Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR SCOLIOSIS STUDY 1 VIEW

Facility

$208.00

Service Code	HCPCS 72081 TC
Hospital Charge Code	5072081
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 SCOLIOSIS STUDY 1 VIEW

Facility

$208.00

Service Code	HCPCS 72081 TC
Hospital Charge Code	5072081
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 SCOLIOSIS STUDY 4-5 VIEWS

Facility

$426.00

Service Code	HCPCS 72083 TC
Hospital Charge Code	5072083
Hospital Revenue Code	320
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$426.00
Rate for Payer: Aetna Commercial	$404.70
Rate for Payer: Aetna Medicare	$383.40
Rate for Payer: BCBS MT CHIP	$383.40
Rate for Payer: BCBS MT Closed Plan Network	$404.70
Rate for Payer: BCBS MT HealthLink	$383.40
Rate for Payer: BCBS MT Medicare	$383.40
Rate for Payer: BCBS MT POS	$404.70
Rate for Payer: BCBS MT Traditional	$426.00
Rate for Payer: Cash Price	$383.40
Rate for Payer: Cigna Commercial	$404.70
Rate for Payer: Cigna Medicare	$383.40
Rate for Payer: Medicaid All Medicaid	$391.92
Rate for Payer: Medicare All Medicare	$298.20
Rate for Payer: Monida Allegiance	$404.70
Rate for Payer: Monida First Choice Health	$413.22
Rate for Payer: Monida Montana Health Co-op	$404.70
Rate for Payer: Monida PacificSource	$404.70

XR SCOLIOSIS STUDY 4-5 VIEWS

Facility

$426.00

Service Code	HCPCS 72083 TC
Hospital Charge Code	5072083
Hospital Revenue Code	320
Min. Negotiated Rate	$298.20
Max. Negotiated Rate	$426.00
Rate for Payer: Aetna Commercial	$404.70
Rate for Payer: Aetna Medicare	$383.40
Rate for Payer: BCBS MT CHIP	$383.40
Rate for Payer: BCBS MT Closed Plan Network	$404.70
Rate for Payer: BCBS MT HealthLink	$383.40
Rate for Payer: BCBS MT Medicare	$383.40
Rate for Payer: BCBS MT POS	$404.70
Rate for Payer: BCBS MT Traditional	$426.00
Rate for Payer: Cash Price	$383.40
Rate for Payer: Cigna Commercial	$404.70
Rate for Payer: Cigna Medicare	$383.40
Rate for Payer: Medicaid All Medicaid	$391.92
Rate for Payer: Medicare All Medicare	$298.20
Rate for Payer: Monida Allegiance	$404.70
Rate for Payer: Monida First Choice Health	$413.22
Rate for Payer: Monida Montana Health Co-op	$404.70
Rate for Payer: Monida PacificSource	$404.70

XR SCOLIOSIS STUDY MIN 6 VIEWS

Facility

$536.00

Service Code	HCPCS 72084 TC
Hospital Charge Code	5072084
Hospital Revenue Code	320
Min. Negotiated Rate	$375.20
Max. Negotiated Rate	$536.00
Rate for Payer: Aetna Commercial	$509.20
Rate for Payer: Aetna Medicare	$482.40
Rate for Payer: BCBS MT CHIP	$482.40
Rate for Payer: BCBS MT Closed Plan Network	$509.20
Rate for Payer: BCBS MT HealthLink	$482.40
Rate for Payer: BCBS MT Medicare	$482.40
Rate for Payer: BCBS MT POS	$509.20
Rate for Payer: BCBS MT Traditional	$536.00
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cigna Commercial	$509.20
Rate for Payer: Cigna Medicare	$482.40
Rate for Payer: Medicaid All Medicaid	$493.12
Rate for Payer: Medicare All Medicare	$375.20
Rate for Payer: Monida Allegiance	$509.20
Rate for Payer: Monida First Choice Health	$519.92
Rate for Payer: Monida Montana Health Co-op	$509.20
Rate for Payer: Monida PacificSource	$509.20

XR SCOLIOSIS STUDY MIN 6 VIEWS

Facility

$536.00

Service Code	HCPCS 72084 TC
Hospital Charge Code	5072084
Hospital Revenue Code	320
Min. Negotiated Rate	$375.20
Max. Negotiated Rate	$536.00
Rate for Payer: Aetna Commercial	$509.20
Rate for Payer: Aetna Medicare	$482.40
Rate for Payer: BCBS MT CHIP	$482.40
Rate for Payer: BCBS MT Closed Plan Network	$509.20
Rate for Payer: BCBS MT HealthLink	$482.40
Rate for Payer: BCBS MT Medicare	$482.40
Rate for Payer: BCBS MT POS	$509.20
Rate for Payer: BCBS MT Traditional	$536.00
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cigna Commercial	$509.20
Rate for Payer: Cigna Medicare	$482.40
Rate for Payer: Medicaid All Medicaid	$493.12
Rate for Payer: Medicare All Medicare	$375.20
Rate for Payer: Monida Allegiance	$509.20
Rate for Payer: Monida First Choice Health	$519.92
Rate for Payer: Monida Montana Health Co-op	$509.20
Rate for Payer: Monida PacificSource	$509.20

XR SHOULDER LT 1 VIEW

Facility

$519.00

Service Code	HCPCS 73020 TC,LT
Hospital Charge Code	5000225
Hospital Revenue Code	320
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

XR SHOULDER LT 1 VIEW

Facility

$519.00

Service Code	HCPCS 73020 TC,LT
Hospital Charge Code	5000225
Hospital Revenue Code	320
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

XR SHOULDER LT 2-3 VIEWS

Facility

$673.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000005
Hospital Revenue Code	320
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

XR SHOULDER LT 2-3 VIEWS

Facility

$673.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000005
Hospital Revenue Code	320
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

XR SHOULDER LT 2 VIEWS

Facility

$641.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000222
Hospital Revenue Code	320
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

XR SHOULDER LT 2 VIEWS

Facility

$641.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000222
Hospital Revenue Code	320
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

XR SHOULDER RT 1 VIEW

Facility

$519.00

Service Code	HCPCS 73020 TC,RT
Hospital Charge Code	5000226
Hospital Revenue Code	320
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

XR SHOULDER RT 1 VIEW

Facility

$519.00

Service Code	HCPCS 73020 TC,RT
Hospital Charge Code	5000226
Hospital Revenue Code	320
Min. Negotiated Rate	$363.30
Max. Negotiated Rate	$519.00
Rate for Payer: Aetna Commercial	$493.05
Rate for Payer: Aetna Medicare	$467.10
Rate for Payer: BCBS MT CHIP	$467.10
Rate for Payer: BCBS MT Closed Plan Network	$493.05
Rate for Payer: BCBS MT HealthLink	$467.10
Rate for Payer: BCBS MT Medicare	$467.10
Rate for Payer: BCBS MT POS	$493.05
Rate for Payer: BCBS MT Traditional	$519.00
Rate for Payer: Cash Price	$467.10
Rate for Payer: Cigna Commercial	$493.05
Rate for Payer: Cigna Medicare	$467.10
Rate for Payer: Medicaid All Medicaid	$477.48
Rate for Payer: Medicare All Medicare	$363.30
Rate for Payer: Monida Allegiance	$493.05
Rate for Payer: Monida First Choice Health	$503.43
Rate for Payer: Monida Montana Health Co-op	$493.05
Rate for Payer: Monida PacificSource	$493.05

XR SHOULDER RT 2-3 VIEWS

Facility

$673.00

Service Code	HCPCS 73030 TC
Hospital Charge Code	5073030
Hospital Revenue Code	320
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

XR SHOULDER RT 2-3 VIEWS

Facility

$673.00

Service Code	HCPCS 73030 TC
Hospital Charge Code	5073030
Hospital Revenue Code	320
Min. Negotiated Rate	$471.10
Max. Negotiated Rate	$673.00
Rate for Payer: Aetna Commercial	$639.35
Rate for Payer: Aetna Medicare	$605.70
Rate for Payer: BCBS MT CHIP	$605.70
Rate for Payer: BCBS MT Closed Plan Network	$639.35
Rate for Payer: BCBS MT HealthLink	$605.70
Rate for Payer: BCBS MT Medicare	$605.70
Rate for Payer: BCBS MT POS	$639.35
Rate for Payer: BCBS MT Traditional	$673.00
Rate for Payer: Cash Price	$605.70
Rate for Payer: Cigna Commercial	$639.35
Rate for Payer: Cigna Medicare	$605.70
Rate for Payer: Medicaid All Medicaid	$619.16
Rate for Payer: Medicare All Medicare	$471.10
Rate for Payer: Monida Allegiance	$639.35
Rate for Payer: Monida First Choice Health	$652.81
Rate for Payer: Monida Montana Health Co-op	$639.35
Rate for Payer: Monida PacificSource	$639.35

XR SHOULDER RT 2 VIEWS

Facility

$641.00

Service Code	HCPCS 73030 TC,RT
Hospital Charge Code	5000223
Hospital Revenue Code	320
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

XR SHOULDER RT 2 VIEWS

Facility

$641.00

Service Code	HCPCS 73030 TC,RT
Hospital Charge Code	5000223
Hospital Revenue Code	320
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

XR SHOULDERS BILATERAL 1 VIEW

Facility

$494.00

Service Code	HCPCS 73020 TC
Hospital Charge Code	5000224
Hospital Revenue Code	320
Min. Negotiated Rate	$345.80
Max. Negotiated Rate	$494.00
Rate for Payer: Aetna Commercial	$469.30
Rate for Payer: Aetna Medicare	$444.60
Rate for Payer: BCBS MT CHIP	$444.60
Rate for Payer: BCBS MT Closed Plan Network	$469.30
Rate for Payer: BCBS MT HealthLink	$444.60
Rate for Payer: BCBS MT Medicare	$444.60
Rate for Payer: BCBS MT POS	$469.30
Rate for Payer: BCBS MT Traditional	$494.00
Rate for Payer: Cash Price	$444.60
Rate for Payer: Cigna Commercial	$469.30
Rate for Payer: Cigna Medicare	$444.60
Rate for Payer: Medicaid All Medicaid	$454.48
Rate for Payer: Medicare All Medicare	$345.80
Rate for Payer: Monida Allegiance	$469.30
Rate for Payer: Monida First Choice Health	$479.18
Rate for Payer: Monida Montana Health Co-op	$469.30
Rate for Payer: Monida PacificSource	$469.30

XR SHOULDERS BILATERAL 1 VIEW

Facility

$494.00

Service Code	HCPCS 73020 TC
Hospital Charge Code	5000224
Hospital Revenue Code	320
Min. Negotiated Rate	$345.80
Max. Negotiated Rate	$494.00
Rate for Payer: Aetna Commercial	$469.30
Rate for Payer: Aetna Medicare	$444.60
Rate for Payer: BCBS MT CHIP	$444.60
Rate for Payer: BCBS MT Closed Plan Network	$469.30
Rate for Payer: BCBS MT HealthLink	$444.60
Rate for Payer: BCBS MT Medicare	$444.60
Rate for Payer: BCBS MT POS	$469.30
Rate for Payer: BCBS MT Traditional	$494.00
Rate for Payer: Cash Price	$444.60
Rate for Payer: Cigna Commercial	$469.30
Rate for Payer: Cigna Medicare	$444.60
Rate for Payer: Medicaid All Medicaid	$454.48
Rate for Payer: Medicare All Medicare	$345.80
Rate for Payer: Monida Allegiance	$469.30
Rate for Payer: Monida First Choice Health	$479.18
Rate for Payer: Monida Montana Health Co-op	$469.30
Rate for Payer: Monida PacificSource	$469.30

XR SHOULDERS BILATERAL 3 VIEWS

Facility

$641.00

Service Code	HCPCS 73030 TC
Hospital Charge Code	5000221
Hospital Revenue Code	320
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

XR SHOULDERS BILATERAL 3 VIEWS

Facility

$641.00

Service Code	HCPCS 73030 TC
Hospital Charge Code	5000221
Hospital Revenue Code	320
Min. Negotiated Rate	$448.70
Max. Negotiated Rate	$641.00
Rate for Payer: Aetna Commercial	$608.95
Rate for Payer: Aetna Medicare	$576.90
Rate for Payer: BCBS MT CHIP	$576.90
Rate for Payer: BCBS MT Closed Plan Network	$608.95
Rate for Payer: BCBS MT HealthLink	$576.90
Rate for Payer: BCBS MT Medicare	$576.90
Rate for Payer: BCBS MT POS	$608.95
Rate for Payer: BCBS MT Traditional	$641.00
Rate for Payer: Cash Price	$576.90
Rate for Payer: Cigna Commercial	$608.95
Rate for Payer: Cigna Medicare	$576.90
Rate for Payer: Medicaid All Medicaid	$589.72
Rate for Payer: Medicare All Medicare	$448.70
Rate for Payer: Monida Allegiance	$608.95
Rate for Payer: Monida First Choice Health	$621.77
Rate for Payer: Monida Montana Health Co-op	$608.95
Rate for Payer: Monida PacificSource	$608.95

XR SI JOINTS 3 VIEWS

Facility

$281.00

Service Code	HCPCS 72202 TC
Hospital Charge Code	5000062
Hospital Revenue Code	320
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$281.00
Rate for Payer: Aetna Commercial	$266.95
Rate for Payer: Aetna Medicare	$252.90
Rate for Payer: BCBS MT CHIP	$252.90
Rate for Payer: BCBS MT Closed Plan Network	$266.95
Rate for Payer: BCBS MT HealthLink	$252.90
Rate for Payer: BCBS MT Medicare	$252.90
Rate for Payer: BCBS MT POS	$266.95
Rate for Payer: BCBS MT Traditional	$281.00
Rate for Payer: Cash Price	$252.90
Rate for Payer: Cigna Commercial	$266.95
Rate for Payer: Cigna Medicare	$252.90
Rate for Payer: Medicaid All Medicaid	$258.52
Rate for Payer: Medicare All Medicare	$196.70
Rate for Payer: Monida Allegiance	$266.95
Rate for Payer: Monida First Choice Health	$272.57
Rate for Payer: Monida Montana Health Co-op	$266.95
Rate for Payer: Monida PacificSource	$266.95

XR SI JOINTS 3 VIEWS

Facility

$281.00

Service Code	HCPCS 72202 TC
Hospital Charge Code	5000062
Hospital Revenue Code	320
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$281.00
Rate for Payer: Aetna Commercial	$266.95
Rate for Payer: Aetna Medicare	$252.90
Rate for Payer: BCBS MT CHIP	$252.90
Rate for Payer: BCBS MT Closed Plan Network	$266.95
Rate for Payer: BCBS MT HealthLink	$252.90
Rate for Payer: BCBS MT Medicare	$252.90
Rate for Payer: BCBS MT POS	$266.95
Rate for Payer: BCBS MT Traditional	$281.00
Rate for Payer: Cash Price	$252.90
Rate for Payer: Cigna Commercial	$266.95
Rate for Payer: Cigna Medicare	$252.90
Rate for Payer: Medicaid All Medicaid	$258.52
Rate for Payer: Medicare All Medicare	$196.70
Rate for Payer: Monida Allegiance	$266.95
Rate for Payer: Monida First Choice Health	$272.57
Rate for Payer: Monida Montana Health Co-op	$266.95
Rate for Payer: Monida PacificSource	$266.95

XR SI JOINTS BILATERAL

Facility

$224.00

Service Code	HCPCS 72200 TC
Hospital Charge Code	5000227
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

Know your out-of-pocket cost for care.

All Charges