Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OSELTAMIVIR SUSPENSION [6 MG/ML]

Facility

$476.00

Service Code	HCPCS J8499
Hospital Charge Code	3000368
Hospital Revenue Code	259
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$476.00
Rate for Payer: Aetna Commercial	$452.20
Rate for Payer: Aetna Medicare	$428.40
Rate for Payer: BCBS MT CHIP	$428.40
Rate for Payer: BCBS MT Closed Plan Network	$452.20
Rate for Payer: BCBS MT HealthLink	$428.40
Rate for Payer: BCBS MT Medicare	$428.40
Rate for Payer: BCBS MT POS	$452.20
Rate for Payer: BCBS MT Traditional	$476.00
Rate for Payer: Cash Price	$428.40
Rate for Payer: Cigna Commercial	$452.20
Rate for Payer: Cigna Medicare	$428.40
Rate for Payer: Medicaid All Medicaid	$437.92
Rate for Payer: Medicare All Medicare	$333.20
Rate for Payer: Monida Allegiance	$452.20
Rate for Payer: Monida First Choice Health	$461.72
Rate for Payer: Monida Montana Health Co-op	$452.20
Rate for Payer: Monida PacificSource	$452.20

OSELTAMIVIR SUSPENSION [6 MG/ML]

Facility

$476.00

Service Code	HCPCS J8499
Hospital Charge Code	3000368
Hospital Revenue Code	259
Min. Negotiated Rate	$333.20
Max. Negotiated Rate	$476.00
Rate for Payer: Aetna Commercial	$452.20
Rate for Payer: Aetna Medicare	$428.40
Rate for Payer: BCBS MT CHIP	$428.40
Rate for Payer: BCBS MT Closed Plan Network	$452.20
Rate for Payer: BCBS MT HealthLink	$428.40
Rate for Payer: BCBS MT Medicare	$428.40
Rate for Payer: BCBS MT POS	$452.20
Rate for Payer: BCBS MT Traditional	$476.00
Rate for Payer: Cash Price	$428.40
Rate for Payer: Cigna Commercial	$452.20
Rate for Payer: Cigna Medicare	$428.40
Rate for Payer: Medicaid All Medicaid	$437.92
Rate for Payer: Medicare All Medicare	$333.20
Rate for Payer: Monida Allegiance	$452.20
Rate for Payer: Monida First Choice Health	$461.72
Rate for Payer: Monida Montana Health Co-op	$452.20
Rate for Payer: Monida PacificSource	$452.20

OSMOLALITY, SERUM (002071)

Facility

$60.00

Service Code	CPT 83930
Hospital Charge Code	4083930
Hospital Revenue Code	301
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

OSMOLALITY, SERUM (002071)

Facility

$60.00

Service Code	CPT 83930
Hospital Charge Code	4083930
Hospital Revenue Code	301
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

OSMOLALITY, URINE (003442)

Facility

$60.00

Service Code	CPT 83935
Hospital Charge Code	4083935
Hospital Revenue Code	301
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

OSMOLALITY, URINE (003442)

Facility

$60.00

Service Code	CPT 83935
Hospital Charge Code	4083935
Hospital Revenue Code	301
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$60.00
Rate for Payer: Aetna Commercial	$57.00
Rate for Payer: Aetna Medicare	$54.00
Rate for Payer: BCBS MT CHIP	$54.00
Rate for Payer: BCBS MT Closed Plan Network	$57.00
Rate for Payer: BCBS MT HealthLink	$54.00
Rate for Payer: BCBS MT Medicare	$54.00
Rate for Payer: BCBS MT POS	$57.00
Rate for Payer: BCBS MT Traditional	$60.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna Commercial	$57.00
Rate for Payer: Cigna Medicare	$54.00
Rate for Payer: Medicaid All Medicaid	$55.20
Rate for Payer: Medicare All Medicare	$42.00
Rate for Payer: Monida Allegiance	$57.00
Rate for Payer: Monida First Choice Health	$58.20
Rate for Payer: Monida Montana Health Co-op	$57.00
Rate for Payer: Monida PacificSource	$57.00

OSTEOGENESIS IMPERFECTA AND LOW DENSITY

Facility

$1,500.00

Service Code	CPT 81405
Hospital Charge Code	4088040
Hospital Revenue Code	302
Min. Negotiated Rate	$1,050.00
Max. Negotiated Rate	$1,500.00
Rate for Payer: Aetna Commercial	$1,425.00
Rate for Payer: Aetna Medicare	$1,350.00
Rate for Payer: BCBS MT CHIP	$1,350.00
Rate for Payer: BCBS MT Closed Plan Network	$1,425.00
Rate for Payer: BCBS MT HealthLink	$1,350.00
Rate for Payer: BCBS MT Medicare	$1,350.00
Rate for Payer: BCBS MT POS	$1,425.00
Rate for Payer: BCBS MT Traditional	$1,500.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Cigna Commercial	$1,425.00
Rate for Payer: Cigna Medicare	$1,350.00
Rate for Payer: Medicaid All Medicaid	$1,380.00
Rate for Payer: Medicare All Medicare	$1,050.00
Rate for Payer: Monida Allegiance	$1,425.00
Rate for Payer: Monida First Choice Health	$1,455.00
Rate for Payer: Monida Montana Health Co-op	$1,425.00
Rate for Payer: Monida PacificSource	$1,425.00

OSTEOGENESIS IMPERFECTA AND LOW DENSITY

Facility

$1,500.00

Service Code	CPT 81405
Hospital Charge Code	4088040
Hospital Revenue Code	302
Min. Negotiated Rate	$1,050.00
Max. Negotiated Rate	$1,500.00
Rate for Payer: Aetna Commercial	$1,425.00
Rate for Payer: Aetna Medicare	$1,350.00
Rate for Payer: BCBS MT CHIP	$1,350.00
Rate for Payer: BCBS MT Closed Plan Network	$1,425.00
Rate for Payer: BCBS MT HealthLink	$1,350.00
Rate for Payer: BCBS MT Medicare	$1,350.00
Rate for Payer: BCBS MT POS	$1,425.00
Rate for Payer: BCBS MT Traditional	$1,500.00
Rate for Payer: Cash Price	$1,350.00
Rate for Payer: Cigna Commercial	$1,425.00
Rate for Payer: Cigna Medicare	$1,350.00
Rate for Payer: Medicaid All Medicaid	$1,380.00
Rate for Payer: Medicare All Medicare	$1,050.00
Rate for Payer: Monida Allegiance	$1,425.00
Rate for Payer: Monida First Choice Health	$1,455.00
Rate for Payer: Monida Montana Health Co-op	$1,425.00
Rate for Payer: Monida PacificSource	$1,425.00

OSTEO MANIPULATION 1-2 BODY REGIONS

Facility

$73.00

Service Code	CPT 98925
Hospital Charge Code	8098925
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

OSTEO MANIPULATION 1-2 BODY REGIONS

Facility

$73.00

Service Code	CPT 98925
Hospital Charge Code	8098925
Hospital Revenue Code	521
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$73.00
Rate for Payer: Aetna Commercial	$69.35
Rate for Payer: Aetna Medicare	$65.70
Rate for Payer: BCBS MT CHIP	$65.70
Rate for Payer: BCBS MT Closed Plan Network	$69.35
Rate for Payer: BCBS MT HealthLink	$65.70
Rate for Payer: BCBS MT Medicare	$65.70
Rate for Payer: BCBS MT POS	$69.35
Rate for Payer: BCBS MT Traditional	$73.00
Rate for Payer: Cash Price	$65.70
Rate for Payer: Cigna Commercial	$69.35
Rate for Payer: Cigna Medicare	$65.70
Rate for Payer: Medicaid All Medicaid	$67.16
Rate for Payer: Medicare All Medicare	$51.10
Rate for Payer: Monida Allegiance	$69.35
Rate for Payer: Monida First Choice Health	$70.81
Rate for Payer: Monida Montana Health Co-op	$69.35
Rate for Payer: Monida PacificSource	$69.35

OSTEO MANIPULATION 3-4 BODY REGIONS

Facility

$105.00

Service Code	CPT 98926
Hospital Charge Code	8098926
Hospital Revenue Code	521
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

OSTEO MANIPULATION 3-4 BODY REGIONS

Facility

$105.00

Service Code	CPT 98926
Hospital Charge Code	8098926
Hospital Revenue Code	521
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$105.00
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: BCBS MT CHIP	$94.50
Rate for Payer: BCBS MT Closed Plan Network	$99.75
Rate for Payer: BCBS MT HealthLink	$94.50
Rate for Payer: BCBS MT Medicare	$94.50
Rate for Payer: BCBS MT POS	$99.75
Rate for Payer: BCBS MT Traditional	$105.00
Rate for Payer: Cash Price	$94.50
Rate for Payer: Cigna Commercial	$99.75
Rate for Payer: Cigna Medicare	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

OSTEO MANIPULATION 5-6 BODY REGIONS

Facility

$139.00

Service Code	CPT 98927
Hospital Charge Code	8098927
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

OSTEO MANIPULATION 5-6 BODY REGIONS

Facility

$139.00

Service Code	CPT 98927
Hospital Charge Code	8098927
Hospital Revenue Code	521
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$139.00
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: BCBS MT CHIP	$125.10
Rate for Payer: BCBS MT Closed Plan Network	$132.05
Rate for Payer: BCBS MT HealthLink	$125.10
Rate for Payer: BCBS MT Medicare	$125.10
Rate for Payer: BCBS MT POS	$132.05
Rate for Payer: BCBS MT Traditional	$139.00
Rate for Payer: Cash Price	$125.10
Rate for Payer: Cigna Commercial	$132.05
Rate for Payer: Cigna Medicare	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

OSTEO MANIPULATION 7-8 BODY REGIONS

Facility

$169.00

Service Code	CPT 98928
Hospital Charge Code	8098928
Hospital Revenue Code	521
Min. Negotiated Rate	$118.30
Max. Negotiated Rate	$169.00
Rate for Payer: Aetna Commercial	$160.55
Rate for Payer: Aetna Medicare	$152.10
Rate for Payer: BCBS MT CHIP	$152.10
Rate for Payer: BCBS MT Closed Plan Network	$160.55
Rate for Payer: BCBS MT HealthLink	$152.10
Rate for Payer: BCBS MT Medicare	$152.10
Rate for Payer: BCBS MT POS	$160.55
Rate for Payer: BCBS MT Traditional	$169.00
Rate for Payer: Cash Price	$152.10
Rate for Payer: Cigna Commercial	$160.55
Rate for Payer: Cigna Medicare	$152.10
Rate for Payer: Medicaid All Medicaid	$155.48
Rate for Payer: Medicare All Medicare	$118.30
Rate for Payer: Monida Allegiance	$160.55
Rate for Payer: Monida First Choice Health	$163.93
Rate for Payer: Monida Montana Health Co-op	$160.55
Rate for Payer: Monida PacificSource	$160.55

OSTEO MANIPULATION 7-8 BODY REGIONS

Facility

$169.00

Service Code	CPT 98928
Hospital Charge Code	8098928
Hospital Revenue Code	521
Min. Negotiated Rate	$118.30
Max. Negotiated Rate	$169.00
Rate for Payer: Aetna Commercial	$160.55
Rate for Payer: Aetna Medicare	$152.10
Rate for Payer: BCBS MT CHIP	$152.10
Rate for Payer: BCBS MT Closed Plan Network	$160.55
Rate for Payer: BCBS MT HealthLink	$152.10
Rate for Payer: BCBS MT Medicare	$152.10
Rate for Payer: BCBS MT POS	$160.55
Rate for Payer: BCBS MT Traditional	$169.00
Rate for Payer: Cash Price	$152.10
Rate for Payer: Cigna Commercial	$160.55
Rate for Payer: Cigna Medicare	$152.10
Rate for Payer: Medicaid All Medicaid	$155.48
Rate for Payer: Medicare All Medicare	$118.30
Rate for Payer: Monida Allegiance	$160.55
Rate for Payer: Monida First Choice Health	$163.93
Rate for Payer: Monida Montana Health Co-op	$160.55
Rate for Payer: Monida PacificSource	$160.55

OSTEO MANIPULATION 9-10 BODY REGIONS

Facility

$197.00

Service Code	CPT 98929
Hospital Charge Code	8098929
Hospital Revenue Code	521
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

OSTEO MANIPULATION 9-10 BODY REGIONS

Facility

$197.00

Service Code	CPT 98929
Hospital Charge Code	8098929
Hospital Revenue Code	521
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

OT APPLY MULTLAY COMPRS LWR LEG

Facility

$664.00

Service Code	CPT 29581
Hospital Charge Code	6229581
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT APPLY MULTLAY COMPRS LWR LEG

Facility

$664.00

Service Code	CPT 29581
Hospital Charge Code	6229581
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT APPLY MULTLAY COMPRS UPR ARM

Facility

$664.00

Service Code	CPT 29584
Hospital Charge Code	6229582
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT APPLY MULTLAY COMPRS UPR ARM

Facility

$664.00

Service Code	CPT 29584
Hospital Charge Code	6229582
Hospital Revenue Code	430
Min. Negotiated Rate	$464.80
Max. Negotiated Rate	$664.00
Rate for Payer: Aetna Commercial	$630.80
Rate for Payer: Aetna Medicare	$597.60
Rate for Payer: BCBS MT CHIP	$597.60
Rate for Payer: BCBS MT Closed Plan Network	$630.80
Rate for Payer: BCBS MT HealthLink	$597.60
Rate for Payer: BCBS MT Medicare	$597.60
Rate for Payer: BCBS MT POS	$630.80
Rate for Payer: BCBS MT Traditional	$664.00
Rate for Payer: Cash Price	$597.60
Rate for Payer: Cigna Commercial	$630.80
Rate for Payer: Cigna Medicare	$597.60
Rate for Payer: Medicaid All Medicaid	$610.88
Rate for Payer: Medicare All Medicare	$464.80
Rate for Payer: Monida Allegiance	$630.80
Rate for Payer: Monida First Choice Health	$644.08
Rate for Payer: Monida Montana Health Co-op	$630.80
Rate for Payer: Monida PacificSource	$630.80

OT COMMUNITY REINTEGRATION 15 MIN

Facility

$81.00

Service Code	CPT 97537
Hospital Charge Code	6297537
Hospital Revenue Code	430
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

OT COMMUNITY REINTEGRATION 15 MIN

Facility

$81.00

Service Code	CPT 97537
Hospital Charge Code	6297537
Hospital Revenue Code	430
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

OT CONTRAST BATHS 15 MIN

Facility

$69.00

Service Code	CPT 97034
Hospital Charge Code	6297034
Hospital Revenue Code	430
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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