Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CTA HEAD AND NECK

Facility

$3,081.33

Service Code	CPT 70471
Hospital Charge Code	5270496
Hospital Revenue Code	350
Min. Negotiated Rate	$2,156.93
Max. Negotiated Rate	$3,081.33
Rate for Payer: Aetna Commercial	$2,927.26
Rate for Payer: Aetna Medicare	$2,773.20
Rate for Payer: BCBS MT CHIP	$2,773.20
Rate for Payer: BCBS MT Closed Plan Network	$2,927.26
Rate for Payer: BCBS MT HealthLink	$2,773.20
Rate for Payer: BCBS MT Medicare	$2,773.20
Rate for Payer: BCBS MT POS	$2,927.26
Rate for Payer: BCBS MT Traditional	$3,081.33
Rate for Payer: Cash Price	$2,773.20
Rate for Payer: Cigna Commercial	$2,927.26
Rate for Payer: Cigna Medicare	$2,773.20
Rate for Payer: Medicaid All Medicaid	$2,834.82
Rate for Payer: Medicare All Medicare	$2,156.93
Rate for Payer: Monida Allegiance	$2,927.26
Rate for Payer: Monida First Choice Health	$2,988.89
Rate for Payer: Monida Montana Health Co-op	$2,927.26
Rate for Payer: Monida PacificSource	$2,927.26

CTA HEAD AND NECK

Facility

$3,081.33

Service Code	CPT 70471
Hospital Charge Code	5270496
Hospital Revenue Code	350
Min. Negotiated Rate	$2,156.93
Max. Negotiated Rate	$3,081.33
Rate for Payer: Aetna Commercial	$2,927.26
Rate for Payer: Aetna Medicare	$2,773.20
Rate for Payer: BCBS MT CHIP	$2,773.20
Rate for Payer: BCBS MT Closed Plan Network	$2,927.26
Rate for Payer: BCBS MT HealthLink	$2,773.20
Rate for Payer: BCBS MT Medicare	$2,773.20
Rate for Payer: BCBS MT POS	$2,927.26
Rate for Payer: BCBS MT Traditional	$3,081.33
Rate for Payer: Cash Price	$2,773.20
Rate for Payer: Cigna Commercial	$2,927.26
Rate for Payer: Cigna Medicare	$2,773.20
Rate for Payer: Medicaid All Medicaid	$2,834.82
Rate for Payer: Medicare All Medicare	$2,156.93
Rate for Payer: Monida Allegiance	$2,927.26
Rate for Payer: Monida First Choice Health	$2,988.89
Rate for Payer: Monida Montana Health Co-op	$2,927.26
Rate for Payer: Monida PacificSource	$2,927.26

CTA LOWER EXT BILAT W CONTRAST

Facility

$2,092.00

Service Code	CPT 73706
Hospital Charge Code	5273706
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CTA LOWER EXT BILAT W CONTRAST

Facility

$2,092.00

Service Code	CPT 73706
Hospital Charge Code	5273706
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CTA LOWER EXTREMITY BILAT W WO CONTRAST

Facility

$2,092.00

Service Code	CPT 73706
Hospital Charge Code	5200028
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CTA LOWER EXTREMITY BILAT W WO CONTRAST

Facility

$2,092.00

Service Code	CPT 73706
Hospital Charge Code	5200028
Hospital Revenue Code	350
Min. Negotiated Rate	$1,464.40
Max. Negotiated Rate	$2,092.00
Rate for Payer: Aetna Commercial	$1,987.40
Rate for Payer: Aetna Medicare	$1,882.80
Rate for Payer: BCBS MT CHIP	$1,882.80
Rate for Payer: BCBS MT Closed Plan Network	$1,987.40
Rate for Payer: BCBS MT HealthLink	$1,882.80
Rate for Payer: BCBS MT Medicare	$1,882.80
Rate for Payer: BCBS MT POS	$1,987.40
Rate for Payer: BCBS MT Traditional	$2,092.00
Rate for Payer: Cash Price	$1,882.80
Rate for Payer: Cigna Commercial	$1,987.40
Rate for Payer: Cigna Medicare	$1,882.80
Rate for Payer: Medicaid All Medicaid	$1,924.64
Rate for Payer: Medicare All Medicare	$1,464.40
Rate for Payer: Monida Allegiance	$1,987.40
Rate for Payer: Monida First Choice Health	$2,029.24
Rate for Payer: Monida Montana Health Co-op	$1,987.40
Rate for Payer: Monida PacificSource	$1,987.40

CTA NECK

Facility

$2,297.00

Service Code	CPT 70498
Hospital Charge Code	5200055
Hospital Revenue Code	350
Min. Negotiated Rate	$1,607.90
Max. Negotiated Rate	$2,297.00
Rate for Payer: Aetna Commercial	$2,182.15
Rate for Payer: Aetna Medicare	$2,067.30
Rate for Payer: BCBS MT CHIP	$2,067.30
Rate for Payer: BCBS MT Closed Plan Network	$2,182.15
Rate for Payer: BCBS MT HealthLink	$2,067.30
Rate for Payer: BCBS MT Medicare	$2,067.30
Rate for Payer: BCBS MT POS	$2,182.15
Rate for Payer: BCBS MT Traditional	$2,297.00
Rate for Payer: Cash Price	$2,067.30
Rate for Payer: Cigna Commercial	$2,182.15
Rate for Payer: Cigna Medicare	$2,067.30
Rate for Payer: Medicaid All Medicaid	$2,113.24
Rate for Payer: Medicare All Medicare	$1,607.90
Rate for Payer: Monida Allegiance	$2,182.15
Rate for Payer: Monida First Choice Health	$2,228.09
Rate for Payer: Monida Montana Health Co-op	$2,182.15
Rate for Payer: Monida PacificSource	$2,182.15

CTA NECK

Facility

$2,297.00

Service Code	CPT 70498
Hospital Charge Code	5200055
Hospital Revenue Code	350
Min. Negotiated Rate	$1,607.90
Max. Negotiated Rate	$2,297.00
Rate for Payer: Aetna Commercial	$2,182.15
Rate for Payer: Aetna Medicare	$2,067.30
Rate for Payer: BCBS MT CHIP	$2,067.30
Rate for Payer: BCBS MT Closed Plan Network	$2,182.15
Rate for Payer: BCBS MT HealthLink	$2,067.30
Rate for Payer: BCBS MT Medicare	$2,067.30
Rate for Payer: BCBS MT POS	$2,182.15
Rate for Payer: BCBS MT Traditional	$2,297.00
Rate for Payer: Cash Price	$2,067.30
Rate for Payer: Cigna Commercial	$2,182.15
Rate for Payer: Cigna Medicare	$2,067.30
Rate for Payer: Medicaid All Medicaid	$2,113.24
Rate for Payer: Medicare All Medicare	$1,607.90
Rate for Payer: Monida Allegiance	$2,182.15
Rate for Payer: Monida First Choice Health	$2,228.09
Rate for Payer: Monida Montana Health Co-op	$2,182.15
Rate for Payer: Monida PacificSource	$2,182.15

CTA ORBIT EAR FOSSA W CONTRAST

Facility

$1,878.00

Service Code	CPT 70481
Hospital Charge Code	5200063
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

CTA ORBIT EAR FOSSA W CONTRAST

Facility

$1,878.00

Service Code	CPT 70481
Hospital Charge Code	5200063
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

CTA PELVIS

Facility

$2,031.00

Service Code	CPT 72191
Hospital Charge Code	5200057
Hospital Revenue Code	350
Min. Negotiated Rate	$1,421.70
Max. Negotiated Rate	$2,031.00
Rate for Payer: Aetna Commercial	$1,929.45
Rate for Payer: Aetna Medicare	$1,827.90
Rate for Payer: BCBS MT CHIP	$1,827.90
Rate for Payer: BCBS MT Closed Plan Network	$1,929.45
Rate for Payer: BCBS MT HealthLink	$1,827.90
Rate for Payer: BCBS MT Medicare	$1,827.90
Rate for Payer: BCBS MT POS	$1,929.45
Rate for Payer: BCBS MT Traditional	$2,031.00
Rate for Payer: Cash Price	$1,827.90
Rate for Payer: Cigna Commercial	$1,929.45
Rate for Payer: Cigna Medicare	$1,827.90
Rate for Payer: Medicaid All Medicaid	$1,868.52
Rate for Payer: Medicare All Medicare	$1,421.70
Rate for Payer: Monida Allegiance	$1,929.45
Rate for Payer: Monida First Choice Health	$1,970.07
Rate for Payer: Monida Montana Health Co-op	$1,929.45
Rate for Payer: Monida PacificSource	$1,929.45

CTA PELVIS

Facility

$2,031.00

Service Code	CPT 72191
Hospital Charge Code	5200057
Hospital Revenue Code	350
Min. Negotiated Rate	$1,421.70
Max. Negotiated Rate	$2,031.00
Rate for Payer: Aetna Commercial	$1,929.45
Rate for Payer: Aetna Medicare	$1,827.90
Rate for Payer: BCBS MT CHIP	$1,827.90
Rate for Payer: BCBS MT Closed Plan Network	$1,929.45
Rate for Payer: BCBS MT HealthLink	$1,827.90
Rate for Payer: BCBS MT Medicare	$1,827.90
Rate for Payer: BCBS MT POS	$1,929.45
Rate for Payer: BCBS MT Traditional	$2,031.00
Rate for Payer: Cash Price	$1,827.90
Rate for Payer: Cigna Commercial	$1,929.45
Rate for Payer: Cigna Medicare	$1,827.90
Rate for Payer: Medicaid All Medicaid	$1,868.52
Rate for Payer: Medicare All Medicare	$1,421.70
Rate for Payer: Monida Allegiance	$1,929.45
Rate for Payer: Monida First Choice Health	$1,970.07
Rate for Payer: Monida Montana Health Co-op	$1,929.45
Rate for Payer: Monida PacificSource	$1,929.45

CTA UPPER EXTREMITY LT W CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200082
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY LT W CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200082
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY LT W/WO CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200128
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY LT W/WO CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200128
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY RT W CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200081
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY RT W CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200081
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY RT W/WO CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200069
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CTA UPPER EXTREMITY RT W/WO CONTRAST

Facility

$2,025.00

Service Code	CPT 73206
Hospital Charge Code	5200069
Hospital Revenue Code	350
Min. Negotiated Rate	$1,417.50
Max. Negotiated Rate	$2,025.00
Rate for Payer: Aetna Commercial	$1,923.75
Rate for Payer: Aetna Medicare	$1,822.50
Rate for Payer: BCBS MT CHIP	$1,822.50
Rate for Payer: BCBS MT Closed Plan Network	$1,923.75
Rate for Payer: BCBS MT HealthLink	$1,822.50
Rate for Payer: BCBS MT Medicare	$1,822.50
Rate for Payer: BCBS MT POS	$1,923.75
Rate for Payer: BCBS MT Traditional	$2,025.00
Rate for Payer: Cash Price	$1,822.50
Rate for Payer: Cigna Commercial	$1,923.75
Rate for Payer: Cigna Medicare	$1,822.50
Rate for Payer: Medicaid All Medicaid	$1,863.00
Rate for Payer: Medicare All Medicare	$1,417.50
Rate for Payer: Monida Allegiance	$1,923.75
Rate for Payer: Monida First Choice Health	$1,964.25
Rate for Payer: Monida Montana Health Co-op	$1,923.75
Rate for Payer: Monida PacificSource	$1,923.75

CT BONE DENSITY

Facility

$371.00

Service Code	CPT 77078
Hospital Charge Code	5200012
Hospital Revenue Code	350
Min. Negotiated Rate	$259.70
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$352.45
Rate for Payer: Aetna Medicare	$333.90
Rate for Payer: BCBS MT CHIP	$333.90
Rate for Payer: BCBS MT Closed Plan Network	$352.45
Rate for Payer: BCBS MT HealthLink	$333.90
Rate for Payer: BCBS MT Medicare	$333.90
Rate for Payer: BCBS MT POS	$352.45
Rate for Payer: BCBS MT Traditional	$371.00
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cigna Commercial	$352.45
Rate for Payer: Cigna Medicare	$333.90
Rate for Payer: Medicaid All Medicaid	$341.32
Rate for Payer: Medicare All Medicare	$259.70
Rate for Payer: Monida Allegiance	$352.45
Rate for Payer: Monida First Choice Health	$359.87
Rate for Payer: Monida Montana Health Co-op	$352.45
Rate for Payer: Monida PacificSource	$352.45

CT BONE DENSITY

Facility

$371.00

Service Code	CPT 77078
Hospital Charge Code	5200012
Hospital Revenue Code	350
Min. Negotiated Rate	$259.70
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$352.45
Rate for Payer: Aetna Medicare	$333.90
Rate for Payer: BCBS MT CHIP	$333.90
Rate for Payer: BCBS MT Closed Plan Network	$352.45
Rate for Payer: BCBS MT HealthLink	$333.90
Rate for Payer: BCBS MT Medicare	$333.90
Rate for Payer: BCBS MT POS	$352.45
Rate for Payer: BCBS MT Traditional	$371.00
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cigna Commercial	$352.45
Rate for Payer: Cigna Medicare	$333.90
Rate for Payer: Medicaid All Medicaid	$341.32
Rate for Payer: Medicare All Medicare	$259.70
Rate for Payer: Monida Allegiance	$352.45
Rate for Payer: Monida First Choice Health	$359.87
Rate for Payer: Monida Montana Health Co-op	$352.45
Rate for Payer: Monida PacificSource	$352.45

CT BONE LENGTH STUDY SCANOGRAM

Facility

$654.00

Service Code	CPT 77073
Hospital Charge Code	5277173
Hospital Revenue Code	350
Min. Negotiated Rate	$457.80
Max. Negotiated Rate	$654.00
Rate for Payer: Aetna Commercial	$621.30
Rate for Payer: Aetna Medicare	$588.60
Rate for Payer: BCBS MT CHIP	$588.60
Rate for Payer: BCBS MT Closed Plan Network	$621.30
Rate for Payer: BCBS MT HealthLink	$588.60
Rate for Payer: BCBS MT Medicare	$588.60
Rate for Payer: BCBS MT POS	$621.30
Rate for Payer: BCBS MT Traditional	$654.00
Rate for Payer: Cash Price	$588.60
Rate for Payer: Cigna Commercial	$621.30
Rate for Payer: Cigna Medicare	$588.60
Rate for Payer: Medicaid All Medicaid	$601.68
Rate for Payer: Medicare All Medicare	$457.80
Rate for Payer: Monida Allegiance	$621.30
Rate for Payer: Monida First Choice Health	$634.38
Rate for Payer: Monida Montana Health Co-op	$621.30
Rate for Payer: Monida PacificSource	$621.30

CT BONE LENGTH STUDY SCANOGRAM

Facility

$654.00

Service Code	CPT 77073
Hospital Charge Code	5277173
Hospital Revenue Code	350
Min. Negotiated Rate	$457.80
Max. Negotiated Rate	$654.00
Rate for Payer: Aetna Commercial	$621.30
Rate for Payer: Aetna Medicare	$588.60
Rate for Payer: BCBS MT CHIP	$588.60
Rate for Payer: BCBS MT Closed Plan Network	$621.30
Rate for Payer: BCBS MT HealthLink	$588.60
Rate for Payer: BCBS MT Medicare	$588.60
Rate for Payer: BCBS MT POS	$621.30
Rate for Payer: BCBS MT Traditional	$654.00
Rate for Payer: Cash Price	$588.60
Rate for Payer: Cigna Commercial	$621.30
Rate for Payer: Cigna Medicare	$588.60
Rate for Payer: Medicaid All Medicaid	$601.68
Rate for Payer: Medicare All Medicare	$457.80
Rate for Payer: Monida Allegiance	$621.30
Rate for Payer: Monida First Choice Health	$634.38
Rate for Payer: Monida Montana Health Co-op	$621.30
Rate for Payer: Monida PacificSource	$621.30

CT CERVICAL SPINE W CONTRAST

Facility

$2,141.00

Service Code	CPT 72126
Hospital Charge Code	5200021
Hospital Revenue Code	350
Min. Negotiated Rate	$1,498.70
Max. Negotiated Rate	$2,141.00
Rate for Payer: Aetna Commercial	$2,033.95
Rate for Payer: Aetna Medicare	$1,926.90
Rate for Payer: BCBS MT CHIP	$1,926.90
Rate for Payer: BCBS MT Closed Plan Network	$2,033.95
Rate for Payer: BCBS MT HealthLink	$1,926.90
Rate for Payer: BCBS MT Medicare	$1,926.90
Rate for Payer: BCBS MT POS	$2,033.95
Rate for Payer: BCBS MT Traditional	$2,141.00
Rate for Payer: Cash Price	$1,926.90
Rate for Payer: Cigna Commercial	$2,033.95
Rate for Payer: Cigna Medicare	$1,926.90
Rate for Payer: Medicaid All Medicaid	$1,969.72
Rate for Payer: Medicare All Medicare	$1,498.70
Rate for Payer: Monida Allegiance	$2,033.95
Rate for Payer: Monida First Choice Health	$2,076.77
Rate for Payer: Monida Montana Health Co-op	$2,033.95
Rate for Payer: Monida PacificSource	$2,033.95

Know your out-of-pocket cost for care.

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