Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CT PELVIS W WO CONTRAST

Facility

$2,222.00

Service Code	CPT 72194
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	CPT 70491
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	CPT 70491
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	CPT 70490
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	CPT 70490
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 W WO CONTRAST

Facility

$2,064.00

Service Code	CPT 70492
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	CPT 70492
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	CPT 70486
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	CPT 70486
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 TEMPORAL BONES W CONTRAST

Facility

$2,113.00

Service Code	CPT 70481
Hospital Charge Code	5200079
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 TEMPORAL BONES W CONTRAST

Facility

$2,113.00

Service Code	CPT 70481
Hospital Charge Code	5200079
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 TEMPORAL BONES WO CONTRAST

Facility

$1,512.00

Service Code	CPT 70480
Hospital Charge Code	5200070
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 TEMPORAL BONES WO CONTRAST

Facility

$1,512.00

Service Code	CPT 70480
Hospital Charge Code	5200070
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 THORACIC SPINE W CONTRAST

Facility

$2,003.00

Service Code	CPT 72129
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	CPT 72129
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	CPT 72128
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	CPT 72128
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	CPT 72130
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	CPT 72130
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	CPT 73201
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	CPT 73201
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	CPT 73200
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	CPT 73200
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	CPT 73202
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	CPT 73202
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

Know your out-of-pocket cost for care.

All Charges