Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR ABDOMEN 2 VIEWS

Facility

$298.00

Service Code	HCPCS 74019 TC
Hospital Charge Code	5074019
Hospital Revenue Code	320
Min. Negotiated Rate	$208.60
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$283.10
Rate for Payer: Aetna Medicare	$268.20
Rate for Payer: BCBS MT CHIP	$268.20
Rate for Payer: BCBS MT Closed Plan Network	$283.10
Rate for Payer: BCBS MT HealthLink	$268.20
Rate for Payer: BCBS MT Medicare	$268.20
Rate for Payer: BCBS MT POS	$283.10
Rate for Payer: BCBS MT Traditional	$298.00
Rate for Payer: Cash Price	$268.20
Rate for Payer: Cigna Commercial	$283.10
Rate for Payer: Cigna Medicare	$268.20
Rate for Payer: Medicaid All Medicaid	$274.16
Rate for Payer: Medicare All Medicare	$208.60
Rate for Payer: Monida Allegiance	$283.10
Rate for Payer: Monida First Choice Health	$289.06
Rate for Payer: Monida Montana Health Co-op	$283.10
Rate for Payer: Monida PacificSource	$283.10

XR ABDOMEN 2 VIEWS

Facility

$298.00

Service Code	HCPCS 74019 TC
Hospital Charge Code	5074019
Hospital Revenue Code	320
Min. Negotiated Rate	$208.60
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$283.10
Rate for Payer: Aetna Medicare	$268.20
Rate for Payer: BCBS MT CHIP	$268.20
Rate for Payer: BCBS MT Closed Plan Network	$283.10
Rate for Payer: BCBS MT HealthLink	$268.20
Rate for Payer: BCBS MT Medicare	$268.20
Rate for Payer: BCBS MT POS	$283.10
Rate for Payer: BCBS MT Traditional	$298.00
Rate for Payer: Cash Price	$268.20
Rate for Payer: Cigna Commercial	$283.10
Rate for Payer: Cigna Medicare	$268.20
Rate for Payer: Medicaid All Medicaid	$274.16
Rate for Payer: Medicare All Medicare	$208.60
Rate for Payer: Monida Allegiance	$283.10
Rate for Payer: Monida First Choice Health	$289.06
Rate for Payer: Monida Montana Health Co-op	$283.10
Rate for Payer: Monida PacificSource	$283.10

XR ABDOMEN 2V WITH CHEST

Facility

$469.00

Service Code	HCPCS 74022 TC
Hospital Charge Code	5000129
Hospital Revenue Code	320
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

XR ABDOMEN 2V WITH CHEST

Facility

$469.00

Service Code	HCPCS 74022 TC
Hospital Charge Code	5000129
Hospital Revenue Code	320
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

XR AC JOINTS W WO WEIGHTS

Facility

$284.00

Service Code	HCPCS 73050 TC
Hospital Charge Code	5000131
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 AC JOINTS W WO WEIGHTS

Facility

$284.00

Service Code	HCPCS 73050 TC
Hospital Charge Code	5000131
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 ANKLE 2 VIEWS BILATERAL

Facility

$392.00

Service Code	HCPCS 73600 TC,50
Hospital Charge Code	5000134
Hospital Revenue Code	320
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$392.00
Rate for Payer: Aetna Commercial	$372.40
Rate for Payer: Aetna Medicare	$352.80
Rate for Payer: BCBS MT CHIP	$352.80
Rate for Payer: BCBS MT Closed Plan Network	$372.40
Rate for Payer: BCBS MT HealthLink	$352.80
Rate for Payer: BCBS MT Medicare	$352.80
Rate for Payer: BCBS MT POS	$372.40
Rate for Payer: BCBS MT Traditional	$392.00
Rate for Payer: Cash Price	$352.80
Rate for Payer: Cigna Commercial	$372.40
Rate for Payer: Cigna Medicare	$352.80
Rate for Payer: Medicaid All Medicaid	$360.64
Rate for Payer: Medicare All Medicare	$274.40
Rate for Payer: Monida Allegiance	$372.40
Rate for Payer: Monida First Choice Health	$380.24
Rate for Payer: Monida Montana Health Co-op	$372.40
Rate for Payer: Monida PacificSource	$372.40

XR ANKLE 2 VIEWS BILATERAL

Facility

$392.00

Service Code	HCPCS 73600 TC,50
Hospital Charge Code	5000134
Hospital Revenue Code	320
Min. Negotiated Rate	$274.40
Max. Negotiated Rate	$392.00
Rate for Payer: Aetna Commercial	$372.40
Rate for Payer: Aetna Medicare	$352.80
Rate for Payer: BCBS MT CHIP	$352.80
Rate for Payer: BCBS MT Closed Plan Network	$372.40
Rate for Payer: BCBS MT HealthLink	$352.80
Rate for Payer: BCBS MT Medicare	$352.80
Rate for Payer: BCBS MT POS	$372.40
Rate for Payer: BCBS MT Traditional	$392.00
Rate for Payer: Cash Price	$352.80
Rate for Payer: Cigna Commercial	$372.40
Rate for Payer: Cigna Medicare	$352.80
Rate for Payer: Medicaid All Medicaid	$360.64
Rate for Payer: Medicare All Medicare	$274.40
Rate for Payer: Monida Allegiance	$372.40
Rate for Payer: Monida First Choice Health	$380.24
Rate for Payer: Monida Montana Health Co-op	$372.40
Rate for Payer: Monida PacificSource	$372.40

XR ANKLE 3 VIEWS BILATERAL

Facility

$461.00

Service Code	HCPCS 73610 TC,50
Hospital Charge Code	5000133
Hospital Revenue Code	320
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$461.00
Rate for Payer: Aetna Commercial	$437.95
Rate for Payer: Aetna Medicare	$414.90
Rate for Payer: BCBS MT CHIP	$414.90
Rate for Payer: BCBS MT Closed Plan Network	$437.95
Rate for Payer: BCBS MT HealthLink	$414.90
Rate for Payer: BCBS MT Medicare	$414.90
Rate for Payer: BCBS MT POS	$437.95
Rate for Payer: BCBS MT Traditional	$461.00
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cigna Commercial	$437.95
Rate for Payer: Cigna Medicare	$414.90
Rate for Payer: Medicaid All Medicaid	$424.12
Rate for Payer: Medicare All Medicare	$322.70
Rate for Payer: Monida Allegiance	$437.95
Rate for Payer: Monida First Choice Health	$447.17
Rate for Payer: Monida Montana Health Co-op	$437.95
Rate for Payer: Monida PacificSource	$437.95

XR ANKLE 3 VIEWS BILATERAL

Facility

$461.00

Service Code	HCPCS 73610 TC,50
Hospital Charge Code	5000133
Hospital Revenue Code	320
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$461.00
Rate for Payer: Aetna Commercial	$437.95
Rate for Payer: Aetna Medicare	$414.90
Rate for Payer: BCBS MT CHIP	$414.90
Rate for Payer: BCBS MT Closed Plan Network	$437.95
Rate for Payer: BCBS MT HealthLink	$414.90
Rate for Payer: BCBS MT Medicare	$414.90
Rate for Payer: BCBS MT POS	$437.95
Rate for Payer: BCBS MT Traditional	$461.00
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cigna Commercial	$437.95
Rate for Payer: Cigna Medicare	$414.90
Rate for Payer: Medicaid All Medicaid	$424.12
Rate for Payer: Medicare All Medicare	$322.70
Rate for Payer: Monida Allegiance	$437.95
Rate for Payer: Monida First Choice Health	$447.17
Rate for Payer: Monida Montana Health Co-op	$437.95
Rate for Payer: Monida PacificSource	$437.95

XR ANKLE LT 1 VIEW

Facility

$261.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000132
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE LT 1 VIEW

Facility

$261.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000132
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE LT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000135
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE LT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73600 TC,LT
Hospital Charge Code	5000135
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE LT 3 VIEWS

Facility

$307.00

Service Code	HCPCS 73610 TC,LT
Hospital Charge Code	5000136
Hospital Revenue Code	320
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

XR ANKLE LT 3 VIEWS

Facility

$307.00

Service Code	HCPCS 73610 TC,LT
Hospital Charge Code	5000136
Hospital Revenue Code	320
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

XR ANKLE RT 1 VIEW

Facility

$261.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000139
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE RT 1 VIEW

Facility

$261.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000139
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE RT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000137
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE RT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73600 TC,RT
Hospital Charge Code	5000137
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR ANKLE RT 3 VIEWS

Facility

$307.00

Service Code	HCPCS 73610 TC,RT
Hospital Charge Code	5000138
Hospital Revenue Code	320
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

XR ANKLE RT 3 VIEWS

Facility

$307.00

Service Code	HCPCS 73610 TC,RT
Hospital Charge Code	5000138
Hospital Revenue Code	320
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

XR BALL CATCHERS

Facility

$261.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	5000006
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR BALL CATCHERS

Facility

$261.00

Service Code	HCPCS 73120 TC
Hospital Charge Code	5000006
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR BONE AGE STUDY

Facility

$348.00

Service Code	HCPCS 77072 TC
Hospital Charge Code	5000140
Hospital Revenue Code	320
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

Know your out-of-pocket cost for care.

All Charges