Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

Know your out-of-pocket cost for care.

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