Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

Know your out-of-pocket cost for care.

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