Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

Know your out-of-pocket cost for care.

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