Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HOME VISIT EST LIMITED (99347)

Facility

$99.00

Service Code	HCPCS 99347
Hospital Charge Code	8099347
Hospital Revenue Code	522
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

HOME VISIT EST LIMITED (99347)

Facility

$99.00

Service Code	HCPCS 99347
Hospital Charge Code	8099347
Hospital Revenue Code	522
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

HOME VISIT EST LOW-MODERATE (99348)

Facility

$159.00

Service Code	HCPCS 99348
Hospital Charge Code	8099348
Hospital Revenue Code	522
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

HOME VISIT EST LOW-MODERATE (99348)

Facility

$159.00

Service Code	HCPCS 99348
Hospital Charge Code	8099348
Hospital Revenue Code	522
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

HOME VISIT EST MODERATE-HIGH (99349)

Facility

$235.00

Service Code	HCPCS 99349
Hospital Charge Code	8099349
Hospital Revenue Code	522
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

HOME VISIT EST MODERATE-HIGH (99349)

Facility

$235.00

Service Code	HCPCS 99349
Hospital Charge Code	8099349
Hospital Revenue Code	522
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

HOME VISIT EST MOD-SEVERE (99350)

Facility

$317.00

Service Code	HCPCS 99350
Hospital Charge Code	8099350
Hospital Revenue Code	522
Min. Negotiated Rate	$221.90
Max. Negotiated Rate	$317.00
Rate for Payer: Aetna Commercial	$301.15
Rate for Payer: Aetna Medicare	$285.30
Rate for Payer: BCBS MT CHIP	$285.30
Rate for Payer: BCBS MT Closed Plan Network	$301.15
Rate for Payer: BCBS MT HealthLink	$285.30
Rate for Payer: BCBS MT Medicare	$285.30
Rate for Payer: BCBS MT POS	$301.15
Rate for Payer: BCBS MT Traditional	$317.00
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial	$301.15
Rate for Payer: Cigna Medicare	$285.30
Rate for Payer: Medicaid All Medicaid	$291.64
Rate for Payer: Medicare All Medicare	$221.90
Rate for Payer: Monida Allegiance	$301.15
Rate for Payer: Monida First Choice Health	$307.49
Rate for Payer: Monida Montana Health Co-op	$301.15
Rate for Payer: Monida PacificSource	$301.15

HOME VISIT EST MOD-SEVERE (99350)

Facility

$317.00

Service Code	HCPCS 99350
Hospital Charge Code	8099350
Hospital Revenue Code	522
Min. Negotiated Rate	$221.90
Max. Negotiated Rate	$317.00
Rate for Payer: Aetna Commercial	$301.15
Rate for Payer: Aetna Medicare	$285.30
Rate for Payer: BCBS MT CHIP	$285.30
Rate for Payer: BCBS MT Closed Plan Network	$301.15
Rate for Payer: BCBS MT HealthLink	$285.30
Rate for Payer: BCBS MT Medicare	$285.30
Rate for Payer: BCBS MT POS	$301.15
Rate for Payer: BCBS MT Traditional	$317.00
Rate for Payer: Cash Price	$285.30
Rate for Payer: Cigna Commercial	$301.15
Rate for Payer: Cigna Medicare	$285.30
Rate for Payer: Medicaid All Medicaid	$291.64
Rate for Payer: Medicare All Medicare	$221.90
Rate for Payer: Monida Allegiance	$301.15
Rate for Payer: Monida First Choice Health	$307.49
Rate for Payer: Monida Montana Health Co-op	$301.15
Rate for Payer: Monida PacificSource	$301.15

HOME VISIT NEW PT HIGH (99344)

Facility

$447.00

Service Code	HCPCS 99344
Hospital Charge Code	8099344
Hospital Revenue Code	522
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

HOME VISIT NEW PT HIGH (99344)

Facility

$447.00

Service Code	HCPCS 99344
Hospital Charge Code	8099344
Hospital Revenue Code	522
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

HOME VISIT NEW PT LIMITED (99341)

Facility

$159.00

Service Code	HCPCS 99341
Hospital Charge Code	8099341
Hospital Revenue Code	522
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

HOME VISIT NEW PT LIMITED (99341)

Facility

$159.00

Service Code	HCPCS 99341
Hospital Charge Code	8099341
Hospital Revenue Code	522
Min. Negotiated Rate	$111.30
Max. Negotiated Rate	$159.00
Rate for Payer: Aetna Commercial	$151.05
Rate for Payer: Aetna Medicare	$143.10
Rate for Payer: BCBS MT CHIP	$143.10
Rate for Payer: BCBS MT Closed Plan Network	$151.05
Rate for Payer: BCBS MT HealthLink	$143.10
Rate for Payer: BCBS MT Medicare	$143.10
Rate for Payer: BCBS MT POS	$151.05
Rate for Payer: BCBS MT Traditional	$159.00
Rate for Payer: Cash Price	$143.10
Rate for Payer: Cigna Commercial	$151.05
Rate for Payer: Cigna Medicare	$143.10
Rate for Payer: Medicaid All Medicaid	$146.28
Rate for Payer: Medicare All Medicare	$111.30
Rate for Payer: Monida Allegiance	$151.05
Rate for Payer: Monida First Choice Health	$154.23
Rate for Payer: Monida Montana Health Co-op	$151.05
Rate for Payer: Monida PacificSource	$151.05

HOME VISIT NEW PT MODERATE (99342)

Facility

$235.00

Service Code	HCPCS 99342
Hospital Charge Code	8099342
Hospital Revenue Code	522
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

HOME VISIT NEW PT MODERATE (99342)

Facility

$235.00

Service Code	HCPCS 99342
Hospital Charge Code	8099342
Hospital Revenue Code	522
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

HOME VISIT NEW PT UNSTABLE HIGH (99345)

Facility

$447.00

Service Code	HCPCS 99345
Hospital Charge Code	8099345
Hospital Revenue Code	522
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

HOME VISIT NEW PT UNSTABLE HIGH (99345)

Facility

$447.00

Service Code	HCPCS 99345
Hospital Charge Code	8099345
Hospital Revenue Code	522
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

HOMOCYSTEINE (706994)

Facility

$92.00

Service Code	HCPCS 83090
Hospital Charge Code	4083090
Hospital Revenue Code	300
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

HOMOCYSTEINE (706994)

Facility

$92.00

Service Code	HCPCS 83090
Hospital Charge Code	4083090
Hospital Revenue Code	300
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

HOT PACK 5 X 8

Facility

$1.00

Hospital Charge Code	2880015
Hospital Revenue Code	270
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna Commercial	$0.95
Rate for Payer: Aetna Medicare	$0.90
Rate for Payer: BCBS MT CHIP	$0.90
Rate for Payer: BCBS MT Closed Plan Network	$0.95
Rate for Payer: BCBS MT HealthLink	$0.90
Rate for Payer: BCBS MT Medicare	$0.90
Rate for Payer: BCBS MT POS	$0.95
Rate for Payer: BCBS MT Traditional	$1.00
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna Commercial	$0.95
Rate for Payer: Cigna Medicare	$0.90
Rate for Payer: Medicaid All Medicaid	$0.92
Rate for Payer: Medicare All Medicare	$0.70
Rate for Payer: Monida Allegiance	$0.95
Rate for Payer: Monida First Choice Health	$0.97
Rate for Payer: Monida Montana Health Co-op	$0.95
Rate for Payer: Monida PacificSource	$0.95

HOT PACK 5 X 8

Facility

$1.00

Hospital Charge Code	2880015
Hospital Revenue Code	270
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna Commercial	$0.95
Rate for Payer: Aetna Medicare	$0.90
Rate for Payer: BCBS MT CHIP	$0.90
Rate for Payer: BCBS MT Closed Plan Network	$0.95
Rate for Payer: BCBS MT HealthLink	$0.90
Rate for Payer: BCBS MT Medicare	$0.90
Rate for Payer: BCBS MT POS	$0.95
Rate for Payer: BCBS MT Traditional	$1.00
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna Commercial	$0.95
Rate for Payer: Cigna Medicare	$0.90
Rate for Payer: Medicaid All Medicaid	$0.92
Rate for Payer: Medicare All Medicare	$0.70
Rate for Payer: Monida Allegiance	$0.95
Rate for Payer: Monida First Choice Health	$0.97
Rate for Payer: Monida Montana Health Co-op	$0.95
Rate for Payer: Monida PacificSource	$0.95

HOV HOME VISI NP INTERMEDIATE

Facility

$273.00

Service Code	HCPCS 99343
Hospital Charge Code	799343
Hospital Revenue Code	522
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

HOV HOME VISI NP INTERMEDIATE

Facility

$273.00

Service Code	HCPCS 99343
Hospital Charge Code	799343
Hospital Revenue Code	522
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

HOV HOME VISIT EST BRIEF

Facility

$116.00

Service Code	HCPCS 99347
Hospital Charge Code	799347
Hospital Revenue Code	522
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

HOV HOME VISIT EST BRIEF

Facility

$116.00

Service Code	HCPCS 99347
Hospital Charge Code	799347
Hospital Revenue Code	522
Min. Negotiated Rate	$81.20
Max. Negotiated Rate	$116.00
Rate for Payer: Aetna Commercial	$110.20
Rate for Payer: Aetna Medicare	$104.40
Rate for Payer: BCBS MT CHIP	$104.40
Rate for Payer: BCBS MT Closed Plan Network	$110.20
Rate for Payer: BCBS MT HealthLink	$104.40
Rate for Payer: BCBS MT Medicare	$104.40
Rate for Payer: BCBS MT POS	$110.20
Rate for Payer: BCBS MT Traditional	$116.00
Rate for Payer: Cash Price	$104.40
Rate for Payer: Cigna Commercial	$110.20
Rate for Payer: Cigna Medicare	$104.40
Rate for Payer: Medicaid All Medicaid	$106.72
Rate for Payer: Medicare All Medicare	$81.20
Rate for Payer: Monida Allegiance	$110.20
Rate for Payer: Monida First Choice Health	$112.52
Rate for Payer: Monida Montana Health Co-op	$110.20
Rate for Payer: Monida PacificSource	$110.20

HOV HOME VISIT EST EXTENDED

Facility

$268.00

Service Code	HCPCS 99349
Hospital Charge Code	799349
Hospital Revenue Code	522
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$268.00
Rate for Payer: Aetna Commercial	$254.60
Rate for Payer: Aetna Medicare	$241.20
Rate for Payer: BCBS MT CHIP	$241.20
Rate for Payer: BCBS MT Closed Plan Network	$254.60
Rate for Payer: BCBS MT HealthLink	$241.20
Rate for Payer: BCBS MT Medicare	$241.20
Rate for Payer: BCBS MT POS	$254.60
Rate for Payer: BCBS MT Traditional	$268.00
Rate for Payer: Cash Price	$241.20
Rate for Payer: Cigna Commercial	$254.60
Rate for Payer: Cigna Medicare	$241.20
Rate for Payer: Medicaid All Medicaid	$246.56
Rate for Payer: Medicare All Medicare	$187.60
Rate for Payer: Monida Allegiance	$254.60
Rate for Payer: Monida First Choice Health	$259.96
Rate for Payer: Monida Montana Health Co-op	$254.60
Rate for Payer: Monida PacificSource	$254.60

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