Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

OP INJ GRTER OCCIPT NERVE BLOCK 64405

Facility

$669.00

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

Facility

$669.00

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

Facility

$822.00

Service Code	CPT 64425
Hospital Charge Code	1564425
Hospital Revenue Code	761
Min. Negotiated Rate	$575.40
Max. Negotiated Rate	$822.00
Rate for Payer: Aetna Commercial	$780.90
Rate for Payer: Aetna Medicare	$739.80
Rate for Payer: BCBS MT CHIP	$739.80
Rate for Payer: BCBS MT Closed Plan Network	$780.90
Rate for Payer: BCBS MT HealthLink	$739.80
Rate for Payer: BCBS MT Medicare	$739.80
Rate for Payer: BCBS MT POS	$780.90
Rate for Payer: BCBS MT Traditional	$822.00
Rate for Payer: Cash Price	$739.80
Rate for Payer: Cigna Commercial	$780.90
Rate for Payer: Cigna Medicare	$739.80
Rate for Payer: Medicaid All Medicaid	$756.24
Rate for Payer: Medicare All Medicare	$575.40
Rate for Payer: Monida Allegiance	$780.90
Rate for Payer: Monida First Choice Health	$797.34
Rate for Payer: Monida Montana Health Co-op	$780.90
Rate for Payer: Monida PacificSource	$780.90

OP INJ ILIOING/ILIOHYPOG NV BLOCK 64425

Facility

$822.00

Service Code	CPT 64425
Hospital Charge Code	1564425
Hospital Revenue Code	761
Min. Negotiated Rate	$575.40
Max. Negotiated Rate	$822.00
Rate for Payer: Aetna Commercial	$780.90
Rate for Payer: Aetna Medicare	$739.80
Rate for Payer: BCBS MT CHIP	$739.80
Rate for Payer: BCBS MT Closed Plan Network	$780.90
Rate for Payer: BCBS MT HealthLink	$739.80
Rate for Payer: BCBS MT Medicare	$739.80
Rate for Payer: BCBS MT POS	$780.90
Rate for Payer: BCBS MT Traditional	$822.00
Rate for Payer: Cash Price	$739.80
Rate for Payer: Cigna Commercial	$780.90
Rate for Payer: Cigna Medicare	$739.80
Rate for Payer: Medicaid All Medicaid	$756.24
Rate for Payer: Medicare All Medicare	$575.40
Rate for Payer: Monida Allegiance	$780.90
Rate for Payer: Monida First Choice Health	$797.34
Rate for Payer: Monida Montana Health Co-op	$780.90
Rate for Payer: Monida PacificSource	$780.90

OP INJ INTRCOST NERVE BLOCK SINGLE 64420

Facility

$848.00

Service Code	CPT 64420
Hospital Charge Code	1564420
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 INTRCOST NERVE BLOCK SINGLE 64420

Facility

$848.00

Service Code	CPT 64420
Hospital Charge Code	1564420
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 INTRLAMIN LUMAB W/IMA 62323

Facility

$2,349.00

Service Code	CPT 62323
Hospital Charge Code	1562323
Hospital Revenue Code	761
Min. Negotiated Rate	$1,644.30
Max. Negotiated Rate	$2,349.00
Rate for Payer: Aetna Commercial	$2,231.55
Rate for Payer: Aetna Medicare	$2,114.10
Rate for Payer: BCBS MT CHIP	$2,114.10
Rate for Payer: BCBS MT Closed Plan Network	$2,231.55
Rate for Payer: BCBS MT HealthLink	$2,114.10
Rate for Payer: BCBS MT Medicare	$2,114.10
Rate for Payer: BCBS MT POS	$2,231.55
Rate for Payer: BCBS MT Traditional	$2,349.00
Rate for Payer: Cash Price	$2,114.10
Rate for Payer: Cigna Commercial	$2,231.55
Rate for Payer: Cigna Medicare	$2,114.10
Rate for Payer: Medicaid All Medicaid	$2,161.08
Rate for Payer: Medicare All Medicare	$1,644.30
Rate for Payer: Monida Allegiance	$2,231.55
Rate for Payer: Monida First Choice Health	$2,278.53
Rate for Payer: Monida Montana Health Co-op	$2,231.55
Rate for Payer: Monida PacificSource	$2,231.55

OP INJ INTRLAMIN LUMAB W/IMA 62323

Facility

$2,349.00

Service Code	CPT 62323
Hospital Charge Code	1562323
Hospital Revenue Code	761
Min. Negotiated Rate	$1,644.30
Max. Negotiated Rate	$2,349.00
Rate for Payer: Aetna Commercial	$2,231.55
Rate for Payer: Aetna Medicare	$2,114.10
Rate for Payer: BCBS MT CHIP	$2,114.10
Rate for Payer: BCBS MT Closed Plan Network	$2,231.55
Rate for Payer: BCBS MT HealthLink	$2,114.10
Rate for Payer: BCBS MT Medicare	$2,114.10
Rate for Payer: BCBS MT POS	$2,231.55
Rate for Payer: BCBS MT Traditional	$2,349.00
Rate for Payer: Cash Price	$2,114.10
Rate for Payer: Cigna Commercial	$2,231.55
Rate for Payer: Cigna Medicare	$2,114.10
Rate for Payer: Medicaid All Medicaid	$2,161.08
Rate for Payer: Medicare All Medicare	$1,644.30
Rate for Payer: Monida Allegiance	$2,231.55
Rate for Payer: Monida First Choice Health	$2,278.53
Rate for Payer: Monida Montana Health Co-op	$2,231.55
Rate for Payer: Monida PacificSource	$2,231.55

OP INJ MAJOR JOINT W/O US 20610

Facility

$984.00

Service Code	CPT 20610
Hospital Charge Code	1520610
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 INJ MAJOR JOINT W/O US 20610

Facility

$984.00

Service Code	CPT 20610
Hospital Charge Code	1520610
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 INJ MAJOR JOINT W/US 20611

Facility

$1,042.00

Service Code	CPT 20611
Hospital Charge Code	1520611
Hospital Revenue Code	761
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

OP INJ MAJOR JOINT W/US 20611

Facility

$1,042.00

Service Code	CPT 20611
Hospital Charge Code	1520611
Hospital Revenue Code	761
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$1,042.00
Rate for Payer: Aetna Commercial	$989.90
Rate for Payer: Aetna Medicare	$937.80
Rate for Payer: BCBS MT CHIP	$937.80
Rate for Payer: BCBS MT Closed Plan Network	$989.90
Rate for Payer: BCBS MT HealthLink	$937.80
Rate for Payer: BCBS MT Medicare	$937.80
Rate for Payer: BCBS MT POS	$989.90
Rate for Payer: BCBS MT Traditional	$1,042.00
Rate for Payer: Cash Price	$937.80
Rate for Payer: Cigna Commercial	$989.90
Rate for Payer: Cigna Medicare	$937.80
Rate for Payer: Medicaid All Medicaid	$958.64
Rate for Payer: Medicare All Medicare	$729.40
Rate for Payer: Monida Allegiance	$989.90
Rate for Payer: Monida First Choice Health	$1,010.74
Rate for Payer: Monida Montana Health Co-op	$989.90
Rate for Payer: Monida PacificSource	$989.90

OP INJ OP INJ TRANFOR C/T ADDTL 64480

Facility

$948.00

Service Code	CPT 64480
Hospital Charge Code	1564480
Hospital Revenue Code	761
Min. Negotiated Rate	$663.60
Max. Negotiated Rate	$948.00
Rate for Payer: Aetna Commercial	$900.60
Rate for Payer: Aetna Medicare	$853.20
Rate for Payer: BCBS MT CHIP	$853.20
Rate for Payer: BCBS MT Closed Plan Network	$900.60
Rate for Payer: BCBS MT HealthLink	$853.20
Rate for Payer: BCBS MT Medicare	$853.20
Rate for Payer: BCBS MT POS	$900.60
Rate for Payer: BCBS MT Traditional	$948.00
Rate for Payer: Cash Price	$853.20
Rate for Payer: Cigna Commercial	$900.60
Rate for Payer: Cigna Medicare	$853.20
Rate for Payer: Medicaid All Medicaid	$872.16
Rate for Payer: Medicare All Medicare	$663.60
Rate for Payer: Monida Allegiance	$900.60
Rate for Payer: Monida First Choice Health	$919.56
Rate for Payer: Monida Montana Health Co-op	$900.60
Rate for Payer: Monida PacificSource	$900.60

OP INJ OP INJ TRANFOR C/T ADDTL 64480

Facility

$948.00

Service Code	CPT 64480
Hospital Charge Code	1564480
Hospital Revenue Code	761
Min. Negotiated Rate	$663.60
Max. Negotiated Rate	$948.00
Rate for Payer: Aetna Commercial	$900.60
Rate for Payer: Aetna Medicare	$853.20
Rate for Payer: BCBS MT CHIP	$853.20
Rate for Payer: BCBS MT Closed Plan Network	$900.60
Rate for Payer: BCBS MT HealthLink	$853.20
Rate for Payer: BCBS MT Medicare	$853.20
Rate for Payer: BCBS MT POS	$900.60
Rate for Payer: BCBS MT Traditional	$948.00
Rate for Payer: Cash Price	$853.20
Rate for Payer: Cigna Commercial	$900.60
Rate for Payer: Cigna Medicare	$853.20
Rate for Payer: Medicaid All Medicaid	$872.16
Rate for Payer: Medicare All Medicare	$663.60
Rate for Payer: Monida Allegiance	$900.60
Rate for Payer: Monida First Choice Health	$919.56
Rate for Payer: Monida Montana Health Co-op	$900.60
Rate for Payer: Monida PacificSource	$900.60

OP INJ OP INJ TRANSFORA L/S 1 64483

Facility

$2,485.00

Service Code	CPT 64483
Hospital Charge Code	1564483
Hospital Revenue Code	761
Min. Negotiated Rate	$1,739.50
Max. Negotiated Rate	$2,485.00
Rate for Payer: Aetna Commercial	$2,360.75
Rate for Payer: Aetna Medicare	$2,236.50
Rate for Payer: BCBS MT CHIP	$2,236.50
Rate for Payer: BCBS MT Closed Plan Network	$2,360.75
Rate for Payer: BCBS MT HealthLink	$2,236.50
Rate for Payer: BCBS MT Medicare	$2,236.50
Rate for Payer: BCBS MT POS	$2,360.75
Rate for Payer: BCBS MT Traditional	$2,485.00
Rate for Payer: Cash Price	$2,236.50
Rate for Payer: Cigna Commercial	$2,360.75
Rate for Payer: Cigna Medicare	$2,236.50
Rate for Payer: Medicaid All Medicaid	$2,286.20
Rate for Payer: Medicare All Medicare	$1,739.50
Rate for Payer: Monida Allegiance	$2,360.75
Rate for Payer: Monida First Choice Health	$2,410.45
Rate for Payer: Monida Montana Health Co-op	$2,360.75
Rate for Payer: Monida PacificSource	$2,360.75

OP INJ OP INJ TRANSFORA L/S 1 64483

Facility

$2,485.00

Service Code	CPT 64483
Hospital Charge Code	1564483
Hospital Revenue Code	761
Min. Negotiated Rate	$1,739.50
Max. Negotiated Rate	$2,485.00
Rate for Payer: Aetna Commercial	$2,360.75
Rate for Payer: Aetna Medicare	$2,236.50
Rate for Payer: BCBS MT CHIP	$2,236.50
Rate for Payer: BCBS MT Closed Plan Network	$2,360.75
Rate for Payer: BCBS MT HealthLink	$2,236.50
Rate for Payer: BCBS MT Medicare	$2,236.50
Rate for Payer: BCBS MT POS	$2,360.75
Rate for Payer: BCBS MT Traditional	$2,485.00
Rate for Payer: Cash Price	$2,236.50
Rate for Payer: Cigna Commercial	$2,360.75
Rate for Payer: Cigna Medicare	$2,236.50
Rate for Payer: Medicaid All Medicaid	$2,286.20
Rate for Payer: Medicare All Medicare	$1,739.50
Rate for Payer: Monida Allegiance	$2,360.75
Rate for Payer: Monida First Choice Health	$2,410.45
Rate for Payer: Monida Montana Health Co-op	$2,360.75
Rate for Payer: Monida PacificSource	$2,360.75

OP INJ PARAVERT SYMP BLOCK T/L 64520

Facility

$1,703.00

Service Code	CPT 64520
Hospital Charge Code	1564520
Hospital Revenue Code	761
Min. Negotiated Rate	$1,192.10
Max. Negotiated Rate	$1,703.00
Rate for Payer: Aetna Commercial	$1,617.85
Rate for Payer: Aetna Medicare	$1,532.70
Rate for Payer: BCBS MT CHIP	$1,532.70
Rate for Payer: BCBS MT Closed Plan Network	$1,617.85
Rate for Payer: BCBS MT HealthLink	$1,532.70
Rate for Payer: BCBS MT Medicare	$1,532.70
Rate for Payer: BCBS MT POS	$1,617.85
Rate for Payer: BCBS MT Traditional	$1,703.00
Rate for Payer: Cash Price	$1,532.70
Rate for Payer: Cigna Commercial	$1,617.85
Rate for Payer: Cigna Medicare	$1,532.70
Rate for Payer: Medicaid All Medicaid	$1,566.76
Rate for Payer: Medicare All Medicare	$1,192.10
Rate for Payer: Monida Allegiance	$1,617.85
Rate for Payer: Monida First Choice Health	$1,651.91
Rate for Payer: Monida Montana Health Co-op	$1,617.85
Rate for Payer: Monida PacificSource	$1,617.85

OP INJ PARAVERT SYMP BLOCK T/L 64520

Facility

$1,703.00

Service Code	CPT 64520
Hospital Charge Code	1564520
Hospital Revenue Code	761
Min. Negotiated Rate	$1,192.10
Max. Negotiated Rate	$1,703.00
Rate for Payer: Aetna Commercial	$1,617.85
Rate for Payer: Aetna Medicare	$1,532.70
Rate for Payer: BCBS MT CHIP	$1,532.70
Rate for Payer: BCBS MT Closed Plan Network	$1,617.85
Rate for Payer: BCBS MT HealthLink	$1,532.70
Rate for Payer: BCBS MT Medicare	$1,532.70
Rate for Payer: BCBS MT POS	$1,617.85
Rate for Payer: BCBS MT Traditional	$1,703.00
Rate for Payer: Cash Price	$1,532.70
Rate for Payer: Cigna Commercial	$1,617.85
Rate for Payer: Cigna Medicare	$1,532.70
Rate for Payer: Medicaid All Medicaid	$1,566.76
Rate for Payer: Medicare All Medicare	$1,192.10
Rate for Payer: Monida Allegiance	$1,617.85
Rate for Payer: Monida First Choice Health	$1,651.91
Rate for Payer: Monida Montana Health Co-op	$1,617.85
Rate for Payer: Monida PacificSource	$1,617.85

OP INJ PLANTAR DIGITAL NERVE BLOCK 64455

Facility

$183.00

Service Code	CPT 64455
Hospital Charge Code	1564455
Hospital Revenue Code	761
Min. Negotiated Rate	$128.10
Max. Negotiated Rate	$183.00
Rate for Payer: Aetna Commercial	$173.85
Rate for Payer: Aetna Medicare	$164.70
Rate for Payer: BCBS MT CHIP	$164.70
Rate for Payer: BCBS MT Closed Plan Network	$173.85
Rate for Payer: BCBS MT HealthLink	$164.70
Rate for Payer: BCBS MT Medicare	$164.70
Rate for Payer: BCBS MT POS	$173.85
Rate for Payer: BCBS MT Traditional	$183.00
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cigna Commercial	$173.85
Rate for Payer: Cigna Medicare	$164.70
Rate for Payer: Medicaid All Medicaid	$168.36
Rate for Payer: Medicare All Medicare	$128.10
Rate for Payer: Monida Allegiance	$173.85
Rate for Payer: Monida First Choice Health	$177.51
Rate for Payer: Monida Montana Health Co-op	$173.85
Rate for Payer: Monida PacificSource	$173.85

OP INJ PLANTAR DIGITAL NERVE BLOCK 64455

Facility

$183.00

Service Code	CPT 64455
Hospital Charge Code	1564455
Hospital Revenue Code	761
Min. Negotiated Rate	$128.10
Max. Negotiated Rate	$183.00
Rate for Payer: Aetna Commercial	$173.85
Rate for Payer: Aetna Medicare	$164.70
Rate for Payer: BCBS MT CHIP	$164.70
Rate for Payer: BCBS MT Closed Plan Network	$173.85
Rate for Payer: BCBS MT HealthLink	$164.70
Rate for Payer: BCBS MT Medicare	$164.70
Rate for Payer: BCBS MT POS	$173.85
Rate for Payer: BCBS MT Traditional	$183.00
Rate for Payer: Cash Price	$164.70
Rate for Payer: Cigna Commercial	$173.85
Rate for Payer: Cigna Medicare	$164.70
Rate for Payer: Medicaid All Medicaid	$168.36
Rate for Payer: Medicare All Medicare	$128.10
Rate for Payer: Monida Allegiance	$173.85
Rate for Payer: Monida First Choice Health	$177.51
Rate for Payer: Monida Montana Health Co-op	$173.85
Rate for Payer: Monida PacificSource	$173.85

OP INJ PMGT TRIGEMINAL NERVE BLOCK 64400

Facility

$526.00

Service Code	CPT 64400
Hospital Charge Code	1564400
Hospital Revenue Code	761
Min. Negotiated Rate	$368.20
Max. Negotiated Rate	$526.00
Rate for Payer: Aetna Commercial	$499.70
Rate for Payer: Aetna Medicare	$473.40
Rate for Payer: BCBS MT CHIP	$473.40
Rate for Payer: BCBS MT Closed Plan Network	$499.70
Rate for Payer: BCBS MT HealthLink	$473.40
Rate for Payer: BCBS MT Medicare	$473.40
Rate for Payer: BCBS MT POS	$499.70
Rate for Payer: BCBS MT Traditional	$526.00
Rate for Payer: Cash Price	$473.40
Rate for Payer: Cigna Commercial	$499.70
Rate for Payer: Cigna Medicare	$473.40
Rate for Payer: Medicaid All Medicaid	$483.92
Rate for Payer: Medicare All Medicare	$368.20
Rate for Payer: Monida Allegiance	$499.70
Rate for Payer: Monida First Choice Health	$510.22
Rate for Payer: Monida Montana Health Co-op	$499.70
Rate for Payer: Monida PacificSource	$499.70

OP INJ PMGT TRIGEMINAL NERVE BLOCK 64400

Facility

$526.00

Service Code	CPT 64400
Hospital Charge Code	1564400
Hospital Revenue Code	761
Min. Negotiated Rate	$368.20
Max. Negotiated Rate	$526.00
Rate for Payer: Aetna Commercial	$499.70
Rate for Payer: Aetna Medicare	$473.40
Rate for Payer: BCBS MT CHIP	$473.40
Rate for Payer: BCBS MT Closed Plan Network	$499.70
Rate for Payer: BCBS MT HealthLink	$473.40
Rate for Payer: BCBS MT Medicare	$473.40
Rate for Payer: BCBS MT POS	$499.70
Rate for Payer: BCBS MT Traditional	$526.00
Rate for Payer: Cash Price	$473.40
Rate for Payer: Cigna Commercial	$499.70
Rate for Payer: Cigna Medicare	$473.40
Rate for Payer: Medicaid All Medicaid	$483.92
Rate for Payer: Medicare All Medicare	$368.20
Rate for Payer: Monida Allegiance	$499.70
Rate for Payer: Monida First Choice Health	$510.22
Rate for Payer: Monida Montana Health Co-op	$499.70
Rate for Payer: Monida PacificSource	$499.70

OP INJ RFA C/T 1ST JOINT 64633

Facility

$2,330.00

Service Code	CPT 64633
Hospital Charge Code	1564633
Hospital Revenue Code	761
Min. Negotiated Rate	$1,631.00
Max. Negotiated Rate	$2,330.00
Rate for Payer: Aetna Commercial	$2,213.50
Rate for Payer: Aetna Medicare	$2,097.00
Rate for Payer: BCBS MT CHIP	$2,097.00
Rate for Payer: BCBS MT Closed Plan Network	$2,213.50
Rate for Payer: BCBS MT HealthLink	$2,097.00
Rate for Payer: BCBS MT Medicare	$2,097.00
Rate for Payer: BCBS MT POS	$2,213.50
Rate for Payer: BCBS MT Traditional	$2,330.00
Rate for Payer: Cash Price	$2,097.00
Rate for Payer: Cigna Commercial	$2,213.50
Rate for Payer: Cigna Medicare	$2,097.00
Rate for Payer: Medicaid All Medicaid	$2,143.60
Rate for Payer: Medicare All Medicare	$1,631.00
Rate for Payer: Monida Allegiance	$2,213.50
Rate for Payer: Monida First Choice Health	$2,260.10
Rate for Payer: Monida Montana Health Co-op	$2,213.50
Rate for Payer: Monida PacificSource	$2,213.50

OP INJ RFA C/T 1ST JOINT 64633

Facility

$2,330.00

Service Code	CPT 64633
Hospital Charge Code	1564633
Hospital Revenue Code	761
Min. Negotiated Rate	$1,631.00
Max. Negotiated Rate	$2,330.00
Rate for Payer: Aetna Commercial	$2,213.50
Rate for Payer: Aetna Medicare	$2,097.00
Rate for Payer: BCBS MT CHIP	$2,097.00
Rate for Payer: BCBS MT Closed Plan Network	$2,213.50
Rate for Payer: BCBS MT HealthLink	$2,097.00
Rate for Payer: BCBS MT Medicare	$2,097.00
Rate for Payer: BCBS MT POS	$2,213.50
Rate for Payer: BCBS MT Traditional	$2,330.00
Rate for Payer: Cash Price	$2,097.00
Rate for Payer: Cigna Commercial	$2,213.50
Rate for Payer: Cigna Medicare	$2,097.00
Rate for Payer: Medicaid All Medicaid	$2,143.60
Rate for Payer: Medicare All Medicare	$1,631.00
Rate for Payer: Monida Allegiance	$2,213.50
Rate for Payer: Monida First Choice Health	$2,260.10
Rate for Payer: Monida Montana Health Co-op	$2,213.50
Rate for Payer: Monida PacificSource	$2,213.50

OP INJ RFA C/T EA ADD ON JT 64634

Facility

$924.00

Service Code	CPT 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

Know your out-of-pocket cost for care.

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