotiated Rate	$1,474.00
Rate for Payer: Aetna Commercial	$1,400.30
Rate for Payer: Aetna Medicare	$1,326.60
Rate for Payer: BCBS MT CHIP	$1,326.60
Rate for Payer: BCBS MT Closed Plan Network	$1,400.30
Rate for Payer: BCBS MT HealthLink	$1,326.60
Rate for Payer: BCBS MT Medicare	$1,326.60
Rate for Payer: BCBS MT POS	$1,400.30
Rate for Payer: BCBS MT Traditional	$1,474.00
Rate for Payer: Cash Price	$1,326.60
Rate for Payer: Cigna Commercial	$1,400.30
Rate for Payer: Cigna Medicare	$1,326.60
Rate for Payer: Medicaid All Medicaid	$1,356.08
Rate for Payer: Medicare All Medicare	$1,031.80
Rate for Payer: Monida Allegiance	$1,400.30
Rate for Payer: Monida First Choice Health	$1,429.78
Rate for Payer: Monida Montana Health Co-op	$1,400.30
Rate for Payer: Monida PacificSource	$1,400.30

CT LOWER EXTREMITY RT W WO CONTRAST

Facility

$2,167.00

Service Code	HCPCS 73702 TC,RT
Hospital Charge Code	5200002
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

CT LOWER EXTREMITY RT W WO CONTRAST

Facility

$2,167.00

Service Code	HCPCS 73702 TC,RT
Hospital Charge Code	5200002
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

CT LUMBAR SPINE W CONTRAST

Facility

$2,042.00

Service Code	HCPCS 72132 TC
Hospital Charge Code	5200036
Hospital Revenue Code	350
Min. Negotiated Rate	$1,429.40
Max. Negotiated Rate	$2,042.00
Rate for Payer: Aetna Commercial	$1,939.90
Rate for Payer: Aetna Medicare	$1,837.80
Rate for Payer: BCBS MT CHIP	$1,837.80
Rate for Payer: BCBS MT Closed Plan Network	$1,939.90
Rate for Payer: BCBS MT HealthLink	$1,837.80
Rate for Payer: BCBS MT Medicare	$1,837.80
Rate for Payer: BCBS MT POS	$1,939.90
Rate for Payer: BCBS MT Traditional	$2,042.00
Rate for Payer: Cash Price	$1,837.80
Rate for Payer: Cigna Commercial	$1,939.90
Rate for Payer: Cigna Medicare	$1,837.80
Rate for Payer: Medicaid All Medicaid	$1,878.64
Rate for Payer: Medicare All Medicare	$1,429.40
Rate for Payer: Monida Allegiance	$1,939.90
Rate for Payer: Monida First Choice Health	$1,980.74
Rate for Payer: Monida Montana Health Co-op	$1,939.90
Rate for Payer: Monida PacificSource	$1,939.90

Know your out-of-pocket cost for care.

All Charges