Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR CLAVICLE BILATERAL COMPLETE

Facility

$250.00

Service Code	HCPCS 73000 TC
Hospital Charge Code	5000146
Hospital Revenue Code	320
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

XR CLAVICLE BILATERAL COMPLETE

Facility

$250.00

Service Code	HCPCS 73000 TC
Hospital Charge Code	5000146
Hospital Revenue Code	320
Min. Negotiated Rate	$175.00
Max. Negotiated Rate	$250.00
Rate for Payer: Aetna Commercial	$237.50
Rate for Payer: Aetna Medicare	$225.00
Rate for Payer: BCBS MT CHIP	$225.00
Rate for Payer: BCBS MT Closed Plan Network	$237.50
Rate for Payer: BCBS MT HealthLink	$225.00
Rate for Payer: BCBS MT Medicare	$225.00
Rate for Payer: BCBS MT POS	$237.50
Rate for Payer: BCBS MT Traditional	$250.00
Rate for Payer: Cash Price	$225.00
Rate for Payer: Cigna Commercial	$237.50
Rate for Payer: Cigna Medicare	$225.00
Rate for Payer: Medicaid All Medicaid	$230.00
Rate for Payer: Medicare All Medicare	$175.00
Rate for Payer: Monida Allegiance	$237.50
Rate for Payer: Monida First Choice Health	$242.50
Rate for Payer: Monida Montana Health Co-op	$237.50
Rate for Payer: Monida PacificSource	$237.50

XR CLAVICLE LT COMPLETE

Facility

$263.00

Service Code	HCPCS 73000 TC,LT
Hospital Charge Code	5000147
Hospital Revenue Code	320
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

XR CLAVICLE LT COMPLETE

Facility

$263.00

Service Code	HCPCS 73000 TC,LT
Hospital Charge Code	5000147
Hospital Revenue Code	320
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

XR CLAVICLE RT COMPLETE

Facility

$263.00

Service Code	HCPCS 73000 TC,RT
Hospital Charge Code	5000148
Hospital Revenue Code	320
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

XR CLAVICLE RT COMPLETE

Facility

$263.00

Service Code	HCPCS 73000 TC,RT
Hospital Charge Code	5000148
Hospital Revenue Code	320
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

XR CTA THORACIC AORTA W OR W/O CONTRAST

Facility

$3,199.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5075635
Hospital Revenue Code	350
Min. Negotiated Rate	$2,239.30
Max. Negotiated Rate	$3,199.00
Rate for Payer: Aetna Commercial	$3,039.05
Rate for Payer: Aetna Medicare	$2,879.10
Rate for Payer: BCBS MT CHIP	$2,879.10
Rate for Payer: BCBS MT Closed Plan Network	$3,039.05
Rate for Payer: BCBS MT HealthLink	$2,879.10
Rate for Payer: BCBS MT Medicare	$2,879.10
Rate for Payer: BCBS MT POS	$3,039.05
Rate for Payer: BCBS MT Traditional	$3,199.00
Rate for Payer: Cash Price	$2,879.10
Rate for Payer: Cigna Commercial	$3,039.05
Rate for Payer: Cigna Medicare	$2,879.10
Rate for Payer: Medicaid All Medicaid	$2,943.08
Rate for Payer: Medicare All Medicare	$2,239.30
Rate for Payer: Monida Allegiance	$3,039.05
Rate for Payer: Monida First Choice Health	$3,103.03
Rate for Payer: Monida Montana Health Co-op	$3,039.05
Rate for Payer: Monida PacificSource	$3,039.05

XR CTA THORACIC AORTA W OR W/O CONTRAST

Facility

$3,199.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5075635
Hospital Revenue Code	350
Min. Negotiated Rate	$2,239.30
Max. Negotiated Rate	$3,199.00
Rate for Payer: Aetna Commercial	$3,039.05
Rate for Payer: Aetna Medicare	$2,879.10
Rate for Payer: BCBS MT CHIP	$2,879.10
Rate for Payer: BCBS MT Closed Plan Network	$3,039.05
Rate for Payer: BCBS MT HealthLink	$2,879.10
Rate for Payer: BCBS MT Medicare	$2,879.10
Rate for Payer: BCBS MT POS	$3,039.05
Rate for Payer: BCBS MT Traditional	$3,199.00
Rate for Payer: Cash Price	$2,879.10
Rate for Payer: Cigna Commercial	$3,039.05
Rate for Payer: Cigna Medicare	$2,879.10
Rate for Payer: Medicaid All Medicaid	$2,943.08
Rate for Payer: Medicare All Medicare	$2,239.30
Rate for Payer: Monida Allegiance	$3,039.05
Rate for Payer: Monida First Choice Health	$3,103.03
Rate for Payer: Monida Montana Health Co-op	$3,039.05
Rate for Payer: Monida PacificSource	$3,039.05

XR ELBOW BILATERAL 2 VIEWS

Facility

$224.00

Service Code	HCPCS 73070 TC
Hospital Charge Code	5000152
Hospital Revenue Code	320
Min. Negotiated Rate	$156.80
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial	$212.80
Rate for Payer: Aetna Medicare	$201.60
Rate for Payer: BCBS MT CHIP	$201.60
Rate for Payer: BCBS MT Closed Plan Network	$212.80
Rate for Payer: BCBS MT HealthLink	$201.60
Rate for Payer: BCBS MT Medicare	$201.60
Rate for Payer: BCBS MT POS	$212.80
Rate for Payer: BCBS MT Traditional	$224.00
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cigna Commercial	$212.80
Rate for Payer: Cigna Medicare	$201.60
Rate for Payer: Medicaid All Medicaid	$206.08
Rate for Payer: Medicare All Medicare	$156.80
Rate for Payer: Monida Allegiance	$212.80
Rate for Payer: Monida First Choice Health	$217.28
Rate for Payer: Monida Montana Health Co-op	$212.80
Rate for Payer: Monida PacificSource	$212.80

XR ELBOW BILATERAL 2 VIEWS

Facility

$224.00

Service Code	HCPCS 73070 TC
Hospital Charge Code	5000152
Hospital Revenue Code	320
Min. Negotiated Rate	$156.80
Max. Negotiated Rate	$224.00
Rate for Payer: Aetna Commercial	$212.80
Rate for Payer: Aetna Medicare	$201.60
Rate for Payer: BCBS MT CHIP	$201.60
Rate for Payer: BCBS MT Closed Plan Network	$212.80
Rate for Payer: BCBS MT HealthLink	$201.60
Rate for Payer: BCBS MT Medicare	$201.60
Rate for Payer: BCBS MT POS	$212.80
Rate for Payer: BCBS MT Traditional	$224.00
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cigna Commercial	$212.80
Rate for Payer: Cigna Medicare	$201.60
Rate for Payer: Medicaid All Medicaid	$206.08
Rate for Payer: Medicare All Medicare	$156.80
Rate for Payer: Monida Allegiance	$212.80
Rate for Payer: Monida First Choice Health	$217.28
Rate for Payer: Monida Montana Health Co-op	$212.80
Rate for Payer: Monida PacificSource	$212.80

XR ELBOW BILATERAL 3 VIEWS

Facility

$276.00

Service Code	HCPCS 73080 TC
Hospital Charge Code	5000153
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 ELBOW BILATERAL 3 VIEWS

Facility

$276.00

Service Code	HCPCS 73080 TC
Hospital Charge Code	5000153
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 ELBOW LT 2 VIEWS

Facility

$235.00

Service Code	HCPCS 73070 TC,LT
Hospital Charge Code	5000154
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 ELBOW LT 2 VIEWS

Facility

$235.00

Service Code	HCPCS 73070 TC,LT
Hospital Charge Code	5000154
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 ELBOW LT 3-4 VIEWS

Facility

$290.00

Service Code	HCPCS 73080 TC,LT
Hospital Charge Code	5000155
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 ELBOW LT 3-4 VIEWS

Facility

$290.00

Service Code	HCPCS 73080 TC,LT
Hospital Charge Code	5000155
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 ELBOW RT 2 VIEWS

Facility

$235.00

Service Code	HCPCS 73070 TC,RT
Hospital Charge Code	5000156
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 ELBOW RT 2 VIEWS

Facility

$235.00

Service Code	HCPCS 73070 TC,RT
Hospital Charge Code	5000156
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 ELBOW RT 3-4 VIEWS

Facility

$290.00

Service Code	HCPCS 73080 TC,RT
Hospital Charge Code	5000157
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 ELBOW RT 3-4 VIEWS

Facility

$290.00

Service Code	HCPCS 73080 TC,RT
Hospital Charge Code	5000157
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 ENTIRE SPINE W SKULL 2 OR 3 VIEWS

Facility

$333.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5000212
Hospital Revenue Code	320
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

XR ENTIRE SPINE W SKULL 2 OR 3 VIEWS

Facility

$333.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5000212
Hospital Revenue Code	320
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

XR ENTIRE SPINE W SKULL 4 OR 5 VIEWS

Facility

$502.00

Service Code	HCPCS 72083 TC
Hospital Charge Code	5000213
Hospital Revenue Code	320
Min. Negotiated Rate	$351.40
Max. Negotiated Rate	$502.00
Rate for Payer: Aetna Commercial	$476.90
Rate for Payer: Aetna Medicare	$451.80
Rate for Payer: BCBS MT CHIP	$451.80
Rate for Payer: BCBS MT Closed Plan Network	$476.90
Rate for Payer: BCBS MT HealthLink	$451.80
Rate for Payer: BCBS MT Medicare	$451.80
Rate for Payer: BCBS MT POS	$476.90
Rate for Payer: BCBS MT Traditional	$502.00
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cigna Commercial	$476.90
Rate for Payer: Cigna Medicare	$451.80
Rate for Payer: Medicaid All Medicaid	$461.84
Rate for Payer: Medicare All Medicare	$351.40
Rate for Payer: Monida Allegiance	$476.90
Rate for Payer: Monida First Choice Health	$486.94
Rate for Payer: Monida Montana Health Co-op	$476.90
Rate for Payer: Monida PacificSource	$476.90

XR ENTIRE SPINE W SKULL 4 OR 5 VIEWS

Facility

$502.00

Service Code	HCPCS 72083 TC
Hospital Charge Code	5000213
Hospital Revenue Code	320
Min. Negotiated Rate	$351.40
Max. Negotiated Rate	$502.00
Rate for Payer: Aetna Commercial	$476.90
Rate for Payer: Aetna Medicare	$451.80
Rate for Payer: BCBS MT CHIP	$451.80
Rate for Payer: BCBS MT Closed Plan Network	$476.90
Rate for Payer: BCBS MT HealthLink	$451.80
Rate for Payer: BCBS MT Medicare	$451.80
Rate for Payer: BCBS MT POS	$476.90
Rate for Payer: BCBS MT Traditional	$502.00
Rate for Payer: Cash Price	$451.80
Rate for Payer: Cigna Commercial	$476.90
Rate for Payer: Cigna Medicare	$451.80
Rate for Payer: Medicaid All Medicaid	$461.84
Rate for Payer: Medicare All Medicare	$351.40
Rate for Payer: Monida Allegiance	$476.90
Rate for Payer: Monida First Choice Health	$486.94
Rate for Payer: Monida Montana Health Co-op	$476.90
Rate for Payer: Monida PacificSource	$476.90

Know your out-of-pocket cost for care.

All Charges