Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR EYE FOREIGN BODY

Facility

$218.00

Service Code	HCPCS 70030 TC
Hospital Charge Code	5000041
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR EYE FOREIGN BODY

Facility

$218.00

Service Code	HCPCS 70030 TC
Hospital Charge Code	5000041
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR FACIAL BONES COMPLETE 3 VIEWS

Facility

$392.00

Service Code	HCPCS 70150 TC
Hospital Charge Code	5000158
Hospital Revenue Code	320
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$392.00
Rate for Payer: Aetna Commercial	$372.40
Rate for Payer: Aetna Medicare	$352.80
Rate for Payer: BCBS MT CHIP	$352.80
Rate for Payer: BCBS MT Closed Plan Network	$372.40
Rate for Payer: BCBS MT HealthLink	$352.80
Rate for Payer: BCBS MT Medicare	$352.80
Rate for Payer: BCBS MT POS	$372.40
Rate for Payer: BCBS MT Traditional	$392.00
Rate for Payer: Cash Price	$352.80
Rate for Payer: Cigna Commercial	$372.40
Rate for Payer: Cigna Medicare	$352.80
Rate for Payer: Medicaid All Medicaid	$360.64
Rate for Payer: Medicare All Medicare	$274.40
Rate for Payer: Monida Allegiance	$372.40
Rate for Payer: Monida First Choice Health	$380.24
Rate for Payer: Monida Montana Health Co-op	$372.40
Rate for Payer: Monida PacificSource	$372.40

XR FACIAL BONES COMPLETE 3 VIEWS

Facility

$392.00

Service Code	HCPCS 70150 TC
Hospital Charge Code	5000158
Hospital Revenue Code	320
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$392.00
Rate for Payer: Aetna Commercial	$372.40
Rate for Payer: Aetna Medicare	$352.80
Rate for Payer: BCBS MT CHIP	$352.80
Rate for Payer: BCBS MT Closed Plan Network	$372.40
Rate for Payer: BCBS MT HealthLink	$352.80
Rate for Payer: BCBS MT Medicare	$352.80
Rate for Payer: BCBS MT POS	$372.40
Rate for Payer: BCBS MT Traditional	$392.00
Rate for Payer: Cash Price	$352.80
Rate for Payer: Cigna Commercial	$372.40
Rate for Payer: Cigna Medicare	$352.80
Rate for Payer: Medicaid All Medicaid	$360.64
Rate for Payer: Medicare All Medicare	$274.40
Rate for Payer: Monida Allegiance	$372.40
Rate for Payer: Monida First Choice Health	$380.24
Rate for Payer: Monida Montana Health Co-op	$372.40
Rate for Payer: Monida PacificSource	$372.40

XR FACIAL BONES LESS THAN 3 VIEWS

Facility

$251.00

Service Code	HCPCS 70140 TC
Hospital Charge Code	5000144
Hospital Revenue Code	320
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

XR FACIAL BONES LESS THAN 3 VIEWS

Facility

$251.00

Service Code	HCPCS 70140 TC
Hospital Charge Code	5000144
Hospital Revenue Code	320
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

XR FEET BILATERAL 2 VIEWS

Facility

$229.00

Service Code	HCPCS 73620 TC
Hospital Charge Code	5000159
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 FEET BILATERAL 2 VIEWS

Facility

$229.00

Service Code	HCPCS 73620 TC
Hospital Charge Code	5000159
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 FEMUR LT 2 VIEWS

Facility

$251.00

Service Code	HCPCS 73552 TC,LT
Hospital Charge Code	5000160
Hospital Revenue Code	320
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

XR FEMUR LT 2 VIEWS

Facility

$251.00

Service Code	HCPCS 73552 TC,LT
Hospital Charge Code	5000160
Hospital Revenue Code	320
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

XR FEMUR RT 2 VIEWS

Facility

$251.00

Service Code	HCPCS 73552 TC,RT
Hospital Charge Code	5000161
Hospital Revenue Code	320
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

XR FEMUR RT 2 VIEWS

Facility

$251.00

Service Code	HCPCS 73552 TC,RT
Hospital Charge Code	5000161
Hospital Revenue Code	320
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

XR FINGERS LT

Facility

$218.00

Service Code	HCPCS 73140 TC,LT
Hospital Charge Code	5000162
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR FINGERS LT

Facility

$218.00

Service Code	HCPCS 73140 TC,LT
Hospital Charge Code	5000162
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR FINGERS RT

Facility

$218.00

Service Code	HCPCS 73140 TC,RT
Hospital Charge Code	5000163
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR FINGERS RT

Facility

$218.00

Service Code	HCPCS 73140 TC,RT
Hospital Charge Code	5000163
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR FOOT BILATERAL 3 OR MORE VIEWS

Facility

$270.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	5000171
Hospital Revenue Code	320
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$256.50
Rate for Payer: Aetna Medicare	$243.00
Rate for Payer: BCBS MT CHIP	$243.00
Rate for Payer: BCBS MT Closed Plan Network	$256.50
Rate for Payer: BCBS MT HealthLink	$243.00
Rate for Payer: BCBS MT Medicare	$243.00
Rate for Payer: BCBS MT POS	$256.50
Rate for Payer: BCBS MT Traditional	$270.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial	$256.50
Rate for Payer: Cigna Medicare	$243.00
Rate for Payer: Medicaid All Medicaid	$248.40
Rate for Payer: Medicare All Medicare	$189.00
Rate for Payer: Monida Allegiance	$256.50
Rate for Payer: Monida First Choice Health	$261.90
Rate for Payer: Monida Montana Health Co-op	$256.50
Rate for Payer: Monida PacificSource	$256.50

XR FOOT BILATERAL 3 OR MORE VIEWS

Facility

$270.00

Service Code	HCPCS 73630 TC
Hospital Charge Code	5000171
Hospital Revenue Code	320
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$256.50
Rate for Payer: Aetna Medicare	$243.00
Rate for Payer: BCBS MT CHIP	$243.00
Rate for Payer: BCBS MT Closed Plan Network	$256.50
Rate for Payer: BCBS MT HealthLink	$243.00
Rate for Payer: BCBS MT Medicare	$243.00
Rate for Payer: BCBS MT POS	$256.50
Rate for Payer: BCBS MT Traditional	$270.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial	$256.50
Rate for Payer: Cigna Medicare	$243.00
Rate for Payer: Medicaid All Medicaid	$248.40
Rate for Payer: Medicare All Medicare	$189.00
Rate for Payer: Monida Allegiance	$256.50
Rate for Payer: Monida First Choice Health	$261.90
Rate for Payer: Monida Montana Health Co-op	$256.50
Rate for Payer: Monida PacificSource	$256.50

XR FOOT LT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73620 TC,LT
Hospital Charge Code	5000164
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 FOOT LT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73620 TC,LT
Hospital Charge Code	5000164
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 FOOT LT 3 VIEWS

Facility

$284.00

Service Code	HCPCS 73630 TC,LT
Hospital Charge Code	5000165
Hospital Revenue Code	320
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

XR FOOT LT 3 VIEWS

Facility

$284.00

Service Code	HCPCS 73630 TC,LT
Hospital Charge Code	5000165
Hospital Revenue Code	320
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

XR FOOT RT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73620 TC,RT
Hospital Charge Code	5000166
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 FOOT RT 2 VIEWS

Facility

$240.00

Service Code	HCPCS 73620 TC,RT
Hospital Charge Code	5000166
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 FOOT RT 3 VIEWS

Facility

$284.00

Service Code	HCPCS 73630 TC,RT
Hospital Charge Code	5000167
Hospital Revenue Code	320
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

Know your out-of-pocket cost for care.

All Charges