Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

OT EVAL LOW COMPLEX

Facility

$445.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	6297165
Hospital Revenue Code	430
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

OT EVAL LOW COMPLEX

Facility

$445.00

Service Code	HCPCS 97165 GO
Hospital Charge Code	6297165
Hospital Revenue Code	430
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

OT EVAL MODERATE COMPLEX

Facility

$526.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	6297166
Hospital Revenue Code	430
Min. Negotiated Rate	$368.20
Max. Negotiated Rate	$526.00
Rate for Payer: Aetna Commercial	$499.70
Rate for Payer: Aetna Medicare	$473.40
Rate for Payer: BCBS MT CHIP	$473.40
Rate for Payer: BCBS MT Closed Plan Network	$499.70
Rate for Payer: BCBS MT HealthLink	$473.40
Rate for Payer: BCBS MT Medicare	$473.40
Rate for Payer: BCBS MT POS	$499.70
Rate for Payer: BCBS MT Traditional	$526.00
Rate for Payer: Cash Price	$473.40
Rate for Payer: Cigna Commercial	$499.70
Rate for Payer: Cigna Medicare	$473.40
Rate for Payer: Medicaid All Medicaid	$483.92
Rate for Payer: Medicare All Medicare	$368.20
Rate for Payer: Monida Allegiance	$499.70
Rate for Payer: Monida First Choice Health	$510.22
Rate for Payer: Monida Montana Health Co-op	$499.70
Rate for Payer: Monida PacificSource	$499.70

OT EVAL MODERATE COMPLEX

Facility

$526.00

Service Code	HCPCS 97166 GO
Hospital Charge Code	6297166
Hospital Revenue Code	430
Min. Negotiated Rate	$368.20
Max. Negotiated Rate	$526.00
Rate for Payer: Aetna Commercial	$499.70
Rate for Payer: Aetna Medicare	$473.40
Rate for Payer: BCBS MT CHIP	$473.40
Rate for Payer: BCBS MT Closed Plan Network	$499.70
Rate for Payer: BCBS MT HealthLink	$473.40
Rate for Payer: BCBS MT Medicare	$473.40
Rate for Payer: BCBS MT POS	$499.70
Rate for Payer: BCBS MT Traditional	$526.00
Rate for Payer: Cash Price	$473.40
Rate for Payer: Cigna Commercial	$499.70
Rate for Payer: Cigna Medicare	$473.40
Rate for Payer: Medicaid All Medicaid	$483.92
Rate for Payer: Medicare All Medicare	$368.20
Rate for Payer: Monida Allegiance	$499.70
Rate for Payer: Monida First Choice Health	$510.22
Rate for Payer: Monida Montana Health Co-op	$499.70
Rate for Payer: Monida PacificSource	$499.70

OT MANUAL THERAPY 15 MIN

Facility

$105.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	6297140
Hospital Revenue Code	430
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

OT MANUAL THERAPY 15 MIN

Facility

$105.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	6297140
Hospital Revenue Code	430
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

OT MASSAGE 15 MIN

Facility

$85.00

Service Code	HCPCS 97124 GO
Hospital Charge Code	6297124
Hospital Revenue Code	430
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$80.75
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS MT CHIP	$76.50
Rate for Payer: BCBS MT Closed Plan Network	$80.75
Rate for Payer: BCBS MT HealthLink	$76.50
Rate for Payer: BCBS MT Medicare	$76.50
Rate for Payer: BCBS MT POS	$80.75
Rate for Payer: BCBS MT Traditional	$85.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Cigna Medicare	$76.50
Rate for Payer: Medicaid All Medicaid	$78.20
Rate for Payer: Medicare All Medicare	$59.50
Rate for Payer: Monida Allegiance	$80.75
Rate for Payer: Monida First Choice Health	$82.45
Rate for Payer: Monida Montana Health Co-op	$80.75
Rate for Payer: Monida PacificSource	$80.75

OT MASSAGE 15 MIN

Facility

$85.00

Service Code	HCPCS 97124 GO
Hospital Charge Code	6297124
Hospital Revenue Code	430
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$80.75
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS MT CHIP	$76.50
Rate for Payer: BCBS MT Closed Plan Network	$80.75
Rate for Payer: BCBS MT HealthLink	$76.50
Rate for Payer: BCBS MT Medicare	$76.50
Rate for Payer: BCBS MT POS	$80.75
Rate for Payer: BCBS MT Traditional	$85.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Cigna Medicare	$76.50
Rate for Payer: Medicaid All Medicaid	$78.20
Rate for Payer: Medicare All Medicare	$59.50
Rate for Payer: Monida Allegiance	$80.75
Rate for Payer: Monida First Choice Health	$82.45
Rate for Payer: Monida Montana Health Co-op	$80.75
Rate for Payer: Monida PacificSource	$80.75

OT MUSCLE TEST EXCLUDES HAND WITH REPOR

Facility

$80.00

Service Code	HCPCS 95831 GO
Hospital Charge Code	6295831
Hospital Revenue Code	430
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

OT MUSCLE TEST EXCLUDES HAND WITH REPOR

Facility

$80.00

Service Code	HCPCS 95831 GO
Hospital Charge Code	6295831
Hospital Revenue Code	430
Min. Negotiated Rate	$56.00
Max. Negotiated Rate	$80.00
Rate for Payer: Aetna Commercial	$76.00
Rate for Payer: Aetna Medicare	$72.00
Rate for Payer: BCBS MT CHIP	$72.00
Rate for Payer: BCBS MT Closed Plan Network	$76.00
Rate for Payer: BCBS MT HealthLink	$72.00
Rate for Payer: BCBS MT Medicare	$72.00
Rate for Payer: BCBS MT POS	$76.00
Rate for Payer: BCBS MT Traditional	$80.00
Rate for Payer: Cash Price	$72.00
Rate for Payer: Cigna Commercial	$76.00
Rate for Payer: Cigna Medicare	$72.00
Rate for Payer: Medicaid All Medicaid	$73.60
Rate for Payer: Medicare All Medicare	$56.00
Rate for Payer: Monida Allegiance	$76.00
Rate for Payer: Monida First Choice Health	$77.60
Rate for Payer: Monida Montana Health Co-op	$76.00
Rate for Payer: Monida PacificSource	$76.00

OT MUSCLE TESTING HAND

Facility

$72.00

Service Code	HCPCS 95832 GO
Hospital Charge Code	6295832
Hospital Revenue Code	430
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

OT MUSCLE TESTING HAND

Facility

$72.00

Service Code	HCPCS 95832 GO
Hospital Charge Code	6295832
Hospital Revenue Code	430
Min. Negotiated Rate	$50.40
Max. Negotiated Rate	$72.00
Rate for Payer: Aetna Commercial	$68.40
Rate for Payer: Aetna Medicare	$64.80
Rate for Payer: BCBS MT CHIP	$64.80
Rate for Payer: BCBS MT Closed Plan Network	$68.40
Rate for Payer: BCBS MT HealthLink	$64.80
Rate for Payer: BCBS MT Medicare	$64.80
Rate for Payer: BCBS MT POS	$68.40
Rate for Payer: BCBS MT Traditional	$72.00
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cigna Commercial	$68.40
Rate for Payer: Cigna Medicare	$64.80
Rate for Payer: Medicaid All Medicaid	$66.24
Rate for Payer: Medicare All Medicare	$50.40
Rate for Payer: Monida Allegiance	$68.40
Rate for Payer: Monida First Choice Health	$69.84
Rate for Payer: Monida Montana Health Co-op	$68.40
Rate for Payer: Monida PacificSource	$68.40

OT MYOFASCIAL RELEASE

Facility

$105.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	6297250
Hospital Revenue Code	430
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

OT MYOFASCIAL RELEASE

Facility

$105.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	6297250
Hospital Revenue Code	430
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

OT NEUROMUSCULAR REEDUCATION 15 MIN

Facility

$206.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	6297112
Hospital Revenue Code	430
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$206.00
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: BCBS MT CHIP	$185.40
Rate for Payer: BCBS MT Closed Plan Network	$195.70
Rate for Payer: BCBS MT HealthLink	$185.40
Rate for Payer: BCBS MT Medicare	$185.40
Rate for Payer: BCBS MT POS	$195.70
Rate for Payer: BCBS MT Traditional	$206.00
Rate for Payer: Cash Price	$185.40
Rate for Payer: Cigna Commercial	$195.70
Rate for Payer: Cigna Medicare	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

OT NEUROMUSCULAR REEDUCATION 15 MIN

Facility

$206.00

Service Code	HCPCS 97112 GO
Hospital Charge Code	6297112
Hospital Revenue Code	430
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$206.00
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: BCBS MT CHIP	$185.40
Rate for Payer: BCBS MT Closed Plan Network	$195.70
Rate for Payer: BCBS MT HealthLink	$185.40
Rate for Payer: BCBS MT Medicare	$185.40
Rate for Payer: BCBS MT POS	$195.70
Rate for Payer: BCBS MT Traditional	$206.00
Rate for Payer: Cash Price	$185.40
Rate for Payer: Cigna Commercial	$195.70
Rate for Payer: Cigna Medicare	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

OT ORTHOTICS FITTING AND TRAINING 15MIN

Facility

$99.00

Service Code	HCPCS 97116 GO
Hospital Charge Code	6297504
Hospital Revenue Code	430
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

OT ORTHOTICS FITTING AND TRAINING 15MIN

Facility

$99.00

Service Code	HCPCS 97116 GO
Hospital Charge Code	6297760
Hospital Revenue Code	430
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

OT ORTHOTICS FITTING AND TRAINING 15MIN

Facility

$99.00

Service Code	HCPCS 97116 GO
Hospital Charge Code	6297504
Hospital Revenue Code	430
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

OT ORTHOTICS FITTING AND TRAINING 15MIN

Facility

$99.00

Service Code	HCPCS 97116 GO
Hospital Charge Code	6297760
Hospital Revenue Code	430
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna Commercial	$94.05
Rate for Payer: Aetna Medicare	$89.10
Rate for Payer: BCBS MT CHIP	$89.10
Rate for Payer: BCBS MT Closed Plan Network	$94.05
Rate for Payer: BCBS MT HealthLink	$89.10
Rate for Payer: BCBS MT Medicare	$89.10
Rate for Payer: BCBS MT POS	$94.05
Rate for Payer: BCBS MT Traditional	$99.00
Rate for Payer: Cash Price	$89.10
Rate for Payer: Cigna Commercial	$94.05
Rate for Payer: Cigna Medicare	$89.10
Rate for Payer: Medicaid All Medicaid	$91.08
Rate for Payer: Medicare All Medicare	$69.30
Rate for Payer: Monida Allegiance	$94.05
Rate for Payer: Monida First Choice Health	$96.03
Rate for Payer: Monida Montana Health Co-op	$94.05
Rate for Payer: Monida PacificSource	$94.05

OT OXIMETRY OVERNIGHT

Facility

$421.00

Service Code	HCPCS 94762
Hospital Charge Code	6294762
Hospital Revenue Code	460
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

OT OXIMETRY OVERNIGHT

Facility

$421.00

Service Code	HCPCS 94762
Hospital Charge Code	6294762
Hospital Revenue Code	460
Min. Negotiated Rate	$294.70
Max. Negotiated Rate	$421.00
Rate for Payer: Aetna Commercial	$399.95
Rate for Payer: Aetna Medicare	$378.90
Rate for Payer: BCBS MT CHIP	$378.90
Rate for Payer: BCBS MT Closed Plan Network	$399.95
Rate for Payer: BCBS MT HealthLink	$378.90
Rate for Payer: BCBS MT Medicare	$378.90
Rate for Payer: BCBS MT POS	$399.95
Rate for Payer: BCBS MT Traditional	$421.00
Rate for Payer: Cash Price	$378.90
Rate for Payer: Cigna Commercial	$399.95
Rate for Payer: Cigna Medicare	$378.90
Rate for Payer: Medicaid All Medicaid	$387.32
Rate for Payer: Medicare All Medicare	$294.70
Rate for Payer: Monida Allegiance	$399.95
Rate for Payer: Monida First Choice Health	$408.37
Rate for Payer: Monida Montana Health Co-op	$399.95
Rate for Payer: Monida PacificSource	$399.95

OT PARAFFIN

Facility

$64.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	6297018
Hospital Revenue Code	430
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

OT PARAFFIN

Facility

$64.00

Service Code	HCPCS 97018 GO
Hospital Charge Code	6297018
Hospital Revenue Code	430
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

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