Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OP IJ PERIPH NV BLOCK/LESSER OCC 64450

Facility

$1,393.00

Service Code	HCPCS 64450
Hospital Charge Code	1564450
Hospital Revenue Code	761
Min. Negotiated Rate	$975.10
Max. Negotiated Rate	$1,393.00
Rate for Payer: Aetna Commercial	$1,323.35
Rate for Payer: Aetna Medicare	$1,253.70
Rate for Payer: BCBS MT CHIP	$1,253.70
Rate for Payer: BCBS MT Closed Plan Network	$1,323.35
Rate for Payer: BCBS MT HealthLink	$1,253.70
Rate for Payer: BCBS MT Medicare	$1,253.70
Rate for Payer: BCBS MT POS	$1,323.35
Rate for Payer: BCBS MT Traditional	$1,393.00
Rate for Payer: Cash Price	$1,253.70
Rate for Payer: Cigna Commercial	$1,323.35
Rate for Payer: Cigna Medicare	$1,253.70
Rate for Payer: Medicaid All Medicaid	$1,281.56
Rate for Payer: Medicare All Medicare	$975.10
Rate for Payer: Monida Allegiance	$1,323.35
Rate for Payer: Monida First Choice Health	$1,351.21
Rate for Payer: Monida Montana Health Co-op	$1,323.35
Rate for Payer: Monida PacificSource	$1,323.35

OP IJ RFA RFA PERPH NV/SUPSCAP 64640

Facility

$1,550.00

Service Code	HCPCS 64640
Hospital Charge Code	1564640
Hospital Revenue Code	761
Min. Negotiated Rate	$1,085.00
Max. Negotiated Rate	$1,550.00
Rate for Payer: Aetna Commercial	$1,472.50
Rate for Payer: Aetna Medicare	$1,395.00
Rate for Payer: BCBS MT CHIP	$1,395.00
Rate for Payer: BCBS MT Closed Plan Network	$1,472.50
Rate for Payer: BCBS MT HealthLink	$1,395.00
Rate for Payer: BCBS MT Medicare	$1,395.00
Rate for Payer: BCBS MT POS	$1,472.50
Rate for Payer: BCBS MT Traditional	$1,550.00
Rate for Payer: Cash Price	$1,395.00
Rate for Payer: Cigna Commercial	$1,472.50
Rate for Payer: Cigna Medicare	$1,395.00
Rate for Payer: Medicaid All Medicaid	$1,426.00
Rate for Payer: Medicare All Medicare	$1,085.00
Rate for Payer: Monida Allegiance	$1,472.50
Rate for Payer: Monida First Choice Health	$1,503.50
Rate for Payer: Monida Montana Health Co-op	$1,472.50
Rate for Payer: Monida PacificSource	$1,472.50

OP IJ RFA RFA PERPH NV/SUPSCAP 64640

Facility

$1,550.00

Service Code	HCPCS 64640
Hospital Charge Code	1564640
Hospital Revenue Code	761
Min. Negotiated Rate	$1,085.00
Max. Negotiated Rate	$1,550.00
Rate for Payer: Aetna Commercial	$1,472.50
Rate for Payer: Aetna Medicare	$1,395.00
Rate for Payer: BCBS MT CHIP	$1,395.00
Rate for Payer: BCBS MT Closed Plan Network	$1,472.50
Rate for Payer: BCBS MT HealthLink	$1,395.00
Rate for Payer: BCBS MT Medicare	$1,395.00
Rate for Payer: BCBS MT POS	$1,472.50
Rate for Payer: BCBS MT Traditional	$1,550.00
Rate for Payer: Cash Price	$1,395.00
Rate for Payer: Cigna Commercial	$1,472.50
Rate for Payer: Cigna Medicare	$1,395.00
Rate for Payer: Medicaid All Medicaid	$1,426.00
Rate for Payer: Medicare All Medicare	$1,085.00
Rate for Payer: Monida Allegiance	$1,472.50
Rate for Payer: Monida First Choice Health	$1,503.50
Rate for Payer: Monida Montana Health Co-op	$1,472.50
Rate for Payer: Monida PacificSource	$1,472.50

OP INJ ANE AGEN AXILLARY NERVE

Facility

$1,668.00

Service Code	HCPCS 64417
Hospital Charge Code	1564417
Hospital Revenue Code	761
Min. Negotiated Rate	$1,167.60
Max. Negotiated Rate	$1,668.00
Rate for Payer: Aetna Commercial	$1,584.60
Rate for Payer: Aetna Medicare	$1,501.20
Rate for Payer: BCBS MT CHIP	$1,501.20
Rate for Payer: BCBS MT Closed Plan Network	$1,584.60
Rate for Payer: BCBS MT HealthLink	$1,501.20
Rate for Payer: BCBS MT Medicare	$1,501.20
Rate for Payer: BCBS MT POS	$1,584.60
Rate for Payer: BCBS MT Traditional	$1,668.00
Rate for Payer: Cash Price	$1,501.20
Rate for Payer: Cigna Commercial	$1,584.60
Rate for Payer: Cigna Medicare	$1,501.20
Rate for Payer: Medicaid All Medicaid	$1,534.56
Rate for Payer: Medicare All Medicare	$1,167.60
Rate for Payer: Monida Allegiance	$1,584.60
Rate for Payer: Monida First Choice Health	$1,617.96
Rate for Payer: Monida Montana Health Co-op	$1,584.60
Rate for Payer: Monida PacificSource	$1,584.60

OP INJ ANE AGEN AXILLARY NERVE

Facility

$1,668.00

Service Code	HCPCS 64417
Hospital Charge Code	1564417
Hospital Revenue Code	761
Min. Negotiated Rate	$1,167.60
Max. Negotiated Rate	$1,668.00
Rate for Payer: Aetna Commercial	$1,584.60
Rate for Payer: Aetna Medicare	$1,501.20
Rate for Payer: BCBS MT CHIP	$1,501.20
Rate for Payer: BCBS MT Closed Plan Network	$1,584.60
Rate for Payer: BCBS MT HealthLink	$1,501.20
Rate for Payer: BCBS MT Medicare	$1,501.20
Rate for Payer: BCBS MT POS	$1,584.60
Rate for Payer: BCBS MT Traditional	$1,668.00
Rate for Payer: Cash Price	$1,501.20
Rate for Payer: Cigna Commercial	$1,584.60
Rate for Payer: Cigna Medicare	$1,501.20
Rate for Payer: Medicaid All Medicaid	$1,534.56
Rate for Payer: Medicare All Medicare	$1,167.60
Rate for Payer: Monida Allegiance	$1,584.60
Rate for Payer: Monida First Choice Health	$1,617.96
Rate for Payer: Monida Montana Health Co-op	$1,584.60
Rate for Payer: Monida PacificSource	$1,584.60

OP INJ BRACHIAL PLEXUS W/IMAGING 64415

Facility

$631.00

Service Code	HCPCS 64415
Hospital Charge Code	1564415
Hospital Revenue Code	761
Min. Negotiated Rate	$441.70
Max. Negotiated Rate	$631.00
Rate for Payer: Aetna Commercial	$599.45
Rate for Payer: Aetna Medicare	$567.90
Rate for Payer: BCBS MT CHIP	$567.90
Rate for Payer: BCBS MT Closed Plan Network	$599.45
Rate for Payer: BCBS MT HealthLink	$567.90
Rate for Payer: BCBS MT Medicare	$567.90
Rate for Payer: BCBS MT POS	$599.45
Rate for Payer: BCBS MT Traditional	$631.00
Rate for Payer: Cash Price	$567.90
Rate for Payer: Cigna Commercial	$599.45
Rate for Payer: Cigna Medicare	$567.90
Rate for Payer: Medicaid All Medicaid	$580.52
Rate for Payer: Medicare All Medicare	$441.70
Rate for Payer: Monida Allegiance	$599.45
Rate for Payer: Monida First Choice Health	$612.07
Rate for Payer: Monida Montana Health Co-op	$599.45
Rate for Payer: Monida PacificSource	$599.45

OP INJ BRACHIAL PLEXUS W/IMAGING 64415

Facility

$631.00

Service Code	HCPCS 64415
Hospital Charge Code	1564415
Hospital Revenue Code	761
Min. Negotiated Rate	$441.70
Max. Negotiated Rate	$631.00
Rate for Payer: Aetna Commercial	$599.45
Rate for Payer: Aetna Medicare	$567.90
Rate for Payer: BCBS MT CHIP	$567.90
Rate for Payer: BCBS MT Closed Plan Network	$599.45
Rate for Payer: BCBS MT HealthLink	$567.90
Rate for Payer: BCBS MT Medicare	$567.90
Rate for Payer: BCBS MT POS	$599.45
Rate for Payer: BCBS MT Traditional	$631.00
Rate for Payer: Cash Price	$567.90
Rate for Payer: Cigna Commercial	$599.45
Rate for Payer: Cigna Medicare	$567.90
Rate for Payer: Medicaid All Medicaid	$580.52
Rate for Payer: Medicare All Medicare	$441.70
Rate for Payer: Monida Allegiance	$599.45
Rate for Payer: Monida First Choice Health	$612.07
Rate for Payer: Monida Montana Health Co-op	$599.45
Rate for Payer: Monida PacificSource	$599.45

OP INJ CELIAC PLEX BLOCK 64530

Facility

$1,734.00

Service Code	HCPCS 64530
Hospital Charge Code	1564530
Hospital Revenue Code	761
Min. Negotiated Rate	$1,213.80
Max. Negotiated Rate	$1,734.00
Rate for Payer: Aetna Commercial	$1,647.30
Rate for Payer: Aetna Medicare	$1,560.60
Rate for Payer: BCBS MT CHIP	$1,560.60
Rate for Payer: BCBS MT Closed Plan Network	$1,647.30
Rate for Payer: BCBS MT HealthLink	$1,560.60
Rate for Payer: BCBS MT Medicare	$1,560.60
Rate for Payer: BCBS MT POS	$1,647.30
Rate for Payer: BCBS MT Traditional	$1,734.00
Rate for Payer: Cash Price	$1,560.60
Rate for Payer: Cigna Commercial	$1,647.30
Rate for Payer: Cigna Medicare	$1,560.60
Rate for Payer: Medicaid All Medicaid	$1,595.28
Rate for Payer: Medicare All Medicare	$1,213.80
Rate for Payer: Monida Allegiance	$1,647.30
Rate for Payer: Monida First Choice Health	$1,681.98
Rate for Payer: Monida Montana Health Co-op	$1,647.30
Rate for Payer: Monida PacificSource	$1,647.30

OP INJ CELIAC PLEX BLOCK 64530

Facility

$1,734.00

Service Code	HCPCS 64530
Hospital Charge Code	1564530
Hospital Revenue Code	761
Min. Negotiated Rate	$1,213.80
Max. Negotiated Rate	$1,734.00
Rate for Payer: Aetna Commercial	$1,647.30
Rate for Payer: Aetna Medicare	$1,560.60
Rate for Payer: BCBS MT CHIP	$1,560.60
Rate for Payer: BCBS MT Closed Plan Network	$1,647.30
Rate for Payer: BCBS MT HealthLink	$1,560.60
Rate for Payer: BCBS MT Medicare	$1,560.60
Rate for Payer: BCBS MT POS	$1,647.30
Rate for Payer: BCBS MT Traditional	$1,734.00
Rate for Payer: Cash Price	$1,560.60
Rate for Payer: Cigna Commercial	$1,647.30
Rate for Payer: Cigna Medicare	$1,560.60
Rate for Payer: Medicaid All Medicaid	$1,595.28
Rate for Payer: Medicare All Medicare	$1,213.80
Rate for Payer: Monida Allegiance	$1,647.30
Rate for Payer: Monida First Choice Health	$1,681.98
Rate for Payer: Monida Montana Health Co-op	$1,647.30
Rate for Payer: Monida PacificSource	$1,647.30

OP INJ DEST FAC NER MIGRN TRT 64615

Facility

$548.00

Service Code	HCPCS 64615
Hospital Charge Code	1564615
Hospital Revenue Code	761
Min. Negotiated Rate	$383.60
Max. Negotiated Rate	$548.00
Rate for Payer: Aetna Commercial	$520.60
Rate for Payer: Aetna Medicare	$493.20
Rate for Payer: BCBS MT CHIP	$493.20
Rate for Payer: BCBS MT Closed Plan Network	$520.60
Rate for Payer: BCBS MT HealthLink	$493.20
Rate for Payer: BCBS MT Medicare	$493.20
Rate for Payer: BCBS MT POS	$520.60
Rate for Payer: BCBS MT Traditional	$548.00
Rate for Payer: Cash Price	$493.20
Rate for Payer: Cigna Commercial	$520.60
Rate for Payer: Cigna Medicare	$493.20
Rate for Payer: Medicaid All Medicaid	$504.16
Rate for Payer: Medicare All Medicare	$383.60
Rate for Payer: Monida Allegiance	$520.60
Rate for Payer: Monida First Choice Health	$531.56
Rate for Payer: Monida Montana Health Co-op	$520.60
Rate for Payer: Monida PacificSource	$520.60

OP INJ DEST FAC NER MIGRN TRT 64615

Facility

$548.00

Service Code	HCPCS 64615
Hospital Charge Code	1564615
Hospital Revenue Code	761
Min. Negotiated Rate	$383.60
Max. Negotiated Rate	$548.00
Rate for Payer: Aetna Commercial	$520.60
Rate for Payer: Aetna Medicare	$493.20
Rate for Payer: BCBS MT CHIP	$493.20
Rate for Payer: BCBS MT Closed Plan Network	$520.60
Rate for Payer: BCBS MT HealthLink	$493.20
Rate for Payer: BCBS MT Medicare	$493.20
Rate for Payer: BCBS MT POS	$520.60
Rate for Payer: BCBS MT Traditional	$548.00
Rate for Payer: Cash Price	$493.20
Rate for Payer: Cigna Commercial	$520.60
Rate for Payer: Cigna Medicare	$493.20
Rate for Payer: Medicaid All Medicaid	$504.16
Rate for Payer: Medicare All Medicare	$383.60
Rate for Payer: Monida Allegiance	$520.60
Rate for Payer: Monida First Choice Health	$531.56
Rate for Payer: Monida Montana Health Co-op	$520.60
Rate for Payer: Monida PacificSource	$520.60

OP INJ DESTR NERO AGT, PLANTAR NV 64632

Facility

$254.00

Service Code	HCPCS 64632
Hospital Charge Code	1564632
Hospital Revenue Code	761
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

OP INJ DESTR NERO AGT, PLANTAR NV 64632

Facility

$254.00

Service Code	HCPCS 64632
Hospital Charge Code	1564632
Hospital Revenue Code	761
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$254.00
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: BCBS MT CHIP	$228.60
Rate for Payer: BCBS MT Closed Plan Network	$241.30
Rate for Payer: BCBS MT HealthLink	$228.60
Rate for Payer: BCBS MT Medicare	$228.60
Rate for Payer: BCBS MT POS	$241.30
Rate for Payer: BCBS MT Traditional	$254.00
Rate for Payer: Cash Price	$228.60
Rate for Payer: Cigna Commercial	$241.30
Rate for Payer: Cigna Medicare	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

OP INJ DESTR NERO AGT, PUDENDAL NV 64630

Facility

$1,662.00

Service Code	HCPCS 64630
Hospital Charge Code	1564630
Hospital Revenue Code	761
Min. Negotiated Rate	$1,163.40
Max. Negotiated Rate	$1,662.00
Rate for Payer: Aetna Commercial	$1,578.90
Rate for Payer: Aetna Medicare	$1,495.80
Rate for Payer: BCBS MT CHIP	$1,495.80
Rate for Payer: BCBS MT Closed Plan Network	$1,578.90
Rate for Payer: BCBS MT HealthLink	$1,495.80
Rate for Payer: BCBS MT Medicare	$1,495.80
Rate for Payer: BCBS MT POS	$1,578.90
Rate for Payer: BCBS MT Traditional	$1,662.00
Rate for Payer: Cash Price	$1,495.80
Rate for Payer: Cigna Commercial	$1,578.90
Rate for Payer: Cigna Medicare	$1,495.80
Rate for Payer: Medicaid All Medicaid	$1,529.04
Rate for Payer: Medicare All Medicare	$1,163.40
Rate for Payer: Monida Allegiance	$1,578.90
Rate for Payer: Monida First Choice Health	$1,612.14
Rate for Payer: Monida Montana Health Co-op	$1,578.90
Rate for Payer: Monida PacificSource	$1,578.90

OP INJ DESTR NERO AGT, PUDENDAL NV 64630

Facility

$1,662.00

Service Code	HCPCS 64630
Hospital Charge Code	1564630
Hospital Revenue Code	761
Min. Negotiated Rate	$1,163.40
Max. Negotiated Rate	$1,662.00
Rate for Payer: Aetna Commercial	$1,578.90
Rate for Payer: Aetna Medicare	$1,495.80
Rate for Payer: BCBS MT CHIP	$1,495.80
Rate for Payer: BCBS MT Closed Plan Network	$1,578.90
Rate for Payer: BCBS MT HealthLink	$1,495.80
Rate for Payer: BCBS MT Medicare	$1,495.80
Rate for Payer: BCBS MT POS	$1,578.90
Rate for Payer: BCBS MT Traditional	$1,662.00
Rate for Payer: Cash Price	$1,495.80
Rate for Payer: Cigna Commercial	$1,578.90
Rate for Payer: Cigna Medicare	$1,495.80
Rate for Payer: Medicaid All Medicaid	$1,529.04
Rate for Payer: Medicare All Medicare	$1,163.40
Rate for Payer: Monida Allegiance	$1,578.90
Rate for Payer: Monida First Choice Health	$1,612.14
Rate for Payer: Monida Montana Health Co-op	$1,578.90
Rate for Payer: Monida PacificSource	$1,578.90

OP INJ DESTRUCTION OF FACIAL NERVE 64612

Facility

$595.00

Service Code	HCPCS 64612
Hospital Charge Code	564612
Hospital Revenue Code	760
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$595.00
Rate for Payer: Aetna Commercial	$565.25
Rate for Payer: Aetna Medicare	$535.50
Rate for Payer: BCBS MT CHIP	$535.50
Rate for Payer: BCBS MT Closed Plan Network	$565.25
Rate for Payer: BCBS MT HealthLink	$535.50
Rate for Payer: BCBS MT Medicare	$535.50
Rate for Payer: BCBS MT POS	$565.25
Rate for Payer: BCBS MT Traditional	$595.00
Rate for Payer: Cash Price	$535.50
Rate for Payer: Cigna Commercial	$565.25
Rate for Payer: Cigna Medicare	$535.50
Rate for Payer: Medicaid All Medicaid	$547.40
Rate for Payer: Medicare All Medicare	$416.50
Rate for Payer: Monida Allegiance	$565.25
Rate for Payer: Monida First Choice Health	$577.15
Rate for Payer: Monida Montana Health Co-op	$565.25
Rate for Payer: Monida PacificSource	$565.25

OP INJ DESTRUCTION OF FACIAL NERVE 64612

Facility

$595.00

Service Code	HCPCS 64612
Hospital Charge Code	564612
Hospital Revenue Code	760
Min. Negotiated Rate	$416.50
Max. Negotiated Rate	$595.00
Rate for Payer: Aetna Commercial	$565.25
Rate for Payer: Aetna Medicare	$535.50
Rate for Payer: BCBS MT CHIP	$535.50
Rate for Payer: BCBS MT Closed Plan Network	$565.25
Rate for Payer: BCBS MT HealthLink	$535.50
Rate for Payer: BCBS MT Medicare	$535.50
Rate for Payer: BCBS MT POS	$565.25
Rate for Payer: BCBS MT Traditional	$595.00
Rate for Payer: Cash Price	$535.50
Rate for Payer: Cigna Commercial	$565.25
Rate for Payer: Cigna Medicare	$535.50
Rate for Payer: Medicaid All Medicaid	$547.40
Rate for Payer: Medicare All Medicare	$416.50
Rate for Payer: Monida Allegiance	$565.25
Rate for Payer: Monida First Choice Health	$577.15
Rate for Payer: Monida Montana Health Co-op	$565.25
Rate for Payer: Monida PacificSource	$565.25

OP INJ FACET JNT C/T 1L W/IMA 64490

Facility

$1,498.00

Service Code	HCPCS 64490
Hospital Charge Code	1564490
Hospital Revenue Code	761
Min. Negotiated Rate	$1,048.60
Max. Negotiated Rate	$1,498.00
Rate for Payer: Aetna Commercial	$1,423.10
Rate for Payer: Aetna Medicare	$1,348.20
Rate for Payer: BCBS MT CHIP	$1,348.20
Rate for Payer: BCBS MT Closed Plan Network	$1,423.10
Rate for Payer: BCBS MT HealthLink	$1,348.20
Rate for Payer: BCBS MT Medicare	$1,348.20
Rate for Payer: BCBS MT POS	$1,423.10
Rate for Payer: BCBS MT Traditional	$1,498.00
Rate for Payer: Cash Price	$1,348.20
Rate for Payer: Cigna Commercial	$1,423.10
Rate for Payer: Cigna Medicare	$1,348.20
Rate for Payer: Medicaid All Medicaid	$1,378.16
Rate for Payer: Medicare All Medicare	$1,048.60
Rate for Payer: Monida Allegiance	$1,423.10
Rate for Payer: Monida First Choice Health	$1,453.06
Rate for Payer: Monida Montana Health Co-op	$1,423.10
Rate for Payer: Monida PacificSource	$1,423.10

OP INJ FACET JNT C/T 1L W/IMA 64490

Facility

$1,498.00

Service Code	HCPCS 64490
Hospital Charge Code	1564490
Hospital Revenue Code	761
Min. Negotiated Rate	$1,048.60
Max. Negotiated Rate	$1,498.00
Rate for Payer: Aetna Commercial	$1,423.10
Rate for Payer: Aetna Medicare	$1,348.20
Rate for Payer: BCBS MT CHIP	$1,348.20
Rate for Payer: BCBS MT Closed Plan Network	$1,423.10
Rate for Payer: BCBS MT HealthLink	$1,348.20
Rate for Payer: BCBS MT Medicare	$1,348.20
Rate for Payer: BCBS MT POS	$1,423.10
Rate for Payer: BCBS MT Traditional	$1,498.00
Rate for Payer: Cash Price	$1,348.20
Rate for Payer: Cigna Commercial	$1,423.10
Rate for Payer: Cigna Medicare	$1,348.20
Rate for Payer: Medicaid All Medicaid	$1,378.16
Rate for Payer: Medicare All Medicare	$1,048.60
Rate for Payer: Monida Allegiance	$1,423.10
Rate for Payer: Monida First Choice Health	$1,453.06
Rate for Payer: Monida Montana Health Co-op	$1,423.10
Rate for Payer: Monida PacificSource	$1,423.10

OP INJ FACET JNT C/T 2ND LEVEL 64491

Facility

$755.00

Service Code	HCPCS 64491
Hospital Charge Code	1564491
Hospital Revenue Code	761
Min. Negotiated Rate	$528.50
Max. Negotiated Rate	$755.00
Rate for Payer: Aetna Commercial	$717.25
Rate for Payer: Aetna Medicare	$679.50
Rate for Payer: BCBS MT CHIP	$679.50
Rate for Payer: BCBS MT Closed Plan Network	$717.25
Rate for Payer: BCBS MT HealthLink	$679.50
Rate for Payer: BCBS MT Medicare	$679.50
Rate for Payer: BCBS MT POS	$717.25
Rate for Payer: BCBS MT Traditional	$755.00
Rate for Payer: Cash Price	$679.50
Rate for Payer: Cigna Commercial	$717.25
Rate for Payer: Cigna Medicare	$679.50
Rate for Payer: Medicaid All Medicaid	$694.60
Rate for Payer: Medicare All Medicare	$528.50
Rate for Payer: Monida Allegiance	$717.25
Rate for Payer: Monida First Choice Health	$732.35
Rate for Payer: Monida Montana Health Co-op	$717.25
Rate for Payer: Monida PacificSource	$717.25

OP INJ FACET JNT C/T 2ND LEVEL 64491

Facility

$755.00

Service Code	HCPCS 64491
Hospital Charge Code	1564491
Hospital Revenue Code	761
Min. Negotiated Rate	$528.50
Max. Negotiated Rate	$755.00
Rate for Payer: Aetna Commercial	$717.25
Rate for Payer: Aetna Medicare	$679.50
Rate for Payer: BCBS MT CHIP	$679.50
Rate for Payer: BCBS MT Closed Plan Network	$717.25
Rate for Payer: BCBS MT HealthLink	$679.50
Rate for Payer: BCBS MT Medicare	$679.50
Rate for Payer: BCBS MT POS	$717.25
Rate for Payer: BCBS MT Traditional	$755.00
Rate for Payer: Cash Price	$679.50
Rate for Payer: Cigna Commercial	$717.25
Rate for Payer: Cigna Medicare	$679.50
Rate for Payer: Medicaid All Medicaid	$694.60
Rate for Payer: Medicare All Medicare	$528.50
Rate for Payer: Monida Allegiance	$717.25
Rate for Payer: Monida First Choice Health	$732.35
Rate for Payer: Monida Montana Health Co-op	$717.25
Rate for Payer: Monida PacificSource	$717.25

OP INJ FACET JNT C/T 3RDL WIM 64492

Facility

$727.00

Service Code	HCPCS 64492
Hospital Charge Code	1564492
Hospital Revenue Code	761
Min. Negotiated Rate	$508.90
Max. Negotiated Rate	$727.00
Rate for Payer: Aetna Commercial	$690.65
Rate for Payer: Aetna Medicare	$654.30
Rate for Payer: BCBS MT CHIP	$654.30
Rate for Payer: BCBS MT Closed Plan Network	$690.65
Rate for Payer: BCBS MT HealthLink	$654.30
Rate for Payer: BCBS MT Medicare	$654.30
Rate for Payer: BCBS MT POS	$690.65
Rate for Payer: BCBS MT Traditional	$727.00
Rate for Payer: Cash Price	$654.30
Rate for Payer: Cigna Commercial	$690.65
Rate for Payer: Cigna Medicare	$654.30
Rate for Payer: Medicaid All Medicaid	$668.84
Rate for Payer: Medicare All Medicare	$508.90
Rate for Payer: Monida Allegiance	$690.65
Rate for Payer: Monida First Choice Health	$705.19
Rate for Payer: Monida Montana Health Co-op	$690.65
Rate for Payer: Monida PacificSource	$690.65

OP INJ FACET JNT C/T 3RDL WIM 64492

Facility

$727.00

Service Code	HCPCS 64492
Hospital Charge Code	1564492
Hospital Revenue Code	761
Min. Negotiated Rate	$508.90
Max. Negotiated Rate	$727.00
Rate for Payer: Aetna Commercial	$690.65
Rate for Payer: Aetna Medicare	$654.30
Rate for Payer: BCBS MT CHIP	$654.30
Rate for Payer: BCBS MT Closed Plan Network	$690.65
Rate for Payer: BCBS MT HealthLink	$654.30
Rate for Payer: BCBS MT Medicare	$654.30
Rate for Payer: BCBS MT POS	$690.65
Rate for Payer: BCBS MT Traditional	$727.00
Rate for Payer: Cash Price	$654.30
Rate for Payer: Cigna Commercial	$690.65
Rate for Payer: Cigna Medicare	$654.30
Rate for Payer: Medicaid All Medicaid	$668.84
Rate for Payer: Medicare All Medicare	$508.90
Rate for Payer: Monida Allegiance	$690.65
Rate for Payer: Monida First Choice Health	$705.19
Rate for Payer: Monida Montana Health Co-op	$690.65
Rate for Payer: Monida PacificSource	$690.65

OP INJ FACET JNT L/S 1L 64493

Facility

$1,524.00

Service Code	HCPCS 64493
Hospital Charge Code	1564493
Hospital Revenue Code	761
Min. Negotiated Rate	$1,066.80
Max. Negotiated Rate	$1,524.00
Rate for Payer: Aetna Commercial	$1,447.80
Rate for Payer: Aetna Medicare	$1,371.60
Rate for Payer: BCBS MT CHIP	$1,371.60
Rate for Payer: BCBS MT Closed Plan Network	$1,447.80
Rate for Payer: BCBS MT HealthLink	$1,371.60
Rate for Payer: BCBS MT Medicare	$1,371.60
Rate for Payer: BCBS MT POS	$1,447.80
Rate for Payer: BCBS MT Traditional	$1,524.00
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Cigna Commercial	$1,447.80
Rate for Payer: Cigna Medicare	$1,371.60
Rate for Payer: Medicaid All Medicaid	$1,402.08
Rate for Payer: Medicare All Medicare	$1,066.80
Rate for Payer: Monida Allegiance	$1,447.80
Rate for Payer: Monida First Choice Health	$1,478.28
Rate for Payer: Monida Montana Health Co-op	$1,447.80
Rate for Payer: Monida PacificSource	$1,447.80

OP INJ FACET JNT L/S 1L 64493

Facility

$1,524.00

Service Code	HCPCS 64493
Hospital Charge Code	1564493
Hospital Revenue Code	761
Min. Negotiated Rate	$1,066.80
Max. Negotiated Rate	$1,524.00
Rate for Payer: Aetna Commercial	$1,447.80
Rate for Payer: Aetna Medicare	$1,371.60
Rate for Payer: BCBS MT CHIP	$1,371.60
Rate for Payer: BCBS MT Closed Plan Network	$1,447.80
Rate for Payer: BCBS MT HealthLink	$1,371.60
Rate for Payer: BCBS MT Medicare	$1,371.60
Rate for Payer: BCBS MT POS	$1,447.80
Rate for Payer: BCBS MT Traditional	$1,524.00
Rate for Payer: Cash Price	$1,371.60
Rate for Payer: Cigna Commercial	$1,447.80
Rate for Payer: Cigna Medicare	$1,371.60
Rate for Payer: Medicaid All Medicaid	$1,402.08
Rate for Payer: Medicare All Medicare	$1,066.80
Rate for Payer: Monida Allegiance	$1,447.80
Rate for Payer: Monida First Choice Health	$1,478.28
Rate for Payer: Monida Montana Health Co-op	$1,447.80
Rate for Payer: Monida PacificSource	$1,447.80

Know your out-of-pocket cost for care.

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