Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR SHOULDERS BILATERAL 2 VIEWS

Facility

$1,019.00

Service Code	HCPCS 73030 TC,50
Hospital Charge Code	5000221
Hospital Revenue Code	320
Min. Negotiated Rate	$713.30
Max. Negotiated Rate	$1,019.00
Rate for Payer: Aetna Commercial	$968.05
Rate for Payer: Aetna Medicare	$917.10
Rate for Payer: BCBS MT CHIP	$917.10
Rate for Payer: BCBS MT Closed Plan Network	$968.05
Rate for Payer: BCBS MT HealthLink	$917.10
Rate for Payer: BCBS MT Medicare	$917.10
Rate for Payer: BCBS MT POS	$968.05
Rate for Payer: BCBS MT Traditional	$1,019.00
Rate for Payer: Cash Price	$917.10
Rate for Payer: Cigna Commercial	$968.05
Rate for Payer: Cigna Medicare	$917.10
Rate for Payer: Medicaid All Medicaid	$937.48
Rate for Payer: Medicare All Medicare	$713.30
Rate for Payer: Monida Allegiance	$968.05
Rate for Payer: Monida First Choice Health	$988.43
Rate for Payer: Monida Montana Health Co-op	$968.05
Rate for Payer: Monida PacificSource	$968.05

XR SHOULDERS BILATERAL 2 VIEWS

Facility

$1,019.00

Service Code	HCPCS 73030 TC,50
Hospital Charge Code	5000221
Hospital Revenue Code	320
Min. Negotiated Rate	$713.30
Max. Negotiated Rate	$1,019.00
Rate for Payer: Aetna Commercial	$968.05
Rate for Payer: Aetna Medicare	$917.10
Rate for Payer: BCBS MT CHIP	$917.10
Rate for Payer: BCBS MT Closed Plan Network	$968.05
Rate for Payer: BCBS MT HealthLink	$917.10
Rate for Payer: BCBS MT Medicare	$917.10
Rate for Payer: BCBS MT POS	$968.05
Rate for Payer: BCBS MT Traditional	$1,019.00
Rate for Payer: Cash Price	$917.10
Rate for Payer: Cigna Commercial	$968.05
Rate for Payer: Cigna Medicare	$917.10
Rate for Payer: Medicaid All Medicaid	$937.48
Rate for Payer: Medicare All Medicare	$713.30
Rate for Payer: Monida Allegiance	$968.05
Rate for Payer: Monida First Choice Health	$988.43
Rate for Payer: Monida Montana Health Co-op	$968.05
Rate for Payer: Monida PacificSource	$968.05

XR SI JOINTS 3 VIEWS

Facility

$298.00

Service Code	HCPCS 72202 TC
Hospital Charge Code	5000062
Hospital Revenue Code	320
Min. Negotiated Rate	$208.60
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$283.10
Rate for Payer: Aetna Medicare	$268.20
Rate for Payer: BCBS MT CHIP	$268.20
Rate for Payer: BCBS MT Closed Plan Network	$283.10
Rate for Payer: BCBS MT HealthLink	$268.20
Rate for Payer: BCBS MT Medicare	$268.20
Rate for Payer: BCBS MT POS	$283.10
Rate for Payer: BCBS MT Traditional	$298.00
Rate for Payer: Cash Price	$268.20
Rate for Payer: Cigna Commercial	$283.10
Rate for Payer: Cigna Medicare	$268.20
Rate for Payer: Medicaid All Medicaid	$274.16
Rate for Payer: Medicare All Medicare	$208.60
Rate for Payer: Monida Allegiance	$283.10
Rate for Payer: Monida First Choice Health	$289.06
Rate for Payer: Monida Montana Health Co-op	$283.10
Rate for Payer: Monida PacificSource	$283.10

XR SI JOINTS 3 VIEWS

Facility

$298.00

Service Code	HCPCS 72202 TC
Hospital Charge Code	5000062
Hospital Revenue Code	320
Min. Negotiated Rate	$208.60
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$283.10
Rate for Payer: Aetna Medicare	$268.20
Rate for Payer: BCBS MT CHIP	$268.20
Rate for Payer: BCBS MT Closed Plan Network	$283.10
Rate for Payer: BCBS MT HealthLink	$268.20
Rate for Payer: BCBS MT Medicare	$268.20
Rate for Payer: BCBS MT POS	$283.10
Rate for Payer: BCBS MT Traditional	$298.00
Rate for Payer: Cash Price	$268.20
Rate for Payer: Cigna Commercial	$283.10
Rate for Payer: Cigna Medicare	$268.20
Rate for Payer: Medicaid All Medicaid	$274.16
Rate for Payer: Medicare All Medicare	$208.60
Rate for Payer: Monida Allegiance	$283.10
Rate for Payer: Monida First Choice Health	$289.06
Rate for Payer: Monida Montana Health Co-op	$283.10
Rate for Payer: Monida PacificSource	$283.10

XR SI JOINTS BILATERAL

Facility

$237.00

Service Code	HCPCS 72200 TC
Hospital Charge Code	5000227
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 SI JOINTS BILATERAL

Facility

$237.00

Service Code	HCPCS 72200 TC
Hospital Charge Code	5000227
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 SINUS 1 OR 2 VIEWS

Facility

$237.00

Service Code	HCPCS 70210 TC
Hospital Charge Code	5000228
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 SINUS 1 OR 2 VIEWS

Facility

$237.00

Service Code	HCPCS 70210 TC
Hospital Charge Code	5000228
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 SINUS COMPLETE

Facility

$371.00

Service Code	HCPCS 70220 TC
Hospital Charge Code	5000229
Hospital Revenue Code	320
Min. Negotiated Rate	$259.70
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$352.45
Rate for Payer: Aetna Medicare	$333.90
Rate for Payer: BCBS MT CHIP	$333.90
Rate for Payer: BCBS MT Closed Plan Network	$352.45
Rate for Payer: BCBS MT HealthLink	$333.90
Rate for Payer: BCBS MT Medicare	$333.90
Rate for Payer: BCBS MT POS	$352.45
Rate for Payer: BCBS MT Traditional	$371.00
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cigna Commercial	$352.45
Rate for Payer: Cigna Medicare	$333.90
Rate for Payer: Medicaid All Medicaid	$341.32
Rate for Payer: Medicare All Medicare	$259.70
Rate for Payer: Monida Allegiance	$352.45
Rate for Payer: Monida First Choice Health	$359.87
Rate for Payer: Monida Montana Health Co-op	$352.45
Rate for Payer: Monida PacificSource	$352.45

XR SINUS COMPLETE

Facility

$371.00

Service Code	HCPCS 70220 TC
Hospital Charge Code	5000229
Hospital Revenue Code	320
Min. Negotiated Rate	$259.70
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna Commercial	$352.45
Rate for Payer: Aetna Medicare	$333.90
Rate for Payer: BCBS MT CHIP	$333.90
Rate for Payer: BCBS MT Closed Plan Network	$352.45
Rate for Payer: BCBS MT HealthLink	$333.90
Rate for Payer: BCBS MT Medicare	$333.90
Rate for Payer: BCBS MT POS	$352.45
Rate for Payer: BCBS MT Traditional	$371.00
Rate for Payer: Cash Price	$333.90
Rate for Payer: Cigna Commercial	$352.45
Rate for Payer: Cigna Medicare	$333.90
Rate for Payer: Medicaid All Medicaid	$341.32
Rate for Payer: Medicare All Medicare	$259.70
Rate for Payer: Monida Allegiance	$352.45
Rate for Payer: Monida First Choice Health	$359.87
Rate for Payer: Monida Montana Health Co-op	$352.45
Rate for Payer: Monida PacificSource	$352.45

XR SKULL 1 TO 3 VIEWS

Facility

$318.00

Service Code	HCPCS 70250 TC
Hospital Charge Code	5000230
Hospital Revenue Code	320
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

XR SKULL 1 TO 3 VIEWS

Facility

$318.00

Service Code	HCPCS 70250 TC
Hospital Charge Code	5000230
Hospital Revenue Code	320
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

XR SKULL COMPLETE 4 VIEWS

Facility

$440.00

Service Code	HCPCS 70260 TC
Hospital Charge Code	5000231
Hospital Revenue Code	320
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$440.00
Rate for Payer: Aetna Commercial	$418.00
Rate for Payer: Aetna Medicare	$396.00
Rate for Payer: BCBS MT CHIP	$396.00
Rate for Payer: BCBS MT Closed Plan Network	$418.00
Rate for Payer: BCBS MT HealthLink	$396.00
Rate for Payer: BCBS MT Medicare	$396.00
Rate for Payer: BCBS MT POS	$418.00
Rate for Payer: BCBS MT Traditional	$440.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cigna Commercial	$418.00
Rate for Payer: Cigna Medicare	$396.00
Rate for Payer: Medicaid All Medicaid	$404.80
Rate for Payer: Medicare All Medicare	$308.00
Rate for Payer: Monida Allegiance	$418.00
Rate for Payer: Monida First Choice Health	$426.80
Rate for Payer: Monida Montana Health Co-op	$418.00
Rate for Payer: Monida PacificSource	$418.00

XR SKULL COMPLETE 4 VIEWS

Facility

$440.00

Service Code	HCPCS 70260 TC
Hospital Charge Code	5000231
Hospital Revenue Code	320
Min. Negotiated Rate	$308.00
Max. Negotiated Rate	$440.00
Rate for Payer: Aetna Commercial	$418.00
Rate for Payer: Aetna Medicare	$396.00
Rate for Payer: BCBS MT CHIP	$396.00
Rate for Payer: BCBS MT Closed Plan Network	$418.00
Rate for Payer: BCBS MT HealthLink	$396.00
Rate for Payer: BCBS MT Medicare	$396.00
Rate for Payer: BCBS MT POS	$418.00
Rate for Payer: BCBS MT Traditional	$440.00
Rate for Payer: Cash Price	$396.00
Rate for Payer: Cigna Commercial	$418.00
Rate for Payer: Cigna Medicare	$396.00
Rate for Payer: Medicaid All Medicaid	$404.80
Rate for Payer: Medicare All Medicare	$308.00
Rate for Payer: Monida Allegiance	$418.00
Rate for Payer: Monida First Choice Health	$426.80
Rate for Payer: Monida Montana Health Co-op	$418.00
Rate for Payer: Monida PacificSource	$418.00

XR SOFT TISSUE NECK

Facility

$266.00

Service Code	HCPCS 70360 TC
Hospital Charge Code	5000207
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 SOFT TISSUE NECK

Facility

$266.00

Service Code	HCPCS 70360 TC
Hospital Charge Code	5000207
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 STERNUM

Facility

$307.00

Service Code	HCPCS 71120 TC
Hospital Charge Code	5000233
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 STERNUM

Facility

$307.00

Service Code	HCPCS 71120 TC
Hospital Charge Code	5000233
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 THORACIC SPINE 1 VIEW

Facility

$261.00

Service Code	HCPCS 72020 TC
Hospital Charge Code	5000232
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR THORACIC SPINE 1 VIEW

Facility

$261.00

Service Code	HCPCS 72020 TC
Hospital Charge Code	5000232
Hospital Revenue Code	320
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

XR THORACIC SPINE 2 VIEWS

Facility

$307.00

Service Code	HCPCS 72070 TC
Hospital Charge Code	5000242
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 THORACIC SPINE 2 VIEWS

Facility

$307.00

Service Code	HCPCS 72070 TC
Hospital Charge Code	5000242
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 THORACIC SPINE 3 VIEWS

Facility

$364.00

Service Code	HCPCS 72072 TC
Hospital Charge Code	5000243
Hospital Revenue Code	320
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

XR THORACIC SPINE 3 VIEWS

Facility

$364.00

Service Code	HCPCS 72072 TC
Hospital Charge Code	5000243
Hospital Revenue Code	320
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

XR THORACIC SPINE 4 VIEWS

Facility

$348.00

Service Code	HCPCS 72074 TC
Hospital Charge Code	5000182
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

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