Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR HIP LT 1 VIEW

Facility

$218.00

Service Code	HCPCS 73501 TC,RT
Hospital Charge Code	5000250
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 HIP LT 1 VIEW

Facility

$218.00

Service Code	HCPCS 73501 TC,RT
Hospital Charge Code	5000250
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 HIP LT 2 VIEWS

Facility

$256.00

Service Code	HCPCS 73502 TC,LT
Hospital Charge Code	5000183
Hospital Revenue Code	320
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$256.00
Rate for Payer: Aetna Commercial	$243.20
Rate for Payer: Aetna Medicare	$230.40
Rate for Payer: BCBS MT CHIP	$230.40
Rate for Payer: BCBS MT Closed Plan Network	$243.20
Rate for Payer: BCBS MT HealthLink	$230.40
Rate for Payer: BCBS MT Medicare	$230.40
Rate for Payer: BCBS MT POS	$243.20
Rate for Payer: BCBS MT Traditional	$256.00
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cigna Commercial	$243.20
Rate for Payer: Cigna Medicare	$230.40
Rate for Payer: Medicaid All Medicaid	$235.52
Rate for Payer: Medicare All Medicare	$179.20
Rate for Payer: Monida Allegiance	$243.20
Rate for Payer: Monida First Choice Health	$248.32
Rate for Payer: Monida Montana Health Co-op	$243.20
Rate for Payer: Monida PacificSource	$243.20

XR HIP LT 2 VIEWS

Facility

$256.00

Service Code	HCPCS 73502 TC,LT
Hospital Charge Code	5000183
Hospital Revenue Code	320
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$256.00
Rate for Payer: Aetna Commercial	$243.20
Rate for Payer: Aetna Medicare	$230.40
Rate for Payer: BCBS MT CHIP	$230.40
Rate for Payer: BCBS MT Closed Plan Network	$243.20
Rate for Payer: BCBS MT HealthLink	$230.40
Rate for Payer: BCBS MT Medicare	$230.40
Rate for Payer: BCBS MT POS	$243.20
Rate for Payer: BCBS MT Traditional	$256.00
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cigna Commercial	$243.20
Rate for Payer: Cigna Medicare	$230.40
Rate for Payer: Medicaid All Medicaid	$235.52
Rate for Payer: Medicare All Medicare	$179.20
Rate for Payer: Monida Allegiance	$243.20
Rate for Payer: Monida First Choice Health	$248.32
Rate for Payer: Monida Montana Health Co-op	$243.20
Rate for Payer: Monida PacificSource	$243.20

XR HIP RT 1 VIEW

Facility

$218.00

Service Code	HCPCS 73501 TC,RT
Hospital Charge Code	5000184
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 HIP RT 1 VIEW

Facility

$218.00

Service Code	HCPCS 73501 TC,RT
Hospital Charge Code	5000184
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 HIP RT 2 VIEWS

Facility

$256.00

Service Code	HCPCS 73502 TC,RT
Hospital Charge Code	5000185
Hospital Revenue Code	320
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$256.00
Rate for Payer: Aetna Commercial	$243.20
Rate for Payer: Aetna Medicare	$230.40
Rate for Payer: BCBS MT CHIP	$230.40
Rate for Payer: BCBS MT Closed Plan Network	$243.20
Rate for Payer: BCBS MT HealthLink	$230.40
Rate for Payer: BCBS MT Medicare	$230.40
Rate for Payer: BCBS MT POS	$243.20
Rate for Payer: BCBS MT Traditional	$256.00
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cigna Commercial	$243.20
Rate for Payer: Cigna Medicare	$230.40
Rate for Payer: Medicaid All Medicaid	$235.52
Rate for Payer: Medicare All Medicare	$179.20
Rate for Payer: Monida Allegiance	$243.20
Rate for Payer: Monida First Choice Health	$248.32
Rate for Payer: Monida Montana Health Co-op	$243.20
Rate for Payer: Monida PacificSource	$243.20

XR HIP RT 2 VIEWS

Facility

$256.00

Service Code	HCPCS 73502 TC,RT
Hospital Charge Code	5000185
Hospital Revenue Code	320
Min. Negotiated Rate	$179.20
Max. Negotiated Rate	$256.00
Rate for Payer: Aetna Commercial	$243.20
Rate for Payer: Aetna Medicare	$230.40
Rate for Payer: BCBS MT CHIP	$230.40
Rate for Payer: BCBS MT Closed Plan Network	$243.20
Rate for Payer: BCBS MT HealthLink	$230.40
Rate for Payer: BCBS MT Medicare	$230.40
Rate for Payer: BCBS MT POS	$243.20
Rate for Payer: BCBS MT Traditional	$256.00
Rate for Payer: Cash Price	$230.40
Rate for Payer: Cigna Commercial	$243.20
Rate for Payer: Cigna Medicare	$230.40
Rate for Payer: Medicaid All Medicaid	$235.52
Rate for Payer: Medicare All Medicare	$179.20
Rate for Payer: Monida Allegiance	$243.20
Rate for Payer: Monida First Choice Health	$248.32
Rate for Payer: Monida Montana Health Co-op	$243.20
Rate for Payer: Monida PacificSource	$243.20

XR HIPS BILATERAL 2 VIEWS W PELVIS

Facility

$508.00

Service Code	HCPCS 73521 TC
Hospital Charge Code	5000186
Hospital Revenue Code	320
Min. Negotiated Rate	$355.60
Max. Negotiated Rate	$508.00
Rate for Payer: Aetna Commercial	$482.60
Rate for Payer: Aetna Medicare	$457.20
Rate for Payer: BCBS MT CHIP	$457.20
Rate for Payer: BCBS MT Closed Plan Network	$482.60
Rate for Payer: BCBS MT HealthLink	$457.20
Rate for Payer: BCBS MT Medicare	$457.20
Rate for Payer: BCBS MT POS	$482.60
Rate for Payer: BCBS MT Traditional	$508.00
Rate for Payer: Cash Price	$457.20
Rate for Payer: Cigna Commercial	$482.60
Rate for Payer: Cigna Medicare	$457.20
Rate for Payer: Medicaid All Medicaid	$467.36
Rate for Payer: Medicare All Medicare	$355.60
Rate for Payer: Monida Allegiance	$482.60
Rate for Payer: Monida First Choice Health	$492.76
Rate for Payer: Monida Montana Health Co-op	$482.60
Rate for Payer: Monida PacificSource	$482.60

XR HIPS BILATERAL 2 VIEWS W PELVIS

Facility

$508.00

Service Code	HCPCS 73521 TC
Hospital Charge Code	5000186
Hospital Revenue Code	320
Min. Negotiated Rate	$355.60
Max. Negotiated Rate	$508.00
Rate for Payer: Aetna Commercial	$482.60
Rate for Payer: Aetna Medicare	$457.20
Rate for Payer: BCBS MT CHIP	$457.20
Rate for Payer: BCBS MT Closed Plan Network	$482.60
Rate for Payer: BCBS MT HealthLink	$457.20
Rate for Payer: BCBS MT Medicare	$457.20
Rate for Payer: BCBS MT POS	$482.60
Rate for Payer: BCBS MT Traditional	$508.00
Rate for Payer: Cash Price	$457.20
Rate for Payer: Cigna Commercial	$482.60
Rate for Payer: Cigna Medicare	$457.20
Rate for Payer: Medicaid All Medicaid	$467.36
Rate for Payer: Medicare All Medicare	$355.60
Rate for Payer: Monida Allegiance	$482.60
Rate for Payer: Monida First Choice Health	$492.76
Rate for Payer: Monida Montana Health Co-op	$482.60
Rate for Payer: Monida PacificSource	$482.60

XR HUMERUS LT 2 VIEWS

Facility

$263.00

Service Code	HCPCS 73060 TC,LT
Hospital Charge Code	5000187
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 HUMERUS LT 2 VIEWS

Facility

$263.00

Service Code	HCPCS 73060 TC,LT
Hospital Charge Code	5000187
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 HUMERUS RT 2 VIEWS

Facility

$263.00

Service Code	HCPCS 73060 TC,RT
Hospital Charge Code	5000188
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 HUMERUS RT 2 VIEWS

Facility

$263.00

Service Code	HCPCS 73060 TC,RT
Hospital Charge Code	5000188
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 IJ SINGLE/MULT TRGR PT 3+ MUSCL 20553

Facility

$410.00

Service Code	HCPCS 20553
Hospital Charge Code	5020553
Hospital Revenue Code	320
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

XR IJ SINGLE/MULT TRGR PT 3+ MUSCL 20553

Facility

$410.00

Service Code	HCPCS 20553
Hospital Charge Code	5020553
Hospital Revenue Code	320
Min. Negotiated Rate	$287.00
Max. Negotiated Rate	$410.00
Rate for Payer: Aetna Commercial	$389.50
Rate for Payer: Aetna Medicare	$369.00
Rate for Payer: BCBS MT CHIP	$369.00
Rate for Payer: BCBS MT Closed Plan Network	$389.50
Rate for Payer: BCBS MT HealthLink	$369.00
Rate for Payer: BCBS MT Medicare	$369.00
Rate for Payer: BCBS MT POS	$389.50
Rate for Payer: BCBS MT Traditional	$410.00
Rate for Payer: Cash Price	$369.00
Rate for Payer: Cigna Commercial	$389.50
Rate for Payer: Cigna Medicare	$369.00
Rate for Payer: Medicaid All Medicaid	$377.20
Rate for Payer: Medicare All Medicare	$287.00
Rate for Payer: Monida Allegiance	$389.50
Rate for Payer: Monida First Choice Health	$397.70
Rate for Payer: Monida Montana Health Co-op	$389.50
Rate for Payer: Monida PacificSource	$389.50

XR JOINT SURVEY BILATERAL 2 VIEWS

Facility

$213.00

Service Code	HCPCS 77077 TC
Hospital Charge Code	5000189
Hospital Revenue Code	320
Min. Negotiated Rate	$149.10
Max. Negotiated Rate	$213.00
Rate for Payer: Aetna Commercial	$202.35
Rate for Payer: Aetna Medicare	$191.70
Rate for Payer: BCBS MT CHIP	$191.70
Rate for Payer: BCBS MT Closed Plan Network	$202.35
Rate for Payer: BCBS MT HealthLink	$191.70
Rate for Payer: BCBS MT Medicare	$191.70
Rate for Payer: BCBS MT POS	$202.35
Rate for Payer: BCBS MT Traditional	$213.00
Rate for Payer: Cash Price	$191.70
Rate for Payer: Cigna Commercial	$202.35
Rate for Payer: Cigna Medicare	$191.70
Rate for Payer: Medicaid All Medicaid	$195.96
Rate for Payer: Medicare All Medicare	$149.10
Rate for Payer: Monida Allegiance	$202.35
Rate for Payer: Monida First Choice Health	$206.61
Rate for Payer: Monida Montana Health Co-op	$202.35
Rate for Payer: Monida PacificSource	$202.35

XR JOINT SURVEY BILATERAL 2 VIEWS

Facility

$213.00

Service Code	HCPCS 77077 TC
Hospital Charge Code	5000189
Hospital Revenue Code	320
Min. Negotiated Rate	$149.10
Max. Negotiated Rate	$213.00
Rate for Payer: Aetna Commercial	$202.35
Rate for Payer: Aetna Medicare	$191.70
Rate for Payer: BCBS MT CHIP	$191.70
Rate for Payer: BCBS MT Closed Plan Network	$202.35
Rate for Payer: BCBS MT HealthLink	$191.70
Rate for Payer: BCBS MT Medicare	$191.70
Rate for Payer: BCBS MT POS	$202.35
Rate for Payer: BCBS MT Traditional	$213.00
Rate for Payer: Cash Price	$191.70
Rate for Payer: Cigna Commercial	$202.35
Rate for Payer: Cigna Medicare	$191.70
Rate for Payer: Medicaid All Medicaid	$195.96
Rate for Payer: Medicare All Medicare	$149.10
Rate for Payer: Monida Allegiance	$202.35
Rate for Payer: Monida First Choice Health	$206.61
Rate for Payer: Monida Montana Health Co-op	$202.35
Rate for Payer: Monida PacificSource	$202.35

XR KNEE LT 2 VIEWS

Facility

$251.00

Service Code	HCPCS 73560 TC,LT
Hospital Charge Code	5000190
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 KNEE LT 2 VIEWS

Facility

$251.00

Service Code	HCPCS 73560 TC,LT
Hospital Charge Code	5000190
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 KNEE LT 3 VIEWS

Facility

$306.00

Service Code	HCPCS 73562 TC,LT
Hospital Charge Code	5000191
Hospital Revenue Code	320
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$306.00
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: BCBS MT CHIP	$275.40
Rate for Payer: BCBS MT Closed Plan Network	$290.70
Rate for Payer: BCBS MT HealthLink	$275.40
Rate for Payer: BCBS MT Medicare	$275.40
Rate for Payer: BCBS MT POS	$290.70
Rate for Payer: BCBS MT Traditional	$306.00
Rate for Payer: Cash Price	$275.40
Rate for Payer: Cigna Commercial	$290.70
Rate for Payer: Cigna Medicare	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

XR KNEE LT 3 VIEWS

Facility

$306.00

Service Code	HCPCS 73562 TC,LT
Hospital Charge Code	5000191
Hospital Revenue Code	320
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$306.00
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: BCBS MT CHIP	$275.40
Rate for Payer: BCBS MT Closed Plan Network	$290.70
Rate for Payer: BCBS MT HealthLink	$275.40
Rate for Payer: BCBS MT Medicare	$275.40
Rate for Payer: BCBS MT POS	$290.70
Rate for Payer: BCBS MT Traditional	$306.00
Rate for Payer: Cash Price	$275.40
Rate for Payer: Cigna Commercial	$290.70
Rate for Payer: Cigna Medicare	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

XR KNEE LT COMPLETE

Facility

$355.00

Service Code	HCPCS 73564 TC,LT
Hospital Charge Code	5000192
Hospital Revenue Code	320
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

XR KNEE LT COMPLETE

Facility

$355.00

Service Code	HCPCS 73564 TC,LT
Hospital Charge Code	5000192
Hospital Revenue Code	320
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

XR KNEE RT 2 VIEWS

Facility

$251.00

Service Code	HCPCS 73560 TC,RT
Hospital Charge Code	5000193
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

Know your out-of-pocket cost for care.

All Charges