Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

INJ AND/OR ASPIRATION JOINT INJ SMALL

Facility

$396.00

Service Code	CPT 20600
Hospital Charge Code	8020600
Hospital Revenue Code	521
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: Aetna Medicare	$356.40
Rate for Payer: BCBS MT CHIP	$356.40
Rate for Payer: BCBS MT Closed Plan Network	$376.20
Rate for Payer: BCBS MT HealthLink	$356.40
Rate for Payer: BCBS MT Medicare	$356.40
Rate for Payer: BCBS MT POS	$376.20
Rate for Payer: BCBS MT Traditional	$396.00
Rate for Payer: Cash Price	$356.40
Rate for Payer: Cigna Commercial	$376.20
Rate for Payer: Cigna Medicare	$356.40
Rate for Payer: Medicaid All Medicaid	$364.32
Rate for Payer: Medicare All Medicare	$277.20
Rate for Payer: Monida Allegiance	$376.20
Rate for Payer: Monida First Choice Health	$384.12
Rate for Payer: Monida Montana Health Co-op	$376.20
Rate for Payer: Monida PacificSource	$376.20

INJ AND/OR ASPIR JNT INTRMD W/O US 20605

Facility

$672.00

Service Code	CPT 20605
Hospital Charge Code	520605
Hospital Revenue Code	761
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

INJ AND/OR ASPIR JNT INTRMD W/O US 20605

Facility

$672.00

Service Code	CPT 20605
Hospital Charge Code	520605
Hospital Revenue Code	761
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

INJ AND/OR ASPIR JNT SMALL 20600

Facility

$396.00

Service Code	CPT 20600
Hospital Charge Code	520600
Hospital Revenue Code	760
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: Aetna Medicare	$356.40
Rate for Payer: BCBS MT CHIP	$356.40
Rate for Payer: BCBS MT Closed Plan Network	$376.20
Rate for Payer: BCBS MT HealthLink	$356.40
Rate for Payer: BCBS MT Medicare	$356.40
Rate for Payer: BCBS MT POS	$376.20
Rate for Payer: BCBS MT Traditional	$396.00
Rate for Payer: Cash Price	$356.40
Rate for Payer: Cigna Commercial	$376.20
Rate for Payer: Cigna Medicare	$356.40
Rate for Payer: Medicaid All Medicaid	$364.32
Rate for Payer: Medicare All Medicare	$277.20
Rate for Payer: Monida Allegiance	$376.20
Rate for Payer: Monida First Choice Health	$384.12
Rate for Payer: Monida Montana Health Co-op	$376.20
Rate for Payer: Monida PacificSource	$376.20

INJ AND/OR ASPIR JNT SMALL 20600

Facility

$396.00

Service Code	CPT 20600
Hospital Charge Code	520600
Hospital Revenue Code	760
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$396.00
Rate for Payer: Aetna Commercial	$376.20
Rate for Payer: Aetna Medicare	$356.40
Rate for Payer: BCBS MT CHIP	$356.40
Rate for Payer: BCBS MT Closed Plan Network	$376.20
Rate for Payer: BCBS MT HealthLink	$356.40
Rate for Payer: BCBS MT Medicare	$356.40
Rate for Payer: BCBS MT POS	$376.20
Rate for Payer: BCBS MT Traditional	$396.00
Rate for Payer: Cash Price	$356.40
Rate for Payer: Cigna Commercial	$376.20
Rate for Payer: Cigna Medicare	$356.40
Rate for Payer: Medicaid All Medicaid	$364.32
Rate for Payer: Medicare All Medicare	$277.20
Rate for Payer: Monida Allegiance	$376.20
Rate for Payer: Monida First Choice Health	$384.12
Rate for Payer: Monida Montana Health Co-op	$376.20
Rate for Payer: Monida PacificSource	$376.20

INJ AND/OR ASPIR JOINT INJ INTERM 20605

Facility

$672.00

Service Code	CPT 20605
Hospital Charge Code	8020605
Hospital Revenue Code	521
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

INJ AND/OR ASPIR JOINT INJ INTERM 20605

Facility

$672.00

Service Code	CPT 20605
Hospital Charge Code	8020605
Hospital Revenue Code	521
Min. Negotiated Rate	$470.40
Max. Negotiated Rate	$672.00
Rate for Payer: Aetna Commercial	$638.40
Rate for Payer: Aetna Medicare	$604.80
Rate for Payer: BCBS MT CHIP	$604.80
Rate for Payer: BCBS MT Closed Plan Network	$638.40
Rate for Payer: BCBS MT HealthLink	$604.80
Rate for Payer: BCBS MT Medicare	$604.80
Rate for Payer: BCBS MT POS	$638.40
Rate for Payer: BCBS MT Traditional	$672.00
Rate for Payer: Cash Price	$604.80
Rate for Payer: Cigna Commercial	$638.40
Rate for Payer: Cigna Medicare	$604.80
Rate for Payer: Medicaid All Medicaid	$618.24
Rate for Payer: Medicare All Medicare	$470.40
Rate for Payer: Monida Allegiance	$638.40
Rate for Payer: Monida First Choice Health	$651.84
Rate for Payer: Monida Montana Health Co-op	$638.40
Rate for Payer: Monida PacificSource	$638.40

INJ AND/OR ASPIR JOINT LG 20610

Facility

$984.00

Service Code	CPT 20610
Hospital Charge Code	8020610
Hospital Revenue Code	521
Min. Negotiated Rate	$688.80
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$934.80
Rate for Payer: Aetna Medicare	$885.60
Rate for Payer: BCBS MT CHIP	$885.60
Rate for Payer: BCBS MT Closed Plan Network	$934.80
Rate for Payer: BCBS MT HealthLink	$885.60
Rate for Payer: BCBS MT Medicare	$885.60
Rate for Payer: BCBS MT POS	$934.80
Rate for Payer: BCBS MT Traditional	$984.00
Rate for Payer: Cash Price	$885.60
Rate for Payer: Cigna Commercial	$934.80
Rate for Payer: Cigna Medicare	$885.60
Rate for Payer: Medicaid All Medicaid	$905.28
Rate for Payer: Medicare All Medicare	$688.80
Rate for Payer: Monida Allegiance	$934.80
Rate for Payer: Monida First Choice Health	$954.48
Rate for Payer: Monida Montana Health Co-op	$934.80
Rate for Payer: Monida PacificSource	$934.80

INJ AND/OR ASPIR JOINT LG 20610

Facility

$984.00

Service Code	CPT 20610
Hospital Charge Code	8020610
Hospital Revenue Code	521
Min. Negotiated Rate	$688.80
Max. Negotiated Rate	$984.00
Rate for Payer: Aetna Commercial	$934.80
Rate for Payer: Aetna Medicare	$885.60
Rate for Payer: BCBS MT CHIP	$885.60
Rate for Payer: BCBS MT Closed Plan Network	$934.80
Rate for Payer: BCBS MT HealthLink	$885.60
Rate for Payer: BCBS MT Medicare	$885.60
Rate for Payer: BCBS MT POS	$934.80
Rate for Payer: BCBS MT Traditional	$984.00
Rate for Payer: Cash Price	$885.60
Rate for Payer: Cigna Commercial	$934.80
Rate for Payer: Cigna Medicare	$885.60
Rate for Payer: Medicaid All Medicaid	$905.28
Rate for Payer: Medicare All Medicare	$688.80
Rate for Payer: Monida Allegiance	$934.80
Rate for Payer: Monida First Choice Health	$954.48
Rate for Payer: Monida Montana Health Co-op	$934.80
Rate for Payer: Monida PacificSource	$934.80

INJECTION, THERAPEUTIC CARPAL TUNNEL

Facility

$260.00

Service Code	CPT 20526
Hospital Charge Code	1520526
Hospital Revenue Code	761
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

INJECTION, THERAPEUTIC CARPAL TUNNEL

Facility

$260.00

Service Code	CPT 20526
Hospital Charge Code	1520526
Hospital Revenue Code	761
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$260.00
Rate for Payer: Aetna Commercial	$247.00
Rate for Payer: Aetna Medicare	$234.00
Rate for Payer: BCBS MT CHIP	$234.00
Rate for Payer: BCBS MT Closed Plan Network	$247.00
Rate for Payer: BCBS MT HealthLink	$234.00
Rate for Payer: BCBS MT Medicare	$234.00
Rate for Payer: BCBS MT POS	$247.00
Rate for Payer: BCBS MT Traditional	$260.00
Rate for Payer: Cash Price	$234.00
Rate for Payer: Cigna Commercial	$247.00
Rate for Payer: Cigna Medicare	$234.00
Rate for Payer: Medicaid All Medicaid	$239.20
Rate for Payer: Medicare All Medicare	$182.00
Rate for Payer: Monida Allegiance	$247.00
Rate for Payer: Monida First Choice Health	$252.20
Rate for Payer: Monida Montana Health Co-op	$247.00
Rate for Payer: Monida PacificSource	$247.00

INJECT SNGL TENDON ORIG/INSERT 20551

Facility

$432.00

Service Code	CPT 20551
Hospital Charge Code	8020551
Hospital Revenue Code	521
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna Commercial	$410.40
Rate for Payer: Aetna Medicare	$388.80
Rate for Payer: BCBS MT CHIP	$388.80
Rate for Payer: BCBS MT Closed Plan Network	$410.40
Rate for Payer: BCBS MT HealthLink	$388.80
Rate for Payer: BCBS MT Medicare	$388.80
Rate for Payer: BCBS MT POS	$410.40
Rate for Payer: BCBS MT Traditional	$432.00
Rate for Payer: Cash Price	$388.80
Rate for Payer: Cigna Commercial	$410.40
Rate for Payer: Cigna Medicare	$388.80
Rate for Payer: Medicaid All Medicaid	$397.44
Rate for Payer: Medicare All Medicare	$302.40
Rate for Payer: Monida Allegiance	$410.40
Rate for Payer: Monida First Choice Health	$419.04
Rate for Payer: Monida Montana Health Co-op	$410.40
Rate for Payer: Monida PacificSource	$410.40

INJECT SNGL TENDON ORIG/INSERT 20551

Facility

$432.00

Service Code	CPT 20551
Hospital Charge Code	8020551
Hospital Revenue Code	521
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna Commercial	$410.40
Rate for Payer: Aetna Medicare	$388.80
Rate for Payer: BCBS MT CHIP	$388.80
Rate for Payer: BCBS MT Closed Plan Network	$410.40
Rate for Payer: BCBS MT HealthLink	$388.80
Rate for Payer: BCBS MT Medicare	$388.80
Rate for Payer: BCBS MT POS	$410.40
Rate for Payer: BCBS MT Traditional	$432.00
Rate for Payer: Cash Price	$388.80
Rate for Payer: Cigna Commercial	$410.40
Rate for Payer: Cigna Medicare	$388.80
Rate for Payer: Medicaid All Medicaid	$397.44
Rate for Payer: Medicare All Medicare	$302.40
Rate for Payer: Monida Allegiance	$410.40
Rate for Payer: Monida First Choice Health	$419.04
Rate for Payer: Monida Montana Health Co-op	$410.40
Rate for Payer: Monida PacificSource	$410.40

INJECT SNGL TENDON SHTH/LIGMT 20550

Facility

$331.00

Service Code	CPT 20550
Hospital Charge Code	8020550
Hospital Revenue Code	521
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$331.00
Rate for Payer: Aetna Commercial	$314.45
Rate for Payer: Aetna Medicare	$297.90
Rate for Payer: BCBS MT CHIP	$297.90
Rate for Payer: BCBS MT Closed Plan Network	$314.45
Rate for Payer: BCBS MT HealthLink	$297.90
Rate for Payer: BCBS MT Medicare	$297.90
Rate for Payer: BCBS MT POS	$314.45
Rate for Payer: BCBS MT Traditional	$331.00
Rate for Payer: Cash Price	$297.90
Rate for Payer: Cigna Commercial	$314.45
Rate for Payer: Cigna Medicare	$297.90
Rate for Payer: Medicaid All Medicaid	$304.52
Rate for Payer: Medicare All Medicare	$231.70
Rate for Payer: Monida Allegiance	$314.45
Rate for Payer: Monida First Choice Health	$321.07
Rate for Payer: Monida Montana Health Co-op	$314.45
Rate for Payer: Monida PacificSource	$314.45

INJECT SNGL TENDON SHTH/LIGMT 20550

Facility

$331.00

Service Code	CPT 20550
Hospital Charge Code	8020550
Hospital Revenue Code	521
Min. Negotiated Rate	$231.70
Max. Negotiated Rate	$331.00
Rate for Payer: Aetna Commercial	$314.45
Rate for Payer: Aetna Medicare	$297.90
Rate for Payer: BCBS MT CHIP	$297.90
Rate for Payer: BCBS MT Closed Plan Network	$314.45
Rate for Payer: BCBS MT HealthLink	$297.90
Rate for Payer: BCBS MT Medicare	$297.90
Rate for Payer: BCBS MT POS	$314.45
Rate for Payer: BCBS MT Traditional	$331.00
Rate for Payer: Cash Price	$297.90
Rate for Payer: Cigna Commercial	$314.45
Rate for Payer: Cigna Medicare	$297.90
Rate for Payer: Medicaid All Medicaid	$304.52
Rate for Payer: Medicare All Medicare	$231.70
Rate for Payer: Monida Allegiance	$314.45
Rate for Payer: Monida First Choice Health	$321.07
Rate for Payer: Monida Montana Health Co-op	$314.45
Rate for Payer: Monida PacificSource	$314.45

INJ INTRALESIONAL, MORE THAN 7 LESIONS

Facility

$193.00

Service Code	CPT 11901
Hospital Charge Code	8011901
Hospital Revenue Code	521
Min. Negotiated Rate	$135.10
Max. Negotiated Rate	$193.00
Rate for Payer: Aetna Commercial	$183.35
Rate for Payer: Aetna Medicare	$173.70
Rate for Payer: BCBS MT CHIP	$173.70
Rate for Payer: BCBS MT Closed Plan Network	$183.35
Rate for Payer: BCBS MT HealthLink	$173.70
Rate for Payer: BCBS MT Medicare	$173.70
Rate for Payer: BCBS MT POS	$183.35
Rate for Payer: BCBS MT Traditional	$193.00
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cigna Commercial	$183.35
Rate for Payer: Cigna Medicare	$173.70
Rate for Payer: Medicaid All Medicaid	$177.56
Rate for Payer: Medicare All Medicare	$135.10
Rate for Payer: Monida Allegiance	$183.35
Rate for Payer: Monida First Choice Health	$187.21
Rate for Payer: Monida Montana Health Co-op	$183.35
Rate for Payer: Monida PacificSource	$183.35

INJ INTRALESIONAL, MORE THAN 7 LESIONS

Facility

$193.00

Service Code	CPT 11901
Hospital Charge Code	8011901
Hospital Revenue Code	521
Min. Negotiated Rate	$135.10
Max. Negotiated Rate	$193.00
Rate for Payer: Aetna Commercial	$183.35
Rate for Payer: Aetna Medicare	$173.70
Rate for Payer: BCBS MT CHIP	$173.70
Rate for Payer: BCBS MT Closed Plan Network	$183.35
Rate for Payer: BCBS MT HealthLink	$173.70
Rate for Payer: BCBS MT Medicare	$173.70
Rate for Payer: BCBS MT POS	$183.35
Rate for Payer: BCBS MT Traditional	$193.00
Rate for Payer: Cash Price	$173.70
Rate for Payer: Cigna Commercial	$183.35
Rate for Payer: Cigna Medicare	$173.70
Rate for Payer: Medicaid All Medicaid	$177.56
Rate for Payer: Medicare All Medicare	$135.10
Rate for Payer: Monida Allegiance	$183.35
Rate for Payer: Monida First Choice Health	$187.21
Rate for Payer: Monida Montana Health Co-op	$183.35
Rate for Payer: Monida PacificSource	$183.35

INJ INTRALESIONAL, UP TO 7 LESIONS

Facility

$182.00

Service Code	CPT 11900
Hospital Charge Code	8011900
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

INJ INTRALESIONAL, UP TO 7 LESIONS

Facility

$182.00

Service Code	CPT 11900
Hospital Charge Code	8011900
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

INJ IPV

Facility

$50.00

Service Code	CPT 90713
Hospital Charge Code	8090713
Hospital Revenue Code	521
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

INJ IPV

Facility

$50.00

Service Code	CPT 90713
Hospital Charge Code	8090713
Hospital Revenue Code	521
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

INJ IV UP TO ONE HR 250-500C

Facility

$5.00

Service Code	CPT 90780
Hospital Charge Code	8090780
Hospital Revenue Code	521
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INJ IV UP TO ONE HR 250-500C

Facility

$5.00

Service Code	CPT 90780
Hospital Charge Code	8090780
Hospital Revenue Code	521
Min. Negotiated Rate	$3.50
Max. Negotiated Rate	$5.00
Rate for Payer: Aetna Commercial	$4.75
Rate for Payer: Aetna Medicare	$4.50
Rate for Payer: BCBS MT CHIP	$4.50
Rate for Payer: BCBS MT Closed Plan Network	$4.75
Rate for Payer: BCBS MT HealthLink	$4.50
Rate for Payer: BCBS MT Medicare	$4.50
Rate for Payer: BCBS MT POS	$4.75
Rate for Payer: BCBS MT Traditional	$5.00
Rate for Payer: Cash Price	$4.50
Rate for Payer: Cigna Commercial	$4.75
Rate for Payer: Cigna Medicare	$4.50
Rate for Payer: Medicaid All Medicaid	$4.60
Rate for Payer: Medicare All Medicare	$3.50
Rate for Payer: Monida Allegiance	$4.75
Rate for Payer: Monida First Choice Health	$4.85
Rate for Payer: Monida Montana Health Co-op	$4.75
Rate for Payer: Monida PacificSource	$4.75

INJ MAJOR JOINT W/US 20611

Facility

$1,042.00

Service Code	CPT 20611
Hospital Charge Code	8020611
Hospital Revenue Code	521
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

INJ MAJOR JOINT W/US 20611

Facility

$1,042.00

Service Code	CPT 20611
Hospital Charge Code	8020611
Hospital Revenue Code	521
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

Know your out-of-pocket cost for care.

All Charges