Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

XR KNEES BILATERAL 3 VIEWS

Facility

$399.00

Service Code	CPT 73562
Hospital Charge Code	5000251
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

XR KNEES BILATERAL 3 VIEWS

Facility

$399.00

Service Code	CPT 73562
Hospital Charge Code	5000251
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

XR KNEES BILATERAL COMPLETE

Facility

$564.00

Service Code	CPT 73564
Hospital Charge Code	5000198
Hospital Revenue Code	320
Min. Negotiated Rate	$394.80
Max. Negotiated Rate	$564.00
Rate for Payer: Aetna Commercial	$535.80
Rate for Payer: Aetna Medicare	$507.60
Rate for Payer: BCBS MT CHIP	$507.60
Rate for Payer: BCBS MT Closed Plan Network	$535.80
Rate for Payer: BCBS MT HealthLink	$507.60
Rate for Payer: BCBS MT Medicare	$507.60
Rate for Payer: BCBS MT POS	$535.80
Rate for Payer: BCBS MT Traditional	$564.00
Rate for Payer: Cash Price	$507.60
Rate for Payer: Cigna Commercial	$535.80
Rate for Payer: Cigna Medicare	$507.60
Rate for Payer: Medicaid All Medicaid	$518.88
Rate for Payer: Medicare All Medicare	$394.80
Rate for Payer: Monida Allegiance	$535.80
Rate for Payer: Monida First Choice Health	$547.08
Rate for Payer: Monida Montana Health Co-op	$535.80
Rate for Payer: Monida PacificSource	$535.80

XR KNEES BILATERAL COMPLETE

Facility

$564.00

Service Code	CPT 73564
Hospital Charge Code	5000198
Hospital Revenue Code	320
Min. Negotiated Rate	$394.80
Max. Negotiated Rate	$564.00
Rate for Payer: Aetna Commercial	$535.80
Rate for Payer: Aetna Medicare	$507.60
Rate for Payer: BCBS MT CHIP	$507.60
Rate for Payer: BCBS MT Closed Plan Network	$535.80
Rate for Payer: BCBS MT HealthLink	$507.60
Rate for Payer: BCBS MT Medicare	$507.60
Rate for Payer: BCBS MT POS	$535.80
Rate for Payer: BCBS MT Traditional	$564.00
Rate for Payer: Cash Price	$507.60
Rate for Payer: Cigna Commercial	$535.80
Rate for Payer: Cigna Medicare	$507.60
Rate for Payer: Medicaid All Medicaid	$518.88
Rate for Payer: Medicare All Medicare	$394.80
Rate for Payer: Monida Allegiance	$535.80
Rate for Payer: Monida First Choice Health	$547.08
Rate for Payer: Monida Montana Health Co-op	$535.80
Rate for Payer: Monida PacificSource	$535.80

XR KNEES BILATERAL STAND AP

Facility

$237.00

Service Code	CPT 73565
Hospital Charge Code	5000199
Hospital Revenue Code	320
Min. Negotiated Rate	$165.90
Max. Negotiated Rate	$237.00
Rate for Payer: Aetna Commercial	$225.15
Rate for Payer: Aetna Medicare	$213.30
Rate for Payer: BCBS MT CHIP	$213.30
Rate for Payer: BCBS MT Closed Plan Network	$225.15
Rate for Payer: BCBS MT HealthLink	$213.30
Rate for Payer: BCBS MT Medicare	$213.30
Rate for Payer: BCBS MT POS	$225.15
Rate for Payer: BCBS MT Traditional	$237.00
Rate for Payer: Cash Price	$213.30
Rate for Payer: Cigna Commercial	$225.15
Rate for Payer: Cigna Medicare	$213.30
Rate for Payer: Medicaid All Medicaid	$218.04
Rate for Payer: Medicare All Medicare	$165.90
Rate for Payer: Monida Allegiance	$225.15
Rate for Payer: Monida First Choice Health	$229.89
Rate for Payer: Monida Montana Health Co-op	$225.15
Rate for Payer: Monida PacificSource	$225.15

XR KNEES BILATERAL STAND AP

Facility

$237.00

Service Code	CPT 73565
Hospital Charge Code	5000199
Hospital Revenue Code	320
Min. Negotiated Rate	$165.90
Max. Negotiated Rate	$237.00
Rate for Payer: Aetna Commercial	$225.15
Rate for Payer: Aetna Medicare	$213.30
Rate for Payer: BCBS MT CHIP	$213.30
Rate for Payer: BCBS MT Closed Plan Network	$225.15
Rate for Payer: BCBS MT HealthLink	$213.30
Rate for Payer: BCBS MT Medicare	$213.30
Rate for Payer: BCBS MT POS	$225.15
Rate for Payer: BCBS MT Traditional	$237.00
Rate for Payer: Cash Price	$213.30
Rate for Payer: Cigna Commercial	$225.15
Rate for Payer: Cigna Medicare	$213.30
Rate for Payer: Medicaid All Medicaid	$218.04
Rate for Payer: Medicare All Medicare	$165.90
Rate for Payer: Monida Allegiance	$225.15
Rate for Payer: Monida First Choice Health	$229.89
Rate for Payer: Monida Montana Health Co-op	$225.15
Rate for Payer: Monida PacificSource	$225.15

XR LOWER EXT LT INFANT (0-12 MONTHS)

Facility

$145.00

Service Code	CPT 73592
Hospital Charge Code	5000130
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LOWER EXT LT INFANT (0-12 MONTHS)

Facility

$145.00

Service Code	CPT 73592
Hospital Charge Code	5000130
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LOWER EXT RT INFANT (0-12 MONTHS)

Facility

$145.00

Service Code	CPT 73592
Hospital Charge Code	5000003
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LOWER EXT RT INFANT (0-12 MONTHS)

Facility

$145.00

Service Code	CPT 73592
Hospital Charge Code	5000003
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$145.00
Rate for Payer: Aetna Commercial	$137.75
Rate for Payer: Aetna Medicare	$130.50
Rate for Payer: BCBS MT CHIP	$130.50
Rate for Payer: BCBS MT Closed Plan Network	$137.75
Rate for Payer: BCBS MT HealthLink	$130.50
Rate for Payer: BCBS MT Medicare	$130.50
Rate for Payer: BCBS MT POS	$137.75
Rate for Payer: BCBS MT Traditional	$145.00
Rate for Payer: Cash Price	$130.50
Rate for Payer: Cigna Commercial	$137.75
Rate for Payer: Cigna Medicare	$130.50
Rate for Payer: Medicaid All Medicaid	$133.40
Rate for Payer: Medicare All Medicare	$101.50
Rate for Payer: Monida Allegiance	$137.75
Rate for Payer: Monida First Choice Health	$140.65
Rate for Payer: Monida Montana Health Co-op	$137.75
Rate for Payer: Monida PacificSource	$137.75

XR LUMBAR SPINE 2 OR 3 VIEWS

Facility

$341.00

Service Code	CPT 72100
Hospital Charge Code	5000201
Hospital Revenue Code	320
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

XR LUMBAR SPINE 2 OR 3 VIEWS

Facility

$341.00

Service Code	CPT 72100
Hospital Charge Code	5000201
Hospital Revenue Code	320
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

XR LUMBAR SPINE 3 VIEWS

Facility

$325.00

Service Code	CPT 72100
Hospital Charge Code	5000202
Hospital Revenue Code	320
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

XR LUMBAR SPINE 3 VIEWS

Facility

$325.00

Service Code	CPT 72100
Hospital Charge Code	5000202
Hospital Revenue Code	320
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$325.00
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: BCBS MT CHIP	$292.50
Rate for Payer: BCBS MT Closed Plan Network	$308.75
Rate for Payer: BCBS MT HealthLink	$292.50
Rate for Payer: BCBS MT Medicare	$292.50
Rate for Payer: BCBS MT POS	$308.75
Rate for Payer: BCBS MT Traditional	$325.00
Rate for Payer: Cash Price	$292.50
Rate for Payer: Cigna Commercial	$308.75
Rate for Payer: Cigna Medicare	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

XR LUMBAR SPINE COMP 4 VIEWS

Facility

$481.00

Service Code	CPT 72110
Hospital Charge Code	5000200
Hospital Revenue Code	320
Min. Negotiated Rate	$336.70
Max. Negotiated Rate	$481.00
Rate for Payer: Aetna Commercial	$456.95
Rate for Payer: Aetna Medicare	$432.90
Rate for Payer: BCBS MT CHIP	$432.90
Rate for Payer: BCBS MT Closed Plan Network	$456.95
Rate for Payer: BCBS MT HealthLink	$432.90
Rate for Payer: BCBS MT Medicare	$432.90
Rate for Payer: BCBS MT POS	$456.95
Rate for Payer: BCBS MT Traditional	$481.00
Rate for Payer: Cash Price	$432.90
Rate for Payer: Cigna Commercial	$456.95
Rate for Payer: Cigna Medicare	$432.90
Rate for Payer: Medicaid All Medicaid	$442.52
Rate for Payer: Medicare All Medicare	$336.70
Rate for Payer: Monida Allegiance	$456.95
Rate for Payer: Monida First Choice Health	$466.57
Rate for Payer: Monida Montana Health Co-op	$456.95
Rate for Payer: Monida PacificSource	$456.95

XR LUMBAR SPINE COMP 4 VIEWS

Facility

$481.00

Service Code	CPT 72110
Hospital Charge Code	5000200
Hospital Revenue Code	320
Min. Negotiated Rate	$336.70
Max. Negotiated Rate	$481.00
Rate for Payer: Aetna Commercial	$456.95
Rate for Payer: Aetna Medicare	$432.90
Rate for Payer: BCBS MT CHIP	$432.90
Rate for Payer: BCBS MT Closed Plan Network	$456.95
Rate for Payer: BCBS MT HealthLink	$432.90
Rate for Payer: BCBS MT Medicare	$432.90
Rate for Payer: BCBS MT POS	$456.95
Rate for Payer: BCBS MT Traditional	$481.00
Rate for Payer: Cash Price	$432.90
Rate for Payer: Cigna Commercial	$456.95
Rate for Payer: Cigna Medicare	$432.90
Rate for Payer: Medicaid All Medicaid	$442.52
Rate for Payer: Medicare All Medicare	$336.70
Rate for Payer: Monida Allegiance	$456.95
Rate for Payer: Monida First Choice Health	$466.57
Rate for Payer: Monida Montana Health Co-op	$456.95
Rate for Payer: Monida PacificSource	$456.95

XR LUMBAR SPINE COMP W FLEX AND EXT

Facility

$599.00

Service Code	CPT 72114
Hospital Charge Code	5072114
Hospital Revenue Code	320
Min. Negotiated Rate	$419.30
Max. Negotiated Rate	$599.00
Rate for Payer: Aetna Commercial	$569.05
Rate for Payer: Aetna Medicare	$539.10
Rate for Payer: BCBS MT CHIP	$539.10
Rate for Payer: BCBS MT Closed Plan Network	$569.05
Rate for Payer: BCBS MT HealthLink	$539.10
Rate for Payer: BCBS MT Medicare	$539.10
Rate for Payer: BCBS MT POS	$569.05
Rate for Payer: BCBS MT Traditional	$599.00
Rate for Payer: Cash Price	$539.10
Rate for Payer: Cigna Commercial	$569.05
Rate for Payer: Cigna Medicare	$539.10
Rate for Payer: Medicaid All Medicaid	$551.08
Rate for Payer: Medicare All Medicare	$419.30
Rate for Payer: Monida Allegiance	$569.05
Rate for Payer: Monida First Choice Health	$581.03
Rate for Payer: Monida Montana Health Co-op	$569.05
Rate for Payer: Monida PacificSource	$569.05

XR LUMBAR SPINE COMP W FLEX AND EXT

Facility

$599.00

Service Code	CPT 72114
Hospital Charge Code	5072114
Hospital Revenue Code	320
Min. Negotiated Rate	$419.30
Max. Negotiated Rate	$599.00
Rate for Payer: Aetna Commercial	$569.05
Rate for Payer: Aetna Medicare	$539.10
Rate for Payer: BCBS MT CHIP	$539.10
Rate for Payer: BCBS MT Closed Plan Network	$569.05
Rate for Payer: BCBS MT HealthLink	$539.10
Rate for Payer: BCBS MT Medicare	$539.10
Rate for Payer: BCBS MT POS	$569.05
Rate for Payer: BCBS MT Traditional	$599.00
Rate for Payer: Cash Price	$539.10
Rate for Payer: Cigna Commercial	$569.05
Rate for Payer: Cigna Medicare	$539.10
Rate for Payer: Medicaid All Medicaid	$551.08
Rate for Payer: Medicare All Medicare	$419.30
Rate for Payer: Monida Allegiance	$569.05
Rate for Payer: Monida First Choice Health	$581.03
Rate for Payer: Monida Montana Health Co-op	$569.05
Rate for Payer: Monida PacificSource	$569.05

XR LUMBAR SPINE FLEX EXT ONLY

Facility

$358.00

Service Code	CPT 72120
Hospital Charge Code	5000058
Hospital Revenue Code	320
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

XR LUMBAR SPINE FLEX EXT ONLY

Facility

$358.00

Service Code	CPT 72120
Hospital Charge Code	5000058
Hospital Revenue Code	320
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

XR MANDIBLE 4 VIEWS

Facility

$387.00

Service Code	CPT 70110
Hospital Charge Code	5000060
Hospital Revenue Code	320
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

XR MANDIBLE 4 VIEWS

Facility

$387.00

Service Code	CPT 70110
Hospital Charge Code	5000060
Hospital Revenue Code	320
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$387.00
Rate for Payer: Aetna Commercial	$367.65
Rate for Payer: Aetna Medicare	$348.30
Rate for Payer: BCBS MT CHIP	$348.30
Rate for Payer: BCBS MT Closed Plan Network	$367.65
Rate for Payer: BCBS MT HealthLink	$348.30
Rate for Payer: BCBS MT Medicare	$348.30
Rate for Payer: BCBS MT POS	$367.65
Rate for Payer: BCBS MT Traditional	$387.00
Rate for Payer: Cash Price	$348.30
Rate for Payer: Cigna Commercial	$367.65
Rate for Payer: Cigna Medicare	$348.30
Rate for Payer: Medicaid All Medicaid	$356.04
Rate for Payer: Medicare All Medicare	$270.90
Rate for Payer: Monida Allegiance	$367.65
Rate for Payer: Monida First Choice Health	$375.39
Rate for Payer: Monida Montana Health Co-op	$367.65
Rate for Payer: Monida PacificSource	$367.65

XR MANDIBLE BILATERAL 1 OR 2 VIEWS

Facility

$249.00

Service Code	CPT 70110
Hospital Charge Code	5000203
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 MANDIBLE BILATERAL 1 OR 2 VIEWS

Facility

$249.00

Service Code	CPT 70110
Hospital Charge Code	5000203
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

Know your out-of-pocket cost for care.

All Charges