Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

OP INJ RFA L/S 1ST JOINT 64635

Facility

$2,587.00

Service Code	CPT 64635
Hospital Charge Code	1564635
Hospital Revenue Code	761
Min. Negotiated Rate	$1,810.90
Max. Negotiated Rate	$2,587.00
Rate for Payer: Aetna Commercial	$2,457.65
Rate for Payer: Aetna Medicare	$2,328.30
Rate for Payer: BCBS MT CHIP	$2,328.30
Rate for Payer: BCBS MT Closed Plan Network	$2,457.65
Rate for Payer: BCBS MT HealthLink	$2,328.30
Rate for Payer: BCBS MT Medicare	$2,328.30
Rate for Payer: BCBS MT POS	$2,457.65
Rate for Payer: BCBS MT Traditional	$2,587.00
Rate for Payer: Cash Price	$2,328.30
Rate for Payer: Cigna Commercial	$2,457.65
Rate for Payer: Cigna Medicare	$2,328.30
Rate for Payer: Medicaid All Medicaid	$2,380.04
Rate for Payer: Medicare All Medicare	$1,810.90
Rate for Payer: Monida Allegiance	$2,457.65
Rate for Payer: Monida First Choice Health	$2,509.39
Rate for Payer: Monida Montana Health Co-op	$2,457.65
Rate for Payer: Monida PacificSource	$2,457.65

OP INJ RFA L/S 1ST JOINT 64635

Facility

$2,587.00

Service Code	CPT 64635
Hospital Charge Code	1564635
Hospital Revenue Code	761
Min. Negotiated Rate	$1,810.90
Max. Negotiated Rate	$2,587.00
Rate for Payer: Aetna Commercial	$2,457.65
Rate for Payer: Aetna Medicare	$2,328.30
Rate for Payer: BCBS MT CHIP	$2,328.30
Rate for Payer: BCBS MT Closed Plan Network	$2,457.65
Rate for Payer: BCBS MT HealthLink	$2,328.30
Rate for Payer: BCBS MT Medicare	$2,328.30
Rate for Payer: BCBS MT POS	$2,457.65
Rate for Payer: BCBS MT Traditional	$2,587.00
Rate for Payer: Cash Price	$2,328.30
Rate for Payer: Cigna Commercial	$2,457.65
Rate for Payer: Cigna Medicare	$2,328.30
Rate for Payer: Medicaid All Medicaid	$2,380.04
Rate for Payer: Medicare All Medicare	$1,810.90
Rate for Payer: Monida Allegiance	$2,457.65
Rate for Payer: Monida First Choice Health	$2,509.39
Rate for Payer: Monida Montana Health Co-op	$2,457.65
Rate for Payer: Monida PacificSource	$2,457.65

OP INJ RFA L/S EADD JOINT 64636

Facility

$1,294.00

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

OP INJ RFA L/S EADD JOINT 64636

Facility

$1,294.00

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

OP INJ SACROILLIAC W/IMAGE 27096

Facility

$289.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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

Know your out-of-pocket cost for care.

All Charges