Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

XR SCOLIOSIS STUDY 4-5 VIEWS

Facility

$452.00

Service Code	CPT 72083
Hospital Charge Code	5072083
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 SCOLIOSIS STUDY 4-5 VIEWS

Facility

$452.00

Service Code	CPT 72083
Hospital Charge Code	5072083
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 SCOLIOSIS STUDY MIN 6 VIEWS

Facility

$568.00

Service Code	CPT 72084
Hospital Charge Code	5072084
Hospital Revenue Code	320
Min. Negotiated Rate	$397.60
Max. Negotiated Rate	$568.00
Rate for Payer: Aetna Commercial	$539.60
Rate for Payer: Aetna Medicare	$511.20
Rate for Payer: BCBS MT CHIP	$511.20
Rate for Payer: BCBS MT Closed Plan Network	$539.60
Rate for Payer: BCBS MT HealthLink	$511.20
Rate for Payer: BCBS MT Medicare	$511.20
Rate for Payer: BCBS MT POS	$539.60
Rate for Payer: BCBS MT Traditional	$568.00
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cigna Commercial	$539.60
Rate for Payer: Cigna Medicare	$511.20
Rate for Payer: Medicaid All Medicaid	$522.56
Rate for Payer: Medicare All Medicare	$397.60
Rate for Payer: Monida Allegiance	$539.60
Rate for Payer: Monida First Choice Health	$550.96
Rate for Payer: Monida Montana Health Co-op	$539.60
Rate for Payer: Monida PacificSource	$539.60

XR SCOLIOSIS STUDY MIN 6 VIEWS

Facility

$568.00

Service Code	CPT 72084
Hospital Charge Code	5072084
Hospital Revenue Code	320
Min. Negotiated Rate	$397.60
Max. Negotiated Rate	$568.00
Rate for Payer: Aetna Commercial	$539.60
Rate for Payer: Aetna Medicare	$511.20
Rate for Payer: BCBS MT CHIP	$511.20
Rate for Payer: BCBS MT Closed Plan Network	$539.60
Rate for Payer: BCBS MT HealthLink	$511.20
Rate for Payer: BCBS MT Medicare	$511.20
Rate for Payer: BCBS MT POS	$539.60
Rate for Payer: BCBS MT Traditional	$568.00
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cigna Commercial	$539.60
Rate for Payer: Cigna Medicare	$511.20
Rate for Payer: Medicaid All Medicaid	$522.56
Rate for Payer: Medicare All Medicare	$397.60
Rate for Payer: Monida Allegiance	$539.60
Rate for Payer: Monida First Choice Health	$550.96
Rate for Payer: Monida Montana Health Co-op	$539.60
Rate for Payer: Monida PacificSource	$539.60

XR SHOULDER LT 1 VIEW

Facility

$154.00

Service Code	CPT 73020
Hospital Charge Code	5000225
Hospital Revenue Code	320
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

XR SHOULDER LT 1 VIEW

Facility

$154.00

Service Code	CPT 73020
Hospital Charge Code	5000225
Hospital Revenue Code	320
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

XR SHOULDER LT 2-3 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5000005
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDER LT 2-3 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5000005
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDER LT 2 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5000222
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDER LT 2 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5000222
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDER RT 1 VIEW

Facility

$154.00

Service Code	CPT 73020
Hospital Charge Code	5000226
Hospital Revenue Code	320
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

XR SHOULDER RT 1 VIEW

Facility

$154.00

Service Code	CPT 73020
Hospital Charge Code	5000226
Hospital Revenue Code	320
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$154.00
Rate for Payer: Aetna Commercial	$146.30
Rate for Payer: Aetna Medicare	$138.60
Rate for Payer: BCBS MT CHIP	$138.60
Rate for Payer: BCBS MT Closed Plan Network	$146.30
Rate for Payer: BCBS MT HealthLink	$138.60
Rate for Payer: BCBS MT Medicare	$138.60
Rate for Payer: BCBS MT POS	$146.30
Rate for Payer: BCBS MT Traditional	$154.00
Rate for Payer: Cash Price	$138.60
Rate for Payer: Cigna Commercial	$146.30
Rate for Payer: Cigna Medicare	$138.60
Rate for Payer: Medicaid All Medicaid	$141.68
Rate for Payer: Medicare All Medicare	$107.80
Rate for Payer: Monida Allegiance	$146.30
Rate for Payer: Monida First Choice Health	$149.38
Rate for Payer: Monida Montana Health Co-op	$146.30
Rate for Payer: Monida PacificSource	$146.30

XR SHOULDER RT 2-3 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5073030
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDER RT 2-3 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5073030
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDER RT 2 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5000223
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDER RT 2 VIEWS

Facility

$287.00

Service Code	CPT 73030
Hospital Charge Code	5000223
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$287.00
Rate for Payer: Aetna Commercial	$272.65
Rate for Payer: Aetna Medicare	$258.30
Rate for Payer: BCBS MT CHIP	$258.30
Rate for Payer: BCBS MT Closed Plan Network	$272.65
Rate for Payer: BCBS MT HealthLink	$258.30
Rate for Payer: BCBS MT Medicare	$258.30
Rate for Payer: BCBS MT POS	$272.65
Rate for Payer: BCBS MT Traditional	$287.00
Rate for Payer: Cash Price	$258.30
Rate for Payer: Cigna Commercial	$272.65
Rate for Payer: Cigna Medicare	$258.30
Rate for Payer: Medicaid All Medicaid	$264.04
Rate for Payer: Medicare All Medicare	$200.90
Rate for Payer: Monida Allegiance	$272.65
Rate for Payer: Monida First Choice Health	$278.39
Rate for Payer: Monida Montana Health Co-op	$272.65
Rate for Payer: Monida PacificSource	$272.65

XR SHOULDERS BILATERAL 1 VIEW

Facility

$231.00

Service Code	CPT 73020
Hospital Charge Code	5000224
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 SHOULDERS BILATERAL 1 VIEW

Facility

$231.00

Service Code	CPT 73020
Hospital Charge Code	5000224
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 SHOULDERS BILATERAL 2-3 VIEWS

Facility

$430.00

Service Code	CPT 73030
Hospital Charge Code	5000221
Hospital Revenue Code	320
Min. Negotiated Rate	$301.00
Max. Negotiated Rate	$430.00
Rate for Payer: Aetna Commercial	$408.50
Rate for Payer: Aetna Medicare	$387.00
Rate for Payer: BCBS MT CHIP	$387.00
Rate for Payer: BCBS MT Closed Plan Network	$408.50
Rate for Payer: BCBS MT HealthLink	$387.00
Rate for Payer: BCBS MT Medicare	$387.00
Rate for Payer: BCBS MT POS	$408.50
Rate for Payer: BCBS MT Traditional	$430.00
Rate for Payer: Cash Price	$387.00
Rate for Payer: Cigna Commercial	$408.50
Rate for Payer: Cigna Medicare	$387.00
Rate for Payer: Medicaid All Medicaid	$395.60
Rate for Payer: Medicare All Medicare	$301.00
Rate for Payer: Monida Allegiance	$408.50
Rate for Payer: Monida First Choice Health	$417.10
Rate for Payer: Monida Montana Health Co-op	$408.50
Rate for Payer: Monida PacificSource	$408.50

XR SHOULDERS BILATERAL 2-3 VIEWS

Facility

$430.00

Service Code	CPT 73030
Hospital Charge Code	5000221
Hospital Revenue Code	320
Min. Negotiated Rate	$301.00
Max. Negotiated Rate	$430.00
Rate for Payer: Aetna Commercial	$408.50
Rate for Payer: Aetna Medicare	$387.00
Rate for Payer: BCBS MT CHIP	$387.00
Rate for Payer: BCBS MT Closed Plan Network	$408.50
Rate for Payer: BCBS MT HealthLink	$387.00
Rate for Payer: BCBS MT Medicare	$387.00
Rate for Payer: BCBS MT POS	$408.50
Rate for Payer: BCBS MT Traditional	$430.00
Rate for Payer: Cash Price	$387.00
Rate for Payer: Cigna Commercial	$408.50
Rate for Payer: Cigna Medicare	$387.00
Rate for Payer: Medicaid All Medicaid	$395.60
Rate for Payer: Medicare All Medicare	$301.00
Rate for Payer: Monida Allegiance	$408.50
Rate for Payer: Monida First Choice Health	$417.10
Rate for Payer: Monida Montana Health Co-op	$408.50
Rate for Payer: Monida PacificSource	$408.50

XR SI JOINTS 3 VIEWS

Facility

$298.00

Service Code	CPT 72202
Hospital Charge Code	5000062
Hospital Revenue Code	320
Min. Negotiated Rate	$208.60
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$283.10
Rate for Payer: Aetna Medicare	$268.20
Rate for Payer: BCBS MT CHIP	$268.20
Rate for Payer: BCBS MT Closed Plan Network	$283.10
Rate for Payer: BCBS MT HealthLink	$268.20
Rate for Payer: BCBS MT Medicare	$268.20
Rate for Payer: BCBS MT POS	$283.10
Rate for Payer: BCBS MT Traditional	$298.00
Rate for Payer: Cash Price	$268.20
Rate for Payer: Cigna Commercial	$283.10
Rate for Payer: Cigna Medicare	$268.20
Rate for Payer: Medicaid All Medicaid	$274.16
Rate for Payer: Medicare All Medicare	$208.60
Rate for Payer: Monida Allegiance	$283.10
Rate for Payer: Monida First Choice Health	$289.06
Rate for Payer: Monida Montana Health Co-op	$283.10
Rate for Payer: Monida PacificSource	$283.10

XR SI JOINTS 3 VIEWS

Facility

$298.00

Service Code	CPT 72202
Hospital Charge Code	5000062
Hospital Revenue Code	320
Min. Negotiated Rate	$208.60
Max. Negotiated Rate	$298.00
Rate for Payer: Aetna Commercial	$283.10
Rate for Payer: Aetna Medicare	$268.20
Rate for Payer: BCBS MT CHIP	$268.20
Rate for Payer: BCBS MT Closed Plan Network	$283.10
Rate for Payer: BCBS MT HealthLink	$268.20
Rate for Payer: BCBS MT Medicare	$268.20
Rate for Payer: BCBS MT POS	$283.10
Rate for Payer: BCBS MT Traditional	$298.00
Rate for Payer: Cash Price	$268.20
Rate for Payer: Cigna Commercial	$283.10
Rate for Payer: Cigna Medicare	$268.20
Rate for Payer: Medicaid All Medicaid	$274.16
Rate for Payer: Medicare All Medicare	$208.60
Rate for Payer: Monida Allegiance	$283.10
Rate for Payer: Monida First Choice Health	$289.06
Rate for Payer: Monida Montana Health Co-op	$283.10
Rate for Payer: Monida PacificSource	$283.10

XR SI JOINTS BILATERAL

Facility

$237.00

Service Code	CPT 72200
Hospital Charge Code	5000227
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 SI JOINTS BILATERAL

Facility

$237.00

Service Code	CPT 72200
Hospital Charge Code	5000227
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 SINUS 1 OR 2 VIEWS

Facility

$237.00

Service Code	CPT 70210
Hospital Charge Code	5000228
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

Know your out-of-pocket cost for care.

All Charges