Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HLA B27 DISEASE ASSOCIATION (006924)

Facility

$79.00

Service Code	HCPCS 81374
Hospital Charge Code	4081374
Hospital Revenue Code	302
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

HLA B27 DISEASE ASSOCIATION (006924)

Facility

$79.00

Service Code	HCPCS 81374
Hospital Charge Code	4081374
Hospital Revenue Code	302
Min. Negotiated Rate	$55.30
Max. Negotiated Rate	$79.00
Rate for Payer: Aetna Commercial	$75.05
Rate for Payer: Aetna Medicare	$71.10
Rate for Payer: BCBS MT CHIP	$71.10
Rate for Payer: BCBS MT Closed Plan Network	$75.05
Rate for Payer: BCBS MT HealthLink	$71.10
Rate for Payer: BCBS MT Medicare	$71.10
Rate for Payer: BCBS MT POS	$75.05
Rate for Payer: BCBS MT Traditional	$79.00
Rate for Payer: Cash Price	$71.10
Rate for Payer: Cigna Commercial	$75.05
Rate for Payer: Cigna Medicare	$71.10
Rate for Payer: Medicaid All Medicaid	$72.68
Rate for Payer: Medicare All Medicare	$55.30
Rate for Payer: Monida Allegiance	$75.05
Rate for Payer: Monida First Choice Health	$76.63
Rate for Payer: Monida Montana Health Co-op	$75.05
Rate for Payer: Monida PacificSource	$75.05

HOLTER 1-48HR APPLY/RECORD/DISCONNECT

Facility

$338.00

Service Code	HCPCS 93225
Hospital Charge Code	114006
Hospital Revenue Code	731
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

HOLTER 1-48HR APPLY/RECORD/DISCONNECT

Facility

$338.00

Service Code	HCPCS 93225
Hospital Charge Code	114006
Hospital Revenue Code	731
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

HOLTER 1-48HR SCAN ANALY W/REP- MEDICAID

Facility

$405.00

Service Code	HCPCS 93226
Hospital Charge Code	114007
Hospital Revenue Code	731
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna Commercial	$384.75
Rate for Payer: Aetna Medicare	$364.50
Rate for Payer: BCBS MT CHIP	$364.50
Rate for Payer: BCBS MT Closed Plan Network	$384.75
Rate for Payer: BCBS MT HealthLink	$364.50
Rate for Payer: BCBS MT Medicare	$364.50
Rate for Payer: BCBS MT POS	$384.75
Rate for Payer: BCBS MT Traditional	$405.00
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cigna Commercial	$384.75
Rate for Payer: Cigna Medicare	$364.50
Rate for Payer: Medicaid All Medicaid	$372.60
Rate for Payer: Medicare All Medicare	$283.50
Rate for Payer: Monida Allegiance	$384.75
Rate for Payer: Monida First Choice Health	$392.85
Rate for Payer: Monida Montana Health Co-op	$384.75
Rate for Payer: Monida PacificSource	$384.75

HOLTER 1-48HR SCAN ANALY W/REP- MEDICAID

Facility

$405.00

Service Code	HCPCS 93226
Hospital Charge Code	114007
Hospital Revenue Code	731
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna Commercial	$384.75
Rate for Payer: Aetna Medicare	$364.50
Rate for Payer: BCBS MT CHIP	$364.50
Rate for Payer: BCBS MT Closed Plan Network	$384.75
Rate for Payer: BCBS MT HealthLink	$364.50
Rate for Payer: BCBS MT Medicare	$364.50
Rate for Payer: BCBS MT POS	$384.75
Rate for Payer: BCBS MT Traditional	$405.00
Rate for Payer: Cash Price	$364.50
Rate for Payer: Cigna Commercial	$384.75
Rate for Payer: Cigna Medicare	$364.50
Rate for Payer: Medicaid All Medicaid	$372.60
Rate for Payer: Medicare All Medicare	$283.50
Rate for Payer: Monida Allegiance	$384.75
Rate for Payer: Monida First Choice Health	$392.85
Rate for Payer: Monida Montana Health Co-op	$384.75
Rate for Payer: Monida PacificSource	$384.75

HOLTER 49HR-7DAY APPLY/RECORD/DISCONNECT

Facility

$251.00

Service Code	HCPCS 93242
Hospital Charge Code	114010
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAY APPLY/RECORD/DISCONNECT

Facility

$251.00

Service Code	HCPCS 93242
Hospital Charge Code	114010
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAY SCAN ANALY W/REP -MEDIC

Facility

$251.00

Service Code	HCPCS 93243
Hospital Charge Code	114011
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAY SCAN ANALY W/REP -MEDIC

Facility

$251.00

Service Code	HCPCS 93243
Hospital Charge Code	114011
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 49HR-7DAYS RECORD/ANALY/INTERPRET

Facility

$473.00

Service Code	HCPCS 93241
Hospital Charge Code	114009
Hospital Revenue Code	731
Min. Negotiated Rate	$331.10
Max. Negotiated Rate	$473.00
Rate for Payer: Aetna Commercial	$449.35
Rate for Payer: Aetna Medicare	$425.70
Rate for Payer: BCBS MT CHIP	$425.70
Rate for Payer: BCBS MT Closed Plan Network	$449.35
Rate for Payer: BCBS MT HealthLink	$425.70
Rate for Payer: BCBS MT Medicare	$425.70
Rate for Payer: BCBS MT POS	$449.35
Rate for Payer: BCBS MT Traditional	$473.00
Rate for Payer: Cash Price	$425.70
Rate for Payer: Cigna Commercial	$449.35
Rate for Payer: Cigna Medicare	$425.70
Rate for Payer: Medicaid All Medicaid	$435.16
Rate for Payer: Medicare All Medicare	$331.10
Rate for Payer: Monida Allegiance	$449.35
Rate for Payer: Monida First Choice Health	$458.81
Rate for Payer: Monida Montana Health Co-op	$449.35
Rate for Payer: Monida PacificSource	$449.35

HOLTER 49HR-7DAYS RECORD/ANALY/INTERPRET

Facility

$473.00

Service Code	HCPCS 93241
Hospital Charge Code	114009
Hospital Revenue Code	731
Min. Negotiated Rate	$331.10
Max. Negotiated Rate	$473.00
Rate for Payer: Aetna Commercial	$449.35
Rate for Payer: Aetna Medicare	$425.70
Rate for Payer: BCBS MT CHIP	$425.70
Rate for Payer: BCBS MT Closed Plan Network	$449.35
Rate for Payer: BCBS MT HealthLink	$425.70
Rate for Payer: BCBS MT Medicare	$425.70
Rate for Payer: BCBS MT POS	$449.35
Rate for Payer: BCBS MT Traditional	$473.00
Rate for Payer: Cash Price	$425.70
Rate for Payer: Cigna Commercial	$449.35
Rate for Payer: Cigna Medicare	$425.70
Rate for Payer: Medicaid All Medicaid	$435.16
Rate for Payer: Medicare All Medicare	$331.10
Rate for Payer: Monida Allegiance	$449.35
Rate for Payer: Monida First Choice Health	$458.81
Rate for Payer: Monida Montana Health Co-op	$449.35
Rate for Payer: Monida PacificSource	$449.35

HOLTER 8-15 DAYS APPLY/RECORD/DISCONNECT

Facility

$251.00

Service Code	HCPCS 93246
Hospital Charge Code	114005
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 8-15 DAYS APPLY/RECORD/DISCONNECT

Facility

$251.00

Service Code	HCPCS 93246
Hospital Charge Code	114005
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 8-15 DAY SCAN ANALYSIS W/REP -MED

Facility

$251.00

Service Code	HCPCS 93247
Hospital Charge Code	114004
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER 8-15 DAY SCAN ANALYSIS W/REP -MED

Facility

$251.00

Service Code	HCPCS 93247
Hospital Charge Code	114004
Hospital Revenue Code	731
Min. Negotiated Rate	$175.70
Max. Negotiated Rate	$251.00
Rate for Payer: Aetna Commercial	$238.45
Rate for Payer: Aetna Medicare	$225.90
Rate for Payer: BCBS MT CHIP	$225.90
Rate for Payer: BCBS MT Closed Plan Network	$238.45
Rate for Payer: BCBS MT HealthLink	$225.90
Rate for Payer: BCBS MT Medicare	$225.90
Rate for Payer: BCBS MT POS	$238.45
Rate for Payer: BCBS MT Traditional	$251.00
Rate for Payer: Cash Price	$225.90
Rate for Payer: Cigna Commercial	$238.45
Rate for Payer: Cigna Medicare	$225.90
Rate for Payer: Medicaid All Medicaid	$230.92
Rate for Payer: Medicare All Medicare	$175.70
Rate for Payer: Monida Allegiance	$238.45
Rate for Payer: Monida First Choice Health	$243.47
Rate for Payer: Monida Montana Health Co-op	$238.45
Rate for Payer: Monida PacificSource	$238.45

HOLTER PRO FEE INTERPRET 1-48HRS

Professional

Both

$39.00

Service Code	HCPCS 93227 AQ
Hospital Charge Code	793227
Hospital Revenue Code	985
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$37.83
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

HOLTER PRO FEE INTERPRET 49HRS-7DAYS

Professional

Both

$50.00

Service Code	HCPCS 93244 AQ
Hospital Charge Code	793244
Hospital Revenue Code	985
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$48.50
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: Cash Price	$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

HOLTER PRO FEE INTERPRET 8-15 DAYS

Professional

Both

$55.00

Service Code	HCPCS 93248 AQ
Hospital Charge Code	793248
Hospital Revenue Code	985
Min. Negotiated Rate	$38.50
Max. Negotiated Rate	$53.35
Rate for Payer: Aetna Commercial	$52.25
Rate for Payer: Aetna Medicare	$49.50
Rate for Payer: Cash Price	$49.50
Rate for Payer: Medicaid All Medicaid	$50.60
Rate for Payer: Medicare All Medicare	$38.50
Rate for Payer: Monida Allegiance	$52.25
Rate for Payer: Monida First Choice Health	$53.35
Rate for Payer: Monida Montana Health Co-op	$52.25
Rate for Payer: Monida PacificSource	$52.25

HOME NEW PT MODERATE-HIGH (99343)

Facility

$376.00

Service Code	HCPCS 99343
Hospital Charge Code	8099343
Hospital Revenue Code	522
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

HOME NEW PT MODERATE-HIGH (99343)

Facility

$376.00

Service Code	HCPCS 99343
Hospital Charge Code	8099343
Hospital Revenue Code	522
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

HOME VISIT EST LIMITED (99347)

Facility

$105.00

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

HOME VISIT EST LIMITED (99347)

Facility

$105.00

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

HOME VISIT EST LOW-MODERATE (99348)

Facility

$169.00

Service Code	HCPCS 99348
Hospital Charge Code	8099348
Hospital Revenue Code	522
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

HOME VISIT EST LOW-MODERATE (99348)

Facility

$169.00

Service Code	HCPCS 99348
Hospital Charge Code	8099348
Hospital Revenue Code	522
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

Know your out-of-pocket cost for care.

All Charges