Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

OP INJ PMGT TRIGEMINAL NERVE BLOCK 64400

Facility

$496.00

Service Code	HCPCS 64400
Hospital Charge Code	1564400
Hospital Revenue Code	761
Min. Negotiated Rate	$347.20
Max. Negotiated Rate	$496.00
Rate for Payer: Aetna Commercial	$471.20
Rate for Payer: Aetna Medicare	$446.40
Rate for Payer: BCBS MT CHIP	$446.40
Rate for Payer: BCBS MT Closed Plan Network	$471.20
Rate for Payer: BCBS MT HealthLink	$446.40
Rate for Payer: BCBS MT Medicare	$446.40
Rate for Payer: BCBS MT POS	$471.20
Rate for Payer: BCBS MT Traditional	$496.00
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cigna Commercial	$471.20
Rate for Payer: Cigna Medicare	$446.40
Rate for Payer: Medicaid All Medicaid	$456.32
Rate for Payer: Medicare All Medicare	$347.20
Rate for Payer: Monida Allegiance	$471.20
Rate for Payer: Monida First Choice Health	$481.12
Rate for Payer: Monida Montana Health Co-op	$471.20
Rate for Payer: Monida PacificSource	$471.20

OP INJ PMGT TRIGEMINAL NERVE BLOCK 64400

Facility

$496.00

Service Code	HCPCS 64400
Hospital Charge Code	1564400
Hospital Revenue Code	761
Min. Negotiated Rate	$347.20
Max. Negotiated Rate	$496.00
Rate for Payer: Aetna Commercial	$471.20
Rate for Payer: Aetna Medicare	$446.40
Rate for Payer: BCBS MT CHIP	$446.40
Rate for Payer: BCBS MT Closed Plan Network	$471.20
Rate for Payer: BCBS MT HealthLink	$446.40
Rate for Payer: BCBS MT Medicare	$446.40
Rate for Payer: BCBS MT POS	$471.20
Rate for Payer: BCBS MT Traditional	$496.00
Rate for Payer: Cash Price	$446.40
Rate for Payer: Cigna Commercial	$471.20
Rate for Payer: Cigna Medicare	$446.40
Rate for Payer: Medicaid All Medicaid	$456.32
Rate for Payer: Medicare All Medicare	$347.20
Rate for Payer: Monida Allegiance	$471.20
Rate for Payer: Monida First Choice Health	$481.12
Rate for Payer: Monida Montana Health Co-op	$471.20
Rate for Payer: Monida PacificSource	$471.20

OP INJ RFA C/T 1ST JOINT 64633

Facility

$2,198.00

Service Code	HCPCS 64633
Hospital Charge Code	1564633
Hospital Revenue Code	761
Min. Negotiated Rate	$1,538.60
Max. Negotiated Rate	$2,198.00
Rate for Payer: Aetna Commercial	$2,088.10
Rate for Payer: Aetna Medicare	$1,978.20
Rate for Payer: BCBS MT CHIP	$1,978.20
Rate for Payer: BCBS MT Closed Plan Network	$2,088.10
Rate for Payer: BCBS MT HealthLink	$1,978.20
Rate for Payer: BCBS MT Medicare	$1,978.20
Rate for Payer: BCBS MT POS	$2,088.10
Rate for Payer: BCBS MT Traditional	$2,198.00
Rate for Payer: Cash Price	$1,978.20
Rate for Payer: Cigna Commercial	$2,088.10
Rate for Payer: Cigna Medicare	$1,978.20
Rate for Payer: Medicaid All Medicaid	$2,022.16
Rate for Payer: Medicare All Medicare	$1,538.60
Rate for Payer: Monida Allegiance	$2,088.10
Rate for Payer: Monida First Choice Health	$2,132.06
Rate for Payer: Monida Montana Health Co-op	$2,088.10
Rate for Payer: Monida PacificSource	$2,088.10

OP INJ RFA C/T 1ST JOINT 64633

Facility

$2,198.00

Service Code	HCPCS 64633
Hospital Charge Code	1564633
Hospital Revenue Code	761
Min. Negotiated Rate	$1,538.60
Max. Negotiated Rate	$2,198.00
Rate for Payer: Aetna Commercial	$2,088.10
Rate for Payer: Aetna Medicare	$1,978.20
Rate for Payer: BCBS MT CHIP	$1,978.20
Rate for Payer: BCBS MT Closed Plan Network	$2,088.10
Rate for Payer: BCBS MT HealthLink	$1,978.20
Rate for Payer: BCBS MT Medicare	$1,978.20
Rate for Payer: BCBS MT POS	$2,088.10
Rate for Payer: BCBS MT Traditional	$2,198.00
Rate for Payer: Cash Price	$1,978.20
Rate for Payer: Cigna Commercial	$2,088.10
Rate for Payer: Cigna Medicare	$1,978.20
Rate for Payer: Medicaid All Medicaid	$2,022.16
Rate for Payer: Medicare All Medicare	$1,538.60
Rate for Payer: Monida Allegiance	$2,088.10
Rate for Payer: Monida First Choice Health	$2,132.06
Rate for Payer: Monida Montana Health Co-op	$2,088.10
Rate for Payer: Monida PacificSource	$2,088.10

OP INJ RFA C/T EA ADD ON JT 64634

Facility

$924.00

Service Code	HCPCS 64634
Hospital Charge Code	1564634
Hospital Revenue Code	761
Min. Negotiated Rate	$646.80
Max. Negotiated Rate	$924.00
Rate for Payer: Aetna Commercial	$877.80
Rate for Payer: Aetna Medicare	$831.60
Rate for Payer: BCBS MT CHIP	$831.60
Rate for Payer: BCBS MT Closed Plan Network	$877.80
Rate for Payer: BCBS MT HealthLink	$831.60
Rate for Payer: BCBS MT Medicare	$831.60
Rate for Payer: BCBS MT POS	$877.80
Rate for Payer: BCBS MT Traditional	$924.00
Rate for Payer: Cash Price	$831.60
Rate for Payer: Cigna Commercial	$877.80
Rate for Payer: Cigna Medicare	$831.60
Rate for Payer: Medicaid All Medicaid	$850.08
Rate for Payer: Medicare All Medicare	$646.80
Rate for Payer: Monida Allegiance	$877.80
Rate for Payer: Monida First Choice Health	$896.28
Rate for Payer: Monida Montana Health Co-op	$877.80
Rate for Payer: Monida PacificSource	$877.80

OP INJ RFA C/T EA ADD ON JT 64634

Facility

$924.00

Service Code	HCPCS 64634
Hospital Charge Code	1564634
Hospital Revenue Code	761
Min. Negotiated Rate	$646.80
Max. Negotiated Rate	$924.00
Rate for Payer: Aetna Commercial	$877.80
Rate for Payer: Aetna Medicare	$831.60
Rate for Payer: BCBS MT CHIP	$831.60
Rate for Payer: BCBS MT Closed Plan Network	$877.80
Rate for Payer: BCBS MT HealthLink	$831.60
Rate for Payer: BCBS MT Medicare	$831.60
Rate for Payer: BCBS MT POS	$877.80
Rate for Payer: BCBS MT Traditional	$924.00
Rate for Payer: Cash Price	$831.60
Rate for Payer: Cigna Commercial	$877.80
Rate for Payer: Cigna Medicare	$831.60
Rate for Payer: Medicaid All Medicaid	$850.08
Rate for Payer: Medicare All Medicare	$646.80
Rate for Payer: Monida Allegiance	$877.80
Rate for Payer: Monida First Choice Health	$896.28
Rate for Payer: Monida Montana Health Co-op	$877.80
Rate for Payer: Monida PacificSource	$877.80

OP INJ RFA L/S 1ST JOINT 64635

Facility

$2,441.00

Service Code	HCPCS 64635
Hospital Charge Code	1564635
Hospital Revenue Code	761
Min. Negotiated Rate	$1,708.70
Max. Negotiated Rate	$2,441.00
Rate for Payer: Aetna Commercial	$2,318.95
Rate for Payer: Aetna Medicare	$2,196.90
Rate for Payer: BCBS MT CHIP	$2,196.90
Rate for Payer: BCBS MT Closed Plan Network	$2,318.95
Rate for Payer: BCBS MT HealthLink	$2,196.90
Rate for Payer: BCBS MT Medicare	$2,196.90
Rate for Payer: BCBS MT POS	$2,318.95
Rate for Payer: BCBS MT Traditional	$2,441.00
Rate for Payer: Cash Price	$2,196.90
Rate for Payer: Cigna Commercial	$2,318.95
Rate for Payer: Cigna Medicare	$2,196.90
Rate for Payer: Medicaid All Medicaid	$2,245.72
Rate for Payer: Medicare All Medicare	$1,708.70
Rate for Payer: Monida Allegiance	$2,318.95
Rate for Payer: Monida First Choice Health	$2,367.77
Rate for Payer: Monida Montana Health Co-op	$2,318.95
Rate for Payer: Monida PacificSource	$2,318.95

OP INJ RFA L/S 1ST JOINT 64635

Facility

$2,441.00

Service Code	HCPCS 64635
Hospital Charge Code	1564635
Hospital Revenue Code	761
Min. Negotiated Rate	$1,708.70
Max. Negotiated Rate	$2,441.00
Rate for Payer: Aetna Commercial	$2,318.95
Rate for Payer: Aetna Medicare	$2,196.90
Rate for Payer: BCBS MT CHIP	$2,196.90
Rate for Payer: BCBS MT Closed Plan Network	$2,318.95
Rate for Payer: BCBS MT HealthLink	$2,196.90
Rate for Payer: BCBS MT Medicare	$2,196.90
Rate for Payer: BCBS MT POS	$2,318.95
Rate for Payer: BCBS MT Traditional	$2,441.00
Rate for Payer: Cash Price	$2,196.90
Rate for Payer: Cigna Commercial	$2,318.95
Rate for Payer: Cigna Medicare	$2,196.90
Rate for Payer: Medicaid All Medicaid	$2,245.72
Rate for Payer: Medicare All Medicare	$1,708.70
Rate for Payer: Monida Allegiance	$2,318.95
Rate for Payer: Monida First Choice Health	$2,367.77
Rate for Payer: Monida Montana Health Co-op	$2,318.95
Rate for Payer: Monida PacificSource	$2,318.95

OP INJ RFA L/S EADD JOINT 64636

Facility

$1,294.00

Service Code	HCPCS 64636
Hospital Charge Code	1564636
Hospital Revenue Code	761
Min. Negotiated Rate	$905.80
Max. Negotiated Rate	$1,294.00
Rate for Payer: Aetna Commercial	$1,229.30
Rate for Payer: Aetna Medicare	$1,164.60
Rate for Payer: BCBS MT CHIP	$1,164.60
Rate for Payer: BCBS MT Closed Plan Network	$1,229.30
Rate for Payer: BCBS MT HealthLink	$1,164.60
Rate for Payer: BCBS MT Medicare	$1,164.60
Rate for Payer: BCBS MT POS	$1,229.30
Rate for Payer: BCBS MT Traditional	$1,294.00
Rate for Payer: Cash Price	$1,164.60
Rate for Payer: Cigna Commercial	$1,229.30
Rate for Payer: Cigna Medicare	$1,164.60
Rate for Payer: Medicaid All Medicaid	$1,190.48
Rate for Payer: Medicare All Medicare	$905.80
Rate for Payer: Monida Allegiance	$1,229.30
Rate for Payer: Monida First Choice Health	$1,255.18
Rate for Payer: Monida Montana Health Co-op	$1,229.30
Rate for Payer: Monida PacificSource	$1,229.30

OP INJ RFA L/S EADD JOINT 64636

Facility

$1,294.00

Service Code	HCPCS 64636
Hospital Charge Code	1564636
Hospital Revenue Code	761
Min. Negotiated Rate	$905.80
Max. Negotiated Rate	$1,294.00
Rate for Payer: Aetna Commercial	$1,229.30
Rate for Payer: Aetna Medicare	$1,164.60
Rate for Payer: BCBS MT CHIP	$1,164.60
Rate for Payer: BCBS MT Closed Plan Network	$1,229.30
Rate for Payer: BCBS MT HealthLink	$1,164.60
Rate for Payer: BCBS MT Medicare	$1,164.60
Rate for Payer: BCBS MT POS	$1,229.30
Rate for Payer: BCBS MT Traditional	$1,294.00
Rate for Payer: Cash Price	$1,164.60
Rate for Payer: Cigna Commercial	$1,229.30
Rate for Payer: Cigna Medicare	$1,164.60
Rate for Payer: Medicaid All Medicaid	$1,190.48
Rate for Payer: Medicare All Medicare	$905.80
Rate for Payer: Monida Allegiance	$1,229.30
Rate for Payer: Monida First Choice Health	$1,255.18
Rate for Payer: Monida Montana Health Co-op	$1,229.30
Rate for Payer: Monida PacificSource	$1,229.30

OP INJ SACROILLIAC W/IMAGE 27096

Facility

$273.00

Service Code	HCPCS 27096
Hospital Charge Code	1527096
Hospital Revenue Code	761
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

OP INJ SACROILLIAC W/IMAGE 27096

Facility

$273.00

Service Code	HCPCS 27096
Hospital Charge Code	1527096
Hospital Revenue Code	761
Min. Negotiated Rate	$191.10
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna Commercial	$259.35
Rate for Payer: Aetna Medicare	$245.70
Rate for Payer: BCBS MT CHIP	$245.70
Rate for Payer: BCBS MT Closed Plan Network	$259.35
Rate for Payer: BCBS MT HealthLink	$245.70
Rate for Payer: BCBS MT Medicare	$245.70
Rate for Payer: BCBS MT POS	$259.35
Rate for Payer: BCBS MT Traditional	$273.00
Rate for Payer: Cash Price	$245.70
Rate for Payer: Cigna Commercial	$259.35
Rate for Payer: Cigna Medicare	$245.70
Rate for Payer: Medicaid All Medicaid	$251.16
Rate for Payer: Medicare All Medicare	$191.10
Rate for Payer: Monida Allegiance	$259.35
Rate for Payer: Monida First Choice Health	$264.81
Rate for Payer: Monida Montana Health Co-op	$259.35
Rate for Payer: Monida PacificSource	$259.35

OP INJ SCIATIC NERVE BLOCK 64445

Facility

$1,825.00

Service Code	HCPCS 64445
Hospital Charge Code	564445
Hospital Revenue Code	760
Min. Negotiated Rate	$1,277.50
Max. Negotiated Rate	$1,825.00
Rate for Payer: Aetna Commercial	$1,733.75
Rate for Payer: Aetna Medicare	$1,642.50
Rate for Payer: BCBS MT CHIP	$1,642.50
Rate for Payer: BCBS MT Closed Plan Network	$1,733.75
Rate for Payer: BCBS MT HealthLink	$1,642.50
Rate for Payer: BCBS MT Medicare	$1,642.50
Rate for Payer: BCBS MT POS	$1,733.75
Rate for Payer: BCBS MT Traditional	$1,825.00
Rate for Payer: Cash Price	$1,642.50
Rate for Payer: Cigna Commercial	$1,733.75
Rate for Payer: Cigna Medicare	$1,642.50
Rate for Payer: Medicaid All Medicaid	$1,679.00
Rate for Payer: Medicare All Medicare	$1,277.50
Rate for Payer: Monida Allegiance	$1,733.75
Rate for Payer: Monida First Choice Health	$1,770.25
Rate for Payer: Monida Montana Health Co-op	$1,733.75
Rate for Payer: Monida PacificSource	$1,733.75

OP INJ SCIATIC NERVE BLOCK 64445

Facility

$1,825.00

Service Code	HCPCS 64445
Hospital Charge Code	564445
Hospital Revenue Code	760
Min. Negotiated Rate	$1,277.50
Max. Negotiated Rate	$1,825.00
Rate for Payer: Aetna Commercial	$1,733.75
Rate for Payer: Aetna Medicare	$1,642.50
Rate for Payer: BCBS MT CHIP	$1,642.50
Rate for Payer: BCBS MT Closed Plan Network	$1,733.75
Rate for Payer: BCBS MT HealthLink	$1,642.50
Rate for Payer: BCBS MT Medicare	$1,642.50
Rate for Payer: BCBS MT POS	$1,733.75
Rate for Payer: BCBS MT Traditional	$1,825.00
Rate for Payer: Cash Price	$1,642.50
Rate for Payer: Cigna Commercial	$1,733.75
Rate for Payer: Cigna Medicare	$1,642.50
Rate for Payer: Medicaid All Medicaid	$1,679.00
Rate for Payer: Medicare All Medicare	$1,277.50
Rate for Payer: Monida Allegiance	$1,733.75
Rate for Payer: Monida First Choice Health	$1,770.25
Rate for Payer: Monida Montana Health Co-op	$1,733.75
Rate for Payer: Monida PacificSource	$1,733.75

OP INJ SPHENOPALGANG BLOC 64505

Facility

$614.00

Service Code	HCPCS 64505
Hospital Charge Code	1564505
Hospital Revenue Code	761
Min. Negotiated Rate	$429.80
Max. Negotiated Rate	$614.00
Rate for Payer: Aetna Commercial	$583.30
Rate for Payer: Aetna Medicare	$552.60
Rate for Payer: BCBS MT CHIP	$552.60
Rate for Payer: BCBS MT Closed Plan Network	$583.30
Rate for Payer: BCBS MT HealthLink	$552.60
Rate for Payer: BCBS MT Medicare	$552.60
Rate for Payer: BCBS MT POS	$583.30
Rate for Payer: BCBS MT Traditional	$614.00
Rate for Payer: Cash Price	$552.60
Rate for Payer: Cigna Commercial	$583.30
Rate for Payer: Cigna Medicare	$552.60
Rate for Payer: Medicaid All Medicaid	$564.88
Rate for Payer: Medicare All Medicare	$429.80
Rate for Payer: Monida Allegiance	$583.30
Rate for Payer: Monida First Choice Health	$595.58
Rate for Payer: Monida Montana Health Co-op	$583.30
Rate for Payer: Monida PacificSource	$583.30

OP INJ SPHENOPALGANG BLOC 64505

Facility

$614.00

Service Code	HCPCS 64505
Hospital Charge Code	1564505
Hospital Revenue Code	761
Min. Negotiated Rate	$429.80
Max. Negotiated Rate	$614.00
Rate for Payer: Aetna Commercial	$583.30
Rate for Payer: Aetna Medicare	$552.60
Rate for Payer: BCBS MT CHIP	$552.60
Rate for Payer: BCBS MT Closed Plan Network	$583.30
Rate for Payer: BCBS MT HealthLink	$552.60
Rate for Payer: BCBS MT Medicare	$552.60
Rate for Payer: BCBS MT POS	$583.30
Rate for Payer: BCBS MT Traditional	$614.00
Rate for Payer: Cash Price	$552.60
Rate for Payer: Cigna Commercial	$583.30
Rate for Payer: Cigna Medicare	$552.60
Rate for Payer: Medicaid All Medicaid	$564.88
Rate for Payer: Medicare All Medicare	$429.80
Rate for Payer: Monida Allegiance	$583.30
Rate for Payer: Monida First Choice Health	$595.58
Rate for Payer: Monida Montana Health Co-op	$583.30
Rate for Payer: Monida PacificSource	$583.30

OP INJ STELLATE GANG BLOCK 64510

Facility

$1,303.00

Service Code	HCPCS 64510
Hospital Charge Code	1564510
Hospital Revenue Code	761
Min. Negotiated Rate	$912.10
Max. Negotiated Rate	$1,303.00
Rate for Payer: Aetna Commercial	$1,237.85
Rate for Payer: Aetna Medicare	$1,172.70
Rate for Payer: BCBS MT CHIP	$1,172.70
Rate for Payer: BCBS MT Closed Plan Network	$1,237.85
Rate for Payer: BCBS MT HealthLink	$1,172.70
Rate for Payer: BCBS MT Medicare	$1,172.70
Rate for Payer: BCBS MT POS	$1,237.85
Rate for Payer: BCBS MT Traditional	$1,303.00
Rate for Payer: Cash Price	$1,172.70
Rate for Payer: Cigna Commercial	$1,237.85
Rate for Payer: Cigna Medicare	$1,172.70
Rate for Payer: Medicaid All Medicaid	$1,198.76
Rate for Payer: Medicare All Medicare	$912.10
Rate for Payer: Monida Allegiance	$1,237.85
Rate for Payer: Monida First Choice Health	$1,263.91
Rate for Payer: Monida Montana Health Co-op	$1,237.85
Rate for Payer: Monida PacificSource	$1,237.85

OP INJ STELLATE GANG BLOCK 64510

Facility

$1,303.00

Service Code	HCPCS 64510
Hospital Charge Code	1564510
Hospital Revenue Code	761
Min. Negotiated Rate	$912.10
Max. Negotiated Rate	$1,303.00
Rate for Payer: Aetna Commercial	$1,237.85
Rate for Payer: Aetna Medicare	$1,172.70
Rate for Payer: BCBS MT CHIP	$1,172.70
Rate for Payer: BCBS MT Closed Plan Network	$1,237.85
Rate for Payer: BCBS MT HealthLink	$1,172.70
Rate for Payer: BCBS MT Medicare	$1,172.70
Rate for Payer: BCBS MT POS	$1,237.85
Rate for Payer: BCBS MT Traditional	$1,303.00
Rate for Payer: Cash Price	$1,172.70
Rate for Payer: Cigna Commercial	$1,237.85
Rate for Payer: Cigna Medicare	$1,172.70
Rate for Payer: Medicaid All Medicaid	$1,198.76
Rate for Payer: Medicare All Medicare	$912.10
Rate for Payer: Monida Allegiance	$1,237.85
Rate for Payer: Monida First Choice Health	$1,263.91
Rate for Payer: Monida Montana Health Co-op	$1,237.85
Rate for Payer: Monida PacificSource	$1,237.85

OP INJ SUP HYPOGSTRC PLX BL 64517

Facility

$1,242.00

Service Code	HCPCS 64517
Hospital Charge Code	1564517
Hospital Revenue Code	761
Min. Negotiated Rate	$869.40
Max. Negotiated Rate	$1,242.00
Rate for Payer: Aetna Commercial	$1,179.90
Rate for Payer: Aetna Medicare	$1,117.80
Rate for Payer: BCBS MT CHIP	$1,117.80
Rate for Payer: BCBS MT Closed Plan Network	$1,179.90
Rate for Payer: BCBS MT HealthLink	$1,117.80
Rate for Payer: BCBS MT Medicare	$1,117.80
Rate for Payer: BCBS MT POS	$1,179.90
Rate for Payer: BCBS MT Traditional	$1,242.00
Rate for Payer: Cash Price	$1,117.80
Rate for Payer: Cigna Commercial	$1,179.90
Rate for Payer: Cigna Medicare	$1,117.80
Rate for Payer: Medicaid All Medicaid	$1,142.64
Rate for Payer: Medicare All Medicare	$869.40
Rate for Payer: Monida Allegiance	$1,179.90
Rate for Payer: Monida First Choice Health	$1,204.74
Rate for Payer: Monida Montana Health Co-op	$1,179.90
Rate for Payer: Monida PacificSource	$1,179.90

OP INJ SUP HYPOGSTRC PLX BL 64517

Facility

$1,242.00

Service Code	HCPCS 64517
Hospital Charge Code	1564517
Hospital Revenue Code	761
Min. Negotiated Rate	$869.40
Max. Negotiated Rate	$1,242.00
Rate for Payer: Aetna Commercial	$1,179.90
Rate for Payer: Aetna Medicare	$1,117.80
Rate for Payer: BCBS MT CHIP	$1,117.80
Rate for Payer: BCBS MT Closed Plan Network	$1,179.90
Rate for Payer: BCBS MT HealthLink	$1,117.80
Rate for Payer: BCBS MT Medicare	$1,117.80
Rate for Payer: BCBS MT POS	$1,179.90
Rate for Payer: BCBS MT Traditional	$1,242.00
Rate for Payer: Cash Price	$1,117.80
Rate for Payer: Cigna Commercial	$1,179.90
Rate for Payer: Cigna Medicare	$1,117.80
Rate for Payer: Medicaid All Medicaid	$1,142.64
Rate for Payer: Medicare All Medicare	$869.40
Rate for Payer: Monida Allegiance	$1,179.90
Rate for Payer: Monida First Choice Health	$1,204.74
Rate for Payer: Monida Montana Health Co-op	$1,179.90
Rate for Payer: Monida PacificSource	$1,179.90

OP INJ SUPRASCAPULAR NERVE 64418

Facility

$800.00

Service Code	HCPCS 64418
Hospital Charge Code	1564418
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 SUPRASCAPULAR NERVE 64418

Facility

$800.00

Service Code	HCPCS 64418
Hospital Charge Code	1564418
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 TRANSFOR C/T 1ST 64479

Facility

$1,634.00

Service Code	HCPCS 64479
Hospital Charge Code	1564479
Hospital Revenue Code	761
Min. Negotiated Rate	$1,143.80
Max. Negotiated Rate	$1,634.00
Rate for Payer: Aetna Commercial	$1,552.30
Rate for Payer: Aetna Medicare	$1,470.60
Rate for Payer: BCBS MT CHIP	$1,470.60
Rate for Payer: BCBS MT Closed Plan Network	$1,552.30
Rate for Payer: BCBS MT HealthLink	$1,470.60
Rate for Payer: BCBS MT Medicare	$1,470.60
Rate for Payer: BCBS MT POS	$1,552.30
Rate for Payer: BCBS MT Traditional	$1,634.00
Rate for Payer: Cash Price	$1,470.60
Rate for Payer: Cigna Commercial	$1,552.30
Rate for Payer: Cigna Medicare	$1,470.60
Rate for Payer: Medicaid All Medicaid	$1,503.28
Rate for Payer: Medicare All Medicare	$1,143.80
Rate for Payer: Monida Allegiance	$1,552.30
Rate for Payer: Monida First Choice Health	$1,584.98
Rate for Payer: Monida Montana Health Co-op	$1,552.30
Rate for Payer: Monida PacificSource	$1,552.30

OP INJ TRANSFOR C/T 1ST 64479

Facility

$1,634.00

Service Code	HCPCS 64479
Hospital Charge Code	1564479
Hospital Revenue Code	761
Min. Negotiated Rate	$1,143.80
Max. Negotiated Rate	$1,634.00
Rate for Payer: Aetna Commercial	$1,552.30
Rate for Payer: Aetna Medicare	$1,470.60
Rate for Payer: BCBS MT CHIP	$1,470.60
Rate for Payer: BCBS MT Closed Plan Network	$1,552.30
Rate for Payer: BCBS MT HealthLink	$1,470.60
Rate for Payer: BCBS MT Medicare	$1,470.60
Rate for Payer: BCBS MT POS	$1,552.30
Rate for Payer: BCBS MT Traditional	$1,634.00
Rate for Payer: Cash Price	$1,470.60
Rate for Payer: Cigna Commercial	$1,552.30
Rate for Payer: Cigna Medicare	$1,470.60
Rate for Payer: Medicaid All Medicaid	$1,503.28
Rate for Payer: Medicare All Medicare	$1,143.80
Rate for Payer: Monida Allegiance	$1,552.30
Rate for Payer: Monida First Choice Health	$1,584.98
Rate for Payer: Monida Montana Health Co-op	$1,552.30
Rate for Payer: Monida PacificSource	$1,552.30

Know your out-of-pocket cost for care.

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