Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR SINUS 1 OR 2 VIEWS

Facility

$224.00

Service Code	HCPCS 70210 TC
Hospital Charge Code	5000228
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 SINUS 1 OR 2 VIEWS

Facility

$224.00

Service Code	HCPCS 70210 TC
Hospital Charge Code	5000228
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 SINUS COMPLETE

Facility

$350.00

Service Code	HCPCS 70220 TC
Hospital Charge Code	5000229
Hospital Revenue Code	320
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

XR SINUS COMPLETE

Facility

$350.00

Service Code	HCPCS 70220 TC
Hospital Charge Code	5000229
Hospital Revenue Code	320
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$350.00
Rate for Payer: Aetna Commercial	$332.50
Rate for Payer: Aetna Medicare	$315.00
Rate for Payer: BCBS MT CHIP	$315.00
Rate for Payer: BCBS MT Closed Plan Network	$332.50
Rate for Payer: BCBS MT HealthLink	$315.00
Rate for Payer: BCBS MT Medicare	$315.00
Rate for Payer: BCBS MT POS	$332.50
Rate for Payer: BCBS MT Traditional	$350.00
Rate for Payer: Cash Price	$315.00
Rate for Payer: Cigna Commercial	$332.50
Rate for Payer: Cigna Medicare	$315.00
Rate for Payer: Medicaid All Medicaid	$322.00
Rate for Payer: Medicare All Medicare	$245.00
Rate for Payer: Monida Allegiance	$332.50
Rate for Payer: Monida First Choice Health	$339.50
Rate for Payer: Monida Montana Health Co-op	$332.50
Rate for Payer: Monida PacificSource	$332.50

XR SKULL 1 TO 3 VIEWS

Facility

$300.00

Service Code	HCPCS 70250 TC
Hospital Charge Code	5000230
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

XR SKULL 1 TO 3 VIEWS

Facility

$300.00

Service Code	HCPCS 70250 TC
Hospital Charge Code	5000230
Hospital Revenue Code	320
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$300.00
Rate for Payer: Aetna Commercial	$285.00
Rate for Payer: Aetna Medicare	$270.00
Rate for Payer: BCBS MT CHIP	$270.00
Rate for Payer: BCBS MT Closed Plan Network	$285.00
Rate for Payer: BCBS MT HealthLink	$270.00
Rate for Payer: BCBS MT Medicare	$270.00
Rate for Payer: BCBS MT POS	$285.00
Rate for Payer: BCBS MT Traditional	$300.00
Rate for Payer: Cash Price	$270.00
Rate for Payer: Cigna Commercial	$285.00
Rate for Payer: Cigna Medicare	$270.00
Rate for Payer: Medicaid All Medicaid	$276.00
Rate for Payer: Medicare All Medicare	$210.00
Rate for Payer: Monida Allegiance	$285.00
Rate for Payer: Monida First Choice Health	$291.00
Rate for Payer: Monida Montana Health Co-op	$285.00
Rate for Payer: Monida PacificSource	$285.00

XR SKULL COMPLETE 4 VIEWS

Facility

$415.00

Service Code	HCPCS 70260 TC
Hospital Charge Code	5000231
Hospital Revenue Code	320
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$415.00
Rate for Payer: Aetna Commercial	$394.25
Rate for Payer: Aetna Medicare	$373.50
Rate for Payer: BCBS MT CHIP	$373.50
Rate for Payer: BCBS MT Closed Plan Network	$394.25
Rate for Payer: BCBS MT HealthLink	$373.50
Rate for Payer: BCBS MT Medicare	$373.50
Rate for Payer: BCBS MT POS	$394.25
Rate for Payer: BCBS MT Traditional	$415.00
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cigna Commercial	$394.25
Rate for Payer: Cigna Medicare	$373.50
Rate for Payer: Medicaid All Medicaid	$381.80
Rate for Payer: Medicare All Medicare	$290.50
Rate for Payer: Monida Allegiance	$394.25
Rate for Payer: Monida First Choice Health	$402.55
Rate for Payer: Monida Montana Health Co-op	$394.25
Rate for Payer: Monida PacificSource	$394.25

XR SKULL COMPLETE 4 VIEWS

Facility

$415.00

Service Code	HCPCS 70260 TC
Hospital Charge Code	5000231
Hospital Revenue Code	320
Min. Negotiated Rate	$290.50
Max. Negotiated Rate	$415.00
Rate for Payer: Aetna Commercial	$394.25
Rate for Payer: Aetna Medicare	$373.50
Rate for Payer: BCBS MT CHIP	$373.50
Rate for Payer: BCBS MT Closed Plan Network	$394.25
Rate for Payer: BCBS MT HealthLink	$373.50
Rate for Payer: BCBS MT Medicare	$373.50
Rate for Payer: BCBS MT POS	$394.25
Rate for Payer: BCBS MT Traditional	$415.00
Rate for Payer: Cash Price	$373.50
Rate for Payer: Cigna Commercial	$394.25
Rate for Payer: Cigna Medicare	$373.50
Rate for Payer: Medicaid All Medicaid	$381.80
Rate for Payer: Medicare All Medicare	$290.50
Rate for Payer: Monida Allegiance	$394.25
Rate for Payer: Monida First Choice Health	$402.55
Rate for Payer: Monida Montana Health Co-op	$394.25
Rate for Payer: Monida PacificSource	$394.25

XR SOFT TISSUE NECK

Facility

$251.00

Service Code	HCPCS 70360 TC
Hospital Charge Code	5000207
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 SOFT TISSUE NECK

Facility

$251.00

Service Code	HCPCS 70360 TC
Hospital Charge Code	5000207
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 STERNUM

Facility

$290.00

Service Code	HCPCS 71120 TC
Hospital Charge Code	5000233
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 STERNUM

Facility

$290.00

Service Code	HCPCS 71120 TC
Hospital Charge Code	5000233
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 THORACIC SPINE 1 VIEW

Facility

$246.00

Service Code	HCPCS 72020 TC
Hospital Charge Code	5000232
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR THORACIC SPINE 1 VIEW

Facility

$246.00

Service Code	HCPCS 72020 TC
Hospital Charge Code	5000232
Hospital Revenue Code	320
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

XR THORACIC SPINE 2 VIEWS

Facility

$290.00

Service Code	HCPCS 72070 TC
Hospital Charge Code	5000242
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 THORACIC SPINE 2 VIEWS

Facility

$290.00

Service Code	HCPCS 72070 TC
Hospital Charge Code	5000242
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 THORACIC SPINE 3 VIEWS

Facility

$343.00

Service Code	HCPCS 72072 TC
Hospital Charge Code	5000243
Hospital Revenue Code	320
Min. Negotiated Rate	$240.10
Max. Negotiated Rate	$343.00
Rate for Payer: Aetna Commercial	$325.85
Rate for Payer: Aetna Medicare	$308.70
Rate for Payer: BCBS MT CHIP	$308.70
Rate for Payer: BCBS MT Closed Plan Network	$325.85
Rate for Payer: BCBS MT HealthLink	$308.70
Rate for Payer: BCBS MT Medicare	$308.70
Rate for Payer: BCBS MT POS	$325.85
Rate for Payer: BCBS MT Traditional	$343.00
Rate for Payer: Cash Price	$308.70
Rate for Payer: Cigna Commercial	$325.85
Rate for Payer: Cigna Medicare	$308.70
Rate for Payer: Medicaid All Medicaid	$315.56
Rate for Payer: Medicare All Medicare	$240.10
Rate for Payer: Monida Allegiance	$325.85
Rate for Payer: Monida First Choice Health	$332.71
Rate for Payer: Monida Montana Health Co-op	$325.85
Rate for Payer: Monida PacificSource	$325.85

XR THORACIC SPINE 3 VIEWS

Facility

$343.00

Service Code	HCPCS 72072 TC
Hospital Charge Code	5000243
Hospital Revenue Code	320
Min. Negotiated Rate	$240.10
Max. Negotiated Rate	$343.00
Rate for Payer: Aetna Commercial	$325.85
Rate for Payer: Aetna Medicare	$308.70
Rate for Payer: BCBS MT CHIP	$308.70
Rate for Payer: BCBS MT Closed Plan Network	$325.85
Rate for Payer: BCBS MT HealthLink	$308.70
Rate for Payer: BCBS MT Medicare	$308.70
Rate for Payer: BCBS MT POS	$325.85
Rate for Payer: BCBS MT Traditional	$343.00
Rate for Payer: Cash Price	$308.70
Rate for Payer: Cigna Commercial	$325.85
Rate for Payer: Cigna Medicare	$308.70
Rate for Payer: Medicaid All Medicaid	$315.56
Rate for Payer: Medicare All Medicare	$240.10
Rate for Payer: Monida Allegiance	$325.85
Rate for Payer: Monida First Choice Health	$332.71
Rate for Payer: Monida Montana Health Co-op	$325.85
Rate for Payer: Monida PacificSource	$325.85

XR THORACIC SPINE 4 VIEWS

Facility

$328.00

Service Code	HCPCS 72074 TC
Hospital Charge Code	5000182
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 THORACIC SPINE 4 VIEWS

Facility

$328.00

Service Code	HCPCS 72074 TC
Hospital Charge Code	5000182
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 THORACOLUMBAR JUNCTION 2 VIEWS

Facility

$290.00

Service Code	HCPCS 72080 TC
Hospital Charge Code	5000237
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 THORACOLUMBAR JUNCTION 2 VIEWS

Facility

$290.00

Service Code	HCPCS 72080 TC
Hospital Charge Code	5000237
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 TIB FIB BILATERAL

Facility

$260.00

Service Code	HCPCS 73590 TC
Hospital Charge Code	5000234
Hospital Revenue Code	320
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

XR TIB FIB BILATERAL

Facility

$260.00

Service Code	HCPCS 73590 TC
Hospital Charge Code	5000234
Hospital Revenue Code	320
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

Know your out-of-pocket cost for care.

All Charges