Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OT PULMONARY FUNCTION (PRE)

Facility

$229.00

Service Code	HCPCS 94010
Hospital Charge Code	6294010
Hospital Revenue Code	460
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

OT PULMONARY FUNCTION (PRE)

Facility

$229.00

Service Code	HCPCS 94010
Hospital Charge Code	6294010
Hospital Revenue Code	460
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$229.00
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: BCBS MT CHIP	$206.10
Rate for Payer: BCBS MT Closed Plan Network	$217.55
Rate for Payer: BCBS MT HealthLink	$206.10
Rate for Payer: BCBS MT Medicare	$206.10
Rate for Payer: BCBS MT POS	$217.55
Rate for Payer: BCBS MT Traditional	$229.00
Rate for Payer: Cash Price	$206.10
Rate for Payer: Cigna Commercial	$217.55
Rate for Payer: Cigna Medicare	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

OT PULMONARY FUNCTION (PRE & POST)

Facility

$421.00

Service Code	HCPCS 94060
Hospital Charge Code	6294060
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 PULMONARY FUNCTION (PRE & POST)

Facility

$421.00

Service Code	HCPCS 94060
Hospital Charge Code	6294060
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 RE-EVAL EST PLAN CAR

Facility

$333.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	6297168
Hospital Revenue Code	430
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

OT RE-EVAL EST PLAN CAR

Facility

$333.00

Service Code	HCPCS 97168 GO
Hospital Charge Code	6297168
Hospital Revenue Code	430
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$333.00
Rate for Payer: Aetna Commercial	$316.35
Rate for Payer: Aetna Medicare	$299.70
Rate for Payer: BCBS MT CHIP	$299.70
Rate for Payer: BCBS MT Closed Plan Network	$316.35
Rate for Payer: BCBS MT HealthLink	$299.70
Rate for Payer: BCBS MT Medicare	$299.70
Rate for Payer: BCBS MT POS	$316.35
Rate for Payer: BCBS MT Traditional	$333.00
Rate for Payer: Cash Price	$299.70
Rate for Payer: Cigna Commercial	$316.35
Rate for Payer: Cigna Medicare	$299.70
Rate for Payer: Medicaid All Medicaid	$306.36
Rate for Payer: Medicare All Medicare	$233.10
Rate for Payer: Monida Allegiance	$316.35
Rate for Payer: Monida First Choice Health	$323.01
Rate for Payer: Monida Montana Health Co-op	$316.35
Rate for Payer: Monida PacificSource	$316.35

OT RESPIRATORY FLOW VOLUME LOOP

Facility

$93.00

Service Code	HCPCS 94375
Hospital Charge Code	6294375
Hospital Revenue Code	460
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

OT RESPIRATORY FLOW VOLUME LOOP

Facility

$93.00

Service Code	HCPCS 94375
Hospital Charge Code	6294375
Hospital Revenue Code	460
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$93.00
Rate for Payer: Aetna Commercial	$88.35
Rate for Payer: Aetna Medicare	$83.70
Rate for Payer: BCBS MT CHIP	$83.70
Rate for Payer: BCBS MT Closed Plan Network	$88.35
Rate for Payer: BCBS MT HealthLink	$83.70
Rate for Payer: BCBS MT Medicare	$83.70
Rate for Payer: BCBS MT POS	$88.35
Rate for Payer: BCBS MT Traditional	$93.00
Rate for Payer: Cash Price	$83.70
Rate for Payer: Cigna Commercial	$88.35
Rate for Payer: Cigna Medicare	$83.70
Rate for Payer: Medicaid All Medicaid	$85.56
Rate for Payer: Medicare All Medicare	$65.10
Rate for Payer: Monida Allegiance	$88.35
Rate for Payer: Monida First Choice Health	$90.21
Rate for Payer: Monida Montana Health Co-op	$88.35
Rate for Payer: Monida PacificSource	$88.35

OT ROM MEASUREMENT HANDS

Facility

$55.00

Service Code	HCPCS 95852 GO
Hospital Charge Code	6295852
Hospital Revenue Code	430
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

OT ROM MEASUREMENT HANDS

Facility

$55.00

Service Code	HCPCS 95852 GO
Hospital Charge Code	6295852
Hospital Revenue Code	430
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

OT ROM MEASURE/REPORT EXCEPT HANDS

Facility

$55.00

Service Code	HCPCS 95851 GO
Hospital Charge Code	6295851
Hospital Revenue Code	430
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

OT ROM MEASURE/REPORT EXCEPT HANDS

Facility

$55.00

Service Code	HCPCS 95851 GO
Hospital Charge Code	6295851
Hospital Revenue Code	430
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$55.00
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: BCBS MT CHIP	$49.50
Rate for Payer: BCBS MT Closed Plan Network	$52.25
Rate for Payer: BCBS MT HealthLink	$49.50
Rate for Payer: BCBS MT Medicare	$49.50
Rate for Payer: BCBS MT POS	$52.25
Rate for Payer: BCBS MT Traditional	$55.00
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cigna Commercial	$52.25
Rate for Payer: Cigna Medicare	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

OT SELF CARE MANAGEMENT 15 MIN

Facility

$198.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	6297535
Hospital Revenue Code	430
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna Commercial	$188.10
Rate for Payer: Aetna Medicare	$178.20
Rate for Payer: BCBS MT CHIP	$178.20
Rate for Payer: BCBS MT Closed Plan Network	$188.10
Rate for Payer: BCBS MT HealthLink	$178.20
Rate for Payer: BCBS MT Medicare	$178.20
Rate for Payer: BCBS MT POS	$188.10
Rate for Payer: BCBS MT Traditional	$198.00
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cigna Commercial	$188.10
Rate for Payer: Cigna Medicare	$178.20
Rate for Payer: Medicaid All Medicaid	$182.16
Rate for Payer: Medicare All Medicare	$138.60
Rate for Payer: Monida Allegiance	$188.10
Rate for Payer: Monida First Choice Health	$192.06
Rate for Payer: Monida Montana Health Co-op	$188.10
Rate for Payer: Monida PacificSource	$188.10

OT SELF CARE MANAGEMENT 15 MIN

Facility

$198.00

Service Code	HCPCS 97535 GO
Hospital Charge Code	6297535
Hospital Revenue Code	430
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna Commercial	$188.10
Rate for Payer: Aetna Medicare	$178.20
Rate for Payer: BCBS MT CHIP	$178.20
Rate for Payer: BCBS MT Closed Plan Network	$188.10
Rate for Payer: BCBS MT HealthLink	$178.20
Rate for Payer: BCBS MT Medicare	$178.20
Rate for Payer: BCBS MT POS	$188.10
Rate for Payer: BCBS MT Traditional	$198.00
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cigna Commercial	$188.10
Rate for Payer: Cigna Medicare	$178.20
Rate for Payer: Medicaid All Medicaid	$182.16
Rate for Payer: Medicare All Medicare	$138.60
Rate for Payer: Monida Allegiance	$188.10
Rate for Payer: Monida First Choice Health	$192.06
Rate for Payer: Monida Montana Health Co-op	$188.10
Rate for Payer: Monida PacificSource	$188.10

OT THERAPEUTIC ACTIVITIES 15 MIN

Facility

$205.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	6297530
Hospital Revenue Code	430
Min. Negotiated Rate	$143.50
Max. Negotiated Rate	$205.00
Rate for Payer: Aetna Commercial	$194.75
Rate for Payer: Aetna Medicare	$184.50
Rate for Payer: BCBS MT CHIP	$184.50
Rate for Payer: BCBS MT Closed Plan Network	$194.75
Rate for Payer: BCBS MT HealthLink	$184.50
Rate for Payer: BCBS MT Medicare	$184.50
Rate for Payer: BCBS MT POS	$194.75
Rate for Payer: BCBS MT Traditional	$205.00
Rate for Payer: Cash Price	$184.50
Rate for Payer: Cigna Commercial	$194.75
Rate for Payer: Cigna Medicare	$184.50
Rate for Payer: Medicaid All Medicaid	$188.60
Rate for Payer: Medicare All Medicare	$143.50
Rate for Payer: Monida Allegiance	$194.75
Rate for Payer: Monida First Choice Health	$198.85
Rate for Payer: Monida Montana Health Co-op	$194.75
Rate for Payer: Monida PacificSource	$194.75

OT THERAPEUTIC ACTIVITIES 15 MIN

Facility

$205.00

Service Code	HCPCS 97530 GO
Hospital Charge Code	6297530
Hospital Revenue Code	430
Min. Negotiated Rate	$143.50
Max. Negotiated Rate	$205.00
Rate for Payer: Aetna Commercial	$194.75
Rate for Payer: Aetna Medicare	$184.50
Rate for Payer: BCBS MT CHIP	$184.50
Rate for Payer: BCBS MT Closed Plan Network	$194.75
Rate for Payer: BCBS MT HealthLink	$184.50
Rate for Payer: BCBS MT Medicare	$184.50
Rate for Payer: BCBS MT POS	$194.75
Rate for Payer: BCBS MT Traditional	$205.00
Rate for Payer: Cash Price	$184.50
Rate for Payer: Cigna Commercial	$194.75
Rate for Payer: Cigna Medicare	$184.50
Rate for Payer: Medicaid All Medicaid	$188.60
Rate for Payer: Medicare All Medicare	$143.50
Rate for Payer: Monida Allegiance	$194.75
Rate for Payer: Monida First Choice Health	$198.85
Rate for Payer: Monida Montana Health Co-op	$194.75
Rate for Payer: Monida PacificSource	$194.75

OT THERAPEUTIC EXERCISE 15 MIN

Facility

$208.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	6297110
Hospital Revenue Code	430
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

OT THERAPEUTIC EXERCISE 15 MIN

Facility

$208.00

Service Code	HCPCS 97110 GO
Hospital Charge Code	6297110
Hospital Revenue Code	430
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$208.00
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: BCBS MT CHIP	$187.20
Rate for Payer: BCBS MT Closed Plan Network	$197.60
Rate for Payer: BCBS MT HealthLink	$187.20
Rate for Payer: BCBS MT Medicare	$187.20
Rate for Payer: BCBS MT POS	$197.60
Rate for Payer: BCBS MT Traditional	$208.00
Rate for Payer: Cash Price	$187.20
Rate for Payer: Cigna Commercial	$197.60
Rate for Payer: Cigna Medicare	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

OT ULTRASOUND

Facility

$80.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	6297035
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 ULTRASOUND

Facility

$80.00

Service Code	HCPCS 97035 GO
Hospital Charge Code	6297035
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 WHEELCHAIR MANAGEMENT 15 MIN

Facility

$91.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	6297542
Hospital Revenue Code	430
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

OT WHEELCHAIR MANAGEMENT 15 MIN

Facility

$91.00

Service Code	HCPCS 97542 GO
Hospital Charge Code	6297542
Hospital Revenue Code	430
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$91.00
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: BCBS MT CHIP	$81.90
Rate for Payer: BCBS MT Closed Plan Network	$86.45
Rate for Payer: BCBS MT HealthLink	$81.90
Rate for Payer: BCBS MT Medicare	$81.90
Rate for Payer: BCBS MT POS	$86.45
Rate for Payer: BCBS MT Traditional	$91.00
Rate for Payer: Cash Price	$81.90
Rate for Payer: Cigna Commercial	$86.45
Rate for Payer: Cigna Medicare	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

OUTPATIENT INJECTION INTRLAM C-T 62321

Facility

$2,285.00

Service Code	HCPCS 62321
Hospital Charge Code	1562321
Hospital Revenue Code	761
Min. Negotiated Rate	$1,599.50
Max. Negotiated Rate	$2,285.00
Rate for Payer: Aetna Commercial	$2,170.75
Rate for Payer: Aetna Medicare	$2,056.50
Rate for Payer: BCBS MT CHIP	$2,056.50
Rate for Payer: BCBS MT Closed Plan Network	$2,170.75
Rate for Payer: BCBS MT HealthLink	$2,056.50
Rate for Payer: BCBS MT Medicare	$2,056.50
Rate for Payer: BCBS MT POS	$2,170.75
Rate for Payer: BCBS MT Traditional	$2,285.00
Rate for Payer: Cash Price	$2,056.50
Rate for Payer: Cigna Commercial	$2,170.75
Rate for Payer: Cigna Medicare	$2,056.50
Rate for Payer: Medicaid All Medicaid	$2,102.20
Rate for Payer: Medicare All Medicare	$1,599.50
Rate for Payer: Monida Allegiance	$2,170.75
Rate for Payer: Monida First Choice Health	$2,216.45
Rate for Payer: Monida Montana Health Co-op	$2,170.75
Rate for Payer: Monida PacificSource	$2,170.75

OUTPATIENT INJECTION INTRLAM C-T 62321

Facility

$2,285.00

Service Code	HCPCS 62321
Hospital Charge Code	1562321
Hospital Revenue Code	761
Min. Negotiated Rate	$1,599.50
Max. Negotiated Rate	$2,285.00
Rate for Payer: Aetna Commercial	$2,170.75
Rate for Payer: Aetna Medicare	$2,056.50
Rate for Payer: BCBS MT CHIP	$2,056.50
Rate for Payer: BCBS MT Closed Plan Network	$2,170.75
Rate for Payer: BCBS MT HealthLink	$2,056.50
Rate for Payer: BCBS MT Medicare	$2,056.50
Rate for Payer: BCBS MT POS	$2,170.75
Rate for Payer: BCBS MT Traditional	$2,285.00
Rate for Payer: Cash Price	$2,056.50
Rate for Payer: Cigna Commercial	$2,170.75
Rate for Payer: Cigna Medicare	$2,056.50
Rate for Payer: Medicaid All Medicaid	$2,102.20
Rate for Payer: Medicare All Medicare	$1,599.50
Rate for Payer: Monida Allegiance	$2,170.75
Rate for Payer: Monida First Choice Health	$2,216.45
Rate for Payer: Monida Montana Health Co-op	$2,170.75
Rate for Payer: Monida PacificSource	$2,170.75

OUTPATIENT TREATMENT ALLERGY SHOT 1

Facility

$38.00

Service Code	HCPCS 95115
Hospital Charge Code	540197
Hospital Revenue Code	761
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$38.00
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: BCBS MT CHIP	$34.20
Rate for Payer: BCBS MT Closed Plan Network	$36.10
Rate for Payer: BCBS MT HealthLink	$34.20
Rate for Payer: BCBS MT Medicare	$34.20
Rate for Payer: BCBS MT POS	$36.10
Rate for Payer: BCBS MT Traditional	$38.00
Rate for Payer: Cash Price	$34.20
Rate for Payer: Cigna Commercial	$36.10
Rate for Payer: Cigna Medicare	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

Know your out-of-pocket cost for care.

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