Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PT THERAPEUTIC PROC GROUP

Facility

$99.00

Service Code	HCPCS 97150 GP
Hospital Charge Code	6197150
Hospital Revenue Code	420
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

PT TRACTION MECHANICAL

Facility

$92.00

Service Code	HCPCS 97012 GP,59
Hospital Charge Code	6197012
Hospital Revenue Code	420
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

PT TRACTION MECHANICAL

Facility

$92.00

Service Code	HCPCS 97012 GP,59
Hospital Charge Code	6197012
Hospital Revenue Code	420
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$92.00
Rate for Payer: Aetna Commercial	$87.40
Rate for Payer: Aetna Medicare	$82.80
Rate for Payer: BCBS MT CHIP	$82.80
Rate for Payer: BCBS MT Closed Plan Network	$87.40
Rate for Payer: BCBS MT HealthLink	$82.80
Rate for Payer: BCBS MT Medicare	$82.80
Rate for Payer: BCBS MT POS	$87.40
Rate for Payer: BCBS MT Traditional	$92.00
Rate for Payer: Cash Price	$82.80
Rate for Payer: Cigna Commercial	$87.40
Rate for Payer: Cigna Medicare	$82.80
Rate for Payer: Medicaid All Medicaid	$84.64
Rate for Payer: Medicare All Medicare	$64.40
Rate for Payer: Monida Allegiance	$87.40
Rate for Payer: Monida First Choice Health	$89.24
Rate for Payer: Monida Montana Health Co-op	$87.40
Rate for Payer: Monida PacificSource	$87.40

PT ULISTED PROCEDURE SPECIFY

Facility

$83.00

Service Code	HCPCS 97139 GP
Hospital Charge Code	6197139
Hospital Revenue Code	420
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

PT ULISTED PROCEDURE SPECIFY

Facility

$83.00

Service Code	HCPCS 97139 GP
Hospital Charge Code	6197139
Hospital Revenue Code	420
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

PT ULTRASOUND

Facility

$85.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	6197035
Hospital Revenue Code	420
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

PT ULTRASOUND

Facility

$85.00

Service Code	HCPCS 97035 GP
Hospital Charge Code	6197035
Hospital Revenue Code	420
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

PT UNLISTED PHYSICAL THERAPY SERVICE

Facility

$152.00

Service Code	HCPCS 97799 GP
Hospital Charge Code	6197799
Hospital Revenue Code	420
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

PT UNLISTED PHYSICAL THERAPY SERVICE

Facility

$152.00

Service Code	HCPCS 97799 GP
Hospital Charge Code	6197799
Hospital Revenue Code	420
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

PT VASOPNEUMATIC DEVICE

Facility

$86.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	6197016
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 VASOPNEUMATIC DEVICE

Facility

$86.00

Service Code	HCPCS 97016 GP
Hospital Charge Code	6197016
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 WHEELCHAIR MGMT

Facility

$102.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	6197542
Hospital Revenue Code	420
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$96.90
Rate for Payer: Aetna Medicare	$91.80
Rate for Payer: BCBS MT CHIP	$91.80
Rate for Payer: BCBS MT Closed Plan Network	$96.90
Rate for Payer: BCBS MT HealthLink	$91.80
Rate for Payer: BCBS MT Medicare	$91.80
Rate for Payer: BCBS MT POS	$96.90
Rate for Payer: BCBS MT Traditional	$102.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial	$96.90
Rate for Payer: Cigna Medicare	$91.80
Rate for Payer: Medicaid All Medicaid	$93.84
Rate for Payer: Medicare All Medicare	$71.40
Rate for Payer: Monida Allegiance	$96.90
Rate for Payer: Monida First Choice Health	$98.94
Rate for Payer: Monida Montana Health Co-op	$96.90
Rate for Payer: Monida PacificSource	$96.90

PT WHEELCHAIR MGMT

Facility

$102.00

Service Code	HCPCS 97542 GP
Hospital Charge Code	6197542
Hospital Revenue Code	420
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$96.90
Rate for Payer: Aetna Medicare	$91.80
Rate for Payer: BCBS MT CHIP	$91.80
Rate for Payer: BCBS MT Closed Plan Network	$96.90
Rate for Payer: BCBS MT HealthLink	$91.80
Rate for Payer: BCBS MT Medicare	$91.80
Rate for Payer: BCBS MT POS	$96.90
Rate for Payer: BCBS MT Traditional	$102.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial	$96.90
Rate for Payer: Cigna Medicare	$91.80
Rate for Payer: Medicaid All Medicaid	$93.84
Rate for Payer: Medicare All Medicare	$71.40
Rate for Payer: Monida Allegiance	$96.90
Rate for Payer: Monida First Choice Health	$98.94
Rate for Payer: Monida Montana Health Co-op	$96.90
Rate for Payer: Monida PacificSource	$96.90

PT WHIRLPOOL

Facility

$109.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	6197022
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 WHIRLPOOL

Facility

$109.00

Service Code	HCPCS 97022 GP
Hospital Charge Code	6197022
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 WORK HARDENING EA ADD HR

Facility

$83.00

Service Code	HCPCS 97546
Hospital Charge Code	6197546
Hospital Revenue Code	420
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

PT WORK HARDENING EA ADD HR

Facility

$83.00

Service Code	HCPCS 97546
Hospital Charge Code	6197546
Hospital Revenue Code	420
Min. Negotiated Rate	$58.10
Max. Negotiated Rate	$83.00
Rate for Payer: Aetna Commercial	$78.85
Rate for Payer: Aetna Medicare	$74.70
Rate for Payer: BCBS MT CHIP	$74.70
Rate for Payer: BCBS MT Closed Plan Network	$78.85
Rate for Payer: BCBS MT HealthLink	$74.70
Rate for Payer: BCBS MT Medicare	$74.70
Rate for Payer: BCBS MT POS	$78.85
Rate for Payer: BCBS MT Traditional	$83.00
Rate for Payer: Cash Price	$74.70
Rate for Payer: Cigna Commercial	$78.85
Rate for Payer: Cigna Medicare	$74.70
Rate for Payer: Medicaid All Medicaid	$76.36
Rate for Payer: Medicare All Medicare	$58.10
Rate for Payer: Monida Allegiance	$78.85
Rate for Payer: Monida First Choice Health	$80.51
Rate for Payer: Monida Montana Health Co-op	$78.85
Rate for Payer: Monida PacificSource	$78.85

PT WORK HARDENING INITIAL 2 HRS

Facility

$330.00

Service Code	HCPCS 97545 GP
Hospital Charge Code	6197545
Hospital Revenue Code	420
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

PT WORK HARDENING INITIAL 2 HRS

Facility

$330.00

Service Code	HCPCS 97545 GP
Hospital Charge Code	6197545
Hospital Revenue Code	420
Min. Negotiated Rate	$231.00
Max. Negotiated Rate	$330.00
Rate for Payer: Aetna Commercial	$313.50
Rate for Payer: Aetna Medicare	$297.00
Rate for Payer: BCBS MT CHIP	$297.00
Rate for Payer: BCBS MT Closed Plan Network	$313.50
Rate for Payer: BCBS MT HealthLink	$297.00
Rate for Payer: BCBS MT Medicare	$297.00
Rate for Payer: BCBS MT POS	$313.50
Rate for Payer: BCBS MT Traditional	$330.00
Rate for Payer: Cash Price	$297.00
Rate for Payer: Cigna Commercial	$313.50
Rate for Payer: Cigna Medicare	$297.00
Rate for Payer: Medicaid All Medicaid	$303.60
Rate for Payer: Medicare All Medicare	$231.00
Rate for Payer: Monida Allegiance	$313.50
Rate for Payer: Monida First Choice Health	$320.10
Rate for Payer: Monida Montana Health Co-op	$313.50
Rate for Payer: Monida PacificSource	$313.50

PURE PAK NASAL TAMPON SM 8/BX

Facility

$32.00

Hospital Charge Code	80040287
Hospital Revenue Code	270
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

PURE PAK NASAL TAMPON SM 8/BX

Facility

$32.00

Hospital Charge Code	80040287
Hospital Revenue Code	270
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$32.00
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: BCBS MT CHIP	$28.80
Rate for Payer: BCBS MT Closed Plan Network	$30.40
Rate for Payer: BCBS MT HealthLink	$28.80
Rate for Payer: BCBS MT Medicare	$28.80
Rate for Payer: BCBS MT POS	$30.40
Rate for Payer: BCBS MT Traditional	$32.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cigna Commercial	$30.40
Rate for Payer: Cigna Medicare	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

PVB THORACIC SECOND AND ANY ADD ON

Facility

$920.00

Service Code	HCPCS 64462
Hospital Charge Code	1564462
Hospital Revenue Code	760
Min. Negotiated Rate	$644.00
Max. Negotiated Rate	$920.00
Rate for Payer: Aetna Commercial	$874.00
Rate for Payer: Aetna Medicare	$828.00
Rate for Payer: BCBS MT CHIP	$828.00
Rate for Payer: BCBS MT Closed Plan Network	$874.00
Rate for Payer: BCBS MT HealthLink	$828.00
Rate for Payer: BCBS MT Medicare	$828.00
Rate for Payer: BCBS MT POS	$874.00
Rate for Payer: BCBS MT Traditional	$920.00
Rate for Payer: Cash Price	$828.00
Rate for Payer: Cigna Commercial	$874.00
Rate for Payer: Cigna Medicare	$828.00
Rate for Payer: Medicaid All Medicaid	$846.40
Rate for Payer: Medicare All Medicare	$644.00
Rate for Payer: Monida Allegiance	$874.00
Rate for Payer: Monida First Choice Health	$892.40
Rate for Payer: Monida Montana Health Co-op	$874.00
Rate for Payer: Monida PacificSource	$874.00

PVB THORACIC SECOND AND ANY ADD ON

Facility

$920.00

Service Code	HCPCS 64462
Hospital Charge Code	1564462
Hospital Revenue Code	760
Min. Negotiated Rate	$644.00
Max. Negotiated Rate	$920.00
Rate for Payer: Aetna Commercial	$874.00
Rate for Payer: Aetna Medicare	$828.00
Rate for Payer: BCBS MT CHIP	$828.00
Rate for Payer: BCBS MT Closed Plan Network	$874.00
Rate for Payer: BCBS MT HealthLink	$828.00
Rate for Payer: BCBS MT Medicare	$828.00
Rate for Payer: BCBS MT POS	$874.00
Rate for Payer: BCBS MT Traditional	$920.00
Rate for Payer: Cash Price	$828.00
Rate for Payer: Cigna Commercial	$874.00
Rate for Payer: Cigna Medicare	$828.00
Rate for Payer: Medicaid All Medicaid	$846.40
Rate for Payer: Medicare All Medicare	$644.00
Rate for Payer: Monida Allegiance	$874.00
Rate for Payer: Monida First Choice Health	$892.40
Rate for Payer: Monida Montana Health Co-op	$874.00
Rate for Payer: Monida PacificSource	$874.00

PVB THORACIC SINGLE

Facility

$1,747.00

Service Code	HCPCS 64461
Hospital Charge Code	1564461
Hospital Revenue Code	760
Min. Negotiated Rate	$1,222.90
Max. Negotiated Rate	$1,747.00
Rate for Payer: Aetna Commercial	$1,659.65
Rate for Payer: Aetna Medicare	$1,572.30
Rate for Payer: BCBS MT CHIP	$1,572.30
Rate for Payer: BCBS MT Closed Plan Network	$1,659.65
Rate for Payer: BCBS MT HealthLink	$1,572.30
Rate for Payer: BCBS MT Medicare	$1,572.30
Rate for Payer: BCBS MT POS	$1,659.65
Rate for Payer: BCBS MT Traditional	$1,747.00
Rate for Payer: Cash Price	$1,572.30
Rate for Payer: Cigna Commercial	$1,659.65
Rate for Payer: Cigna Medicare	$1,572.30
Rate for Payer: Medicaid All Medicaid	$1,607.24
Rate for Payer: Medicare All Medicare	$1,222.90
Rate for Payer: Monida Allegiance	$1,659.65
Rate for Payer: Monida First Choice Health	$1,694.59
Rate for Payer: Monida Montana Health Co-op	$1,659.65
Rate for Payer: Monida PacificSource	$1,659.65

PVB THORACIC SINGLE

Facility

$1,747.00

Service Code	HCPCS 64461
Hospital Charge Code	1564461
Hospital Revenue Code	760
Min. Negotiated Rate	$1,222.90
Max. Negotiated Rate	$1,747.00
Rate for Payer: Aetna Commercial	$1,659.65
Rate for Payer: Aetna Medicare	$1,572.30
Rate for Payer: BCBS MT CHIP	$1,572.30
Rate for Payer: BCBS MT Closed Plan Network	$1,659.65
Rate for Payer: BCBS MT HealthLink	$1,572.30
Rate for Payer: BCBS MT Medicare	$1,572.30
Rate for Payer: BCBS MT POS	$1,659.65
Rate for Payer: BCBS MT Traditional	$1,747.00
Rate for Payer: Cash Price	$1,572.30
Rate for Payer: Cigna Commercial	$1,659.65
Rate for Payer: Cigna Medicare	$1,572.30
Rate for Payer: Medicaid All Medicaid	$1,607.24
Rate for Payer: Medicare All Medicare	$1,222.90
Rate for Payer: Monida Allegiance	$1,659.65
Rate for Payer: Monida First Choice Health	$1,694.59
Rate for Payer: Monida Montana Health Co-op	$1,659.65
Rate for Payer: Monida PacificSource	$1,659.65

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