Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR PELVIS 3 VIEWS

Facility

$328.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	5000211
Hospital Revenue Code	320
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

XR PELVIS 3 VIEWS

Facility

$328.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	5000211
Hospital Revenue Code	320
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

XR RIBS BILATERAL 3 VIEWS

Facility

$360.00

Service Code	HCPCS 71110 TC
Hospital Charge Code	5000215
Hospital Revenue Code	320
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

XR RIBS BILATERAL 3 VIEWS

Facility

$360.00

Service Code	HCPCS 71110 TC
Hospital Charge Code	5000215
Hospital Revenue Code	320
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$360.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: Aetna Medicare	$324.00
Rate for Payer: BCBS MT CHIP	$324.00
Rate for Payer: BCBS MT Closed Plan Network	$342.00
Rate for Payer: BCBS MT HealthLink	$324.00
Rate for Payer: BCBS MT Medicare	$324.00
Rate for Payer: BCBS MT POS	$342.00
Rate for Payer: BCBS MT Traditional	$360.00
Rate for Payer: Cash Price	$324.00
Rate for Payer: Cigna Commercial	$342.00
Rate for Payer: Cigna Medicare	$324.00
Rate for Payer: Medicaid All Medicaid	$331.20
Rate for Payer: Medicare All Medicare	$252.00
Rate for Payer: Monida Allegiance	$342.00
Rate for Payer: Monida First Choice Health	$349.20
Rate for Payer: Monida Montana Health Co-op	$342.00
Rate for Payer: Monida PacificSource	$342.00

XR RIBS BILATERAL W PA CHEST

Facility

$355.00

Service Code	HCPCS 71101 TC
Hospital Charge Code	5000214
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 RIBS BILATERAL W PA CHEST

Facility

$355.00

Service Code	HCPCS 71101 TC
Hospital Charge Code	5000214
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 RIBS LT 2 VIEWS

Facility

$278.00

Service Code	HCPCS 71100 TC,LT
Hospital Charge Code	5000216
Hospital Revenue Code	320
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

XR RIBS LT 2 VIEWS

Facility

$278.00

Service Code	HCPCS 71100 TC,LT
Hospital Charge Code	5000216
Hospital Revenue Code	320
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

XR RIBS LT 3 VIEWS WITH PA CHEST

Facility

$303.00

Service Code	HCPCS 71100 TC,LT
Hospital Charge Code	5000004
Hospital Revenue Code	320
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

XR RIBS LT 3 VIEWS WITH PA CHEST

Facility

$303.00

Service Code	HCPCS 71100 TC,LT
Hospital Charge Code	5000004
Hospital Revenue Code	320
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

XR RIBS RT 2 VIEWS

Facility

$278.00

Service Code	HCPCS 71100 TC,RT
Hospital Charge Code	5000217
Hospital Revenue Code	320
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

XR RIBS RT 2 VIEWS

Facility

$278.00

Service Code	HCPCS 71100 TC,RT
Hospital Charge Code	5000217
Hospital Revenue Code	320
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$278.00
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: BCBS MT CHIP	$250.20
Rate for Payer: BCBS MT Closed Plan Network	$264.10
Rate for Payer: BCBS MT HealthLink	$250.20
Rate for Payer: BCBS MT Medicare	$250.20
Rate for Payer: BCBS MT POS	$264.10
Rate for Payer: BCBS MT Traditional	$278.00
Rate for Payer: Cash Price	$250.20
Rate for Payer: Cigna Commercial	$264.10
Rate for Payer: Cigna Medicare	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

XR RIBS RT 3 VIEWS WITH PA CHEST

Facility

$303.00

Service Code	HCPCS 71100 TC
Hospital Charge Code	5071100
Hospital Revenue Code	320
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

XR RIBS RT 3 VIEWS WITH PA CHEST

Facility

$303.00

Service Code	HCPCS 71100 TC
Hospital Charge Code	5071100
Hospital Revenue Code	320
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$303.00
Rate for Payer: Aetna Commercial	$287.85
Rate for Payer: Aetna Medicare	$272.70
Rate for Payer: BCBS MT CHIP	$272.70
Rate for Payer: BCBS MT Closed Plan Network	$287.85
Rate for Payer: BCBS MT HealthLink	$272.70
Rate for Payer: BCBS MT Medicare	$272.70
Rate for Payer: BCBS MT POS	$287.85
Rate for Payer: BCBS MT Traditional	$303.00
Rate for Payer: Cash Price	$272.70
Rate for Payer: Cigna Commercial	$287.85
Rate for Payer: Cigna Medicare	$272.70
Rate for Payer: Medicaid All Medicaid	$278.76
Rate for Payer: Medicare All Medicare	$212.10
Rate for Payer: Monida Allegiance	$287.85
Rate for Payer: Monida First Choice Health	$293.91
Rate for Payer: Monida Montana Health Co-op	$287.85
Rate for Payer: Monida PacificSource	$287.85

XR SACRUM COCCYX 2 VIEWS

Facility

$290.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	5000218
Hospital Revenue Code	320
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

XR SACRUM COCCYX 2 VIEWS

Facility

$290.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	5000218
Hospital Revenue Code	320
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

XR SCAPULA LT

Facility

$273.00

Service Code	HCPCS 73010 TC,LT
Hospital Charge Code	5000219
Hospital Revenue Code	320
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

XR SCAPULA LT

Facility

$273.00

Service Code	HCPCS 73010 TC,LT
Hospital Charge Code	5000219
Hospital Revenue Code	320
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

XR SCAPULA RT

Facility

$273.00

Service Code	HCPCS 73010 TC,RT
Hospital Charge Code	5000220
Hospital Revenue Code	320
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

XR SCAPULA RT

Facility

$273.00

Service Code	HCPCS 73010 TC,RT
Hospital Charge Code	5000220
Hospital Revenue Code	320
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

XR SC JOINTS 3 VIEWS

Facility

$251.00

Service Code	HCPCS 71130 TC
Hospital Charge Code	5000076
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 SC JOINTS 3 VIEWS

Facility

$251.00

Service Code	HCPCS 71130 TC
Hospital Charge Code	5000076
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 SCOLIOSIS STUDY

Facility

$317.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5072082
Hospital Revenue Code	320
Min. Negotiated Rate	$221.90
Max. Negotiated Rate	$317.00
Rate for Payer: Aetna Commercial	$301.15
Rate for Payer: Aetna Medicare	$285.30
Rate for Payer: BCBS MT CHIP	$285.30
Rate for Payer: BCBS MT Closed Plan Network	$301.15
Rate for Payer: BCBS MT HealthLink	$285.30
Rate for Payer: BCBS MT Medicare	$285.30
Rate for Payer: BCBS MT POS	$301.15
Rate for Payer: BCBS MT Traditional	$317.00
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial	$301.15
Rate for Payer: Cigna Medicare	$285.30
Rate for Payer: Medicaid All Medicaid	$291.64
Rate for Payer: Medicare All Medicare	$221.90
Rate for Payer: Monida Allegiance	$301.15
Rate for Payer: Monida First Choice Health	$307.49
Rate for Payer: Monida Montana Health Co-op	$301.15
Rate for Payer: Monida PacificSource	$301.15

XR SCOLIOSIS STUDY

Facility

$317.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5072082
Hospital Revenue Code	320
Min. Negotiated Rate	$221.90
Max. Negotiated Rate	$317.00
Rate for Payer: Aetna Commercial	$301.15
Rate for Payer: Aetna Medicare	$285.30
Rate for Payer: BCBS MT CHIP	$285.30
Rate for Payer: BCBS MT Closed Plan Network	$301.15
Rate for Payer: BCBS MT HealthLink	$285.30
Rate for Payer: BCBS MT Medicare	$285.30
Rate for Payer: BCBS MT POS	$301.15
Rate for Payer: BCBS MT Traditional	$317.00
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial	$301.15
Rate for Payer: Cigna Medicare	$285.30
Rate for Payer: Medicaid All Medicaid	$291.64
Rate for Payer: Medicare All Medicare	$221.90
Rate for Payer: Monida Allegiance	$301.15
Rate for Payer: Monida First Choice Health	$307.49
Rate for Payer: Monida Montana Health Co-op	$301.15
Rate for Payer: Monida PacificSource	$301.15

Know your out-of-pocket cost for care.

All Charges