Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OP INJ SACROILLIAC W/IMAGE 27096

Facility

$289.00

Service Code	HCPCS 27096
Hospital Charge Code	1527096
Hospital Revenue Code	761
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

OP INJ SACROILLIAC W/IMAGE 27096

Facility

$289.00

Service Code	HCPCS 27096
Hospital Charge Code	1527096
Hospital Revenue Code	761
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

OP INJ SCIATIC NERVE BLOCK 64445

Facility

$1,935.00

Service Code	HCPCS 64445
Hospital Charge Code	564445
Hospital Revenue Code	760
Min. Negotiated Rate	$1,354.50
Max. Negotiated Rate	$1,935.00
Rate for Payer: Aetna Commercial	$1,838.25
Rate for Payer: Aetna Medicare	$1,741.50
Rate for Payer: BCBS MT CHIP	$1,741.50
Rate for Payer: BCBS MT Closed Plan Network	$1,838.25
Rate for Payer: BCBS MT HealthLink	$1,741.50
Rate for Payer: BCBS MT Medicare	$1,741.50
Rate for Payer: BCBS MT POS	$1,838.25
Rate for Payer: BCBS MT Traditional	$1,935.00
Rate for Payer: Cash Price	$1,741.50
Rate for Payer: Cigna Commercial	$1,838.25
Rate for Payer: Cigna Medicare	$1,741.50
Rate for Payer: Medicaid All Medicaid	$1,780.20
Rate for Payer: Medicare All Medicare	$1,354.50
Rate for Payer: Monida Allegiance	$1,838.25
Rate for Payer: Monida First Choice Health	$1,876.95
Rate for Payer: Monida Montana Health Co-op	$1,838.25
Rate for Payer: Monida PacificSource	$1,838.25

OP INJ SCIATIC NERVE BLOCK 64445

Facility

$1,935.00

Service Code	HCPCS 64445
Hospital Charge Code	564445
Hospital Revenue Code	760
Min. Negotiated Rate	$1,354.50
Max. Negotiated Rate	$1,935.00
Rate for Payer: Aetna Commercial	$1,838.25
Rate for Payer: Aetna Medicare	$1,741.50
Rate for Payer: BCBS MT CHIP	$1,741.50
Rate for Payer: BCBS MT Closed Plan Network	$1,838.25
Rate for Payer: BCBS MT HealthLink	$1,741.50
Rate for Payer: BCBS MT Medicare	$1,741.50
Rate for Payer: BCBS MT POS	$1,838.25
Rate for Payer: BCBS MT Traditional	$1,935.00
Rate for Payer: Cash Price	$1,741.50
Rate for Payer: Cigna Commercial	$1,838.25
Rate for Payer: Cigna Medicare	$1,741.50
Rate for Payer: Medicaid All Medicaid	$1,780.20
Rate for Payer: Medicare All Medicare	$1,354.50
Rate for Payer: Monida Allegiance	$1,838.25
Rate for Payer: Monida First Choice Health	$1,876.95
Rate for Payer: Monida Montana Health Co-op	$1,838.25
Rate for Payer: Monida PacificSource	$1,838.25

OP INJ SPHENOPALGANG BLOC 64505

Facility

$651.00

Service Code	HCPCS 64505
Hospital Charge Code	1564505
Hospital Revenue Code	761
Min. Negotiated Rate	$455.70
Max. Negotiated Rate	$651.00
Rate for Payer: Aetna Commercial	$618.45
Rate for Payer: Aetna Medicare	$585.90
Rate for Payer: BCBS MT CHIP	$585.90
Rate for Payer: BCBS MT Closed Plan Network	$618.45
Rate for Payer: BCBS MT HealthLink	$585.90
Rate for Payer: BCBS MT Medicare	$585.90
Rate for Payer: BCBS MT POS	$618.45
Rate for Payer: BCBS MT Traditional	$651.00
Rate for Payer: Cash Price	$585.90
Rate for Payer: Cigna Commercial	$618.45
Rate for Payer: Cigna Medicare	$585.90
Rate for Payer: Medicaid All Medicaid	$598.92
Rate for Payer: Medicare All Medicare	$455.70
Rate for Payer: Monida Allegiance	$618.45
Rate for Payer: Monida First Choice Health	$631.47
Rate for Payer: Monida Montana Health Co-op	$618.45
Rate for Payer: Monida PacificSource	$618.45

OP INJ SPHENOPALGANG BLOC 64505

Facility

$651.00

Service Code	HCPCS 64505
Hospital Charge Code	1564505
Hospital Revenue Code	761
Min. Negotiated Rate	$455.70
Max. Negotiated Rate	$651.00
Rate for Payer: Aetna Commercial	$618.45
Rate for Payer: Aetna Medicare	$585.90
Rate for Payer: BCBS MT CHIP	$585.90
Rate for Payer: BCBS MT Closed Plan Network	$618.45
Rate for Payer: BCBS MT HealthLink	$585.90
Rate for Payer: BCBS MT Medicare	$585.90
Rate for Payer: BCBS MT POS	$618.45
Rate for Payer: BCBS MT Traditional	$651.00
Rate for Payer: Cash Price	$585.90
Rate for Payer: Cigna Commercial	$618.45
Rate for Payer: Cigna Medicare	$585.90
Rate for Payer: Medicaid All Medicaid	$598.92
Rate for Payer: Medicare All Medicare	$455.70
Rate for Payer: Monida Allegiance	$618.45
Rate for Payer: Monida First Choice Health	$631.47
Rate for Payer: Monida Montana Health Co-op	$618.45
Rate for Payer: Monida PacificSource	$618.45

OP INJ STELLATE GANG BLOCK 64510

Facility

$1,381.00

Service Code	HCPCS 64510
Hospital Charge Code	1564510
Hospital Revenue Code	761
Min. Negotiated Rate	$966.70
Max. Negotiated Rate	$1,381.00
Rate for Payer: Aetna Commercial	$1,311.95
Rate for Payer: Aetna Medicare	$1,242.90
Rate for Payer: BCBS MT CHIP	$1,242.90
Rate for Payer: BCBS MT Closed Plan Network	$1,311.95
Rate for Payer: BCBS MT HealthLink	$1,242.90
Rate for Payer: BCBS MT Medicare	$1,242.90
Rate for Payer: BCBS MT POS	$1,311.95
Rate for Payer: BCBS MT Traditional	$1,381.00
Rate for Payer: Cash Price	$1,242.90
Rate for Payer: Cigna Commercial	$1,311.95
Rate for Payer: Cigna Medicare	$1,242.90
Rate for Payer: Medicaid All Medicaid	$1,270.52
Rate for Payer: Medicare All Medicare	$966.70
Rate for Payer: Monida Allegiance	$1,311.95
Rate for Payer: Monida First Choice Health	$1,339.57
Rate for Payer: Monida Montana Health Co-op	$1,311.95
Rate for Payer: Monida PacificSource	$1,311.95

OP INJ STELLATE GANG BLOCK 64510

Facility

$1,381.00

Service Code	HCPCS 64510
Hospital Charge Code	1564510
Hospital Revenue Code	761
Min. Negotiated Rate	$966.70
Max. Negotiated Rate	$1,381.00
Rate for Payer: Aetna Commercial	$1,311.95
Rate for Payer: Aetna Medicare	$1,242.90
Rate for Payer: BCBS MT CHIP	$1,242.90
Rate for Payer: BCBS MT Closed Plan Network	$1,311.95
Rate for Payer: BCBS MT HealthLink	$1,242.90
Rate for Payer: BCBS MT Medicare	$1,242.90
Rate for Payer: BCBS MT POS	$1,311.95
Rate for Payer: BCBS MT Traditional	$1,381.00
Rate for Payer: Cash Price	$1,242.90
Rate for Payer: Cigna Commercial	$1,311.95
Rate for Payer: Cigna Medicare	$1,242.90
Rate for Payer: Medicaid All Medicaid	$1,270.52
Rate for Payer: Medicare All Medicare	$966.70
Rate for Payer: Monida Allegiance	$1,311.95
Rate for Payer: Monida First Choice Health	$1,339.57
Rate for Payer: Monida Montana Health Co-op	$1,311.95
Rate for Payer: Monida PacificSource	$1,311.95

OP INJ SUP HYPOGSTRC PLX BL 64517

Facility

$1,317.00

Service Code	HCPCS 64517
Hospital Charge Code	1564517
Hospital Revenue Code	761
Min. Negotiated Rate	$921.90
Max. Negotiated Rate	$1,317.00
Rate for Payer: Aetna Commercial	$1,251.15
Rate for Payer: Aetna Medicare	$1,185.30
Rate for Payer: BCBS MT CHIP	$1,185.30
Rate for Payer: BCBS MT Closed Plan Network	$1,251.15
Rate for Payer: BCBS MT HealthLink	$1,185.30
Rate for Payer: BCBS MT Medicare	$1,185.30
Rate for Payer: BCBS MT POS	$1,251.15
Rate for Payer: BCBS MT Traditional	$1,317.00
Rate for Payer: Cash Price	$1,185.30
Rate for Payer: Cigna Commercial	$1,251.15
Rate for Payer: Cigna Medicare	$1,185.30
Rate for Payer: Medicaid All Medicaid	$1,211.64
Rate for Payer: Medicare All Medicare	$921.90
Rate for Payer: Monida Allegiance	$1,251.15
Rate for Payer: Monida First Choice Health	$1,277.49
Rate for Payer: Monida Montana Health Co-op	$1,251.15
Rate for Payer: Monida PacificSource	$1,251.15

OP INJ SUP HYPOGSTRC PLX BL 64517

Facility

$1,317.00

Service Code	HCPCS 64517
Hospital Charge Code	1564517
Hospital Revenue Code	761
Min. Negotiated Rate	$921.90
Max. Negotiated Rate	$1,317.00
Rate for Payer: Aetna Commercial	$1,251.15
Rate for Payer: Aetna Medicare	$1,185.30
Rate for Payer: BCBS MT CHIP	$1,185.30
Rate for Payer: BCBS MT Closed Plan Network	$1,251.15
Rate for Payer: BCBS MT HealthLink	$1,185.30
Rate for Payer: BCBS MT Medicare	$1,185.30
Rate for Payer: BCBS MT POS	$1,251.15
Rate for Payer: BCBS MT Traditional	$1,317.00
Rate for Payer: Cash Price	$1,185.30
Rate for Payer: Cigna Commercial	$1,251.15
Rate for Payer: Cigna Medicare	$1,185.30
Rate for Payer: Medicaid All Medicaid	$1,211.64
Rate for Payer: Medicare All Medicare	$921.90
Rate for Payer: Monida Allegiance	$1,251.15
Rate for Payer: Monida First Choice Health	$1,277.49
Rate for Payer: Monida Montana Health Co-op	$1,251.15
Rate for Payer: Monida PacificSource	$1,251.15

OP INJ SUPRASCAPULAR NERVE 64418

Facility

$848.00

Service Code	HCPCS 64418
Hospital Charge Code	1564418
Hospital Revenue Code	761
Min. Negotiated Rate	$593.60
Max. Negotiated Rate	$848.00
Rate for Payer: Aetna Commercial	$805.60
Rate for Payer: Aetna Medicare	$763.20
Rate for Payer: BCBS MT CHIP	$763.20
Rate for Payer: BCBS MT Closed Plan Network	$805.60
Rate for Payer: BCBS MT HealthLink	$763.20
Rate for Payer: BCBS MT Medicare	$763.20
Rate for Payer: BCBS MT POS	$805.60
Rate for Payer: BCBS MT Traditional	$848.00
Rate for Payer: Cash Price	$763.20
Rate for Payer: Cigna Commercial	$805.60
Rate for Payer: Cigna Medicare	$763.20
Rate for Payer: Medicaid All Medicaid	$780.16
Rate for Payer: Medicare All Medicare	$593.60
Rate for Payer: Monida Allegiance	$805.60
Rate for Payer: Monida First Choice Health	$822.56
Rate for Payer: Monida Montana Health Co-op	$805.60
Rate for Payer: Monida PacificSource	$805.60

OP INJ SUPRASCAPULAR NERVE 64418

Facility

$848.00

Service Code	HCPCS 64418
Hospital Charge Code	1564418
Hospital Revenue Code	761
Min. Negotiated Rate	$593.60
Max. Negotiated Rate	$848.00
Rate for Payer: Aetna Commercial	$805.60
Rate for Payer: Aetna Medicare	$763.20
Rate for Payer: BCBS MT CHIP	$763.20
Rate for Payer: BCBS MT Closed Plan Network	$805.60
Rate for Payer: BCBS MT HealthLink	$763.20
Rate for Payer: BCBS MT Medicare	$763.20
Rate for Payer: BCBS MT POS	$805.60
Rate for Payer: BCBS MT Traditional	$848.00
Rate for Payer: Cash Price	$763.20
Rate for Payer: Cigna Commercial	$805.60
Rate for Payer: Cigna Medicare	$763.20
Rate for Payer: Medicaid All Medicaid	$780.16
Rate for Payer: Medicare All Medicare	$593.60
Rate for Payer: Monida Allegiance	$805.60
Rate for Payer: Monida First Choice Health	$822.56
Rate for Payer: Monida Montana Health Co-op	$805.60
Rate for Payer: Monida PacificSource	$805.60

OP INJ TRANSFOR C/T 1ST 64479

Facility

$1,732.00

Service Code	HCPCS 64479
Hospital Charge Code	1564479
Hospital Revenue Code	761
Min. Negotiated Rate	$1,212.40
Max. Negotiated Rate	$1,732.00
Rate for Payer: Aetna Commercial	$1,645.40
Rate for Payer: Aetna Medicare	$1,558.80
Rate for Payer: BCBS MT CHIP	$1,558.80
Rate for Payer: BCBS MT Closed Plan Network	$1,645.40
Rate for Payer: BCBS MT HealthLink	$1,558.80
Rate for Payer: BCBS MT Medicare	$1,558.80
Rate for Payer: BCBS MT POS	$1,645.40
Rate for Payer: BCBS MT Traditional	$1,732.00
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Cigna Commercial	$1,645.40
Rate for Payer: Cigna Medicare	$1,558.80
Rate for Payer: Medicaid All Medicaid	$1,593.44
Rate for Payer: Medicare All Medicare	$1,212.40
Rate for Payer: Monida Allegiance	$1,645.40
Rate for Payer: Monida First Choice Health	$1,680.04
Rate for Payer: Monida Montana Health Co-op	$1,645.40
Rate for Payer: Monida PacificSource	$1,645.40

OP INJ TRANSFOR C/T 1ST 64479

Facility

$1,732.00

Service Code	HCPCS 64479
Hospital Charge Code	1564479
Hospital Revenue Code	761
Min. Negotiated Rate	$1,212.40
Max. Negotiated Rate	$1,732.00
Rate for Payer: Aetna Commercial	$1,645.40
Rate for Payer: Aetna Medicare	$1,558.80
Rate for Payer: BCBS MT CHIP	$1,558.80
Rate for Payer: BCBS MT Closed Plan Network	$1,645.40
Rate for Payer: BCBS MT HealthLink	$1,558.80
Rate for Payer: BCBS MT Medicare	$1,558.80
Rate for Payer: BCBS MT POS	$1,645.40
Rate for Payer: BCBS MT Traditional	$1,732.00
Rate for Payer: Cash Price	$1,558.80
Rate for Payer: Cigna Commercial	$1,645.40
Rate for Payer: Cigna Medicare	$1,558.80
Rate for Payer: Medicaid All Medicaid	$1,593.44
Rate for Payer: Medicare All Medicare	$1,212.40
Rate for Payer: Monida Allegiance	$1,645.40
Rate for Payer: Monida First Choice Health	$1,680.04
Rate for Payer: Monida Montana Health Co-op	$1,645.40
Rate for Payer: Monida PacificSource	$1,645.40

OP INJ TRANSFOR L/S ADD 64484

Facility

$840.00

Service Code	HCPCS 64484
Hospital Charge Code	1564484
Hospital Revenue Code	761
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna Commercial	$798.00
Rate for Payer: Aetna Medicare	$756.00
Rate for Payer: BCBS MT CHIP	$756.00
Rate for Payer: BCBS MT Closed Plan Network	$798.00
Rate for Payer: BCBS MT HealthLink	$756.00
Rate for Payer: BCBS MT Medicare	$756.00
Rate for Payer: BCBS MT POS	$798.00
Rate for Payer: BCBS MT Traditional	$840.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial	$798.00
Rate for Payer: Cigna Medicare	$756.00
Rate for Payer: Medicaid All Medicaid	$772.80
Rate for Payer: Medicare All Medicare	$588.00
Rate for Payer: Monida Allegiance	$798.00
Rate for Payer: Monida First Choice Health	$814.80
Rate for Payer: Monida Montana Health Co-op	$798.00
Rate for Payer: Monida PacificSource	$798.00

OP INJ TRANSFOR L/S ADD 64484

Facility

$840.00

Service Code	HCPCS 64484
Hospital Charge Code	1564484
Hospital Revenue Code	761
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna Commercial	$798.00
Rate for Payer: Aetna Medicare	$756.00
Rate for Payer: BCBS MT CHIP	$756.00
Rate for Payer: BCBS MT Closed Plan Network	$798.00
Rate for Payer: BCBS MT HealthLink	$756.00
Rate for Payer: BCBS MT Medicare	$756.00
Rate for Payer: BCBS MT POS	$798.00
Rate for Payer: BCBS MT Traditional	$840.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial	$798.00
Rate for Payer: Cigna Medicare	$756.00
Rate for Payer: Medicaid All Medicaid	$772.80
Rate for Payer: Medicare All Medicare	$588.00
Rate for Payer: Monida Allegiance	$798.00
Rate for Payer: Monida First Choice Health	$814.80
Rate for Payer: Monida Montana Health Co-op	$798.00
Rate for Payer: Monida PacificSource	$798.00

OP INTO/INJ GENICULAR NERVE BRANCH 64454

Facility

$695.00

Service Code	HCPCS 64454
Hospital Charge Code	1564454
Hospital Revenue Code	761
Min. Negotiated Rate	$486.50
Max. Negotiated Rate	$695.00
Rate for Payer: Aetna Commercial	$660.25
Rate for Payer: Aetna Medicare	$625.50
Rate for Payer: BCBS MT CHIP	$625.50
Rate for Payer: BCBS MT Closed Plan Network	$660.25
Rate for Payer: BCBS MT HealthLink	$625.50
Rate for Payer: BCBS MT Medicare	$625.50
Rate for Payer: BCBS MT POS	$660.25
Rate for Payer: BCBS MT Traditional	$695.00
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cigna Commercial	$660.25
Rate for Payer: Cigna Medicare	$625.50
Rate for Payer: Medicaid All Medicaid	$639.40
Rate for Payer: Medicare All Medicare	$486.50
Rate for Payer: Monida Allegiance	$660.25
Rate for Payer: Monida First Choice Health	$674.15
Rate for Payer: Monida Montana Health Co-op	$660.25
Rate for Payer: Monida PacificSource	$660.25

OP INTO/INJ GENICULAR NERVE BRANCH 64454

Facility

$695.00

Service Code	HCPCS 64454
Hospital Charge Code	1564454
Hospital Revenue Code	761
Min. Negotiated Rate	$486.50
Max. Negotiated Rate	$695.00
Rate for Payer: Aetna Commercial	$660.25
Rate for Payer: Aetna Medicare	$625.50
Rate for Payer: BCBS MT CHIP	$625.50
Rate for Payer: BCBS MT Closed Plan Network	$660.25
Rate for Payer: BCBS MT HealthLink	$625.50
Rate for Payer: BCBS MT Medicare	$625.50
Rate for Payer: BCBS MT POS	$660.25
Rate for Payer: BCBS MT Traditional	$695.00
Rate for Payer: Cash Price	$625.50
Rate for Payer: Cigna Commercial	$660.25
Rate for Payer: Cigna Medicare	$625.50
Rate for Payer: Medicaid All Medicaid	$639.40
Rate for Payer: Medicare All Medicare	$486.50
Rate for Payer: Monida Allegiance	$660.25
Rate for Payer: Monida First Choice Health	$674.15
Rate for Payer: Monida Montana Health Co-op	$660.25
Rate for Payer: Monida PacificSource	$660.25

OP MAJOR JOINT INJ W/O US 20610

Facility

$984.00

Service Code	HCPCS 20610
Hospital Charge Code	520610
Hospital Revenue Code	761
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

OP MAJOR JOINT INJ W/O US 20610

Facility

$984.00

Service Code	HCPCS 20610
Hospital Charge Code	520610
Hospital Revenue Code	761
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

OP MOD CON SEDATION ADDTL 15 MIN 99153

Facility

$129.00

Service Code	HCPCS 99153
Hospital Charge Code	1599153
Hospital Revenue Code	370
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$129.00
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$116.10
Rate for Payer: BCBS MT CHIP	$116.10
Rate for Payer: BCBS MT Closed Plan Network	$122.55
Rate for Payer: BCBS MT HealthLink	$116.10
Rate for Payer: BCBS MT Medicare	$116.10
Rate for Payer: BCBS MT POS	$122.55
Rate for Payer: BCBS MT Traditional	$129.00
Rate for Payer: Cash Price	$116.10
Rate for Payer: Cigna Commercial	$122.55
Rate for Payer: Cigna Medicare	$116.10
Rate for Payer: Medicaid All Medicaid	$118.68
Rate for Payer: Medicare All Medicare	$90.30
Rate for Payer: Monida Allegiance	$122.55
Rate for Payer: Monida First Choice Health	$125.13
Rate for Payer: Monida Montana Health Co-op	$122.55
Rate for Payer: Monida PacificSource	$122.55

OP MOD CON SEDATION ADDTL 15 MIN 99153

Facility

$129.00

Service Code	HCPCS 99153
Hospital Charge Code	1599153
Hospital Revenue Code	370
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$129.00
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$116.10
Rate for Payer: BCBS MT CHIP	$116.10
Rate for Payer: BCBS MT Closed Plan Network	$122.55
Rate for Payer: BCBS MT HealthLink	$116.10
Rate for Payer: BCBS MT Medicare	$116.10
Rate for Payer: BCBS MT POS	$122.55
Rate for Payer: BCBS MT Traditional	$129.00
Rate for Payer: Cash Price	$116.10
Rate for Payer: Cigna Commercial	$122.55
Rate for Payer: Cigna Medicare	$116.10
Rate for Payer: Medicaid All Medicaid	$118.68
Rate for Payer: Medicare All Medicare	$90.30
Rate for Payer: Monida Allegiance	$122.55
Rate for Payer: Monida First Choice Health	$125.13
Rate for Payer: Monida Montana Health Co-op	$122.55
Rate for Payer: Monida PacificSource	$122.55

OPO DIRECT ADMISSION

Facility

$197.00

Service Code	HCPCS G0379
Hospital Charge Code	210053
Hospital Revenue Code	762
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

OPO DIRECT ADMISSION

Facility

$197.00

Service Code	HCPCS G0379
Hospital Charge Code	210053
Hospital Revenue Code	762
Min. Negotiated Rate	$137.90
Max. Negotiated Rate	$197.00
Rate for Payer: Aetna Commercial	$187.15
Rate for Payer: Aetna Medicare	$177.30
Rate for Payer: BCBS MT CHIP	$177.30
Rate for Payer: BCBS MT Closed Plan Network	$187.15
Rate for Payer: BCBS MT HealthLink	$177.30
Rate for Payer: BCBS MT Medicare	$177.30
Rate for Payer: BCBS MT POS	$187.15
Rate for Payer: BCBS MT Traditional	$197.00
Rate for Payer: Cash Price	$177.30
Rate for Payer: Cigna Commercial	$187.15
Rate for Payer: Cigna Medicare	$177.30
Rate for Payer: Medicaid All Medicaid	$181.24
Rate for Payer: Medicare All Medicare	$137.90
Rate for Payer: Monida Allegiance	$187.15
Rate for Payer: Monida First Choice Health	$191.09
Rate for Payer: Monida Montana Health Co-op	$187.15
Rate for Payer: Monida PacificSource	$187.15

OPO FIRST HOUR

Facility

$186.00

Service Code	HCPCS G0378
Hospital Charge Code	210051
Hospital Revenue Code	762
Min. Negotiated Rate	$130.20
Max. Negotiated Rate	$186.00
Rate for Payer: Aetna Commercial	$176.70
Rate for Payer: Aetna Medicare	$167.40
Rate for Payer: BCBS MT CHIP	$167.40
Rate for Payer: BCBS MT Closed Plan Network	$176.70
Rate for Payer: BCBS MT HealthLink	$167.40
Rate for Payer: BCBS MT Medicare	$167.40
Rate for Payer: BCBS MT POS	$176.70
Rate for Payer: BCBS MT Traditional	$186.00
Rate for Payer: Cash Price	$167.40
Rate for Payer: Cigna Commercial	$176.70
Rate for Payer: Cigna Medicare	$167.40
Rate for Payer: Medicaid All Medicaid	$171.12
Rate for Payer: Medicare All Medicare	$130.20
Rate for Payer: Monida Allegiance	$176.70
Rate for Payer: Monida First Choice Health	$180.42
Rate for Payer: Monida Montana Health Co-op	$176.70
Rate for Payer: Monida PacificSource	$176.70

Know your out-of-pocket cost for care.

All Charges