Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR FOOT RT 3 VIEWS

Facility

$301.00

Service Code	HCPCS 73630 TC,RT
Hospital Charge Code	5000167
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR FOOT RT 3 VIEWS

Facility

$301.00

Service Code	HCPCS 73630 TC,RT
Hospital Charge Code	5000167
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR FOREARM BILATERAL 2 VIEW

Facility

$419.00

Service Code	HCPCS 73090 TC,50
Hospital Charge Code	5000168
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 FOREARM BILATERAL 2 VIEW

Facility

$419.00

Service Code	HCPCS 73090 TC,50
Hospital Charge Code	5000168
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 FOREARM LT 2 VIEW

Facility

$279.00

Service Code	HCPCS 73090 TC,LT
Hospital Charge Code	5000169
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 FOREARM LT 2 VIEW

Facility

$279.00

Service Code	HCPCS 73090 TC,LT
Hospital Charge Code	5000169
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 FOREARM RT 2 VIEW

Facility

$279.00

Service Code	HCPCS 73090 TC,RT
Hospital Charge Code	5000170
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 FOREARM RT 2 VIEW

Facility

$279.00

Service Code	HCPCS 73090 TC,RT
Hospital Charge Code	5000170
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 GUIDANCE FOR NEEDLE PLACE 77002

Facility

$492.00

Service Code	HCPCS 77002
Hospital Charge Code	5077002
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 GUIDANCE FOR NEEDLE PLACE 77002

Facility

$492.00

Service Code	HCPCS 77002
Hospital Charge Code	5077002
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 GUIDANCE SPINAL INJ 77003

Facility

$541.00

Service Code	HCPCS 77003
Hospital Charge Code	5077003
Hospital Revenue Code	320
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$541.00
Rate for Payer: Aetna Commercial	$513.95
Rate for Payer: Aetna Medicare	$486.90
Rate for Payer: BCBS MT CHIP	$486.90
Rate for Payer: BCBS MT Closed Plan Network	$513.95
Rate for Payer: BCBS MT HealthLink	$486.90
Rate for Payer: BCBS MT Medicare	$486.90
Rate for Payer: BCBS MT POS	$513.95
Rate for Payer: BCBS MT Traditional	$541.00
Rate for Payer: Cash Price	$486.90
Rate for Payer: Cigna Commercial	$513.95
Rate for Payer: Cigna Medicare	$486.90
Rate for Payer: Medicaid All Medicaid	$497.72
Rate for Payer: Medicare All Medicare	$378.70
Rate for Payer: Monida Allegiance	$513.95
Rate for Payer: Monida First Choice Health	$524.77
Rate for Payer: Monida Montana Health Co-op	$513.95
Rate for Payer: Monida PacificSource	$513.95

XR GUIDANCE SPINAL INJ 77003

Facility

$541.00

Service Code	HCPCS 77003
Hospital Charge Code	5077003
Hospital Revenue Code	320
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$541.00
Rate for Payer: Aetna Commercial	$513.95
Rate for Payer: Aetna Medicare	$486.90
Rate for Payer: BCBS MT CHIP	$486.90
Rate for Payer: BCBS MT Closed Plan Network	$513.95
Rate for Payer: BCBS MT HealthLink	$486.90
Rate for Payer: BCBS MT Medicare	$486.90
Rate for Payer: BCBS MT POS	$513.95
Rate for Payer: BCBS MT Traditional	$541.00
Rate for Payer: Cash Price	$486.90
Rate for Payer: Cigna Commercial	$513.95
Rate for Payer: Cigna Medicare	$486.90
Rate for Payer: Medicaid All Medicaid	$497.72
Rate for Payer: Medicare All Medicare	$378.70
Rate for Payer: Monida Allegiance	$513.95
Rate for Payer: Monida First Choice Health	$524.77
Rate for Payer: Monida Montana Health Co-op	$513.95
Rate for Payer: Monida PacificSource	$513.95

XR HAND LT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73120 TC,LT
Hospital Charge Code	5000172
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 HAND LT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73120 TC,LT
Hospital Charge Code	5000172
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 HAND LT 3 VIEWS

Facility

$301.00

Service Code	HCPCS 73130 TC,LT
Hospital Charge Code	5000173
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR HAND LT 3 VIEWS

Facility

$301.00

Service Code	HCPCS 73130 TC,LT
Hospital Charge Code	5000173
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR HAND RT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73120 TC,RT
Hospital Charge Code	5000174
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 HAND RT 2 VIEWS

Facility

$261.00

Service Code	HCPCS 73120 TC,RT
Hospital Charge Code	5000174
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 HAND RT 3 VIEWS

Facility

$301.00

Service Code	HCPCS 73130 TC,RT
Hospital Charge Code	5000175
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR HAND RT 3 VIEWS

Facility

$301.00

Service Code	HCPCS 73130 TC,RT
Hospital Charge Code	5000175
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR HANDS BILATERAL 1 VIEW

Facility

$248.00

Service Code	HCPCS 73120 TC,50
Hospital Charge Code	5000176
Hospital Revenue Code	320
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$248.00
Rate for Payer: Aetna Commercial	$235.60
Rate for Payer: Aetna Medicare	$223.20
Rate for Payer: BCBS MT CHIP	$223.20
Rate for Payer: BCBS MT Closed Plan Network	$235.60
Rate for Payer: BCBS MT HealthLink	$223.20
Rate for Payer: BCBS MT Medicare	$223.20
Rate for Payer: BCBS MT POS	$235.60
Rate for Payer: BCBS MT Traditional	$248.00
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cigna Commercial	$235.60
Rate for Payer: Cigna Medicare	$223.20
Rate for Payer: Medicaid All Medicaid	$228.16
Rate for Payer: Medicare All Medicare	$173.60
Rate for Payer: Monida Allegiance	$235.60
Rate for Payer: Monida First Choice Health	$240.56
Rate for Payer: Monida Montana Health Co-op	$235.60
Rate for Payer: Monida PacificSource	$235.60

XR HANDS BILATERAL 1 VIEW

Facility

$248.00

Service Code	HCPCS 73120 TC,50
Hospital Charge Code	5000176
Hospital Revenue Code	320
Min. Negotiated Rate	$173.60
Max. Negotiated Rate	$248.00
Rate for Payer: Aetna Commercial	$235.60
Rate for Payer: Aetna Medicare	$223.20
Rate for Payer: BCBS MT CHIP	$223.20
Rate for Payer: BCBS MT Closed Plan Network	$235.60
Rate for Payer: BCBS MT HealthLink	$223.20
Rate for Payer: BCBS MT Medicare	$223.20
Rate for Payer: BCBS MT POS	$235.60
Rate for Payer: BCBS MT Traditional	$248.00
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cigna Commercial	$235.60
Rate for Payer: Cigna Medicare	$223.20
Rate for Payer: Medicaid All Medicaid	$228.16
Rate for Payer: Medicare All Medicare	$173.60
Rate for Payer: Monida Allegiance	$235.60
Rate for Payer: Monida First Choice Health	$240.56
Rate for Payer: Monida Montana Health Co-op	$235.60
Rate for Payer: Monida PacificSource	$235.60

XR HANDS BILATERAL 2 VIEWS

Facility

$392.00

Service Code	HCPCS 73120 TC,50
Hospital Charge Code	5000177
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 HANDS BILATERAL 2 VIEWS

Facility

$392.00

Service Code	HCPCS 73120 TC,50
Hospital Charge Code	5000177
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 HANDS BILATERAL 3 VIEWS

Facility

$452.00

Service Code	HCPCS 73130 TC,50
Hospital Charge Code	5000178
Hospital Revenue Code	320
Min. Negotiated Rate	$316.40
Max. Negotiated Rate	$452.00
Rate for Payer: Aetna Commercial	$429.40
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: BCBS MT CHIP	$406.80
Rate for Payer: BCBS MT Closed Plan Network	$429.40
Rate for Payer: BCBS MT HealthLink	$406.80
Rate for Payer: BCBS MT Medicare	$406.80
Rate for Payer: BCBS MT POS	$429.40
Rate for Payer: BCBS MT Traditional	$452.00
Rate for Payer: Cash Price	$406.80
Rate for Payer: Cigna Commercial	$429.40
Rate for Payer: Cigna Medicare	$406.80
Rate for Payer: Medicaid All Medicaid	$415.84
Rate for Payer: Medicare All Medicare	$316.40
Rate for Payer: Monida Allegiance	$429.40
Rate for Payer: Monida First Choice Health	$438.44
Rate for Payer: Monida Montana Health Co-op	$429.40
Rate for Payer: Monida PacificSource	$429.40

Know your out-of-pocket cost for care.

All Charges