Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR CLAVICLE RT COMPLETE

Facility

$279.00

Service Code	CPT 73000
Hospital Charge Code	5000148
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 RT COMPLETE

Facility

$279.00

Service Code	CPT 73000
Hospital Charge Code	5000148
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 CTA THORACIC AORTA W OR W/O CONTRAST

Facility

$3,199.00

Service Code	CPT 75635
Hospital Charge Code	5075635
Hospital Revenue Code	350
Min. Negotiated Rate	$2,239.30
Max. Negotiated Rate	$3,199.00
Rate for Payer: Aetna Commercial	$3,039.05
Rate for Payer: Aetna Medicare	$2,879.10
Rate for Payer: BCBS MT CHIP	$2,879.10
Rate for Payer: BCBS MT Closed Plan Network	$3,039.05
Rate for Payer: BCBS MT HealthLink	$2,879.10
Rate for Payer: BCBS MT Medicare	$2,879.10
Rate for Payer: BCBS MT POS	$3,039.05
Rate for Payer: BCBS MT Traditional	$3,199.00
Rate for Payer: Cash Price	$2,879.10
Rate for Payer: Cigna Commercial	$3,039.05
Rate for Payer: Cigna Medicare	$2,879.10
Rate for Payer: Medicaid All Medicaid	$2,943.08
Rate for Payer: Medicare All Medicare	$2,239.30
Rate for Payer: Monida Allegiance	$3,039.05
Rate for Payer: Monida First Choice Health	$3,103.03
Rate for Payer: Monida Montana Health Co-op	$3,039.05
Rate for Payer: Monida PacificSource	$3,039.05

XR CTA THORACIC AORTA W OR W/O CONTRAST

Facility

$3,199.00

Service Code	CPT 75635
Hospital Charge Code	5075635
Hospital Revenue Code	350
Min. Negotiated Rate	$2,239.30
Max. Negotiated Rate	$3,199.00
Rate for Payer: Aetna Commercial	$3,039.05
Rate for Payer: Aetna Medicare	$2,879.10
Rate for Payer: BCBS MT CHIP	$2,879.10
Rate for Payer: BCBS MT Closed Plan Network	$3,039.05
Rate for Payer: BCBS MT HealthLink	$2,879.10
Rate for Payer: BCBS MT Medicare	$2,879.10
Rate for Payer: BCBS MT POS	$3,039.05
Rate for Payer: BCBS MT Traditional	$3,199.00
Rate for Payer: Cash Price	$2,879.10
Rate for Payer: Cigna Commercial	$3,039.05
Rate for Payer: Cigna Medicare	$2,879.10
Rate for Payer: Medicaid All Medicaid	$2,943.08
Rate for Payer: Medicare All Medicare	$2,239.30
Rate for Payer: Monida Allegiance	$3,039.05
Rate for Payer: Monida First Choice Health	$3,103.03
Rate for Payer: Monida Montana Health Co-op	$3,039.05
Rate for Payer: Monida PacificSource	$3,039.05

XR ELBOW BILATERAL 2 VIEWS

Facility

$374.00

Service Code	CPT 73070
Hospital Charge Code	5000152
Hospital Revenue Code	320
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

XR ELBOW BILATERAL 2 VIEWS

Facility

$374.00

Service Code	CPT 73070
Hospital Charge Code	5000152
Hospital Revenue Code	320
Min. Negotiated Rate	$261.80
Max. Negotiated Rate	$374.00
Rate for Payer: Aetna Commercial	$355.30
Rate for Payer: Aetna Medicare	$336.60
Rate for Payer: BCBS MT CHIP	$336.60
Rate for Payer: BCBS MT Closed Plan Network	$355.30
Rate for Payer: BCBS MT HealthLink	$336.60
Rate for Payer: BCBS MT Medicare	$336.60
Rate for Payer: BCBS MT POS	$355.30
Rate for Payer: BCBS MT Traditional	$374.00
Rate for Payer: Cash Price	$336.60
Rate for Payer: Cigna Commercial	$355.30
Rate for Payer: Cigna Medicare	$336.60
Rate for Payer: Medicaid All Medicaid	$344.08
Rate for Payer: Medicare All Medicare	$261.80
Rate for Payer: Monida Allegiance	$355.30
Rate for Payer: Monida First Choice Health	$362.78
Rate for Payer: Monida Montana Health Co-op	$355.30
Rate for Payer: Monida PacificSource	$355.30

XR ELBOW BILATERAL 3 VIEWS

Facility

$461.00

Service Code	CPT 73080
Hospital Charge Code	5000153
Hospital Revenue Code	320
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$461.00
Rate for Payer: Aetna Commercial	$437.95
Rate for Payer: Aetna Medicare	$414.90
Rate for Payer: BCBS MT CHIP	$414.90
Rate for Payer: BCBS MT Closed Plan Network	$437.95
Rate for Payer: BCBS MT HealthLink	$414.90
Rate for Payer: BCBS MT Medicare	$414.90
Rate for Payer: BCBS MT POS	$437.95
Rate for Payer: BCBS MT Traditional	$461.00
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cigna Commercial	$437.95
Rate for Payer: Cigna Medicare	$414.90
Rate for Payer: Medicaid All Medicaid	$424.12
Rate for Payer: Medicare All Medicare	$322.70
Rate for Payer: Monida Allegiance	$437.95
Rate for Payer: Monida First Choice Health	$447.17
Rate for Payer: Monida Montana Health Co-op	$437.95
Rate for Payer: Monida PacificSource	$437.95

XR ELBOW BILATERAL 3 VIEWS

Facility

$461.00

Service Code	CPT 73080
Hospital Charge Code	5000153
Hospital Revenue Code	320
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$461.00
Rate for Payer: Aetna Commercial	$437.95
Rate for Payer: Aetna Medicare	$414.90
Rate for Payer: BCBS MT CHIP	$414.90
Rate for Payer: BCBS MT Closed Plan Network	$437.95
Rate for Payer: BCBS MT HealthLink	$414.90
Rate for Payer: BCBS MT Medicare	$414.90
Rate for Payer: BCBS MT POS	$437.95
Rate for Payer: BCBS MT Traditional	$461.00
Rate for Payer: Cash Price	$414.90
Rate for Payer: Cigna Commercial	$437.95
Rate for Payer: Cigna Medicare	$414.90
Rate for Payer: Medicaid All Medicaid	$424.12
Rate for Payer: Medicare All Medicare	$322.70
Rate for Payer: Monida Allegiance	$437.95
Rate for Payer: Monida First Choice Health	$447.17
Rate for Payer: Monida Montana Health Co-op	$437.95
Rate for Payer: Monida PacificSource	$437.95

XR ELBOW LT 2 VIEWS

Facility

$249.00

Service Code	CPT 73070
Hospital Charge Code	5000154
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 ELBOW LT 2 VIEWS

Facility

$249.00

Service Code	CPT 73070
Hospital Charge Code	5000154
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 ELBOW LT 3-4 VIEWS

Facility

$307.00

Service Code	CPT 73080
Hospital Charge Code	5000155
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 ELBOW LT 3-4 VIEWS

Facility

$307.00

Service Code	CPT 73080
Hospital Charge Code	5000155
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 ELBOW RT 2 VIEWS

Facility

$249.00

Service Code	CPT 73070
Hospital Charge Code	5000156
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 ELBOW RT 2 VIEWS

Facility

$249.00

Service Code	CPT 73070
Hospital Charge Code	5000156
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 ELBOW RT 3-4 VIEWS

Facility

$307.00

Service Code	CPT 73080
Hospital Charge Code	5000157
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 ELBOW RT 3-4 VIEWS

Facility

$307.00

Service Code	CPT 73080
Hospital Charge Code	5000157
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 ENTIRE SPINE W SKULL 2 OR 3 VIEWS

Facility

$353.00

Service Code	CPT 72082
Hospital Charge Code	5000212
Hospital Revenue Code	320
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

XR ENTIRE SPINE W SKULL 2 OR 3 VIEWS

Facility

$353.00

Service Code	CPT 72082
Hospital Charge Code	5000212
Hospital Revenue Code	320
Min. Negotiated Rate	$247.10
Max. Negotiated Rate	$353.00
Rate for Payer: Aetna Commercial	$335.35
Rate for Payer: Aetna Medicare	$317.70
Rate for Payer: BCBS MT CHIP	$317.70
Rate for Payer: BCBS MT Closed Plan Network	$335.35
Rate for Payer: BCBS MT HealthLink	$317.70
Rate for Payer: BCBS MT Medicare	$317.70
Rate for Payer: BCBS MT POS	$335.35
Rate for Payer: BCBS MT Traditional	$353.00
Rate for Payer: Cash Price	$317.70
Rate for Payer: Cigna Commercial	$335.35
Rate for Payer: Cigna Medicare	$317.70
Rate for Payer: Medicaid All Medicaid	$324.76
Rate for Payer: Medicare All Medicare	$247.10
Rate for Payer: Monida Allegiance	$335.35
Rate for Payer: Monida First Choice Health	$342.41
Rate for Payer: Monida Montana Health Co-op	$335.35
Rate for Payer: Monida PacificSource	$335.35

XR ENTIRE SPINE W SKULL 4 OR 5 VIEWS

Facility

$532.00

Service Code	CPT 72083
Hospital Charge Code	5000213
Hospital Revenue Code	320
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$532.00
Rate for Payer: Aetna Commercial	$505.40
Rate for Payer: Aetna Medicare	$478.80
Rate for Payer: BCBS MT CHIP	$478.80
Rate for Payer: BCBS MT Closed Plan Network	$505.40
Rate for Payer: BCBS MT HealthLink	$478.80
Rate for Payer: BCBS MT Medicare	$478.80
Rate for Payer: BCBS MT POS	$505.40
Rate for Payer: BCBS MT Traditional	$532.00
Rate for Payer: Cash Price	$478.80
Rate for Payer: Cigna Commercial	$505.40
Rate for Payer: Cigna Medicare	$478.80
Rate for Payer: Medicaid All Medicaid	$489.44
Rate for Payer: Medicare All Medicare	$372.40
Rate for Payer: Monida Allegiance	$505.40
Rate for Payer: Monida First Choice Health	$516.04
Rate for Payer: Monida Montana Health Co-op	$505.40
Rate for Payer: Monida PacificSource	$505.40

XR ENTIRE SPINE W SKULL 4 OR 5 VIEWS

Facility

$532.00

Service Code	CPT 72083
Hospital Charge Code	5000213
Hospital Revenue Code	320
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$532.00
Rate for Payer: Aetna Commercial	$505.40
Rate for Payer: Aetna Medicare	$478.80
Rate for Payer: BCBS MT CHIP	$478.80
Rate for Payer: BCBS MT Closed Plan Network	$505.40
Rate for Payer: BCBS MT HealthLink	$478.80
Rate for Payer: BCBS MT Medicare	$478.80
Rate for Payer: BCBS MT POS	$505.40
Rate for Payer: BCBS MT Traditional	$532.00
Rate for Payer: Cash Price	$478.80
Rate for Payer: Cigna Commercial	$505.40
Rate for Payer: Cigna Medicare	$478.80
Rate for Payer: Medicaid All Medicaid	$489.44
Rate for Payer: Medicare All Medicare	$372.40
Rate for Payer: Monida Allegiance	$505.40
Rate for Payer: Monida First Choice Health	$516.04
Rate for Payer: Monida Montana Health Co-op	$505.40
Rate for Payer: Monida PacificSource	$505.40

XR EYE FOREIGN BODY

Facility

$231.00

Service Code	CPT 70030
Hospital Charge Code	5000041
Hospital Revenue Code	320
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

XR EYE FOREIGN BODY

Facility

$231.00

Service Code	CPT 70030
Hospital Charge Code	5000041
Hospital Revenue Code	320
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

XR FACIAL BONES COMPLETE 3 VIEWS

Facility

$416.00

Service Code	CPT 70150
Hospital Charge Code	5000158
Hospital Revenue Code	320
Min. Negotiated Rate	$291.20
Max. Negotiated Rate	$416.00
Rate for Payer: Aetna Commercial	$395.20
Rate for Payer: Aetna Medicare	$374.40
Rate for Payer: BCBS MT CHIP	$374.40
Rate for Payer: BCBS MT Closed Plan Network	$395.20
Rate for Payer: BCBS MT HealthLink	$374.40
Rate for Payer: BCBS MT Medicare	$374.40
Rate for Payer: BCBS MT POS	$395.20
Rate for Payer: BCBS MT Traditional	$416.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cigna Commercial	$395.20
Rate for Payer: Cigna Medicare	$374.40
Rate for Payer: Medicaid All Medicaid	$382.72
Rate for Payer: Medicare All Medicare	$291.20
Rate for Payer: Monida Allegiance	$395.20
Rate for Payer: Monida First Choice Health	$403.52
Rate for Payer: Monida Montana Health Co-op	$395.20
Rate for Payer: Monida PacificSource	$395.20

XR FACIAL BONES COMPLETE 3 VIEWS

Facility

$416.00

Service Code	CPT 70150
Hospital Charge Code	5000158
Hospital Revenue Code	320
Min. Negotiated Rate	$291.20
Max. Negotiated Rate	$416.00
Rate for Payer: Aetna Commercial	$395.20
Rate for Payer: Aetna Medicare	$374.40
Rate for Payer: BCBS MT CHIP	$374.40
Rate for Payer: BCBS MT Closed Plan Network	$395.20
Rate for Payer: BCBS MT HealthLink	$374.40
Rate for Payer: BCBS MT Medicare	$374.40
Rate for Payer: BCBS MT POS	$395.20
Rate for Payer: BCBS MT Traditional	$416.00
Rate for Payer: Cash Price	$374.40
Rate for Payer: Cigna Commercial	$395.20
Rate for Payer: Cigna Medicare	$374.40
Rate for Payer: Medicaid All Medicaid	$382.72
Rate for Payer: Medicare All Medicare	$291.20
Rate for Payer: Monida Allegiance	$395.20
Rate for Payer: Monida First Choice Health	$403.52
Rate for Payer: Monida Montana Health Co-op	$395.20
Rate for Payer: Monida PacificSource	$395.20

XR FACIAL BONES LESS THAN 3 VIEWS

Facility

$266.00

Service Code	CPT 70140
Hospital Charge Code	5000144
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

Know your out-of-pocket cost for care.

All Charges