Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

HOME VISIT EST MODERATE-HIGH (99349)

Facility

$249.00

Service Code	HCPCS 99349
Hospital Charge Code	8099349
Hospital Revenue Code	522
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

HOME VISIT EST MODERATE-HIGH (99349)

Facility

$249.00

Service Code	HCPCS 99349
Hospital Charge Code	8099349
Hospital Revenue Code	522
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

HOME VISIT EST MOD-SEVERE (99350)

Facility

$336.00

Service Code	HCPCS 99350
Hospital Charge Code	8099350
Hospital Revenue Code	522
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

HOME VISIT EST MOD-SEVERE (99350)

Facility

$336.00

Service Code	HCPCS 99350
Hospital Charge Code	8099350
Hospital Revenue Code	522
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

HOME VISIT NEW PT HIGH (99344)

Facility

$474.00

Service Code	HCPCS 99344
Hospital Charge Code	8099344
Hospital Revenue Code	522
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

HOME VISIT NEW PT HIGH (99344)

Facility

$474.00

Service Code	HCPCS 99344
Hospital Charge Code	8099344
Hospital Revenue Code	522
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

HOME VISIT NEW PT LIMITED (99341)

Facility

$169.00

Service Code	HCPCS 99341
Hospital Charge Code	8099341
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 NEW PT LIMITED (99341)

Facility

$169.00

Service Code	HCPCS 99341
Hospital Charge Code	8099341
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 NEW PT MODERATE (99342)

Facility

$249.00

Service Code	HCPCS 99342
Hospital Charge Code	8099342
Hospital Revenue Code	522
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

HOME VISIT NEW PT MODERATE (99342)

Facility

$249.00

Service Code	HCPCS 99342
Hospital Charge Code	8099342
Hospital Revenue Code	522
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

HOME VISIT NEW PT UNSTABLE HIGH (99345)

Facility

$474.00

Service Code	HCPCS 99345
Hospital Charge Code	8099345
Hospital Revenue Code	522
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

HOME VISIT NEW PT UNSTABLE HIGH (99345)

Facility

$474.00

Service Code	HCPCS 99345
Hospital Charge Code	8099345
Hospital Revenue Code	522
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$474.00
Rate for Payer: Aetna Commercial	$450.30
Rate for Payer: Aetna Medicare	$426.60
Rate for Payer: BCBS MT CHIP	$426.60
Rate for Payer: BCBS MT Closed Plan Network	$450.30
Rate for Payer: BCBS MT HealthLink	$426.60
Rate for Payer: BCBS MT Medicare	$426.60
Rate for Payer: BCBS MT POS	$450.30
Rate for Payer: BCBS MT Traditional	$474.00
Rate for Payer: Cash Price	$426.60
Rate for Payer: Cigna Commercial	$450.30
Rate for Payer: Cigna Medicare	$426.60
Rate for Payer: Medicaid All Medicaid	$436.08
Rate for Payer: Medicare All Medicare	$331.80
Rate for Payer: Monida Allegiance	$450.30
Rate for Payer: Monida First Choice Health	$459.78
Rate for Payer: Monida Montana Health Co-op	$450.30
Rate for Payer: Monida PacificSource	$450.30

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

$289.00

Service Code	HCPCS 99343
Hospital Charge Code	799343
Hospital Revenue Code	522
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

HOV HOME VISI NP INTERMEDIATE

Facility

$289.00

Service Code	HCPCS 99343
Hospital Charge Code	799343
Hospital Revenue Code	522
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

HOV HOME VISIT EST BRIEF

Facility

$123.00

Service Code	HCPCS 99347
Hospital Charge Code	799347
Hospital Revenue Code	522
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna Commercial	$116.85
Rate for Payer: Aetna Medicare	$110.70
Rate for Payer: BCBS MT CHIP	$110.70
Rate for Payer: BCBS MT Closed Plan Network	$116.85
Rate for Payer: BCBS MT HealthLink	$110.70
Rate for Payer: BCBS MT Medicare	$110.70
Rate for Payer: BCBS MT POS	$116.85
Rate for Payer: BCBS MT Traditional	$123.00
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial	$116.85
Rate for Payer: Cigna Medicare	$110.70
Rate for Payer: Medicaid All Medicaid	$113.16
Rate for Payer: Medicare All Medicare	$86.10
Rate for Payer: Monida Allegiance	$116.85
Rate for Payer: Monida First Choice Health	$119.31
Rate for Payer: Monida Montana Health Co-op	$116.85
Rate for Payer: Monida PacificSource	$116.85

HOV HOME VISIT EST BRIEF

Facility

$123.00

Service Code	HCPCS 99347
Hospital Charge Code	799347
Hospital Revenue Code	522
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$123.00
Rate for Payer: Aetna Commercial	$116.85
Rate for Payer: Aetna Medicare	$110.70
Rate for Payer: BCBS MT CHIP	$110.70
Rate for Payer: BCBS MT Closed Plan Network	$116.85
Rate for Payer: BCBS MT HealthLink	$110.70
Rate for Payer: BCBS MT Medicare	$110.70
Rate for Payer: BCBS MT POS	$116.85
Rate for Payer: BCBS MT Traditional	$123.00
Rate for Payer: Cash Price	$110.70
Rate for Payer: Cigna Commercial	$116.85
Rate for Payer: Cigna Medicare	$110.70
Rate for Payer: Medicaid All Medicaid	$113.16
Rate for Payer: Medicare All Medicare	$86.10
Rate for Payer: Monida Allegiance	$116.85
Rate for Payer: Monida First Choice Health	$119.31
Rate for Payer: Monida Montana Health Co-op	$116.85
Rate for Payer: Monida PacificSource	$116.85

HOV HOME VISIT EST EXTENDED

Facility

$284.00

Service Code	HCPCS 99349
Hospital Charge Code	799349
Hospital Revenue Code	522
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

HOV HOME VISIT EST EXTENDED

Facility

$284.00

Service Code	HCPCS 99349
Hospital Charge Code	799349
Hospital Revenue Code	522
Min. Negotiated Rate	$198.80
Max. Negotiated Rate	$284.00
Rate for Payer: Aetna Commercial	$269.80
Rate for Payer: Aetna Medicare	$255.60
Rate for Payer: BCBS MT CHIP	$255.60
Rate for Payer: BCBS MT Closed Plan Network	$269.80
Rate for Payer: BCBS MT HealthLink	$255.60
Rate for Payer: BCBS MT Medicare	$255.60
Rate for Payer: BCBS MT POS	$269.80
Rate for Payer: BCBS MT Traditional	$284.00
Rate for Payer: Cash Price	$255.60
Rate for Payer: Cigna Commercial	$269.80
Rate for Payer: Cigna Medicare	$255.60
Rate for Payer: Medicaid All Medicaid	$261.28
Rate for Payer: Medicare All Medicare	$198.80
Rate for Payer: Monida Allegiance	$269.80
Rate for Payer: Monida First Choice Health	$275.48
Rate for Payer: Monida Montana Health Co-op	$269.80
Rate for Payer: Monida PacificSource	$269.80

HOV HOME VISIT EST INTERMEDIATE

Facility

$190.00

Service Code	HCPCS 99348
Hospital Charge Code	799348
Hospital Revenue Code	522
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$190.00
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: BCBS MT CHIP	$171.00
Rate for Payer: BCBS MT Closed Plan Network	$180.50
Rate for Payer: BCBS MT HealthLink	$171.00
Rate for Payer: BCBS MT Medicare	$171.00
Rate for Payer: BCBS MT POS	$180.50
Rate for Payer: BCBS MT Traditional	$190.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cigna Commercial	$180.50
Rate for Payer: Cigna Medicare	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

HOV HOME VISIT EST INTERMEDIATE

Facility

$190.00

Service Code	HCPCS 99348
Hospital Charge Code	799348
Hospital Revenue Code	522
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$190.00
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: BCBS MT CHIP	$171.00
Rate for Payer: BCBS MT Closed Plan Network	$180.50
Rate for Payer: BCBS MT HealthLink	$171.00
Rate for Payer: BCBS MT Medicare	$171.00
Rate for Payer: BCBS MT POS	$180.50
Rate for Payer: BCBS MT Traditional	$190.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cigna Commercial	$180.50
Rate for Payer: Cigna Medicare	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

HPV GENOTYPES 16 AND 18

Facility

$136.00

Service Code	HCPCS 87625
Hospital Charge Code	4087957
Hospital Revenue Code	310
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$136.00
Rate for Payer: Aetna Commercial	$129.20
Rate for Payer: Aetna Medicare	$122.40
Rate for Payer: BCBS MT CHIP	$122.40
Rate for Payer: BCBS MT Closed Plan Network	$129.20
Rate for Payer: BCBS MT HealthLink	$122.40
Rate for Payer: BCBS MT Medicare	$122.40
Rate for Payer: BCBS MT POS	$129.20
Rate for Payer: BCBS MT Traditional	$136.00
Rate for Payer: Cash Price	$122.40
Rate for Payer: Cigna Commercial	$129.20
Rate for Payer: Cigna Medicare	$122.40
Rate for Payer: Medicaid All Medicaid	$125.12
Rate for Payer: Medicare All Medicare	$95.20
Rate for Payer: Monida Allegiance	$129.20
Rate for Payer: Monida First Choice Health	$131.92
Rate for Payer: Monida Montana Health Co-op	$129.20
Rate for Payer: Monida PacificSource	$129.20

Know your out-of-pocket cost for care.

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