Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR ABDOMEN 2 VIEWS

Facility

$281.00

Service Code	HCPCS 74019 TC
Hospital Charge Code	5074019
Hospital Revenue Code	320
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$281.00
Rate for Payer: Aetna Commercial	$266.95
Rate for Payer: Aetna Medicare	$252.90
Rate for Payer: BCBS MT CHIP	$252.90
Rate for Payer: BCBS MT Closed Plan Network	$266.95
Rate for Payer: BCBS MT HealthLink	$252.90
Rate for Payer: BCBS MT Medicare	$252.90
Rate for Payer: BCBS MT POS	$266.95
Rate for Payer: BCBS MT Traditional	$281.00
Rate for Payer: Cash Price	$252.90
Rate for Payer: Cigna Commercial	$266.95
Rate for Payer: Cigna Medicare	$252.90
Rate for Payer: Medicaid All Medicaid	$258.52
Rate for Payer: Medicare All Medicare	$196.70
Rate for Payer: Monida Allegiance	$266.95
Rate for Payer: Monida First Choice Health	$272.57
Rate for Payer: Monida Montana Health Co-op	$266.95
Rate for Payer: Monida PacificSource	$266.95

XR ABDOMEN ACUTE

Facility

$442.00

Service Code	HCPCS 74022 TC
Hospital Charge Code	5000129
Hospital Revenue Code	320
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

XR ABDOMEN ACUTE

Facility

$442.00

Service Code	HCPCS 74022 TC
Hospital Charge Code	5000129
Hospital Revenue Code	320
Min. Negotiated Rate	$309.40
Max. Negotiated Rate	$442.00
Rate for Payer: Aetna Commercial	$419.90
Rate for Payer: Aetna Medicare	$397.80
Rate for Payer: BCBS MT CHIP	$397.80
Rate for Payer: BCBS MT Closed Plan Network	$419.90
Rate for Payer: BCBS MT HealthLink	$397.80
Rate for Payer: BCBS MT Medicare	$397.80
Rate for Payer: BCBS MT POS	$419.90
Rate for Payer: BCBS MT Traditional	$442.00
Rate for Payer: Cash Price	$397.80
Rate for Payer: Cigna Commercial	$419.90
Rate for Payer: Cigna Medicare	$397.80
Rate for Payer: Medicaid All Medicaid	$406.64
Rate for Payer: Medicare All Medicare	$309.40
Rate for Payer: Monida Allegiance	$419.90
Rate for Payer: Monida First Choice Health	$428.74
Rate for Payer: Monida Montana Health Co-op	$419.90
Rate for Payer: Monida PacificSource	$419.90

XR AC JOINTS W WO WEIGHTS

Facility

$268.00

Service Code	HCPCS 73050 TC
Hospital Charge Code	5000131
Hospital Revenue Code	320
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

XR AC JOINTS W WO WEIGHTS

Facility

$268.00

Service Code	HCPCS 73050 TC
Hospital Charge Code	5000131
Hospital Revenue Code	320
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

XR ANKLE 2 VIEWS BILATERAL

Facility

$234.00

Service Code	HCPCS 73600 TC
Hospital Charge Code	5000134
Hospital Revenue Code	320
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: BCBS MT CHIP	$210.60
Rate for Payer: BCBS MT Closed Plan Network	$222.30
Rate for Payer: BCBS MT HealthLink	$210.60
Rate for Payer: BCBS MT Medicare	$210.60
Rate for Payer: BCBS MT POS	$222.30
Rate for Payer: BCBS MT Traditional	$234.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna Commercial	$222.30
Rate for Payer: Cigna Medicare	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

XR ANKLE 2 VIEWS BILATERAL

Facility

$234.00

Service Code	HCPCS 73600 TC
Hospital Charge Code	5000134
Hospital Revenue Code	320
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: BCBS MT CHIP	$210.60
Rate for Payer: BCBS MT Closed Plan Network	$222.30
Rate for Payer: BCBS MT HealthLink	$210.60
Rate for Payer: BCBS MT Medicare	$210.60
Rate for Payer: BCBS MT POS	$222.30
Rate for Payer: BCBS MT Traditional	$234.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna Commercial	$222.30
Rate for Payer: Cigna Medicare	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

XR ANKLE 3 VIEWS BILATERAL

Facility

$276.00

Service Code	HCPCS 73610 TC
Hospital Charge Code	5000133
Hospital Revenue Code	320
Min. Negotiated Rate	$193.20
Max. Negotiated Rate	$276.00
Rate for Payer: Aetna Commercial	$262.20
Rate for Payer: Aetna Medicare	$248.40
Rate for Payer: BCBS MT CHIP	$248.40
Rate for Payer: BCBS MT Closed Plan Network	$262.20
Rate for Payer: BCBS MT HealthLink	$248.40
Rate for Payer: BCBS MT Medicare	$248.40
Rate for Payer: BCBS MT POS	$262.20
Rate for Payer: BCBS MT Traditional	$276.00
Rate for Payer: Cash Price	$248.40
Rate for Payer: Cigna Commercial	$262.20
Rate for Payer: Cigna Medicare	$248.40
Rate for Payer: Medicaid All Medicaid	$253.92
Rate for Payer: Medicare All Medicare	$193.20
Rate for Payer: Monida Allegiance	$262.20
Rate for Payer: Monida First Choice Health	$267.72
Rate for Payer: Monida Montana Health Co-op	$262.20
Rate for Payer: Monida PacificSource	$262.20

XR ANKLE 3 VIEWS BILATERAL

Facility

$276.00

Service Code	HCPCS 73610 TC
Hospital Charge Code	5000133
Hospital Revenue Code	320
Min. Negotiated Rate	$193.20
Max. Negotiated Rate	$276.00
Rate for Payer: Aetna Commercial	$262.20
Rate for Payer: Aetna Medicare	$248.40
Rate for Payer: BCBS MT CHIP	$248.40
Rate for Payer: BCBS MT Closed Plan Network	$262.20
Rate for Payer: BCBS MT HealthLink	$248.40
Rate for Payer: BCBS MT Medicare	$248.40
Rate for Payer: BCBS MT POS	$262.20
Rate for Payer: BCBS MT Traditional	$276.00
Rate for Payer: Cash Price	$248.40
Rate for Payer: Cigna Commercial	$262.20
Rate for Payer: Cigna Medicare	$248.40
Rate for Payer: Medicaid All Medicaid	$253.92
Rate for Payer: Medicare All Medicare	$193.20
Rate for Payer: Monida Allegiance	$262.20
Rate for Payer: Monida First Choice Health	$267.72
Rate for Payer: Monida Montana Health Co-op	$262.20
Rate for Payer: Monida PacificSource	$262.20

XR ANKLE LT 1 VIEW

Facility

$246.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000132
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE LT 1 VIEW

Facility

$246.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000132
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE LT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000135
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE LT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000135
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE LT 3 VIEWS

Facility

$290.00

Service Code	HCPCS 73610 TC,LT
Hospital Charge Code	5000136
Hospital Revenue Code	320
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

XR ANKLE LT 3 VIEWS

Facility

$290.00

Service Code	HCPCS 73610 TC,LT
Hospital Charge Code	5000136
Hospital Revenue Code	320
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

XR ANKLE RT 1 VIEW

Facility

$246.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000139
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE RT 1 VIEW

Facility

$246.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000139
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE RT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000137
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE RT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000137
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR ANKLE RT 3 VIEWS

Facility

$290.00

Service Code	HCPCS 73610 TC,RT
Hospital Charge Code	5000138
Hospital Revenue Code	320
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

XR ANKLE RT 3 VIEWS

Facility

$290.00

Service Code	HCPCS 73610 TC,RT
Hospital Charge Code	5000138
Hospital Revenue Code	320
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

XR BALL CATCHERS

Facility

$246.00

Service Code	HCPCS 73120
Hospital Charge Code	5000006
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR BALL CATCHERS

Facility

$246.00

Service Code	HCPCS 73120
Hospital Charge Code	5000006
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR BONE AGE STUDY

Facility

$328.00

Service Code	HCPCS 77072 TC
Hospital Charge Code	5000140
Hospital Revenue Code	320
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

XR BONE AGE STUDY

Facility

$328.00

Service Code	HCPCS 77072 TC
Hospital Charge Code	5000140
Hospital Revenue Code	320
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

Know your out-of-pocket cost for care.

All Charges