Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

NPA 12F

Facility

$45.00

Hospital Charge Code	80030234
Hospital Revenue Code	270
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: BCBS MT CHIP	$40.50
Rate for Payer: BCBS MT Closed Plan Network	$42.75
Rate for Payer: BCBS MT HealthLink	$40.50
Rate for Payer: BCBS MT Medicare	$40.50
Rate for Payer: BCBS MT POS	$42.75
Rate for Payer: BCBS MT Traditional	$45.00
Rate for Payer: Cash Price	$40.50
Rate for Payer: Cigna Commercial	$42.75
Rate for Payer: Cigna Medicare	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

NS 100mL Charge only

Facility

$9.00

Service Code	HCPCS J7050
Hospital Charge Code	3000355
Hospital Revenue Code	258
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

NS 100mL Charge only

Facility

$9.00

Service Code	HCPCS J7050
Hospital Charge Code	3000355
Hospital Revenue Code	258
Min. Negotiated Rate	$6.30
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna Commercial	$8.55
Rate for Payer: Aetna Medicare	$8.10
Rate for Payer: BCBS MT CHIP	$8.10
Rate for Payer: BCBS MT Closed Plan Network	$8.55
Rate for Payer: BCBS MT HealthLink	$8.10
Rate for Payer: BCBS MT Medicare	$8.10
Rate for Payer: BCBS MT POS	$8.55
Rate for Payer: BCBS MT Traditional	$9.00
Rate for Payer: Cash Price	$8.10
Rate for Payer: Cigna Commercial	$8.55
Rate for Payer: Cigna Medicare	$8.10
Rate for Payer: Medicaid All Medicaid	$8.28
Rate for Payer: Medicare All Medicare	$6.30
Rate for Payer: Monida Allegiance	$8.55
Rate for Payer: Monida First Choice Health	$8.73
Rate for Payer: Monida Montana Health Co-op	$8.55
Rate for Payer: Monida PacificSource	$8.55

NT-PROBNP (143000)

Facility

$341.00

Service Code	CPT 83880
Hospital Charge Code	4000050
Hospital Revenue Code	300
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

NT-PROBNP (143000)

Facility

$341.00

Service Code	CPT 83880
Hospital Charge Code	4000050
Hospital Revenue Code	300
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$341.00
Rate for Payer: Aetna Commercial	$323.95
Rate for Payer: Aetna Medicare	$306.90
Rate for Payer: BCBS MT CHIP	$306.90
Rate for Payer: BCBS MT Closed Plan Network	$323.95
Rate for Payer: BCBS MT HealthLink	$306.90
Rate for Payer: BCBS MT Medicare	$306.90
Rate for Payer: BCBS MT POS	$323.95
Rate for Payer: BCBS MT Traditional	$341.00
Rate for Payer: Cash Price	$306.90
Rate for Payer: Cigna Commercial	$323.95
Rate for Payer: Cigna Medicare	$306.90
Rate for Payer: Medicaid All Medicaid	$313.72
Rate for Payer: Medicare All Medicare	$238.70
Rate for Payer: Monida Allegiance	$323.95
Rate for Payer: Monida First Choice Health	$330.77
Rate for Payer: Monida Montana Health Co-op	$323.95
Rate for Payer: Monida PacificSource	$323.95

NYSTATIN OINT [100000 UNITS] 15GM NF

Facility

$54.00

Service Code	HCPCS J3490
Hospital Charge Code	3000551
Hospital Revenue Code	259
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

NYSTATIN OINT [100000 UNITS] 15GM NF

Facility

$54.00

Service Code	HCPCS J3490
Hospital Charge Code	3000551
Hospital Revenue Code	259
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

NYSTATIN POWDER [100000U/1GM] 15GM

Facility

$88.00

Service Code	HCPCS J8499
Hospital Charge Code	3000523
Hospital Revenue Code	250
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

NYSTATIN POWDER [100000U/1GM] 15GM

Facility

$88.00

Service Code	HCPCS J8499
Hospital Charge Code	3000523
Hospital Revenue Code	250
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$88.00
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: BCBS MT CHIP	$79.20
Rate for Payer: BCBS MT Closed Plan Network	$83.60
Rate for Payer: BCBS MT HealthLink	$79.20
Rate for Payer: BCBS MT Medicare	$79.20
Rate for Payer: BCBS MT POS	$83.60
Rate for Payer: BCBS MT Traditional	$88.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Cigna Commercial	$83.60
Rate for Payer: Cigna Medicare	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

NYSTATIN POWDER [100 MU/GM] D/C

Facility

$90.00

Service Code	HCPCS J3490
Hospital Charge Code	3000356
Hospital Revenue Code	250
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

NYSTATIN POWDER [100 MU/GM] D/C

Facility

$90.00

Service Code	HCPCS J3490
Hospital Charge Code	3000356
Hospital Revenue Code	250
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: BCBS MT CHIP	$81.00
Rate for Payer: BCBS MT Closed Plan Network	$85.50
Rate for Payer: BCBS MT HealthLink	$81.00
Rate for Payer: BCBS MT Medicare	$81.00
Rate for Payer: BCBS MT POS	$85.50
Rate for Payer: BCBS MT Traditional	$90.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Cigna Commercial	$85.50
Rate for Payer: Cigna Medicare	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

NYSTATIN SUSP [100,000 U/ML] 60 ML BTL

Facility

$48.00

Service Code	HCPCS J8499
Hospital Charge Code	3000357
Hospital Revenue Code	250
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

NYSTATIN SUSP [100,000 U/ML] 60 ML BTL

Facility

$48.00

Service Code	HCPCS J8499
Hospital Charge Code	3000357
Hospital Revenue Code	250
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$48.00
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: BCBS MT CHIP	$43.20
Rate for Payer: BCBS MT Closed Plan Network	$45.60
Rate for Payer: BCBS MT HealthLink	$43.20
Rate for Payer: BCBS MT Medicare	$43.20
Rate for Payer: BCBS MT POS	$45.60
Rate for Payer: BCBS MT Traditional	$48.00
Rate for Payer: Cash Price	$43.20
Rate for Payer: Cigna Commercial	$45.60
Rate for Payer: Cigna Medicare	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

NYSTATIN-TRIAMCINOLONE CRM [15 GM]

Facility

$376.00

Service Code	HCPCS J3490
Hospital Charge Code	3000358
Hospital Revenue Code	259
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

NYSTATIN-TRIAMCINOLONE CRM [15 GM]

Facility

$376.00

Service Code	HCPCS J3490
Hospital Charge Code	3000358
Hospital Revenue Code	259
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

OBSV CARE DO NOT USE

Facility

$200.00

Service Code	CPT 99217
Hospital Charge Code	709217
Hospital Revenue Code	521
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: BCBS MT CHIP	$180.00
Rate for Payer: BCBS MT Closed Plan Network	$190.00
Rate for Payer: BCBS MT HealthLink	$180.00
Rate for Payer: BCBS MT Medicare	$180.00
Rate for Payer: BCBS MT POS	$190.00
Rate for Payer: BCBS MT Traditional	$200.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna Commercial	$190.00
Rate for Payer: Cigna Medicare	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

OBSV CARE DO NOT USE

Facility

$200.00

Service Code	CPT 99217
Hospital Charge Code	709217
Hospital Revenue Code	521
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: BCBS MT CHIP	$180.00
Rate for Payer: BCBS MT Closed Plan Network	$190.00
Rate for Payer: BCBS MT HealthLink	$180.00
Rate for Payer: BCBS MT Medicare	$180.00
Rate for Payer: BCBS MT POS	$190.00
Rate for Payer: BCBS MT Traditional	$200.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna Commercial	$190.00
Rate for Payer: Cigna Medicare	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

OBSV CARE SEP DAY ADMIT HIGH COMP 99223

Facility

$368.00

Service Code	CPT 99223
Hospital Charge Code	709220
Hospital Revenue Code	521
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

OBSV CARE SEP DAY ADMIT HIGH COMP 99223

Facility

$368.00

Service Code	CPT 99223
Hospital Charge Code	709220
Hospital Revenue Code	521
Min. Negotiated Rate	$257.60
Max. Negotiated Rate	$368.00
Rate for Payer: Aetna Commercial	$349.60
Rate for Payer: Aetna Medicare	$331.20
Rate for Payer: BCBS MT CHIP	$331.20
Rate for Payer: BCBS MT Closed Plan Network	$349.60
Rate for Payer: BCBS MT HealthLink	$331.20
Rate for Payer: BCBS MT Medicare	$331.20
Rate for Payer: BCBS MT POS	$349.60
Rate for Payer: BCBS MT Traditional	$368.00
Rate for Payer: Cash Price	$331.20
Rate for Payer: Cigna Commercial	$349.60
Rate for Payer: Cigna Medicare	$331.20
Rate for Payer: Medicaid All Medicaid	$338.56
Rate for Payer: Medicare All Medicare	$257.60
Rate for Payer: Monida Allegiance	$349.60
Rate for Payer: Monida First Choice Health	$356.96
Rate for Payer: Monida Montana Health Co-op	$349.60
Rate for Payer: Monida PacificSource	$349.60

OBSV CARE SEP DAY ADMIT LOW COMPL 99221

Facility

$223.00

Service Code	CPT 99221
Hospital Charge Code	709218
Hospital Revenue Code	521
Min. Negotiated Rate	$156.10
Max. Negotiated Rate	$223.00
Rate for Payer: Aetna Commercial	$211.85
Rate for Payer: Aetna Medicare	$200.70
Rate for Payer: BCBS MT CHIP	$200.70
Rate for Payer: BCBS MT Closed Plan Network	$211.85
Rate for Payer: BCBS MT HealthLink	$200.70
Rate for Payer: BCBS MT Medicare	$200.70
Rate for Payer: BCBS MT POS	$211.85
Rate for Payer: BCBS MT Traditional	$223.00
Rate for Payer: Cash Price	$200.70
Rate for Payer: Cigna Commercial	$211.85
Rate for Payer: Cigna Medicare	$200.70
Rate for Payer: Medicaid All Medicaid	$205.16
Rate for Payer: Medicare All Medicare	$156.10
Rate for Payer: Monida Allegiance	$211.85
Rate for Payer: Monida First Choice Health	$216.31
Rate for Payer: Monida Montana Health Co-op	$211.85
Rate for Payer: Monida PacificSource	$211.85

OBSV CARE SEP DAY ADMIT LOW COMPL 99221

Facility

$223.00

Service Code	CPT 99221
Hospital Charge Code	709218
Hospital Revenue Code	521
Min. Negotiated Rate	$156.10
Max. Negotiated Rate	$223.00
Rate for Payer: Aetna Commercial	$211.85
Rate for Payer: Aetna Medicare	$200.70
Rate for Payer: BCBS MT CHIP	$200.70
Rate for Payer: BCBS MT Closed Plan Network	$211.85
Rate for Payer: BCBS MT HealthLink	$200.70
Rate for Payer: BCBS MT Medicare	$200.70
Rate for Payer: BCBS MT POS	$211.85
Rate for Payer: BCBS MT Traditional	$223.00
Rate for Payer: Cash Price	$200.70
Rate for Payer: Cigna Commercial	$211.85
Rate for Payer: Cigna Medicare	$200.70
Rate for Payer: Medicaid All Medicaid	$205.16
Rate for Payer: Medicare All Medicare	$156.10
Rate for Payer: Monida Allegiance	$211.85
Rate for Payer: Monida First Choice Health	$216.31
Rate for Payer: Monida Montana Health Co-op	$211.85
Rate for Payer: Monida PacificSource	$211.85

OBSV CARE SEP DAY ADMIT MOD COMPL 99222

Facility

$301.00

Service Code	CPT 99222
Hospital Charge Code	709219
Hospital Revenue Code	521
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

OBSV CARE SEP DAY ADMIT MOD COMPL 99222

Facility

$301.00

Service Code	CPT 99222
Hospital Charge Code	709219
Hospital Revenue Code	521
Min. Negotiated Rate	$210.70
Max. Negotiated Rate	$301.00
Rate for Payer: Aetna Commercial	$285.95
Rate for Payer: Aetna Medicare	$270.90
Rate for Payer: BCBS MT CHIP	$270.90
Rate for Payer: BCBS MT Closed Plan Network	$285.95
Rate for Payer: BCBS MT HealthLink	$270.90
Rate for Payer: BCBS MT Medicare	$270.90
Rate for Payer: BCBS MT POS	$285.95
Rate for Payer: BCBS MT Traditional	$301.00
Rate for Payer: Cash Price	$270.90
Rate for Payer: Cigna Commercial	$285.95
Rate for Payer: Cigna Medicare	$270.90
Rate for Payer: Medicaid All Medicaid	$276.92
Rate for Payer: Medicare All Medicare	$210.70
Rate for Payer: Monida Allegiance	$285.95
Rate for Payer: Monida First Choice Health	$291.97
Rate for Payer: Monida Montana Health Co-op	$285.95
Rate for Payer: Monida PacificSource	$285.95

OBSV CARE SEP DISCHARGE 30 MIN/LESS

Facility

$200.00

Service Code	CPT 99238
Hospital Charge Code	7099238
Hospital Revenue Code	521
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: BCBS MT CHIP	$180.00
Rate for Payer: BCBS MT Closed Plan Network	$190.00
Rate for Payer: BCBS MT HealthLink	$180.00
Rate for Payer: BCBS MT Medicare	$180.00
Rate for Payer: BCBS MT POS	$190.00
Rate for Payer: BCBS MT Traditional	$200.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna Commercial	$190.00
Rate for Payer: Cigna Medicare	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

OBSV CARE SEP DISCHARGE 30 MIN/LESS

Facility

$200.00

Service Code	CPT 99238
Hospital Charge Code	7099238
Hospital Revenue Code	521
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$200.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: BCBS MT CHIP	$180.00
Rate for Payer: BCBS MT Closed Plan Network	$190.00
Rate for Payer: BCBS MT HealthLink	$180.00
Rate for Payer: BCBS MT Medicare	$180.00
Rate for Payer: BCBS MT POS	$190.00
Rate for Payer: BCBS MT Traditional	$200.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Cigna Commercial	$190.00
Rate for Payer: Cigna Medicare	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

Know your out-of-pocket cost for care.

All Charges