Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OP INJ FACET JNT L/S 2 L 64494

Facility

$785.00

Service Code	HCPCS 64494
Hospital Charge Code	1564494
Hospital Revenue Code	761
Min. Negotiated Rate	$549.50
Max. Negotiated Rate	$785.00
Rate for Payer: Aetna Commercial	$745.75
Rate for Payer: Aetna Medicare	$706.50
Rate for Payer: BCBS MT CHIP	$706.50
Rate for Payer: BCBS MT Closed Plan Network	$745.75
Rate for Payer: BCBS MT HealthLink	$706.50
Rate for Payer: BCBS MT Medicare	$706.50
Rate for Payer: BCBS MT POS	$745.75
Rate for Payer: BCBS MT Traditional	$785.00
Rate for Payer: Cash Price	$706.50
Rate for Payer: Cigna Commercial	$745.75
Rate for Payer: Cigna Medicare	$706.50
Rate for Payer: Medicaid All Medicaid	$722.20
Rate for Payer: Medicare All Medicare	$549.50
Rate for Payer: Monida Allegiance	$745.75
Rate for Payer: Monida First Choice Health	$761.45
Rate for Payer: Monida Montana Health Co-op	$745.75
Rate for Payer: Monida PacificSource	$745.75

OP INJ FACET JNT L/S 2 L 64494

Facility

$785.00

Service Code	HCPCS 64494
Hospital Charge Code	1564494
Hospital Revenue Code	761
Min. Negotiated Rate	$549.50
Max. Negotiated Rate	$785.00
Rate for Payer: Aetna Commercial	$745.75
Rate for Payer: Aetna Medicare	$706.50
Rate for Payer: BCBS MT CHIP	$706.50
Rate for Payer: BCBS MT Closed Plan Network	$745.75
Rate for Payer: BCBS MT HealthLink	$706.50
Rate for Payer: BCBS MT Medicare	$706.50
Rate for Payer: BCBS MT POS	$745.75
Rate for Payer: BCBS MT Traditional	$785.00
Rate for Payer: Cash Price	$706.50
Rate for Payer: Cigna Commercial	$745.75
Rate for Payer: Cigna Medicare	$706.50
Rate for Payer: Medicaid All Medicaid	$722.20
Rate for Payer: Medicare All Medicare	$549.50
Rate for Payer: Monida Allegiance	$745.75
Rate for Payer: Monida First Choice Health	$761.45
Rate for Payer: Monida Montana Health Co-op	$745.75
Rate for Payer: Monida PacificSource	$745.75

OP INJ FACET JNT L/S 3L + 64495

Facility

$748.00

Service Code	HCPCS 64495
Hospital Charge Code	1564495
Hospital Revenue Code	761
Min. Negotiated Rate	$523.60
Max. Negotiated Rate	$748.00
Rate for Payer: Aetna Commercial	$710.60
Rate for Payer: Aetna Medicare	$673.20
Rate for Payer: BCBS MT CHIP	$673.20
Rate for Payer: BCBS MT Closed Plan Network	$710.60
Rate for Payer: BCBS MT HealthLink	$673.20
Rate for Payer: BCBS MT Medicare	$673.20
Rate for Payer: BCBS MT POS	$710.60
Rate for Payer: BCBS MT Traditional	$748.00
Rate for Payer: Cash Price	$673.20
Rate for Payer: Cigna Commercial	$710.60
Rate for Payer: Cigna Medicare	$673.20
Rate for Payer: Medicaid All Medicaid	$688.16
Rate for Payer: Medicare All Medicare	$523.60
Rate for Payer: Monida Allegiance	$710.60
Rate for Payer: Monida First Choice Health	$725.56
Rate for Payer: Monida Montana Health Co-op	$710.60
Rate for Payer: Monida PacificSource	$710.60

OP INJ FACET JNT L/S 3L + 64495

Facility

$748.00

Service Code	HCPCS 64495
Hospital Charge Code	1564495
Hospital Revenue Code	761
Min. Negotiated Rate	$523.60
Max. Negotiated Rate	$748.00
Rate for Payer: Aetna Commercial	$710.60
Rate for Payer: Aetna Medicare	$673.20
Rate for Payer: BCBS MT CHIP	$673.20
Rate for Payer: BCBS MT Closed Plan Network	$710.60
Rate for Payer: BCBS MT HealthLink	$673.20
Rate for Payer: BCBS MT Medicare	$673.20
Rate for Payer: BCBS MT POS	$710.60
Rate for Payer: BCBS MT Traditional	$748.00
Rate for Payer: Cash Price	$673.20
Rate for Payer: Cigna Commercial	$710.60
Rate for Payer: Cigna Medicare	$673.20
Rate for Payer: Medicaid All Medicaid	$688.16
Rate for Payer: Medicare All Medicare	$523.60
Rate for Payer: Monida Allegiance	$710.60
Rate for Payer: Monida First Choice Health	$725.56
Rate for Payer: Monida Montana Health Co-op	$710.60
Rate for Payer: Monida PacificSource	$710.60

OP INJ FEMORAL NERVE BLOCK 64447

Facility

$1,892.00

Service Code	HCPCS 64447
Hospital Charge Code	1564447
Hospital Revenue Code	761
Min. Negotiated Rate	$1,324.40
Max. Negotiated Rate	$1,892.00
Rate for Payer: Aetna Commercial	$1,797.40
Rate for Payer: Aetna Medicare	$1,702.80
Rate for Payer: BCBS MT CHIP	$1,702.80
Rate for Payer: BCBS MT Closed Plan Network	$1,797.40
Rate for Payer: BCBS MT HealthLink	$1,702.80
Rate for Payer: BCBS MT Medicare	$1,702.80
Rate for Payer: BCBS MT POS	$1,797.40
Rate for Payer: BCBS MT Traditional	$1,892.00
Rate for Payer: Cash Price	$1,702.80
Rate for Payer: Cigna Commercial	$1,797.40
Rate for Payer: Cigna Medicare	$1,702.80
Rate for Payer: Medicaid All Medicaid	$1,740.64
Rate for Payer: Medicare All Medicare	$1,324.40
Rate for Payer: Monida Allegiance	$1,797.40
Rate for Payer: Monida First Choice Health	$1,835.24
Rate for Payer: Monida Montana Health Co-op	$1,797.40
Rate for Payer: Monida PacificSource	$1,797.40

OP INJ FEMORAL NERVE BLOCK 64447

Facility

$1,892.00

Service Code	HCPCS 64447
Hospital Charge Code	1564447
Hospital Revenue Code	761
Min. Negotiated Rate	$1,324.40
Max. Negotiated Rate	$1,892.00
Rate for Payer: Aetna Commercial	$1,797.40
Rate for Payer: Aetna Medicare	$1,702.80
Rate for Payer: BCBS MT CHIP	$1,702.80
Rate for Payer: BCBS MT Closed Plan Network	$1,797.40
Rate for Payer: BCBS MT HealthLink	$1,702.80
Rate for Payer: BCBS MT Medicare	$1,702.80
Rate for Payer: BCBS MT POS	$1,797.40
Rate for Payer: BCBS MT Traditional	$1,892.00
Rate for Payer: Cash Price	$1,702.80
Rate for Payer: Cigna Commercial	$1,797.40
Rate for Payer: Cigna Medicare	$1,702.80
Rate for Payer: Medicaid All Medicaid	$1,740.64
Rate for Payer: Medicare All Medicare	$1,324.40
Rate for Payer: Monida Allegiance	$1,797.40
Rate for Payer: Monida First Choice Health	$1,835.24
Rate for Payer: Monida Montana Health Co-op	$1,797.40
Rate for Payer: Monida PacificSource	$1,797.40

OP INJ GRTER OCCIPT NERVE BLOCK 64405

Facility

$631.00

Service Code	HCPCS 64405
Hospital Charge Code	1564405
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 GRTER OCCIPT NERVE BLOCK 64405

Facility

$631.00

Service Code	HCPCS 64405
Hospital Charge Code	1564405
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 ILIOING/ILIOHYPOG NV BLOCK 64425

Facility

$775.00

Service Code	HCPCS 64425
Hospital Charge Code	1564425
Hospital Revenue Code	761
Min. Negotiated Rate	$542.50
Max. Negotiated Rate	$775.00
Rate for Payer: Aetna Commercial	$736.25
Rate for Payer: Aetna Medicare	$697.50
Rate for Payer: BCBS MT CHIP	$697.50
Rate for Payer: BCBS MT Closed Plan Network	$736.25
Rate for Payer: BCBS MT HealthLink	$697.50
Rate for Payer: BCBS MT Medicare	$697.50
Rate for Payer: BCBS MT POS	$736.25
Rate for Payer: BCBS MT Traditional	$775.00
Rate for Payer: Cash Price	$697.50
Rate for Payer: Cigna Commercial	$736.25
Rate for Payer: Cigna Medicare	$697.50
Rate for Payer: Medicaid All Medicaid	$713.00
Rate for Payer: Medicare All Medicare	$542.50
Rate for Payer: Monida Allegiance	$736.25
Rate for Payer: Monida First Choice Health	$751.75
Rate for Payer: Monida Montana Health Co-op	$736.25
Rate for Payer: Monida PacificSource	$736.25

OP INJ ILIOING/ILIOHYPOG NV BLOCK 64425

Facility

$775.00

Service Code	HCPCS 64425
Hospital Charge Code	1564425
Hospital Revenue Code	761
Min. Negotiated Rate	$542.50
Max. Negotiated Rate	$775.00
Rate for Payer: Aetna Commercial	$736.25
Rate for Payer: Aetna Medicare	$697.50
Rate for Payer: BCBS MT CHIP	$697.50
Rate for Payer: BCBS MT Closed Plan Network	$736.25
Rate for Payer: BCBS MT HealthLink	$697.50
Rate for Payer: BCBS MT Medicare	$697.50
Rate for Payer: BCBS MT POS	$736.25
Rate for Payer: BCBS MT Traditional	$775.00
Rate for Payer: Cash Price	$697.50
Rate for Payer: Cigna Commercial	$736.25
Rate for Payer: Cigna Medicare	$697.50
Rate for Payer: Medicaid All Medicaid	$713.00
Rate for Payer: Medicare All Medicare	$542.50
Rate for Payer: Monida Allegiance	$736.25
Rate for Payer: Monida First Choice Health	$751.75
Rate for Payer: Monida Montana Health Co-op	$736.25
Rate for Payer: Monida PacificSource	$736.25

OP INJ INTRCOST NERVE BLOCK SINGLE 64420

Facility

$800.00

Service Code	HCPCS 64420
Hospital Charge Code	1564420
Hospital Revenue Code	761
Min. Negotiated Rate	$560.00
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$760.00
Rate for Payer: Aetna Medicare	$720.00
Rate for Payer: BCBS MT CHIP	$720.00
Rate for Payer: BCBS MT Closed Plan Network	$760.00
Rate for Payer: BCBS MT HealthLink	$720.00
Rate for Payer: BCBS MT Medicare	$720.00
Rate for Payer: BCBS MT POS	$760.00
Rate for Payer: BCBS MT Traditional	$800.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial	$760.00
Rate for Payer: Cigna Medicare	$720.00
Rate for Payer: Medicaid All Medicaid	$736.00
Rate for Payer: Medicare All Medicare	$560.00
Rate for Payer: Monida Allegiance	$760.00
Rate for Payer: Monida First Choice Health	$776.00
Rate for Payer: Monida Montana Health Co-op	$760.00
Rate for Payer: Monida PacificSource	$760.00

OP INJ INTRCOST NERVE BLOCK SINGLE 64420

Facility

$800.00

Service Code	HCPCS 64420
Hospital Charge Code	1564420
Hospital Revenue Code	761
Min. Negotiated Rate	$560.00
Max. Negotiated Rate	$800.00
Rate for Payer: Aetna Commercial	$760.00
Rate for Payer: Aetna Medicare	$720.00
Rate for Payer: BCBS MT CHIP	$720.00
Rate for Payer: BCBS MT Closed Plan Network	$760.00
Rate for Payer: BCBS MT HealthLink	$720.00
Rate for Payer: BCBS MT Medicare	$720.00
Rate for Payer: BCBS MT POS	$760.00
Rate for Payer: BCBS MT Traditional	$800.00
Rate for Payer: Cash Price	$720.00
Rate for Payer: Cigna Commercial	$760.00
Rate for Payer: Cigna Medicare	$720.00
Rate for Payer: Medicaid All Medicaid	$736.00
Rate for Payer: Medicare All Medicare	$560.00
Rate for Payer: Monida Allegiance	$760.00
Rate for Payer: Monida First Choice Health	$776.00
Rate for Payer: Monida Montana Health Co-op	$760.00
Rate for Payer: Monida PacificSource	$760.00

OP INJ INTRLAMIN LUMAB W/IMA 62323

Facility

$2,216.00

Service Code	HCPCS 62323
Hospital Charge Code	1562323
Hospital Revenue Code	761
Min. Negotiated Rate	$1,551.20
Max. Negotiated Rate	$2,216.00
Rate for Payer: Aetna Commercial	$2,105.20
Rate for Payer: Aetna Medicare	$1,994.40
Rate for Payer: BCBS MT CHIP	$1,994.40
Rate for Payer: BCBS MT Closed Plan Network	$2,105.20
Rate for Payer: BCBS MT HealthLink	$1,994.40
Rate for Payer: BCBS MT Medicare	$1,994.40
Rate for Payer: BCBS MT POS	$2,105.20
Rate for Payer: BCBS MT Traditional	$2,216.00
Rate for Payer: Cash Price	$1,994.40
Rate for Payer: Cigna Commercial	$2,105.20
Rate for Payer: Cigna Medicare	$1,994.40
Rate for Payer: Medicaid All Medicaid	$2,038.72
Rate for Payer: Medicare All Medicare	$1,551.20
Rate for Payer: Monida Allegiance	$2,105.20
Rate for Payer: Monida First Choice Health	$2,149.52
Rate for Payer: Monida Montana Health Co-op	$2,105.20
Rate for Payer: Monida PacificSource	$2,105.20

OP INJ INTRLAMIN LUMAB W/IMA 62323

Facility

$2,216.00

Service Code	HCPCS 62323
Hospital Charge Code	1562323
Hospital Revenue Code	761
Min. Negotiated Rate	$1,551.20
Max. Negotiated Rate	$2,216.00
Rate for Payer: Aetna Commercial	$2,105.20
Rate for Payer: Aetna Medicare	$1,994.40
Rate for Payer: BCBS MT CHIP	$1,994.40
Rate for Payer: BCBS MT Closed Plan Network	$2,105.20
Rate for Payer: BCBS MT HealthLink	$1,994.40
Rate for Payer: BCBS MT Medicare	$1,994.40
Rate for Payer: BCBS MT POS	$2,105.20
Rate for Payer: BCBS MT Traditional	$2,216.00
Rate for Payer: Cash Price	$1,994.40
Rate for Payer: Cigna Commercial	$2,105.20
Rate for Payer: Cigna Medicare	$1,994.40
Rate for Payer: Medicaid All Medicaid	$2,038.72
Rate for Payer: Medicare All Medicare	$1,551.20
Rate for Payer: Monida Allegiance	$2,105.20
Rate for Payer: Monida First Choice Health	$2,149.52
Rate for Payer: Monida Montana Health Co-op	$2,105.20
Rate for Payer: Monida PacificSource	$2,105.20

OP INJ MAJOR JOINT W/O US 20610

Facility

$979.00

Service Code	HCPCS 20610
Hospital Charge Code	1520610
Hospital Revenue Code	761
Min. Negotiated Rate	$685.30
Max. Negotiated Rate	$979.00
Rate for Payer: Aetna Commercial	$930.05
Rate for Payer: Aetna Medicare	$881.10
Rate for Payer: BCBS MT CHIP	$881.10
Rate for Payer: BCBS MT Closed Plan Network	$930.05
Rate for Payer: BCBS MT HealthLink	$881.10
Rate for Payer: BCBS MT Medicare	$881.10
Rate for Payer: BCBS MT POS	$930.05
Rate for Payer: BCBS MT Traditional	$979.00
Rate for Payer: Cash Price	$881.10
Rate for Payer: Cigna Commercial	$930.05
Rate for Payer: Cigna Medicare	$881.10
Rate for Payer: Medicaid All Medicaid	$900.68
Rate for Payer: Medicare All Medicare	$685.30
Rate for Payer: Monida Allegiance	$930.05
Rate for Payer: Monida First Choice Health	$949.63
Rate for Payer: Monida Montana Health Co-op	$930.05
Rate for Payer: Monida PacificSource	$930.05

OP INJ MAJOR JOINT W/O US 20610

Facility

$979.00

Service Code	HCPCS 20610
Hospital Charge Code	1520610
Hospital Revenue Code	761
Min. Negotiated Rate	$685.30
Max. Negotiated Rate	$979.00
Rate for Payer: Aetna Commercial	$930.05
Rate for Payer: Aetna Medicare	$881.10
Rate for Payer: BCBS MT CHIP	$881.10
Rate for Payer: BCBS MT Closed Plan Network	$930.05
Rate for Payer: BCBS MT HealthLink	$881.10
Rate for Payer: BCBS MT Medicare	$881.10
Rate for Payer: BCBS MT POS	$930.05
Rate for Payer: BCBS MT Traditional	$979.00
Rate for Payer: Cash Price	$881.10
Rate for Payer: Cigna Commercial	$930.05
Rate for Payer: Cigna Medicare	$881.10
Rate for Payer: Medicaid All Medicaid	$900.68
Rate for Payer: Medicare All Medicare	$685.30
Rate for Payer: Monida Allegiance	$930.05
Rate for Payer: Monida First Choice Health	$949.63
Rate for Payer: Monida Montana Health Co-op	$930.05
Rate for Payer: Monida PacificSource	$930.05

OP INJ MAJOR JOINT W/US 20611

Facility

$979.00

Service Code	HCPCS 20611
Hospital Charge Code	1520611
Hospital Revenue Code	761
Min. Negotiated Rate	$685.30
Max. Negotiated Rate	$979.00
Rate for Payer: Aetna Commercial	$930.05
Rate for Payer: Aetna Medicare	$881.10
Rate for Payer: BCBS MT CHIP	$881.10
Rate for Payer: BCBS MT Closed Plan Network	$930.05
Rate for Payer: BCBS MT HealthLink	$881.10
Rate for Payer: BCBS MT Medicare	$881.10
Rate for Payer: BCBS MT POS	$930.05
Rate for Payer: BCBS MT Traditional	$979.00
Rate for Payer: Cash Price	$881.10
Rate for Payer: Cigna Commercial	$930.05
Rate for Payer: Cigna Medicare	$881.10
Rate for Payer: Medicaid All Medicaid	$900.68
Rate for Payer: Medicare All Medicare	$685.30
Rate for Payer: Monida Allegiance	$930.05
Rate for Payer: Monida First Choice Health	$949.63
Rate for Payer: Monida Montana Health Co-op	$930.05
Rate for Payer: Monida PacificSource	$930.05

OP INJ MAJOR JOINT W/US 20611

Facility

$979.00

Service Code	HCPCS 20611
Hospital Charge Code	1520611
Hospital Revenue Code	761
Min. Negotiated Rate	$685.30
Max. Negotiated Rate	$979.00
Rate for Payer: Aetna Commercial	$930.05
Rate for Payer: Aetna Medicare	$881.10
Rate for Payer: BCBS MT CHIP	$881.10
Rate for Payer: BCBS MT Closed Plan Network	$930.05
Rate for Payer: BCBS MT HealthLink	$881.10
Rate for Payer: BCBS MT Medicare	$881.10
Rate for Payer: BCBS MT POS	$930.05
Rate for Payer: BCBS MT Traditional	$979.00
Rate for Payer: Cash Price	$881.10
Rate for Payer: Cigna Commercial	$930.05
Rate for Payer: Cigna Medicare	$881.10
Rate for Payer: Medicaid All Medicaid	$900.68
Rate for Payer: Medicare All Medicare	$685.30
Rate for Payer: Monida Allegiance	$930.05
Rate for Payer: Monida First Choice Health	$949.63
Rate for Payer: Monida Montana Health Co-op	$930.05
Rate for Payer: Monida PacificSource	$930.05

OP INJ OP INJ TRANFOR C/T ADDTL 64480

Facility

$894.00

Service Code	HCPCS 64480
Hospital Charge Code	1564480
Hospital Revenue Code	761
Min. Negotiated Rate	$625.80
Max. Negotiated Rate	$894.00
Rate for Payer: Aetna Commercial	$849.30
Rate for Payer: Aetna Medicare	$804.60
Rate for Payer: BCBS MT CHIP	$804.60
Rate for Payer: BCBS MT Closed Plan Network	$849.30
Rate for Payer: BCBS MT HealthLink	$804.60
Rate for Payer: BCBS MT Medicare	$804.60
Rate for Payer: BCBS MT POS	$849.30
Rate for Payer: BCBS MT Traditional	$894.00
Rate for Payer: Cash Price	$804.60
Rate for Payer: Cigna Commercial	$849.30
Rate for Payer: Cigna Medicare	$804.60
Rate for Payer: Medicaid All Medicaid	$822.48
Rate for Payer: Medicare All Medicare	$625.80
Rate for Payer: Monida Allegiance	$849.30
Rate for Payer: Monida First Choice Health	$867.18
Rate for Payer: Monida Montana Health Co-op	$849.30
Rate for Payer: Monida PacificSource	$849.30

OP INJ OP INJ TRANFOR C/T ADDTL 64480

Facility

$894.00

Service Code	HCPCS 64480
Hospital Charge Code	1564480
Hospital Revenue Code	761
Min. Negotiated Rate	$625.80
Max. Negotiated Rate	$894.00
Rate for Payer: Aetna Commercial	$849.30
Rate for Payer: Aetna Medicare	$804.60
Rate for Payer: BCBS MT CHIP	$804.60
Rate for Payer: BCBS MT Closed Plan Network	$849.30
Rate for Payer: BCBS MT HealthLink	$804.60
Rate for Payer: BCBS MT Medicare	$804.60
Rate for Payer: BCBS MT POS	$849.30
Rate for Payer: BCBS MT Traditional	$894.00
Rate for Payer: Cash Price	$804.60
Rate for Payer: Cigna Commercial	$849.30
Rate for Payer: Cigna Medicare	$804.60
Rate for Payer: Medicaid All Medicaid	$822.48
Rate for Payer: Medicare All Medicare	$625.80
Rate for Payer: Monida Allegiance	$849.30
Rate for Payer: Monida First Choice Health	$867.18
Rate for Payer: Monida Montana Health Co-op	$849.30
Rate for Payer: Monida PacificSource	$849.30

OP INJ OP INJ TRANSFORA L/S 1 64483

Facility

$2,344.00

Service Code	HCPCS 64483
Hospital Charge Code	1564483
Hospital Revenue Code	761
Min. Negotiated Rate	$1,640.80
Max. Negotiated Rate	$2,344.00
Rate for Payer: Aetna Commercial	$2,226.80
Rate for Payer: Aetna Medicare	$2,109.60
Rate for Payer: BCBS MT CHIP	$2,109.60
Rate for Payer: BCBS MT Closed Plan Network	$2,226.80
Rate for Payer: BCBS MT HealthLink	$2,109.60
Rate for Payer: BCBS MT Medicare	$2,109.60
Rate for Payer: BCBS MT POS	$2,226.80
Rate for Payer: BCBS MT Traditional	$2,344.00
Rate for Payer: Cash Price	$2,109.60
Rate for Payer: Cigna Commercial	$2,226.80
Rate for Payer: Cigna Medicare	$2,109.60
Rate for Payer: Medicaid All Medicaid	$2,156.48
Rate for Payer: Medicare All Medicare	$1,640.80
Rate for Payer: Monida Allegiance	$2,226.80
Rate for Payer: Monida First Choice Health	$2,273.68
Rate for Payer: Monida Montana Health Co-op	$2,226.80
Rate for Payer: Monida PacificSource	$2,226.80

OP INJ OP INJ TRANSFORA L/S 1 64483

Facility

$2,344.00

Service Code	HCPCS 64483
Hospital Charge Code	1564483
Hospital Revenue Code	761
Min. Negotiated Rate	$1,640.80
Max. Negotiated Rate	$2,344.00
Rate for Payer: Aetna Commercial	$2,226.80
Rate for Payer: Aetna Medicare	$2,109.60
Rate for Payer: BCBS MT CHIP	$2,109.60
Rate for Payer: BCBS MT Closed Plan Network	$2,226.80
Rate for Payer: BCBS MT HealthLink	$2,109.60
Rate for Payer: BCBS MT Medicare	$2,109.60
Rate for Payer: BCBS MT POS	$2,226.80
Rate for Payer: BCBS MT Traditional	$2,344.00
Rate for Payer: Cash Price	$2,109.60
Rate for Payer: Cigna Commercial	$2,226.80
Rate for Payer: Cigna Medicare	$2,109.60
Rate for Payer: Medicaid All Medicaid	$2,156.48
Rate for Payer: Medicare All Medicare	$1,640.80
Rate for Payer: Monida Allegiance	$2,226.80
Rate for Payer: Monida First Choice Health	$2,273.68
Rate for Payer: Monida Montana Health Co-op	$2,226.80
Rate for Payer: Monida PacificSource	$2,226.80

OP INJ PARAVERT SYMP BLOCK T/L 64520

Facility

$1,607.00

Service Code	HCPCS 64520
Hospital Charge Code	1564520
Hospital Revenue Code	761
Min. Negotiated Rate	$1,124.90
Max. Negotiated Rate	$1,607.00
Rate for Payer: Aetna Commercial	$1,526.65
Rate for Payer: Aetna Medicare	$1,446.30
Rate for Payer: BCBS MT CHIP	$1,446.30
Rate for Payer: BCBS MT Closed Plan Network	$1,526.65
Rate for Payer: BCBS MT HealthLink	$1,446.30
Rate for Payer: BCBS MT Medicare	$1,446.30
Rate for Payer: BCBS MT POS	$1,526.65
Rate for Payer: BCBS MT Traditional	$1,607.00
Rate for Payer: Cash Price	$1,446.30
Rate for Payer: Cigna Commercial	$1,526.65
Rate for Payer: Cigna Medicare	$1,446.30
Rate for Payer: Medicaid All Medicaid	$1,478.44
Rate for Payer: Medicare All Medicare	$1,124.90
Rate for Payer: Monida Allegiance	$1,526.65
Rate for Payer: Monida First Choice Health	$1,558.79
Rate for Payer: Monida Montana Health Co-op	$1,526.65
Rate for Payer: Monida PacificSource	$1,526.65

OP INJ PARAVERT SYMP BLOCK T/L 64520

Facility

$1,607.00

Service Code	HCPCS 64520
Hospital Charge Code	1564520
Hospital Revenue Code	761
Min. Negotiated Rate	$1,124.90
Max. Negotiated Rate	$1,607.00
Rate for Payer: Aetna Commercial	$1,526.65
Rate for Payer: Aetna Medicare	$1,446.30
Rate for Payer: BCBS MT CHIP	$1,446.30
Rate for Payer: BCBS MT Closed Plan Network	$1,526.65
Rate for Payer: BCBS MT HealthLink	$1,446.30
Rate for Payer: BCBS MT Medicare	$1,446.30
Rate for Payer: BCBS MT POS	$1,526.65
Rate for Payer: BCBS MT Traditional	$1,607.00
Rate for Payer: Cash Price	$1,446.30
Rate for Payer: Cigna Commercial	$1,526.65
Rate for Payer: Cigna Medicare	$1,446.30
Rate for Payer: Medicaid All Medicaid	$1,478.44
Rate for Payer: Medicare All Medicare	$1,124.90
Rate for Payer: Monida Allegiance	$1,526.65
Rate for Payer: Monida First Choice Health	$1,558.79
Rate for Payer: Monida Montana Health Co-op	$1,526.65
Rate for Payer: Monida PacificSource	$1,526.65

OP INJ PLANTAR DIGITAL NERVE BLOCK 64455

Facility

$173.00

Service Code	HCPCS 64455
Hospital Charge Code	1564455
Hospital Revenue Code	761
Min. Negotiated Rate	$121.10
Max. Negotiated Rate	$173.00
Rate for Payer: Aetna Commercial	$164.35
Rate for Payer: Aetna Medicare	$155.70
Rate for Payer: BCBS MT CHIP	$155.70
Rate for Payer: BCBS MT Closed Plan Network	$164.35
Rate for Payer: BCBS MT HealthLink	$155.70
Rate for Payer: BCBS MT Medicare	$155.70
Rate for Payer: BCBS MT POS	$164.35
Rate for Payer: BCBS MT Traditional	$173.00
Rate for Payer: Cash Price	$155.70
Rate for Payer: Cigna Commercial	$164.35
Rate for Payer: Cigna Medicare	$155.70
Rate for Payer: Medicaid All Medicaid	$159.16
Rate for Payer: Medicare All Medicare	$121.10
Rate for Payer: Monida Allegiance	$164.35
Rate for Payer: Monida First Choice Health	$167.81
Rate for Payer: Monida Montana Health Co-op	$164.35
Rate for Payer: Monida PacificSource	$164.35

Know your out-of-pocket cost for care.

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