Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR SC JOINTS 3 VIEWS

Facility

$266.00

Service Code	HCPCS 71130 TC
Hospital Charge Code	5000076
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 SC JOINTS 3 VIEWS

Facility

$266.00

Service Code	HCPCS 71130 TC
Hospital Charge Code	5000076
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 SCOLIOSIS STUDY

Facility

$336.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5072082
Hospital Revenue Code	320
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

XR SCOLIOSIS STUDY

Facility

$336.00

Service Code	HCPCS 72082 TC
Hospital Charge Code	5072082
Hospital Revenue Code	320
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

XR SCOLIOSIS STUDY 1 VIEW

Facility

$220.00

Service Code	HCPCS 72081 TC
Hospital Charge Code	5072081
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 SCOLIOSIS STUDY 1 VIEW

Facility

$220.00

Service Code	HCPCS 72081 TC
Hospital Charge Code	5072081
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 SCOLIOSIS STUDY 4-5 VIEWS

Facility

$452.00

Service Code	HCPCS 72083 TC
Hospital Charge Code	5072083
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

XR SCOLIOSIS STUDY 4-5 VIEWS

Facility

$452.00

Service Code	HCPCS 72083 TC
Hospital Charge Code	5072083
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

XR SCOLIOSIS STUDY MIN 6 VIEWS

Facility

$568.00

Service Code	HCPCS 72084 TC
Hospital Charge Code	5072084
Hospital Revenue Code	320
Min. Negotiated Rate	$397.60
Max. Negotiated Rate	$568.00
Rate for Payer: Aetna Commercial	$539.60
Rate for Payer: Aetna Medicare	$511.20
Rate for Payer: BCBS MT CHIP	$511.20
Rate for Payer: BCBS MT Closed Plan Network	$539.60
Rate for Payer: BCBS MT HealthLink	$511.20
Rate for Payer: BCBS MT Medicare	$511.20
Rate for Payer: BCBS MT POS	$539.60
Rate for Payer: BCBS MT Traditional	$568.00
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cigna Commercial	$539.60
Rate for Payer: Cigna Medicare	$511.20
Rate for Payer: Medicaid All Medicaid	$522.56
Rate for Payer: Medicare All Medicare	$397.60
Rate for Payer: Monida Allegiance	$539.60
Rate for Payer: Monida First Choice Health	$550.96
Rate for Payer: Monida Montana Health Co-op	$539.60
Rate for Payer: Monida PacificSource	$539.60

XR SCOLIOSIS STUDY MIN 6 VIEWS

Facility

$568.00

Service Code	HCPCS 72084 TC
Hospital Charge Code	5072084
Hospital Revenue Code	320
Min. Negotiated Rate	$397.60
Max. Negotiated Rate	$568.00
Rate for Payer: Aetna Commercial	$539.60
Rate for Payer: Aetna Medicare	$511.20
Rate for Payer: BCBS MT CHIP	$511.20
Rate for Payer: BCBS MT Closed Plan Network	$539.60
Rate for Payer: BCBS MT HealthLink	$511.20
Rate for Payer: BCBS MT Medicare	$511.20
Rate for Payer: BCBS MT POS	$539.60
Rate for Payer: BCBS MT Traditional	$568.00
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cigna Commercial	$539.60
Rate for Payer: Cigna Medicare	$511.20
Rate for Payer: Medicaid All Medicaid	$522.56
Rate for Payer: Medicare All Medicare	$397.60
Rate for Payer: Monida Allegiance	$539.60
Rate for Payer: Monida First Choice Health	$550.96
Rate for Payer: Monida Montana Health Co-op	$539.60
Rate for Payer: Monida PacificSource	$539.60

XR SHOULDER LT 1 VIEW

Facility

$550.00

Service Code	HCPCS 73020 TC,LT
Hospital Charge Code	5000225
Hospital Revenue Code	320
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

XR SHOULDER LT 1 VIEW

Facility

$550.00

Service Code	HCPCS 73020 TC,LT
Hospital Charge Code	5000225
Hospital Revenue Code	320
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

XR SHOULDER LT 2-3 VIEWS

Facility

$713.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000005
Hospital Revenue Code	320
Min. Negotiated Rate	$499.10
Max. Negotiated Rate	$713.00
Rate for Payer: Aetna Commercial	$677.35
Rate for Payer: Aetna Medicare	$641.70
Rate for Payer: BCBS MT CHIP	$641.70
Rate for Payer: BCBS MT Closed Plan Network	$677.35
Rate for Payer: BCBS MT HealthLink	$641.70
Rate for Payer: BCBS MT Medicare	$641.70
Rate for Payer: BCBS MT POS	$677.35
Rate for Payer: BCBS MT Traditional	$713.00
Rate for Payer: Cash Price	$641.70
Rate for Payer: Cigna Commercial	$677.35
Rate for Payer: Cigna Medicare	$641.70
Rate for Payer: Medicaid All Medicaid	$655.96
Rate for Payer: Medicare All Medicare	$499.10
Rate for Payer: Monida Allegiance	$677.35
Rate for Payer: Monida First Choice Health	$691.61
Rate for Payer: Monida Montana Health Co-op	$677.35
Rate for Payer: Monida PacificSource	$677.35

XR SHOULDER LT 2-3 VIEWS

Facility

$713.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000005
Hospital Revenue Code	320
Min. Negotiated Rate	$499.10
Max. Negotiated Rate	$713.00
Rate for Payer: Aetna Commercial	$677.35
Rate for Payer: Aetna Medicare	$641.70
Rate for Payer: BCBS MT CHIP	$641.70
Rate for Payer: BCBS MT Closed Plan Network	$677.35
Rate for Payer: BCBS MT HealthLink	$641.70
Rate for Payer: BCBS MT Medicare	$641.70
Rate for Payer: BCBS MT POS	$677.35
Rate for Payer: BCBS MT Traditional	$713.00
Rate for Payer: Cash Price	$641.70
Rate for Payer: Cigna Commercial	$677.35
Rate for Payer: Cigna Medicare	$641.70
Rate for Payer: Medicaid All Medicaid	$655.96
Rate for Payer: Medicare All Medicare	$499.10
Rate for Payer: Monida Allegiance	$677.35
Rate for Payer: Monida First Choice Health	$691.61
Rate for Payer: Monida Montana Health Co-op	$677.35
Rate for Payer: Monida PacificSource	$677.35

XR SHOULDER LT 2 VIEWS

Facility

$679.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000222
Hospital Revenue Code	320
Min. Negotiated Rate	$475.30
Max. Negotiated Rate	$679.00
Rate for Payer: Aetna Commercial	$645.05
Rate for Payer: Aetna Medicare	$611.10
Rate for Payer: BCBS MT CHIP	$611.10
Rate for Payer: BCBS MT Closed Plan Network	$645.05
Rate for Payer: BCBS MT HealthLink	$611.10
Rate for Payer: BCBS MT Medicare	$611.10
Rate for Payer: BCBS MT POS	$645.05
Rate for Payer: BCBS MT Traditional	$679.00
Rate for Payer: Cash Price	$611.10
Rate for Payer: Cigna Commercial	$645.05
Rate for Payer: Cigna Medicare	$611.10
Rate for Payer: Medicaid All Medicaid	$624.68
Rate for Payer: Medicare All Medicare	$475.30
Rate for Payer: Monida Allegiance	$645.05
Rate for Payer: Monida First Choice Health	$658.63
Rate for Payer: Monida Montana Health Co-op	$645.05
Rate for Payer: Monida PacificSource	$645.05

XR SHOULDER LT 2 VIEWS

Facility

$679.00

Service Code	HCPCS 73030 TC,LT
Hospital Charge Code	5000222
Hospital Revenue Code	320
Min. Negotiated Rate	$475.30
Max. Negotiated Rate	$679.00
Rate for Payer: Aetna Commercial	$645.05
Rate for Payer: Aetna Medicare	$611.10
Rate for Payer: BCBS MT CHIP	$611.10
Rate for Payer: BCBS MT Closed Plan Network	$645.05
Rate for Payer: BCBS MT HealthLink	$611.10
Rate for Payer: BCBS MT Medicare	$611.10
Rate for Payer: BCBS MT POS	$645.05
Rate for Payer: BCBS MT Traditional	$679.00
Rate for Payer: Cash Price	$611.10
Rate for Payer: Cigna Commercial	$645.05
Rate for Payer: Cigna Medicare	$611.10
Rate for Payer: Medicaid All Medicaid	$624.68
Rate for Payer: Medicare All Medicare	$475.30
Rate for Payer: Monida Allegiance	$645.05
Rate for Payer: Monida First Choice Health	$658.63
Rate for Payer: Monida Montana Health Co-op	$645.05
Rate for Payer: Monida PacificSource	$645.05

XR SHOULDER RT 1 VIEW

Facility

$550.00

Service Code	HCPCS 73020 TC,RT
Hospital Charge Code	5000226
Hospital Revenue Code	320
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

XR SHOULDER RT 1 VIEW

Facility

$550.00

Service Code	HCPCS 73020 TC,RT
Hospital Charge Code	5000226
Hospital Revenue Code	320
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

XR SHOULDER RT 2-3 VIEWS

Facility

$713.00

Service Code	HCPCS 73030 TC,RT
Hospital Charge Code	5073030
Hospital Revenue Code	320
Min. Negotiated Rate	$499.10
Max. Negotiated Rate	$713.00
Rate for Payer: Aetna Commercial	$677.35
Rate for Payer: Aetna Medicare	$641.70
Rate for Payer: BCBS MT CHIP	$641.70
Rate for Payer: BCBS MT Closed Plan Network	$677.35
Rate for Payer: BCBS MT HealthLink	$641.70
Rate for Payer: BCBS MT Medicare	$641.70
Rate for Payer: BCBS MT POS	$677.35
Rate for Payer: BCBS MT Traditional	$713.00
Rate for Payer: Cash Price	$641.70
Rate for Payer: Cigna Commercial	$677.35
Rate for Payer: Cigna Medicare	$641.70
Rate for Payer: Medicaid All Medicaid	$655.96
Rate for Payer: Medicare All Medicare	$499.10
Rate for Payer: Monida Allegiance	$677.35
Rate for Payer: Monida First Choice Health	$691.61
Rate for Payer: Monida Montana Health Co-op	$677.35
Rate for Payer: Monida PacificSource	$677.35

XR SHOULDER RT 2-3 VIEWS

Facility

$713.00

Service Code	HCPCS 73030 TC,RT
Hospital Charge Code	5073030
Hospital Revenue Code	320
Min. Negotiated Rate	$499.10
Max. Negotiated Rate	$713.00
Rate for Payer: Aetna Commercial	$677.35
Rate for Payer: Aetna Medicare	$641.70
Rate for Payer: BCBS MT CHIP	$641.70
Rate for Payer: BCBS MT Closed Plan Network	$677.35
Rate for Payer: BCBS MT HealthLink	$641.70
Rate for Payer: BCBS MT Medicare	$641.70
Rate for Payer: BCBS MT POS	$677.35
Rate for Payer: BCBS MT Traditional	$713.00
Rate for Payer: Cash Price	$641.70
Rate for Payer: Cigna Commercial	$677.35
Rate for Payer: Cigna Medicare	$641.70
Rate for Payer: Medicaid All Medicaid	$655.96
Rate for Payer: Medicare All Medicare	$499.10
Rate for Payer: Monida Allegiance	$677.35
Rate for Payer: Monida First Choice Health	$691.61
Rate for Payer: Monida Montana Health Co-op	$677.35
Rate for Payer: Monida PacificSource	$677.35

XR SHOULDER RT 2 VIEWS

Facility

$679.00

Service Code	HCPCS 73030 TC,RT
Hospital Charge Code	5000223
Hospital Revenue Code	320
Min. Negotiated Rate	$475.30
Max. Negotiated Rate	$679.00
Rate for Payer: Aetna Commercial	$645.05
Rate for Payer: Aetna Medicare	$611.10
Rate for Payer: BCBS MT CHIP	$611.10
Rate for Payer: BCBS MT Closed Plan Network	$645.05
Rate for Payer: BCBS MT HealthLink	$611.10
Rate for Payer: BCBS MT Medicare	$611.10
Rate for Payer: BCBS MT POS	$645.05
Rate for Payer: BCBS MT Traditional	$679.00
Rate for Payer: Cash Price	$611.10
Rate for Payer: Cigna Commercial	$645.05
Rate for Payer: Cigna Medicare	$611.10
Rate for Payer: Medicaid All Medicaid	$624.68
Rate for Payer: Medicare All Medicare	$475.30
Rate for Payer: Monida Allegiance	$645.05
Rate for Payer: Monida First Choice Health	$658.63
Rate for Payer: Monida Montana Health Co-op	$645.05
Rate for Payer: Monida PacificSource	$645.05

XR SHOULDER RT 2 VIEWS

Facility

$679.00

Service Code	HCPCS 73030 TC,RT
Hospital Charge Code	5000223
Hospital Revenue Code	320
Min. Negotiated Rate	$475.30
Max. Negotiated Rate	$679.00
Rate for Payer: Aetna Commercial	$645.05
Rate for Payer: Aetna Medicare	$611.10
Rate for Payer: BCBS MT CHIP	$611.10
Rate for Payer: BCBS MT Closed Plan Network	$645.05
Rate for Payer: BCBS MT HealthLink	$611.10
Rate for Payer: BCBS MT Medicare	$611.10
Rate for Payer: BCBS MT POS	$645.05
Rate for Payer: BCBS MT Traditional	$679.00
Rate for Payer: Cash Price	$611.10
Rate for Payer: Cigna Commercial	$645.05
Rate for Payer: Cigna Medicare	$611.10
Rate for Payer: Medicaid All Medicaid	$624.68
Rate for Payer: Medicare All Medicare	$475.30
Rate for Payer: Monida Allegiance	$645.05
Rate for Payer: Monida First Choice Health	$658.63
Rate for Payer: Monida Montana Health Co-op	$645.05
Rate for Payer: Monida PacificSource	$645.05

XR SHOULDERS BILATERAL 1 VIEW

Facility

$825.00

Service Code	HCPCS 73020 TC,50
Hospital Charge Code	5000224
Hospital Revenue Code	320
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna Commercial	$783.75
Rate for Payer: Aetna Medicare	$742.50
Rate for Payer: BCBS MT CHIP	$742.50
Rate for Payer: BCBS MT Closed Plan Network	$783.75
Rate for Payer: BCBS MT HealthLink	$742.50
Rate for Payer: BCBS MT Medicare	$742.50
Rate for Payer: BCBS MT POS	$783.75
Rate for Payer: BCBS MT Traditional	$825.00
Rate for Payer: Cash Price	$742.50
Rate for Payer: Cigna Commercial	$783.75
Rate for Payer: Cigna Medicare	$742.50
Rate for Payer: Medicaid All Medicaid	$759.00
Rate for Payer: Medicare All Medicare	$577.50
Rate for Payer: Monida Allegiance	$783.75
Rate for Payer: Monida First Choice Health	$800.25
Rate for Payer: Monida Montana Health Co-op	$783.75
Rate for Payer: Monida PacificSource	$783.75

XR SHOULDERS BILATERAL 1 VIEW

Facility

$825.00

Service Code	HCPCS 73020 TC,50
Hospital Charge Code	5000224
Hospital Revenue Code	320
Min. Negotiated Rate	$577.50
Max. Negotiated Rate	$825.00
Rate for Payer: Aetna Commercial	$783.75
Rate for Payer: Aetna Medicare	$742.50
Rate for Payer: BCBS MT CHIP	$742.50
Rate for Payer: BCBS MT Closed Plan Network	$783.75
Rate for Payer: BCBS MT HealthLink	$742.50
Rate for Payer: BCBS MT Medicare	$742.50
Rate for Payer: BCBS MT POS	$783.75
Rate for Payer: BCBS MT Traditional	$825.00
Rate for Payer: Cash Price	$742.50
Rate for Payer: Cigna Commercial	$783.75
Rate for Payer: Cigna Medicare	$742.50
Rate for Payer: Medicaid All Medicaid	$759.00
Rate for Payer: Medicare All Medicare	$577.50
Rate for Payer: Monida Allegiance	$783.75
Rate for Payer: Monida First Choice Health	$800.25
Rate for Payer: Monida Montana Health Co-op	$783.75
Rate for Payer: Monida PacificSource	$783.75

Know your out-of-pocket cost for care.

All Charges