Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR CALCANEUS LT 2 VIEWS

Facility

$254.00

Service Code	CPT 73650
Hospital Charge Code	5000179
Hospital Revenue Code	320
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

XR CALCANEUS RT 2 VIEWS

Facility

$254.00

Service Code	CPT 73650
Hospital Charge Code	5000180
Hospital Revenue Code	320
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

XR CALCANEUS RT 2 VIEWS

Facility

$254.00

Service Code	CPT 73650
Hospital Charge Code	5000180
Hospital Revenue Code	320
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

XR CERVICAL SPINE 2 TO 3 VIEWS

Facility

$318.00

Service Code	CPT 72040
Hospital Charge Code	5000149
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 CERVICAL SPINE 2 TO 3 VIEWS

Facility

$318.00

Service Code	CPT 72040
Hospital Charge Code	5000149
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 CERVICAL SPINE COMPLETE

Facility

$463.00

Service Code	CPT 72050
Hospital Charge Code	5000150
Hospital Revenue Code	320
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

XR CERVICAL SPINE COMPLETE

Facility

$463.00

Service Code	CPT 72050
Hospital Charge Code	5000150
Hospital Revenue Code	320
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

XR CERVICAL SPINE COMP W/ FLEX/EXT

Facility

$520.00

Service Code	CPT 72052
Hospital Charge Code	5000151
Hospital Revenue Code	320
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

XR CERVICAL SPINE COMP W/ FLEX/EXT

Facility

$520.00

Service Code	CPT 72052
Hospital Charge Code	5000151
Hospital Revenue Code	320
Min. Negotiated Rate	$364.00
Max. Negotiated Rate	$520.00
Rate for Payer: Aetna Commercial	$494.00
Rate for Payer: Aetna Medicare	$468.00
Rate for Payer: BCBS MT CHIP	$468.00
Rate for Payer: BCBS MT Closed Plan Network	$494.00
Rate for Payer: BCBS MT HealthLink	$468.00
Rate for Payer: BCBS MT Medicare	$468.00
Rate for Payer: BCBS MT POS	$494.00
Rate for Payer: BCBS MT Traditional	$520.00
Rate for Payer: Cash Price	$468.00
Rate for Payer: Cigna Commercial	$494.00
Rate for Payer: Cigna Medicare	$468.00
Rate for Payer: Medicaid All Medicaid	$478.40
Rate for Payer: Medicare All Medicare	$364.00
Rate for Payer: Monida Allegiance	$494.00
Rate for Payer: Monida First Choice Health	$504.40
Rate for Payer: Monida Montana Health Co-op	$494.00
Rate for Payer: Monida PacificSource	$494.00

XR CHEST 1 VIEW

Facility

$249.00

Service Code	CPT 71045
Hospital Charge Code	5000141
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 CHEST 1 VIEW

Facility

$249.00

Service Code	CPT 71045
Hospital Charge Code	5000141
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 CHEST 2 VIEWS

Facility

$318.00

Service Code	CPT 71046
Hospital Charge Code	5000142
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 CHEST 2 VIEWS

Facility

$318.00

Service Code	CPT 71046
Hospital Charge Code	5000142
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 CHEST CHILD 1 VIEW

Facility

$249.00

Service Code	CPT 71045
Hospital Charge Code	5000145
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 CHEST CHILD 1 VIEW

Facility

$249.00

Service Code	CPT 71045
Hospital Charge Code	5000145
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 CHEST/RIBS 4/> VIEWS

Facility

$492.00

Service Code	CPT 71111
Hospital Charge Code	5000127
Hospital Revenue Code	320
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

XR CHEST/RIBS 4/> VIEWS

Facility

$492.00

Service Code	CPT 71111
Hospital Charge Code	5000127
Hospital Revenue Code	320
Min. Negotiated Rate	$344.40
Max. Negotiated Rate	$492.00
Rate for Payer: Aetna Commercial	$467.40
Rate for Payer: Aetna Medicare	$442.80
Rate for Payer: BCBS MT CHIP	$442.80
Rate for Payer: BCBS MT Closed Plan Network	$467.40
Rate for Payer: BCBS MT HealthLink	$442.80
Rate for Payer: BCBS MT Medicare	$442.80
Rate for Payer: BCBS MT POS	$467.40
Rate for Payer: BCBS MT Traditional	$492.00
Rate for Payer: Cash Price	$442.80
Rate for Payer: Cigna Commercial	$467.40
Rate for Payer: Cigna Medicare	$442.80
Rate for Payer: Medicaid All Medicaid	$452.64
Rate for Payer: Medicare All Medicare	$344.40
Rate for Payer: Monida Allegiance	$467.40
Rate for Payer: Monida First Choice Health	$477.24
Rate for Payer: Monida Montana Health Co-op	$467.40
Rate for Payer: Monida PacificSource	$467.40

XR CHEST SINGLE VIEW

Facility

$249.00

Service Code	CPT 71045
Hospital Charge Code	5071045
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 CHEST SINGLE VIEW

Facility

$249.00

Service Code	CPT 71045
Hospital Charge Code	5071045
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 CINE/VIDEO THROAT/ESOPH

Facility

$675.00

Service Code	CPT 74230
Hospital Charge Code	5074230
Hospital Revenue Code	320
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna Commercial	$641.25
Rate for Payer: Aetna Medicare	$607.50
Rate for Payer: BCBS MT CHIP	$607.50
Rate for Payer: BCBS MT Closed Plan Network	$641.25
Rate for Payer: BCBS MT HealthLink	$607.50
Rate for Payer: BCBS MT Medicare	$607.50
Rate for Payer: BCBS MT POS	$641.25
Rate for Payer: BCBS MT Traditional	$675.00
Rate for Payer: Cash Price	$607.50
Rate for Payer: Cigna Commercial	$641.25
Rate for Payer: Cigna Medicare	$607.50
Rate for Payer: Medicaid All Medicaid	$621.00
Rate for Payer: Medicare All Medicare	$472.50
Rate for Payer: Monida Allegiance	$641.25
Rate for Payer: Monida First Choice Health	$654.75
Rate for Payer: Monida Montana Health Co-op	$641.25
Rate for Payer: Monida PacificSource	$641.25

XR CINE/VIDEO THROAT/ESOPH

Facility

$675.00

Service Code	CPT 74230
Hospital Charge Code	5074230
Hospital Revenue Code	320
Min. Negotiated Rate	$472.50
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna Commercial	$641.25
Rate for Payer: Aetna Medicare	$607.50
Rate for Payer: BCBS MT CHIP	$607.50
Rate for Payer: BCBS MT Closed Plan Network	$641.25
Rate for Payer: BCBS MT HealthLink	$607.50
Rate for Payer: BCBS MT Medicare	$607.50
Rate for Payer: BCBS MT POS	$641.25
Rate for Payer: BCBS MT Traditional	$675.00
Rate for Payer: Cash Price	$607.50
Rate for Payer: Cigna Commercial	$641.25
Rate for Payer: Cigna Medicare	$607.50
Rate for Payer: Medicaid All Medicaid	$621.00
Rate for Payer: Medicare All Medicare	$472.50
Rate for Payer: Monida Allegiance	$641.25
Rate for Payer: Monida First Choice Health	$654.75
Rate for Payer: Monida Montana Health Co-op	$641.25
Rate for Payer: Monida PacificSource	$641.25

XR CLAVICLE BILATERAL COMPLETE

Facility

$419.00

Service Code	CPT 73000
Hospital Charge Code	5000146
Hospital Revenue Code	320
Min. Negotiated Rate	$293.30
Max. Negotiated Rate	$419.00
Rate for Payer: Aetna Commercial	$398.05
Rate for Payer: Aetna Medicare	$377.10
Rate for Payer: BCBS MT CHIP	$377.10
Rate for Payer: BCBS MT Closed Plan Network	$398.05
Rate for Payer: BCBS MT HealthLink	$377.10
Rate for Payer: BCBS MT Medicare	$377.10
Rate for Payer: BCBS MT POS	$398.05
Rate for Payer: BCBS MT Traditional	$419.00
Rate for Payer: Cash Price	$377.10
Rate for Payer: Cigna Commercial	$398.05
Rate for Payer: Cigna Medicare	$377.10
Rate for Payer: Medicaid All Medicaid	$385.48
Rate for Payer: Medicare All Medicare	$293.30
Rate for Payer: Monida Allegiance	$398.05
Rate for Payer: Monida First Choice Health	$406.43
Rate for Payer: Monida Montana Health Co-op	$398.05
Rate for Payer: Monida PacificSource	$398.05

XR CLAVICLE BILATERAL COMPLETE

Facility

$419.00

Service Code	CPT 73000
Hospital Charge Code	5000146
Hospital Revenue Code	320
Min. Negotiated Rate	$293.30
Max. Negotiated Rate	$419.00
Rate for Payer: Aetna Commercial	$398.05
Rate for Payer: Aetna Medicare	$377.10
Rate for Payer: BCBS MT CHIP	$377.10
Rate for Payer: BCBS MT Closed Plan Network	$398.05
Rate for Payer: BCBS MT HealthLink	$377.10
Rate for Payer: BCBS MT Medicare	$377.10
Rate for Payer: BCBS MT POS	$398.05
Rate for Payer: BCBS MT Traditional	$419.00
Rate for Payer: Cash Price	$377.10
Rate for Payer: Cigna Commercial	$398.05
Rate for Payer: Cigna Medicare	$377.10
Rate for Payer: Medicaid All Medicaid	$385.48
Rate for Payer: Medicare All Medicare	$293.30
Rate for Payer: Monida Allegiance	$398.05
Rate for Payer: Monida First Choice Health	$406.43
Rate for Payer: Monida Montana Health Co-op	$398.05
Rate for Payer: Monida PacificSource	$398.05

XR CLAVICLE LT COMPLETE

Facility

$279.00

Service Code	CPT 73000
Hospital Charge Code	5000147
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 CLAVICLE LT COMPLETE

Facility

$279.00

Service Code	CPT 73000
Hospital Charge Code	5000147
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

Know your out-of-pocket cost for care.

All Charges