Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR TIB FIB LT

Facility

$273.00

Service Code	HCPCS 73590 TC,LT
Hospital Charge Code	5000235
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 TIB FIB LT

Facility

$273.00

Service Code	HCPCS 73590 TC,LT
Hospital Charge Code	5000235
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 TIB FIB RT

Facility

$273.00

Service Code	HCPCS 73590 TC,RT
Hospital Charge Code	5000236
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 TIB FIB RT

Facility

$273.00

Service Code	HCPCS 73590 TC,RT
Hospital Charge Code	5000236
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 TMJ

Facility

$191.00

Service Code	HCPCS 70328 TC
Hospital Charge Code	5000238
Hospital Revenue Code	320
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: BCBS MT CHIP	$171.90
Rate for Payer: BCBS MT Closed Plan Network	$181.45
Rate for Payer: BCBS MT HealthLink	$171.90
Rate for Payer: BCBS MT Medicare	$171.90
Rate for Payer: BCBS MT POS	$181.45
Rate for Payer: BCBS MT Traditional	$191.00
Rate for Payer: Cash Price	$171.90
Rate for Payer: Cigna Commercial	$181.45
Rate for Payer: Cigna Medicare	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

XR TMJ

Facility

$191.00

Service Code	HCPCS 70328 TC
Hospital Charge Code	5000238
Hospital Revenue Code	320
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: BCBS MT CHIP	$171.90
Rate for Payer: BCBS MT Closed Plan Network	$181.45
Rate for Payer: BCBS MT HealthLink	$171.90
Rate for Payer: BCBS MT Medicare	$171.90
Rate for Payer: BCBS MT POS	$181.45
Rate for Payer: BCBS MT Traditional	$191.00
Rate for Payer: Cash Price	$171.90
Rate for Payer: Cigna Commercial	$181.45
Rate for Payer: Cigna Medicare	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

XR TMJ LT

Facility

$311.00

Service Code	HCPCS 70330 TC
Hospital Charge Code	5000075
Hospital Revenue Code	320
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

XR TMJ LT

Facility

$311.00

Service Code	HCPCS 70330 TC
Hospital Charge Code	5000075
Hospital Revenue Code	320
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

XR TMJ RT

Facility

$311.00

Service Code	HCPCS 70330 TC,RT
Hospital Charge Code	5000002
Hospital Revenue Code	320
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

XR TMJ RT

Facility

$311.00

Service Code	HCPCS 70330 TC,RT
Hospital Charge Code	5000002
Hospital Revenue Code	320
Min. Negotiated Rate	$217.70
Max. Negotiated Rate	$311.00
Rate for Payer: Aetna Commercial	$295.45
Rate for Payer: Aetna Medicare	$279.90
Rate for Payer: BCBS MT CHIP	$279.90
Rate for Payer: BCBS MT Closed Plan Network	$295.45
Rate for Payer: BCBS MT HealthLink	$279.90
Rate for Payer: BCBS MT Medicare	$279.90
Rate for Payer: BCBS MT POS	$295.45
Rate for Payer: BCBS MT Traditional	$311.00
Rate for Payer: Cash Price	$279.90
Rate for Payer: Cigna Commercial	$295.45
Rate for Payer: Cigna Medicare	$279.90
Rate for Payer: Medicaid All Medicaid	$286.12
Rate for Payer: Medicare All Medicare	$217.70
Rate for Payer: Monida Allegiance	$295.45
Rate for Payer: Monida First Choice Health	$301.67
Rate for Payer: Monida Montana Health Co-op	$295.45
Rate for Payer: Monida PacificSource	$295.45

XR TOES BILATERAL

Facility

$218.00

Service Code	HCPCS 73660 TC
Hospital Charge Code	5000239
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR TOES BILATERAL

Facility

$218.00

Service Code	HCPCS 73660 TC
Hospital Charge Code	5000239
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR TOES LT

Facility

$229.00

Service Code	HCPCS 73660 TC,LT
Hospital Charge Code	5000240
Hospital Revenue Code	320
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

XR TOES LT

Facility

$229.00

Service Code	HCPCS 73660 TC,LT
Hospital Charge Code	5000240
Hospital Revenue Code	320
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

XR TOES RT

Facility

$229.00

Service Code	HCPCS 73660 TC,RT
Hospital Charge Code	5000241
Hospital Revenue Code	320
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

XR TOES RT

Facility

$229.00

Service Code	HCPCS 73660 TC,RT
Hospital Charge Code	5000241
Hospital Revenue Code	320
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

XR ULTRASOUND NEEDLE GUID 76942

Facility

$1,194.00

Service Code	HCPCS 76942
Hospital Charge Code	5076942
Hospital Revenue Code	402
Min. Negotiated Rate	$835.80
Max. Negotiated Rate	$1,194.00
Rate for Payer: Aetna Commercial	$1,134.30
Rate for Payer: Aetna Medicare	$1,074.60
Rate for Payer: BCBS MT CHIP	$1,074.60
Rate for Payer: BCBS MT Closed Plan Network	$1,134.30
Rate for Payer: BCBS MT HealthLink	$1,074.60
Rate for Payer: BCBS MT Medicare	$1,074.60
Rate for Payer: BCBS MT POS	$1,134.30
Rate for Payer: BCBS MT Traditional	$1,194.00
Rate for Payer: Cash Price	$1,074.60
Rate for Payer: Cigna Commercial	$1,134.30
Rate for Payer: Cigna Medicare	$1,074.60
Rate for Payer: Medicaid All Medicaid	$1,098.48
Rate for Payer: Medicare All Medicare	$835.80
Rate for Payer: Monida Allegiance	$1,134.30
Rate for Payer: Monida First Choice Health	$1,158.18
Rate for Payer: Monida Montana Health Co-op	$1,134.30
Rate for Payer: Monida PacificSource	$1,134.30

XR ULTRASOUND NEEDLE GUID 76942

Facility

$1,194.00

Service Code	HCPCS 76942
Hospital Charge Code	5076942
Hospital Revenue Code	402
Min. Negotiated Rate	$835.80
Max. Negotiated Rate	$1,194.00
Rate for Payer: Aetna Commercial	$1,134.30
Rate for Payer: Aetna Medicare	$1,074.60
Rate for Payer: BCBS MT CHIP	$1,074.60
Rate for Payer: BCBS MT Closed Plan Network	$1,134.30
Rate for Payer: BCBS MT HealthLink	$1,074.60
Rate for Payer: BCBS MT Medicare	$1,074.60
Rate for Payer: BCBS MT POS	$1,134.30
Rate for Payer: BCBS MT Traditional	$1,194.00
Rate for Payer: Cash Price	$1,074.60
Rate for Payer: Cigna Commercial	$1,134.30
Rate for Payer: Cigna Medicare	$1,074.60
Rate for Payer: Medicaid All Medicaid	$1,098.48
Rate for Payer: Medicare All Medicare	$835.80
Rate for Payer: Monida Allegiance	$1,134.30
Rate for Payer: Monida First Choice Health	$1,158.18
Rate for Payer: Monida Montana Health Co-op	$1,134.30
Rate for Payer: Monida PacificSource	$1,134.30

XR UPPER EXTREMITY LT INFANT

Facility

$218.00

Service Code	HCPCS 73092 TC
Hospital Charge Code	5000070
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR UPPER EXTREMITY LT INFANT

Facility

$218.00

Service Code	HCPCS 73092 TC
Hospital Charge Code	5000070
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR UPPER EXTREMITY RT INFANT

Facility

$218.00

Service Code	HCPCS 73092 TC,RT
Hospital Charge Code	5000001
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR UPPER EXTREMITY RT INFANT

Facility

$218.00

Service Code	HCPCS 73092 TC,RT
Hospital Charge Code	5000001
Hospital Revenue Code	320
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$218.00
Rate for Payer: Aetna Commercial	$207.10
Rate for Payer: Aetna Medicare	$196.20
Rate for Payer: BCBS MT CHIP	$196.20
Rate for Payer: BCBS MT Closed Plan Network	$207.10
Rate for Payer: BCBS MT HealthLink	$196.20
Rate for Payer: BCBS MT Medicare	$196.20
Rate for Payer: BCBS MT POS	$207.10
Rate for Payer: BCBS MT Traditional	$218.00
Rate for Payer: Cash Price	$196.20
Rate for Payer: Cigna Commercial	$207.10
Rate for Payer: Cigna Medicare	$196.20
Rate for Payer: Medicaid All Medicaid	$200.56
Rate for Payer: Medicare All Medicare	$152.60
Rate for Payer: Monida Allegiance	$207.10
Rate for Payer: Monida First Choice Health	$211.46
Rate for Payer: Monida Montana Health Co-op	$207.10
Rate for Payer: Monida PacificSource	$207.10

XR WRIST BILATERAL 2 VIEWS

Facility

$224.00

Service Code	HCPCS 73100 TC
Hospital Charge Code	5000244
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 WRIST BILATERAL 2 VIEWS

Facility

$224.00

Service Code	HCPCS 73100 TC
Hospital Charge Code	5000244
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 WRIST BILATERAL 3 VIEWS

Facility

$270.00

Service Code	HCPCS 73110 TC
Hospital Charge Code	5000245
Hospital Revenue Code	320
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna Commercial	$256.50
Rate for Payer: Aetna Medicare	$243.00
Rate for Payer: BCBS MT CHIP	$243.00
Rate for Payer: BCBS MT Closed Plan Network	$256.50
Rate for Payer: BCBS MT HealthLink	$243.00
Rate for Payer: BCBS MT Medicare	$243.00
Rate for Payer: BCBS MT POS	$256.50
Rate for Payer: BCBS MT Traditional	$270.00
Rate for Payer: Cash Price	$243.00
Rate for Payer: Cigna Commercial	$256.50
Rate for Payer: Cigna Medicare	$243.00
Rate for Payer: Medicaid All Medicaid	$248.40
Rate for Payer: Medicare All Medicare	$189.00
Rate for Payer: Monida Allegiance	$256.50
Rate for Payer: Monida First Choice Health	$261.90
Rate for Payer: Monida Montana Health Co-op	$256.50
Rate for Payer: Monida PacificSource	$256.50

Know your out-of-pocket cost for care.

All Charges