Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CT HEAD WO CONTRAST

Facility

$1,518.00

Service Code	HCPCS 70450 TC
Hospital Charge Code	5200025
Hospital Revenue Code	350
Min. Negotiated Rate	$1,062.60
Max. Negotiated Rate	$1,518.00
Rate for Payer: Aetna Commercial	$1,442.10
Rate for Payer: Aetna Medicare	$1,366.20
Rate for Payer: BCBS MT CHIP	$1,366.20
Rate for Payer: BCBS MT Closed Plan Network	$1,442.10
Rate for Payer: BCBS MT HealthLink	$1,366.20
Rate for Payer: BCBS MT Medicare	$1,366.20
Rate for Payer: BCBS MT POS	$1,442.10
Rate for Payer: BCBS MT Traditional	$1,518.00
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Cigna Commercial	$1,442.10
Rate for Payer: Cigna Medicare	$1,366.20
Rate for Payer: Medicaid All Medicaid	$1,396.56
Rate for Payer: Medicare All Medicare	$1,062.60
Rate for Payer: Monida Allegiance	$1,442.10
Rate for Payer: Monida First Choice Health	$1,472.46
Rate for Payer: Monida Montana Health Co-op	$1,442.10
Rate for Payer: Monida PacificSource	$1,442.10

CT HEAD WO CONTRAST

Facility

$1,518.00

Service Code	HCPCS 70450 TC
Hospital Charge Code	5200025
Hospital Revenue Code	350
Min. Negotiated Rate	$1,062.60
Max. Negotiated Rate	$1,518.00
Rate for Payer: Aetna Commercial	$1,442.10
Rate for Payer: Aetna Medicare	$1,366.20
Rate for Payer: BCBS MT CHIP	$1,366.20
Rate for Payer: BCBS MT Closed Plan Network	$1,442.10
Rate for Payer: BCBS MT HealthLink	$1,366.20
Rate for Payer: BCBS MT Medicare	$1,366.20
Rate for Payer: BCBS MT POS	$1,442.10
Rate for Payer: BCBS MT Traditional	$1,518.00
Rate for Payer: Cash Price	$1,366.20
Rate for Payer: Cigna Commercial	$1,442.10
Rate for Payer: Cigna Medicare	$1,366.20
Rate for Payer: Medicaid All Medicaid	$1,396.56
Rate for Payer: Medicare All Medicare	$1,062.60
Rate for Payer: Monida Allegiance	$1,442.10
Rate for Payer: Monida First Choice Health	$1,472.46
Rate for Payer: Monida Montana Health Co-op	$1,442.10
Rate for Payer: Monida PacificSource	$1,442.10

CT HEAD W WO CONTRAST

Facility

$2,233.00

Service Code	HCPCS 70470 TC
Hospital Charge Code	5200026
Hospital Revenue Code	350
Min. Negotiated Rate	$1,563.10
Max. Negotiated Rate	$2,233.00
Rate for Payer: Aetna Commercial	$2,121.35
Rate for Payer: Aetna Medicare	$2,009.70
Rate for Payer: BCBS MT CHIP	$2,009.70
Rate for Payer: BCBS MT Closed Plan Network	$2,121.35
Rate for Payer: BCBS MT HealthLink	$2,009.70
Rate for Payer: BCBS MT Medicare	$2,009.70
Rate for Payer: BCBS MT POS	$2,121.35
Rate for Payer: BCBS MT Traditional	$2,233.00
Rate for Payer: Cash Price	$2,009.70
Rate for Payer: Cigna Commercial	$2,121.35
Rate for Payer: Cigna Medicare	$2,009.70
Rate for Payer: Medicaid All Medicaid	$2,054.36
Rate for Payer: Medicare All Medicare	$1,563.10
Rate for Payer: Monida Allegiance	$2,121.35
Rate for Payer: Monida First Choice Health	$2,166.01
Rate for Payer: Monida Montana Health Co-op	$2,121.35
Rate for Payer: Monida PacificSource	$2,121.35

CT HEAD W WO CONTRAST

Facility

$2,233.00

Service Code	HCPCS 70470 TC
Hospital Charge Code	5200026
Hospital Revenue Code	350
Min. Negotiated Rate	$1,563.10
Max. Negotiated Rate	$2,233.00
Rate for Payer: Aetna Commercial	$2,121.35
Rate for Payer: Aetna Medicare	$2,009.70
Rate for Payer: BCBS MT CHIP	$2,009.70
Rate for Payer: BCBS MT Closed Plan Network	$2,121.35
Rate for Payer: BCBS MT HealthLink	$2,009.70
Rate for Payer: BCBS MT Medicare	$2,009.70
Rate for Payer: BCBS MT POS	$2,121.35
Rate for Payer: BCBS MT Traditional	$2,233.00
Rate for Payer: Cash Price	$2,009.70
Rate for Payer: Cigna Commercial	$2,121.35
Rate for Payer: Cigna Medicare	$2,009.70
Rate for Payer: Medicaid All Medicaid	$2,054.36
Rate for Payer: Medicare All Medicare	$1,563.10
Rate for Payer: Monida Allegiance	$2,121.35
Rate for Payer: Monida First Choice Health	$2,166.01
Rate for Payer: Monida Montana Health Co-op	$2,121.35
Rate for Payer: Monida PacificSource	$2,121.35

CT HIGH REZ CHEST

Facility

$1,597.00

Service Code	HCPCS 71250 TC
Hospital Charge Code	5200075
Hospital Revenue Code	350
Min. Negotiated Rate	$1,117.90
Max. Negotiated Rate	$1,597.00
Rate for Payer: Aetna Commercial	$1,517.15
Rate for Payer: Aetna Medicare	$1,437.30
Rate for Payer: BCBS MT CHIP	$1,437.30
Rate for Payer: BCBS MT Closed Plan Network	$1,517.15
Rate for Payer: BCBS MT HealthLink	$1,437.30
Rate for Payer: BCBS MT Medicare	$1,437.30
Rate for Payer: BCBS MT POS	$1,517.15
Rate for Payer: BCBS MT Traditional	$1,597.00
Rate for Payer: Cash Price	$1,437.30
Rate for Payer: Cigna Commercial	$1,517.15
Rate for Payer: Cigna Medicare	$1,437.30
Rate for Payer: Medicaid All Medicaid	$1,469.24
Rate for Payer: Medicare All Medicare	$1,117.90
Rate for Payer: Monida Allegiance	$1,517.15
Rate for Payer: Monida First Choice Health	$1,549.09
Rate for Payer: Monida Montana Health Co-op	$1,517.15
Rate for Payer: Monida PacificSource	$1,517.15

CT HIGH REZ CHEST

Facility

$1,597.00

Service Code	HCPCS 71250 TC
Hospital Charge Code	5200075
Hospital Revenue Code	350
Min. Negotiated Rate	$1,117.90
Max. Negotiated Rate	$1,597.00
Rate for Payer: Aetna Commercial	$1,517.15
Rate for Payer: Aetna Medicare	$1,437.30
Rate for Payer: BCBS MT CHIP	$1,437.30
Rate for Payer: BCBS MT Closed Plan Network	$1,517.15
Rate for Payer: BCBS MT HealthLink	$1,437.30
Rate for Payer: BCBS MT Medicare	$1,437.30
Rate for Payer: BCBS MT POS	$1,517.15
Rate for Payer: BCBS MT Traditional	$1,597.00
Rate for Payer: Cash Price	$1,437.30
Rate for Payer: Cigna Commercial	$1,517.15
Rate for Payer: Cigna Medicare	$1,437.30
Rate for Payer: Medicaid All Medicaid	$1,469.24
Rate for Payer: Medicare All Medicare	$1,117.90
Rate for Payer: Monida Allegiance	$1,517.15
Rate for Payer: Monida First Choice Health	$1,549.09
Rate for Payer: Monida Montana Health Co-op	$1,517.15
Rate for Payer: Monida PacificSource	$1,517.15

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

$966.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	5200030
Hospital Revenue Code	350
Min. Negotiated Rate	$676.20
Max. Negotiated Rate	$966.00
Rate for Payer: Aetna Commercial	$917.70
Rate for Payer: Aetna Medicare	$869.40
Rate for Payer: BCBS MT CHIP	$869.40
Rate for Payer: BCBS MT Closed Plan Network	$917.70
Rate for Payer: BCBS MT HealthLink	$869.40
Rate for Payer: BCBS MT Medicare	$869.40
Rate for Payer: BCBS MT POS	$917.70
Rate for Payer: BCBS MT Traditional	$966.00
Rate for Payer: Cash Price	$869.40
Rate for Payer: Cigna Commercial	$917.70
Rate for Payer: Cigna Medicare	$869.40
Rate for Payer: Medicaid All Medicaid	$888.72
Rate for Payer: Medicare All Medicare	$676.20
Rate for Payer: Monida Allegiance	$917.70
Rate for Payer: Monida First Choice Health	$937.02
Rate for Payer: Monida Montana Health Co-op	$917.70
Rate for Payer: Monida PacificSource	$917.70

CT LIMITED ORBITS FOR MRI

Facility

$966.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	5200030
Hospital Revenue Code	350
Min. Negotiated Rate	$676.20
Max. Negotiated Rate	$966.00
Rate for Payer: Aetna Commercial	$917.70
Rate for Payer: Aetna Medicare	$869.40
Rate for Payer: BCBS MT CHIP	$869.40
Rate for Payer: BCBS MT Closed Plan Network	$917.70
Rate for Payer: BCBS MT HealthLink	$869.40
Rate for Payer: BCBS MT Medicare	$869.40
Rate for Payer: BCBS MT POS	$917.70
Rate for Payer: BCBS MT Traditional	$966.00
Rate for Payer: Cash Price	$869.40
Rate for Payer: Cigna Commercial	$917.70
Rate for Payer: Cigna Medicare	$869.40
Rate for Payer: Medicaid All Medicaid	$888.72
Rate for Payer: Medicare All Medicare	$676.20
Rate for Payer: Monida Allegiance	$917.70
Rate for Payer: Monida First Choice Health	$937.02
Rate for Payer: Monida Montana Health Co-op	$917.70
Rate for Payer: Monida PacificSource	$917.70

CT LOW DOSE CHEST FOLLOW UP

Facility

$492.00

Service Code	HCPCS 71250 TC
Hospital Charge Code	5271250
Hospital Revenue Code	350
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

CT LOW DOSE CHEST FOLLOW UP

Facility

$492.00

Service Code	HCPCS 71250 TC
Hospital Charge Code	5271250
Hospital Revenue Code	350
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

CT LOW DOSE LUNG SCREEN ANNUAL

Facility

$492.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	5070297
Hospital Revenue Code	350
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

CT LOW DOSE LUNG SCREEN ANNUAL

Facility

$492.00

Service Code	HCPCS 71271 TC
Hospital Charge Code	5070297
Hospital Revenue Code	350
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

CT LOWER EXTREMITY LT W CONTRAST

Facility

$1,928.00

Service Code	HCPCS 73701 TC,LT
Hospital Charge Code	5200033
Hospital Revenue Code	350
Min. Negotiated Rate	$1,349.60
Max. Negotiated Rate	$1,928.00
Rate for Payer: Aetna Commercial	$1,831.60
Rate for Payer: Aetna Medicare	$1,735.20
Rate for Payer: BCBS MT CHIP	$1,735.20
Rate for Payer: BCBS MT Closed Plan Network	$1,831.60
Rate for Payer: BCBS MT HealthLink	$1,735.20
Rate for Payer: BCBS MT Medicare	$1,735.20
Rate for Payer: BCBS MT POS	$1,831.60
Rate for Payer: BCBS MT Traditional	$1,928.00
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Cigna Commercial	$1,831.60
Rate for Payer: Cigna Medicare	$1,735.20
Rate for Payer: Medicaid All Medicaid	$1,773.76
Rate for Payer: Medicare All Medicare	$1,349.60
Rate for Payer: Monida Allegiance	$1,831.60
Rate for Payer: Monida First Choice Health	$1,870.16
Rate for Payer: Monida Montana Health Co-op	$1,831.60
Rate for Payer: Monida PacificSource	$1,831.60

CT LOWER EXTREMITY LT W CONTRAST

Facility

$1,928.00

Service Code	HCPCS 73701 TC,LT
Hospital Charge Code	5200033
Hospital Revenue Code	350
Min. Negotiated Rate	$1,349.60
Max. Negotiated Rate	$1,928.00
Rate for Payer: Aetna Commercial	$1,831.60
Rate for Payer: Aetna Medicare	$1,735.20
Rate for Payer: BCBS MT CHIP	$1,735.20
Rate for Payer: BCBS MT Closed Plan Network	$1,831.60
Rate for Payer: BCBS MT HealthLink	$1,735.20
Rate for Payer: BCBS MT Medicare	$1,735.20
Rate for Payer: BCBS MT POS	$1,831.60
Rate for Payer: BCBS MT Traditional	$1,928.00
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Cigna Commercial	$1,831.60
Rate for Payer: Cigna Medicare	$1,735.20
Rate for Payer: Medicaid All Medicaid	$1,773.76
Rate for Payer: Medicare All Medicare	$1,349.60
Rate for Payer: Monida Allegiance	$1,831.60
Rate for Payer: Monida First Choice Health	$1,870.16
Rate for Payer: Monida Montana Health Co-op	$1,831.60
Rate for Payer: Monida PacificSource	$1,831.60

CT LOWER EXTREMITY LT WO CONTRAST

Facility

$1,474.00

Service Code	HCPCS 73700 TC,LT
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,LT
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

$2,064.00

Service Code	HCPCS 73702 TC,LT
Hospital Charge Code	5200001
Hospital Revenue Code	350
Min. Negotiated Rate	$1,444.80
Max. Negotiated Rate	$2,064.00
Rate for Payer: Aetna Commercial	$1,960.80
Rate for Payer: Aetna Medicare	$1,857.60
Rate for Payer: BCBS MT CHIP	$1,857.60
Rate for Payer: BCBS MT Closed Plan Network	$1,960.80
Rate for Payer: BCBS MT HealthLink	$1,857.60
Rate for Payer: BCBS MT Medicare	$1,857.60
Rate for Payer: BCBS MT POS	$1,960.80
Rate for Payer: BCBS MT Traditional	$2,064.00
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Cigna Commercial	$1,960.80
Rate for Payer: Cigna Medicare	$1,857.60
Rate for Payer: Medicaid All Medicaid	$1,898.88
Rate for Payer: Medicare All Medicare	$1,444.80
Rate for Payer: Monida Allegiance	$1,960.80
Rate for Payer: Monida First Choice Health	$2,002.08
Rate for Payer: Monida Montana Health Co-op	$1,960.80
Rate for Payer: Monida PacificSource	$1,960.80

CT LOWER EXTREMITY LT W WO CONTRAST

Facility

$2,064.00

Service Code	HCPCS 73702 TC,LT
Hospital Charge Code	5200001
Hospital Revenue Code	350
Min. Negotiated Rate	$1,444.80
Max. Negotiated Rate	$2,064.00
Rate for Payer: Aetna Commercial	$1,960.80
Rate for Payer: Aetna Medicare	$1,857.60
Rate for Payer: BCBS MT CHIP	$1,857.60
Rate for Payer: BCBS MT Closed Plan Network	$1,960.80
Rate for Payer: BCBS MT HealthLink	$1,857.60
Rate for Payer: BCBS MT Medicare	$1,857.60
Rate for Payer: BCBS MT POS	$1,960.80
Rate for Payer: BCBS MT Traditional	$2,064.00
Rate for Payer: Cash Price	$1,857.60
Rate for Payer: Cigna Commercial	$1,960.80
Rate for Payer: Cigna Medicare	$1,857.60
Rate for Payer: Medicaid All Medicaid	$1,898.88
Rate for Payer: Medicare All Medicare	$1,444.80
Rate for Payer: Monida Allegiance	$1,960.80
Rate for Payer: Monida First Choice Health	$2,002.08
Rate for Payer: Monida Montana Health Co-op	$1,960.80
Rate for Payer: Monida PacificSource	$1,960.80

CT LOWER EXTREMITY RT W CONTRAST

Facility

$1,928.00

Service Code	HCPCS 73701 TC,RT
Hospital Charge Code	5200031
Hospital Revenue Code	350
Min. Negotiated Rate	$1,349.60
Max. Negotiated Rate	$1,928.00
Rate for Payer: Aetna Commercial	$1,831.60
Rate for Payer: Aetna Medicare	$1,735.20
Rate for Payer: BCBS MT CHIP	$1,735.20
Rate for Payer: BCBS MT Closed Plan Network	$1,831.60
Rate for Payer: BCBS MT HealthLink	$1,735.20
Rate for Payer: BCBS MT Medicare	$1,735.20
Rate for Payer: BCBS MT POS	$1,831.60
Rate for Payer: BCBS MT Traditional	$1,928.00
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Cigna Commercial	$1,831.60
Rate for Payer: Cigna Medicare	$1,735.20
Rate for Payer: Medicaid All Medicaid	$1,773.76
Rate for Payer: Medicare All Medicare	$1,349.60
Rate for Payer: Monida Allegiance	$1,831.60
Rate for Payer: Monida First Choice Health	$1,870.16
Rate for Payer: Monida Montana Health Co-op	$1,831.60
Rate for Payer: Monida PacificSource	$1,831.60

CT LOWER EXTREMITY RT W CONTRAST

Facility

$1,928.00

Service Code	HCPCS 73701 TC,RT
Hospital Charge Code	5200031
Hospital Revenue Code	350
Min. Negotiated Rate	$1,349.60
Max. Negotiated Rate	$1,928.00
Rate for Payer: Aetna Commercial	$1,831.60
Rate for Payer: Aetna Medicare	$1,735.20
Rate for Payer: BCBS MT CHIP	$1,735.20
Rate for Payer: BCBS MT Closed Plan Network	$1,831.60
Rate for Payer: BCBS MT HealthLink	$1,735.20
Rate for Payer: BCBS MT Medicare	$1,735.20
Rate for Payer: BCBS MT POS	$1,831.60
Rate for Payer: BCBS MT Traditional	$1,928.00
Rate for Payer: Cash Price	$1,735.20
Rate for Payer: Cigna Commercial	$1,831.60
Rate for Payer: Cigna Medicare	$1,735.20
Rate for Payer: Medicaid All Medicaid	$1,773.76
Rate for Payer: Medicare All Medicare	$1,349.60
Rate for Payer: Monida Allegiance	$1,831.60
Rate for Payer: Monida First Choice Health	$1,870.16
Rate for Payer: Monida Montana Health Co-op	$1,831.60
Rate for Payer: Monida PacificSource	$1,831.60

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

Know your out-of-pocket cost for care.

All Charges