Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR CINE/VIDEO THROAT/ESOPH

Facility

$675.00

Service Code	HCPCS 74230 TC
Hospital Charge Code	5074230
Hospital Revenue Code	320
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna Commercial	$641.25
Rate for Payer: Aetna Medicare	$607.50
Rate for Payer: BCBS MT CHIP	$607.50
Rate for Payer: BCBS MT Closed Plan Network	$641.25
Rate for Payer: BCBS MT HealthLink	$607.50
Rate for Payer: BCBS MT Medicare	$607.50
Rate for Payer: BCBS MT POS	$641.25
Rate for Payer: BCBS MT Traditional	$675.00
Rate for Payer: Cash Price	$607.50
Rate for Payer: Cigna Commercial	$641.25
Rate for Payer: Cigna Medicare	$607.50
Rate for Payer: Medicaid All Medicaid	$621.00
Rate for Payer: Medicare All Medicare	$472.50
Rate for Payer: Monida Allegiance	$641.25
Rate for Payer: Monida First Choice Health	$654.75
Rate for Payer: Monida Montana Health Co-op	$641.25
Rate for Payer: Monida PacificSource	$641.25

XR CINE/VIDEO THROAT/ESOPH

Facility

$675.00

Service Code	HCPCS 74230 TC
Hospital Charge Code	5074230
Hospital Revenue Code	320
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna Commercial	$641.25
Rate for Payer: Aetna Medicare	$607.50
Rate for Payer: BCBS MT CHIP	$607.50
Rate for Payer: BCBS MT Closed Plan Network	$641.25
Rate for Payer: BCBS MT HealthLink	$607.50
Rate for Payer: BCBS MT Medicare	$607.50
Rate for Payer: BCBS MT POS	$641.25
Rate for Payer: BCBS MT Traditional	$675.00
Rate for Payer: Cash Price	$607.50
Rate for Payer: Cigna Commercial	$641.25
Rate for Payer: Cigna Medicare	$607.50
Rate for Payer: Medicaid All Medicaid	$621.00
Rate for Payer: Medicare All Medicare	$472.50
Rate for Payer: Monida Allegiance	$641.25
Rate for Payer: Monida First Choice Health	$654.75
Rate for Payer: Monida Montana Health Co-op	$641.25
Rate for Payer: Monida PacificSource	$641.25

XR CLAVICLE BILATERAL COMPLETE

Facility

$419.00

Service Code	HCPCS 73000 TC,50
Hospital Charge Code	5000146
Hospital Revenue Code	320
Min. Negotiated Rate	$293.30
Max. Negotiated Rate	$419.00
Rate for Payer: Aetna Commercial	$398.05
Rate for Payer: Aetna Medicare	$377.10
Rate for Payer: BCBS MT CHIP	$377.10
Rate for Payer: BCBS MT Closed Plan Network	$398.05
Rate for Payer: BCBS MT HealthLink	$377.10
Rate for Payer: BCBS MT Medicare	$377.10
Rate for Payer: BCBS MT POS	$398.05
Rate for Payer: BCBS MT Traditional	$419.00
Rate for Payer: Cash Price	$377.10
Rate for Payer: Cigna Commercial	$398.05
Rate for Payer: Cigna Medicare	$377.10
Rate for Payer: Medicaid All Medicaid	$385.48
Rate for Payer: Medicare All Medicare	$293.30
Rate for Payer: Monida Allegiance	$398.05
Rate for Payer: Monida First Choice Health	$406.43
Rate for Payer: Monida Montana Health Co-op	$398.05
Rate for Payer: Monida PacificSource	$398.05

XR CLAVICLE BILATERAL COMPLETE

Facility

$419.00

Service Code	HCPCS 73000 TC,50
Hospital Charge Code	5000146
Hospital Revenue Code	320
Min. Negotiated Rate	$293.30
Max. Negotiated Rate	$419.00
Rate for Payer: Aetna Commercial	$398.05
Rate for Payer: Aetna Medicare	$377.10
Rate for Payer: BCBS MT CHIP	$377.10
Rate for Payer: BCBS MT Closed Plan Network	$398.05
Rate for Payer: BCBS MT HealthLink	$377.10
Rate for Payer: BCBS MT Medicare	$377.10
Rate for Payer: BCBS MT POS	$398.05
Rate for Payer: BCBS MT Traditional	$419.00
Rate for Payer: Cash Price	$377.10
Rate for Payer: Cigna Commercial	$398.05
Rate for Payer: Cigna Medicare	$377.10
Rate for Payer: Medicaid All Medicaid	$385.48
Rate for Payer: Medicare All Medicare	$293.30
Rate for Payer: Monida Allegiance	$398.05
Rate for Payer: Monida First Choice Health	$406.43
Rate for Payer: Monida Montana Health Co-op	$398.05
Rate for Payer: Monida PacificSource	$398.05

XR CLAVICLE LT COMPLETE

Facility

$279.00

Service Code	HCPCS 73000 TC,LT
Hospital Charge Code	5000147
Hospital Revenue Code	320
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

XR CLAVICLE LT COMPLETE

Facility

$279.00

Service Code	HCPCS 73000 TC,LT
Hospital Charge Code	5000147
Hospital Revenue Code	320
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

XR CLAVICLE RT COMPLETE

Facility

$279.00

Service Code	HCPCS 73000 TC,RT
Hospital Charge Code	5000148
Hospital Revenue Code	320
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

XR CLAVICLE RT COMPLETE

Facility

$279.00

Service Code	HCPCS 73000 TC,RT
Hospital Charge Code	5000148
Hospital Revenue Code	320
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

XR CTA THORACIC AORTA W OR W/O CONTRAST

Facility

$3,199.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5075635
Hospital Revenue Code	350
Min. Negotiated Rate	$2,239.30
Max. Negotiated Rate	$3,199.00
Rate for Payer: Aetna Commercial	$3,039.05
Rate for Payer: Aetna Medicare	$2,879.10
Rate for Payer: BCBS MT CHIP	$2,879.10
Rate for Payer: BCBS MT Closed Plan Network	$3,039.05
Rate for Payer: BCBS MT HealthLink	$2,879.10
Rate for Payer: BCBS MT Medicare	$2,879.10
Rate for Payer: BCBS MT POS	$3,039.05
Rate for Payer: BCBS MT Traditional	$3,199.00
Rate for Payer: Cash Price	$2,879.10
Rate for Payer: Cigna Commercial	$3,039.05
Rate for Payer: Cigna Medicare	$2,879.10
Rate for Payer: Medicaid All Medicaid	$2,943.08
Rate for Payer: Medicare All Medicare	$2,239.30
Rate for Payer: Monida Allegiance	$3,039.05
Rate for Payer: Monida First Choice Health	$3,103.03
Rate for Payer: Monida Montana Health Co-op	$3,039.05
Rate for Payer: Monida PacificSource	$3,039.05

XR CTA THORACIC AORTA W OR W/O CONTRAST

Facility

$3,199.00

Service Code	HCPCS 75635 TC
Hospital Charge Code	5075635
Hospital Revenue Code	350
Min. Negotiated Rate	$2,239.30
Max. Negotiated Rate	$3,199.00
Rate for Payer: Aetna Commercial	$3,039.05
Rate for Payer: Aetna Medicare	$2,879.10
Rate for Payer: BCBS MT CHIP	$2,879.10
Rate for Payer: BCBS MT Closed Plan Network	$3,039.05
Rate for Payer: BCBS MT HealthLink	$2,879.10
Rate for Payer: BCBS MT Medicare	$2,879.10
Rate for Payer: BCBS MT POS	$3,039.05
Rate for Payer: BCBS MT Traditional	$3,199.00
Rate for Payer: Cash Price	$2,879.10
Rate for Payer: Cigna Commercial	$3,039.05
Rate for Payer: Cigna Medicare	$2,879.10
Rate for Payer: Medicaid All Medicaid	$2,943.08
Rate for Payer: Medicare All Medicare	$2,239.30
Rate for Payer: Monida Allegiance	$3,039.05
Rate for Payer: Monida First Choice Health	$3,103.03
Rate for Payer: Monida Montana Health Co-op	$3,039.05
Rate for Payer: Monida PacificSource	$3,039.05

XR ELBOW BILATERAL 2 VIEWS

Facility

$374.00

Service Code	HCPCS 73070 TC,50
Hospital Charge Code	5000152
Hospital Revenue Code	320
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

XR ELBOW BILATERAL 2 VIEWS

Facility

$374.00

Service Code	HCPCS 73070 TC,50
Hospital Charge Code	5000152
Hospital Revenue Code	320
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

XR ELBOW BILATERAL 3 VIEWS

Facility

$461.00

Service Code	HCPCS 73080 TC,50
Hospital Charge Code	5000153
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 ELBOW BILATERAL 3 VIEWS

Facility

$461.00

Service Code	HCPCS 73080 TC,50
Hospital Charge Code	5000153
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 ELBOW LT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73070 TC,LT
Hospital Charge Code	5000154
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 ELBOW LT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73070 TC,LT
Hospital Charge Code	5000154
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 ELBOW LT 3-4 VIEWS

Facility

$307.00

Service Code	HCPCS 73080 TC,LT
Hospital Charge Code	5000155
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 ELBOW LT 3-4 VIEWS

Facility

$307.00

Service Code	HCPCS 73080 TC,LT
Hospital Charge Code	5000155
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 ELBOW RT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73070 TC,RT
Hospital Charge Code	5000156
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 ELBOW RT 2 VIEWS

Facility

$249.00

Service Code	HCPCS 73070 TC,RT
Hospital Charge Code	5000156
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 ELBOW RT 3-4 VIEWS

Facility

$307.00

Service Code	HCPCS 73080 TC,RT
Hospital Charge Code	5000157
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 ELBOW RT 3-4 VIEWS

Facility

$307.00

Service Code	HCPCS 73080 TC,RT
Hospital Charge Code	5000157
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 ENTIRE SPINE W SKULL 2 OR 3 VIEWS

Facility

$353.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5000212
Hospital Revenue Code	320
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

XR ENTIRE SPINE W SKULL 2 OR 3 VIEWS

Facility

$353.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5000212
Hospital Revenue Code	320
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

XR ENTIRE SPINE W SKULL 4 OR 5 VIEWS

Facility

$532.00

Service Code	HCPCS 72083 TC
Hospital Charge Code	5000213
Hospital Revenue Code	320
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$532.00
Rate for Payer: Aetna Commercial	$505.40
Rate for Payer: Aetna Medicare	$478.80
Rate for Payer: BCBS MT CHIP	$478.80
Rate for Payer: BCBS MT Closed Plan Network	$505.40
Rate for Payer: BCBS MT HealthLink	$478.80
Rate for Payer: BCBS MT Medicare	$478.80
Rate for Payer: BCBS MT POS	$505.40
Rate for Payer: BCBS MT Traditional	$532.00
Rate for Payer: Cash Price	$478.80
Rate for Payer: Cigna Commercial	$505.40
Rate for Payer: Cigna Medicare	$478.80
Rate for Payer: Medicaid All Medicaid	$489.44
Rate for Payer: Medicare All Medicare	$372.40
Rate for Payer: Monida Allegiance	$505.40
Rate for Payer: Monida First Choice Health	$516.04
Rate for Payer: Monida Montana Health Co-op	$505.40
Rate for Payer: Monida PacificSource	$505.40

Know your out-of-pocket cost for care.

All Charges