Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR FINGERS LT

Facility

$231.00

Service Code	CPT 73140
Hospital Charge Code	5000162
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 FINGERS LT

Facility

$231.00

Service Code	CPT 73140
Hospital Charge Code	5000162
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 FINGERS RT

Facility

$231.00

Service Code	CPT 73140
Hospital Charge Code	5000163
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 FINGERS RT

Facility

$231.00

Service Code	CPT 73140
Hospital Charge Code	5000163
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 FOOT BILATERAL 2 VIEWS

Facility

$381.00

Service Code	CPT 73620
Hospital Charge Code	5000159
Hospital Revenue Code	320
Min. Negotiated Rate	$266.70
Max. Negotiated Rate	$381.00
Rate for Payer: Aetna Commercial	$361.95
Rate for Payer: Aetna Medicare	$342.90
Rate for Payer: BCBS MT CHIP	$342.90
Rate for Payer: BCBS MT Closed Plan Network	$361.95
Rate for Payer: BCBS MT HealthLink	$342.90
Rate for Payer: BCBS MT Medicare	$342.90
Rate for Payer: BCBS MT POS	$361.95
Rate for Payer: BCBS MT Traditional	$381.00
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cigna Commercial	$361.95
Rate for Payer: Cigna Medicare	$342.90
Rate for Payer: Medicaid All Medicaid	$350.52
Rate for Payer: Medicare All Medicare	$266.70
Rate for Payer: Monida Allegiance	$361.95
Rate for Payer: Monida First Choice Health	$369.57
Rate for Payer: Monida Montana Health Co-op	$361.95
Rate for Payer: Monida PacificSource	$361.95

XR FOOT BILATERAL 2 VIEWS

Facility

$381.00

Service Code	CPT 73620
Hospital Charge Code	5000159
Hospital Revenue Code	320
Min. Negotiated Rate	$266.70
Max. Negotiated Rate	$381.00
Rate for Payer: Aetna Commercial	$361.95
Rate for Payer: Aetna Medicare	$342.90
Rate for Payer: BCBS MT CHIP	$342.90
Rate for Payer: BCBS MT Closed Plan Network	$361.95
Rate for Payer: BCBS MT HealthLink	$342.90
Rate for Payer: BCBS MT Medicare	$342.90
Rate for Payer: BCBS MT POS	$361.95
Rate for Payer: BCBS MT Traditional	$381.00
Rate for Payer: Cash Price	$342.90
Rate for Payer: Cigna Commercial	$361.95
Rate for Payer: Cigna Medicare	$342.90
Rate for Payer: Medicaid All Medicaid	$350.52
Rate for Payer: Medicare All Medicare	$266.70
Rate for Payer: Monida Allegiance	$361.95
Rate for Payer: Monida First Choice Health	$369.57
Rate for Payer: Monida Montana Health Co-op	$361.95
Rate for Payer: Monida PacificSource	$361.95

XR FOOT BILATERAL 3 VIEWS

Facility

$452.00

Service Code	CPT 73630
Hospital Charge Code	5000171
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 FOOT BILATERAL 3 VIEWS

Facility

$452.00

Service Code	CPT 73630
Hospital Charge Code	5000171
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 FOOT LT 2 VIEWS

Facility

$254.00

Service Code	CPT 73620
Hospital Charge Code	5000164
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 FOOT LT 2 VIEWS

Facility

$254.00

Service Code	CPT 73620
Hospital Charge Code	5000164
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 FOOT LT 3 VIEWS

Facility

$301.00

Service Code	CPT 73630
Hospital Charge Code	5000165
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR FOOT LT 3 VIEWS

Facility

$301.00

Service Code	CPT 73630
Hospital Charge Code	5000165
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR FOOT RT 2 VIEWS

Facility

$254.00

Service Code	CPT 73620
Hospital Charge Code	5000166
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 FOOT RT 2 VIEWS

Facility

$254.00

Service Code	CPT 73620
Hospital Charge Code	5000166
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 FOOT RT 3 VIEWS

Facility

$301.00

Service Code	CPT 73630
Hospital Charge Code	5000167
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR FOOT RT 3 VIEWS

Facility

$301.00

Service Code	CPT 73630
Hospital Charge Code	5000167
Hospital Revenue Code	320
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

XR FOREARM BILATERAL 2 VIEW

Facility

$419.00

Service Code	CPT 73090
Hospital Charge Code	5000168
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 FOREARM BILATERAL 2 VIEW

Facility

$419.00

Service Code	CPT 73090
Hospital Charge Code	5000168
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 FOREARM LT 2 VIEW

Facility

$279.00

Service Code	CPT 73090
Hospital Charge Code	5000169
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 FOREARM LT 2 VIEW

Facility

$279.00

Service Code	CPT 73090
Hospital Charge Code	5000169
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 FOREARM RT 2 VIEW

Facility

$279.00

Service Code	CPT 73090
Hospital Charge Code	5000170
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 FOREARM RT 2 VIEW

Facility

$279.00

Service Code	CPT 73090
Hospital Charge Code	5000170
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 GUIDANCE FOR NEEDLE PLACE 77002

Facility

$492.00

Service Code	CPT 77002
Hospital Charge Code	5077002
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 GUIDANCE FOR NEEDLE PLACE 77002

Facility

$492.00

Service Code	CPT 77002
Hospital Charge Code	5077002
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 GUIDANCE SPINAL INJ 77003

Facility

$541.00

Service Code	CPT 77003
Hospital Charge Code	5077003
Hospital Revenue Code	320
Min. Negotiated Rate	$378.70
Max. Negotiated Rate	$541.00
Rate for Payer: Aetna Commercial	$513.95
Rate for Payer: Aetna Medicare	$486.90
Rate for Payer: BCBS MT CHIP	$486.90
Rate for Payer: BCBS MT Closed Plan Network	$513.95
Rate for Payer: BCBS MT HealthLink	$486.90
Rate for Payer: BCBS MT Medicare	$486.90
Rate for Payer: BCBS MT POS	$513.95
Rate for Payer: BCBS MT Traditional	$541.00
Rate for Payer: Cash Price	$486.90
Rate for Payer: Cigna Commercial	$513.95
Rate for Payer: Cigna Medicare	$486.90
Rate for Payer: Medicaid All Medicaid	$497.72
Rate for Payer: Medicare All Medicare	$378.70
Rate for Payer: Monida Allegiance	$513.95
Rate for Payer: Monida First Choice Health	$524.77
Rate for Payer: Monida Montana Health Co-op	$513.95
Rate for Payer: Monida PacificSource	$513.95

Know your out-of-pocket cost for care.

All Charges