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

$57.00

Service Code	HCPCS E0116
Hospital Charge Code	2893284
Hospital Revenue Code	290
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

CRUTCH DRESSED CHILD

Facility

$57.00

Service Code	HCPCS E0116
Hospital Charge Code	2893284
Hospital Revenue Code	290
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

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

$387.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5200005
Hospital Revenue Code	350
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

CT 3D RECONSTRUCTION

Facility

$387.00

Service Code	HCPCS 76376 TC
Hospital Charge Code	5200005
Hospital Revenue Code	350
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

CTA ABDOMEN PELVIS W CONTRAST

Facility

$2,975.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	5200053
Hospital Revenue Code	350
Min. Negotiated Rate	$2,082.50
Max. Negotiated Rate	$2,975.00
Rate for Payer: Aetna Commercial	$2,826.25
Rate for Payer: Aetna Medicare	$2,677.50
Rate for Payer: BCBS MT CHIP	$2,677.50
Rate for Payer: BCBS MT Closed Plan Network	$2,826.25
Rate for Payer: BCBS MT HealthLink	$2,677.50
Rate for Payer: BCBS MT Medicare	$2,677.50
Rate for Payer: BCBS MT POS	$2,826.25
Rate for Payer: BCBS MT Traditional	$2,975.00
Rate for Payer: Cash Price	$2,677.50
Rate for Payer: Cigna Commercial	$2,826.25
Rate for Payer: Cigna Medicare	$2,677.50
Rate for Payer: Medicaid All Medicaid	$2,737.00
Rate for Payer: Medicare All Medicare	$2,082.50
Rate for Payer: Monida Allegiance	$2,826.25
Rate for Payer: Monida First Choice Health	$2,885.75
Rate for Payer: Monida Montana Health Co-op	$2,826.25
Rate for Payer: Monida PacificSource	$2,826.25

CTA ABDOMEN PELVIS W CONTRAST

Facility

$2,975.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	5200053
Hospital Revenue Code	350
Min. Negotiated Rate	$2,082.50
Max. Negotiated Rate	$2,975.00
Rate for Payer: Aetna Commercial	$2,826.25
Rate for Payer: Aetna Medicare	$2,677.50
Rate for Payer: BCBS MT CHIP	$2,677.50
Rate for Payer: BCBS MT Closed Plan Network	$2,826.25
Rate for Payer: BCBS MT HealthLink	$2,677.50
Rate for Payer: BCBS MT Medicare	$2,677.50
Rate for Payer: BCBS MT POS	$2,826.25
Rate for Payer: BCBS MT Traditional	$2,975.00
Rate for Payer: Cash Price	$2,677.50
Rate for Payer: Cigna Commercial	$2,826.25
Rate for Payer: Cigna Medicare	$2,677.50
Rate for Payer: Medicaid All Medicaid	$2,737.00
Rate for Payer: Medicare All Medicare	$2,082.50
Rate for Payer: Monida Allegiance	$2,826.25
Rate for Payer: Monida First Choice Health	$2,885.75
Rate for Payer: Monida Montana Health Co-op	$2,826.25
Rate for Payer: Monida PacificSource	$2,826.25

CTA ABDOMEN PELVIS W WO CONTRAST

Facility

$2,975.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	5200250
Hospital Revenue Code	350
Min. Negotiated Rate	$2,082.50
Max. Negotiated Rate	$2,975.00
Rate for Payer: Aetna Commercial	$2,826.25
Rate for Payer: Aetna Medicare	$2,677.50
Rate for Payer: BCBS MT CHIP	$2,677.50
Rate for Payer: BCBS MT Closed Plan Network	$2,826.25
Rate for Payer: BCBS MT HealthLink	$2,677.50
Rate for Payer: BCBS MT Medicare	$2,677.50
Rate for Payer: BCBS MT POS	$2,826.25
Rate for Payer: BCBS MT Traditional	$2,975.00
Rate for Payer: Cash Price	$2,677.50
Rate for Payer: Cigna Commercial	$2,826.25
Rate for Payer: Cigna Medicare	$2,677.50
Rate for Payer: Medicaid All Medicaid	$2,737.00
Rate for Payer: Medicare All Medicare	$2,082.50
Rate for Payer: Monida Allegiance	$2,826.25
Rate for Payer: Monida First Choice Health	$2,885.75
Rate for Payer: Monida Montana Health Co-op	$2,826.25
Rate for Payer: Monida PacificSource	$2,826.25

CTA ABDOMEN PELVIS W WO CONTRAST

Facility

$2,975.00

Service Code	HCPCS 74174 TC
Hospital Charge Code	5200250
Hospital Revenue Code	350
Min. Negotiated Rate	$2,082.50
Max. Negotiated Rate	$2,975.00
Rate for Payer: Aetna Commercial	$2,826.25
Rate for Payer: Aetna Medicare	$2,677.50
Rate for Payer: BCBS MT CHIP	$2,677.50
Rate for Payer: BCBS MT Closed Plan Network	$2,826.25
Rate for Payer: BCBS MT HealthLink	$2,677.50
Rate for Payer: BCBS MT Medicare	$2,677.50
Rate for Payer: BCBS MT POS	$2,826.25
Rate for Payer: BCBS MT Traditional	$2,975.00
Rate for Payer: Cash Price	$2,677.50
Rate for Payer: Cigna Commercial	$2,826.25
Rate for Payer: Cigna Medicare	$2,677.50
Rate for Payer: Medicaid All Medicaid	$2,737.00
Rate for Payer: Medicare All Medicare	$2,082.50
Rate for Payer: Monida Allegiance	$2,826.25
Rate for Payer: Monida First Choice Health	$2,885.75
Rate for Payer: Monida Montana Health Co-op	$2,826.25
Rate for Payer: Monida PacificSource	$2,826.25

CTA AORTA ILIAC RUNOFF

Facility

$2,362.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5200054
Hospital Revenue Code	350
Min. Negotiated Rate	$1,653.40
Max. Negotiated Rate	$2,362.00
Rate for Payer: Aetna Commercial	$2,243.90
Rate for Payer: Aetna Medicare	$2,125.80
Rate for Payer: BCBS MT CHIP	$2,125.80
Rate for Payer: BCBS MT Closed Plan Network	$2,243.90
Rate for Payer: BCBS MT HealthLink	$2,125.80
Rate for Payer: BCBS MT Medicare	$2,125.80
Rate for Payer: BCBS MT POS	$2,243.90
Rate for Payer: BCBS MT Traditional	$2,362.00
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cigna Commercial	$2,243.90
Rate for Payer: Cigna Medicare	$2,125.80
Rate for Payer: Medicaid All Medicaid	$2,173.04
Rate for Payer: Medicare All Medicare	$1,653.40
Rate for Payer: Monida Allegiance	$2,243.90
Rate for Payer: Monida First Choice Health	$2,291.14
Rate for Payer: Monida Montana Health Co-op	$2,243.90
Rate for Payer: Monida PacificSource	$2,243.90

CTA AORTA ILIAC RUNOFF

Facility

$2,362.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5200054
Hospital Revenue Code	350
Min. Negotiated Rate	$1,653.40
Max. Negotiated Rate	$2,362.00
Rate for Payer: Aetna Commercial	$2,243.90
Rate for Payer: Aetna Medicare	$2,125.80
Rate for Payer: BCBS MT CHIP	$2,125.80
Rate for Payer: BCBS MT Closed Plan Network	$2,243.90
Rate for Payer: BCBS MT HealthLink	$2,125.80
Rate for Payer: BCBS MT Medicare	$2,125.80
Rate for Payer: BCBS MT POS	$2,243.90
Rate for Payer: BCBS MT Traditional	$2,362.00
Rate for Payer: Cash Price	$2,125.80
Rate for Payer: Cigna Commercial	$2,243.90
Rate for Payer: Cigna Medicare	$2,125.80
Rate for Payer: Medicaid All Medicaid	$2,173.04
Rate for Payer: Medicare All Medicare	$1,653.40
Rate for Payer: Monida Allegiance	$2,243.90
Rate for Payer: Monida First Choice Health	$2,291.14
Rate for Payer: Monida Montana Health Co-op	$2,243.90
Rate for Payer: Monida PacificSource	$2,243.90

CT ABDOMEN PELVIS W CONTRAST

Facility

$3,207.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	5200011
Hospital Revenue Code	350
Min. Negotiated Rate	$2,244.90
Max. Negotiated Rate	$3,207.00
Rate for Payer: Aetna Commercial	$3,046.65
Rate for Payer: Aetna Medicare	$2,886.30
Rate for Payer: BCBS MT CHIP	$2,886.30
Rate for Payer: BCBS MT Closed Plan Network	$3,046.65
Rate for Payer: BCBS MT HealthLink	$2,886.30
Rate for Payer: BCBS MT Medicare	$2,886.30
Rate for Payer: BCBS MT POS	$3,046.65
Rate for Payer: BCBS MT Traditional	$3,207.00
Rate for Payer: Cash Price	$2,886.30
Rate for Payer: Cigna Commercial	$3,046.65
Rate for Payer: Cigna Medicare	$2,886.30
Rate for Payer: Medicaid All Medicaid	$2,950.44
Rate for Payer: Medicare All Medicare	$2,244.90
Rate for Payer: Monida Allegiance	$3,046.65
Rate for Payer: Monida First Choice Health	$3,110.79
Rate for Payer: Monida Montana Health Co-op	$3,046.65
Rate for Payer: Monida PacificSource	$3,046.65

CT ABDOMEN PELVIS W CONTRAST

Facility

$3,207.00

Service Code	HCPCS 74177 TC
Hospital Charge Code	5200011
Hospital Revenue Code	350
Min. Negotiated Rate	$2,244.90
Max. Negotiated Rate	$3,207.00
Rate for Payer: Aetna Commercial	$3,046.65
Rate for Payer: Aetna Medicare	$2,886.30
Rate for Payer: BCBS MT CHIP	$2,886.30
Rate for Payer: BCBS MT Closed Plan Network	$3,046.65
Rate for Payer: BCBS MT HealthLink	$2,886.30
Rate for Payer: BCBS MT Medicare	$2,886.30
Rate for Payer: BCBS MT POS	$3,046.65
Rate for Payer: BCBS MT Traditional	$3,207.00
Rate for Payer: Cash Price	$2,886.30
Rate for Payer: Cigna Commercial	$3,046.65
Rate for Payer: Cigna Medicare	$2,886.30
Rate for Payer: Medicaid All Medicaid	$2,950.44
Rate for Payer: Medicare All Medicare	$2,244.90
Rate for Payer: Monida Allegiance	$3,046.65
Rate for Payer: Monida First Choice Health	$3,110.79
Rate for Payer: Monida Montana Health Co-op	$3,046.65
Rate for Payer: Monida PacificSource	$3,046.65

CT ABDOMEN PELVIS WO CONTRAST

Facility

$2,519.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	5200009
Hospital Revenue Code	350
Min. Negotiated Rate	$1,763.30
Max. Negotiated Rate	$2,519.00
Rate for Payer: Aetna Commercial	$2,393.05
Rate for Payer: Aetna Medicare	$2,267.10
Rate for Payer: BCBS MT CHIP	$2,267.10
Rate for Payer: BCBS MT Closed Plan Network	$2,393.05
Rate for Payer: BCBS MT HealthLink	$2,267.10
Rate for Payer: BCBS MT Medicare	$2,267.10
Rate for Payer: BCBS MT POS	$2,393.05
Rate for Payer: BCBS MT Traditional	$2,519.00
Rate for Payer: Cash Price	$2,267.10
Rate for Payer: Cigna Commercial	$2,393.05
Rate for Payer: Cigna Medicare	$2,267.10
Rate for Payer: Medicaid All Medicaid	$2,317.48
Rate for Payer: Medicare All Medicare	$1,763.30
Rate for Payer: Monida Allegiance	$2,393.05
Rate for Payer: Monida First Choice Health	$2,443.43
Rate for Payer: Monida Montana Health Co-op	$2,393.05
Rate for Payer: Monida PacificSource	$2,393.05

CT ABDOMEN PELVIS WO CONTRAST

Facility

$2,519.00

Service Code	HCPCS 74176 TC
Hospital Charge Code	5200009
Hospital Revenue Code	350
Min. Negotiated Rate	$1,763.30
Max. Negotiated Rate	$2,519.00
Rate for Payer: Aetna Commercial	$2,393.05
Rate for Payer: Aetna Medicare	$2,267.10
Rate for Payer: BCBS MT CHIP	$2,267.10
Rate for Payer: BCBS MT Closed Plan Network	$2,393.05
Rate for Payer: BCBS MT HealthLink	$2,267.10
Rate for Payer: BCBS MT Medicare	$2,267.10
Rate for Payer: BCBS MT POS	$2,393.05
Rate for Payer: BCBS MT Traditional	$2,519.00
Rate for Payer: Cash Price	$2,267.10
Rate for Payer: Cigna Commercial	$2,393.05
Rate for Payer: Cigna Medicare	$2,267.10
Rate for Payer: Medicaid All Medicaid	$2,317.48
Rate for Payer: Medicare All Medicare	$1,763.30
Rate for Payer: Monida Allegiance	$2,393.05
Rate for Payer: Monida First Choice Health	$2,443.43
Rate for Payer: Monida Montana Health Co-op	$2,393.05
Rate for Payer: Monida PacificSource	$2,393.05

CT ABDOMEN PELVIS W WO CONTRAST

Facility

$3,559.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	5200010
Hospital Revenue Code	350
Min. Negotiated Rate	$2,491.30
Max. Negotiated Rate	$3,559.00
Rate for Payer: Aetna Commercial	$3,381.05
Rate for Payer: Aetna Medicare	$3,203.10
Rate for Payer: BCBS MT CHIP	$3,203.10
Rate for Payer: BCBS MT Closed Plan Network	$3,381.05
Rate for Payer: BCBS MT HealthLink	$3,203.10
Rate for Payer: BCBS MT Medicare	$3,203.10
Rate for Payer: BCBS MT POS	$3,381.05
Rate for Payer: BCBS MT Traditional	$3,559.00
Rate for Payer: Cash Price	$3,203.10
Rate for Payer: Cigna Commercial	$3,381.05
Rate for Payer: Cigna Medicare	$3,203.10
Rate for Payer: Medicaid All Medicaid	$3,274.28
Rate for Payer: Medicare All Medicare	$2,491.30
Rate for Payer: Monida Allegiance	$3,381.05
Rate for Payer: Monida First Choice Health	$3,452.23
Rate for Payer: Monida Montana Health Co-op	$3,381.05
Rate for Payer: Monida PacificSource	$3,381.05

CT ABDOMEN PELVIS W WO CONTRAST

Facility

$3,559.00

Service Code	HCPCS 74178 TC
Hospital Charge Code	5200010
Hospital Revenue Code	350
Min. Negotiated Rate	$2,491.30
Max. Negotiated Rate	$3,559.00
Rate for Payer: Aetna Commercial	$3,381.05
Rate for Payer: Aetna Medicare	$3,203.10
Rate for Payer: BCBS MT CHIP	$3,203.10
Rate for Payer: BCBS MT Closed Plan Network	$3,381.05
Rate for Payer: BCBS MT HealthLink	$3,203.10
Rate for Payer: BCBS MT Medicare	$3,203.10
Rate for Payer: BCBS MT POS	$3,381.05
Rate for Payer: BCBS MT Traditional	$3,559.00
Rate for Payer: Cash Price	$3,203.10
Rate for Payer: Cigna Commercial	$3,381.05
Rate for Payer: Cigna Medicare	$3,203.10
Rate for Payer: Medicaid All Medicaid	$3,274.28
Rate for Payer: Medicare All Medicare	$2,491.30
Rate for Payer: Monida Allegiance	$3,381.05
Rate for Payer: Monida First Choice Health	$3,452.23
Rate for Payer: Monida Montana Health Co-op	$3,381.05
Rate for Payer: Monida PacificSource	$3,381.05

CT ABDOMEN W CONTRAST

Facility

$2,084.00

Service Code	HCPCS 74160 TC
Hospital Charge Code	5200008
Hospital Revenue Code	350
Min. Negotiated Rate	$1,458.80
Max. Negotiated Rate	$2,084.00
Rate for Payer: Aetna Commercial	$1,979.80
Rate for Payer: Aetna Medicare	$1,875.60
Rate for Payer: BCBS MT CHIP	$1,875.60
Rate for Payer: BCBS MT Closed Plan Network	$1,979.80
Rate for Payer: BCBS MT HealthLink	$1,875.60
Rate for Payer: BCBS MT Medicare	$1,875.60
Rate for Payer: BCBS MT POS	$1,979.80
Rate for Payer: BCBS MT Traditional	$2,084.00
Rate for Payer: Cash Price	$1,875.60
Rate for Payer: Cigna Commercial	$1,979.80
Rate for Payer: Cigna Medicare	$1,875.60
Rate for Payer: Medicaid All Medicaid	$1,917.28
Rate for Payer: Medicare All Medicare	$1,458.80
Rate for Payer: Monida Allegiance	$1,979.80
Rate for Payer: Monida First Choice Health	$2,021.48
Rate for Payer: Monida Montana Health Co-op	$1,979.80
Rate for Payer: Monida PacificSource	$1,979.80

CT ABDOMEN W CONTRAST

Facility

$2,084.00

Service Code	HCPCS 74160 TC
Hospital Charge Code	5200008
Hospital Revenue Code	350
Min. Negotiated Rate	$1,458.80
Max. Negotiated Rate	$2,084.00
Rate for Payer: Aetna Commercial	$1,979.80
Rate for Payer: Aetna Medicare	$1,875.60
Rate for Payer: BCBS MT CHIP	$1,875.60
Rate for Payer: BCBS MT Closed Plan Network	$1,979.80
Rate for Payer: BCBS MT HealthLink	$1,875.60
Rate for Payer: BCBS MT Medicare	$1,875.60
Rate for Payer: BCBS MT POS	$1,979.80
Rate for Payer: BCBS MT Traditional	$2,084.00
Rate for Payer: Cash Price	$1,875.60
Rate for Payer: Cigna Commercial	$1,979.80
Rate for Payer: Cigna Medicare	$1,875.60
Rate for Payer: Medicaid All Medicaid	$1,917.28
Rate for Payer: Medicare All Medicare	$1,458.80
Rate for Payer: Monida Allegiance	$1,979.80
Rate for Payer: Monida First Choice Health	$2,021.48
Rate for Payer: Monida Montana Health Co-op	$1,979.80
Rate for Payer: Monida PacificSource	$1,979.80

CT ABDOMEN WO CONTRAST

Facility

$1,631.00

Service Code	HCPCS 74150 TC
Hospital Charge Code	5200006
Hospital Revenue Code	350
Min. Negotiated Rate	$1,141.70
Max. Negotiated Rate	$1,631.00
Rate for Payer: Aetna Commercial	$1,549.45
Rate for Payer: Aetna Medicare	$1,467.90
Rate for Payer: BCBS MT CHIP	$1,467.90
Rate for Payer: BCBS MT Closed Plan Network	$1,549.45
Rate for Payer: BCBS MT HealthLink	$1,467.90
Rate for Payer: BCBS MT Medicare	$1,467.90
Rate for Payer: BCBS MT POS	$1,549.45
Rate for Payer: BCBS MT Traditional	$1,631.00
Rate for Payer: Cash Price	$1,467.90
Rate for Payer: Cigna Commercial	$1,549.45
Rate for Payer: Cigna Medicare	$1,467.90
Rate for Payer: Medicaid All Medicaid	$1,500.52
Rate for Payer: Medicare All Medicare	$1,141.70
Rate for Payer: Monida Allegiance	$1,549.45
Rate for Payer: Monida First Choice Health	$1,582.07
Rate for Payer: Monida Montana Health Co-op	$1,549.45
Rate for Payer: Monida PacificSource	$1,549.45

CT ABDOMEN WO CONTRAST

Facility

$1,631.00

Service Code	HCPCS 74150 TC
Hospital Charge Code	5200006
Hospital Revenue Code	350
Min. Negotiated Rate	$1,141.70
Max. Negotiated Rate	$1,631.00
Rate for Payer: Aetna Commercial	$1,549.45
Rate for Payer: Aetna Medicare	$1,467.90
Rate for Payer: BCBS MT CHIP	$1,467.90
Rate for Payer: BCBS MT Closed Plan Network	$1,549.45
Rate for Payer: BCBS MT HealthLink	$1,467.90
Rate for Payer: BCBS MT Medicare	$1,467.90
Rate for Payer: BCBS MT POS	$1,549.45
Rate for Payer: BCBS MT Traditional	$1,631.00
Rate for Payer: Cash Price	$1,467.90
Rate for Payer: Cigna Commercial	$1,549.45
Rate for Payer: Cigna Medicare	$1,467.90
Rate for Payer: Medicaid All Medicaid	$1,500.52
Rate for Payer: Medicare All Medicare	$1,141.70
Rate for Payer: Monida Allegiance	$1,549.45
Rate for Payer: Monida First Choice Health	$1,582.07
Rate for Payer: Monida Montana Health Co-op	$1,549.45
Rate for Payer: Monida PacificSource	$1,549.45

Know your out-of-pocket cost for care.

All Charges