Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

OP INJ CELIAC PLEX BLOCK 64530

Facility

$1,838.00

Service Code	CPT 64530
Hospital Charge Code	1564530
Hospital Revenue Code	761
Min. Negotiated Rate	$1,286.60
Max. Negotiated Rate	$1,838.00
Rate for Payer: Aetna Commercial	$1,746.10
Rate for Payer: Aetna Medicare	$1,654.20
Rate for Payer: BCBS MT CHIP	$1,654.20
Rate for Payer: BCBS MT Closed Plan Network	$1,746.10
Rate for Payer: BCBS MT HealthLink	$1,654.20
Rate for Payer: BCBS MT Medicare	$1,654.20
Rate for Payer: BCBS MT POS	$1,746.10
Rate for Payer: BCBS MT Traditional	$1,838.00
Rate for Payer: Cash Price	$1,654.20
Rate for Payer: Cigna Commercial	$1,746.10
Rate for Payer: Cigna Medicare	$1,654.20
Rate for Payer: Medicaid All Medicaid	$1,690.96
Rate for Payer: Medicare All Medicare	$1,286.60
Rate for Payer: Monida Allegiance	$1,746.10
Rate for Payer: Monida First Choice Health	$1,782.86
Rate for Payer: Monida Montana Health Co-op	$1,746.10
Rate for Payer: Monida PacificSource	$1,746.10

OP INJ CELIAC PLEX BLOCK 64530

Facility

$1,838.00

Service Code	CPT 64530
Hospital Charge Code	1564530
Hospital Revenue Code	761
Min. Negotiated Rate	$1,286.60
Max. Negotiated Rate	$1,838.00
Rate for Payer: Aetna Commercial	$1,746.10
Rate for Payer: Aetna Medicare	$1,654.20
Rate for Payer: BCBS MT CHIP	$1,654.20
Rate for Payer: BCBS MT Closed Plan Network	$1,746.10
Rate for Payer: BCBS MT HealthLink	$1,654.20
Rate for Payer: BCBS MT Medicare	$1,654.20
Rate for Payer: BCBS MT POS	$1,746.10
Rate for Payer: BCBS MT Traditional	$1,838.00
Rate for Payer: Cash Price	$1,654.20
Rate for Payer: Cigna Commercial	$1,746.10
Rate for Payer: Cigna Medicare	$1,654.20
Rate for Payer: Medicaid All Medicaid	$1,690.96
Rate for Payer: Medicare All Medicare	$1,286.60
Rate for Payer: Monida Allegiance	$1,746.10
Rate for Payer: Monida First Choice Health	$1,782.86
Rate for Payer: Monida Montana Health Co-op	$1,746.10
Rate for Payer: Monida PacificSource	$1,746.10

OP INJ DEST FAC NER MIGRN TRT 64615

Facility

$581.00

Service Code	CPT 64615
Hospital Charge Code	1564615
Hospital Revenue Code	761
Min. Negotiated Rate	$406.70
Max. Negotiated Rate	$581.00
Rate for Payer: Aetna Commercial	$551.95
Rate for Payer: Aetna Medicare	$522.90
Rate for Payer: BCBS MT CHIP	$522.90
Rate for Payer: BCBS MT Closed Plan Network	$551.95
Rate for Payer: BCBS MT HealthLink	$522.90
Rate for Payer: BCBS MT Medicare	$522.90
Rate for Payer: BCBS MT POS	$551.95
Rate for Payer: BCBS MT Traditional	$581.00
Rate for Payer: Cash Price	$522.90
Rate for Payer: Cigna Commercial	$551.95
Rate for Payer: Cigna Medicare	$522.90
Rate for Payer: Medicaid All Medicaid	$534.52
Rate for Payer: Medicare All Medicare	$406.70
Rate for Payer: Monida Allegiance	$551.95
Rate for Payer: Monida First Choice Health	$563.57
Rate for Payer: Monida Montana Health Co-op	$551.95
Rate for Payer: Monida PacificSource	$551.95

OP INJ DEST FAC NER MIGRN TRT 64615

Facility

$581.00

Service Code	CPT 64615
Hospital Charge Code	1564615
Hospital Revenue Code	761
Min. Negotiated Rate	$406.70
Max. Negotiated Rate	$581.00
Rate for Payer: Aetna Commercial	$551.95
Rate for Payer: Aetna Medicare	$522.90
Rate for Payer: BCBS MT CHIP	$522.90
Rate for Payer: BCBS MT Closed Plan Network	$551.95
Rate for Payer: BCBS MT HealthLink	$522.90
Rate for Payer: BCBS MT Medicare	$522.90
Rate for Payer: BCBS MT POS	$551.95
Rate for Payer: BCBS MT Traditional	$581.00
Rate for Payer: Cash Price	$522.90
Rate for Payer: Cigna Commercial	$551.95
Rate for Payer: Cigna Medicare	$522.90
Rate for Payer: Medicaid All Medicaid	$534.52
Rate for Payer: Medicare All Medicare	$406.70
Rate for Payer: Monida Allegiance	$551.95
Rate for Payer: Monida First Choice Health	$563.57
Rate for Payer: Monida Montana Health Co-op	$551.95
Rate for Payer: Monida PacificSource	$551.95

OP INJ DESTR NERO AGT, PLANTAR NV 64632

Facility

$269.00

Service Code	CPT 64632
Hospital Charge Code	1564632
Hospital Revenue Code	761
Min. Negotiated Rate	$188.30
Max. Negotiated Rate	$269.00
Rate for Payer: Aetna Commercial	$255.55
Rate for Payer: Aetna Medicare	$242.10
Rate for Payer: BCBS MT CHIP	$242.10
Rate for Payer: BCBS MT Closed Plan Network	$255.55
Rate for Payer: BCBS MT HealthLink	$242.10
Rate for Payer: BCBS MT Medicare	$242.10
Rate for Payer: BCBS MT POS	$255.55
Rate for Payer: BCBS MT Traditional	$269.00
Rate for Payer: Cash Price	$242.10
Rate for Payer: Cigna Commercial	$255.55
Rate for Payer: Cigna Medicare	$242.10
Rate for Payer: Medicaid All Medicaid	$247.48
Rate for Payer: Medicare All Medicare	$188.30
Rate for Payer: Monida Allegiance	$255.55
Rate for Payer: Monida First Choice Health	$260.93
Rate for Payer: Monida Montana Health Co-op	$255.55
Rate for Payer: Monida PacificSource	$255.55

OP INJ DESTR NERO AGT, PLANTAR NV 64632

Facility

$269.00

Service Code	CPT 64632
Hospital Charge Code	1564632
Hospital Revenue Code	761
Min. Negotiated Rate	$188.30
Max. Negotiated Rate	$269.00
Rate for Payer: Aetna Commercial	$255.55
Rate for Payer: Aetna Medicare	$242.10
Rate for Payer: BCBS MT CHIP	$242.10
Rate for Payer: BCBS MT Closed Plan Network	$255.55
Rate for Payer: BCBS MT HealthLink	$242.10
Rate for Payer: BCBS MT Medicare	$242.10
Rate for Payer: BCBS MT POS	$255.55
Rate for Payer: BCBS MT Traditional	$269.00
Rate for Payer: Cash Price	$242.10
Rate for Payer: Cigna Commercial	$255.55
Rate for Payer: Cigna Medicare	$242.10
Rate for Payer: Medicaid All Medicaid	$247.48
Rate for Payer: Medicare All Medicare	$188.30
Rate for Payer: Monida Allegiance	$255.55
Rate for Payer: Monida First Choice Health	$260.93
Rate for Payer: Monida Montana Health Co-op	$255.55
Rate for Payer: Monida PacificSource	$255.55

OP INJ DESTR NERO AGT, PUDENDAL NV 64630

Facility

$1,762.00

Service Code	CPT 64630
Hospital Charge Code	1564630
Hospital Revenue Code	761
Min. Negotiated Rate	$1,233.40
Max. Negotiated Rate	$1,762.00
Rate for Payer: Aetna Commercial	$1,673.90
Rate for Payer: Aetna Medicare	$1,585.80
Rate for Payer: BCBS MT CHIP	$1,585.80
Rate for Payer: BCBS MT Closed Plan Network	$1,673.90
Rate for Payer: BCBS MT HealthLink	$1,585.80
Rate for Payer: BCBS MT Medicare	$1,585.80
Rate for Payer: BCBS MT POS	$1,673.90
Rate for Payer: BCBS MT Traditional	$1,762.00
Rate for Payer: Cash Price	$1,585.80
Rate for Payer: Cigna Commercial	$1,673.90
Rate for Payer: Cigna Medicare	$1,585.80
Rate for Payer: Medicaid All Medicaid	$1,621.04
Rate for Payer: Medicare All Medicare	$1,233.40
Rate for Payer: Monida Allegiance	$1,673.90
Rate for Payer: Monida First Choice Health	$1,709.14
Rate for Payer: Monida Montana Health Co-op	$1,673.90
Rate for Payer: Monida PacificSource	$1,673.90

OP INJ DESTR NERO AGT, PUDENDAL NV 64630

Facility

$1,762.00

Service Code	CPT 64630
Hospital Charge Code	1564630
Hospital Revenue Code	761
Min. Negotiated Rate	$1,233.40
Max. Negotiated Rate	$1,762.00
Rate for Payer: Aetna Commercial	$1,673.90
Rate for Payer: Aetna Medicare	$1,585.80
Rate for Payer: BCBS MT CHIP	$1,585.80
Rate for Payer: BCBS MT Closed Plan Network	$1,673.90
Rate for Payer: BCBS MT HealthLink	$1,585.80
Rate for Payer: BCBS MT Medicare	$1,585.80
Rate for Payer: BCBS MT POS	$1,673.90
Rate for Payer: BCBS MT Traditional	$1,762.00
Rate for Payer: Cash Price	$1,585.80
Rate for Payer: Cigna Commercial	$1,673.90
Rate for Payer: Cigna Medicare	$1,585.80
Rate for Payer: Medicaid All Medicaid	$1,621.04
Rate for Payer: Medicare All Medicare	$1,233.40
Rate for Payer: Monida Allegiance	$1,673.90
Rate for Payer: Monida First Choice Health	$1,709.14
Rate for Payer: Monida Montana Health Co-op	$1,673.90
Rate for Payer: Monida PacificSource	$1,673.90

OP INJ DESTRUCTION OF FACIAL NERVE 64612

Facility

$631.00

Service Code	CPT 64612
Hospital Charge Code	564612
Hospital Revenue Code	760
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 DESTRUCTION OF FACIAL NERVE 64612

Facility

$631.00

Service Code	CPT 64612
Hospital Charge Code	564612
Hospital Revenue Code	760
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 FACET JNT C/T 1L W/IMA 64490

Facility

$1,588.00

Service Code	CPT 64490
Hospital Charge Code	1564490
Hospital Revenue Code	761
Min. Negotiated Rate	$1,111.60
Max. Negotiated Rate	$1,588.00
Rate for Payer: Aetna Commercial	$1,508.60
Rate for Payer: Aetna Medicare	$1,429.20
Rate for Payer: BCBS MT CHIP	$1,429.20
Rate for Payer: BCBS MT Closed Plan Network	$1,508.60
Rate for Payer: BCBS MT HealthLink	$1,429.20
Rate for Payer: BCBS MT Medicare	$1,429.20
Rate for Payer: BCBS MT POS	$1,508.60
Rate for Payer: BCBS MT Traditional	$1,588.00
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Cigna Commercial	$1,508.60
Rate for Payer: Cigna Medicare	$1,429.20
Rate for Payer: Medicaid All Medicaid	$1,460.96
Rate for Payer: Medicare All Medicare	$1,111.60
Rate for Payer: Monida Allegiance	$1,508.60
Rate for Payer: Monida First Choice Health	$1,540.36
Rate for Payer: Monida Montana Health Co-op	$1,508.60
Rate for Payer: Monida PacificSource	$1,508.60

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

Facility

$1,588.00

Service Code	CPT 64490
Hospital Charge Code	1564490
Hospital Revenue Code	761
Min. Negotiated Rate	$1,111.60
Max. Negotiated Rate	$1,588.00
Rate for Payer: Aetna Commercial	$1,508.60
Rate for Payer: Aetna Medicare	$1,429.20
Rate for Payer: BCBS MT CHIP	$1,429.20
Rate for Payer: BCBS MT Closed Plan Network	$1,508.60
Rate for Payer: BCBS MT HealthLink	$1,429.20
Rate for Payer: BCBS MT Medicare	$1,429.20
Rate for Payer: BCBS MT POS	$1,508.60
Rate for Payer: BCBS MT Traditional	$1,588.00
Rate for Payer: Cash Price	$1,429.20
Rate for Payer: Cigna Commercial	$1,508.60
Rate for Payer: Cigna Medicare	$1,429.20
Rate for Payer: Medicaid All Medicaid	$1,460.96
Rate for Payer: Medicare All Medicare	$1,111.60
Rate for Payer: Monida Allegiance	$1,508.60
Rate for Payer: Monida First Choice Health	$1,540.36
Rate for Payer: Monida Montana Health Co-op	$1,508.60
Rate for Payer: Monida PacificSource	$1,508.60

OP INJ FACET JNT C/T 2ND LEVEL 64491

Facility

$755.00

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

OP INJ FACET JNT C/T 2ND LEVEL 64491

Facility

$755.00

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

OP INJ FACET JNT C/T 3RDL WIM 64492

Facility

$771.00

Service Code	CPT 64492
Hospital Charge Code	1564492
Hospital Revenue Code	761
Min. Negotiated Rate	$539.70
Max. Negotiated Rate	$771.00
Rate for Payer: Aetna Commercial	$732.45
Rate for Payer: Aetna Medicare	$693.90
Rate for Payer: BCBS MT CHIP	$693.90
Rate for Payer: BCBS MT Closed Plan Network	$732.45
Rate for Payer: BCBS MT HealthLink	$693.90
Rate for Payer: BCBS MT Medicare	$693.90
Rate for Payer: BCBS MT POS	$732.45
Rate for Payer: BCBS MT Traditional	$771.00
Rate for Payer: Cash Price	$693.90
Rate for Payer: Cigna Commercial	$732.45
Rate for Payer: Cigna Medicare	$693.90
Rate for Payer: Medicaid All Medicaid	$709.32
Rate for Payer: Medicare All Medicare	$539.70
Rate for Payer: Monida Allegiance	$732.45
Rate for Payer: Monida First Choice Health	$747.87
Rate for Payer: Monida Montana Health Co-op	$732.45
Rate for Payer: Monida PacificSource	$732.45

OP INJ FACET JNT C/T 3RDL WIM 64492

Facility

$771.00

Service Code	CPT 64492
Hospital Charge Code	1564492
Hospital Revenue Code	761
Min. Negotiated Rate	$539.70
Max. Negotiated Rate	$771.00
Rate for Payer: Aetna Commercial	$732.45
Rate for Payer: Aetna Medicare	$693.90
Rate for Payer: BCBS MT CHIP	$693.90
Rate for Payer: BCBS MT Closed Plan Network	$732.45
Rate for Payer: BCBS MT HealthLink	$693.90
Rate for Payer: BCBS MT Medicare	$693.90
Rate for Payer: BCBS MT POS	$732.45
Rate for Payer: BCBS MT Traditional	$771.00
Rate for Payer: Cash Price	$693.90
Rate for Payer: Cigna Commercial	$732.45
Rate for Payer: Cigna Medicare	$693.90
Rate for Payer: Medicaid All Medicaid	$709.32
Rate for Payer: Medicare All Medicare	$539.70
Rate for Payer: Monida Allegiance	$732.45
Rate for Payer: Monida First Choice Health	$747.87
Rate for Payer: Monida Montana Health Co-op	$732.45
Rate for Payer: Monida PacificSource	$732.45

OP INJ FACET JNT L/S 1L 64493

Facility

$1,615.00

Service Code	CPT 64493
Hospital Charge Code	1564493
Hospital Revenue Code	761
Min. Negotiated Rate	$1,130.50
Max. Negotiated Rate	$1,615.00
Rate for Payer: Aetna Commercial	$1,534.25
Rate for Payer: Aetna Medicare	$1,453.50
Rate for Payer: BCBS MT CHIP	$1,453.50
Rate for Payer: BCBS MT Closed Plan Network	$1,534.25
Rate for Payer: BCBS MT HealthLink	$1,453.50
Rate for Payer: BCBS MT Medicare	$1,453.50
Rate for Payer: BCBS MT POS	$1,534.25
Rate for Payer: BCBS MT Traditional	$1,615.00
Rate for Payer: Cash Price	$1,453.50
Rate for Payer: Cigna Commercial	$1,534.25
Rate for Payer: Cigna Medicare	$1,453.50
Rate for Payer: Medicaid All Medicaid	$1,485.80
Rate for Payer: Medicare All Medicare	$1,130.50
Rate for Payer: Monida Allegiance	$1,534.25
Rate for Payer: Monida First Choice Health	$1,566.55
Rate for Payer: Monida Montana Health Co-op	$1,534.25
Rate for Payer: Monida PacificSource	$1,534.25

OP INJ FACET JNT L/S 1L 64493

Facility

$1,615.00

Service Code	CPT 64493
Hospital Charge Code	1564493
Hospital Revenue Code	761
Min. Negotiated Rate	$1,130.50
Max. Negotiated Rate	$1,615.00
Rate for Payer: Aetna Commercial	$1,534.25
Rate for Payer: Aetna Medicare	$1,453.50
Rate for Payer: BCBS MT CHIP	$1,453.50
Rate for Payer: BCBS MT Closed Plan Network	$1,534.25
Rate for Payer: BCBS MT HealthLink	$1,453.50
Rate for Payer: BCBS MT Medicare	$1,453.50
Rate for Payer: BCBS MT POS	$1,534.25
Rate for Payer: BCBS MT Traditional	$1,615.00
Rate for Payer: Cash Price	$1,453.50
Rate for Payer: Cigna Commercial	$1,534.25
Rate for Payer: Cigna Medicare	$1,453.50
Rate for Payer: Medicaid All Medicaid	$1,485.80
Rate for Payer: Medicare All Medicare	$1,130.50
Rate for Payer: Monida Allegiance	$1,534.25
Rate for Payer: Monida First Choice Health	$1,566.55
Rate for Payer: Monida Montana Health Co-op	$1,534.25
Rate for Payer: Monida PacificSource	$1,534.25

OP INJ FACET JNT L/S 2 L 64494

Facility

$785.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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

$2,006.00

Service Code	CPT 64447
Hospital Charge Code	1564447
Hospital Revenue Code	761
Min. Negotiated Rate	$1,404.20
Max. Negotiated Rate	$2,006.00
Rate for Payer: Aetna Commercial	$1,905.70
Rate for Payer: Aetna Medicare	$1,805.40
Rate for Payer: BCBS MT CHIP	$1,805.40
Rate for Payer: BCBS MT Closed Plan Network	$1,905.70
Rate for Payer: BCBS MT HealthLink	$1,805.40
Rate for Payer: BCBS MT Medicare	$1,805.40
Rate for Payer: BCBS MT POS	$1,905.70
Rate for Payer: BCBS MT Traditional	$2,006.00
Rate for Payer: Cash Price	$1,805.40
Rate for Payer: Cigna Commercial	$1,905.70
Rate for Payer: Cigna Medicare	$1,805.40
Rate for Payer: Medicaid All Medicaid	$1,845.52
Rate for Payer: Medicare All Medicare	$1,404.20
Rate for Payer: Monida Allegiance	$1,905.70
Rate for Payer: Monida First Choice Health	$1,945.82
Rate for Payer: Monida Montana Health Co-op	$1,905.70
Rate for Payer: Monida PacificSource	$1,905.70

OP INJ FEMORAL NERVE BLOCK 64447

Facility

$2,006.00

Service Code	CPT 64447
Hospital Charge Code	1564447
Hospital Revenue Code	761
Min. Negotiated Rate	$1,404.20
Max. Negotiated Rate	$2,006.00
Rate for Payer: Aetna Commercial	$1,905.70
Rate for Payer: Aetna Medicare	$1,805.40
Rate for Payer: BCBS MT CHIP	$1,805.40
Rate for Payer: BCBS MT Closed Plan Network	$1,905.70
Rate for Payer: BCBS MT HealthLink	$1,805.40
Rate for Payer: BCBS MT Medicare	$1,805.40
Rate for Payer: BCBS MT POS	$1,905.70
Rate for Payer: BCBS MT Traditional	$2,006.00
Rate for Payer: Cash Price	$1,805.40
Rate for Payer: Cigna Commercial	$1,905.70
Rate for Payer: Cigna Medicare	$1,805.40
Rate for Payer: Medicaid All Medicaid	$1,845.52
Rate for Payer: Medicare All Medicare	$1,404.20
Rate for Payer: Monida Allegiance	$1,905.70
Rate for Payer: Monida First Choice Health	$1,945.82
Rate for Payer: Monida Montana Health Co-op	$1,905.70
Rate for Payer: Monida PacificSource	$1,905.70

Know your out-of-pocket cost for care.

All Charges