Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR LUMBOSACRAL WITH FLEX AND EXT

Facility

$599.00

Service Code	HCPCS 72114 TC
Hospital Charge Code	5072114
Hospital Revenue Code	320
Min. Negotiated Rate	$419.30
Max. Negotiated Rate	$599.00
Rate for Payer: Aetna Commercial	$569.05
Rate for Payer: Aetna Medicare	$539.10
Rate for Payer: BCBS MT CHIP	$539.10
Rate for Payer: BCBS MT Closed Plan Network	$569.05
Rate for Payer: BCBS MT HealthLink	$539.10
Rate for Payer: BCBS MT Medicare	$539.10
Rate for Payer: BCBS MT POS	$569.05
Rate for Payer: BCBS MT Traditional	$599.00
Rate for Payer: Cash Price	$539.10
Rate for Payer: Cigna Commercial	$569.05
Rate for Payer: Cigna Medicare	$539.10
Rate for Payer: Medicaid All Medicaid	$551.08
Rate for Payer: Medicare All Medicare	$419.30
Rate for Payer: Monida Allegiance	$569.05
Rate for Payer: Monida First Choice Health	$581.03
Rate for Payer: Monida Montana Health Co-op	$569.05
Rate for Payer: Monida PacificSource	$569.05

XR LUMBOSACRAL WITH FLEX AND EXT

Facility

$599.00

Service Code	HCPCS 72114 TC
Hospital Charge Code	5072114
Hospital Revenue Code	320
Min. Negotiated Rate	$419.30
Max. Negotiated Rate	$599.00
Rate for Payer: Aetna Commercial	$569.05
Rate for Payer: Aetna Medicare	$539.10
Rate for Payer: BCBS MT CHIP	$539.10
Rate for Payer: BCBS MT Closed Plan Network	$569.05
Rate for Payer: BCBS MT HealthLink	$539.10
Rate for Payer: BCBS MT Medicare	$539.10
Rate for Payer: BCBS MT POS	$569.05
Rate for Payer: BCBS MT Traditional	$599.00
Rate for Payer: Cash Price	$539.10
Rate for Payer: Cigna Commercial	$569.05
Rate for Payer: Cigna Medicare	$539.10
Rate for Payer: Medicaid All Medicaid	$551.08
Rate for Payer: Medicare All Medicare	$419.30
Rate for Payer: Monida Allegiance	$569.05
Rate for Payer: Monida First Choice Health	$581.03
Rate for Payer: Monida Montana Health Co-op	$569.05
Rate for Payer: Monida PacificSource	$569.05

XR MANDIBLE 4 VIEWS

Facility

$387.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	5000060
Hospital Revenue Code	320
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

XR MANDIBLE 4 VIEWS

Facility

$387.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	5000060
Hospital Revenue Code	320
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

XR MANDIBLE BILATERAL 1 OR 2 VIEWS

Facility

$249.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	5000203
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 MANDIBLE BILATERAL 1 OR 2 VIEWS

Facility

$249.00

Service Code	HCPCS 70110 TC
Hospital Charge Code	5000203
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 MANDIBLE LT 1-2 VIEW

Facility

$249.00

Service Code	HCPCS 70100 TC,LT
Hospital Charge Code	5000204
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 MANDIBLE LT 1-2 VIEW

Facility

$249.00

Service Code	HCPCS 70100 TC,LT
Hospital Charge Code	5000204
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 MANDIBLE RT 1-2 VIEW

Facility

$249.00

Service Code	HCPCS 70100 TC,RT
Hospital Charge Code	5000205
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 MANDIBLE RT 1-2 VIEW

Facility

$249.00

Service Code	HCPCS 70100 TC,RT
Hospital Charge Code	5000205
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 MASTOIDS GREATER THAN 3 PER SIDE

Facility

$281.00

Service Code	HCPCS 70130 TC
Hospital Charge Code	5000143
Hospital Revenue Code	320
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$281.00
Rate for Payer: Aetna Commercial	$266.95
Rate for Payer: Aetna Medicare	$252.90
Rate for Payer: BCBS MT CHIP	$252.90
Rate for Payer: BCBS MT Closed Plan Network	$266.95
Rate for Payer: BCBS MT HealthLink	$252.90
Rate for Payer: BCBS MT Medicare	$252.90
Rate for Payer: BCBS MT POS	$266.95
Rate for Payer: BCBS MT Traditional	$281.00
Rate for Payer: Cash Price	$252.90
Rate for Payer: Cigna Commercial	$266.95
Rate for Payer: Cigna Medicare	$252.90
Rate for Payer: Medicaid All Medicaid	$258.52
Rate for Payer: Medicare All Medicare	$196.70
Rate for Payer: Monida Allegiance	$266.95
Rate for Payer: Monida First Choice Health	$272.57
Rate for Payer: Monida Montana Health Co-op	$266.95
Rate for Payer: Monida PacificSource	$266.95

XR MASTOIDS GREATER THAN 3 PER SIDE

Facility

$281.00

Service Code	HCPCS 70130 TC
Hospital Charge Code	5000143
Hospital Revenue Code	320
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$281.00
Rate for Payer: Aetna Commercial	$266.95
Rate for Payer: Aetna Medicare	$252.90
Rate for Payer: BCBS MT CHIP	$252.90
Rate for Payer: BCBS MT Closed Plan Network	$266.95
Rate for Payer: BCBS MT HealthLink	$252.90
Rate for Payer: BCBS MT Medicare	$252.90
Rate for Payer: BCBS MT POS	$266.95
Rate for Payer: BCBS MT Traditional	$281.00
Rate for Payer: Cash Price	$252.90
Rate for Payer: Cigna Commercial	$266.95
Rate for Payer: Cigna Medicare	$252.90
Rate for Payer: Medicaid All Medicaid	$258.52
Rate for Payer: Medicare All Medicare	$196.70
Rate for Payer: Monida Allegiance	$266.95
Rate for Payer: Monida First Choice Health	$272.57
Rate for Payer: Monida Montana Health Co-op	$266.95
Rate for Payer: Monida PacificSource	$266.95

XR MASTOIDS LESS THAN 3 PER SIDE

Facility

$143.00

Service Code	HCPCS 70120 TC
Hospital Charge Code	5000059
Hospital Revenue Code	320
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$135.85
Rate for Payer: Aetna Medicare	$128.70
Rate for Payer: BCBS MT CHIP	$128.70
Rate for Payer: BCBS MT Closed Plan Network	$135.85
Rate for Payer: BCBS MT HealthLink	$128.70
Rate for Payer: BCBS MT Medicare	$128.70
Rate for Payer: BCBS MT POS	$135.85
Rate for Payer: BCBS MT Traditional	$143.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cigna Commercial	$135.85
Rate for Payer: Cigna Medicare	$128.70
Rate for Payer: Medicaid All Medicaid	$131.56
Rate for Payer: Medicare All Medicare	$100.10
Rate for Payer: Monida Allegiance	$135.85
Rate for Payer: Monida First Choice Health	$138.71
Rate for Payer: Monida Montana Health Co-op	$135.85
Rate for Payer: Monida PacificSource	$135.85

XR MASTOIDS LESS THAN 3 PER SIDE

Facility

$143.00

Service Code	HCPCS 70120 TC
Hospital Charge Code	5000059
Hospital Revenue Code	320
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$143.00
Rate for Payer: Aetna Commercial	$135.85
Rate for Payer: Aetna Medicare	$128.70
Rate for Payer: BCBS MT CHIP	$128.70
Rate for Payer: BCBS MT Closed Plan Network	$135.85
Rate for Payer: BCBS MT HealthLink	$128.70
Rate for Payer: BCBS MT Medicare	$128.70
Rate for Payer: BCBS MT POS	$135.85
Rate for Payer: BCBS MT Traditional	$143.00
Rate for Payer: Cash Price	$128.70
Rate for Payer: Cigna Commercial	$135.85
Rate for Payer: Cigna Medicare	$128.70
Rate for Payer: Medicaid All Medicaid	$131.56
Rate for Payer: Medicare All Medicare	$100.10
Rate for Payer: Monida Allegiance	$135.85
Rate for Payer: Monida First Choice Health	$138.71
Rate for Payer: Monida Montana Health Co-op	$135.85
Rate for Payer: Monida PacificSource	$135.85

XR NASAL BONES 3 VIEWS

Facility

$301.00

Service Code	HCPCS 70160 TC
Hospital Charge Code	5000206
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 NASAL BONES 3 VIEWS

Facility

$301.00

Service Code	HCPCS 70160 TC
Hospital Charge Code	5000206
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 NOSE TO RECTUM CHILD 1 VIEW

Facility

$260.00

Service Code	HCPCS 76010 TC
Hospital Charge Code	5076010
Hospital Revenue Code	350
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

XR NOSE TO RECTUM CHILD 1 VIEW

Facility

$260.00

Service Code	HCPCS 76010 TC
Hospital Charge Code	5076010
Hospital Revenue Code	350
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

XR OP MAJOR JOINT INJ W/US 20611

Facility

$1,042.00

Service Code	HCPCS 20611
Hospital Charge Code	5020611
Hospital Revenue Code	409
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

XR OP MAJOR JOINT INJ W/US 20611

Facility

$1,042.00

Service Code	HCPCS 20611
Hospital Charge Code	5020611
Hospital Revenue Code	409
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

XR ORBITS 1 VIEW

Facility

$220.00

Service Code	HCPCS 70190 TC
Hospital Charge Code	5000061
Hospital Revenue Code	320
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$220.00
Rate for Payer: Aetna Commercial	$209.00
Rate for Payer: Aetna Medicare	$198.00
Rate for Payer: BCBS MT CHIP	$198.00
Rate for Payer: BCBS MT Closed Plan Network	$209.00
Rate for Payer: BCBS MT HealthLink	$198.00
Rate for Payer: BCBS MT Medicare	$198.00
Rate for Payer: BCBS MT POS	$209.00
Rate for Payer: BCBS MT Traditional	$220.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial	$209.00
Rate for Payer: Cigna Medicare	$198.00
Rate for Payer: Medicaid All Medicaid	$202.40
Rate for Payer: Medicare All Medicare	$154.00
Rate for Payer: Monida Allegiance	$209.00
Rate for Payer: Monida First Choice Health	$213.40
Rate for Payer: Monida Montana Health Co-op	$209.00
Rate for Payer: Monida PacificSource	$209.00

XR ORBITS 1 VIEW

Facility

$220.00

Service Code	HCPCS 70190 TC
Hospital Charge Code	5000061
Hospital Revenue Code	320
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$220.00
Rate for Payer: Aetna Commercial	$209.00
Rate for Payer: Aetna Medicare	$198.00
Rate for Payer: BCBS MT CHIP	$198.00
Rate for Payer: BCBS MT Closed Plan Network	$209.00
Rate for Payer: BCBS MT HealthLink	$198.00
Rate for Payer: BCBS MT Medicare	$198.00
Rate for Payer: BCBS MT POS	$209.00
Rate for Payer: BCBS MT Traditional	$220.00
Rate for Payer: Cash Price	$198.00
Rate for Payer: Cigna Commercial	$209.00
Rate for Payer: Cigna Medicare	$198.00
Rate for Payer: Medicaid All Medicaid	$202.40
Rate for Payer: Medicare All Medicare	$154.00
Rate for Payer: Monida Allegiance	$209.00
Rate for Payer: Monida First Choice Health	$213.40
Rate for Payer: Monida Montana Health Co-op	$209.00
Rate for Payer: Monida PacificSource	$209.00

XR ORBITS COMPLETE 4 VIEWS

Facility

$358.00

Service Code	HCPCS 70200 TC
Hospital Charge Code	5000208
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 ORBITS COMPLETE 4 VIEWS

Facility

$358.00

Service Code	HCPCS 70200 TC
Hospital Charge Code	5000208
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

Know your out-of-pocket cost for care.

All Charges