Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR BONE LENGTH STUDY

Facility

$311.00

Service Code	HCPCS 77073 TC
Hospital Charge Code	5077073
Hospital Revenue Code	350
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 BONE LENGTH STUDY

Facility

$311.00

Service Code	HCPCS 77073 TC
Hospital Charge Code	5077073
Hospital Revenue Code	350
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 CALCANEUS BILATERAL 2 VIEWS

Facility

$381.00

Service Code	HCPCS 73650 TC,50
Hospital Charge Code	5000181
Hospital Revenue Code	320
Min. Negotiated Rate	$266.70
Max. Negotiated Rate	$381.00
Rate for Payer: Aetna Commercial	$361.95
Rate for Payer: Aetna Medicare	$342.90
Rate for Payer: BCBS MT CHIP	$342.90
Rate for Payer: BCBS MT Closed Plan Network	$361.95
Rate for Payer: BCBS MT HealthLink	$342.90
Rate for Payer: BCBS MT Medicare	$342.90
Rate for Payer: BCBS MT POS	$361.95
Rate for Payer: BCBS MT Traditional	$381.00
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cigna Commercial	$361.95
Rate for Payer: Cigna Medicare	$342.90
Rate for Payer: Medicaid All Medicaid	$350.52
Rate for Payer: Medicare All Medicare	$266.70
Rate for Payer: Monida Allegiance	$361.95
Rate for Payer: Monida First Choice Health	$369.57
Rate for Payer: Monida Montana Health Co-op	$361.95
Rate for Payer: Monida PacificSource	$361.95

XR CALCANEUS BILATERAL 2 VIEWS

Facility

$381.00

Service Code	HCPCS 73650 TC,50
Hospital Charge Code	5000181
Hospital Revenue Code	320
Min. Negotiated Rate	$266.70
Max. Negotiated Rate	$381.00
Rate for Payer: Aetna Commercial	$361.95
Rate for Payer: Aetna Medicare	$342.90
Rate for Payer: BCBS MT CHIP	$342.90
Rate for Payer: BCBS MT Closed Plan Network	$361.95
Rate for Payer: BCBS MT HealthLink	$342.90
Rate for Payer: BCBS MT Medicare	$342.90
Rate for Payer: BCBS MT POS	$361.95
Rate for Payer: BCBS MT Traditional	$381.00
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cigna Commercial	$361.95
Rate for Payer: Cigna Medicare	$342.90
Rate for Payer: Medicaid All Medicaid	$350.52
Rate for Payer: Medicare All Medicare	$266.70
Rate for Payer: Monida Allegiance	$361.95
Rate for Payer: Monida First Choice Health	$369.57
Rate for Payer: Monida Montana Health Co-op	$361.95
Rate for Payer: Monida PacificSource	$361.95

XR CALCANEUS LT 2 VIEWS

Facility

$254.00

Service Code	HCPCS 73650 TC,LT
Hospital Charge Code	5000179
Hospital Revenue Code	320
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

XR CALCANEUS LT 2 VIEWS

Facility

$254.00

Service Code	HCPCS 73650 TC,LT
Hospital Charge Code	5000179
Hospital Revenue Code	320
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

XR CALCANEUS RT 2 VIEWS

Facility

$254.00

Service Code	HCPCS 73650 TC,RT
Hospital Charge Code	5000180
Hospital Revenue Code	320
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

XR CALCANEUS RT 2 VIEWS

Facility

$254.00

Service Code	HCPCS 73650 TC,RT
Hospital Charge Code	5000180
Hospital Revenue Code	320
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

XR CERVICAL SPINE 2 TO 3 VIEWS

Facility

$318.00

Service Code	HCPCS 72040 TC
Hospital Charge Code	5000149
Hospital Revenue Code	320
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

XR CERVICAL SPINE 2 TO 3 VIEWS

Facility

$318.00

Service Code	HCPCS 72040 TC
Hospital Charge Code	5000149
Hospital Revenue Code	320
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

XR CERVICAL SPINE COMPLETE

Facility

$463.00

Service Code	HCPCS 72050 TC
Hospital Charge Code	5000150
Hospital Revenue Code	320
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

XR CERVICAL SPINE COMPLETE

Facility

$463.00

Service Code	HCPCS 72050 TC
Hospital Charge Code	5000150
Hospital Revenue Code	320
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

XR CERVICAL SPINE COMPLETE W/ FLEX/EXT

Facility

$520.00

Service Code	HCPCS 72052 TC
Hospital Charge Code	5000151
Hospital Revenue Code	320
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

XR CERVICAL SPINE COMPLETE W/ FLEX/EXT

Facility

$520.00

Service Code	HCPCS 72052 TC
Hospital Charge Code	5000151
Hospital Revenue Code	320
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

XR CHEST 1 VIEW

Facility

$249.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000141
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR CHEST 1 VIEW

Facility

$249.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000141
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR CHEST 2 VIEWS

Facility

$318.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	5000142
Hospital Revenue Code	320
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

XR CHEST 2 VIEWS

Facility

$318.00

Service Code	HCPCS 71046 TC
Hospital Charge Code	5000142
Hospital Revenue Code	320
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

XR CHEST CHILD 1 VIEW

Facility

$249.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000145
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR CHEST CHILD 1 VIEW

Facility

$249.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5000145
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR CHEST/RIBS 4/> VIEWS

Facility

$492.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	5000127
Hospital Revenue Code	320
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

XR CHEST/RIBS 4/> VIEWS

Facility

$492.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	5000127
Hospital Revenue Code	320
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

XR CHEST SINGLE VIEW

Facility

$249.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5071045
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

XR CHEST SINGLE VIEW

Facility

$249.00

Service Code	HCPCS 71045 TC
Hospital Charge Code	5071045
Hospital Revenue Code	320
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

Know your out-of-pocket cost for care.

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