Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR PELVIS 1 VIEW

Facility

$279.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	5000209
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 PELVIS 1 VIEW

Facility

$279.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	5000209
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 PELVIS 2 VIEWS

Facility

$265.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	5000210
Hospital Revenue Code	320
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

XR PELVIS 2 VIEWS

Facility

$265.00

Service Code	HCPCS 72170 TC
Hospital Charge Code	5000210
Hospital Revenue Code	320
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$265.00
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: BCBS MT CHIP	$238.50
Rate for Payer: BCBS MT Closed Plan Network	$251.75
Rate for Payer: BCBS MT HealthLink	$238.50
Rate for Payer: BCBS MT Medicare	$238.50
Rate for Payer: BCBS MT POS	$251.75
Rate for Payer: BCBS MT Traditional	$265.00
Rate for Payer: Cash Price	$238.50
Rate for Payer: Cigna Commercial	$251.75
Rate for Payer: Cigna Medicare	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

XR PELVIS Inlet-Outlet 3 V

Facility

$348.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	5000211
Hospital Revenue Code	320
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

XR PELVIS Inlet-Outlet 3 V

Facility

$348.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	5000211
Hospital Revenue Code	320
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

XR PELVIS JUDETS 3 VIEW

Facility

$348.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	5072190
Hospital Revenue Code	320
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

XR PELVIS JUDETS 3 VIEW

Facility

$348.00

Service Code	HCPCS 72190 TC
Hospital Charge Code	5072190
Hospital Revenue Code	320
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

XR RIBS BILATERAL 3 VIEWS

Facility

$382.00

Service Code	HCPCS 71110 TC
Hospital Charge Code	5000215
Hospital Revenue Code	320
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$382.00
Rate for Payer: Aetna Commercial	$362.90
Rate for Payer: Aetna Medicare	$343.80
Rate for Payer: BCBS MT CHIP	$343.80
Rate for Payer: BCBS MT Closed Plan Network	$362.90
Rate for Payer: BCBS MT HealthLink	$343.80
Rate for Payer: BCBS MT Medicare	$343.80
Rate for Payer: BCBS MT POS	$362.90
Rate for Payer: BCBS MT Traditional	$382.00
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cigna Commercial	$362.90
Rate for Payer: Cigna Medicare	$343.80
Rate for Payer: Medicaid All Medicaid	$351.44
Rate for Payer: Medicare All Medicare	$267.40
Rate for Payer: Monida Allegiance	$362.90
Rate for Payer: Monida First Choice Health	$370.54
Rate for Payer: Monida Montana Health Co-op	$362.90
Rate for Payer: Monida PacificSource	$362.90

XR RIBS BILATERAL 3 VIEWS

Facility

$382.00

Service Code	HCPCS 71110 TC
Hospital Charge Code	5000215
Hospital Revenue Code	320
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$382.00
Rate for Payer: Aetna Commercial	$362.90
Rate for Payer: Aetna Medicare	$343.80
Rate for Payer: BCBS MT CHIP	$343.80
Rate for Payer: BCBS MT Closed Plan Network	$362.90
Rate for Payer: BCBS MT HealthLink	$343.80
Rate for Payer: BCBS MT Medicare	$343.80
Rate for Payer: BCBS MT POS	$362.90
Rate for Payer: BCBS MT Traditional	$382.00
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cigna Commercial	$362.90
Rate for Payer: Cigna Medicare	$343.80
Rate for Payer: Medicaid All Medicaid	$351.44
Rate for Payer: Medicare All Medicare	$267.40
Rate for Payer: Monida Allegiance	$362.90
Rate for Payer: Monida First Choice Health	$370.54
Rate for Payer: Monida Montana Health Co-op	$362.90
Rate for Payer: Monida PacificSource	$362.90

XR RIBS BILATERAL W PA CHEST

Facility

$376.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	5000214
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 RIBS BILATERAL W PA CHEST

Facility

$376.00

Service Code	HCPCS 71111 TC
Hospital Charge Code	5000214
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 RIBS LT 2 VIEWS

Facility

$321.00

Service Code	HCPCS 71100 TC,LT
Hospital Charge Code	5000216
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR RIBS LT 2 VIEWS

Facility

$321.00

Service Code	HCPCS 71100 TC,LT
Hospital Charge Code	5000216
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR RIBS LT 3 VIEWS WITH PA CHEST

Facility

$321.00

Service Code	HCPCS 71101 TC,LT
Hospital Charge Code	5000004
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR RIBS LT 3 VIEWS WITH PA CHEST

Facility

$321.00

Service Code	HCPCS 71101 TC,LT
Hospital Charge Code	5000004
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR RIBS RT 2 VIEWS

Facility

$321.00

Service Code	HCPCS 71100 TC,RT
Hospital Charge Code	5000217
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR RIBS RT 2 VIEWS

Facility

$321.00

Service Code	HCPCS 71100 TC,RT
Hospital Charge Code	5000217
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR RIBS RT 3 VIEWS WITH PA CHEST

Facility

$321.00

Service Code	HCPCS 71101 TC,RT
Hospital Charge Code	5071100
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR RIBS RT 3 VIEWS WITH PA CHEST

Facility

$321.00

Service Code	HCPCS 71101 TC,RT
Hospital Charge Code	5071100
Hospital Revenue Code	320
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$321.00
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: BCBS MT CHIP	$288.90
Rate for Payer: BCBS MT Closed Plan Network	$304.95
Rate for Payer: BCBS MT HealthLink	$288.90
Rate for Payer: BCBS MT Medicare	$288.90
Rate for Payer: BCBS MT POS	$304.95
Rate for Payer: BCBS MT Traditional	$321.00
Rate for Payer: Cash Price	$288.90
Rate for Payer: Cigna Commercial	$304.95
Rate for Payer: Cigna Medicare	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

XR SACRUM COCCYX 2 VIEWS

Facility

$307.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	5000218
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 SACRUM COCCYX 2 VIEWS

Facility

$307.00

Service Code	HCPCS 72220 TC
Hospital Charge Code	5000218
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 SCAPULA LT

Facility

$289.00

Service Code	HCPCS 73010 TC,LT
Hospital Charge Code	5000219
Hospital Revenue Code	320
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

XR SCAPULA LT

Facility

$289.00

Service Code	HCPCS 73010 TC,LT
Hospital Charge Code	5000219
Hospital Revenue Code	320
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

XR SCAPULA RT

Facility

$289.00

Service Code	HCPCS 73010 TC,RT
Hospital Charge Code	5000220
Hospital Revenue Code	320
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

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