Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OUTPATIENT TRIGR PT INJECTION 3+ 20553

Facility

$747.00

Service Code	CPT 20553
Hospital Charge Code	520553
Hospital Revenue Code	760
Min. Negotiated Rate	$522.90
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna Commercial	$709.65
Rate for Payer: Aetna Medicare	$672.30
Rate for Payer: BCBS MT CHIP	$672.30
Rate for Payer: BCBS MT Closed Plan Network	$709.65
Rate for Payer: BCBS MT HealthLink	$672.30
Rate for Payer: BCBS MT Medicare	$672.30
Rate for Payer: BCBS MT POS	$709.65
Rate for Payer: BCBS MT Traditional	$747.00
Rate for Payer: Cash Price	$672.30
Rate for Payer: Cigna Commercial	$709.65
Rate for Payer: Cigna Medicare	$672.30
Rate for Payer: Medicaid All Medicaid	$687.24
Rate for Payer: Medicare All Medicare	$522.90
Rate for Payer: Monida Allegiance	$709.65
Rate for Payer: Monida First Choice Health	$724.59
Rate for Payer: Monida Montana Health Co-op	$709.65
Rate for Payer: Monida PacificSource	$709.65

OUTPATIENT TRIGR PT INJECTION 3+ 20553

Facility

$747.00

Service Code	CPT 20553
Hospital Charge Code	520553
Hospital Revenue Code	760
Min. Negotiated Rate	$522.90
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna Commercial	$709.65
Rate for Payer: Aetna Medicare	$672.30
Rate for Payer: BCBS MT CHIP	$672.30
Rate for Payer: BCBS MT Closed Plan Network	$709.65
Rate for Payer: BCBS MT HealthLink	$672.30
Rate for Payer: BCBS MT Medicare	$672.30
Rate for Payer: BCBS MT POS	$709.65
Rate for Payer: BCBS MT Traditional	$747.00
Rate for Payer: Cash Price	$672.30
Rate for Payer: Cigna Commercial	$709.65
Rate for Payer: Cigna Medicare	$672.30
Rate for Payer: Medicaid All Medicaid	$687.24
Rate for Payer: Medicare All Medicare	$522.90
Rate for Payer: Monida Allegiance	$709.65
Rate for Payer: Monida First Choice Health	$724.59
Rate for Payer: Monida Montana Health Co-op	$709.65
Rate for Payer: Monida PacificSource	$709.65

OVA & PARASITES EXAM (3001662 TRAVEL)

Facility

$69.00

Service Code	CPT 87177
Hospital Charge Code	4087177
Hospital Revenue Code	300
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

OVA & PARASITES EXAM (3001662 TRAVEL)

Facility

$69.00

Service Code	CPT 87177
Hospital Charge Code	4087177
Hospital Revenue Code	300
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

.OVA & PARASITES EXAM STAIN

Facility

$50.00

Service Code	CPT 87209
Hospital Charge Code	4088136
Hospital Revenue Code	300
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

.OVA & PARASITES EXAM STAIN

Facility

$50.00

Service Code	CPT 87209
Hospital Charge Code	4088136
Hospital Revenue Code	300
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$50.00
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: BCBS MT CHIP	$45.00
Rate for Payer: BCBS MT Closed Plan Network	$47.50
Rate for Payer: BCBS MT HealthLink	$45.00
Rate for Payer: BCBS MT Medicare	$45.00
Rate for Payer: BCBS MT POS	$47.50
Rate for Payer: BCBS MT Traditional	$50.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Cigna Commercial	$47.50
Rate for Payer: Cigna Medicare	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

OVA & PARASITES SCREEN (GIARDIA/CRYPTO)

Facility

$94.00

Service Code	CPT 87272
Hospital Charge Code	4087209
Hospital Revenue Code	300
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

OVA & PARASITES SCREEN (GIARDIA/CRYPTO)

Facility

$94.00

Service Code	CPT 87272
Hospital Charge Code	4087209
Hospital Revenue Code	300
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

OV BRIEF ESTAB PATIENT (99212)

Facility

$105.00

Service Code	CPT 99212
Hospital Charge Code	8099212
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

OV BRIEF ESTAB PATIENT (99212)

Facility

$105.00

Service Code	CPT 99212
Hospital Charge Code	8099212
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

OV CERV/VAG CANCER SCREEN W/ PELV&BREAST

Facility

$98.00

Service Code	HCPCS G0101
Hospital Charge Code	8000101
Hospital Revenue Code	521
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

OV CERV/VAG CANCER SCREEN W/ PELV&BREAST

Facility

$98.00

Service Code	HCPCS G0101
Hospital Charge Code	8000101
Hospital Revenue Code	521
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$98.00
Rate for Payer: Aetna Commercial	$93.10
Rate for Payer: Aetna Medicare	$88.20
Rate for Payer: BCBS MT CHIP	$88.20
Rate for Payer: BCBS MT Closed Plan Network	$93.10
Rate for Payer: BCBS MT HealthLink	$88.20
Rate for Payer: BCBS MT Medicare	$88.20
Rate for Payer: BCBS MT POS	$93.10
Rate for Payer: BCBS MT Traditional	$98.00
Rate for Payer: Cash Price	$88.20
Rate for Payer: Cigna Commercial	$93.10
Rate for Payer: Cigna Medicare	$88.20
Rate for Payer: Medicaid All Medicaid	$90.16
Rate for Payer: Medicare All Medicare	$68.60
Rate for Payer: Monida Allegiance	$93.10
Rate for Payer: Monida First Choice Health	$95.06
Rate for Payer: Monida Montana Health Co-op	$93.10
Rate for Payer: Monida PacificSource	$93.10

OV COMPREHENSIVE NEW PATIENT (99205)

Facility

$447.00

Service Code	CPT 99205
Hospital Charge Code	8099205
Hospital Revenue Code	521
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$447.00
Rate for Payer: Aetna Commercial	$424.65
Rate for Payer: Aetna Medicare	$402.30
Rate for Payer: BCBS MT CHIP	$402.30
Rate for Payer: BCBS MT Closed Plan Network	$424.65
Rate for Payer: BCBS MT HealthLink	$402.30
Rate for Payer: BCBS MT Medicare	$402.30
Rate for Payer: BCBS MT POS	$424.65
Rate for Payer: BCBS MT Traditional	$447.00
Rate for Payer: Cash Price	$402.30
Rate for Payer: Cigna Commercial	$424.65
Rate for Payer: Cigna Medicare	$402.30
Rate for Payer: Medicaid All Medicaid	$411.24
Rate for Payer: Medicare All Medicare	$312.90
Rate for Payer: Monida Allegiance	$424.65
Rate for Payer: Monida First Choice Health	$433.59
Rate for Payer: Monida Montana Health Co-op	$424.65
Rate for Payer: Monida PacificSource	$424.65

OV COMPREHENSIVE NEW PATIENT (99205)

Facility

$447.00

Service Code	CPT 99205
Hospital Charge Code	8099205
Hospital Revenue Code	521
Min. Negotiated Rate	$312.90
Max. Negotiated Rate	$447.00
Rate for Payer: Aetna Commercial	$424.65
Rate for Payer: Aetna Medicare	$402.30
Rate for Payer: BCBS MT CHIP	$402.30
Rate for Payer: BCBS MT Closed Plan Network	$424.65
Rate for Payer: BCBS MT HealthLink	$402.30
Rate for Payer: BCBS MT Medicare	$402.30
Rate for Payer: BCBS MT POS	$424.65
Rate for Payer: BCBS MT Traditional	$447.00
Rate for Payer: Cash Price	$402.30
Rate for Payer: Cigna Commercial	$424.65
Rate for Payer: Cigna Medicare	$402.30
Rate for Payer: Medicaid All Medicaid	$411.24
Rate for Payer: Medicare All Medicare	$312.90
Rate for Payer: Monida Allegiance	$424.65
Rate for Payer: Monida First Choice Health	$433.59
Rate for Payer: Monida Montana Health Co-op	$424.65
Rate for Payer: Monida PacificSource	$424.65

OV DISABILITY WC OR MEDICAL EVAL

Facility

$318.00

Service Code	CPT 99455
Hospital Charge Code	8099455
Hospital Revenue Code	521
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

OV DISABILITY WC OR MEDICAL EVAL

Facility

$318.00

Service Code	CPT 99455
Hospital Charge Code	8099455
Hospital Revenue Code	521
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

OV EXTENDED ESTAB PATIENT (99215)

Facility

$336.00

Service Code	CPT 99215
Hospital Charge Code	8099215
Hospital Revenue Code	521
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

OV EXTENDED ESTAB PATIENT (99215)

Facility

$336.00

Service Code	CPT 99215
Hospital Charge Code	8099215
Hospital Revenue Code	521
Min. Negotiated Rate	$235.20
Max. Negotiated Rate	$336.00
Rate for Payer: Aetna Commercial	$319.20
Rate for Payer: Aetna Medicare	$302.40
Rate for Payer: BCBS MT CHIP	$302.40
Rate for Payer: BCBS MT Closed Plan Network	$319.20
Rate for Payer: BCBS MT HealthLink	$302.40
Rate for Payer: BCBS MT Medicare	$302.40
Rate for Payer: BCBS MT POS	$319.20
Rate for Payer: BCBS MT Traditional	$336.00
Rate for Payer: Cash Price	$302.40
Rate for Payer: Cigna Commercial	$319.20
Rate for Payer: Cigna Medicare	$302.40
Rate for Payer: Medicaid All Medicaid	$309.12
Rate for Payer: Medicare All Medicare	$235.20
Rate for Payer: Monida Allegiance	$319.20
Rate for Payer: Monida First Choice Health	$325.92
Rate for Payer: Monida Montana Health Co-op	$319.20
Rate for Payer: Monida PacificSource	$319.20

OV EXTENDED NEW PATIENT (99204)

Facility

$355.00

Service Code	CPT 99204
Hospital Charge Code	8099204
Hospital Revenue Code	521
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

OV EXTENDED NEW PATIENT (99204)

Facility

$355.00

Service Code	CPT 99204
Hospital Charge Code	8099204
Hospital Revenue Code	521
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

OV INTERMEDIATE ESTAB PATIENT (99214)

Facility

$249.00

Service Code	CPT 99214
Hospital Charge Code	8099214
Hospital Revenue Code	521
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

OV INTERMEDIATE ESTAB PATIENT (99214)

Facility

$249.00

Service Code	CPT 99214
Hospital Charge Code	8099214
Hospital Revenue Code	521
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

OV INTERMEDIATE NEW PATIENT (99203)

Facility

$249.00

Service Code	CPT 99203
Hospital Charge Code	8099203
Hospital Revenue Code	521
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

OV INTERMEDIATE NEW PATIENT (99203)

Facility

$249.00

Service Code	CPT 99203
Hospital Charge Code	8099203
Hospital Revenue Code	521
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$249.00
Rate for Payer: Aetna Commercial	$236.55
Rate for Payer: Aetna Medicare	$224.10
Rate for Payer: BCBS MT CHIP	$224.10
Rate for Payer: BCBS MT Closed Plan Network	$236.55
Rate for Payer: BCBS MT HealthLink	$224.10
Rate for Payer: BCBS MT Medicare	$224.10
Rate for Payer: BCBS MT POS	$236.55
Rate for Payer: BCBS MT Traditional	$249.00
Rate for Payer: Cash Price	$224.10
Rate for Payer: Cigna Commercial	$236.55
Rate for Payer: Cigna Medicare	$224.10
Rate for Payer: Medicaid All Medicaid	$229.08
Rate for Payer: Medicare All Medicare	$174.30
Rate for Payer: Monida Allegiance	$236.55
Rate for Payer: Monida First Choice Health	$241.53
Rate for Payer: Monida Montana Health Co-op	$236.55
Rate for Payer: Monida PacificSource	$236.55

OV LIFE, DOT, SPORTS EVAL

Facility

$182.00

Service Code	CPT 99450
Hospital Charge Code	8099450
Hospital Revenue Code	521
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$182.00
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: BCBS MT CHIP	$163.80
Rate for Payer: BCBS MT Closed Plan Network	$172.90
Rate for Payer: BCBS MT HealthLink	$163.80
Rate for Payer: BCBS MT Medicare	$163.80
Rate for Payer: BCBS MT POS	$172.90
Rate for Payer: BCBS MT Traditional	$182.00
Rate for Payer: Cash Price	$163.80
Rate for Payer: Cigna Commercial	$172.90
Rate for Payer: Cigna Medicare	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

Know your out-of-pocket cost for care.

All Charges