Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR FOREARM, BILATERAL AP/LATERAL VIEW

Facility

$250.00

Service Code	HCPCS 73090 TC
Hospital Charge Code	5000168
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 FOREARM, BILATERAL AP/LATERAL VIEW

Facility

$250.00

Service Code	HCPCS 73090 TC
Hospital Charge Code	5000168
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 FOREARM, LEFT AP/LATERAL VIEW

Facility

$263.00

Service Code	HCPCS 73090 TC,LT
Hospital Charge Code	5000169
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 FOREARM, LEFT AP/LATERAL VIEW

Facility

$263.00

Service Code	HCPCS 73090 TC,LT
Hospital Charge Code	5000169
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 FOREARM, RIGHT AP/LATERAL VIEW

Facility

$263.00

Service Code	HCPCS 73090 TC,RT
Hospital Charge Code	5000170
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 FOREARM, RIGHT AP/LATERAL VIEW

Facility

$263.00

Service Code	HCPCS 73090 TC,RT
Hospital Charge Code	5000170
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 GUIDANCE FOR NEEDLE PLACE 77002

Facility

$464.00

Service Code	HCPCS 77002
Hospital Charge Code	5077002
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 GUIDANCE FOR NEEDLE PLACE 77002

Facility

$464.00

Service Code	HCPCS 77002
Hospital Charge Code	5077002
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 GUIDANCE SPINAL INJ 77003

Facility

$510.00

Service Code	HCPCS 77003
Hospital Charge Code	5077003
Hospital Revenue Code	320
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

XR GUIDANCE SPINAL INJ 77003

Facility

$510.00

Service Code	HCPCS 77003
Hospital Charge Code	5077003
Hospital Revenue Code	320
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

XR HAND LT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73120 TC,LT
Hospital Charge Code	5000172
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 HAND LT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73120 TC,LT
Hospital Charge Code	5000172
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 HAND LT 3 VIEWS

Facility

$284.00

Service Code	HCPCS 73130 TC,LT
Hospital Charge Code	5000173
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 HAND LT 3 VIEWS

Facility

$284.00

Service Code	HCPCS 73130 TC,LT
Hospital Charge Code	5000173
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 HAND RT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73120 TC,RT
Hospital Charge Code	5000174
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 HAND RT 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73120 TC,RT
Hospital Charge Code	5000174
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 HAND RT 3 VIEWS

Facility

$284.00

Service Code	HCPCS 73130 TC,RT
Hospital Charge Code	5000175
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 HAND RT 3 VIEWS

Facility

$284.00

Service Code	HCPCS 73130 TC,RT
Hospital Charge Code	5000175
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 HANDS BILATERAL 1 VIEW

Facility

$234.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	5000176
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 HANDS BILATERAL 1 VIEW

Facility

$234.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	5000176
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 HANDS BILATERAL 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	5000177
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 HANDS BILATERAL 2 VIEWS

Facility

$246.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	5000177
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 HANDS BILATERAL 3 VIEWS

Facility

$270.00

Service Code	HCPCS 73130 TC
Hospital Charge Code	5000178
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 HANDS BILATERAL 3 VIEWS

Facility

$270.00

Service Code	HCPCS 73130 TC
Hospital Charge Code	5000178
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

Know your out-of-pocket cost for care.

All Charges