Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$2,165.00

Service Code	HCPCS 72132 TC
Hospital Charge Code	5200036
Hospital Revenue Code	350
Min. Negotiated Rate	$1,515.50
Max. Negotiated Rate	$2,165.00
Rate for Payer: Aetna Commercial	$2,056.75
Rate for Payer: Aetna Medicare	$1,948.50
Rate for Payer: BCBS MT CHIP	$1,948.50
Rate for Payer: BCBS MT Closed Plan Network	$2,056.75
Rate for Payer: BCBS MT HealthLink	$1,948.50
Rate for Payer: BCBS MT Medicare	$1,948.50
Rate for Payer: BCBS MT POS	$2,056.75
Rate for Payer: BCBS MT Traditional	$2,165.00
Rate for Payer: Cash Price	$1,948.50
Rate for Payer: Cigna Commercial	$2,056.75
Rate for Payer: Cigna Medicare	$1,948.50
Rate for Payer: Medicaid All Medicaid	$1,991.80
Rate for Payer: Medicare All Medicare	$1,515.50
Rate for Payer: Monida Allegiance	$2,056.75
Rate for Payer: Monida First Choice Health	$2,100.05
Rate for Payer: Monida Montana Health Co-op	$2,056.75
Rate for Payer: Monida PacificSource	$2,056.75

CT LUMBAR SPINE W CONTRAST

Facility

$2,165.00

Service Code	HCPCS 72132 TC
Hospital Charge Code	5200036
Hospital Revenue Code	350
Min. Negotiated Rate	$1,515.50
Max. Negotiated Rate	$2,165.00
Rate for Payer: Aetna Commercial	$2,056.75
Rate for Payer: Aetna Medicare	$1,948.50
Rate for Payer: BCBS MT CHIP	$1,948.50
Rate for Payer: BCBS MT Closed Plan Network	$2,056.75
Rate for Payer: BCBS MT HealthLink	$1,948.50
Rate for Payer: BCBS MT Medicare	$1,948.50
Rate for Payer: BCBS MT POS	$2,056.75
Rate for Payer: BCBS MT Traditional	$2,165.00
Rate for Payer: Cash Price	$1,948.50
Rate for Payer: Cigna Commercial	$2,056.75
Rate for Payer: Cigna Medicare	$1,948.50
Rate for Payer: Medicaid All Medicaid	$1,991.80
Rate for Payer: Medicare All Medicare	$1,515.50
Rate for Payer: Monida Allegiance	$2,056.75
Rate for Payer: Monida First Choice Health	$2,100.05
Rate for Payer: Monida Montana Health Co-op	$2,056.75
Rate for Payer: Monida PacificSource	$2,056.75

CT LUMBAR SPINE WO CONTRAST

Facility

$1,616.00

Service Code	HCPCS 72131 TC
Hospital Charge Code	5200003
Hospital Revenue Code	350
Min. Negotiated Rate	$1,131.20
Max. Negotiated Rate	$1,616.00
Rate for Payer: Aetna Commercial	$1,535.20
Rate for Payer: Aetna Medicare	$1,454.40
Rate for Payer: BCBS MT CHIP	$1,454.40
Rate for Payer: BCBS MT Closed Plan Network	$1,535.20
Rate for Payer: BCBS MT HealthLink	$1,454.40
Rate for Payer: BCBS MT Medicare	$1,454.40
Rate for Payer: BCBS MT POS	$1,535.20
Rate for Payer: BCBS MT Traditional	$1,616.00
Rate for Payer: Cash Price	$1,454.40
Rate for Payer: Cigna Commercial	$1,535.20
Rate for Payer: Cigna Medicare	$1,454.40
Rate for Payer: Medicaid All Medicaid	$1,486.72
Rate for Payer: Medicare All Medicare	$1,131.20
Rate for Payer: Monida Allegiance	$1,535.20
Rate for Payer: Monida First Choice Health	$1,567.52
Rate for Payer: Monida Montana Health Co-op	$1,535.20
Rate for Payer: Monida PacificSource	$1,535.20

CT LUMBAR SPINE WO CONTRAST

Facility

$1,616.00

Service Code	HCPCS 72131 TC
Hospital Charge Code	5200003
Hospital Revenue Code	350
Min. Negotiated Rate	$1,131.20
Max. Negotiated Rate	$1,616.00
Rate for Payer: Aetna Commercial	$1,535.20
Rate for Payer: Aetna Medicare	$1,454.40
Rate for Payer: BCBS MT CHIP	$1,454.40
Rate for Payer: BCBS MT Closed Plan Network	$1,535.20
Rate for Payer: BCBS MT HealthLink	$1,454.40
Rate for Payer: BCBS MT Medicare	$1,454.40
Rate for Payer: BCBS MT POS	$1,535.20
Rate for Payer: BCBS MT Traditional	$1,616.00
Rate for Payer: Cash Price	$1,454.40
Rate for Payer: Cigna Commercial	$1,535.20
Rate for Payer: Cigna Medicare	$1,454.40
Rate for Payer: Medicaid All Medicaid	$1,486.72
Rate for Payer: Medicare All Medicare	$1,131.20
Rate for Payer: Monida Allegiance	$1,535.20
Rate for Payer: Monida First Choice Health	$1,567.52
Rate for Payer: Monida Montana Health Co-op	$1,535.20
Rate for Payer: Monida PacificSource	$1,535.20

CT LUMBAR SPINE W WO CONTRAST

Facility

$2,343.00

Service Code	HCPCS 72133 TC
Hospital Charge Code	5200035
Hospital Revenue Code	350
Min. Negotiated Rate	$1,640.10
Max. Negotiated Rate	$2,343.00
Rate for Payer: Aetna Commercial	$2,225.85
Rate for Payer: Aetna Medicare	$2,108.70
Rate for Payer: BCBS MT CHIP	$2,108.70
Rate for Payer: BCBS MT Closed Plan Network	$2,225.85
Rate for Payer: BCBS MT HealthLink	$2,108.70
Rate for Payer: BCBS MT Medicare	$2,108.70
Rate for Payer: BCBS MT POS	$2,225.85
Rate for Payer: BCBS MT Traditional	$2,343.00
Rate for Payer: Cash Price	$2,108.70
Rate for Payer: Cigna Commercial	$2,225.85
Rate for Payer: Cigna Medicare	$2,108.70
Rate for Payer: Medicaid All Medicaid	$2,155.56
Rate for Payer: Medicare All Medicare	$1,640.10
Rate for Payer: Monida Allegiance	$2,225.85
Rate for Payer: Monida First Choice Health	$2,272.71
Rate for Payer: Monida Montana Health Co-op	$2,225.85
Rate for Payer: Monida PacificSource	$2,225.85

CT LUMBAR SPINE W WO CONTRAST

Facility

$2,343.00

Service Code	HCPCS 72133 TC
Hospital Charge Code	5200035
Hospital Revenue Code	350
Min. Negotiated Rate	$1,640.10
Max. Negotiated Rate	$2,343.00
Rate for Payer: Aetna Commercial	$2,225.85
Rate for Payer: Aetna Medicare	$2,108.70
Rate for Payer: BCBS MT CHIP	$2,108.70
Rate for Payer: BCBS MT Closed Plan Network	$2,225.85
Rate for Payer: BCBS MT HealthLink	$2,108.70
Rate for Payer: BCBS MT Medicare	$2,108.70
Rate for Payer: BCBS MT POS	$2,225.85
Rate for Payer: BCBS MT Traditional	$2,343.00
Rate for Payer: Cash Price	$2,108.70
Rate for Payer: Cigna Commercial	$2,225.85
Rate for Payer: Cigna Medicare	$2,108.70
Rate for Payer: Medicaid All Medicaid	$2,155.56
Rate for Payer: Medicare All Medicare	$1,640.10
Rate for Payer: Monida Allegiance	$2,225.85
Rate for Payer: Monida First Choice Health	$2,272.71
Rate for Payer: Monida Montana Health Co-op	$2,225.85
Rate for Payer: Monida PacificSource	$2,225.85

CT OMNIPAQUE CONTRAST 350 ML

Facility

$311.00

Service Code	HCPCS Q9967
Hospital Charge Code	5200350
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 OMNIPAQUE CONTRAST 350 ML

Facility

$311.00

Service Code	HCPCS Q9967
Hospital Charge Code	5200350
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 ORBITS W CONTRAST

Facility

$2,113.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	5200074
Hospital Revenue Code	350
Min. Negotiated Rate	$1,479.10
Max. Negotiated Rate	$2,113.00
Rate for Payer: Aetna Commercial	$2,007.35
Rate for Payer: Aetna Medicare	$1,901.70
Rate for Payer: BCBS MT CHIP	$1,901.70
Rate for Payer: BCBS MT Closed Plan Network	$2,007.35
Rate for Payer: BCBS MT HealthLink	$1,901.70
Rate for Payer: BCBS MT Medicare	$1,901.70
Rate for Payer: BCBS MT POS	$2,007.35
Rate for Payer: BCBS MT Traditional	$2,113.00
Rate for Payer: Cash Price	$1,901.70
Rate for Payer: Cigna Commercial	$2,007.35
Rate for Payer: Cigna Medicare	$1,901.70
Rate for Payer: Medicaid All Medicaid	$1,943.96
Rate for Payer: Medicare All Medicare	$1,479.10
Rate for Payer: Monida Allegiance	$2,007.35
Rate for Payer: Monida First Choice Health	$2,049.61
Rate for Payer: Monida Montana Health Co-op	$2,007.35
Rate for Payer: Monida PacificSource	$2,007.35

CT ORBITS W CONTRAST

Facility

$2,113.00

Service Code	HCPCS 70481 TC
Hospital Charge Code	5200074
Hospital Revenue Code	350
Min. Negotiated Rate	$1,479.10
Max. Negotiated Rate	$2,113.00
Rate for Payer: Aetna Commercial	$2,007.35
Rate for Payer: Aetna Medicare	$1,901.70
Rate for Payer: BCBS MT CHIP	$1,901.70
Rate for Payer: BCBS MT Closed Plan Network	$2,007.35
Rate for Payer: BCBS MT HealthLink	$1,901.70
Rate for Payer: BCBS MT Medicare	$1,901.70
Rate for Payer: BCBS MT POS	$2,007.35
Rate for Payer: BCBS MT Traditional	$2,113.00
Rate for Payer: Cash Price	$1,901.70
Rate for Payer: Cigna Commercial	$2,007.35
Rate for Payer: Cigna Medicare	$1,901.70
Rate for Payer: Medicaid All Medicaid	$1,943.96
Rate for Payer: Medicare All Medicare	$1,479.10
Rate for Payer: Monida Allegiance	$2,007.35
Rate for Payer: Monida First Choice Health	$2,049.61
Rate for Payer: Monida Montana Health Co-op	$2,007.35
Rate for Payer: Monida PacificSource	$2,007.35

CT ORBITS WO CONTRAST

Facility

$1,512.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	5200037
Hospital Revenue Code	350
Min. Negotiated Rate	$1,058.40
Max. Negotiated Rate	$1,512.00
Rate for Payer: Aetna Commercial	$1,436.40
Rate for Payer: Aetna Medicare	$1,360.80
Rate for Payer: BCBS MT CHIP	$1,360.80
Rate for Payer: BCBS MT Closed Plan Network	$1,436.40
Rate for Payer: BCBS MT HealthLink	$1,360.80
Rate for Payer: BCBS MT Medicare	$1,360.80
Rate for Payer: BCBS MT POS	$1,436.40
Rate for Payer: BCBS MT Traditional	$1,512.00
Rate for Payer: Cash Price	$1,360.80
Rate for Payer: Cigna Commercial	$1,436.40
Rate for Payer: Cigna Medicare	$1,360.80
Rate for Payer: Medicaid All Medicaid	$1,391.04
Rate for Payer: Medicare All Medicare	$1,058.40
Rate for Payer: Monida Allegiance	$1,436.40
Rate for Payer: Monida First Choice Health	$1,466.64
Rate for Payer: Monida Montana Health Co-op	$1,436.40
Rate for Payer: Monida PacificSource	$1,436.40

CT ORBITS WO CONTRAST

Facility

$1,512.00

Service Code	HCPCS 70480 TC
Hospital Charge Code	5200037
Hospital Revenue Code	350
Min. Negotiated Rate	$1,058.40
Max. Negotiated Rate	$1,512.00
Rate for Payer: Aetna Commercial	$1,436.40
Rate for Payer: Aetna Medicare	$1,360.80
Rate for Payer: BCBS MT CHIP	$1,360.80
Rate for Payer: BCBS MT Closed Plan Network	$1,436.40
Rate for Payer: BCBS MT HealthLink	$1,360.80
Rate for Payer: BCBS MT Medicare	$1,360.80
Rate for Payer: BCBS MT POS	$1,436.40
Rate for Payer: BCBS MT Traditional	$1,512.00
Rate for Payer: Cash Price	$1,360.80
Rate for Payer: Cigna Commercial	$1,436.40
Rate for Payer: Cigna Medicare	$1,360.80
Rate for Payer: Medicaid All Medicaid	$1,391.04
Rate for Payer: Medicare All Medicare	$1,058.40
Rate for Payer: Monida Allegiance	$1,436.40
Rate for Payer: Monida First Choice Health	$1,466.64
Rate for Payer: Monida Montana Health Co-op	$1,436.40
Rate for Payer: Monida PacificSource	$1,436.40

CT PELVIS W CONTRAST

Facility

$1,966.00

Service Code	HCPCS 72193 TC
Hospital Charge Code	5200040
Hospital Revenue Code	350
Min. Negotiated Rate	$1,376.20
Max. Negotiated Rate	$1,966.00
Rate for Payer: Aetna Commercial	$1,867.70
Rate for Payer: Aetna Medicare	$1,769.40
Rate for Payer: BCBS MT CHIP	$1,769.40
Rate for Payer: BCBS MT Closed Plan Network	$1,867.70
Rate for Payer: BCBS MT HealthLink	$1,769.40
Rate for Payer: BCBS MT Medicare	$1,769.40
Rate for Payer: BCBS MT POS	$1,867.70
Rate for Payer: BCBS MT Traditional	$1,966.00
Rate for Payer: Cash Price	$1,769.40
Rate for Payer: Cigna Commercial	$1,867.70
Rate for Payer: Cigna Medicare	$1,769.40
Rate for Payer: Medicaid All Medicaid	$1,808.72
Rate for Payer: Medicare All Medicare	$1,376.20
Rate for Payer: Monida Allegiance	$1,867.70
Rate for Payer: Monida First Choice Health	$1,907.02
Rate for Payer: Monida Montana Health Co-op	$1,867.70
Rate for Payer: Monida PacificSource	$1,867.70

CT PELVIS W CONTRAST

Facility

$1,966.00

Service Code	HCPCS 72193 TC
Hospital Charge Code	5200040
Hospital Revenue Code	350
Min. Negotiated Rate	$1,376.20
Max. Negotiated Rate	$1,966.00
Rate for Payer: Aetna Commercial	$1,867.70
Rate for Payer: Aetna Medicare	$1,769.40
Rate for Payer: BCBS MT CHIP	$1,769.40
Rate for Payer: BCBS MT Closed Plan Network	$1,867.70
Rate for Payer: BCBS MT HealthLink	$1,769.40
Rate for Payer: BCBS MT Medicare	$1,769.40
Rate for Payer: BCBS MT POS	$1,867.70
Rate for Payer: BCBS MT Traditional	$1,966.00
Rate for Payer: Cash Price	$1,769.40
Rate for Payer: Cigna Commercial	$1,867.70
Rate for Payer: Cigna Medicare	$1,769.40
Rate for Payer: Medicaid All Medicaid	$1,808.72
Rate for Payer: Medicare All Medicare	$1,376.20
Rate for Payer: Monida Allegiance	$1,867.70
Rate for Payer: Monida First Choice Health	$1,907.02
Rate for Payer: Monida Montana Health Co-op	$1,867.70
Rate for Payer: Monida PacificSource	$1,867.70

CT PELVIS WO CONTRAST

Facility

$1,546.00

Service Code	HCPCS 72192 TC
Hospital Charge Code	5200038
Hospital Revenue Code	350
Min. Negotiated Rate	$1,082.20
Max. Negotiated Rate	$1,546.00
Rate for Payer: Aetna Commercial	$1,468.70
Rate for Payer: Aetna Medicare	$1,391.40
Rate for Payer: BCBS MT CHIP	$1,391.40
Rate for Payer: BCBS MT Closed Plan Network	$1,468.70
Rate for Payer: BCBS MT HealthLink	$1,391.40
Rate for Payer: BCBS MT Medicare	$1,391.40
Rate for Payer: BCBS MT POS	$1,468.70
Rate for Payer: BCBS MT Traditional	$1,546.00
Rate for Payer: Cash Price	$1,391.40
Rate for Payer: Cigna Commercial	$1,468.70
Rate for Payer: Cigna Medicare	$1,391.40
Rate for Payer: Medicaid All Medicaid	$1,422.32
Rate for Payer: Medicare All Medicare	$1,082.20
Rate for Payer: Monida Allegiance	$1,468.70
Rate for Payer: Monida First Choice Health	$1,499.62
Rate for Payer: Monida Montana Health Co-op	$1,468.70
Rate for Payer: Monida PacificSource	$1,468.70

CT PELVIS WO CONTRAST

Facility

$1,546.00

Service Code	HCPCS 72192 TC
Hospital Charge Code	5200038
Hospital Revenue Code	350
Min. Negotiated Rate	$1,082.20
Max. Negotiated Rate	$1,546.00
Rate for Payer: Aetna Commercial	$1,468.70
Rate for Payer: Aetna Medicare	$1,391.40
Rate for Payer: BCBS MT CHIP	$1,391.40
Rate for Payer: BCBS MT Closed Plan Network	$1,468.70
Rate for Payer: BCBS MT HealthLink	$1,391.40
Rate for Payer: BCBS MT Medicare	$1,391.40
Rate for Payer: BCBS MT POS	$1,468.70
Rate for Payer: BCBS MT Traditional	$1,546.00
Rate for Payer: Cash Price	$1,391.40
Rate for Payer: Cigna Commercial	$1,468.70
Rate for Payer: Cigna Medicare	$1,391.40
Rate for Payer: Medicaid All Medicaid	$1,422.32
Rate for Payer: Medicare All Medicare	$1,082.20
Rate for Payer: Monida Allegiance	$1,468.70
Rate for Payer: Monida First Choice Health	$1,499.62
Rate for Payer: Monida Montana Health Co-op	$1,468.70
Rate for Payer: Monida PacificSource	$1,468.70

CT PELVIS W WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 72194 TC
Hospital Charge Code	5200039
Hospital Revenue Code	350
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

CT PELVIS W WO CONTRAST

Facility

$2,222.00

Service Code	HCPCS 72194 TC
Hospital Charge Code	5200039
Hospital Revenue Code	350
Min. Negotiated Rate	$1,555.40
Max. Negotiated Rate	$2,222.00
Rate for Payer: Aetna Commercial	$2,110.90
Rate for Payer: Aetna Medicare	$1,999.80
Rate for Payer: BCBS MT CHIP	$1,999.80
Rate for Payer: BCBS MT Closed Plan Network	$2,110.90
Rate for Payer: BCBS MT HealthLink	$1,999.80
Rate for Payer: BCBS MT Medicare	$1,999.80
Rate for Payer: BCBS MT POS	$2,110.90
Rate for Payer: BCBS MT Traditional	$2,222.00
Rate for Payer: Cash Price	$1,999.80
Rate for Payer: Cigna Commercial	$2,110.90
Rate for Payer: Cigna Medicare	$1,999.80
Rate for Payer: Medicaid All Medicaid	$2,044.24
Rate for Payer: Medicare All Medicare	$1,555.40
Rate for Payer: Monida Allegiance	$2,110.90
Rate for Payer: Monida First Choice Health	$2,155.34
Rate for Payer: Monida Montana Health Co-op	$2,110.90
Rate for Payer: Monida PacificSource	$2,110.90

CT SOFT TISSUE NECK W CONTRAST

Facility

$1,957.00

Service Code	HCPCS 70491 TC
Hospital Charge Code	5200043
Hospital Revenue Code	350
Min. Negotiated Rate	$1,369.90
Max. Negotiated Rate	$1,957.00
Rate for Payer: Aetna Commercial	$1,859.15
Rate for Payer: Aetna Medicare	$1,761.30
Rate for Payer: BCBS MT CHIP	$1,761.30
Rate for Payer: BCBS MT Closed Plan Network	$1,859.15
Rate for Payer: BCBS MT HealthLink	$1,761.30
Rate for Payer: BCBS MT Medicare	$1,761.30
Rate for Payer: BCBS MT POS	$1,859.15
Rate for Payer: BCBS MT Traditional	$1,957.00
Rate for Payer: Cash Price	$1,761.30
Rate for Payer: Cigna Commercial	$1,859.15
Rate for Payer: Cigna Medicare	$1,761.30
Rate for Payer: Medicaid All Medicaid	$1,800.44
Rate for Payer: Medicare All Medicare	$1,369.90
Rate for Payer: Monida Allegiance	$1,859.15
Rate for Payer: Monida First Choice Health	$1,898.29
Rate for Payer: Monida Montana Health Co-op	$1,859.15
Rate for Payer: Monida PacificSource	$1,859.15

CT SOFT TISSUE NECK W CONTRAST

Facility

$1,957.00

Service Code	HCPCS 70491 TC
Hospital Charge Code	5200043
Hospital Revenue Code	350
Min. Negotiated Rate	$1,369.90
Max. Negotiated Rate	$1,957.00
Rate for Payer: Aetna Commercial	$1,859.15
Rate for Payer: Aetna Medicare	$1,761.30
Rate for Payer: BCBS MT CHIP	$1,761.30
Rate for Payer: BCBS MT Closed Plan Network	$1,859.15
Rate for Payer: BCBS MT HealthLink	$1,761.30
Rate for Payer: BCBS MT Medicare	$1,761.30
Rate for Payer: BCBS MT POS	$1,859.15
Rate for Payer: BCBS MT Traditional	$1,957.00
Rate for Payer: Cash Price	$1,761.30
Rate for Payer: Cigna Commercial	$1,859.15
Rate for Payer: Cigna Medicare	$1,761.30
Rate for Payer: Medicaid All Medicaid	$1,800.44
Rate for Payer: Medicare All Medicare	$1,369.90
Rate for Payer: Monida Allegiance	$1,859.15
Rate for Payer: Monida First Choice Health	$1,898.29
Rate for Payer: Monida Montana Health Co-op	$1,859.15
Rate for Payer: Monida PacificSource	$1,859.15

CT SOFT TISSUE NECK WO CONTRAST

Facility

$1,539.00

Service Code	HCPCS 70490 TC
Hospital Charge Code	5200044
Hospital Revenue Code	350
Min. Negotiated Rate	$1,077.30
Max. Negotiated Rate	$1,539.00
Rate for Payer: Aetna Commercial	$1,462.05
Rate for Payer: Aetna Medicare	$1,385.10
Rate for Payer: BCBS MT CHIP	$1,385.10
Rate for Payer: BCBS MT Closed Plan Network	$1,462.05
Rate for Payer: BCBS MT HealthLink	$1,385.10
Rate for Payer: BCBS MT Medicare	$1,385.10
Rate for Payer: BCBS MT POS	$1,462.05
Rate for Payer: BCBS MT Traditional	$1,539.00
Rate for Payer: Cash Price	$1,385.10
Rate for Payer: Cigna Commercial	$1,462.05
Rate for Payer: Cigna Medicare	$1,385.10
Rate for Payer: Medicaid All Medicaid	$1,415.88
Rate for Payer: Medicare All Medicare	$1,077.30
Rate for Payer: Monida Allegiance	$1,462.05
Rate for Payer: Monida First Choice Health	$1,492.83
Rate for Payer: Monida Montana Health Co-op	$1,462.05
Rate for Payer: Monida PacificSource	$1,462.05

CT SOFT TISSUE NECK WO CONTRAST

Facility

$1,539.00

Service Code	HCPCS 70490 TC
Hospital Charge Code	5200044
Hospital Revenue Code	350
Min. Negotiated Rate	$1,077.30
Max. Negotiated Rate	$1,539.00
Rate for Payer: Aetna Commercial	$1,462.05
Rate for Payer: Aetna Medicare	$1,385.10
Rate for Payer: BCBS MT CHIP	$1,385.10
Rate for Payer: BCBS MT Closed Plan Network	$1,462.05
Rate for Payer: BCBS MT HealthLink	$1,385.10
Rate for Payer: BCBS MT Medicare	$1,385.10
Rate for Payer: BCBS MT POS	$1,462.05
Rate for Payer: BCBS MT Traditional	$1,539.00
Rate for Payer: Cash Price	$1,385.10
Rate for Payer: Cigna Commercial	$1,462.05
Rate for Payer: Cigna Medicare	$1,385.10
Rate for Payer: Medicaid All Medicaid	$1,415.88
Rate for Payer: Medicare All Medicare	$1,077.30
Rate for Payer: Monida Allegiance	$1,462.05
Rate for Payer: Monida First Choice Health	$1,492.83
Rate for Payer: Monida Montana Health Co-op	$1,462.05
Rate for Payer: Monida PacificSource	$1,462.05

Know your out-of-pocket cost for care.

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