Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$113.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	6297250
Hospital Revenue Code	430
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

OT MYOFASCIAL RELEASE

Facility

$113.00

Service Code	HCPCS 97140 GO
Hospital Charge Code	6297250
Hospital Revenue Code	430
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

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	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 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 OXIMETRY OVERNIGHT

Facility

$446.00

Service Code	HCPCS 94762
Hospital Charge Code	6294762
Hospital Revenue Code	460
Min. Negotiated Rate	$312.20
Max. Negotiated Rate	$446.00
Rate for Payer: Aetna Commercial	$423.70
Rate for Payer: Aetna Medicare	$401.40
Rate for Payer: BCBS MT CHIP	$401.40
Rate for Payer: BCBS MT Closed Plan Network	$423.70
Rate for Payer: BCBS MT HealthLink	$401.40
Rate for Payer: BCBS MT Medicare	$401.40
Rate for Payer: BCBS MT POS	$423.70
Rate for Payer: BCBS MT Traditional	$446.00
Rate for Payer: Cash Price	$401.40
Rate for Payer: Cigna Commercial	$423.70
Rate for Payer: Cigna Medicare	$401.40
Rate for Payer: Medicaid All Medicaid	$410.32
Rate for Payer: Medicare All Medicare	$312.20
Rate for Payer: Monida Allegiance	$423.70
Rate for Payer: Monida First Choice Health	$432.62
Rate for Payer: Monida Montana Health Co-op	$423.70
Rate for Payer: Monida PacificSource	$423.70

OT OXIMETRY OVERNIGHT

Facility

$446.00

Service Code	HCPCS 94762
Hospital Charge Code	6294762
Hospital Revenue Code	460
Min. Negotiated Rate	$312.20
Max. Negotiated Rate	$446.00
Rate for Payer: Aetna Commercial	$423.70
Rate for Payer: Aetna Medicare	$401.40
Rate for Payer: BCBS MT CHIP	$401.40
Rate for Payer: BCBS MT Closed Plan Network	$423.70
Rate for Payer: BCBS MT HealthLink	$401.40
Rate for Payer: BCBS MT Medicare	$401.40
Rate for Payer: BCBS MT POS	$423.70
Rate for Payer: BCBS MT Traditional	$446.00
Rate for Payer: Cash Price	$401.40
Rate for Payer: Cigna Commercial	$423.70
Rate for Payer: Cigna Medicare	$401.40
Rate for Payer: Medicaid All Medicaid	$410.32
Rate for Payer: Medicare All Medicare	$312.20
Rate for Payer: Monida Allegiance	$423.70
Rate for Payer: Monida First Choice Health	$432.62
Rate for Payer: Monida Montana Health Co-op	$423.70
Rate for Payer: Monida PacificSource	$423.70

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

OT PULMONARY FUNCTION (PRE)

Facility

$243.00

Service Code	HCPCS 94010
Hospital Charge Code	6294010
Hospital Revenue Code	460
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: BCBS MT CHIP	$218.70
Rate for Payer: BCBS MT Closed Plan Network	$230.85
Rate for Payer: BCBS MT HealthLink	$218.70
Rate for Payer: BCBS MT Medicare	$218.70
Rate for Payer: BCBS MT POS	$230.85
Rate for Payer: BCBS MT Traditional	$243.00
Rate for Payer: Cash Price	$218.70
Rate for Payer: Cigna Commercial	$230.85
Rate for Payer: Cigna Medicare	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

OT PULMONARY FUNCTION (PRE)

Facility

$243.00

Service Code	HCPCS 94010
Hospital Charge Code	6294010
Hospital Revenue Code	460
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: BCBS MT CHIP	$218.70
Rate for Payer: BCBS MT Closed Plan Network	$230.85
Rate for Payer: BCBS MT HealthLink	$218.70
Rate for Payer: BCBS MT Medicare	$218.70
Rate for Payer: BCBS MT POS	$230.85
Rate for Payer: BCBS MT Traditional	$243.00
Rate for Payer: Cash Price	$218.70
Rate for Payer: Cigna Commercial	$230.85
Rate for Payer: Cigna Medicare	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

OT PULMONARY FUNCTION (PRE & POST)

Facility

$446.00

Service Code	HCPCS 94060
Hospital Charge Code	6294060
Hospital Revenue Code	460
Min. Negotiated Rate	$312.20
Max. Negotiated Rate	$446.00
Rate for Payer: Aetna Commercial	$423.70
Rate for Payer: Aetna Medicare	$401.40
Rate for Payer: BCBS MT CHIP	$401.40
Rate for Payer: BCBS MT Closed Plan Network	$423.70
Rate for Payer: BCBS MT HealthLink	$401.40
Rate for Payer: BCBS MT Medicare	$401.40
Rate for Payer: BCBS MT POS	$423.70
Rate for Payer: BCBS MT Traditional	$446.00
Rate for Payer: Cash Price	$401.40
Rate for Payer: Cigna Commercial	$423.70
Rate for Payer: Cigna Medicare	$401.40
Rate for Payer: Medicaid All Medicaid	$410.32
Rate for Payer: Medicare All Medicare	$312.20
Rate for Payer: Monida Allegiance	$423.70
Rate for Payer: Monida First Choice Health	$432.62
Rate for Payer: Monida Montana Health Co-op	$423.70
Rate for Payer: Monida PacificSource	$423.70

OT PULMONARY FUNCTION (PRE & POST)

Facility

$446.00

Service Code	HCPCS 94060
Hospital Charge Code	6294060
Hospital Revenue Code	460
Min. Negotiated Rate	$312.20
Max. Negotiated Rate	$446.00
Rate for Payer: Aetna Commercial	$423.70
Rate for Payer: Aetna Medicare	$401.40
Rate for Payer: BCBS MT CHIP	$401.40
Rate for Payer: BCBS MT Closed Plan Network	$423.70
Rate for Payer: BCBS MT HealthLink	$401.40
Rate for Payer: BCBS MT Medicare	$401.40
Rate for Payer: BCBS MT POS	$423.70
Rate for Payer: BCBS MT Traditional	$446.00
Rate for Payer: Cash Price	$401.40
Rate for Payer: Cigna Commercial	$423.70
Rate for Payer: Cigna Medicare	$401.40
Rate for Payer: Medicaid All Medicaid	$410.32
Rate for Payer: Medicare All Medicare	$312.20
Rate for Payer: Monida Allegiance	$423.70
Rate for Payer: Monida First Choice Health	$432.62
Rate for Payer: Monida Montana Health Co-op	$423.70
Rate for Payer: Monida PacificSource	$423.70

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

$99.00

Service Code	HCPCS 94375
Hospital Charge Code	6294375
Hospital Revenue Code	460
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 RESPIRATORY FLOW VOLUME LOOP

Facility

$99.00

Service Code	HCPCS 94375
Hospital Charge Code	6294375
Hospital Revenue Code	460
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 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

Know your out-of-pocket cost for care.

All Charges