Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

$2,422.00

Service Code	HCPCS 62321
Hospital Charge Code	1562321
Hospital Revenue Code	761
Min. Negotiated Rate	$1,695.40
Max. Negotiated Rate	$2,422.00
Rate for Payer: Aetna Commercial	$2,300.90
Rate for Payer: Aetna Medicare	$2,179.80
Rate for Payer: BCBS MT CHIP	$2,179.80
Rate for Payer: BCBS MT Closed Plan Network	$2,300.90
Rate for Payer: BCBS MT HealthLink	$2,179.80
Rate for Payer: BCBS MT Medicare	$2,179.80
Rate for Payer: BCBS MT POS	$2,300.90
Rate for Payer: BCBS MT Traditional	$2,422.00
Rate for Payer: Cash Price	$2,179.80
Rate for Payer: Cigna Commercial	$2,300.90
Rate for Payer: Cigna Medicare	$2,179.80
Rate for Payer: Medicaid All Medicaid	$2,228.24
Rate for Payer: Medicare All Medicare	$1,695.40
Rate for Payer: Monida Allegiance	$2,300.90
Rate for Payer: Monida First Choice Health	$2,349.34
Rate for Payer: Monida Montana Health Co-op	$2,300.90
Rate for Payer: Monida PacificSource	$2,300.90

OUTPATIENT INJECTION INTRLAM C-T 62321

Facility

$2,422.00

Service Code	HCPCS 62321
Hospital Charge Code	1562321
Hospital Revenue Code	761
Min. Negotiated Rate	$1,695.40
Max. Negotiated Rate	$2,422.00
Rate for Payer: Aetna Commercial	$2,300.90
Rate for Payer: Aetna Medicare	$2,179.80
Rate for Payer: BCBS MT CHIP	$2,179.80
Rate for Payer: BCBS MT Closed Plan Network	$2,300.90
Rate for Payer: BCBS MT HealthLink	$2,179.80
Rate for Payer: BCBS MT Medicare	$2,179.80
Rate for Payer: BCBS MT POS	$2,300.90
Rate for Payer: BCBS MT Traditional	$2,422.00
Rate for Payer: Cash Price	$2,179.80
Rate for Payer: Cigna Commercial	$2,300.90
Rate for Payer: Cigna Medicare	$2,179.80
Rate for Payer: Medicaid All Medicaid	$2,228.24
Rate for Payer: Medicare All Medicare	$1,695.40
Rate for Payer: Monida Allegiance	$2,300.90
Rate for Payer: Monida First Choice Health	$2,349.34
Rate for Payer: Monida Montana Health Co-op	$2,300.90
Rate for Payer: Monida PacificSource	$2,300.90

OUTPATIENT TREATMENT ALLERGY SHOT 1

Facility

$40.00

Service Code	HCPCS 95115
Hospital Charge Code	540197
Hospital Revenue Code	761
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

OUTPATIENT TREATMENT ALLERGY SHOT 1

Facility

$40.00

Service Code	HCPCS 95115
Hospital Charge Code	540197
Hospital Revenue Code	761
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

OUTPATIENT TREATMENT ALLERGY SHOT 2

Facility

$75.00

Service Code	HCPCS 95117
Hospital Charge Code	540198
Hospital Revenue Code	761
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

OUTPATIENT TREATMENT ALLERGY SHOT 2

Facility

$75.00

Service Code	HCPCS 95117
Hospital Charge Code	540198
Hospital Revenue Code	761
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

OUTPATIENT TREATMENT ESRD

Facility

$78.00

Service Code	HCPCS G0257
Hospital Charge Code	540200
Hospital Revenue Code	761
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

OUTPATIENT TREATMENT ESRD

Facility

$78.00

Service Code	HCPCS G0257
Hospital Charge Code	540200
Hospital Revenue Code	761
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$78.00
Rate for Payer: Aetna Commercial	$74.10
Rate for Payer: Aetna Medicare	$70.20
Rate for Payer: BCBS MT CHIP	$70.20
Rate for Payer: BCBS MT Closed Plan Network	$74.10
Rate for Payer: BCBS MT HealthLink	$70.20
Rate for Payer: BCBS MT Medicare	$70.20
Rate for Payer: BCBS MT POS	$74.10
Rate for Payer: BCBS MT Traditional	$78.00
Rate for Payer: Cash Price	$70.20
Rate for Payer: Cigna Commercial	$74.10
Rate for Payer: Cigna Medicare	$70.20
Rate for Payer: Medicaid All Medicaid	$71.76
Rate for Payer: Medicare All Medicare	$54.60
Rate for Payer: Monida Allegiance	$74.10
Rate for Payer: Monida First Choice Health	$75.66
Rate for Payer: Monida Montana Health Co-op	$74.10
Rate for Payer: Monida PacificSource	$74.10

OUTPATIENT TRIGGER POINT INJ 1-2 GROUPS

Facility

$466.00

Service Code	HCPCS 20552
Hospital Charge Code	1520552
Hospital Revenue Code	761
Min. Negotiated Rate	$326.20
Max. Negotiated Rate	$466.00
Rate for Payer: Aetna Commercial	$442.70
Rate for Payer: Aetna Medicare	$419.40
Rate for Payer: BCBS MT CHIP	$419.40
Rate for Payer: BCBS MT Closed Plan Network	$442.70
Rate for Payer: BCBS MT HealthLink	$419.40
Rate for Payer: BCBS MT Medicare	$419.40
Rate for Payer: BCBS MT POS	$442.70
Rate for Payer: BCBS MT Traditional	$466.00
Rate for Payer: Cash Price	$419.40
Rate for Payer: Cigna Commercial	$442.70
Rate for Payer: Cigna Medicare	$419.40
Rate for Payer: Medicaid All Medicaid	$428.72
Rate for Payer: Medicare All Medicare	$326.20
Rate for Payer: Monida Allegiance	$442.70
Rate for Payer: Monida First Choice Health	$452.02
Rate for Payer: Monida Montana Health Co-op	$442.70
Rate for Payer: Monida PacificSource	$442.70

OUTPATIENT TRIGGER POINT INJ 1-2 GROUPS

Facility

$466.00

Service Code	HCPCS 20552
Hospital Charge Code	1520552
Hospital Revenue Code	761
Min. Negotiated Rate	$326.20
Max. Negotiated Rate	$466.00
Rate for Payer: Aetna Commercial	$442.70
Rate for Payer: Aetna Medicare	$419.40
Rate for Payer: BCBS MT CHIP	$419.40
Rate for Payer: BCBS MT Closed Plan Network	$442.70
Rate for Payer: BCBS MT HealthLink	$419.40
Rate for Payer: BCBS MT Medicare	$419.40
Rate for Payer: BCBS MT POS	$442.70
Rate for Payer: BCBS MT Traditional	$466.00
Rate for Payer: Cash Price	$419.40
Rate for Payer: Cigna Commercial	$442.70
Rate for Payer: Cigna Medicare	$419.40
Rate for Payer: Medicaid All Medicaid	$428.72
Rate for Payer: Medicare All Medicare	$326.20
Rate for Payer: Monida Allegiance	$442.70
Rate for Payer: Monida First Choice Health	$452.02
Rate for Payer: Monida Montana Health Co-op	$442.70
Rate for Payer: Monida PacificSource	$442.70

OUTPATIENT TRIGR PT INJECTION 3+ 20553

Facility

$747.00

Service Code	HCPCS 20553
Hospital Charge Code	520553
Hospital Revenue Code	760
Min. Negotiated Rate	$522.90
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna Commercial	$709.65
Rate for Payer: Aetna Medicare	$672.30
Rate for Payer: BCBS MT CHIP	$672.30
Rate for Payer: BCBS MT Closed Plan Network	$709.65
Rate for Payer: BCBS MT HealthLink	$672.30
Rate for Payer: BCBS MT Medicare	$672.30
Rate for Payer: BCBS MT POS	$709.65
Rate for Payer: BCBS MT Traditional	$747.00
Rate for Payer: Cash Price	$672.30
Rate for Payer: Cigna Commercial	$709.65
Rate for Payer: Cigna Medicare	$672.30
Rate for Payer: Medicaid All Medicaid	$687.24
Rate for Payer: Medicare All Medicare	$522.90
Rate for Payer: Monida Allegiance	$709.65
Rate for Payer: Monida First Choice Health	$724.59
Rate for Payer: Monida Montana Health Co-op	$709.65
Rate for Payer: Monida PacificSource	$709.65

OUTPATIENT TRIGR PT INJECTION 3+ 20553

Facility

$747.00

Service Code	HCPCS 20553
Hospital Charge Code	520553
Hospital Revenue Code	760
Min. Negotiated Rate	$522.90
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna Commercial	$709.65
Rate for Payer: Aetna Medicare	$672.30
Rate for Payer: BCBS MT CHIP	$672.30
Rate for Payer: BCBS MT Closed Plan Network	$709.65
Rate for Payer: BCBS MT HealthLink	$672.30
Rate for Payer: BCBS MT Medicare	$672.30
Rate for Payer: BCBS MT POS	$709.65
Rate for Payer: BCBS MT Traditional	$747.00
Rate for Payer: Cash Price	$672.30
Rate for Payer: Cigna Commercial	$709.65
Rate for Payer: Cigna Medicare	$672.30
Rate for Payer: Medicaid All Medicaid	$687.24
Rate for Payer: Medicare All Medicare	$522.90
Rate for Payer: Monida Allegiance	$709.65
Rate for Payer: Monida First Choice Health	$724.59
Rate for Payer: Monida Montana Health Co-op	$709.65
Rate for Payer: Monida PacificSource	$709.65

OVA & PARASITES EXAM (008623)

Facility

$69.00

Service Code	HCPCS 87177
Hospital Charge Code	4087177
Hospital Revenue Code	300
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

OVA & PARASITES EXAM (008623)

Facility

$69.00

Service Code	HCPCS 87177
Hospital Charge Code	4087177
Hospital Revenue Code	300
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

Know your out-of-pocket cost for care.

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