Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PSYLLIUM PACKET [28 %]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000409
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

PSYLLIUM PACKET [28 %]

Facility

$5.00

Service Code	HCPCS J3490
Hospital Charge Code	3000409
Hospital Revenue Code	250
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

PSYTX CRISIS INITIAL 60 MIN

Facility

$208.00

Service Code	HCPCS 90839
Hospital Charge Code	8190839
Hospital Revenue Code	900
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

PSYTX CRISIS INITIAL 60 MIN

Facility

$208.00

Service Code	HCPCS 90839
Hospital Charge Code	8190839
Hospital Revenue Code	900
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

PT ASSISTED BATH

Facility

$33.00

Hospital Charge Code	6130069
Hospital Revenue Code	420
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

PT ASSISTED BATH

Facility

$33.00

Hospital Charge Code	6130069
Hospital Revenue Code	420
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

PT CANALITH REPOSITIONING PROC

Facility

$129.00

Service Code	HCPCS 95992 GP
Hospital Charge Code	6195992
Hospital Revenue Code	420
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$129.00
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$116.10
Rate for Payer: BCBS MT CHIP	$116.10
Rate for Payer: BCBS MT Closed Plan Network	$122.55
Rate for Payer: BCBS MT HealthLink	$116.10
Rate for Payer: BCBS MT Medicare	$116.10
Rate for Payer: BCBS MT POS	$122.55
Rate for Payer: BCBS MT Traditional	$129.00
Rate for Payer: Cash Price	$116.10
Rate for Payer: Cigna Commercial	$122.55
Rate for Payer: Cigna Medicare	$116.10
Rate for Payer: Medicaid All Medicaid	$118.68
Rate for Payer: Medicare All Medicare	$90.30
Rate for Payer: Monida Allegiance	$122.55
Rate for Payer: Monida First Choice Health	$125.13
Rate for Payer: Monida Montana Health Co-op	$122.55
Rate for Payer: Monida PacificSource	$122.55

PT CANALITH REPOSITIONING PROC

Facility

$129.00

Service Code	HCPCS 95992 GP
Hospital Charge Code	6195992
Hospital Revenue Code	420
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$129.00
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$116.10
Rate for Payer: BCBS MT CHIP	$116.10
Rate for Payer: BCBS MT Closed Plan Network	$122.55
Rate for Payer: BCBS MT HealthLink	$116.10
Rate for Payer: BCBS MT Medicare	$116.10
Rate for Payer: BCBS MT POS	$122.55
Rate for Payer: BCBS MT Traditional	$129.00
Rate for Payer: Cash Price	$116.10
Rate for Payer: Cigna Commercial	$122.55
Rate for Payer: Cigna Medicare	$116.10
Rate for Payer: Medicaid All Medicaid	$118.68
Rate for Payer: Medicare All Medicare	$90.30
Rate for Payer: Monida Allegiance	$122.55
Rate for Payer: Monida First Choice Health	$125.13
Rate for Payer: Monida Montana Health Co-op	$122.55
Rate for Payer: Monida PacificSource	$122.55

PT COMMUNITY/WORK REINTEGRATION

Facility

$87.00

Service Code	HCPCS 97537 GP
Hospital Charge Code	6197537
Hospital Revenue Code	420
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

PT COMMUNITY/WORK REINTEGRATION

Facility

$87.00

Service Code	HCPCS 97537 GP
Hospital Charge Code	6197537
Hospital Revenue Code	420
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$87.00
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: BCBS MT CHIP	$78.30
Rate for Payer: BCBS MT Closed Plan Network	$82.65
Rate for Payer: BCBS MT HealthLink	$78.30
Rate for Payer: BCBS MT Medicare	$78.30
Rate for Payer: BCBS MT POS	$82.65
Rate for Payer: BCBS MT Traditional	$87.00
Rate for Payer: Cash Price	$78.30
Rate for Payer: Cigna Commercial	$82.65
Rate for Payer: Cigna Medicare	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

PT CONSULTATION (15 MINUTE UNIT)

Facility

$54.00

Hospital Charge Code	6111113
Hospital Revenue Code	420
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

PT CONSULTATION (15 MINUTE UNIT)

Facility

$54.00

Hospital Charge Code	6111113
Hospital Revenue Code	420
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

PT CONTRAST BATHS

Facility

$75.00

Service Code	HCPCS 97034 GP
Hospital Charge Code	6197126
Hospital Revenue Code	420
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

PT CONTRAST BATHS

Facility

$75.00

Service Code	HCPCS 97034 GP
Hospital Charge Code	6197126
Hospital Revenue Code	420
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

PT DEBRIDEMENT

Facility

$213.00

Service Code	HCPCS 97602 GP
Hospital Charge Code	6107602
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

PT DEBRIDEMENT

Facility

$213.00

Service Code	HCPCS 97602 GP
Hospital Charge Code	6107602
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

PT DRESSING CHANGE

Facility

$213.00

Service Code	HCPCS 97602 GP
Hospital Charge Code	6197602
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

PT DRESSING CHANGE

Facility

$213.00

Service Code	HCPCS 97602 GP
Hospital Charge Code	6197602
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

PT E-STIM MAN INCLUDES TENS

Facility

$109.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	6197032
Hospital Revenue Code	420
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

PT E-STIM MAN INCLUDES TENS

Facility

$109.00

Service Code	HCPCS 97032 GP
Hospital Charge Code	6197032
Hospital Revenue Code	420
Min. Negotiated Rate	$76.30
Max. Negotiated Rate	$109.00
Rate for Payer: Aetna Commercial	$103.55
Rate for Payer: Aetna Medicare	$98.10
Rate for Payer: BCBS MT CHIP	$98.10
Rate for Payer: BCBS MT Closed Plan Network	$103.55
Rate for Payer: BCBS MT HealthLink	$98.10
Rate for Payer: BCBS MT Medicare	$98.10
Rate for Payer: BCBS MT POS	$103.55
Rate for Payer: BCBS MT Traditional	$109.00
Rate for Payer: Cash Price	$98.10
Rate for Payer: Cigna Commercial	$103.55
Rate for Payer: Cigna Medicare	$98.10
Rate for Payer: Medicaid All Medicaid	$100.28
Rate for Payer: Medicare All Medicare	$76.30
Rate for Payer: Monida Allegiance	$103.55
Rate for Payer: Monida First Choice Health	$105.73
Rate for Payer: Monida Montana Health Co-op	$103.55
Rate for Payer: Monida PacificSource	$103.55

PT E-STIMULATION UNATTENDED

Facility

$86.00

Service Code	HCPCS G0283 GP
Hospital Charge Code	6197014
Hospital Revenue Code	420
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$86.00
Rate for Payer: Aetna Commercial	$81.70
Rate for Payer: Aetna Medicare	$77.40
Rate for Payer: BCBS MT CHIP	$77.40
Rate for Payer: BCBS MT Closed Plan Network	$81.70
Rate for Payer: BCBS MT HealthLink	$77.40
Rate for Payer: BCBS MT Medicare	$77.40
Rate for Payer: BCBS MT POS	$81.70
Rate for Payer: BCBS MT Traditional	$86.00
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cigna Commercial	$81.70
Rate for Payer: Cigna Medicare	$77.40
Rate for Payer: Medicaid All Medicaid	$79.12
Rate for Payer: Medicare All Medicare	$60.20
Rate for Payer: Monida Allegiance	$81.70
Rate for Payer: Monida First Choice Health	$83.42
Rate for Payer: Monida Montana Health Co-op	$81.70
Rate for Payer: Monida PacificSource	$81.70

PT E-STIMULATION UNATTENDED

Facility

$86.00

Service Code	HCPCS G0283 GP
Hospital Charge Code	6197014
Hospital Revenue Code	420
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$86.00
Rate for Payer: Aetna Commercial	$81.70
Rate for Payer: Aetna Medicare	$77.40
Rate for Payer: BCBS MT CHIP	$77.40
Rate for Payer: BCBS MT Closed Plan Network	$81.70
Rate for Payer: BCBS MT HealthLink	$77.40
Rate for Payer: BCBS MT Medicare	$77.40
Rate for Payer: BCBS MT POS	$81.70
Rate for Payer: BCBS MT Traditional	$86.00
Rate for Payer: Cash Price	$77.40
Rate for Payer: Cigna Commercial	$81.70
Rate for Payer: Cigna Medicare	$77.40
Rate for Payer: Medicaid All Medicaid	$79.12
Rate for Payer: Medicare All Medicare	$60.20
Rate for Payer: Monida Allegiance	$81.70
Rate for Payer: Monida First Choice Health	$83.42
Rate for Payer: Monida Montana Health Co-op	$81.70
Rate for Payer: Monida PacificSource	$81.70

PT EVAL HIGH COMPLEX 45 MIN

Facility

$254.00

Service Code	HCPCS 97163 GP
Hospital Charge Code	6197163
Hospital Revenue Code	420
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

PT EVAL HIGH COMPLEX 45 MIN

Facility

$254.00

Service Code	HCPCS 97163 GP
Hospital Charge Code	6197163
Hospital Revenue Code	420
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

PT EVAL LOW COMPLEX 20 MIN

Facility

$197.00

Service Code	HCPCS 97161 GP
Hospital Charge Code	6197161
Hospital Revenue Code	420
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

Know your out-of-pocket cost for care.

All Charges