Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OMNIPOD 5 [10 POD] KIT

Facility

$1,045.00

Hospital Charge Code	3007581
Hospital Revenue Code	250
Min. Negotiated Rate	$731.50
Max. Negotiated Rate	$1,045.00
Rate for Payer: Aetna Commercial	$992.75
Rate for Payer: Aetna Medicare	$940.50
Rate for Payer: BCBS MT CHIP	$940.50
Rate for Payer: BCBS MT Closed Plan Network	$992.75
Rate for Payer: BCBS MT HealthLink	$940.50
Rate for Payer: BCBS MT Medicare	$940.50
Rate for Payer: BCBS MT POS	$992.75
Rate for Payer: BCBS MT Traditional	$1,045.00
Rate for Payer: Cash Price	$940.50
Rate for Payer: Cigna Commercial	$992.75
Rate for Payer: Cigna Medicare	$940.50
Rate for Payer: Medicaid All Medicaid	$961.40
Rate for Payer: Medicare All Medicare	$731.50
Rate for Payer: Monida Allegiance	$992.75
Rate for Payer: Monida First Choice Health	$1,013.65
Rate for Payer: Monida Montana Health Co-op	$992.75
Rate for Payer: Monida PacificSource	$992.75

OMNIPOD 5 [10 POD] KIT

Facility

$1,045.00

Hospital Charge Code	3007581
Hospital Revenue Code	250
Min. Negotiated Rate	$731.50
Max. Negotiated Rate	$1,045.00
Rate for Payer: Aetna Commercial	$992.75
Rate for Payer: Aetna Medicare	$940.50
Rate for Payer: BCBS MT CHIP	$940.50
Rate for Payer: BCBS MT Closed Plan Network	$992.75
Rate for Payer: BCBS MT HealthLink	$940.50
Rate for Payer: BCBS MT Medicare	$940.50
Rate for Payer: BCBS MT POS	$992.75
Rate for Payer: BCBS MT Traditional	$1,045.00
Rate for Payer: Cash Price	$940.50
Rate for Payer: Cigna Commercial	$992.75
Rate for Payer: Cigna Medicare	$940.50
Rate for Payer: Medicaid All Medicaid	$961.40
Rate for Payer: Medicare All Medicare	$731.50
Rate for Payer: Monida Allegiance	$992.75
Rate for Payer: Monida First Choice Health	$1,013.65
Rate for Payer: Monida Montana Health Co-op	$992.75
Rate for Payer: Monida PacificSource	$992.75

ONDANSETRON INJ [2 MG/ML]

Facility

$26.00

Service Code	HCPCS J2405
Hospital Charge Code	3000364
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

ONDANSETRON INJ [2 MG/ML]

Facility

$26.00

Service Code	HCPCS J2405
Hospital Charge Code	3000364
Hospital Revenue Code	636
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: BCBS MT CHIP	$23.40
Rate for Payer: BCBS MT Closed Plan Network	$24.70
Rate for Payer: BCBS MT HealthLink	$23.40
Rate for Payer: BCBS MT Medicare	$23.40
Rate for Payer: BCBS MT POS	$24.70
Rate for Payer: BCBS MT Traditional	$26.00
Rate for Payer: Cash Price	$23.40
Rate for Payer: Cigna Commercial	$24.70
Rate for Payer: Cigna Medicare	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

ONDANSETRON ODT TAB [4 MG]

Facility

$8.00

Service Code	HCPCS S0119
Hospital Charge Code	3000365
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

ONDANSETRON ODT TAB [4 MG]

Facility

$8.00

Service Code	HCPCS S0119
Hospital Charge Code	3000365
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

.ONE ALLELE OR ALLELE GRP EA (MOLC PATH)

Facility

$469.00

Service Code	CPT 81383
Hospital Charge Code	4081383
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

.ONE ALLELE OR ALLELE GRP EA (MOLC PATH)

Facility

$469.00

Service Code	CPT 81383
Hospital Charge Code	4081383
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

.ONE ANTIGEN EQUIVALENT EACH (MOLC PATH)

Facility

$469.00

Service Code	CPT 81377
Hospital Charge Code	4081377
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

.ONE ANTIGEN EQUIVALENT EACH (MOLC PATH)

Facility

$469.00

Service Code	CPT 81377
Hospital Charge Code	4081377
Hospital Revenue Code	307
Min. Negotiated Rate	$328.30
Max. Negotiated Rate	$469.00
Rate for Payer: Aetna Commercial	$445.55
Rate for Payer: Aetna Medicare	$422.10
Rate for Payer: BCBS MT CHIP	$422.10
Rate for Payer: BCBS MT Closed Plan Network	$445.55
Rate for Payer: BCBS MT HealthLink	$422.10
Rate for Payer: BCBS MT Medicare	$422.10
Rate for Payer: BCBS MT POS	$445.55
Rate for Payer: BCBS MT Traditional	$469.00
Rate for Payer: Cash Price	$422.10
Rate for Payer: Cigna Commercial	$445.55
Rate for Payer: Cigna Medicare	$422.10
Rate for Payer: Medicaid All Medicaid	$431.48
Rate for Payer: Medicare All Medicare	$328.30
Rate for Payer: Monida Allegiance	$445.55
Rate for Payer: Monida First Choice Health	$454.93
Rate for Payer: Monida Montana Health Co-op	$445.55
Rate for Payer: Monida PacificSource	$445.55

O/P EST PT LOW 20 MIN 99213

Facility

$261.00

Service Code	CPT 99213
Hospital Charge Code	5399213
Hospital Revenue Code	761
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

O/P EST PT LOW 20 MIN 99213

Facility

$261.00

Service Code	CPT 99213
Hospital Charge Code	5399213
Hospital Revenue Code	761
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

O/P EST PT MOD 30 MIN 99214

Facility

$261.00

Service Code	CPT 99214
Hospital Charge Code	5399214
Hospital Revenue Code	761
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

O/P EST PT MOD 30 MIN 99214

Facility

$261.00

Service Code	CPT 99214
Hospital Charge Code	5399214
Hospital Revenue Code	761
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$261.00
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: BCBS MT CHIP	$234.90
Rate for Payer: BCBS MT Closed Plan Network	$247.95
Rate for Payer: BCBS MT HealthLink	$234.90
Rate for Payer: BCBS MT Medicare	$234.90
Rate for Payer: BCBS MT POS	$247.95
Rate for Payer: BCBS MT Traditional	$261.00
Rate for Payer: Cash Price	$234.90
Rate for Payer: Cigna Commercial	$247.95
Rate for Payer: Cigna Medicare	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

O/P EST PT SF 10 MIN 99212

Facility

$142.00

Service Code	CPT 99212
Hospital Charge Code	5399212
Hospital Revenue Code	761
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

O/P EST PT SF 10 MIN 99212

Facility

$142.00

Service Code	CPT 99212
Hospital Charge Code	5399212
Hospital Revenue Code	761
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$142.00
Rate for Payer: Aetna Commercial	$134.90
Rate for Payer: Aetna Medicare	$127.80
Rate for Payer: BCBS MT CHIP	$127.80
Rate for Payer: BCBS MT Closed Plan Network	$134.90
Rate for Payer: BCBS MT HealthLink	$127.80
Rate for Payer: BCBS MT Medicare	$127.80
Rate for Payer: BCBS MT POS	$134.90
Rate for Payer: BCBS MT Traditional	$142.00
Rate for Payer: Cash Price	$127.80
Rate for Payer: Cigna Commercial	$134.90
Rate for Payer: Cigna Medicare	$127.80
Rate for Payer: Medicaid All Medicaid	$130.64
Rate for Payer: Medicare All Medicare	$99.40
Rate for Payer: Monida Allegiance	$134.90
Rate for Payer: Monida First Choice Health	$137.74
Rate for Payer: Monida Montana Health Co-op	$134.90
Rate for Payer: Monida PacificSource	$134.90

OP IJ INTERCOSTAL NRVE BLK EA ADD 64421

Facility

$2,257.00

Service Code	CPT 64421
Hospital Charge Code	564421
Hospital Revenue Code	760
Min. Negotiated Rate	$1,579.90
Max. Negotiated Rate	$2,257.00
Rate for Payer: Aetna Commercial	$2,144.15
Rate for Payer: Aetna Medicare	$2,031.30
Rate for Payer: BCBS MT CHIP	$2,031.30
Rate for Payer: BCBS MT Closed Plan Network	$2,144.15
Rate for Payer: BCBS MT HealthLink	$2,031.30
Rate for Payer: BCBS MT Medicare	$2,031.30
Rate for Payer: BCBS MT POS	$2,144.15
Rate for Payer: BCBS MT Traditional	$2,257.00
Rate for Payer: Cash Price	$2,031.30
Rate for Payer: Cigna Commercial	$2,144.15
Rate for Payer: Cigna Medicare	$2,031.30
Rate for Payer: Medicaid All Medicaid	$2,076.44
Rate for Payer: Medicare All Medicare	$1,579.90
Rate for Payer: Monida Allegiance	$2,144.15
Rate for Payer: Monida First Choice Health	$2,189.29
Rate for Payer: Monida Montana Health Co-op	$2,144.15
Rate for Payer: Monida PacificSource	$2,144.15

OP IJ INTERCOSTAL NRVE BLK EA ADD 64421

Facility

$2,257.00

Service Code	CPT 64421
Hospital Charge Code	564421
Hospital Revenue Code	760
Min. Negotiated Rate	$1,579.90
Max. Negotiated Rate	$2,257.00
Rate for Payer: Aetna Commercial	$2,144.15
Rate for Payer: Aetna Medicare	$2,031.30
Rate for Payer: BCBS MT CHIP	$2,031.30
Rate for Payer: BCBS MT Closed Plan Network	$2,144.15
Rate for Payer: BCBS MT HealthLink	$2,031.30
Rate for Payer: BCBS MT Medicare	$2,031.30
Rate for Payer: BCBS MT POS	$2,144.15
Rate for Payer: BCBS MT Traditional	$2,257.00
Rate for Payer: Cash Price	$2,031.30
Rate for Payer: Cigna Commercial	$2,144.15
Rate for Payer: Cigna Medicare	$2,031.30
Rate for Payer: Medicaid All Medicaid	$2,076.44
Rate for Payer: Medicare All Medicare	$1,579.90
Rate for Payer: Monida Allegiance	$2,144.15
Rate for Payer: Monida First Choice Health	$2,189.29
Rate for Payer: Monida Montana Health Co-op	$2,144.15
Rate for Payer: Monida PacificSource	$2,144.15

OP IJ PERIPH NV BLOCK/LESSER OCC 64450

Facility

$1,477.00

Service Code	CPT 64450
Hospital Charge Code	1564450
Hospital Revenue Code	761
Min. Negotiated Rate	$1,033.90
Max. Negotiated Rate	$1,477.00
Rate for Payer: Aetna Commercial	$1,403.15
Rate for Payer: Aetna Medicare	$1,329.30
Rate for Payer: BCBS MT CHIP	$1,329.30
Rate for Payer: BCBS MT Closed Plan Network	$1,403.15
Rate for Payer: BCBS MT HealthLink	$1,329.30
Rate for Payer: BCBS MT Medicare	$1,329.30
Rate for Payer: BCBS MT POS	$1,403.15
Rate for Payer: BCBS MT Traditional	$1,477.00
Rate for Payer: Cash Price	$1,329.30
Rate for Payer: Cigna Commercial	$1,403.15
Rate for Payer: Cigna Medicare	$1,329.30
Rate for Payer: Medicaid All Medicaid	$1,358.84
Rate for Payer: Medicare All Medicare	$1,033.90
Rate for Payer: Monida Allegiance	$1,403.15
Rate for Payer: Monida First Choice Health	$1,432.69
Rate for Payer: Monida Montana Health Co-op	$1,403.15
Rate for Payer: Monida PacificSource	$1,403.15

OP IJ PERIPH NV BLOCK/LESSER OCC 64450

Facility

$1,477.00

Service Code	CPT 64450
Hospital Charge Code	1564450
Hospital Revenue Code	761
Min. Negotiated Rate	$1,033.90
Max. Negotiated Rate	$1,477.00
Rate for Payer: Aetna Commercial	$1,403.15
Rate for Payer: Aetna Medicare	$1,329.30
Rate for Payer: BCBS MT CHIP	$1,329.30
Rate for Payer: BCBS MT Closed Plan Network	$1,403.15
Rate for Payer: BCBS MT HealthLink	$1,329.30
Rate for Payer: BCBS MT Medicare	$1,329.30
Rate for Payer: BCBS MT POS	$1,403.15
Rate for Payer: BCBS MT Traditional	$1,477.00
Rate for Payer: Cash Price	$1,329.30
Rate for Payer: Cigna Commercial	$1,403.15
Rate for Payer: Cigna Medicare	$1,329.30
Rate for Payer: Medicaid All Medicaid	$1,358.84
Rate for Payer: Medicare All Medicare	$1,033.90
Rate for Payer: Monida Allegiance	$1,403.15
Rate for Payer: Monida First Choice Health	$1,432.69
Rate for Payer: Monida Montana Health Co-op	$1,403.15
Rate for Payer: Monida PacificSource	$1,403.15

OP IJ RFA RFA PERPH NV/SUPSCAP 64640

Facility

$1,643.00

Service Code	CPT 64640
Hospital Charge Code	1564640
Hospital Revenue Code	761
Min. Negotiated Rate	$1,150.10
Max. Negotiated Rate	$1,643.00
Rate for Payer: Aetna Commercial	$1,560.85
Rate for Payer: Aetna Medicare	$1,478.70
Rate for Payer: BCBS MT CHIP	$1,478.70
Rate for Payer: BCBS MT Closed Plan Network	$1,560.85
Rate for Payer: BCBS MT HealthLink	$1,478.70
Rate for Payer: BCBS MT Medicare	$1,478.70
Rate for Payer: BCBS MT POS	$1,560.85
Rate for Payer: BCBS MT Traditional	$1,643.00
Rate for Payer: Cash Price	$1,478.70
Rate for Payer: Cigna Commercial	$1,560.85
Rate for Payer: Cigna Medicare	$1,478.70
Rate for Payer: Medicaid All Medicaid	$1,511.56
Rate for Payer: Medicare All Medicare	$1,150.10
Rate for Payer: Monida Allegiance	$1,560.85
Rate for Payer: Monida First Choice Health	$1,593.71
Rate for Payer: Monida Montana Health Co-op	$1,560.85
Rate for Payer: Monida PacificSource	$1,560.85

OP IJ RFA RFA PERPH NV/SUPSCAP 64640

Facility

$1,643.00

Service Code	CPT 64640
Hospital Charge Code	1564640
Hospital Revenue Code	761
Min. Negotiated Rate	$1,150.10
Max. Negotiated Rate	$1,643.00
Rate for Payer: Aetna Commercial	$1,560.85
Rate for Payer: Aetna Medicare	$1,478.70
Rate for Payer: BCBS MT CHIP	$1,478.70
Rate for Payer: BCBS MT Closed Plan Network	$1,560.85
Rate for Payer: BCBS MT HealthLink	$1,478.70
Rate for Payer: BCBS MT Medicare	$1,478.70
Rate for Payer: BCBS MT POS	$1,560.85
Rate for Payer: BCBS MT Traditional	$1,643.00
Rate for Payer: Cash Price	$1,478.70
Rate for Payer: Cigna Commercial	$1,560.85
Rate for Payer: Cigna Medicare	$1,478.70
Rate for Payer: Medicaid All Medicaid	$1,511.56
Rate for Payer: Medicare All Medicare	$1,150.10
Rate for Payer: Monida Allegiance	$1,560.85
Rate for Payer: Monida First Choice Health	$1,593.71
Rate for Payer: Monida Montana Health Co-op	$1,560.85
Rate for Payer: Monida PacificSource	$1,560.85

OP INJ ANE AGEN AXILLARY NERVE

Facility

$1,768.00

Service Code	CPT 64417
Hospital Charge Code	1564417
Hospital Revenue Code	761
Min. Negotiated Rate	$1,237.60
Max. Negotiated Rate	$1,768.00
Rate for Payer: Aetna Commercial	$1,679.60
Rate for Payer: Aetna Medicare	$1,591.20
Rate for Payer: BCBS MT CHIP	$1,591.20
Rate for Payer: BCBS MT Closed Plan Network	$1,679.60
Rate for Payer: BCBS MT HealthLink	$1,591.20
Rate for Payer: BCBS MT Medicare	$1,591.20
Rate for Payer: BCBS MT POS	$1,679.60
Rate for Payer: BCBS MT Traditional	$1,768.00
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Cigna Commercial	$1,679.60
Rate for Payer: Cigna Medicare	$1,591.20
Rate for Payer: Medicaid All Medicaid	$1,626.56
Rate for Payer: Medicare All Medicare	$1,237.60
Rate for Payer: Monida Allegiance	$1,679.60
Rate for Payer: Monida First Choice Health	$1,714.96
Rate for Payer: Monida Montana Health Co-op	$1,679.60
Rate for Payer: Monida PacificSource	$1,679.60

OP INJ ANE AGEN AXILLARY NERVE

Facility

$1,768.00

Service Code	CPT 64417
Hospital Charge Code	1564417
Hospital Revenue Code	761
Min. Negotiated Rate	$1,237.60
Max. Negotiated Rate	$1,768.00
Rate for Payer: Aetna Commercial	$1,679.60
Rate for Payer: Aetna Medicare	$1,591.20
Rate for Payer: BCBS MT CHIP	$1,591.20
Rate for Payer: BCBS MT Closed Plan Network	$1,679.60
Rate for Payer: BCBS MT HealthLink	$1,591.20
Rate for Payer: BCBS MT Medicare	$1,591.20
Rate for Payer: BCBS MT POS	$1,679.60
Rate for Payer: BCBS MT Traditional	$1,768.00
Rate for Payer: Cash Price	$1,591.20
Rate for Payer: Cigna Commercial	$1,679.60
Rate for Payer: Cigna Medicare	$1,591.20
Rate for Payer: Medicaid All Medicaid	$1,626.56
Rate for Payer: Medicare All Medicare	$1,237.60
Rate for Payer: Monida Allegiance	$1,679.60
Rate for Payer: Monida First Choice Health	$1,714.96
Rate for Payer: Monida Montana Health Co-op	$1,679.60
Rate for Payer: Monida PacificSource	$1,679.60

OP INJ BRACHIAL PLEXUS W/IMAGING 64415

Facility

$669.00

Service Code	CPT 64415
Hospital Charge Code	1564415
Hospital Revenue Code	761
Min. Negotiated Rate	$468.30
Max. Negotiated Rate	$669.00
Rate for Payer: Aetna Commercial	$635.55
Rate for Payer: Aetna Medicare	$602.10
Rate for Payer: BCBS MT CHIP	$602.10
Rate for Payer: BCBS MT Closed Plan Network	$635.55
Rate for Payer: BCBS MT HealthLink	$602.10
Rate for Payer: BCBS MT Medicare	$602.10
Rate for Payer: BCBS MT POS	$635.55
Rate for Payer: BCBS MT Traditional	$669.00
Rate for Payer: Cash Price	$602.10
Rate for Payer: Cigna Commercial	$635.55
Rate for Payer: Cigna Medicare	$602.10
Rate for Payer: Medicaid All Medicaid	$615.48
Rate for Payer: Medicare All Medicare	$468.30
Rate for Payer: Monida Allegiance	$635.55
Rate for Payer: Monida First Choice Health	$648.93
Rate for Payer: Monida Montana Health Co-op	$635.55
Rate for Payer: Monida PacificSource	$635.55

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