Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PT SHARP DEBRIDEMENT

Facility

$524.00

Service Code	HCPCS 97597 GP
Hospital Charge Code	6107597
Hospital Revenue Code	420
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$524.00
Rate for Payer: Aetna Commercial	$497.80
Rate for Payer: Aetna Medicare	$471.60
Rate for Payer: BCBS MT CHIP	$471.60
Rate for Payer: BCBS MT Closed Plan Network	$497.80
Rate for Payer: BCBS MT HealthLink	$471.60
Rate for Payer: BCBS MT Medicare	$471.60
Rate for Payer: BCBS MT POS	$497.80
Rate for Payer: BCBS MT Traditional	$524.00
Rate for Payer: Cash Price	$471.60
Rate for Payer: Cigna Commercial	$497.80
Rate for Payer: Cigna Medicare	$471.60
Rate for Payer: Medicaid All Medicaid	$482.08
Rate for Payer: Medicare All Medicare	$366.80
Rate for Payer: Monida Allegiance	$497.80
Rate for Payer: Monida First Choice Health	$508.28
Rate for Payer: Monida Montana Health Co-op	$497.80
Rate for Payer: Monida PacificSource	$497.80

PT SHARP DEBRIDEMENT

Facility

$226.00

Service Code	HCPCS 97602 GP
Hospital Charge Code	6107601
Hospital Revenue Code	420
Min. Negotiated Rate	$158.20
Max. Negotiated Rate	$226.00
Rate for Payer: Aetna Commercial	$214.70
Rate for Payer: Aetna Medicare	$203.40
Rate for Payer: BCBS MT CHIP	$203.40
Rate for Payer: BCBS MT Closed Plan Network	$214.70
Rate for Payer: BCBS MT HealthLink	$203.40
Rate for Payer: BCBS MT Medicare	$203.40
Rate for Payer: BCBS MT POS	$214.70
Rate for Payer: BCBS MT Traditional	$226.00
Rate for Payer: Cash Price	$203.40
Rate for Payer: Cigna Commercial	$214.70
Rate for Payer: Cigna Medicare	$203.40
Rate for Payer: Medicaid All Medicaid	$207.92
Rate for Payer: Medicare All Medicare	$158.20
Rate for Payer: Monida Allegiance	$214.70
Rate for Payer: Monida First Choice Health	$219.22
Rate for Payer: Monida Montana Health Co-op	$214.70
Rate for Payer: Monida PacificSource	$214.70

PT SPECIAL REPORTS

Facility

$135.00

Service Code	HCPCS 99080
Hospital Charge Code	6199080
Hospital Revenue Code	420
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

PT SPECIAL REPORTS

Facility

$135.00

Service Code	HCPCS 99080
Hospital Charge Code	6199080
Hospital Revenue Code	420
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna Commercial	$128.25
Rate for Payer: Aetna Medicare	$121.50
Rate for Payer: BCBS MT CHIP	$121.50
Rate for Payer: BCBS MT Closed Plan Network	$128.25
Rate for Payer: BCBS MT HealthLink	$121.50
Rate for Payer: BCBS MT Medicare	$121.50
Rate for Payer: BCBS MT POS	$128.25
Rate for Payer: BCBS MT Traditional	$135.00
Rate for Payer: Cash Price	$121.50
Rate for Payer: Cigna Commercial	$128.25
Rate for Payer: Cigna Medicare	$121.50
Rate for Payer: Medicaid All Medicaid	$124.20
Rate for Payer: Medicare All Medicare	$94.50
Rate for Payer: Monida Allegiance	$128.25
Rate for Payer: Monida First Choice Health	$130.95
Rate for Payer: Monida Montana Health Co-op	$128.25
Rate for Payer: Monida PacificSource	$128.25

PT STANDARDIZED DEVELOP TESTING

Facility

$57.00

Hospital Charge Code	6111111
Hospital Revenue Code	420
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

PT STANDARDIZED DEVELOP TESTING

Facility

$57.00

Hospital Charge Code	6111111
Hospital Revenue Code	420
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$57.00
Rate for Payer: Aetna Commercial	$54.15
Rate for Payer: Aetna Medicare	$51.30
Rate for Payer: BCBS MT CHIP	$51.30
Rate for Payer: BCBS MT Closed Plan Network	$54.15
Rate for Payer: BCBS MT HealthLink	$51.30
Rate for Payer: BCBS MT Medicare	$51.30
Rate for Payer: BCBS MT POS	$54.15
Rate for Payer: BCBS MT Traditional	$57.00
Rate for Payer: Cash Price	$51.30
Rate for Payer: Cigna Commercial	$54.15
Rate for Payer: Cigna Medicare	$51.30
Rate for Payer: Medicaid All Medicaid	$52.44
Rate for Payer: Medicare All Medicare	$39.90
Rate for Payer: Monida Allegiance	$54.15
Rate for Payer: Monida First Choice Health	$55.29
Rate for Payer: Monida Montana Health Co-op	$54.15
Rate for Payer: Monida PacificSource	$54.15

PT THERA CANE

Facility

$108.00

Hospital Charge Code	6199998
Hospital Revenue Code	420
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: BCBS MT CHIP	$97.20
Rate for Payer: BCBS MT Closed Plan Network	$102.60
Rate for Payer: BCBS MT HealthLink	$97.20
Rate for Payer: BCBS MT Medicare	$97.20
Rate for Payer: BCBS MT POS	$102.60
Rate for Payer: BCBS MT Traditional	$108.00
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial	$102.60
Rate for Payer: Cigna Medicare	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

PT THERA CANE

Facility

$108.00

Hospital Charge Code	6199998
Hospital Revenue Code	420
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$108.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: BCBS MT CHIP	$97.20
Rate for Payer: BCBS MT Closed Plan Network	$102.60
Rate for Payer: BCBS MT HealthLink	$97.20
Rate for Payer: BCBS MT Medicare	$97.20
Rate for Payer: BCBS MT POS	$102.60
Rate for Payer: BCBS MT Traditional	$108.00
Rate for Payer: Cash Price	$97.20
Rate for Payer: Cigna Commercial	$102.60
Rate for Payer: Cigna Medicare	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

PT THERAPEUTIC ACTIVITIES

Facility

$205.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	6197530
Hospital Revenue Code	420
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

PT THERAPEUTIC ACTIVITIES

Facility

$205.00

Service Code	HCPCS 97530 GP
Hospital Charge Code	6197530
Hospital Revenue Code	420
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

PT THERAPEUTIC EXERCISES

Facility

$114.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	6197110
Hospital Revenue Code	420
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

PT THERAPEUTIC EXERCISES

Facility

$114.00

Service Code	HCPCS 97110 GP
Hospital Charge Code	6197110
Hospital Revenue Code	420
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$108.30
Rate for Payer: Aetna Medicare	$102.60
Rate for Payer: BCBS MT CHIP	$102.60
Rate for Payer: BCBS MT Closed Plan Network	$108.30
Rate for Payer: BCBS MT HealthLink	$102.60
Rate for Payer: BCBS MT Medicare	$102.60
Rate for Payer: BCBS MT POS	$108.30
Rate for Payer: BCBS MT Traditional	$114.00
Rate for Payer: Cash Price	$102.60
Rate for Payer: Cigna Commercial	$108.30
Rate for Payer: Cigna Medicare	$102.60
Rate for Payer: Medicaid All Medicaid	$104.88
Rate for Payer: Medicare All Medicare	$79.80
Rate for Payer: Monida Allegiance	$108.30
Rate for Payer: Monida First Choice Health	$110.58
Rate for Payer: Monida Montana Health Co-op	$108.30
Rate for Payer: Monida PacificSource	$108.30

PT THERAPEUTIC MASSAGE

Facility

$99.00

Service Code	HCPCS 97124 GP
Hospital Charge Code	6197124
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 THERAPEUTIC MASSAGE

Facility

$99.00

Service Code	HCPCS 97124 GP
Hospital Charge Code	6197124
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 THERAPEUTIC PROC GROUP

Facility

$105.00

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

PT THERAPEUTIC PROC GROUP

Facility

$105.00

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

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

$88.00

Service Code	HCPCS 97139 GP
Hospital Charge Code	6197139
Hospital Revenue Code	420
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

PT ULISTED PROCEDURE SPECIFY

Facility

$88.00

Service Code	HCPCS 97139 GP
Hospital Charge Code	6197139
Hospital Revenue Code	420
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

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

$161.00

Service Code	HCPCS 97799 GP
Hospital Charge Code	6197799
Hospital Revenue Code	420
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

PT UNLISTED PHYSICAL THERAPY SERVICE

Facility

$161.00

Service Code	HCPCS 97799 GP
Hospital Charge Code	6197799
Hospital Revenue Code	420
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$161.00
Rate for Payer: Aetna Commercial	$152.95
Rate for Payer: Aetna Medicare	$144.90
Rate for Payer: BCBS MT CHIP	$144.90
Rate for Payer: BCBS MT Closed Plan Network	$152.95
Rate for Payer: BCBS MT HealthLink	$144.90
Rate for Payer: BCBS MT Medicare	$144.90
Rate for Payer: BCBS MT POS	$152.95
Rate for Payer: BCBS MT Traditional	$161.00
Rate for Payer: Cash Price	$144.90
Rate for Payer: Cigna Commercial	$152.95
Rate for Payer: Cigna Medicare	$144.90
Rate for Payer: Medicaid All Medicaid	$148.12
Rate for Payer: Medicare All Medicare	$112.70
Rate for Payer: Monida Allegiance	$152.95
Rate for Payer: Monida First Choice Health	$156.17
Rate for Payer: Monida Montana Health Co-op	$152.95
Rate for Payer: Monida PacificSource	$152.95

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

Know your out-of-pocket cost for care.

All Charges