▸ Hospital · SD · CCN 431323
Monument Health Custer Hospital
1220 MONTGOMERY STREET, CUSTER, SD, 57730-
12 bedsCritical Access Hospitals2
Compliance grade
A
100/100
Procedures tracked
83
of 209 target codes
Payers
30
with negotiated rates
Rates published
43,955
last crawl 2026-05-24
Procedures & rates
| Procedure | Type | Code | Payers | Gross | Cash | Neg min | Neg median | Neg max |
|---|---|---|---|---|---|---|---|---|
| behavioral | ||||||||
| Psychiatric diagnostic evaluation | CPT | 90791 | 3 | $529 | $529 | $148.12 | $151.82 | $151.82 |
| Psychotherapy 30 minutes | CPT | 90832 | 3 | $229 | $229 | $64.12 | $65.72 | $65.72 |
| Psychotherapy 45 minutes | CPT | 90834 | 3 | $302 | $302 | $84.56 | $86.67 | $86.67 |
| Psychotherapy 60 minutes | CPT | 90837 | 3 | $445 | $445 | $124.6 | $127.72 | $127.72 |
| emergency | ||||||||
| ED visit level 1 | CPT | 99281 | 35 | $319 | $319 | $48.61 | $312.62 | $319 |
| ED visit level 2 | CPT | 99282 | 35 | $509 | $509 | $78.4 | $498.82 | $509 |
| ED visit level 3 | CPT | 99283 | 35 | $817 | $817 | $85.12 | $792.49 | $817 |
| ED visit level 4 | CPT | 99284 | 35 | $1,327 | $1,327 | $127.12 | $1,287.19 | $1,327 |
| ED visit level 5 | CPT | 99285 | 35 | $1,892 | $1,892 | $190.68 | $1,835.24 | $1,892 |
| Critical care, first hour | CPT | 99291 | 35 | $2,868 | $2,868 | $329.28 | $2,810.64 | $2,868 |
| imaging | ||||||||
| CT head without contrast | CPT | 70450 | 35 | $2,163 | $2,163 | $405.54 | $2,119.74 | $2,163 |
| CT head with and without contrast | CPT | 70470 | 35 | $3,266 | $3,266 | $590.56 | $3,200.68 | $3,266 |
| CT neck with contrast | CPT | 70491 | 35 | $2,931 | $2,931 | $502.72 | $2,872.38 | $2,931 |
| MRI brain without contrast | CPT | 70551 | 35 | $3,740 | $3,740 | $1,027.87 | $3,665.2 | $3,740 |
| MRI brain with and without contrast | CPT | 70553 | 35 | $5,035 | $5,035 | $1,308.2 | $4,934.3 | $5,035 |
| Chest X-ray single view | CPT | 71045 | 35 | $407 | $407 | $44.85 | $398.86 | $407 |
| Chest X-ray 2 views | CPT | 71046 | 35 | $428 | $428 | $59.8 | $419.44 | $428 |
| CT chest without contrast | CPT | 71250 | 35 | $2,319 | $2,319 | $493.38 | $2,272.62 | $2,319 |
| CT chest with contrast | CPT | 71260 | 35 | $3,110 | $3,110 | $568.13 | $3,047.8 | $3,110 |
| Lumbosacral spine X-ray | CPT | 72100 | 35 | $452 | $452 | $61.67 | $442.96 | $452 |
| CT cervical spine without contrast | CPT | 72125 | 35 | $2,319 | $2,319 | $485.9 | $2,272.62 | $2,319 |
| CT thoracic spine without contrast | CPT | 72128 | 35 | $2,319 | $2,319 | $485.9 | $2,272.62 | $2,319 |
| CT lumbar spine without contrast | CPT | 72131 | 35 | $2,268 | $2,268 | $485.9 | $2,222.64 | $2,268 |
| MRI cervical spine without contrast | CPT | 72141 | 35 | $3,808 | $3,808 | $1,027.87 | $3,731.84 | $3,808 |
| MRI thoracic spine without contrast | CPT | 72146 | 35 | $3,808 | $3,808 | $1,027.87 | $3,731.84 | $3,808 |
| MRI lumbar spine without contrast | CPT | 72148 | 35 | $3,808 | $3,808 | $1,027.87 | $3,731.84 | $3,808 |
| MRI cervical spine with and without contrast | CPT | 72156 | 35 | $5,002 | $5,002 | $1,308.2 | $4,901.96 | $5,002 |
| MRI lumbar spine with contrast | CPT | 72158 | 35 | $5,138 | $5,138 | $1,308.2 | $5,035.24 | $5,138 |
| CT pelvis without contrast | CPT | 72192 | 35 | $2,099 | $2,099 | $476.56 | $2,057.02 | $2,099 |
| CT pelvis with contrast | CPT | 72193 | 35 | $2,573 | $2,573 | $532.63 | $2,521.54 | $2,573 |
| Shoulder X-ray | CPT | 73030 | 35 | $398 | $398 | $11.2 | $386.06 | $398 |
| Humerus X-ray | CPT | 73060 | 35 | $341 | $341 | $52.33 | $334.18 | $341 |
| Hand X-ray 3 views | CPT | 73130 | 35 | $349 | $349 | $52.33 | $342.02 | $349 |
| MRI upper extremity joint without contrast | CPT | 73221 | 35 | $4,183 | $4,183 | $1,027.87 | $4,099.34 | $4,183 |
| MRI upper extremity joint with and without contrast | CPT | 73223 | 35 | $4,978 | $4,978 | $1,308.2 | $4,878.44 | $4,978 |
| Knee X-ray 1-2 views | CPT | 73560 | 35 | $314 | $314 | $46.72 | $307.72 | $314 |
| Ankle X-ray 3 views | CPT | 73610 | 35 | $325 | $325 | $52.33 | $318.5 | $325 |
| MRI lower extremity joint without contrast | CPT | 73721 | 35 | $3,692 | $3,692 | $1,027.87 | $3,618.16 | $3,692 |
| CT abdomen without contrast | CPT | 74150 | 35 | $2,257 | $2,257 | $467.22 | $2,211.86 | $2,257 |
| CT abdomen with contrast | CPT | 74160 | 35 | $3,545 | $3,545 | $556.92 | $3,474.1 | $3,545 |
| CT abdomen with and without contrast | CPT | 74170 | 35 | $3,976 | $3,976 | $672.79 | $3,896.48 | $3,976 |
| CT abdomen and pelvis without contrast | CPT | 74176 | 35 | $4,158 | $4,158 | $388.72 | $4,074.84 | $4,158 |
| CT abdomen and pelvis with contrast | CPT | 74177 | 35 | $5,471 | $5,471 | $609.25 | $5,361.58 | $5,471 |
| CT abdomen and pelvis with and without contrast | CPT | 74178 | 35 | $5,294 | $5,294 | $771.84 | $5,188.12 | $5,294 |
| MRI abdomen without contrast | CPT | 74181 | 35 | $4,171 | $4,171 | $1,027.87 | $4,087.58 | $4,171 |
| MRI abdomen with and without contrast | CPT | 74183 | 35 | $5,073 | $5,073 | $1,308.2 | $4,971.54 | $5,073 |
| Abdominal ultrasound complete | CPT | 76700 | 35 | $1,344 | $1,344 | $192.49 | $1,317.12 | $1,344 |
| Abdominal ultrasound limited | CPT | 76705 | 35 | $1,025 | $1,025 | $143.9 | $1,004.5 | $1,025 |
| Retroperitoneal ultrasound complete | CPT | 76770 | 35 | $1,025 | $1,025 | $186.89 | $1,004.5 | $1,025 |
| Obstetric ultrasound first trimester | CPT | 76801 | 35 | $577 | $577 | $149.51 | $565.46 | $577 |
| Obstetric ultrasound after first trimester | CPT | 76805 | 35 | $569 | $569 | $159.32 | $557.62 | $569 |
| Transvaginal ultrasound | CPT | 76830 | 35 | $675 | $675 | $186.89 | $661.5 | $675 |
| Pelvic ultrasound complete | CPT | 76856 | 35 | $1,199 | $1,199 | $168.2 | $1,175.02 | $1,199 |
| Scrotal ultrasound | CPT | 76870 | 35 | $1,147 | $1,147 | $149.51 | $1,124.06 | $1,147 |
| Screening mammography bilateral | CPT | 77067 | 35 | $564 | $564 | $124.73 | $552.72 | $564 |
| EKG complete | CPT | 93000 | 3 | $51 | $51 | $13.72 | $14.17 | $14.64 |
| EKG tracing only | CPT | 93005 | 35 | $281 | $281 | $25.75 | $275.38 | $281 |
| EKG interpretation only | CPT | 93010 | 3 | $25 | $25 | $7 | $7.18 | $7.18 |
| Transthoracic echocardiogram complete | CPT | 93306 | 35 | $2,796 | $2,796 | $470.02 | $2,740.08 | $2,796 |
| lab | ||||||||
| Basic metabolic panel (BMP) | CPT | 80048 | 35 | $172 | $172 | $13.54 | $166.84 | $172 |
| General health panel | CPT | 80050 | 35 | $293 | $293 | $61.72 | $284.21 | $293 |
| Electrolyte panel | CPT | 80051 | 35 | $120 | $120 | $11.37 | $116.4 | $120 |
| Comprehensive metabolic panel | CPT | 80053 | 35 | $192 | $192 | $16.78 | $186.24 | $192 |
| Lipid panel | CPT | 80061 | 35 | $129 | $129 | $21.66 | $125.13 | $129 |
| Renal function panel | CPT | 80069 | 35 | $167 | $167 | $14.08 | $161.99 | $167 |
| Hepatic function panel | CPT | 80076 | 35 | $167 | $167 | $12.99 | $161.99 | $167 |
| Urinalysis automated | CPT | 81003 | 35 | $47 | $47 | $3.79 | $45.59 | $47 |
| Glucose quantitative | CPT | 82947 | 35 | $71 | $71 | $6.5 | $68.87 | $71 |
| Hemoglobin A1c | CPT | 83036 | 35 | $88 | $88 | $11.48 | $40.59 | $88 |
| Thyroid stimulating hormone (TSH) | CPT | 84443 | 35 | $192 | $192 | $7.56 | $104 | $192 |
| Complete blood count with automated differential | CPT | 85025 | 35 | $129 | $129 | $12.45 | $125.13 | $129 |
| Complete blood count without differential | CPT | 85027 | 35 | $102 | $102 | $10.29 | $98.94 | $102 |
| Urine culture identification | CPT | 87088 | 35 | $77 | $77 | $12.99 | $74.69 | $77 |
| Tissue exam by pathologist level IV | CPT | 88305 | 35 | $323 | $323 | $63.28 | $222.72 | $323 |
| office | ||||||||
| Office visit, new patient, 15-29 min | CPT | 99202 | 3 | $216 | $216 | $60.48 | $61.99 | $61.99 |
| Office visit, new patient, 30-44 minutes | CPT | 99203 | 3 | $330 | $330 | $92.4 | $94.71 | $94.71 |
| Office visit, new patient, 45-59 min | CPT | 99204 | 3 | $492 | $492 | $137.76 | $141.2 | $141.2 |
| Office visit, new patient, 60-74 min | CPT | 99205 | 3 | $651 | $651 | $182.28 | $186.84 | $186.84 |
| Office visit, established patient, 5 min | CPT | 99211 | 3 | $70 | $70 | $19.6 | $20.09 | $20.09 |
| Office visit, established patient, 10-19 min | CPT | 99212 | 3 | $168 | $168 | $47.04 | $48.22 | $48.22 |
| Office visit, established patient, 20-29 minutes | CPT | 99213 | 3 | $269 | $269 | $75.32 | $77.2 | $77.2 |
| Office visit, established patient, 30-39 minutes | CPT | 99214 | 3 | $381 | $381 | $106.68 | $109.35 | $109.35 |
| Office visit, established patient, 40-54 min | CPT | 99215 | 3 | $535 | $535 | $149.8 | $153.55 | $153.55 |
Payer mix (top 30)
| Payer | Codes covered | Median rate |
|---|---|---|
| Blue Cross Blue Shield | 83 | $385.73 |
| UnitedHealthcare | 83 | $661.5 |
| Medicare | 83 | $145.32 |
| Cigna | 68 | $1,014.75 |
| coresource 38225 [3081146] | 68 | $922.5 |
| employee benefit management 12x44 [3081079] | 68 | $922.5 |
| fedmed inc [3081283] | 68 | $994.25 |
| govt employees health assn [3081090] | 68 | $1,004.5 |
| group and pension administrators inc [3081098] | 68 | $994.25 |
| Health Net | 68 | $287 |
| health partners sx009 [3081102] | 68 | $1,004.5 |
| healthpartners [3081368] | 68 | $1,004.5 |
| Humana | 68 | $1,025 |
| key benefit administrators [3081332] | 68 | $1,014.75 |
| medica (commercial) 94265 [3081118] | 68 | $1,004.5 |
| Meritain Health | 68 | $1,014.75 |
| midlands choice 47080 [3081136] | 68 | $1,014.75 |
| Multiplan | 68 | $994.25 |
| national telephone cooperative assn 52103 [3081149] | 68 | $1,004.5 |
| pacificsource health plans [3081333] | 68 | $922.5 |
| preferred one 41147 [3081160] | 68 | $1,014.75 |
| risk admin svs [3081167] | 68 | $407.2 |
| rocky mountain admin llc 83028 [3081168] | 68 | $922.5 |
| sanford health plan 91184 [3081174] | 68 | $994.25 |
| surest [3081369] | 68 | $1,004.5 |
| tlc advantage llc [3081189] | 68 | $963.5 |
| TRICARE | 68 | $415.03 |
| triwest healthcare alliance [3081322] | 68 | $287 |
| va black hills health care system 12115 [3081206] | 68 | $287 |
| va black hills health care system 12115 [3081207] | 68 | $287 |