Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INTREPID ORIENTATION OF STAFF

Facility

$48.00

Hospital Charge Code	611002
Hospital Revenue Code	421
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

INTREPID TRAVEL TIME/HR

Facility

$68.00

Hospital Charge Code	611006
Hospital Revenue Code	429
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

INTREPID TRAVEL TIME/HR

Facility

$68.00

Hospital Charge Code	611006
Hospital Revenue Code	429
Min. Negotiated Rate	$47.60
Max. Negotiated Rate	$68.00
Rate for Payer: Aetna Commercial	$64.60
Rate for Payer: Aetna Medicare	$61.20
Rate for Payer: BCBS MT CHIP	$61.20
Rate for Payer: BCBS MT Closed Plan Network	$64.60
Rate for Payer: BCBS MT HealthLink	$61.20
Rate for Payer: BCBS MT Medicare	$61.20
Rate for Payer: BCBS MT POS	$64.60
Rate for Payer: BCBS MT Traditional	$68.00
Rate for Payer: Cash Price	$61.20
Rate for Payer: Cigna Commercial	$64.60
Rate for Payer: Cigna Medicare	$61.20
Rate for Payer: Medicaid All Medicaid	$62.56
Rate for Payer: Medicare All Medicare	$47.60
Rate for Payer: Monida Allegiance	$64.60
Rate for Payer: Monida First Choice Health	$65.96
Rate for Payer: Monida Montana Health Co-op	$64.60
Rate for Payer: Monida PacificSource	$64.60

INTREPID VISIT

Facility

$94.00

Service Code	HCPCS G0151
Hospital Charge Code	611005
Hospital Revenue Code	421
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

INTREPID VISIT

Facility

$94.00

Service Code	HCPCS G0151
Hospital Charge Code	611005
Hospital Revenue Code	421
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

INTRINSIC FACTOR BLOCKING ANTIBODY

Facility

$96.00

Service Code	CPT 86340
Hospital Charge Code	4087990
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

INTRINSIC FACTOR BLOCKING ANTIBODY

Facility

$96.00

Service Code	CPT 86340
Hospital Charge Code	4087990
Hospital Revenue Code	302
Min. Negotiated Rate	$67.20
Max. Negotiated Rate	$96.00
Rate for Payer: Aetna Commercial	$91.20
Rate for Payer: Aetna Medicare	$86.40
Rate for Payer: BCBS MT CHIP	$86.40
Rate for Payer: BCBS MT Closed Plan Network	$91.20
Rate for Payer: BCBS MT HealthLink	$86.40
Rate for Payer: BCBS MT Medicare	$86.40
Rate for Payer: BCBS MT POS	$91.20
Rate for Payer: BCBS MT Traditional	$96.00
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cigna Commercial	$91.20
Rate for Payer: Cigna Medicare	$86.40
Rate for Payer: Medicaid All Medicaid	$88.32
Rate for Payer: Medicare All Medicare	$67.20
Rate for Payer: Monida Allegiance	$91.20
Rate for Payer: Monida First Choice Health	$93.12
Rate for Payer: Monida Montana Health Co-op	$91.20
Rate for Payer: Monida PacificSource	$91.20

INVALID RING

Facility

$9.00

Hospital Charge Code	2830195
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

INVALID RING

Facility

$9.00

Hospital Charge Code	2830195
Hospital Revenue Code	270
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

IODOFORM PACKING 1/4 '

Facility

$4.00

Hospital Charge Code	80030179
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

IODOFORM PACKING 1/4 '

Facility

$4.00

Hospital Charge Code	80030179
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

IP/OBS ADMIT HIGH LEVEL (99223)

Facility

$445.00

Service Code	CPT 99223
Hospital Charge Code	799223
Hospital Revenue Code	521
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

IP/OBS ADMIT HIGH LEVEL (99223)

Facility

$445.00

Service Code	CPT 99223
Hospital Charge Code	799223
Hospital Revenue Code	521
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

IP/OBS ADMIT LOW LEVEL(99221)

Facility

$228.00

Service Code	CPT 99221
Hospital Charge Code	799221
Hospital Revenue Code	521
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: BCBS MT CHIP	$205.20
Rate for Payer: BCBS MT Closed Plan Network	$216.60
Rate for Payer: BCBS MT HealthLink	$205.20
Rate for Payer: BCBS MT Medicare	$205.20
Rate for Payer: BCBS MT POS	$216.60
Rate for Payer: BCBS MT Traditional	$228.00
Rate for Payer: Cash Price	$205.20
Rate for Payer: Cigna Commercial	$216.60
Rate for Payer: Cigna Medicare	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

IP/OBS ADMIT LOW LEVEL(99221)

Facility

$228.00

Service Code	CPT 99221
Hospital Charge Code	799221
Hospital Revenue Code	521
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$228.00
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: BCBS MT CHIP	$205.20
Rate for Payer: BCBS MT Closed Plan Network	$216.60
Rate for Payer: BCBS MT HealthLink	$205.20
Rate for Payer: BCBS MT Medicare	$205.20
Rate for Payer: BCBS MT POS	$216.60
Rate for Payer: BCBS MT Traditional	$228.00
Rate for Payer: Cash Price	$205.20
Rate for Payer: Cigna Commercial	$216.60
Rate for Payer: Cigna Medicare	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

IP/OBS ADMIT MODERATE LEVEL (99222)

Facility

$301.00

Service Code	CPT 99222
Hospital Charge Code	799222
Hospital Revenue Code	521
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

IP/OBS ADMIT MODERATE LEVEL (99222)

Facility

$301.00

Service Code	CPT 99222
Hospital Charge Code	799222
Hospital Revenue Code	521
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

IP/OBS SAME DAY ADM/DC HIGH CMPLEX 99236

Facility

$484.00

Service Code	CPT 99236
Hospital Charge Code	709236
Hospital Revenue Code	521
Min. Negotiated Rate	$338.80
Max. Negotiated Rate	$484.00
Rate for Payer: Aetna Commercial	$459.80
Rate for Payer: Aetna Medicare	$435.60
Rate for Payer: BCBS MT CHIP	$435.60
Rate for Payer: BCBS MT Closed Plan Network	$459.80
Rate for Payer: BCBS MT HealthLink	$435.60
Rate for Payer: BCBS MT Medicare	$435.60
Rate for Payer: BCBS MT POS	$459.80
Rate for Payer: BCBS MT Traditional	$484.00
Rate for Payer: Cash Price	$435.60
Rate for Payer: Cigna Commercial	$459.80
Rate for Payer: Cigna Medicare	$435.60
Rate for Payer: Medicaid All Medicaid	$445.28
Rate for Payer: Medicare All Medicare	$338.80
Rate for Payer: Monida Allegiance	$459.80
Rate for Payer: Monida First Choice Health	$469.48
Rate for Payer: Monida Montana Health Co-op	$459.80
Rate for Payer: Monida PacificSource	$459.80

IP/OBS SAME DAY ADM/DC HIGH CMPLEX 99236

Facility

$484.00

Service Code	CPT 99236
Hospital Charge Code	709236
Hospital Revenue Code	521
Min. Negotiated Rate	$338.80
Max. Negotiated Rate	$484.00
Rate for Payer: Aetna Commercial	$459.80
Rate for Payer: Aetna Medicare	$435.60
Rate for Payer: BCBS MT CHIP	$435.60
Rate for Payer: BCBS MT Closed Plan Network	$459.80
Rate for Payer: BCBS MT HealthLink	$435.60
Rate for Payer: BCBS MT Medicare	$435.60
Rate for Payer: BCBS MT POS	$459.80
Rate for Payer: BCBS MT Traditional	$484.00
Rate for Payer: Cash Price	$435.60
Rate for Payer: Cigna Commercial	$459.80
Rate for Payer: Cigna Medicare	$435.60
Rate for Payer: Medicaid All Medicaid	$445.28
Rate for Payer: Medicare All Medicare	$338.80
Rate for Payer: Monida Allegiance	$459.80
Rate for Payer: Monida First Choice Health	$469.48
Rate for Payer: Monida Montana Health Co-op	$459.80
Rate for Payer: Monida PacificSource	$459.80

IP/OBS SAME DAY ADM/DC LOW COMPLEX 99234

Facility

$295.00

Service Code	CPT 99234
Hospital Charge Code	799234
Hospital Revenue Code	521
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$295.00
Rate for Payer: Aetna Commercial	$280.25
Rate for Payer: Aetna Medicare	$265.50
Rate for Payer: BCBS MT CHIP	$265.50
Rate for Payer: BCBS MT Closed Plan Network	$280.25
Rate for Payer: BCBS MT HealthLink	$265.50
Rate for Payer: BCBS MT Medicare	$265.50
Rate for Payer: BCBS MT POS	$280.25
Rate for Payer: BCBS MT Traditional	$295.00
Rate for Payer: Cash Price	$265.50
Rate for Payer: Cigna Commercial	$280.25
Rate for Payer: Cigna Medicare	$265.50
Rate for Payer: Medicaid All Medicaid	$271.40
Rate for Payer: Medicare All Medicare	$206.50
Rate for Payer: Monida Allegiance	$280.25
Rate for Payer: Monida First Choice Health	$286.15
Rate for Payer: Monida Montana Health Co-op	$280.25
Rate for Payer: Monida PacificSource	$280.25

IP/OBS SAME DAY ADM/DC LOW COMPLEX 99234

Facility

$295.00

Service Code	CPT 99234
Hospital Charge Code	799234
Hospital Revenue Code	521
Min. Negotiated Rate	$206.50
Max. Negotiated Rate	$295.00
Rate for Payer: Aetna Commercial	$280.25
Rate for Payer: Aetna Medicare	$265.50
Rate for Payer: BCBS MT CHIP	$265.50
Rate for Payer: BCBS MT Closed Plan Network	$280.25
Rate for Payer: BCBS MT HealthLink	$265.50
Rate for Payer: BCBS MT Medicare	$265.50
Rate for Payer: BCBS MT POS	$280.25
Rate for Payer: BCBS MT Traditional	$295.00
Rate for Payer: Cash Price	$265.50
Rate for Payer: Cigna Commercial	$280.25
Rate for Payer: Cigna Medicare	$265.50
Rate for Payer: Medicaid All Medicaid	$271.40
Rate for Payer: Medicare All Medicare	$206.50
Rate for Payer: Monida Allegiance	$280.25
Rate for Payer: Monida First Choice Health	$286.15
Rate for Payer: Monida Montana Health Co-op	$280.25
Rate for Payer: Monida PacificSource	$280.25

IP/OBS SAME DAY ADM/DC MOD COMPLEX 99235

Facility

$373.00

Service Code	CPT 99235
Hospital Charge Code	799235
Hospital Revenue Code	521
Min. Negotiated Rate	$261.10
Max. Negotiated Rate	$373.00
Rate for Payer: Aetna Commercial	$354.35
Rate for Payer: Aetna Medicare	$335.70
Rate for Payer: BCBS MT CHIP	$335.70
Rate for Payer: BCBS MT Closed Plan Network	$354.35
Rate for Payer: BCBS MT HealthLink	$335.70
Rate for Payer: BCBS MT Medicare	$335.70
Rate for Payer: BCBS MT POS	$354.35
Rate for Payer: BCBS MT Traditional	$373.00
Rate for Payer: Cash Price	$335.70
Rate for Payer: Cigna Commercial	$354.35
Rate for Payer: Cigna Medicare	$335.70
Rate for Payer: Medicaid All Medicaid	$343.16
Rate for Payer: Medicare All Medicare	$261.10
Rate for Payer: Monida Allegiance	$354.35
Rate for Payer: Monida First Choice Health	$361.81
Rate for Payer: Monida Montana Health Co-op	$354.35
Rate for Payer: Monida PacificSource	$354.35

IP/OBS SAME DAY ADM/DC MOD COMPLEX 99235

Facility

$373.00

Service Code	CPT 99235
Hospital Charge Code	799235
Hospital Revenue Code	521
Min. Negotiated Rate	$261.10
Max. Negotiated Rate	$373.00
Rate for Payer: Aetna Commercial	$354.35
Rate for Payer: Aetna Medicare	$335.70
Rate for Payer: BCBS MT CHIP	$335.70
Rate for Payer: BCBS MT Closed Plan Network	$354.35
Rate for Payer: BCBS MT HealthLink	$335.70
Rate for Payer: BCBS MT Medicare	$335.70
Rate for Payer: BCBS MT POS	$354.35
Rate for Payer: BCBS MT Traditional	$373.00
Rate for Payer: Cash Price	$335.70
Rate for Payer: Cigna Commercial	$354.35
Rate for Payer: Cigna Medicare	$335.70
Rate for Payer: Medicaid All Medicaid	$343.16
Rate for Payer: Medicare All Medicare	$261.10
Rate for Payer: Monida Allegiance	$354.35
Rate for Payer: Monida First Choice Health	$361.81
Rate for Payer: Monida Montana Health Co-op	$354.35
Rate for Payer: Monida PacificSource	$354.35

IP/OBS SEP DAY DISCHARGE <30 MIN (99238)

Facility

$161.00

Service Code	CPT 99238
Hospital Charge Code	709238
Hospital Revenue Code	521
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

IP/OBS SEP DAY DISCHARGE <30 MIN (99238)

Facility

$161.00

Service Code	CPT 99238
Hospital Charge Code	709238
Hospital Revenue Code	521
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

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