Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR LUMBOSACRAL WITH FLEX AND EXT

Facility

$565.00

Service Code	HCPCS 72114
Hospital Charge Code	5072114
Hospital Revenue Code	320
Min. Negotiated Rate	$395.50
Max. Negotiated Rate	$565.00
Rate for Payer: Aetna Commercial	$536.75
Rate for Payer: Aetna Medicare	$508.50
Rate for Payer: BCBS MT CHIP	$508.50
Rate for Payer: BCBS MT Closed Plan Network	$536.75
Rate for Payer: BCBS MT HealthLink	$508.50
Rate for Payer: BCBS MT Medicare	$508.50
Rate for Payer: BCBS MT POS	$536.75
Rate for Payer: BCBS MT Traditional	$565.00
Rate for Payer: Cash Price	$508.50
Rate for Payer: Cigna Commercial	$536.75
Rate for Payer: Cigna Medicare	$508.50
Rate for Payer: Medicaid All Medicaid	$519.80
Rate for Payer: Medicare All Medicare	$395.50
Rate for Payer: Monida Allegiance	$536.75
Rate for Payer: Monida First Choice Health	$548.05
Rate for Payer: Monida Montana Health Co-op	$536.75
Rate for Payer: Monida PacificSource	$536.75

XR LUMBOSACRAL WITH FLEX AND EXT

Facility

$565.00

Service Code	HCPCS 72114
Hospital Charge Code	5072114
Hospital Revenue Code	320
Min. Negotiated Rate	$395.50
Max. Negotiated Rate	$565.00
Rate for Payer: Aetna Commercial	$536.75
Rate for Payer: Aetna Medicare	$508.50
Rate for Payer: BCBS MT CHIP	$508.50
Rate for Payer: BCBS MT Closed Plan Network	$536.75
Rate for Payer: BCBS MT HealthLink	$508.50
Rate for Payer: BCBS MT Medicare	$508.50
Rate for Payer: BCBS MT POS	$536.75
Rate for Payer: BCBS MT Traditional	$565.00
Rate for Payer: Cash Price	$508.50
Rate for Payer: Cigna Commercial	$536.75
Rate for Payer: Cigna Medicare	$508.50
Rate for Payer: Medicaid All Medicaid	$519.80
Rate for Payer: Medicare All Medicare	$395.50
Rate for Payer: Monida Allegiance	$536.75
Rate for Payer: Monida First Choice Health	$548.05
Rate for Payer: Monida Montana Health Co-op	$536.75
Rate for Payer: Monida PacificSource	$536.75

XR MANDIBLE 4 VIEWS

Facility

$365.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	5000060
Hospital Revenue Code	320
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

XR MANDIBLE 4 VIEWS

Facility

$365.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	5000060
Hospital Revenue Code	320
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$365.00
Rate for Payer: Aetna Commercial	$346.75
Rate for Payer: Aetna Medicare	$328.50
Rate for Payer: BCBS MT CHIP	$328.50
Rate for Payer: BCBS MT Closed Plan Network	$346.75
Rate for Payer: BCBS MT HealthLink	$328.50
Rate for Payer: BCBS MT Medicare	$328.50
Rate for Payer: BCBS MT POS	$346.75
Rate for Payer: BCBS MT Traditional	$365.00
Rate for Payer: Cash Price	$328.50
Rate for Payer: Cigna Commercial	$346.75
Rate for Payer: Cigna Medicare	$328.50
Rate for Payer: Medicaid All Medicaid	$335.80
Rate for Payer: Medicare All Medicare	$255.50
Rate for Payer: Monida Allegiance	$346.75
Rate for Payer: Monida First Choice Health	$354.05
Rate for Payer: Monida Montana Health Co-op	$346.75
Rate for Payer: Monida PacificSource	$346.75

XR MANDIBLE BILATERAL 1 OR 2 VIEWS

Facility

$235.00

Service Code	HCPCS 70100 TC
Hospital Charge Code	5000203
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR MANDIBLE BILATERAL 1 OR 2 VIEWS

Facility

$235.00

Service Code	HCPCS 70100 TC
Hospital Charge Code	5000203
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR MANDIBLE LT 1-2 VIEW

Facility

$235.00

Service Code	HCPCS 70100 TC,LT
Hospital Charge Code	5000204
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR MANDIBLE LT 1-2 VIEW

Facility

$235.00

Service Code	HCPCS 70100 TC,LT
Hospital Charge Code	5000204
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR MANDIBLE RT 1-2 VIEW

Facility

$235.00

Service Code	HCPCS 70100 TC,RT
Hospital Charge Code	5000205
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR MANDIBLE RT 1-2 VIEW

Facility

$235.00

Service Code	HCPCS 70100 TC,RT
Hospital Charge Code	5000205
Hospital Revenue Code	320
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

XR MASTOIDS GREATER THAN 3 PER SIDE

Facility

$265.00

Service Code	HCPCS 70130 TC
Hospital Charge Code	5000143
Hospital Revenue Code	320
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

XR MASTOIDS GREATER THAN 3 PER SIDE

Facility

$265.00

Service Code	HCPCS 70130 TC
Hospital Charge Code	5000143
Hospital Revenue Code	320
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

XR MASTOIDS LESS THAN 3 PER SIDE

Facility

$135.00

Service Code	HCPCS 70120 TC
Hospital Charge Code	5000059
Hospital Revenue Code	320
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

XR MASTOIDS LESS THAN 3 PER SIDE

Facility

$135.00

Service Code	HCPCS 70120 TC
Hospital Charge Code	5000059
Hospital Revenue Code	320
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

XR NASAL BONES 3 VIEWS

Facility

$284.00

Service Code	HCPCS 70160 TC
Hospital Charge Code	5000206
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 NASAL BONES 3 VIEWS

Facility

$284.00

Service Code	HCPCS 70160 TC
Hospital Charge Code	5000206
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 OP MAJOR JOINT INJ W/US 20611

Facility

$983.00

Service Code	HCPCS 20611
Hospital Charge Code	5020611
Hospital Revenue Code	409
Min. Negotiated Rate	$688.10
Max. Negotiated Rate	$983.00
Rate for Payer: Aetna Commercial	$933.85
Rate for Payer: Aetna Medicare	$884.70
Rate for Payer: BCBS MT CHIP	$884.70
Rate for Payer: BCBS MT Closed Plan Network	$933.85
Rate for Payer: BCBS MT HealthLink	$884.70
Rate for Payer: BCBS MT Medicare	$884.70
Rate for Payer: BCBS MT POS	$933.85
Rate for Payer: BCBS MT Traditional	$983.00
Rate for Payer: Cash Price	$884.70
Rate for Payer: Cigna Commercial	$933.85
Rate for Payer: Cigna Medicare	$884.70
Rate for Payer: Medicaid All Medicaid	$904.36
Rate for Payer: Medicare All Medicare	$688.10
Rate for Payer: Monida Allegiance	$933.85
Rate for Payer: Monida First Choice Health	$953.51
Rate for Payer: Monida Montana Health Co-op	$933.85
Rate for Payer: Monida PacificSource	$933.85

XR OP MAJOR JOINT INJ W/US 20611

Facility

$983.00

Service Code	HCPCS 20611
Hospital Charge Code	5020611
Hospital Revenue Code	409
Min. Negotiated Rate	$688.10
Max. Negotiated Rate	$983.00
Rate for Payer: Aetna Commercial	$933.85
Rate for Payer: Aetna Medicare	$884.70
Rate for Payer: BCBS MT CHIP	$884.70
Rate for Payer: BCBS MT Closed Plan Network	$933.85
Rate for Payer: BCBS MT HealthLink	$884.70
Rate for Payer: BCBS MT Medicare	$884.70
Rate for Payer: BCBS MT POS	$933.85
Rate for Payer: BCBS MT Traditional	$983.00
Rate for Payer: Cash Price	$884.70
Rate for Payer: Cigna Commercial	$933.85
Rate for Payer: Cigna Medicare	$884.70
Rate for Payer: Medicaid All Medicaid	$904.36
Rate for Payer: Medicare All Medicare	$688.10
Rate for Payer: Monida Allegiance	$933.85
Rate for Payer: Monida First Choice Health	$953.51
Rate for Payer: Monida Montana Health Co-op	$933.85
Rate for Payer: Monida PacificSource	$933.85

XR ORBITS 1 VIEW

Facility

$208.00

Service Code	HCPCS 70190 TC
Hospital Charge Code	5000061
Hospital Revenue Code	320
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

XR ORBITS 1 VIEW

Facility

$208.00

Service Code	HCPCS 70190 TC
Hospital Charge Code	5000061
Hospital Revenue Code	320
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

XR ORBITS COMPLETE 4 VIEWS

Facility

$338.00

Service Code	HCPCS 70200 TC
Hospital Charge Code	5000208
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 ORBITS COMPLETE 4 VIEWS

Facility

$338.00

Service Code	HCPCS 70200 TC
Hospital Charge Code	5000208
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 PELVIS 1 VIEW

Facility

$263.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	5000209
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 PELVIS 1 VIEW

Facility

$263.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	5000209
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 PELVIS 2 VIEWS

Facility

$250.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	5000210
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

Know your out-of-pocket cost for care.

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