Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR KNEE RT 2 VIEWS

Facility

$266.00

Service Code	HCPCS 73560 TC,RT
Hospital Charge Code	5000193
Hospital Revenue Code	320
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

XR KNEE RT 2 VIEWS

Facility

$266.00

Service Code	HCPCS 73560 TC,RT
Hospital Charge Code	5000193
Hospital Revenue Code	320
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$266.00
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: BCBS MT CHIP	$239.40
Rate for Payer: BCBS MT Closed Plan Network	$252.70
Rate for Payer: BCBS MT HealthLink	$239.40
Rate for Payer: BCBS MT Medicare	$239.40
Rate for Payer: BCBS MT POS	$252.70
Rate for Payer: BCBS MT Traditional	$266.00
Rate for Payer: Cash Price	$239.40
Rate for Payer: Cigna Commercial	$252.70
Rate for Payer: Cigna Medicare	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

XR KNEE RT 3 VIEWS

Facility

$324.00

Service Code	HCPCS 73562 TC,RT
Hospital Charge Code	5000194
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

XR KNEE RT 3 VIEWS

Facility

$324.00

Service Code	HCPCS 73562 TC,RT
Hospital Charge Code	5000194
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

XR KNEE RT COMPLETE

Facility

$376.00

Service Code	HCPCS 73564 TC,RT
Hospital Charge Code	5000195
Hospital Revenue Code	320
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

XR KNEE RT COMPLETE

Facility

$376.00

Service Code	HCPCS 73564 TC,RT
Hospital Charge Code	5000195
Hospital Revenue Code	320
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

XR KNEES BILATERAL 1 VIEW

Facility

$253.00

Service Code	HCPCS 73560 TC,50
Hospital Charge Code	5000196
Hospital Revenue Code	320
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$253.00
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: BCBS MT CHIP	$227.70
Rate for Payer: BCBS MT Closed Plan Network	$240.35
Rate for Payer: BCBS MT HealthLink	$227.70
Rate for Payer: BCBS MT Medicare	$227.70
Rate for Payer: BCBS MT POS	$240.35
Rate for Payer: BCBS MT Traditional	$253.00
Rate for Payer: Cash Price	$227.70
Rate for Payer: Cigna Commercial	$240.35
Rate for Payer: Cigna Medicare	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

XR KNEES BILATERAL 1 VIEW

Facility

$253.00

Service Code	HCPCS 73560 TC,50
Hospital Charge Code	5000196
Hospital Revenue Code	320
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$253.00
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: BCBS MT CHIP	$227.70
Rate for Payer: BCBS MT Closed Plan Network	$240.35
Rate for Payer: BCBS MT HealthLink	$227.70
Rate for Payer: BCBS MT Medicare	$227.70
Rate for Payer: BCBS MT POS	$240.35
Rate for Payer: BCBS MT Traditional	$253.00
Rate for Payer: Cash Price	$227.70
Rate for Payer: Cigna Commercial	$240.35
Rate for Payer: Cigna Medicare	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

XR KNEES BILATERAL 2 VIEWS

Facility

$399.00

Service Code	HCPCS 73560 TC,50
Hospital Charge Code	5000197
Hospital Revenue Code	320
Min. Negotiated Rate	$279.30
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$379.05
Rate for Payer: Aetna Medicare	$359.10
Rate for Payer: BCBS MT CHIP	$359.10
Rate for Payer: BCBS MT Closed Plan Network	$379.05
Rate for Payer: BCBS MT HealthLink	$359.10
Rate for Payer: BCBS MT Medicare	$359.10
Rate for Payer: BCBS MT POS	$379.05
Rate for Payer: BCBS MT Traditional	$399.00
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial	$379.05
Rate for Payer: Cigna Medicare	$359.10
Rate for Payer: Medicaid All Medicaid	$367.08
Rate for Payer: Medicare All Medicare	$279.30
Rate for Payer: Monida Allegiance	$379.05
Rate for Payer: Monida First Choice Health	$387.03
Rate for Payer: Monida Montana Health Co-op	$379.05
Rate for Payer: Monida PacificSource	$379.05

XR KNEES BILATERAL 2 VIEWS

Facility

$399.00

Service Code	HCPCS 73560 TC,50
Hospital Charge Code	5000197
Hospital Revenue Code	320
Min. Negotiated Rate	$279.30
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$379.05
Rate for Payer: Aetna Medicare	$359.10
Rate for Payer: BCBS MT CHIP	$359.10
Rate for Payer: BCBS MT Closed Plan Network	$379.05
Rate for Payer: BCBS MT HealthLink	$359.10
Rate for Payer: BCBS MT Medicare	$359.10
Rate for Payer: BCBS MT POS	$379.05
Rate for Payer: BCBS MT Traditional	$399.00
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial	$379.05
Rate for Payer: Cigna Medicare	$359.10
Rate for Payer: Medicaid All Medicaid	$367.08
Rate for Payer: Medicare All Medicare	$279.30
Rate for Payer: Monida Allegiance	$379.05
Rate for Payer: Monida First Choice Health	$387.03
Rate for Payer: Monida Montana Health Co-op	$379.05
Rate for Payer: Monida PacificSource	$379.05

XR KNEES BILATERAL COMPLETE

Facility

$564.00

Service Code	HCPCS 73564 TC,50
Hospital Charge Code	5000198
Hospital Revenue Code	320
Min. Negotiated Rate	$394.80
Max. Negotiated Rate	$564.00
Rate for Payer: Aetna Commercial	$535.80
Rate for Payer: Aetna Medicare	$507.60
Rate for Payer: BCBS MT CHIP	$507.60
Rate for Payer: BCBS MT Closed Plan Network	$535.80
Rate for Payer: BCBS MT HealthLink	$507.60
Rate for Payer: BCBS MT Medicare	$507.60
Rate for Payer: BCBS MT POS	$535.80
Rate for Payer: BCBS MT Traditional	$564.00
Rate for Payer: Cash Price	$507.60
Rate for Payer: Cigna Commercial	$535.80
Rate for Payer: Cigna Medicare	$507.60
Rate for Payer: Medicaid All Medicaid	$518.88
Rate for Payer: Medicare All Medicare	$394.80
Rate for Payer: Monida Allegiance	$535.80
Rate for Payer: Monida First Choice Health	$547.08
Rate for Payer: Monida Montana Health Co-op	$535.80
Rate for Payer: Monida PacificSource	$535.80

XR KNEES BILATERAL COMPLETE

Facility

$564.00

Service Code	HCPCS 73564 TC,50
Hospital Charge Code	5000198
Hospital Revenue Code	320
Min. Negotiated Rate	$394.80
Max. Negotiated Rate	$564.00
Rate for Payer: Aetna Commercial	$535.80
Rate for Payer: Aetna Medicare	$507.60
Rate for Payer: BCBS MT CHIP	$507.60
Rate for Payer: BCBS MT Closed Plan Network	$535.80
Rate for Payer: BCBS MT HealthLink	$507.60
Rate for Payer: BCBS MT Medicare	$507.60
Rate for Payer: BCBS MT POS	$535.80
Rate for Payer: BCBS MT Traditional	$564.00
Rate for Payer: Cash Price	$507.60
Rate for Payer: Cigna Commercial	$535.80
Rate for Payer: Cigna Medicare	$507.60
Rate for Payer: Medicaid All Medicaid	$518.88
Rate for Payer: Medicare All Medicare	$394.80
Rate for Payer: Monida Allegiance	$535.80
Rate for Payer: Monida First Choice Health	$547.08
Rate for Payer: Monida Montana Health Co-op	$535.80
Rate for Payer: Monida PacificSource	$535.80

XR KNEES BILATERAL STAND AP

Facility

$237.00

Service Code	HCPCS 73565 TC,50
Hospital Charge Code	5000199
Hospital Revenue Code	320
Min. Negotiated Rate	$165.90
Max. Negotiated Rate	$237.00
Rate for Payer: Aetna Commercial	$225.15
Rate for Payer: Aetna Medicare	$213.30
Rate for Payer: BCBS MT CHIP	$213.30
Rate for Payer: BCBS MT Closed Plan Network	$225.15
Rate for Payer: BCBS MT HealthLink	$213.30
Rate for Payer: BCBS MT Medicare	$213.30
Rate for Payer: BCBS MT POS	$225.15
Rate for Payer: BCBS MT Traditional	$237.00
Rate for Payer: Cash Price	$213.30
Rate for Payer: Cigna Commercial	$225.15
Rate for Payer: Cigna Medicare	$213.30
Rate for Payer: Medicaid All Medicaid	$218.04
Rate for Payer: Medicare All Medicare	$165.90
Rate for Payer: Monida Allegiance	$225.15
Rate for Payer: Monida First Choice Health	$229.89
Rate for Payer: Monida Montana Health Co-op	$225.15
Rate for Payer: Monida PacificSource	$225.15

XR KNEES BILATERAL STAND AP

Facility

$237.00

Service Code	HCPCS 73565 TC,50
Hospital Charge Code	5000199
Hospital Revenue Code	320
Min. Negotiated Rate	$165.90
Max. Negotiated Rate	$237.00
Rate for Payer: Aetna Commercial	$225.15
Rate for Payer: Aetna Medicare	$213.30
Rate for Payer: BCBS MT CHIP	$213.30
Rate for Payer: BCBS MT Closed Plan Network	$225.15
Rate for Payer: BCBS MT HealthLink	$213.30
Rate for Payer: BCBS MT Medicare	$213.30
Rate for Payer: BCBS MT POS	$225.15
Rate for Payer: BCBS MT Traditional	$237.00
Rate for Payer: Cash Price	$213.30
Rate for Payer: Cigna Commercial	$225.15
Rate for Payer: Cigna Medicare	$213.30
Rate for Payer: Medicaid All Medicaid	$218.04
Rate for Payer: Medicare All Medicare	$165.90
Rate for Payer: Monida Allegiance	$225.15
Rate for Payer: Monida First Choice Health	$229.89
Rate for Payer: Monida Montana Health Co-op	$225.15
Rate for Payer: Monida PacificSource	$225.15

XR LOWER EXTREMITY LT INFANT

Facility

$145.00

Service Code	HCPCS 73592 TC
Hospital Charge Code	5000130
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LOWER EXTREMITY LT INFANT

Facility

$145.00

Service Code	HCPCS 73592 TC
Hospital Charge Code	5000130
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LOWER EXTREMITY RT INFANT

Facility

$145.00

Service Code	HCPCS 73592 TC,RT
Hospital Charge Code	5000003
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LOWER EXTREMITY RT INFANT

Facility

$145.00

Service Code	HCPCS 73592 TC,RT
Hospital Charge Code	5000003
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LUMBAR SPINE 2 OR 3 VIEWS

Facility

$341.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000201
Hospital Revenue Code	320
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

XR LUMBAR SPINE 2 OR 3 VIEWS

Facility

$341.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000201
Hospital Revenue Code	320
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

XR LUMBAR SPINE 3 VIEWS

Facility

$325.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000202
Hospital Revenue Code	320
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

XR LUMBAR SPINE 3 VIEWS

Facility

$325.00

Service Code	HCPCS 72100 TC
Hospital Charge Code	5000202
Hospital Revenue Code	320
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

XR LUMBAR SPINE BEND ONLY

Facility

$358.00

Service Code	HCPCS 72120 TC
Hospital Charge Code	5000058
Hospital Revenue Code	320
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

XR LUMBAR SPINE BEND ONLY

Facility

$358.00

Service Code	HCPCS 72120 TC
Hospital Charge Code	5000058
Hospital Revenue Code	320
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

XR LUMBAR SPINE COMPLETE 4 VIEWS

Facility

$481.00

Service Code	HCPCS 72110 TC
Hospital Charge Code	5000200
Hospital Revenue Code	320
Min. Negotiated Rate	$336.70
Max. Negotiated Rate	$481.00
Rate for Payer: Aetna Commercial	$456.95
Rate for Payer: Aetna Medicare	$432.90
Rate for Payer: BCBS MT CHIP	$432.90
Rate for Payer: BCBS MT Closed Plan Network	$456.95
Rate for Payer: BCBS MT HealthLink	$432.90
Rate for Payer: BCBS MT Medicare	$432.90
Rate for Payer: BCBS MT POS	$456.95
Rate for Payer: BCBS MT Traditional	$481.00
Rate for Payer: Cash Price	$432.90
Rate for Payer: Cigna Commercial	$456.95
Rate for Payer: Cigna Medicare	$432.90
Rate for Payer: Medicaid All Medicaid	$442.52
Rate for Payer: Medicare All Medicare	$336.70
Rate for Payer: Monida Allegiance	$456.95
Rate for Payer: Monida First Choice Health	$466.57
Rate for Payer: Monida Montana Health Co-op	$456.95
Rate for Payer: Monida PacificSource	$456.95

Know your out-of-pocket cost for care.

All Charges