Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CTA AORTA ILIAC RUNOFF

Facility

$2,362.00

Service Code	CPT 75635
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	CPT 75635
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	CPT 74177
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	CPT 74177
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	CPT 74176
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	CPT 74176
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	CPT 74178
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	CPT 74178
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	CPT 74160
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	CPT 74160
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	CPT 74150
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	CPT 74150
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 W WO CONTRAST

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200007
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200007
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - ADRENALS

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200076
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - ADRENALS

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200076
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - LIVER

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200071
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - LIVER

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200071
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - PANCREAS

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200073
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - PANCREAS

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200073
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - RENAL

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200072
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CT ABDOMEN W WO CONTRAST - RENAL

Facility

$2,454.00

Service Code	CPT 74170
Hospital Charge Code	5200072
Hospital Revenue Code	350
Min. Negotiated Rate	$1,717.80
Max. Negotiated Rate	$2,454.00
Rate for Payer: Aetna Commercial	$2,331.30
Rate for Payer: Aetna Medicare	$2,208.60
Rate for Payer: BCBS MT CHIP	$2,208.60
Rate for Payer: BCBS MT Closed Plan Network	$2,331.30
Rate for Payer: BCBS MT HealthLink	$2,208.60
Rate for Payer: BCBS MT Medicare	$2,208.60
Rate for Payer: BCBS MT POS	$2,331.30
Rate for Payer: BCBS MT Traditional	$2,454.00
Rate for Payer: Cash Price	$2,208.60
Rate for Payer: Cigna Commercial	$2,331.30
Rate for Payer: Cigna Medicare	$2,208.60
Rate for Payer: Medicaid All Medicaid	$2,257.68
Rate for Payer: Medicare All Medicare	$1,717.80
Rate for Payer: Monida Allegiance	$2,331.30
Rate for Payer: Monida First Choice Health	$2,380.38
Rate for Payer: Monida Montana Health Co-op	$2,331.30
Rate for Payer: Monida PacificSource	$2,331.30

CTA CHEST PE STUDY

Facility

$2,420.00

Service Code	CPT 71275
Hospital Charge Code	5200064
Hospital Revenue Code	350
Min. Negotiated Rate	$1,694.00
Max. Negotiated Rate	$2,420.00
Rate for Payer: Aetna Commercial	$2,299.00
Rate for Payer: Aetna Medicare	$2,178.00
Rate for Payer: BCBS MT CHIP	$2,178.00
Rate for Payer: BCBS MT Closed Plan Network	$2,299.00
Rate for Payer: BCBS MT HealthLink	$2,178.00
Rate for Payer: BCBS MT Medicare	$2,178.00
Rate for Payer: BCBS MT POS	$2,299.00
Rate for Payer: BCBS MT Traditional	$2,420.00
Rate for Payer: Cash Price	$2,178.00
Rate for Payer: Cigna Commercial	$2,299.00
Rate for Payer: Cigna Medicare	$2,178.00
Rate for Payer: Medicaid All Medicaid	$2,226.40
Rate for Payer: Medicare All Medicare	$1,694.00
Rate for Payer: Monida Allegiance	$2,299.00
Rate for Payer: Monida First Choice Health	$2,347.40
Rate for Payer: Monida Montana Health Co-op	$2,299.00
Rate for Payer: Monida PacificSource	$2,299.00

CTA CHEST PE STUDY

Facility

$2,420.00

Service Code	CPT 71275
Hospital Charge Code	5200064
Hospital Revenue Code	350
Min. Negotiated Rate	$1,694.00
Max. Negotiated Rate	$2,420.00
Rate for Payer: Aetna Commercial	$2,299.00
Rate for Payer: Aetna Medicare	$2,178.00
Rate for Payer: BCBS MT CHIP	$2,178.00
Rate for Payer: BCBS MT Closed Plan Network	$2,299.00
Rate for Payer: BCBS MT HealthLink	$2,178.00
Rate for Payer: BCBS MT Medicare	$2,178.00
Rate for Payer: BCBS MT POS	$2,299.00
Rate for Payer: BCBS MT Traditional	$2,420.00
Rate for Payer: Cash Price	$2,178.00
Rate for Payer: Cigna Commercial	$2,299.00
Rate for Payer: Cigna Medicare	$2,178.00
Rate for Payer: Medicaid All Medicaid	$2,226.40
Rate for Payer: Medicare All Medicare	$1,694.00
Rate for Payer: Monida Allegiance	$2,299.00
Rate for Payer: Monida First Choice Health	$2,347.40
Rate for Payer: Monida Montana Health Co-op	$2,299.00
Rate for Payer: Monida PacificSource	$2,299.00

CTA CHEST THORACIC AORTA

Facility

$2,420.00

Service Code	CPT 71275
Hospital Charge Code	5200068
Hospital Revenue Code	350
Min. Negotiated Rate	$1,694.00
Max. Negotiated Rate	$2,420.00
Rate for Payer: Aetna Commercial	$2,299.00
Rate for Payer: Aetna Medicare	$2,178.00
Rate for Payer: BCBS MT CHIP	$2,178.00
Rate for Payer: BCBS MT Closed Plan Network	$2,299.00
Rate for Payer: BCBS MT HealthLink	$2,178.00
Rate for Payer: BCBS MT Medicare	$2,178.00
Rate for Payer: BCBS MT POS	$2,299.00
Rate for Payer: BCBS MT Traditional	$2,420.00
Rate for Payer: Cash Price	$2,178.00
Rate for Payer: Cigna Commercial	$2,299.00
Rate for Payer: Cigna Medicare	$2,178.00
Rate for Payer: Medicaid All Medicaid	$2,226.40
Rate for Payer: Medicare All Medicare	$1,694.00
Rate for Payer: Monida Allegiance	$2,299.00
Rate for Payer: Monida First Choice Health	$2,347.40
Rate for Payer: Monida Montana Health Co-op	$2,299.00
Rate for Payer: Monida PacificSource	$2,299.00

Know your out-of-pocket cost for care.

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