Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR BONE LENGTH STUDY

Facility

$293.00

Service Code	HCPCS 77073 TC
Hospital Charge Code	5077073
Hospital Revenue Code	350
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$293.00
Rate for Payer: Aetna Commercial	$278.35
Rate for Payer: Aetna Medicare	$263.70
Rate for Payer: BCBS MT CHIP	$263.70
Rate for Payer: BCBS MT Closed Plan Network	$278.35
Rate for Payer: BCBS MT HealthLink	$263.70
Rate for Payer: BCBS MT Medicare	$263.70
Rate for Payer: BCBS MT POS	$278.35
Rate for Payer: BCBS MT Traditional	$293.00
Rate for Payer: Cash Price	$263.70
Rate for Payer: Cigna Commercial	$278.35
Rate for Payer: Cigna Medicare	$263.70
Rate for Payer: Medicaid All Medicaid	$269.56
Rate for Payer: Medicare All Medicare	$205.10
Rate for Payer: Monida Allegiance	$278.35
Rate for Payer: Monida First Choice Health	$284.21
Rate for Payer: Monida Montana Health Co-op	$278.35
Rate for Payer: Monida PacificSource	$278.35

XR BONE LENGTH STUDY

Facility

$293.00

Service Code	HCPCS 77073 TC
Hospital Charge Code	5077073
Hospital Revenue Code	350
Min. Negotiated Rate	$205.10
Max. Negotiated Rate	$293.00
Rate for Payer: Aetna Commercial	$278.35
Rate for Payer: Aetna Medicare	$263.70
Rate for Payer: BCBS MT CHIP	$263.70
Rate for Payer: BCBS MT Closed Plan Network	$278.35
Rate for Payer: BCBS MT HealthLink	$263.70
Rate for Payer: BCBS MT Medicare	$263.70
Rate for Payer: BCBS MT POS	$278.35
Rate for Payer: BCBS MT Traditional	$293.00
Rate for Payer: Cash Price	$263.70
Rate for Payer: Cigna Commercial	$278.35
Rate for Payer: Cigna Medicare	$263.70
Rate for Payer: Medicaid All Medicaid	$269.56
Rate for Payer: Medicare All Medicare	$205.10
Rate for Payer: Monida Allegiance	$278.35
Rate for Payer: Monida First Choice Health	$284.21
Rate for Payer: Monida Montana Health Co-op	$278.35
Rate for Payer: Monida PacificSource	$278.35

XR CALCANEUS BILATERAL 2 VIEWS

Facility

$229.00

Service Code	HCPCS 73650 TC
Hospital Charge Code	5000181
Hospital Revenue Code	320
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

XR CALCANEUS BILATERAL 2 VIEWS

Facility

$229.00

Service Code	HCPCS 73650 TC
Hospital Charge Code	5000181
Hospital Revenue Code	320
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

XR CALCANEUS LT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73650 TC,LT
Hospital Charge Code	5000179
Hospital Revenue Code	320
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

XR CALCANEUS LT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73650 TC,LT
Hospital Charge Code	5000179
Hospital Revenue Code	320
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

XR CALCANEUS RT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73650 TC,RT
Hospital Charge Code	5000180
Hospital Revenue Code	320
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

XR CALCANEUS RT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73650 TC,RT
Hospital Charge Code	5000180
Hospital Revenue Code	320
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$240.00
Rate for Payer: Aetna Commercial	$228.00
Rate for Payer: Aetna Medicare	$216.00
Rate for Payer: BCBS MT CHIP	$216.00
Rate for Payer: BCBS MT Closed Plan Network	$228.00
Rate for Payer: BCBS MT HealthLink	$216.00
Rate for Payer: BCBS MT Medicare	$216.00
Rate for Payer: BCBS MT POS	$228.00
Rate for Payer: BCBS MT Traditional	$240.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Cigna Commercial	$228.00
Rate for Payer: Cigna Medicare	$216.00
Rate for Payer: Medicaid All Medicaid	$220.80
Rate for Payer: Medicare All Medicare	$168.00
Rate for Payer: Monida Allegiance	$228.00
Rate for Payer: Monida First Choice Health	$232.80
Rate for Payer: Monida Montana Health Co-op	$228.00
Rate for Payer: Monida PacificSource	$228.00

XR CERVICAL SPINE 2 TO 3 VIEWS

Facility

$300.00

Service Code	HCPCS 72040 TC
Hospital Charge Code	5000149
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

XR CERVICAL SPINE 2 TO 3 VIEWS

Facility

$300.00

Service Code	HCPCS 72040 TC
Hospital Charge Code	5000149
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

XR CERVICAL SPINE COMPLETE

Facility

$437.00

Service Code	HCPCS 72050 TC
Hospital Charge Code	5000150
Hospital Revenue Code	320
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$437.00
Rate for Payer: Aetna Commercial	$415.15
Rate for Payer: Aetna Medicare	$393.30
Rate for Payer: BCBS MT CHIP	$393.30
Rate for Payer: BCBS MT Closed Plan Network	$415.15
Rate for Payer: BCBS MT HealthLink	$393.30
Rate for Payer: BCBS MT Medicare	$393.30
Rate for Payer: BCBS MT POS	$415.15
Rate for Payer: BCBS MT Traditional	$437.00
Rate for Payer: Cash Price	$393.30
Rate for Payer: Cigna Commercial	$415.15
Rate for Payer: Cigna Medicare	$393.30
Rate for Payer: Medicaid All Medicaid	$402.04
Rate for Payer: Medicare All Medicare	$305.90
Rate for Payer: Monida Allegiance	$415.15
Rate for Payer: Monida First Choice Health	$423.89
Rate for Payer: Monida Montana Health Co-op	$415.15
Rate for Payer: Monida PacificSource	$415.15

XR CERVICAL SPINE COMPLETE

Facility

$437.00

Service Code	HCPCS 72050 TC
Hospital Charge Code	5000150
Hospital Revenue Code	320
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$437.00
Rate for Payer: Aetna Commercial	$415.15
Rate for Payer: Aetna Medicare	$393.30
Rate for Payer: BCBS MT CHIP	$393.30
Rate for Payer: BCBS MT Closed Plan Network	$415.15
Rate for Payer: BCBS MT HealthLink	$393.30
Rate for Payer: BCBS MT Medicare	$393.30
Rate for Payer: BCBS MT POS	$415.15
Rate for Payer: BCBS MT Traditional	$437.00
Rate for Payer: Cash Price	$393.30
Rate for Payer: Cigna Commercial	$415.15
Rate for Payer: Cigna Medicare	$393.30
Rate for Payer: Medicaid All Medicaid	$402.04
Rate for Payer: Medicare All Medicare	$305.90
Rate for Payer: Monida Allegiance	$415.15
Rate for Payer: Monida First Choice Health	$423.89
Rate for Payer: Monida Montana Health Co-op	$415.15
Rate for Payer: Monida PacificSource	$415.15

XR CERVICAL SPINE COMPLETE W/ FLEX/EXT

Facility

$491.00

Service Code	HCPCS 72052 TC
Hospital Charge Code	5000151
Hospital Revenue Code	320
Min. Negotiated Rate	$343.70
Max. Negotiated Rate	$491.00
Rate for Payer: Aetna Commercial	$466.45
Rate for Payer: Aetna Medicare	$441.90
Rate for Payer: BCBS MT CHIP	$441.90
Rate for Payer: BCBS MT Closed Plan Network	$466.45
Rate for Payer: BCBS MT HealthLink	$441.90
Rate for Payer: BCBS MT Medicare	$441.90
Rate for Payer: BCBS MT POS	$466.45
Rate for Payer: BCBS MT Traditional	$491.00
Rate for Payer: Cash Price	$441.90
Rate for Payer: Cigna Commercial	$466.45
Rate for Payer: Cigna Medicare	$441.90
Rate for Payer: Medicaid All Medicaid	$451.72
Rate for Payer: Medicare All Medicare	$343.70
Rate for Payer: Monida Allegiance	$466.45
Rate for Payer: Monida First Choice Health	$476.27
Rate for Payer: Monida Montana Health Co-op	$466.45
Rate for Payer: Monida PacificSource	$466.45

XR CERVICAL SPINE COMPLETE W/ FLEX/EXT

Facility

$491.00

Service Code	HCPCS 72052 TC
Hospital Charge Code	5000151
Hospital Revenue Code	320
Min. Negotiated Rate	$343.70
Max. Negotiated Rate	$491.00
Rate for Payer: Aetna Commercial	$466.45
Rate for Payer: Aetna Medicare	$441.90
Rate for Payer: BCBS MT CHIP	$441.90
Rate for Payer: BCBS MT Closed Plan Network	$466.45
Rate for Payer: BCBS MT HealthLink	$441.90
Rate for Payer: BCBS MT Medicare	$441.90
Rate for Payer: BCBS MT POS	$466.45
Rate for Payer: BCBS MT Traditional	$491.00
Rate for Payer: Cash Price	$441.90
Rate for Payer: Cigna Commercial	$466.45
Rate for Payer: Cigna Medicare	$441.90
Rate for Payer: Medicaid All Medicaid	$451.72
Rate for Payer: Medicare All Medicare	$343.70
Rate for Payer: Monida Allegiance	$466.45
Rate for Payer: Monida First Choice Health	$476.27
Rate for Payer: Monida Montana Health Co-op	$466.45
Rate for Payer: Monida PacificSource	$466.45

XR CHEST 1 VIEW

Facility

$235.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000141
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR CHEST 1 VIEW

Facility

$235.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000141
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR CHEST 2 VIEWS

Facility

$300.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	5000142
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

XR CHEST 2 VIEWS

Facility

$300.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	5000142
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

XR CHEST CHILD 1 VIEW

Facility

$196.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000145
Hospital Revenue Code	320
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

XR CHEST CHILD 1 VIEW

Facility

$196.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000145
Hospital Revenue Code	320
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

XR CHEST/RIBS 4/> VIEWS

Facility

$464.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	5000127
Hospital Revenue Code	320
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$464.00
Rate for Payer: Aetna Commercial	$440.80
Rate for Payer: Aetna Medicare	$417.60
Rate for Payer: BCBS MT CHIP	$417.60
Rate for Payer: BCBS MT Closed Plan Network	$440.80
Rate for Payer: BCBS MT HealthLink	$417.60
Rate for Payer: BCBS MT Medicare	$417.60
Rate for Payer: BCBS MT POS	$440.80
Rate for Payer: BCBS MT Traditional	$464.00
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cigna Commercial	$440.80
Rate for Payer: Cigna Medicare	$417.60
Rate for Payer: Medicaid All Medicaid	$426.88
Rate for Payer: Medicare All Medicare	$324.80
Rate for Payer: Monida Allegiance	$440.80
Rate for Payer: Monida First Choice Health	$450.08
Rate for Payer: Monida Montana Health Co-op	$440.80
Rate for Payer: Monida PacificSource	$440.80

XR CHEST/RIBS 4/> VIEWS

Facility

$464.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	5000127
Hospital Revenue Code	320
Min. Negotiated Rate	$324.80
Max. Negotiated Rate	$464.00
Rate for Payer: Aetna Commercial	$440.80
Rate for Payer: Aetna Medicare	$417.60
Rate for Payer: BCBS MT CHIP	$417.60
Rate for Payer: BCBS MT Closed Plan Network	$440.80
Rate for Payer: BCBS MT HealthLink	$417.60
Rate for Payer: BCBS MT Medicare	$417.60
Rate for Payer: BCBS MT POS	$440.80
Rate for Payer: BCBS MT Traditional	$464.00
Rate for Payer: Cash Price	$417.60
Rate for Payer: Cigna Commercial	$440.80
Rate for Payer: Cigna Medicare	$417.60
Rate for Payer: Medicaid All Medicaid	$426.88
Rate for Payer: Medicare All Medicare	$324.80
Rate for Payer: Monida Allegiance	$440.80
Rate for Payer: Monida First Choice Health	$450.08
Rate for Payer: Monida Montana Health Co-op	$440.80
Rate for Payer: Monida PacificSource	$440.80

XR CHEST SINGLE VIEW

Facility

$234.00

Service Code	HCPCS 71045
Hospital Charge Code	5071045
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 CHEST SINGLE VIEW

Facility

$234.00

Service Code	HCPCS 71045
Hospital Charge Code	5071045
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 CINE/VIDEO THROAT/ESOPH

Facility

$637.00

Service Code	HCPCS 74230
Hospital Charge Code	5074230
Hospital Revenue Code	320
Min. Negotiated Rate	$445.90
Max. Negotiated Rate	$637.00
Rate for Payer: Aetna Commercial	$605.15
Rate for Payer: Aetna Medicare	$573.30
Rate for Payer: BCBS MT CHIP	$573.30
Rate for Payer: BCBS MT Closed Plan Network	$605.15
Rate for Payer: BCBS MT HealthLink	$573.30
Rate for Payer: BCBS MT Medicare	$573.30
Rate for Payer: BCBS MT POS	$605.15
Rate for Payer: BCBS MT Traditional	$637.00
Rate for Payer: Cash Price	$573.30
Rate for Payer: Cigna Commercial	$605.15
Rate for Payer: Cigna Medicare	$573.30
Rate for Payer: Medicaid All Medicaid	$586.04
Rate for Payer: Medicare All Medicare	$445.90
Rate for Payer: Monida Allegiance	$605.15
Rate for Payer: Monida First Choice Health	$617.89
Rate for Payer: Monida Montana Health Co-op	$605.15
Rate for Payer: Monida PacificSource	$605.15

Know your out-of-pocket cost for care.

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