Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

WV CHILD NEW PATIENT 12-17YEARS OLD

Facility

$313.00

Service Code	CPT 99384
Hospital Charge Code	8099384
Hospital Revenue Code	521
Min. Negotiated Rate	$219.10
Max. Negotiated Rate	$313.00
Rate for Payer: Aetna Commercial	$297.35
Rate for Payer: Aetna Medicare	$281.70
Rate for Payer: BCBS MT CHIP	$281.70
Rate for Payer: BCBS MT Closed Plan Network	$297.35
Rate for Payer: BCBS MT HealthLink	$281.70
Rate for Payer: BCBS MT Medicare	$281.70
Rate for Payer: BCBS MT POS	$297.35
Rate for Payer: BCBS MT Traditional	$313.00
Rate for Payer: Cash Price	$281.70
Rate for Payer: Cigna Commercial	$297.35
Rate for Payer: Cigna Medicare	$281.70
Rate for Payer: Medicaid All Medicaid	$287.96
Rate for Payer: Medicare All Medicare	$219.10
Rate for Payer: Monida Allegiance	$297.35
Rate for Payer: Monida First Choice Health	$303.61
Rate for Payer: Monida Montana Health Co-op	$297.35
Rate for Payer: Monida PacificSource	$297.35

WV CHILD NEW PATIENT 1-4YEARS OLD

Facility

$266.00

Service Code	CPT 99382
Hospital Charge Code	8099382
Hospital Revenue Code	521
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

WV CHILD NEW PATIENT 1-4YEARS OLD

Facility

$266.00

Service Code	CPT 99382
Hospital Charge Code	8099382
Hospital Revenue Code	521
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

WV CHILD NEW PATIENTS 5-11YEARS OLD

Facility

$279.00

Service Code	CPT 99383
Hospital Charge Code	8099383
Hospital Revenue Code	521
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

WV CHILD NEW PATIENTS 5-11YEARS OLD

Facility

$279.00

Service Code	CPT 99383
Hospital Charge Code	8099383
Hospital Revenue Code	521
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

WV ESTAB PATIENT 18-39 YEARS OLD

Facility

$271.00

Service Code	CPT 99395
Hospital Charge Code	8099395
Hospital Revenue Code	521
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$271.00
Rate for Payer: Aetna Commercial	$257.45
Rate for Payer: Aetna Medicare	$243.90
Rate for Payer: BCBS MT CHIP	$243.90
Rate for Payer: BCBS MT Closed Plan Network	$257.45
Rate for Payer: BCBS MT HealthLink	$243.90
Rate for Payer: BCBS MT Medicare	$243.90
Rate for Payer: BCBS MT POS	$257.45
Rate for Payer: BCBS MT Traditional	$271.00
Rate for Payer: Cash Price	$243.90
Rate for Payer: Cigna Commercial	$257.45
Rate for Payer: Cigna Medicare	$243.90
Rate for Payer: Medicaid All Medicaid	$249.32
Rate for Payer: Medicare All Medicare	$189.70
Rate for Payer: Monida Allegiance	$257.45
Rate for Payer: Monida First Choice Health	$262.87
Rate for Payer: Monida Montana Health Co-op	$257.45
Rate for Payer: Monida PacificSource	$257.45

WV ESTAB PATIENT 18-39 YEARS OLD

Facility

$271.00

Service Code	CPT 99395
Hospital Charge Code	8099395
Hospital Revenue Code	521
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$271.00
Rate for Payer: Aetna Commercial	$257.45
Rate for Payer: Aetna Medicare	$243.90
Rate for Payer: BCBS MT CHIP	$243.90
Rate for Payer: BCBS MT Closed Plan Network	$257.45
Rate for Payer: BCBS MT HealthLink	$243.90
Rate for Payer: BCBS MT Medicare	$243.90
Rate for Payer: BCBS MT POS	$257.45
Rate for Payer: BCBS MT Traditional	$271.00
Rate for Payer: Cash Price	$243.90
Rate for Payer: Cigna Commercial	$257.45
Rate for Payer: Cigna Medicare	$243.90
Rate for Payer: Medicaid All Medicaid	$249.32
Rate for Payer: Medicare All Medicare	$189.70
Rate for Payer: Monida Allegiance	$257.45
Rate for Payer: Monida First Choice Health	$262.87
Rate for Payer: Monida Montana Health Co-op	$257.45
Rate for Payer: Monida PacificSource	$257.45

WV OCCUPATIONAL PE (WINSTON)

Facility

$231.00

Service Code	CPT 99499
Hospital Charge Code	8099499
Hospital Revenue Code	521
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

WV OCCUPATIONAL PE (WINSTON)

Facility

$231.00

Service Code	CPT 99499
Hospital Charge Code	8099499
Hospital Revenue Code	521
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$231.00
Rate for Payer: Aetna Commercial	$219.45
Rate for Payer: Aetna Medicare	$207.90
Rate for Payer: BCBS MT CHIP	$207.90
Rate for Payer: BCBS MT Closed Plan Network	$219.45
Rate for Payer: BCBS MT HealthLink	$207.90
Rate for Payer: BCBS MT Medicare	$207.90
Rate for Payer: BCBS MT POS	$219.45
Rate for Payer: BCBS MT Traditional	$231.00
Rate for Payer: Cash Price	$207.90
Rate for Payer: Cigna Commercial	$219.45
Rate for Payer: Cigna Medicare	$207.90
Rate for Payer: Medicaid All Medicaid	$212.52
Rate for Payer: Medicare All Medicare	$161.70
Rate for Payer: Monida Allegiance	$219.45
Rate for Payer: Monida First Choice Health	$224.07
Rate for Payer: Monida Montana Health Co-op	$219.45
Rate for Payer: Monida PacificSource	$219.45

XDIPHENHYDRAMINE SYRUP [12.5 MG/5 ML] UD

Facility

$8.00

Service Code	HCPCS Q0163
Hospital Charge Code	3000126
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

XDIPHENHYDRAMINE SYRUP [12.5 MG/5 ML] UD

Facility

$8.00

Service Code	HCPCS Q0163
Hospital Charge Code	3000126
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

XEROFORM 1X8

Facility

$5.00

Hospital Charge Code	80033301
Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

XEROFORM 1X8

Facility

$5.00

Hospital Charge Code	80033301
Hospital Revenue Code	270
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

XEROFORM 5X9

Facility

$13.00

Hospital Charge Code	80033605
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

XEROFORM 5X9

Facility

$13.00

Hospital Charge Code	80033605
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

XN CHECK HEME CONTROL

Facility

$375.00

Hospital Charge Code	90197161
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

XN CHECK HEME CONTROL

Facility

$375.00

Hospital Charge Code	90197161
Hospital Revenue Code	270
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

XR ABDOMEN 1 VIEW

Facility

$247.00

Service Code	CPT 74018
Hospital Charge Code	5074018
Hospital Revenue Code	320
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$247.00
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna Medicare	$222.30
Rate for Payer: BCBS MT CHIP	$222.30
Rate for Payer: BCBS MT Closed Plan Network	$234.65
Rate for Payer: BCBS MT HealthLink	$222.30
Rate for Payer: BCBS MT Medicare	$222.30
Rate for Payer: BCBS MT POS	$234.65
Rate for Payer: BCBS MT Traditional	$247.00
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial	$234.65
Rate for Payer: Cigna Medicare	$222.30
Rate for Payer: Medicaid All Medicaid	$227.24
Rate for Payer: Medicare All Medicare	$172.90
Rate for Payer: Monida Allegiance	$234.65
Rate for Payer: Monida First Choice Health	$239.59
Rate for Payer: Monida Montana Health Co-op	$234.65
Rate for Payer: Monida PacificSource	$234.65

XR ABDOMEN 1 VIEW

Facility

$247.00

Service Code	CPT 74018
Hospital Charge Code	5074018
Hospital Revenue Code	320
Min. Negotiated Rate	$172.90
Max. Negotiated Rate	$247.00
Rate for Payer: Aetna Commercial	$234.65
Rate for Payer: Aetna Medicare	$222.30
Rate for Payer: BCBS MT CHIP	$222.30
Rate for Payer: BCBS MT Closed Plan Network	$234.65
Rate for Payer: BCBS MT HealthLink	$222.30
Rate for Payer: BCBS MT Medicare	$222.30
Rate for Payer: BCBS MT POS	$234.65
Rate for Payer: BCBS MT Traditional	$247.00
Rate for Payer: Cash Price	$222.30
Rate for Payer: Cigna Commercial	$234.65
Rate for Payer: Cigna Medicare	$222.30
Rate for Payer: Medicaid All Medicaid	$227.24
Rate for Payer: Medicare All Medicare	$172.90
Rate for Payer: Monida Allegiance	$234.65
Rate for Payer: Monida First Choice Health	$239.59
Rate for Payer: Monida Montana Health Co-op	$234.65
Rate for Payer: Monida PacificSource	$234.65

XR ABDOMEN 2 VIEWS

Facility

$298.00

Service Code	CPT 74019
Hospital Charge Code	5074019
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 ABDOMEN 2 VIEWS

Facility

$298.00

Service Code	CPT 74019
Hospital Charge Code	5074019
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 ABDOMEN 2V WITH CHEST

Facility

$469.00

Service Code	CPT 74022
Hospital Charge Code	5000129
Hospital Revenue Code	320
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

XR ABDOMEN 2V WITH CHEST

Facility

$469.00

Service Code	CPT 74022
Hospital Charge Code	5000129
Hospital Revenue Code	320
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

XR AC JOINTS W WO WEIGHTS

Facility

$284.00

Service Code	CPT 73050
Hospital Charge Code	5000131
Hospital Revenue Code	320
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

XR AC JOINTS W WO WEIGHTS

Facility

$284.00

Service Code	CPT 73050
Hospital Charge Code	5000131
Hospital Revenue Code	320
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

Know your out-of-pocket cost for care.

All Charges