Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ORAL AIRWAY # 12 120MM

Facility

$4.00

Hospital Charge Code	80040161
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

ORAL AIRWAY # 12 120MM

Facility

$4.00

Hospital Charge Code	80040161
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

OSELTAMIVIR CAP[30MG]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000367
Hospital Revenue Code	636
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

OSELTAMIVIR CAP[30MG]

Facility

$48.00

Service Code	HCPCS J3490
Hospital Charge Code	3000367
Hospital Revenue Code	636
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

OSELTAMIVIR CAP [75 MG]

Facility

$52.00

Service Code	HCPCS J3490
Hospital Charge Code	3000366
Hospital Revenue Code	259
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

OSELTAMIVIR CAP [75 MG]

Facility

$52.00

Service Code	HCPCS J3490
Hospital Charge Code	3000366
Hospital Revenue Code	259
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$52.00
Rate for Payer: Aetna Commercial	$49.40
Rate for Payer: Aetna Medicare	$46.80
Rate for Payer: BCBS MT CHIP	$46.80
Rate for Payer: BCBS MT Closed Plan Network	$49.40
Rate for Payer: BCBS MT HealthLink	$46.80
Rate for Payer: BCBS MT Medicare	$46.80
Rate for Payer: BCBS MT POS	$49.40
Rate for Payer: BCBS MT Traditional	$52.00
Rate for Payer: Cash Price	$46.80
Rate for Payer: Cigna Commercial	$49.40
Rate for Payer: Cigna Medicare	$46.80
Rate for Payer: Medicaid All Medicaid	$47.84
Rate for Payer: Medicare All Medicare	$36.40
Rate for Payer: Monida Allegiance	$49.40
Rate for Payer: Monida First Choice Health	$50.44
Rate for Payer: Monida Montana Health Co-op	$49.40
Rate for Payer: Monida PacificSource	$49.40

OSELTAMIVIR SUSPENSION [ 6MG/ML ]

Facility

$499.00

Service Code	HCPCS J3490
Hospital Charge Code	3000368
Hospital Revenue Code	259
Min. Negotiated Rate	$349.30
Max. Negotiated Rate	$499.00
Rate for Payer: Aetna Commercial	$474.05
Rate for Payer: Aetna Medicare	$449.10
Rate for Payer: BCBS MT CHIP	$449.10
Rate for Payer: BCBS MT Closed Plan Network	$474.05
Rate for Payer: BCBS MT HealthLink	$449.10
Rate for Payer: BCBS MT Medicare	$449.10
Rate for Payer: BCBS MT POS	$474.05
Rate for Payer: BCBS MT Traditional	$499.00
Rate for Payer: Cash Price	$449.10
Rate for Payer: Cigna Commercial	$474.05
Rate for Payer: Cigna Medicare	$449.10
Rate for Payer: Medicaid All Medicaid	$459.08
Rate for Payer: Medicare All Medicare	$349.30
Rate for Payer: Monida Allegiance	$474.05
Rate for Payer: Monida First Choice Health	$484.03
Rate for Payer: Monida Montana Health Co-op	$474.05
Rate for Payer: Monida PacificSource	$474.05

OSELTAMIVIR SUSPENSION [ 6MG/ML ]

Facility

$499.00

Service Code	HCPCS J3490
Hospital Charge Code	3000368
Hospital Revenue Code	259
Min. Negotiated Rate	$349.30
Max. Negotiated Rate	$499.00
Rate for Payer: Aetna Commercial	$474.05
Rate for Payer: Aetna Medicare	$449.10
Rate for Payer: BCBS MT CHIP	$449.10
Rate for Payer: BCBS MT Closed Plan Network	$474.05
Rate for Payer: BCBS MT HealthLink	$449.10
Rate for Payer: BCBS MT Medicare	$449.10
Rate for Payer: BCBS MT POS	$474.05
Rate for Payer: BCBS MT Traditional	$499.00
Rate for Payer: Cash Price	$449.10
Rate for Payer: Cigna Commercial	$474.05
Rate for Payer: Cigna Medicare	$449.10
Rate for Payer: Medicaid All Medicaid	$459.08
Rate for Payer: Medicare All Medicare	$349.30
Rate for Payer: Monida Allegiance	$474.05
Rate for Payer: Monida First Choice Health	$484.03
Rate for Payer: Monida Montana Health Co-op	$474.05
Rate for Payer: Monida PacificSource	$474.05

OSMOLALITY, SERUM (002071)

Facility

$26.00

Service Code	HCPCS 83930
Hospital Charge Code	4083930
Hospital Revenue Code	301
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

OSMOLALITY, SERUM (002071)

Facility

$26.00

Service Code	HCPCS 83930
Hospital Charge Code	4083930
Hospital Revenue Code	301
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

OSMOLALITY, URINE (003442)

Facility

$27.00

Service Code	HCPCS 83935
Hospital Charge Code	4083935
Hospital Revenue Code	301
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

OSMOLALITY, URINE (003442)

Facility

$27.00

Service Code	HCPCS 83935
Hospital Charge Code	4083935
Hospital Revenue Code	301
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

OT APPLY MULTLAY COMPRS LWR LEG

Facility

$664.00

Service Code	HCPCS 29581
Hospital Charge Code	6229581
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT APPLY MULTLAY COMPRS LWR LEG

Facility

$664.00

Service Code	HCPCS 29581
Hospital Charge Code	6229581
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT APPLY MULTLAY COMPRS UPR ARM

Facility

$664.00

Service Code	HCPCS 29584
Hospital Charge Code	6229582
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT APPLY MULTLAY COMPRS UPR ARM

Facility

$664.00

Service Code	HCPCS 29584
Hospital Charge Code	6229582
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT COMMUNITY REINTEGRATION 15 MIN

Facility

$81.00

Service Code	HCPCS 97537 GO
Hospital Charge Code	6297537
Hospital Revenue Code	430
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

OT COMMUNITY REINTEGRATION 15 MIN

Facility

$81.00

Service Code	HCPCS 97537 GO
Hospital Charge Code	6297537
Hospital Revenue Code	430
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

OT CONTRAST BATHS 15 MIN

Facility

$69.00

Service Code	HCPCS 97034 GO
Hospital Charge Code	6297034
Hospital Revenue Code	430
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

OT CONTRAST BATHS 15 MIN

Facility

$69.00

Service Code	HCPCS 97034 GO
Hospital Charge Code	6297034
Hospital Revenue Code	430
Min. Negotiated Rate	$48.30
Max. Negotiated Rate	$69.00
Rate for Payer: Aetna Commercial	$65.55
Rate for Payer: Aetna Medicare	$62.10
Rate for Payer: BCBS MT CHIP	$62.10
Rate for Payer: BCBS MT Closed Plan Network	$65.55
Rate for Payer: BCBS MT HealthLink	$62.10
Rate for Payer: BCBS MT Medicare	$62.10
Rate for Payer: BCBS MT POS	$65.55
Rate for Payer: BCBS MT Traditional	$69.00
Rate for Payer: Cash Price	$62.10
Rate for Payer: Cigna Commercial	$65.55
Rate for Payer: Cigna Medicare	$62.10
Rate for Payer: Medicaid All Medicaid	$63.48
Rate for Payer: Medicare All Medicare	$48.30
Rate for Payer: Monida Allegiance	$65.55
Rate for Payer: Monida First Choice Health	$66.93
Rate for Payer: Monida Montana Health Co-op	$65.55
Rate for Payer: Monida PacificSource	$65.55

OT DEBRIDEMENT

Facility

$213.00

Service Code	HCPCS 97602 GP
Hospital Charge Code	6107603
Hospital Revenue Code	420
Min. Negotiated Rate	$149.10
Max. Negotiated Rate	$213.00
Rate for Payer: Aetna Commercial	$202.35
Rate for Payer: Aetna Medicare	$191.70
Rate for Payer: BCBS MT CHIP	$191.70
Rate for Payer: BCBS MT Closed Plan Network	$202.35
Rate for Payer: BCBS MT HealthLink	$191.70
Rate for Payer: BCBS MT Medicare	$191.70
Rate for Payer: BCBS MT POS	$202.35
Rate for Payer: BCBS MT Traditional	$213.00
Rate for Payer: Cash Price	$191.70
Rate for Payer: Cigna Commercial	$202.35
Rate for Payer: Cigna Medicare	$191.70
Rate for Payer: Medicaid All Medicaid	$195.96
Rate for Payer: Medicare All Medicare	$149.10
Rate for Payer: Monida Allegiance	$202.35
Rate for Payer: Monida First Choice Health	$206.61
Rate for Payer: Monida Montana Health Co-op	$202.35
Rate for Payer: Monida PacificSource	$202.35

OT DEBRIDEMENT

Facility

$213.00

Service Code	HCPCS 97602 GP
Hospital Charge Code	6107603
Hospital Revenue Code	420
Min. Negotiated Rate	$149.10
Max. Negotiated Rate	$213.00
Rate for Payer: Aetna Commercial	$202.35
Rate for Payer: Aetna Medicare	$191.70
Rate for Payer: BCBS MT CHIP	$191.70
Rate for Payer: BCBS MT Closed Plan Network	$202.35
Rate for Payer: BCBS MT HealthLink	$191.70
Rate for Payer: BCBS MT Medicare	$191.70
Rate for Payer: BCBS MT POS	$202.35
Rate for Payer: BCBS MT Traditional	$213.00
Rate for Payer: Cash Price	$191.70
Rate for Payer: Cigna Commercial	$202.35
Rate for Payer: Cigna Medicare	$191.70
Rate for Payer: Medicaid All Medicaid	$195.96
Rate for Payer: Medicare All Medicare	$149.10
Rate for Payer: Monida Allegiance	$202.35
Rate for Payer: Monida First Choice Health	$206.61
Rate for Payer: Monida Montana Health Co-op	$202.35
Rate for Payer: Monida PacificSource	$202.35

OT DEVELOPMTL TEST EXTENDED/REPT PER HR

Facility

$318.00

Service Code	HCPCS 96111 GO
Hospital Charge Code	6296111
Hospital Revenue Code	430
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

OT DEVELOPMTL TEST EXTENDED/REPT PER HR

Facility

$318.00

Service Code	HCPCS 96111 GO
Hospital Charge Code	6296111
Hospital Revenue Code	430
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

OT EVAL HIGH COMPLEX

Facility

$609.00

Service Code	HCPCS 97167 GO
Hospital Charge Code	6297167
Hospital Revenue Code	430
Min. Negotiated Rate	$426.30
Max. Negotiated Rate	$609.00
Rate for Payer: Aetna Commercial	$578.55
Rate for Payer: Aetna Medicare	$548.10
Rate for Payer: BCBS MT CHIP	$548.10
Rate for Payer: BCBS MT Closed Plan Network	$578.55
Rate for Payer: BCBS MT HealthLink	$548.10
Rate for Payer: BCBS MT Medicare	$548.10
Rate for Payer: BCBS MT POS	$578.55
Rate for Payer: BCBS MT Traditional	$609.00
Rate for Payer: Cash Price	$548.10
Rate for Payer: Cigna Commercial	$578.55
Rate for Payer: Cigna Medicare	$548.10
Rate for Payer: Medicaid All Medicaid	$560.28
Rate for Payer: Medicare All Medicare	$426.30
Rate for Payer: Monida Allegiance	$578.55
Rate for Payer: Monida First Choice Health	$590.73
Rate for Payer: Monida Montana Health Co-op	$578.55
Rate for Payer: Monida PacificSource	$578.55

Know your out-of-pocket cost for care.

All Charges