Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR KNEE RT 3 VIEWS

Facility

$306.00

Service Code	HCPCS 73562 TC,RT
Hospital Charge Code	5000194
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 RT 3 VIEWS

Facility

$306.00

Service Code	HCPCS 73562 TC,RT
Hospital Charge Code	5000194
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 RT COMPLETE

Facility

$355.00

Service Code	HCPCS 73564 TC,RT
Hospital Charge Code	5000195
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 COMPLETE

Facility

$355.00

Service Code	HCPCS 73564 TC,RT
Hospital Charge Code	5000195
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 KNEES BILATERAL 1 VIEW

Facility

$239.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	5000196
Hospital Revenue Code	320
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$227.05
Rate for Payer: Aetna Medicare	$215.10
Rate for Payer: BCBS MT CHIP	$215.10
Rate for Payer: BCBS MT Closed Plan Network	$227.05
Rate for Payer: BCBS MT HealthLink	$215.10
Rate for Payer: BCBS MT Medicare	$215.10
Rate for Payer: BCBS MT POS	$227.05
Rate for Payer: BCBS MT Traditional	$239.00
Rate for Payer: Cash Price	$215.10
Rate for Payer: Cigna Commercial	$227.05
Rate for Payer: Cigna Medicare	$215.10
Rate for Payer: Medicaid All Medicaid	$219.88
Rate for Payer: Medicare All Medicare	$167.30
Rate for Payer: Monida Allegiance	$227.05
Rate for Payer: Monida First Choice Health	$231.83
Rate for Payer: Monida Montana Health Co-op	$227.05
Rate for Payer: Monida PacificSource	$227.05

XR KNEES BILATERAL 1 VIEW

Facility

$239.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	5000196
Hospital Revenue Code	320
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$227.05
Rate for Payer: Aetna Medicare	$215.10
Rate for Payer: BCBS MT CHIP	$215.10
Rate for Payer: BCBS MT Closed Plan Network	$227.05
Rate for Payer: BCBS MT HealthLink	$215.10
Rate for Payer: BCBS MT Medicare	$215.10
Rate for Payer: BCBS MT POS	$227.05
Rate for Payer: BCBS MT Traditional	$239.00
Rate for Payer: Cash Price	$215.10
Rate for Payer: Cigna Commercial	$227.05
Rate for Payer: Cigna Medicare	$215.10
Rate for Payer: Medicaid All Medicaid	$219.88
Rate for Payer: Medicare All Medicare	$167.30
Rate for Payer: Monida Allegiance	$227.05
Rate for Payer: Monida First Choice Health	$231.83
Rate for Payer: Monida Montana Health Co-op	$227.05
Rate for Payer: Monida PacificSource	$227.05

XR KNEES BILATERAL 2 VIEWS

Facility

$239.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	5000197
Hospital Revenue Code	320
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$227.05
Rate for Payer: Aetna Medicare	$215.10
Rate for Payer: BCBS MT CHIP	$215.10
Rate for Payer: BCBS MT Closed Plan Network	$227.05
Rate for Payer: BCBS MT HealthLink	$215.10
Rate for Payer: BCBS MT Medicare	$215.10
Rate for Payer: BCBS MT POS	$227.05
Rate for Payer: BCBS MT Traditional	$239.00
Rate for Payer: Cash Price	$215.10
Rate for Payer: Cigna Commercial	$227.05
Rate for Payer: Cigna Medicare	$215.10
Rate for Payer: Medicaid All Medicaid	$219.88
Rate for Payer: Medicare All Medicare	$167.30
Rate for Payer: Monida Allegiance	$227.05
Rate for Payer: Monida First Choice Health	$231.83
Rate for Payer: Monida Montana Health Co-op	$227.05
Rate for Payer: Monida PacificSource	$227.05

XR KNEES BILATERAL 2 VIEWS

Facility

$239.00

Service Code	HCPCS 73560 TC
Hospital Charge Code	5000197
Hospital Revenue Code	320
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$239.00
Rate for Payer: Aetna Commercial	$227.05
Rate for Payer: Aetna Medicare	$215.10
Rate for Payer: BCBS MT CHIP	$215.10
Rate for Payer: BCBS MT Closed Plan Network	$227.05
Rate for Payer: BCBS MT HealthLink	$215.10
Rate for Payer: BCBS MT Medicare	$215.10
Rate for Payer: BCBS MT POS	$227.05
Rate for Payer: BCBS MT Traditional	$239.00
Rate for Payer: Cash Price	$215.10
Rate for Payer: Cigna Commercial	$227.05
Rate for Payer: Cigna Medicare	$215.10
Rate for Payer: Medicaid All Medicaid	$219.88
Rate for Payer: Medicare All Medicare	$167.30
Rate for Payer: Monida Allegiance	$227.05
Rate for Payer: Monida First Choice Health	$231.83
Rate for Payer: Monida Montana Health Co-op	$227.05
Rate for Payer: Monida PacificSource	$227.05

XR KNEES BILATERAL COMPLETE

Facility

$783.00

Service Code	HCPCS 73564 TC
Hospital Charge Code	5000198
Hospital Revenue Code	320
Min. Negotiated Rate	$548.10
Max. Negotiated Rate	$783.00
Rate for Payer: Aetna Commercial	$743.85
Rate for Payer: Aetna Medicare	$704.70
Rate for Payer: BCBS MT CHIP	$704.70
Rate for Payer: BCBS MT Closed Plan Network	$743.85
Rate for Payer: BCBS MT HealthLink	$704.70
Rate for Payer: BCBS MT Medicare	$704.70
Rate for Payer: BCBS MT POS	$743.85
Rate for Payer: BCBS MT Traditional	$783.00
Rate for Payer: Cash Price	$704.70
Rate for Payer: Cigna Commercial	$743.85
Rate for Payer: Cigna Medicare	$704.70
Rate for Payer: Medicaid All Medicaid	$720.36
Rate for Payer: Medicare All Medicare	$548.10
Rate for Payer: Monida Allegiance	$743.85
Rate for Payer: Monida First Choice Health	$759.51
Rate for Payer: Monida Montana Health Co-op	$743.85
Rate for Payer: Monida PacificSource	$743.85

XR KNEES BILATERAL COMPLETE

Facility

$783.00

Service Code	HCPCS 73564 TC
Hospital Charge Code	5000198
Hospital Revenue Code	320
Min. Negotiated Rate	$548.10
Max. Negotiated Rate	$783.00
Rate for Payer: Aetna Commercial	$743.85
Rate for Payer: Aetna Medicare	$704.70
Rate for Payer: BCBS MT CHIP	$704.70
Rate for Payer: BCBS MT Closed Plan Network	$743.85
Rate for Payer: BCBS MT HealthLink	$704.70
Rate for Payer: BCBS MT Medicare	$704.70
Rate for Payer: BCBS MT POS	$743.85
Rate for Payer: BCBS MT Traditional	$783.00
Rate for Payer: Cash Price	$704.70
Rate for Payer: Cigna Commercial	$743.85
Rate for Payer: Cigna Medicare	$704.70
Rate for Payer: Medicaid All Medicaid	$720.36
Rate for Payer: Medicare All Medicare	$548.10
Rate for Payer: Monida Allegiance	$743.85
Rate for Payer: Monida First Choice Health	$759.51
Rate for Payer: Monida Montana Health Co-op	$743.85
Rate for Payer: Monida PacificSource	$743.85

XR KNEES BILATERAL STAND AP

Facility

$224.00

Service Code	HCPCS 73565 TC
Hospital Charge Code	5000199
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 KNEES BILATERAL STAND AP

Facility

$224.00

Service Code	HCPCS 73565 TC
Hospital Charge Code	5000199
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 LOWER EXTREMITY LT INFANT

Facility

$137.00

Service Code	HCPCS 73592 TC
Hospital Charge Code	5000130
Hospital Revenue Code	320
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$137.00
Rate for Payer: Aetna Commercial	$130.15
Rate for Payer: Aetna Medicare	$123.30
Rate for Payer: BCBS MT CHIP	$123.30
Rate for Payer: BCBS MT Closed Plan Network	$130.15
Rate for Payer: BCBS MT HealthLink	$123.30
Rate for Payer: BCBS MT Medicare	$123.30
Rate for Payer: BCBS MT POS	$130.15
Rate for Payer: BCBS MT Traditional	$137.00
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial	$130.15
Rate for Payer: Cigna Medicare	$123.30
Rate for Payer: Medicaid All Medicaid	$126.04
Rate for Payer: Medicare All Medicare	$95.90
Rate for Payer: Monida Allegiance	$130.15
Rate for Payer: Monida First Choice Health	$132.89
Rate for Payer: Monida Montana Health Co-op	$130.15
Rate for Payer: Monida PacificSource	$130.15

XR LOWER EXTREMITY LT INFANT

Facility

$137.00

Service Code	HCPCS 73592 TC
Hospital Charge Code	5000130
Hospital Revenue Code	320
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$137.00
Rate for Payer: Aetna Commercial	$130.15
Rate for Payer: Aetna Medicare	$123.30
Rate for Payer: BCBS MT CHIP	$123.30
Rate for Payer: BCBS MT Closed Plan Network	$130.15
Rate for Payer: BCBS MT HealthLink	$123.30
Rate for Payer: BCBS MT Medicare	$123.30
Rate for Payer: BCBS MT POS	$130.15
Rate for Payer: BCBS MT Traditional	$137.00
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial	$130.15
Rate for Payer: Cigna Medicare	$123.30
Rate for Payer: Medicaid All Medicaid	$126.04
Rate for Payer: Medicare All Medicare	$95.90
Rate for Payer: Monida Allegiance	$130.15
Rate for Payer: Monida First Choice Health	$132.89
Rate for Payer: Monida Montana Health Co-op	$130.15
Rate for Payer: Monida PacificSource	$130.15

XR LOWER EXTREMITY RT INFANT

Facility

$137.00

Service Code	HCPCS 73592 TC,RT
Hospital Charge Code	5000003
Hospital Revenue Code	320
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$137.00
Rate for Payer: Aetna Commercial	$130.15
Rate for Payer: Aetna Medicare	$123.30
Rate for Payer: BCBS MT CHIP	$123.30
Rate for Payer: BCBS MT Closed Plan Network	$130.15
Rate for Payer: BCBS MT HealthLink	$123.30
Rate for Payer: BCBS MT Medicare	$123.30
Rate for Payer: BCBS MT POS	$130.15
Rate for Payer: BCBS MT Traditional	$137.00
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial	$130.15
Rate for Payer: Cigna Medicare	$123.30
Rate for Payer: Medicaid All Medicaid	$126.04
Rate for Payer: Medicare All Medicare	$95.90
Rate for Payer: Monida Allegiance	$130.15
Rate for Payer: Monida First Choice Health	$132.89
Rate for Payer: Monida Montana Health Co-op	$130.15
Rate for Payer: Monida PacificSource	$130.15

XR LOWER EXTREMITY RT INFANT

Facility

$137.00

Service Code	HCPCS 73592 TC,RT
Hospital Charge Code	5000003
Hospital Revenue Code	320
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$137.00
Rate for Payer: Aetna Commercial	$130.15
Rate for Payer: Aetna Medicare	$123.30
Rate for Payer: BCBS MT CHIP	$123.30
Rate for Payer: BCBS MT Closed Plan Network	$130.15
Rate for Payer: BCBS MT HealthLink	$123.30
Rate for Payer: BCBS MT Medicare	$123.30
Rate for Payer: BCBS MT POS	$130.15
Rate for Payer: BCBS MT Traditional	$137.00
Rate for Payer: Cash Price	$123.30
Rate for Payer: Cigna Commercial	$130.15
Rate for Payer: Cigna Medicare	$123.30
Rate for Payer: Medicaid All Medicaid	$126.04
Rate for Payer: Medicare All Medicare	$95.90
Rate for Payer: Monida Allegiance	$130.15
Rate for Payer: Monida First Choice Health	$132.89
Rate for Payer: Monida Montana Health Co-op	$130.15
Rate for Payer: Monida PacificSource	$130.15

XR LUMBAR SPINE 2 OR 3 VIEWS

Facility

$322.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000201
Hospital Revenue Code	320
Min. Negotiated Rate	$225.40
Max. Negotiated Rate	$322.00
Rate for Payer: Aetna Commercial	$305.90
Rate for Payer: Aetna Medicare	$289.80
Rate for Payer: BCBS MT CHIP	$289.80
Rate for Payer: BCBS MT Closed Plan Network	$305.90
Rate for Payer: BCBS MT HealthLink	$289.80
Rate for Payer: BCBS MT Medicare	$289.80
Rate for Payer: BCBS MT POS	$305.90
Rate for Payer: BCBS MT Traditional	$322.00
Rate for Payer: Cash Price	$289.80
Rate for Payer: Cigna Commercial	$305.90
Rate for Payer: Cigna Medicare	$289.80
Rate for Payer: Medicaid All Medicaid	$296.24
Rate for Payer: Medicare All Medicare	$225.40
Rate for Payer: Monida Allegiance	$305.90
Rate for Payer: Monida First Choice Health	$312.34
Rate for Payer: Monida Montana Health Co-op	$305.90
Rate for Payer: Monida PacificSource	$305.90

XR LUMBAR SPINE 2 OR 3 VIEWS

Facility

$322.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000201
Hospital Revenue Code	320
Min. Negotiated Rate	$225.40
Max. Negotiated Rate	$322.00
Rate for Payer: Aetna Commercial	$305.90
Rate for Payer: Aetna Medicare	$289.80
Rate for Payer: BCBS MT CHIP	$289.80
Rate for Payer: BCBS MT Closed Plan Network	$305.90
Rate for Payer: BCBS MT HealthLink	$289.80
Rate for Payer: BCBS MT Medicare	$289.80
Rate for Payer: BCBS MT POS	$305.90
Rate for Payer: BCBS MT Traditional	$322.00
Rate for Payer: Cash Price	$289.80
Rate for Payer: Cigna Commercial	$305.90
Rate for Payer: Cigna Medicare	$289.80
Rate for Payer: Medicaid All Medicaid	$296.24
Rate for Payer: Medicare All Medicare	$225.40
Rate for Payer: Monida Allegiance	$305.90
Rate for Payer: Monida First Choice Health	$312.34
Rate for Payer: Monida Montana Health Co-op	$305.90
Rate for Payer: Monida PacificSource	$305.90

XR LUMBAR SPINE 3 VIEWS

Facility

$307.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000202
Hospital Revenue Code	320
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

XR LUMBAR SPINE 3 VIEWS

Facility

$307.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000202
Hospital Revenue Code	320
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

XR LUMBAR SPINE BEND ONLY

Facility

$338.00

Service Code	HCPCS 72120 TC
Hospital Charge Code	5000058
Hospital Revenue Code	320
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

XR LUMBAR SPINE BEND ONLY

Facility

$338.00

Service Code	HCPCS 72120 TC
Hospital Charge Code	5000058
Hospital Revenue Code	320
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

XR LUMBAR SPINE COMPLETE 4 VIEWS

Facility

$454.00

Service Code	HCPCS 72110 TC
Hospital Charge Code	5000200
Hospital Revenue Code	320
Min. Negotiated Rate	$317.80
Max. Negotiated Rate	$454.00
Rate for Payer: Aetna Commercial	$431.30
Rate for Payer: Aetna Medicare	$408.60
Rate for Payer: BCBS MT CHIP	$408.60
Rate for Payer: BCBS MT Closed Plan Network	$431.30
Rate for Payer: BCBS MT HealthLink	$408.60
Rate for Payer: BCBS MT Medicare	$408.60
Rate for Payer: BCBS MT POS	$431.30
Rate for Payer: BCBS MT Traditional	$454.00
Rate for Payer: Cash Price	$408.60
Rate for Payer: Cigna Commercial	$431.30
Rate for Payer: Cigna Medicare	$408.60
Rate for Payer: Medicaid All Medicaid	$417.68
Rate for Payer: Medicare All Medicare	$317.80
Rate for Payer: Monida Allegiance	$431.30
Rate for Payer: Monida First Choice Health	$440.38
Rate for Payer: Monida Montana Health Co-op	$431.30
Rate for Payer: Monida PacificSource	$431.30

XR LUMBAR SPINE COMPLETE 4 VIEWS

Facility

$454.00

Service Code	HCPCS 72110 TC
Hospital Charge Code	5000200
Hospital Revenue Code	320
Min. Negotiated Rate	$317.80
Max. Negotiated Rate	$454.00
Rate for Payer: Aetna Commercial	$431.30
Rate for Payer: Aetna Medicare	$408.60
Rate for Payer: BCBS MT CHIP	$408.60
Rate for Payer: BCBS MT Closed Plan Network	$431.30
Rate for Payer: BCBS MT HealthLink	$408.60
Rate for Payer: BCBS MT Medicare	$408.60
Rate for Payer: BCBS MT POS	$431.30
Rate for Payer: BCBS MT Traditional	$454.00
Rate for Payer: Cash Price	$408.60
Rate for Payer: Cigna Commercial	$431.30
Rate for Payer: Cigna Medicare	$408.60
Rate for Payer: Medicaid All Medicaid	$417.68
Rate for Payer: Medicare All Medicare	$317.80
Rate for Payer: Monida Allegiance	$431.30
Rate for Payer: Monida First Choice Health	$440.38
Rate for Payer: Monida Montana Health Co-op	$431.30
Rate for Payer: Monida PacificSource	$431.30

Know your out-of-pocket cost for care.

All Charges