Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR HIPS BILATERAL 2 VIEWS W PELVIS

Facility

$538.00

Service Code	CPT 73521
Hospital Charge Code	5000186
Hospital Revenue Code	320
Min. Negotiated Rate	$376.60
Max. Negotiated Rate	$538.00
Rate for Payer: Aetna Commercial	$511.10
Rate for Payer: Aetna Medicare	$484.20
Rate for Payer: BCBS MT CHIP	$484.20
Rate for Payer: BCBS MT Closed Plan Network	$511.10
Rate for Payer: BCBS MT HealthLink	$484.20
Rate for Payer: BCBS MT Medicare	$484.20
Rate for Payer: BCBS MT POS	$511.10
Rate for Payer: BCBS MT Traditional	$538.00
Rate for Payer: Cash Price	$484.20
Rate for Payer: Cigna Commercial	$511.10
Rate for Payer: Cigna Medicare	$484.20
Rate for Payer: Medicaid All Medicaid	$494.96
Rate for Payer: Medicare All Medicare	$376.60
Rate for Payer: Monida Allegiance	$511.10
Rate for Payer: Monida First Choice Health	$521.86
Rate for Payer: Monida Montana Health Co-op	$511.10
Rate for Payer: Monida PacificSource	$511.10

XR HIPS BILATERAL 2 VIEWS W PELVIS

Facility

$538.00

Service Code	CPT 73521
Hospital Charge Code	5000186
Hospital Revenue Code	320
Min. Negotiated Rate	$376.60
Max. Negotiated Rate	$538.00
Rate for Payer: Aetna Commercial	$511.10
Rate for Payer: Aetna Medicare	$484.20
Rate for Payer: BCBS MT CHIP	$484.20
Rate for Payer: BCBS MT Closed Plan Network	$511.10
Rate for Payer: BCBS MT HealthLink	$484.20
Rate for Payer: BCBS MT Medicare	$484.20
Rate for Payer: BCBS MT POS	$511.10
Rate for Payer: BCBS MT Traditional	$538.00
Rate for Payer: Cash Price	$484.20
Rate for Payer: Cigna Commercial	$511.10
Rate for Payer: Cigna Medicare	$484.20
Rate for Payer: Medicaid All Medicaid	$494.96
Rate for Payer: Medicare All Medicare	$376.60
Rate for Payer: Monida Allegiance	$511.10
Rate for Payer: Monida First Choice Health	$521.86
Rate for Payer: Monida Montana Health Co-op	$511.10
Rate for Payer: Monida PacificSource	$511.10

XR HUMERUS LT 2 VIEWS

Facility

$279.00

Service Code	CPT 73060
Hospital Charge Code	5000187
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 HUMERUS LT 2 VIEWS

Facility

$279.00

Service Code	CPT 73060
Hospital Charge Code	5000187
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 HUMERUS RT 2 VIEWS

Facility

$279.00

Service Code	CPT 73060
Hospital Charge Code	5000188
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 HUMERUS RT 2 VIEWS

Facility

$279.00

Service Code	CPT 73060
Hospital Charge Code	5000188
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 IJ SINGLE/MULT TRGR PT 3+ MUSCL 20553

Facility

$435.00

Service Code	CPT 20553
Hospital Charge Code	5020553
Hospital Revenue Code	320
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$435.00
Rate for Payer: Aetna Commercial	$413.25
Rate for Payer: Aetna Medicare	$391.50
Rate for Payer: BCBS MT CHIP	$391.50
Rate for Payer: BCBS MT Closed Plan Network	$413.25
Rate for Payer: BCBS MT HealthLink	$391.50
Rate for Payer: BCBS MT Medicare	$391.50
Rate for Payer: BCBS MT POS	$413.25
Rate for Payer: BCBS MT Traditional	$435.00
Rate for Payer: Cash Price	$391.50
Rate for Payer: Cigna Commercial	$413.25
Rate for Payer: Cigna Medicare	$391.50
Rate for Payer: Medicaid All Medicaid	$400.20
Rate for Payer: Medicare All Medicare	$304.50
Rate for Payer: Monida Allegiance	$413.25
Rate for Payer: Monida First Choice Health	$421.95
Rate for Payer: Monida Montana Health Co-op	$413.25
Rate for Payer: Monida PacificSource	$413.25

XR IJ SINGLE/MULT TRGR PT 3+ MUSCL 20553

Facility

$435.00

Service Code	CPT 20553
Hospital Charge Code	5020553
Hospital Revenue Code	320
Min. Negotiated Rate	$304.50
Max. Negotiated Rate	$435.00
Rate for Payer: Aetna Commercial	$413.25
Rate for Payer: Aetna Medicare	$391.50
Rate for Payer: BCBS MT CHIP	$391.50
Rate for Payer: BCBS MT Closed Plan Network	$413.25
Rate for Payer: BCBS MT HealthLink	$391.50
Rate for Payer: BCBS MT Medicare	$391.50
Rate for Payer: BCBS MT POS	$413.25
Rate for Payer: BCBS MT Traditional	$435.00
Rate for Payer: Cash Price	$391.50
Rate for Payer: Cigna Commercial	$413.25
Rate for Payer: Cigna Medicare	$391.50
Rate for Payer: Medicaid All Medicaid	$400.20
Rate for Payer: Medicare All Medicare	$304.50
Rate for Payer: Monida Allegiance	$413.25
Rate for Payer: Monida First Choice Health	$421.95
Rate for Payer: Monida Montana Health Co-op	$413.25
Rate for Payer: Monida PacificSource	$413.25

XR JOINT SURVEY SINGLE VIEW 2 + JOINTS

Facility

$226.00

Service Code	CPT 77077
Hospital Charge Code	5000189
Hospital Revenue Code	320
Min. Negotiated Rate	$158.20
Max. Negotiated Rate	$226.00
Rate for Payer: Aetna Commercial	$214.70
Rate for Payer: Aetna Medicare	$203.40
Rate for Payer: BCBS MT CHIP	$203.40
Rate for Payer: BCBS MT Closed Plan Network	$214.70
Rate for Payer: BCBS MT HealthLink	$203.40
Rate for Payer: BCBS MT Medicare	$203.40
Rate for Payer: BCBS MT POS	$214.70
Rate for Payer: BCBS MT Traditional	$226.00
Rate for Payer: Cash Price	$203.40
Rate for Payer: Cigna Commercial	$214.70
Rate for Payer: Cigna Medicare	$203.40
Rate for Payer: Medicaid All Medicaid	$207.92
Rate for Payer: Medicare All Medicare	$158.20
Rate for Payer: Monida Allegiance	$214.70
Rate for Payer: Monida First Choice Health	$219.22
Rate for Payer: Monida Montana Health Co-op	$214.70
Rate for Payer: Monida PacificSource	$214.70

XR JOINT SURVEY SINGLE VIEW 2 + JOINTS

Facility

$226.00

Service Code	CPT 77077
Hospital Charge Code	5000189
Hospital Revenue Code	320
Min. Negotiated Rate	$158.20
Max. Negotiated Rate	$226.00
Rate for Payer: Aetna Commercial	$214.70
Rate for Payer: Aetna Medicare	$203.40
Rate for Payer: BCBS MT CHIP	$203.40
Rate for Payer: BCBS MT Closed Plan Network	$214.70
Rate for Payer: BCBS MT HealthLink	$203.40
Rate for Payer: BCBS MT Medicare	$203.40
Rate for Payer: BCBS MT POS	$214.70
Rate for Payer: BCBS MT Traditional	$226.00
Rate for Payer: Cash Price	$203.40
Rate for Payer: Cigna Commercial	$214.70
Rate for Payer: Cigna Medicare	$203.40
Rate for Payer: Medicaid All Medicaid	$207.92
Rate for Payer: Medicare All Medicare	$158.20
Rate for Payer: Monida Allegiance	$214.70
Rate for Payer: Monida First Choice Health	$219.22
Rate for Payer: Monida Montana Health Co-op	$214.70
Rate for Payer: Monida PacificSource	$214.70

XR KNEE LT 1-2 VIEWS

Facility

$266.00

Service Code	CPT 73560
Hospital Charge Code	5000190
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 KNEE LT 1-2 VIEWS

Facility

$266.00

Service Code	CPT 73560
Hospital Charge Code	5000190
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 KNEE LT 3 VIEWS

Facility

$324.00

Service Code	CPT 73562
Hospital Charge Code	5000191
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

XR KNEE LT 3 VIEWS

Facility

$324.00

Service Code	CPT 73562
Hospital Charge Code	5000191
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

XR KNEE LT COMPLETE

Facility

$376.00

Service Code	CPT 73564
Hospital Charge Code	5000192
Hospital Revenue Code	320
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

XR KNEE LT COMPLETE

Facility

$376.00

Service Code	CPT 73564
Hospital Charge Code	5000192
Hospital Revenue Code	320
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

XR KNEE RT 1-2 VIEWS

Facility

$266.00

Service Code	CPT 73560
Hospital Charge Code	5000193
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 KNEE RT 1-2 VIEWS

Facility

$266.00

Service Code	CPT 73560
Hospital Charge Code	5000193
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 KNEE RT 3 VIEWS

Facility

$324.00

Service Code	CPT 73562
Hospital Charge Code	5000194
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

XR KNEE RT 3 VIEWS

Facility

$324.00

Service Code	CPT 73562
Hospital Charge Code	5000194
Hospital Revenue Code	320
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna Commercial	$307.80
Rate for Payer: Aetna Medicare	$291.60
Rate for Payer: BCBS MT CHIP	$291.60
Rate for Payer: BCBS MT Closed Plan Network	$307.80
Rate for Payer: BCBS MT HealthLink	$291.60
Rate for Payer: BCBS MT Medicare	$291.60
Rate for Payer: BCBS MT POS	$307.80
Rate for Payer: BCBS MT Traditional	$324.00
Rate for Payer: Cash Price	$291.60
Rate for Payer: Cigna Commercial	$307.80
Rate for Payer: Cigna Medicare	$291.60
Rate for Payer: Medicaid All Medicaid	$298.08
Rate for Payer: Medicare All Medicare	$226.80
Rate for Payer: Monida Allegiance	$307.80
Rate for Payer: Monida First Choice Health	$314.28
Rate for Payer: Monida Montana Health Co-op	$307.80
Rate for Payer: Monida PacificSource	$307.80

XR KNEE RT COMPLETE

Facility

$376.00

Service Code	CPT 73564
Hospital Charge Code	5000195
Hospital Revenue Code	320
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

XR KNEE RT COMPLETE

Facility

$376.00

Service Code	CPT 73564
Hospital Charge Code	5000195
Hospital Revenue Code	320
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

XR KNEES BILATERAL 1 VIEW

Facility

$253.00

Service Code	CPT 73560
Hospital Charge Code	5000196
Hospital Revenue Code	320
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$253.00
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: BCBS MT CHIP	$227.70
Rate for Payer: BCBS MT Closed Plan Network	$240.35
Rate for Payer: BCBS MT HealthLink	$227.70
Rate for Payer: BCBS MT Medicare	$227.70
Rate for Payer: BCBS MT POS	$240.35
Rate for Payer: BCBS MT Traditional	$253.00
Rate for Payer: Cash Price	$227.70
Rate for Payer: Cigna Commercial	$240.35
Rate for Payer: Cigna Medicare	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

XR KNEES BILATERAL 1 VIEW

Facility

$253.00

Service Code	CPT 73560
Hospital Charge Code	5000196
Hospital Revenue Code	320
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$253.00
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: BCBS MT CHIP	$227.70
Rate for Payer: BCBS MT Closed Plan Network	$240.35
Rate for Payer: BCBS MT HealthLink	$227.70
Rate for Payer: BCBS MT Medicare	$227.70
Rate for Payer: BCBS MT POS	$240.35
Rate for Payer: BCBS MT Traditional	$253.00
Rate for Payer: Cash Price	$227.70
Rate for Payer: Cigna Commercial	$240.35
Rate for Payer: Cigna Medicare	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

XR KNEES BILATERAL 2 VIEWS

Facility

$399.00

Service Code	CPT 73560
Hospital Charge Code	5000197
Hospital Revenue Code	320
Min. Negotiated Rate	$279.30
Max. Negotiated Rate	$399.00
Rate for Payer: Aetna Commercial	$379.05
Rate for Payer: Aetna Medicare	$359.10
Rate for Payer: BCBS MT CHIP	$359.10
Rate for Payer: BCBS MT Closed Plan Network	$379.05
Rate for Payer: BCBS MT HealthLink	$359.10
Rate for Payer: BCBS MT Medicare	$359.10
Rate for Payer: BCBS MT POS	$379.05
Rate for Payer: BCBS MT Traditional	$399.00
Rate for Payer: Cash Price	$359.10
Rate for Payer: Cigna Commercial	$379.05
Rate for Payer: Cigna Medicare	$359.10
Rate for Payer: Medicaid All Medicaid	$367.08
Rate for Payer: Medicare All Medicare	$279.30
Rate for Payer: Monida Allegiance	$379.05
Rate for Payer: Monida First Choice Health	$387.03
Rate for Payer: Monida Montana Health Co-op	$379.05
Rate for Payer: Monida PacificSource	$379.05

Know your out-of-pocket cost for care.

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