Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CT SOFT TISSUE NECK W WO CONTRAST

Facility

$2,064.00

Service Code	HCPCS 70492 TC
Hospital Charge Code	5200042
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 SOFT TISSUE NECK W WO CONTRAST

Facility

$2,064.00

Service Code	HCPCS 70492 TC
Hospital Charge Code	5200042
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 STEREO SINUS WO CONTRAST

Facility

$1,522.00

Service Code	HCPCS 70486 TC
Hospital Charge Code	5200067
Hospital Revenue Code	350
Min. Negotiated Rate	$1,065.40
Max. Negotiated Rate	$1,522.00
Rate for Payer: Aetna Commercial	$1,445.90
Rate for Payer: Aetna Medicare	$1,369.80
Rate for Payer: BCBS MT CHIP	$1,369.80
Rate for Payer: BCBS MT Closed Plan Network	$1,445.90
Rate for Payer: BCBS MT HealthLink	$1,369.80
Rate for Payer: BCBS MT Medicare	$1,369.80
Rate for Payer: BCBS MT POS	$1,445.90
Rate for Payer: BCBS MT Traditional	$1,522.00
Rate for Payer: Cash Price	$1,369.80
Rate for Payer: Cigna Commercial	$1,445.90
Rate for Payer: Cigna Medicare	$1,369.80
Rate for Payer: Medicaid All Medicaid	$1,400.24
Rate for Payer: Medicare All Medicare	$1,065.40
Rate for Payer: Monida Allegiance	$1,445.90
Rate for Payer: Monida First Choice Health	$1,476.34
Rate for Payer: Monida Montana Health Co-op	$1,445.90
Rate for Payer: Monida PacificSource	$1,445.90

CT STEREO SINUS WO CONTRAST

Facility

$1,522.00

Service Code	HCPCS 70486 TC
Hospital Charge Code	5200067
Hospital Revenue Code	350
Min. Negotiated Rate	$1,065.40
Max. Negotiated Rate	$1,522.00
Rate for Payer: Aetna Commercial	$1,445.90
Rate for Payer: Aetna Medicare	$1,369.80
Rate for Payer: BCBS MT CHIP	$1,369.80
Rate for Payer: BCBS MT Closed Plan Network	$1,445.90
Rate for Payer: BCBS MT HealthLink	$1,369.80
Rate for Payer: BCBS MT Medicare	$1,369.80
Rate for Payer: BCBS MT POS	$1,445.90
Rate for Payer: BCBS MT Traditional	$1,522.00
Rate for Payer: Cash Price	$1,369.80
Rate for Payer: Cigna Commercial	$1,445.90
Rate for Payer: Cigna Medicare	$1,369.80
Rate for Payer: Medicaid All Medicaid	$1,400.24
Rate for Payer: Medicare All Medicare	$1,065.40
Rate for Payer: Monida Allegiance	$1,445.90
Rate for Payer: Monida First Choice Health	$1,476.34
Rate for Payer: Monida Montana Health Co-op	$1,445.90
Rate for Payer: Monida PacificSource	$1,445.90

CT THORACIC SPINE W CONTRAST

Facility

$2,003.00

Service Code	HCPCS 72129 TC
Hospital Charge Code	5200047
Hospital Revenue Code	350
Min. Negotiated Rate	$1,402.10
Max. Negotiated Rate	$2,003.00
Rate for Payer: Aetna Commercial	$1,902.85
Rate for Payer: Aetna Medicare	$1,802.70
Rate for Payer: BCBS MT CHIP	$1,802.70
Rate for Payer: BCBS MT Closed Plan Network	$1,902.85
Rate for Payer: BCBS MT HealthLink	$1,802.70
Rate for Payer: BCBS MT Medicare	$1,802.70
Rate for Payer: BCBS MT POS	$1,902.85
Rate for Payer: BCBS MT Traditional	$2,003.00
Rate for Payer: Cash Price	$1,802.70
Rate for Payer: Cigna Commercial	$1,902.85
Rate for Payer: Cigna Medicare	$1,802.70
Rate for Payer: Medicaid All Medicaid	$1,842.76
Rate for Payer: Medicare All Medicare	$1,402.10
Rate for Payer: Monida Allegiance	$1,902.85
Rate for Payer: Monida First Choice Health	$1,942.91
Rate for Payer: Monida Montana Health Co-op	$1,902.85
Rate for Payer: Monida PacificSource	$1,902.85

CT THORACIC SPINE W CONTRAST

Facility

$2,003.00

Service Code	HCPCS 72129 TC
Hospital Charge Code	5200047
Hospital Revenue Code	350
Min. Negotiated Rate	$1,402.10
Max. Negotiated Rate	$2,003.00
Rate for Payer: Aetna Commercial	$1,902.85
Rate for Payer: Aetna Medicare	$1,802.70
Rate for Payer: BCBS MT CHIP	$1,802.70
Rate for Payer: BCBS MT Closed Plan Network	$1,902.85
Rate for Payer: BCBS MT HealthLink	$1,802.70
Rate for Payer: BCBS MT Medicare	$1,802.70
Rate for Payer: BCBS MT POS	$1,902.85
Rate for Payer: BCBS MT Traditional	$2,003.00
Rate for Payer: Cash Price	$1,802.70
Rate for Payer: Cigna Commercial	$1,902.85
Rate for Payer: Cigna Medicare	$1,802.70
Rate for Payer: Medicaid All Medicaid	$1,842.76
Rate for Payer: Medicare All Medicare	$1,402.10
Rate for Payer: Monida Allegiance	$1,902.85
Rate for Payer: Monida First Choice Health	$1,942.91
Rate for Payer: Monida Montana Health Co-op	$1,902.85
Rate for Payer: Monida PacificSource	$1,902.85

CT THORACIC SPINE WO CONTRAST

Facility

$1,611.00

Service Code	HCPCS 72128 TC
Hospital Charge Code	5200045
Hospital Revenue Code	350
Min. Negotiated Rate	$1,127.70
Max. Negotiated Rate	$1,611.00
Rate for Payer: Aetna Commercial	$1,530.45
Rate for Payer: Aetna Medicare	$1,449.90
Rate for Payer: BCBS MT CHIP	$1,449.90
Rate for Payer: BCBS MT Closed Plan Network	$1,530.45
Rate for Payer: BCBS MT HealthLink	$1,449.90
Rate for Payer: BCBS MT Medicare	$1,449.90
Rate for Payer: BCBS MT POS	$1,530.45
Rate for Payer: BCBS MT Traditional	$1,611.00
Rate for Payer: Cash Price	$1,449.90
Rate for Payer: Cigna Commercial	$1,530.45
Rate for Payer: Cigna Medicare	$1,449.90
Rate for Payer: Medicaid All Medicaid	$1,482.12
Rate for Payer: Medicare All Medicare	$1,127.70
Rate for Payer: Monida Allegiance	$1,530.45
Rate for Payer: Monida First Choice Health	$1,562.67
Rate for Payer: Monida Montana Health Co-op	$1,530.45
Rate for Payer: Monida PacificSource	$1,530.45

CT THORACIC SPINE WO CONTRAST

Facility

$1,611.00

Service Code	HCPCS 72128 TC
Hospital Charge Code	5200045
Hospital Revenue Code	350
Min. Negotiated Rate	$1,127.70
Max. Negotiated Rate	$1,611.00
Rate for Payer: Aetna Commercial	$1,530.45
Rate for Payer: Aetna Medicare	$1,449.90
Rate for Payer: BCBS MT CHIP	$1,449.90
Rate for Payer: BCBS MT Closed Plan Network	$1,530.45
Rate for Payer: BCBS MT HealthLink	$1,449.90
Rate for Payer: BCBS MT Medicare	$1,449.90
Rate for Payer: BCBS MT POS	$1,530.45
Rate for Payer: BCBS MT Traditional	$1,611.00
Rate for Payer: Cash Price	$1,449.90
Rate for Payer: Cigna Commercial	$1,530.45
Rate for Payer: Cigna Medicare	$1,449.90
Rate for Payer: Medicaid All Medicaid	$1,482.12
Rate for Payer: Medicare All Medicare	$1,127.70
Rate for Payer: Monida Allegiance	$1,530.45
Rate for Payer: Monida First Choice Health	$1,562.67
Rate for Payer: Monida Montana Health Co-op	$1,530.45
Rate for Payer: Monida PacificSource	$1,530.45

CT THORACIC SPINE W WO CONTRAST

Facility

$2,288.00

Service Code	HCPCS 72130 TC
Hospital Charge Code	5200046
Hospital Revenue Code	350
Min. Negotiated Rate	$1,601.60
Max. Negotiated Rate	$2,288.00
Rate for Payer: Aetna Commercial	$2,173.60
Rate for Payer: Aetna Medicare	$2,059.20
Rate for Payer: BCBS MT CHIP	$2,059.20
Rate for Payer: BCBS MT Closed Plan Network	$2,173.60
Rate for Payer: BCBS MT HealthLink	$2,059.20
Rate for Payer: BCBS MT Medicare	$2,059.20
Rate for Payer: BCBS MT POS	$2,173.60
Rate for Payer: BCBS MT Traditional	$2,288.00
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Cigna Commercial	$2,173.60
Rate for Payer: Cigna Medicare	$2,059.20
Rate for Payer: Medicaid All Medicaid	$2,104.96
Rate for Payer: Medicare All Medicare	$1,601.60
Rate for Payer: Monida Allegiance	$2,173.60
Rate for Payer: Monida First Choice Health	$2,219.36
Rate for Payer: Monida Montana Health Co-op	$2,173.60
Rate for Payer: Monida PacificSource	$2,173.60

CT THORACIC SPINE W WO CONTRAST

Facility

$2,288.00

Service Code	HCPCS 72130 TC
Hospital Charge Code	5200046
Hospital Revenue Code	350
Min. Negotiated Rate	$1,601.60
Max. Negotiated Rate	$2,288.00
Rate for Payer: Aetna Commercial	$2,173.60
Rate for Payer: Aetna Medicare	$2,059.20
Rate for Payer: BCBS MT CHIP	$2,059.20
Rate for Payer: BCBS MT Closed Plan Network	$2,173.60
Rate for Payer: BCBS MT HealthLink	$2,059.20
Rate for Payer: BCBS MT Medicare	$2,059.20
Rate for Payer: BCBS MT POS	$2,173.60
Rate for Payer: BCBS MT Traditional	$2,288.00
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Cigna Commercial	$2,173.60
Rate for Payer: Cigna Medicare	$2,059.20
Rate for Payer: Medicaid All Medicaid	$2,104.96
Rate for Payer: Medicare All Medicare	$1,601.60
Rate for Payer: Monida Allegiance	$2,173.60
Rate for Payer: Monida First Choice Health	$2,219.36
Rate for Payer: Monida Montana Health Co-op	$2,173.60
Rate for Payer: Monida PacificSource	$2,173.60

CT UPPER EXTREMITY LT W CONTRAST

Facility

$1,841.00

Service Code	HCPCS 73201 TC,LT
Hospital Charge Code	5200048
Hospital Revenue Code	350
Min. Negotiated Rate	$1,288.70
Max. Negotiated Rate	$1,841.00
Rate for Payer: Aetna Commercial	$1,748.95
Rate for Payer: Aetna Medicare	$1,656.90
Rate for Payer: BCBS MT CHIP	$1,656.90
Rate for Payer: BCBS MT Closed Plan Network	$1,748.95
Rate for Payer: BCBS MT HealthLink	$1,656.90
Rate for Payer: BCBS MT Medicare	$1,656.90
Rate for Payer: BCBS MT POS	$1,748.95
Rate for Payer: BCBS MT Traditional	$1,841.00
Rate for Payer: Cash Price	$1,656.90
Rate for Payer: Cigna Commercial	$1,748.95
Rate for Payer: Cigna Medicare	$1,656.90
Rate for Payer: Medicaid All Medicaid	$1,693.72
Rate for Payer: Medicare All Medicare	$1,288.70
Rate for Payer: Monida Allegiance	$1,748.95
Rate for Payer: Monida First Choice Health	$1,785.77
Rate for Payer: Monida Montana Health Co-op	$1,748.95
Rate for Payer: Monida PacificSource	$1,748.95

CT UPPER EXTREMITY LT W CONTRAST

Facility

$1,841.00

Service Code	HCPCS 73201 TC,LT
Hospital Charge Code	5200048
Hospital Revenue Code	350
Min. Negotiated Rate	$1,288.70
Max. Negotiated Rate	$1,841.00
Rate for Payer: Aetna Commercial	$1,748.95
Rate for Payer: Aetna Medicare	$1,656.90
Rate for Payer: BCBS MT CHIP	$1,656.90
Rate for Payer: BCBS MT Closed Plan Network	$1,748.95
Rate for Payer: BCBS MT HealthLink	$1,656.90
Rate for Payer: BCBS MT Medicare	$1,656.90
Rate for Payer: BCBS MT POS	$1,748.95
Rate for Payer: BCBS MT Traditional	$1,841.00
Rate for Payer: Cash Price	$1,656.90
Rate for Payer: Cigna Commercial	$1,748.95
Rate for Payer: Cigna Medicare	$1,656.90
Rate for Payer: Medicaid All Medicaid	$1,693.72
Rate for Payer: Medicare All Medicare	$1,288.70
Rate for Payer: Monida Allegiance	$1,748.95
Rate for Payer: Monida First Choice Health	$1,785.77
Rate for Payer: Monida Montana Health Co-op	$1,748.95
Rate for Payer: Monida PacificSource	$1,748.95

CT UPPER EXTREMITY LT WO CONTRAST

Facility

$1,534.00

Service Code	HCPCS 73200 TC,LT
Hospital Charge Code	5200049
Hospital Revenue Code	350
Min. Negotiated Rate	$1,073.80
Max. Negotiated Rate	$1,534.00
Rate for Payer: Aetna Commercial	$1,457.30
Rate for Payer: Aetna Medicare	$1,380.60
Rate for Payer: BCBS MT CHIP	$1,380.60
Rate for Payer: BCBS MT Closed Plan Network	$1,457.30
Rate for Payer: BCBS MT HealthLink	$1,380.60
Rate for Payer: BCBS MT Medicare	$1,380.60
Rate for Payer: BCBS MT POS	$1,457.30
Rate for Payer: BCBS MT Traditional	$1,534.00
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Cigna Commercial	$1,457.30
Rate for Payer: Cigna Medicare	$1,380.60
Rate for Payer: Medicaid All Medicaid	$1,411.28
Rate for Payer: Medicare All Medicare	$1,073.80
Rate for Payer: Monida Allegiance	$1,457.30
Rate for Payer: Monida First Choice Health	$1,487.98
Rate for Payer: Monida Montana Health Co-op	$1,457.30
Rate for Payer: Monida PacificSource	$1,457.30

CT UPPER EXTREMITY LT WO CONTRAST

Facility

$1,534.00

Service Code	HCPCS 73200 TC,LT
Hospital Charge Code	5200049
Hospital Revenue Code	350
Min. Negotiated Rate	$1,073.80
Max. Negotiated Rate	$1,534.00
Rate for Payer: Aetna Commercial	$1,457.30
Rate for Payer: Aetna Medicare	$1,380.60
Rate for Payer: BCBS MT CHIP	$1,380.60
Rate for Payer: BCBS MT Closed Plan Network	$1,457.30
Rate for Payer: BCBS MT HealthLink	$1,380.60
Rate for Payer: BCBS MT Medicare	$1,380.60
Rate for Payer: BCBS MT POS	$1,457.30
Rate for Payer: BCBS MT Traditional	$1,534.00
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Cigna Commercial	$1,457.30
Rate for Payer: Cigna Medicare	$1,380.60
Rate for Payer: Medicaid All Medicaid	$1,411.28
Rate for Payer: Medicare All Medicare	$1,073.80
Rate for Payer: Monida Allegiance	$1,457.30
Rate for Payer: Monida First Choice Health	$1,487.98
Rate for Payer: Monida Montana Health Co-op	$1,457.30
Rate for Payer: Monida PacificSource	$1,457.30

CT UPPER EXTREMITY LT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,LT
Hospital Charge Code	5200050
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CT UPPER EXTREMITY LT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,LT
Hospital Charge Code	5200050
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CT UPPER EXTREMITY RT W CONTRAST

Facility

$1,841.00

Service Code	HCPCS 73201 TC,RT
Hospital Charge Code	5200051
Hospital Revenue Code	350
Min. Negotiated Rate	$1,288.70
Max. Negotiated Rate	$1,841.00
Rate for Payer: Aetna Commercial	$1,748.95
Rate for Payer: Aetna Medicare	$1,656.90
Rate for Payer: BCBS MT CHIP	$1,656.90
Rate for Payer: BCBS MT Closed Plan Network	$1,748.95
Rate for Payer: BCBS MT HealthLink	$1,656.90
Rate for Payer: BCBS MT Medicare	$1,656.90
Rate for Payer: BCBS MT POS	$1,748.95
Rate for Payer: BCBS MT Traditional	$1,841.00
Rate for Payer: Cash Price	$1,656.90
Rate for Payer: Cigna Commercial	$1,748.95
Rate for Payer: Cigna Medicare	$1,656.90
Rate for Payer: Medicaid All Medicaid	$1,693.72
Rate for Payer: Medicare All Medicare	$1,288.70
Rate for Payer: Monida Allegiance	$1,748.95
Rate for Payer: Monida First Choice Health	$1,785.77
Rate for Payer: Monida Montana Health Co-op	$1,748.95
Rate for Payer: Monida PacificSource	$1,748.95

CT UPPER EXTREMITY RT W CONTRAST

Facility

$1,841.00

Service Code	HCPCS 73201 TC,RT
Hospital Charge Code	5200051
Hospital Revenue Code	350
Min. Negotiated Rate	$1,288.70
Max. Negotiated Rate	$1,841.00
Rate for Payer: Aetna Commercial	$1,748.95
Rate for Payer: Aetna Medicare	$1,656.90
Rate for Payer: BCBS MT CHIP	$1,656.90
Rate for Payer: BCBS MT Closed Plan Network	$1,748.95
Rate for Payer: BCBS MT HealthLink	$1,656.90
Rate for Payer: BCBS MT Medicare	$1,656.90
Rate for Payer: BCBS MT POS	$1,748.95
Rate for Payer: BCBS MT Traditional	$1,841.00
Rate for Payer: Cash Price	$1,656.90
Rate for Payer: Cigna Commercial	$1,748.95
Rate for Payer: Cigna Medicare	$1,656.90
Rate for Payer: Medicaid All Medicaid	$1,693.72
Rate for Payer: Medicare All Medicare	$1,288.70
Rate for Payer: Monida Allegiance	$1,748.95
Rate for Payer: Monida First Choice Health	$1,785.77
Rate for Payer: Monida Montana Health Co-op	$1,748.95
Rate for Payer: Monida PacificSource	$1,748.95

CT UPPER EXTREMITY RT WO CONTRAST

Facility

$1,534.00

Service Code	HCPCS 73200 TC,RT
Hospital Charge Code	5200004
Hospital Revenue Code	350
Min. Negotiated Rate	$1,073.80
Max. Negotiated Rate	$1,534.00
Rate for Payer: Aetna Commercial	$1,457.30
Rate for Payer: Aetna Medicare	$1,380.60
Rate for Payer: BCBS MT CHIP	$1,380.60
Rate for Payer: BCBS MT Closed Plan Network	$1,457.30
Rate for Payer: BCBS MT HealthLink	$1,380.60
Rate for Payer: BCBS MT Medicare	$1,380.60
Rate for Payer: BCBS MT POS	$1,457.30
Rate for Payer: BCBS MT Traditional	$1,534.00
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Cigna Commercial	$1,457.30
Rate for Payer: Cigna Medicare	$1,380.60
Rate for Payer: Medicaid All Medicaid	$1,411.28
Rate for Payer: Medicare All Medicare	$1,073.80
Rate for Payer: Monida Allegiance	$1,457.30
Rate for Payer: Monida First Choice Health	$1,487.98
Rate for Payer: Monida Montana Health Co-op	$1,457.30
Rate for Payer: Monida PacificSource	$1,457.30

CT UPPER EXTREMITY RT WO CONTRAST

Facility

$1,534.00

Service Code	HCPCS 73200 TC,RT
Hospital Charge Code	5200004
Hospital Revenue Code	350
Min. Negotiated Rate	$1,073.80
Max. Negotiated Rate	$1,534.00
Rate for Payer: Aetna Commercial	$1,457.30
Rate for Payer: Aetna Medicare	$1,380.60
Rate for Payer: BCBS MT CHIP	$1,380.60
Rate for Payer: BCBS MT Closed Plan Network	$1,457.30
Rate for Payer: BCBS MT HealthLink	$1,380.60
Rate for Payer: BCBS MT Medicare	$1,380.60
Rate for Payer: BCBS MT POS	$1,457.30
Rate for Payer: BCBS MT Traditional	$1,534.00
Rate for Payer: Cash Price	$1,380.60
Rate for Payer: Cigna Commercial	$1,457.30
Rate for Payer: Cigna Medicare	$1,380.60
Rate for Payer: Medicaid All Medicaid	$1,411.28
Rate for Payer: Medicare All Medicare	$1,073.80
Rate for Payer: Monida Allegiance	$1,457.30
Rate for Payer: Monida First Choice Health	$1,487.98
Rate for Payer: Monida Montana Health Co-op	$1,457.30
Rate for Payer: Monida PacificSource	$1,457.30

CT UPPER EXTREMITY RT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,RT
Hospital Charge Code	5200052
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CT UPPER EXTREMITY RT W WO CONTRAST

Facility

$1,878.00

Service Code	HCPCS 73202 TC,RT
Hospital Charge Code	5200052
Hospital Revenue Code	350
Min. Negotiated Rate	$1,314.60
Max. Negotiated Rate	$1,878.00
Rate for Payer: Aetna Commercial	$1,784.10
Rate for Payer: Aetna Medicare	$1,690.20
Rate for Payer: BCBS MT CHIP	$1,690.20
Rate for Payer: BCBS MT Closed Plan Network	$1,784.10
Rate for Payer: BCBS MT HealthLink	$1,690.20
Rate for Payer: BCBS MT Medicare	$1,690.20
Rate for Payer: BCBS MT POS	$1,784.10
Rate for Payer: BCBS MT Traditional	$1,878.00
Rate for Payer: Cash Price	$1,690.20
Rate for Payer: Cigna Commercial	$1,784.10
Rate for Payer: Cigna Medicare	$1,690.20
Rate for Payer: Medicaid All Medicaid	$1,727.76
Rate for Payer: Medicare All Medicare	$1,314.60
Rate for Payer: Monida Allegiance	$1,784.10
Rate for Payer: Monida First Choice Health	$1,821.66
Rate for Payer: Monida Montana Health Co-op	$1,784.10
Rate for Payer: Monida PacificSource	$1,784.10

CYANOCOBALAMIN INJ [1000 MCG/ML]

Facility

$29.00

Service Code	HCPCS J3420
Hospital Charge Code	3000105
Hospital Revenue Code	259
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

CYANOCOBALAMIN INJ [1000 MCG/ML]

Facility

$29.00

Service Code	HCPCS J3420
Hospital Charge Code	3000105
Hospital Revenue Code	259
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$29.00
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: BCBS MT CHIP	$26.10
Rate for Payer: BCBS MT Closed Plan Network	$27.55
Rate for Payer: BCBS MT HealthLink	$26.10
Rate for Payer: BCBS MT Medicare	$26.10
Rate for Payer: BCBS MT POS	$27.55
Rate for Payer: BCBS MT Traditional	$29.00
Rate for Payer: Cash Price	$26.10
Rate for Payer: Cigna Commercial	$27.55
Rate for Payer: Cigna Medicare	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

CYCLOBENZAPRINE TAB [10 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000106
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

Know your out-of-pocket cost for care.

All Charges