Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

OT DEBRIDEMENT

Facility

$226.00

Service Code	CPT 97602
Hospital Charge Code	6107603
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

OT DEBRIDEMENT

Facility

$226.00

Service Code	CPT 97602
Hospital Charge Code	6107603
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

OT DEVELOPMTL TEST EXTENDED/REPT PER HR

Facility

$318.00

Service Code	CPT 96111
Hospital Charge Code	6296111
Hospital Revenue Code	430
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

OT DEVELOPMTL TEST EXTENDED/REPT PER HR

Facility

$318.00

Service Code	CPT 96111
Hospital Charge Code	6296111
Hospital Revenue Code	430
Min. Negotiated Rate	$222.60
Max. Negotiated Rate	$318.00
Rate for Payer: Aetna Commercial	$302.10
Rate for Payer: Aetna Medicare	$286.20
Rate for Payer: BCBS MT CHIP	$286.20
Rate for Payer: BCBS MT Closed Plan Network	$302.10
Rate for Payer: BCBS MT HealthLink	$286.20
Rate for Payer: BCBS MT Medicare	$286.20
Rate for Payer: BCBS MT POS	$302.10
Rate for Payer: BCBS MT Traditional	$318.00
Rate for Payer: Cash Price	$286.20
Rate for Payer: Cigna Commercial	$302.10
Rate for Payer: Cigna Medicare	$286.20
Rate for Payer: Medicaid All Medicaid	$292.56
Rate for Payer: Medicare All Medicare	$222.60
Rate for Payer: Monida Allegiance	$302.10
Rate for Payer: Monida First Choice Health	$308.46
Rate for Payer: Monida Montana Health Co-op	$302.10
Rate for Payer: Monida PacificSource	$302.10

OT EVAL HIGH COMPLEX

Facility

$609.00

Service Code	CPT 97167
Hospital Charge Code	6297167
Hospital Revenue Code	430
Min. Negotiated Rate	$426.30
Max. Negotiated Rate	$609.00
Rate for Payer: Aetna Commercial	$578.55
Rate for Payer: Aetna Medicare	$548.10
Rate for Payer: BCBS MT CHIP	$548.10
Rate for Payer: BCBS MT Closed Plan Network	$578.55
Rate for Payer: BCBS MT HealthLink	$548.10
Rate for Payer: BCBS MT Medicare	$548.10
Rate for Payer: BCBS MT POS	$578.55
Rate for Payer: BCBS MT Traditional	$609.00
Rate for Payer: Cash Price	$548.10
Rate for Payer: Cigna Commercial	$578.55
Rate for Payer: Cigna Medicare	$548.10
Rate for Payer: Medicaid All Medicaid	$560.28
Rate for Payer: Medicare All Medicare	$426.30
Rate for Payer: Monida Allegiance	$578.55
Rate for Payer: Monida First Choice Health	$590.73
Rate for Payer: Monida Montana Health Co-op	$578.55
Rate for Payer: Monida PacificSource	$578.55

OT EVAL HIGH COMPLEX

Facility

$609.00

Service Code	CPT 97167
Hospital Charge Code	6297167
Hospital Revenue Code	430
Min. Negotiated Rate	$426.30
Max. Negotiated Rate	$609.00
Rate for Payer: Aetna Commercial	$578.55
Rate for Payer: Aetna Medicare	$548.10
Rate for Payer: BCBS MT CHIP	$548.10
Rate for Payer: BCBS MT Closed Plan Network	$578.55
Rate for Payer: BCBS MT HealthLink	$548.10
Rate for Payer: BCBS MT Medicare	$548.10
Rate for Payer: BCBS MT POS	$578.55
Rate for Payer: BCBS MT Traditional	$609.00
Rate for Payer: Cash Price	$548.10
Rate for Payer: Cigna Commercial	$578.55
Rate for Payer: Cigna Medicare	$548.10
Rate for Payer: Medicaid All Medicaid	$560.28
Rate for Payer: Medicare All Medicare	$426.30
Rate for Payer: Monida Allegiance	$578.55
Rate for Payer: Monida First Choice Health	$590.73
Rate for Payer: Monida Montana Health Co-op	$578.55
Rate for Payer: Monida PacificSource	$578.55

OT EVAL LOW COMPLEX

Facility

$445.00

Service Code	CPT 97165
Hospital Charge Code	6297165
Hospital Revenue Code	430
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

OT EVAL LOW COMPLEX

Facility

$445.00

Service Code	CPT 97165
Hospital Charge Code	6297165
Hospital Revenue Code	430
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

OT EVAL MODERATE COMPLEX

Facility

$526.00

Service Code	CPT 97166
Hospital Charge Code	6297166
Hospital Revenue Code	430
Min. Negotiated Rate	$368.20
Max. Negotiated Rate	$526.00
Rate for Payer: Aetna Commercial	$499.70
Rate for Payer: Aetna Medicare	$473.40
Rate for Payer: BCBS MT CHIP	$473.40
Rate for Payer: BCBS MT Closed Plan Network	$499.70
Rate for Payer: BCBS MT HealthLink	$473.40
Rate for Payer: BCBS MT Medicare	$473.40
Rate for Payer: BCBS MT POS	$499.70
Rate for Payer: BCBS MT Traditional	$526.00
Rate for Payer: Cash Price	$473.40
Rate for Payer: Cigna Commercial	$499.70
Rate for Payer: Cigna Medicare	$473.40
Rate for Payer: Medicaid All Medicaid	$483.92
Rate for Payer: Medicare All Medicare	$368.20
Rate for Payer: Monida Allegiance	$499.70
Rate for Payer: Monida First Choice Health	$510.22
Rate for Payer: Monida Montana Health Co-op	$499.70
Rate for Payer: Monida PacificSource	$499.70

OT EVAL MODERATE COMPLEX

Facility

$526.00

Service Code	CPT 97166
Hospital Charge Code	6297166
Hospital Revenue Code	430
Min. Negotiated Rate	$368.20
Max. Negotiated Rate	$526.00
Rate for Payer: Aetna Commercial	$499.70
Rate for Payer: Aetna Medicare	$473.40
Rate for Payer: BCBS MT CHIP	$473.40
Rate for Payer: BCBS MT Closed Plan Network	$499.70
Rate for Payer: BCBS MT HealthLink	$473.40
Rate for Payer: BCBS MT Medicare	$473.40
Rate for Payer: BCBS MT POS	$499.70
Rate for Payer: BCBS MT Traditional	$526.00
Rate for Payer: Cash Price	$473.40
Rate for Payer: Cigna Commercial	$499.70
Rate for Payer: Cigna Medicare	$473.40
Rate for Payer: Medicaid All Medicaid	$483.92
Rate for Payer: Medicare All Medicare	$368.20
Rate for Payer: Monida Allegiance	$499.70
Rate for Payer: Monida First Choice Health	$510.22
Rate for Payer: Monida Montana Health Co-op	$499.70
Rate for Payer: Monida PacificSource	$499.70

OT MANUAL THERAPY 15 MIN

Facility

$113.00

Service Code	CPT 97140
Hospital Charge Code	6297140
Hospital Revenue Code	430
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

OT MANUAL THERAPY 15 MIN

Facility

$113.00

Service Code	CPT 97140
Hospital Charge Code	6297140
Hospital Revenue Code	430
Min. Negotiated Rate	$79.10
Max. Negotiated Rate	$113.00
Rate for Payer: Aetna Commercial	$107.35
Rate for Payer: Aetna Medicare	$101.70
Rate for Payer: BCBS MT CHIP	$101.70
Rate for Payer: BCBS MT Closed Plan Network	$107.35
Rate for Payer: BCBS MT HealthLink	$101.70
Rate for Payer: BCBS MT Medicare	$101.70
Rate for Payer: BCBS MT POS	$107.35
Rate for Payer: BCBS MT Traditional	$113.00
Rate for Payer: Cash Price	$101.70
Rate for Payer: Cigna Commercial	$107.35
Rate for Payer: Cigna Medicare	$101.70
Rate for Payer: Medicaid All Medicaid	$103.96
Rate for Payer: Medicare All Medicare	$79.10
Rate for Payer: Monida Allegiance	$107.35
Rate for Payer: Monida First Choice Health	$109.61
Rate for Payer: Monida Montana Health Co-op	$107.35
Rate for Payer: Monida PacificSource	$107.35

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