Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

STRETCH BANDAGE 2'' STERILE

Facility

$11.00

Hospital Charge Code	80030026
Hospital Revenue Code	270
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$11.00
Rate for Payer: Aetna Commercial	$10.45
Rate for Payer: Aetna Medicare	$9.90
Rate for Payer: BCBS MT CHIP	$9.90
Rate for Payer: BCBS MT Closed Plan Network	$10.45
Rate for Payer: BCBS MT HealthLink	$9.90
Rate for Payer: BCBS MT Medicare	$9.90
Rate for Payer: BCBS MT POS	$10.45
Rate for Payer: BCBS MT Traditional	$11.00
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cigna Commercial	$10.45
Rate for Payer: Cigna Medicare	$9.90
Rate for Payer: Medicaid All Medicaid	$10.12
Rate for Payer: Medicare All Medicare	$7.70
Rate for Payer: Monida Allegiance	$10.45
Rate for Payer: Monida First Choice Health	$10.67
Rate for Payer: Monida Montana Health Co-op	$10.45
Rate for Payer: Monida PacificSource	$10.45

STRETCH BANDAGE 3''

Facility

$4.00

Hospital Charge Code	80030024
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

STRETCH BANDAGE 3''

Facility

$4.00

Hospital Charge Code	80030024
Hospital Revenue Code	270
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$4.00
Rate for Payer: Aetna Commercial	$3.80
Rate for Payer: Aetna Medicare	$3.60
Rate for Payer: BCBS MT CHIP	$3.60
Rate for Payer: BCBS MT Closed Plan Network	$3.80
Rate for Payer: BCBS MT HealthLink	$3.60
Rate for Payer: BCBS MT Medicare	$3.60
Rate for Payer: BCBS MT POS	$3.80
Rate for Payer: BCBS MT Traditional	$4.00
Rate for Payer: Cash Price	$3.60
Rate for Payer: Cigna Commercial	$3.80
Rate for Payer: Cigna Medicare	$3.60
Rate for Payer: Medicaid All Medicaid	$3.68
Rate for Payer: Medicare All Medicare	$2.80
Rate for Payer: Monida Allegiance	$3.80
Rate for Payer: Monida First Choice Health	$3.88
Rate for Payer: Monida Montana Health Co-op	$3.80
Rate for Payer: Monida PacificSource	$3.80

STRETCH BANDAGE 3'' STERILE

Facility

$13.00

Hospital Charge Code	80030027
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

STRETCH BANDAGE 3'' STERILE

Facility

$13.00

Hospital Charge Code	80030027
Hospital Revenue Code	270
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

STROMATOLYSER 4DL 5 LITERS

Facility

$116.20

Hospital Charge Code	90195077
Hospital Revenue Code	270
Min. Negotiated Rate	$81.34
Max. Negotiated Rate	$116.20
Rate for Payer: Aetna Commercial	$110.39
Rate for Payer: Aetna Medicare	$104.58
Rate for Payer: BCBS MT CHIP	$104.58
Rate for Payer: BCBS MT Closed Plan Network	$110.39
Rate for Payer: BCBS MT HealthLink	$104.58
Rate for Payer: BCBS MT Medicare	$104.58
Rate for Payer: BCBS MT POS	$110.39
Rate for Payer: BCBS MT Traditional	$116.20
Rate for Payer: Cash Price	$104.58
Rate for Payer: Cigna Commercial	$110.39
Rate for Payer: Cigna Medicare	$104.58
Rate for Payer: Medicaid All Medicaid	$106.90
Rate for Payer: Medicare All Medicare	$81.34
Rate for Payer: Monida Allegiance	$110.39
Rate for Payer: Monida First Choice Health	$112.71
Rate for Payer: Monida Montana Health Co-op	$110.39
Rate for Payer: Monida PacificSource	$110.39

STROMATOLYSER 4DL 5 LITERS

Facility

$116.20

Hospital Charge Code	90195077
Hospital Revenue Code	270
Min. Negotiated Rate	$81.34
Max. Negotiated Rate	$116.20
Rate for Payer: Aetna Commercial	$110.39
Rate for Payer: Aetna Medicare	$104.58
Rate for Payer: BCBS MT CHIP	$104.58
Rate for Payer: BCBS MT Closed Plan Network	$110.39
Rate for Payer: BCBS MT HealthLink	$104.58
Rate for Payer: BCBS MT Medicare	$104.58
Rate for Payer: BCBS MT POS	$110.39
Rate for Payer: BCBS MT Traditional	$116.20
Rate for Payer: Cash Price	$104.58
Rate for Payer: Cigna Commercial	$110.39
Rate for Payer: Cigna Medicare	$104.58
Rate for Payer: Medicaid All Medicaid	$106.90
Rate for Payer: Medicare All Medicare	$81.34
Rate for Payer: Monida Allegiance	$110.39
Rate for Payer: Monida First Choice Health	$112.71
Rate for Payer: Monida Montana Health Co-op	$110.39
Rate for Payer: Monida PacificSource	$110.39

ST SELF CARE HOME MGMT ADL EA 15 MIN

Facility

$105.00

Service Code	HCPCS 97535 GN
Hospital Charge Code	6397535
Hospital Revenue Code	440
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

ST SELF CARE HOME MGMT ADL EA 15 MIN

Facility

$105.00

Service Code	HCPCS 97535 GN
Hospital Charge Code	6397535
Hospital Revenue Code	440
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

ST SGD EVAL 1ST HR

Facility

$471.00

Service Code	HCPCS 92607 GN
Hospital Charge Code	6392607
Hospital Revenue Code	440
Min. Negotiated Rate	$329.70
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$447.45
Rate for Payer: Aetna Medicare	$423.90
Rate for Payer: BCBS MT CHIP	$423.90
Rate for Payer: BCBS MT Closed Plan Network	$447.45
Rate for Payer: BCBS MT HealthLink	$423.90
Rate for Payer: BCBS MT Medicare	$423.90
Rate for Payer: BCBS MT POS	$447.45
Rate for Payer: BCBS MT Traditional	$471.00
Rate for Payer: Cash Price	$423.90
Rate for Payer: Cigna Commercial	$447.45
Rate for Payer: Cigna Medicare	$423.90
Rate for Payer: Medicaid All Medicaid	$433.32
Rate for Payer: Medicare All Medicare	$329.70
Rate for Payer: Monida Allegiance	$447.45
Rate for Payer: Monida First Choice Health	$456.87
Rate for Payer: Monida Montana Health Co-op	$447.45
Rate for Payer: Monida PacificSource	$447.45

ST SGD EVAL 1ST HR

Facility

$471.00

Service Code	HCPCS 92607 GN
Hospital Charge Code	6392607
Hospital Revenue Code	440
Min. Negotiated Rate	$329.70
Max. Negotiated Rate	$471.00
Rate for Payer: Aetna Commercial	$447.45
Rate for Payer: Aetna Medicare	$423.90
Rate for Payer: BCBS MT CHIP	$423.90
Rate for Payer: BCBS MT Closed Plan Network	$447.45
Rate for Payer: BCBS MT HealthLink	$423.90
Rate for Payer: BCBS MT Medicare	$423.90
Rate for Payer: BCBS MT POS	$447.45
Rate for Payer: BCBS MT Traditional	$471.00
Rate for Payer: Cash Price	$423.90
Rate for Payer: Cigna Commercial	$447.45
Rate for Payer: Cigna Medicare	$423.90
Rate for Payer: Medicaid All Medicaid	$433.32
Rate for Payer: Medicare All Medicare	$329.70
Rate for Payer: Monida Allegiance	$447.45
Rate for Payer: Monida First Choice Health	$456.87
Rate for Payer: Monida Montana Health Co-op	$447.45
Rate for Payer: Monida PacificSource	$447.45

ST SGD EVAL ADD 1/2 HR

Facility

$205.00

Service Code	HCPCS 92608 GN
Hospital Charge Code	6392608
Hospital Revenue Code	440
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

ST SGD EVAL ADD 1/2 HR

Facility

$205.00

Service Code	HCPCS 92608 GN
Hospital Charge Code	6392608
Hospital Revenue Code	440
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

ST SGD THERAPY, PRGM MOD

Facility

$191.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	6392609
Hospital Revenue Code	440
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: BCBS MT CHIP	$171.90
Rate for Payer: BCBS MT Closed Plan Network	$181.45
Rate for Payer: BCBS MT HealthLink	$171.90
Rate for Payer: BCBS MT Medicare	$171.90
Rate for Payer: BCBS MT POS	$181.45
Rate for Payer: BCBS MT Traditional	$191.00
Rate for Payer: Cash Price	$171.90
Rate for Payer: Cigna Commercial	$181.45
Rate for Payer: Cigna Medicare	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

ST SGD THERAPY, PRGM MOD

Facility

$191.00

Service Code	HCPCS 92609 GN
Hospital Charge Code	6392609
Hospital Revenue Code	440
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$191.00
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: BCBS MT CHIP	$171.90
Rate for Payer: BCBS MT Closed Plan Network	$181.45
Rate for Payer: BCBS MT HealthLink	$171.90
Rate for Payer: BCBS MT Medicare	$171.90
Rate for Payer: BCBS MT POS	$181.45
Rate for Payer: BCBS MT Traditional	$191.00
Rate for Payer: Cash Price	$171.90
Rate for Payer: Cigna Commercial	$181.45
Rate for Payer: Cigna Medicare	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

ST STD CONGNITIVE PERFORMANCE TEST PER H

Facility

$282.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	6396125
Hospital Revenue Code	440
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

ST STD CONGNITIVE PERFORMANCE TEST PER H

Facility

$282.00

Service Code	HCPCS 96125 GN
Hospital Charge Code	6396125
Hospital Revenue Code	440
Min. Negotiated Rate	$197.40
Max. Negotiated Rate	$282.00
Rate for Payer: Aetna Commercial	$267.90
Rate for Payer: Aetna Medicare	$253.80
Rate for Payer: BCBS MT CHIP	$253.80
Rate for Payer: BCBS MT Closed Plan Network	$267.90
Rate for Payer: BCBS MT HealthLink	$253.80
Rate for Payer: BCBS MT Medicare	$253.80
Rate for Payer: BCBS MT POS	$267.90
Rate for Payer: BCBS MT Traditional	$282.00
Rate for Payer: Cash Price	$253.80
Rate for Payer: Cigna Commercial	$267.90
Rate for Payer: Cigna Medicare	$253.80
Rate for Payer: Medicaid All Medicaid	$259.44
Rate for Payer: Medicare All Medicare	$197.40
Rate for Payer: Monida Allegiance	$267.90
Rate for Payer: Monida First Choice Health	$273.54
Rate for Payer: Monida Montana Health Co-op	$267.90
Rate for Payer: Monida PacificSource	$267.90

ST THERAPEUTIC ACTIVITIES

Facility

$205.00

Service Code	HCPCS 97530 GN
Hospital Charge Code	6397530
Hospital Revenue Code	440
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

ST THERAPEUTIC ACTIVITIES

Facility

$205.00

Service Code	HCPCS 97530 GN
Hospital Charge Code	6397530
Hospital Revenue Code	440
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

ST THERAPEUTIC EXERCISE

Facility

$112.00

Service Code	HCPCS 97110 GN
Hospital Charge Code	6397110
Hospital Revenue Code	440
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

ST THERAPEUTIC EXERCISE

Facility

$112.00

Service Code	HCPCS 97110 GN
Hospital Charge Code	6397110
Hospital Revenue Code	440
Min. Negotiated Rate	$78.40
Max. Negotiated Rate	$112.00
Rate for Payer: Aetna Commercial	$106.40
Rate for Payer: Aetna Medicare	$100.80
Rate for Payer: BCBS MT CHIP	$100.80
Rate for Payer: BCBS MT Closed Plan Network	$106.40
Rate for Payer: BCBS MT HealthLink	$100.80
Rate for Payer: BCBS MT Medicare	$100.80
Rate for Payer: BCBS MT POS	$106.40
Rate for Payer: BCBS MT Traditional	$112.00
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cigna Commercial	$106.40
Rate for Payer: Cigna Medicare	$100.80
Rate for Payer: Medicaid All Medicaid	$103.04
Rate for Payer: Medicare All Medicare	$78.40
Rate for Payer: Monida Allegiance	$106.40
Rate for Payer: Monida First Choice Health	$108.64
Rate for Payer: Monida Montana Health Co-op	$106.40
Rate for Payer: Monida PacificSource	$106.40

ST THER INTVENTION COGNI FUNCT 1ST 15MIN

Facility

$75.00

Service Code	HCPCS 97129
Hospital Charge Code	6397129
Hospital Revenue Code	440
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

ST THER INTVENTION COGNI FUNCT 1ST 15MIN

Facility

$75.00

Service Code	HCPCS 97129
Hospital Charge Code	6397129
Hospital Revenue Code	440
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$75.00
Rate for Payer: Aetna Commercial	$71.25
Rate for Payer: Aetna Medicare	$67.50
Rate for Payer: BCBS MT CHIP	$67.50
Rate for Payer: BCBS MT Closed Plan Network	$71.25
Rate for Payer: BCBS MT HealthLink	$67.50
Rate for Payer: BCBS MT Medicare	$67.50
Rate for Payer: BCBS MT POS	$71.25
Rate for Payer: BCBS MT Traditional	$75.00
Rate for Payer: Cash Price	$67.50
Rate for Payer: Cigna Commercial	$71.25
Rate for Payer: Cigna Medicare	$67.50
Rate for Payer: Medicaid All Medicaid	$69.00
Rate for Payer: Medicare All Medicare	$52.50
Rate for Payer: Monida Allegiance	$71.25
Rate for Payer: Monida First Choice Health	$72.75
Rate for Payer: Monida Montana Health Co-op	$71.25
Rate for Payer: Monida PacificSource	$71.25

ST THERP INTERVENT EA ADDL 15 MIN

Facility

$69.00

Service Code	HCPCS 97130
Hospital Charge Code	6397130
Hospital Revenue Code	440
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

ST THERP INTERVENT EA ADDL 15 MIN

Facility

$69.00

Service Code	HCPCS 97130
Hospital Charge Code	6397130
Hospital Revenue Code	440
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.

All Charges