Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

DEBRIDEMENT NON-SELECTIVE W/O ANES 97602

Facility

$364.00

Service Code	CPT 97602
Hospital Charge Code	597602
Hospital Revenue Code	761
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

DEBRIDEMENT NON-SELECTIVE W/O ANESTH

Facility

$364.00

Service Code	CPT 97602
Hospital Charge Code	8097602
Hospital Revenue Code	521
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

DEBRIDEMENT NON-SELECTIVE W/O ANESTH

Facility

$364.00

Service Code	CPT 97602
Hospital Charge Code	8097602
Hospital Revenue Code	521
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$364.00
Rate for Payer: Aetna Commercial	$345.80
Rate for Payer: Aetna Medicare	$327.60
Rate for Payer: BCBS MT CHIP	$327.60
Rate for Payer: BCBS MT Closed Plan Network	$345.80
Rate for Payer: BCBS MT HealthLink	$327.60
Rate for Payer: BCBS MT Medicare	$327.60
Rate for Payer: BCBS MT POS	$345.80
Rate for Payer: BCBS MT Traditional	$364.00
Rate for Payer: Cash Price	$327.60
Rate for Payer: Cigna Commercial	$345.80
Rate for Payer: Cigna Medicare	$327.60
Rate for Payer: Medicaid All Medicaid	$334.88
Rate for Payer: Medicare All Medicare	$254.80
Rate for Payer: Monida Allegiance	$345.80
Rate for Payer: Monida First Choice Health	$353.08
Rate for Payer: Monida Montana Health Co-op	$345.80
Rate for Payer: Monida PacificSource	$345.80

DEBRIDEMENT SKIN INFECTED UP TO 10%

Facility

$525.00

Service Code	CPT 11000
Hospital Charge Code	8011000
Hospital Revenue Code	521
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

DEBRIDEMENT SKIN INFECTED UP TO 10%

Facility

$525.00

Service Code	CPT 11000
Hospital Charge Code	8011000
Hospital Revenue Code	521
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$525.00
Rate for Payer: Aetna Commercial	$498.75
Rate for Payer: Aetna Medicare	$472.50
Rate for Payer: BCBS MT CHIP	$472.50
Rate for Payer: BCBS MT Closed Plan Network	$498.75
Rate for Payer: BCBS MT HealthLink	$472.50
Rate for Payer: BCBS MT Medicare	$472.50
Rate for Payer: BCBS MT POS	$498.75
Rate for Payer: BCBS MT Traditional	$525.00
Rate for Payer: Cash Price	$472.50
Rate for Payer: Cigna Commercial	$498.75
Rate for Payer: Cigna Medicare	$472.50
Rate for Payer: Medicaid All Medicaid	$483.00
Rate for Payer: Medicare All Medicare	$367.50
Rate for Payer: Monida Allegiance	$498.75
Rate for Payer: Monida First Choice Health	$509.25
Rate for Payer: Monida Montana Health Co-op	$498.75
Rate for Payer: Monida PacificSource	$498.75

DEBRIDEMENT, SUBCU, FIRST 20CM (11042)

Facility

$307.00

Service Code	CPT 11042
Hospital Charge Code	8011042
Hospital Revenue Code	521
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

DEBRIDEMENT, SUBCU, FIRST 20CM (11042)

Facility

$307.00

Service Code	CPT 11042
Hospital Charge Code	8011042
Hospital Revenue Code	521
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$307.00
Rate for Payer: Aetna Commercial	$291.65
Rate for Payer: Aetna Medicare	$276.30
Rate for Payer: BCBS MT CHIP	$276.30
Rate for Payer: BCBS MT Closed Plan Network	$291.65
Rate for Payer: BCBS MT HealthLink	$276.30
Rate for Payer: BCBS MT Medicare	$276.30
Rate for Payer: BCBS MT POS	$291.65
Rate for Payer: BCBS MT Traditional	$307.00
Rate for Payer: Cash Price	$276.30
Rate for Payer: Cigna Commercial	$291.65
Rate for Payer: Cigna Medicare	$276.30
Rate for Payer: Medicaid All Medicaid	$282.44
Rate for Payer: Medicare All Medicare	$214.90
Rate for Payer: Monida Allegiance	$291.65
Rate for Payer: Monida First Choice Health	$297.79
Rate for Payer: Monida Montana Health Co-op	$291.65
Rate for Payer: Monida PacificSource	$291.65

DEBRIDE, MSCLE/FASCIA, 1st 20CM (11043)

Facility

$535.00

Service Code	CPT 11043
Hospital Charge Code	8011043
Hospital Revenue Code	521
Min. Negotiated Rate	$374.50
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna Commercial	$508.25
Rate for Payer: Aetna Medicare	$481.50
Rate for Payer: BCBS MT CHIP	$481.50
Rate for Payer: BCBS MT Closed Plan Network	$508.25
Rate for Payer: BCBS MT HealthLink	$481.50
Rate for Payer: BCBS MT Medicare	$481.50
Rate for Payer: BCBS MT POS	$508.25
Rate for Payer: BCBS MT Traditional	$535.00
Rate for Payer: Cash Price	$481.50
Rate for Payer: Cigna Commercial	$508.25
Rate for Payer: Cigna Medicare	$481.50
Rate for Payer: Medicaid All Medicaid	$492.20
Rate for Payer: Medicare All Medicare	$374.50
Rate for Payer: Monida Allegiance	$508.25
Rate for Payer: Monida First Choice Health	$518.95
Rate for Payer: Monida Montana Health Co-op	$508.25
Rate for Payer: Monida PacificSource	$508.25

DEBRIDE, MSCLE/FASCIA, 1st 20CM (11043)

Facility

$535.00

Service Code	CPT 11043
Hospital Charge Code	8011043
Hospital Revenue Code	521
Min. Negotiated Rate	$374.50
Max. Negotiated Rate	$535.00
Rate for Payer: Aetna Commercial	$508.25
Rate for Payer: Aetna Medicare	$481.50
Rate for Payer: BCBS MT CHIP	$481.50
Rate for Payer: BCBS MT Closed Plan Network	$508.25
Rate for Payer: BCBS MT HealthLink	$481.50
Rate for Payer: BCBS MT Medicare	$481.50
Rate for Payer: BCBS MT POS	$508.25
Rate for Payer: BCBS MT Traditional	$535.00
Rate for Payer: Cash Price	$481.50
Rate for Payer: Cigna Commercial	$508.25
Rate for Payer: Cigna Medicare	$481.50
Rate for Payer: Medicaid All Medicaid	$492.20
Rate for Payer: Medicare All Medicare	$374.50
Rate for Payer: Monida Allegiance	$508.25
Rate for Payer: Monida First Choice Health	$518.95
Rate for Payer: Monida Montana Health Co-op	$508.25
Rate for Payer: Monida PacificSource	$508.25

DECLOTTING IMPLANTED DEVICE

Facility

$463.00

Service Code	CPT 36593
Hospital Charge Code	1036593
Hospital Revenue Code	761
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

DECLOTTING IMPLANTED DEVICE

Facility

$463.00

Service Code	CPT 36593
Hospital Charge Code	1036593
Hospital Revenue Code	761
Min. Negotiated Rate	$324.10
Max. Negotiated Rate	$463.00
Rate for Payer: Aetna Commercial	$439.85
Rate for Payer: Aetna Medicare	$416.70
Rate for Payer: BCBS MT CHIP	$416.70
Rate for Payer: BCBS MT Closed Plan Network	$439.85
Rate for Payer: BCBS MT HealthLink	$416.70
Rate for Payer: BCBS MT Medicare	$416.70
Rate for Payer: BCBS MT POS	$439.85
Rate for Payer: BCBS MT Traditional	$463.00
Rate for Payer: Cash Price	$416.70
Rate for Payer: Cigna Commercial	$439.85
Rate for Payer: Cigna Medicare	$416.70
Rate for Payer: Medicaid All Medicaid	$425.96
Rate for Payer: Medicare All Medicare	$324.10
Rate for Payer: Monida Allegiance	$439.85
Rate for Payer: Monida First Choice Health	$449.11
Rate for Payer: Monida Montana Health Co-op	$439.85
Rate for Payer: Monida PacificSource	$439.85

DENOSUMAB INJ [60 MG/ML] SPEC ORDER

Facility

$2,530.00

Service Code	HCPCS J0897
Hospital Charge Code	3000108
Hospital Revenue Code	636
Min. Negotiated Rate	$1,771.00
Max. Negotiated Rate	$2,530.00
Rate for Payer: Aetna Commercial	$2,403.50
Rate for Payer: Aetna Medicare	$2,277.00
Rate for Payer: BCBS MT CHIP	$2,277.00
Rate for Payer: BCBS MT Closed Plan Network	$2,403.50
Rate for Payer: BCBS MT HealthLink	$2,277.00
Rate for Payer: BCBS MT Medicare	$2,277.00
Rate for Payer: BCBS MT POS	$2,403.50
Rate for Payer: BCBS MT Traditional	$2,530.00
Rate for Payer: Cash Price	$2,277.00
Rate for Payer: Cigna Commercial	$2,403.50
Rate for Payer: Cigna Medicare	$2,277.00
Rate for Payer: Medicaid All Medicaid	$2,327.60
Rate for Payer: Medicare All Medicare	$1,771.00
Rate for Payer: Monida Allegiance	$2,403.50
Rate for Payer: Monida First Choice Health	$2,454.10
Rate for Payer: Monida Montana Health Co-op	$2,403.50
Rate for Payer: Monida PacificSource	$2,403.50

DENOSUMAB INJ [60 MG/ML] SPEC ORDER

Facility

$2,530.00

Service Code	HCPCS J0897
Hospital Charge Code	3000108
Hospital Revenue Code	636
Min. Negotiated Rate	$1,771.00
Max. Negotiated Rate	$2,530.00
Rate for Payer: Aetna Commercial	$2,403.50
Rate for Payer: Aetna Medicare	$2,277.00
Rate for Payer: BCBS MT CHIP	$2,277.00
Rate for Payer: BCBS MT Closed Plan Network	$2,403.50
Rate for Payer: BCBS MT HealthLink	$2,277.00
Rate for Payer: BCBS MT Medicare	$2,277.00
Rate for Payer: BCBS MT POS	$2,403.50
Rate for Payer: BCBS MT Traditional	$2,530.00
Rate for Payer: Cash Price	$2,277.00
Rate for Payer: Cigna Commercial	$2,403.50
Rate for Payer: Cigna Medicare	$2,277.00
Rate for Payer: Medicaid All Medicaid	$2,327.60
Rate for Payer: Medicare All Medicare	$1,771.00
Rate for Payer: Monida Allegiance	$2,403.50
Rate for Payer: Monida First Choice Health	$2,454.10
Rate for Payer: Monida Montana Health Co-op	$2,403.50
Rate for Payer: Monida PacificSource	$2,403.50

DERMAFLEX

Facility

$63.00

Hospital Charge Code	80040171
Hospital Revenue Code	270
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

DERMAFLEX

Facility

$63.00

Hospital Charge Code	80040171
Hospital Revenue Code	270
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

DEST. MALGNT LES. 0.5CM OR LESS (17260)

Facility

$184.00

Service Code	CPT 17260
Hospital Charge Code	8017260
Hospital Revenue Code	521
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$184.00
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: BCBS MT CHIP	$165.60
Rate for Payer: BCBS MT Closed Plan Network	$174.80
Rate for Payer: BCBS MT HealthLink	$165.60
Rate for Payer: BCBS MT Medicare	$165.60
Rate for Payer: BCBS MT POS	$174.80
Rate for Payer: BCBS MT Traditional	$184.00
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial	$174.80
Rate for Payer: Cigna Medicare	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

DEST. MALGNT LES. 0.5CM OR LESS (17260)

Facility

$184.00

Service Code	CPT 17260
Hospital Charge Code	8017260
Hospital Revenue Code	521
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$184.00
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: BCBS MT CHIP	$165.60
Rate for Payer: BCBS MT Closed Plan Network	$174.80
Rate for Payer: BCBS MT HealthLink	$165.60
Rate for Payer: BCBS MT Medicare	$165.60
Rate for Payer: BCBS MT POS	$174.80
Rate for Payer: BCBS MT Traditional	$184.00
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cigna Commercial	$174.80
Rate for Payer: Cigna Medicare	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

DESTROY LESIONS BENIGN <15 (17004)

Facility

$358.00

Service Code	CPT 17004
Hospital Charge Code	8017004
Hospital Revenue Code	521
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

DESTROY LESIONS BENIGN <15 (17004)

Facility

$358.00

Service Code	CPT 17004
Hospital Charge Code	8017004
Hospital Revenue Code	521
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

DESTRUCTION LESION BENIGN 1ST (17000)

Facility

$127.00

Service Code	CPT 17000
Hospital Charge Code	8017000
Hospital Revenue Code	521
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$127.00
Rate for Payer: Aetna Commercial	$120.65
Rate for Payer: Aetna Medicare	$114.30
Rate for Payer: BCBS MT CHIP	$114.30
Rate for Payer: BCBS MT Closed Plan Network	$120.65
Rate for Payer: BCBS MT HealthLink	$114.30
Rate for Payer: BCBS MT Medicare	$114.30
Rate for Payer: BCBS MT POS	$120.65
Rate for Payer: BCBS MT Traditional	$127.00
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cigna Commercial	$120.65
Rate for Payer: Cigna Medicare	$114.30
Rate for Payer: Medicaid All Medicaid	$116.84
Rate for Payer: Medicare All Medicare	$88.90
Rate for Payer: Monida Allegiance	$120.65
Rate for Payer: Monida First Choice Health	$123.19
Rate for Payer: Monida Montana Health Co-op	$120.65
Rate for Payer: Monida PacificSource	$120.65

DESTRUCTION LESION BENIGN 1ST (17000)

Facility

$127.00

Service Code	CPT 17000
Hospital Charge Code	8017000
Hospital Revenue Code	521
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$127.00
Rate for Payer: Aetna Commercial	$120.65
Rate for Payer: Aetna Medicare	$114.30
Rate for Payer: BCBS MT CHIP	$114.30
Rate for Payer: BCBS MT Closed Plan Network	$120.65
Rate for Payer: BCBS MT HealthLink	$114.30
Rate for Payer: BCBS MT Medicare	$114.30
Rate for Payer: BCBS MT POS	$120.65
Rate for Payer: BCBS MT Traditional	$127.00
Rate for Payer: Cash Price	$114.30
Rate for Payer: Cigna Commercial	$120.65
Rate for Payer: Cigna Medicare	$114.30
Rate for Payer: Medicaid All Medicaid	$116.84
Rate for Payer: Medicare All Medicare	$88.90
Rate for Payer: Monida Allegiance	$120.65
Rate for Payer: Monida First Choice Health	$123.19
Rate for Payer: Monida Montana Health Co-op	$120.65
Rate for Payer: Monida PacificSource	$120.65

DESTRUCTION NEUROLYTIC AGT GENICULAR NE

Facility

$4,759.00

Service Code	CPT 64624
Hospital Charge Code	1564624
Hospital Revenue Code	761
Min. Negotiated Rate	$3,331.30
Max. Negotiated Rate	$4,759.00
Rate for Payer: Aetna Commercial	$4,521.05
Rate for Payer: Aetna Medicare	$4,283.10
Rate for Payer: BCBS MT CHIP	$4,283.10
Rate for Payer: BCBS MT Closed Plan Network	$4,521.05
Rate for Payer: BCBS MT HealthLink	$4,283.10
Rate for Payer: BCBS MT Medicare	$4,283.10
Rate for Payer: BCBS MT POS	$4,521.05
Rate for Payer: BCBS MT Traditional	$4,759.00
Rate for Payer: Cash Price	$4,283.10
Rate for Payer: Cigna Commercial	$4,521.05
Rate for Payer: Cigna Medicare	$4,283.10
Rate for Payer: Medicaid All Medicaid	$4,378.28
Rate for Payer: Medicare All Medicare	$3,331.30
Rate for Payer: Monida Allegiance	$4,521.05
Rate for Payer: Monida First Choice Health	$4,616.23
Rate for Payer: Monida Montana Health Co-op	$4,521.05
Rate for Payer: Monida PacificSource	$4,521.05

DESTRUCTION NEUROLYTIC AGT GENICULAR NE

Facility

$4,759.00

Service Code	CPT 64624
Hospital Charge Code	1564624
Hospital Revenue Code	761
Min. Negotiated Rate	$3,331.30
Max. Negotiated Rate	$4,759.00
Rate for Payer: Aetna Commercial	$4,521.05
Rate for Payer: Aetna Medicare	$4,283.10
Rate for Payer: BCBS MT CHIP	$4,283.10
Rate for Payer: BCBS MT Closed Plan Network	$4,521.05
Rate for Payer: BCBS MT HealthLink	$4,283.10
Rate for Payer: BCBS MT Medicare	$4,283.10
Rate for Payer: BCBS MT POS	$4,521.05
Rate for Payer: BCBS MT Traditional	$4,759.00
Rate for Payer: Cash Price	$4,283.10
Rate for Payer: Cigna Commercial	$4,521.05
Rate for Payer: Cigna Medicare	$4,283.10
Rate for Payer: Medicaid All Medicaid	$4,378.28
Rate for Payer: Medicare All Medicare	$3,331.30
Rate for Payer: Monida Allegiance	$4,521.05
Rate for Payer: Monida First Choice Health	$4,616.23
Rate for Payer: Monida Montana Health Co-op	$4,521.05
Rate for Payer: Monida PacificSource	$4,521.05

DESTRUCT LSION BNIGN ADD 2-14 EACH(17003

Facility

$40.00

Service Code	CPT 17003
Hospital Charge Code	8017003
Hospital Revenue Code	521
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

DESTRUCT LSION BNIGN ADD 2-14 EACH(17003

Facility

$40.00

Service Code	CPT 17003
Hospital Charge Code	8017003
Hospital Revenue Code	521
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$40.00
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: BCBS MT CHIP	$36.00
Rate for Payer: BCBS MT Closed Plan Network	$38.00
Rate for Payer: BCBS MT HealthLink	$36.00
Rate for Payer: BCBS MT Medicare	$36.00
Rate for Payer: BCBS MT POS	$38.00
Rate for Payer: BCBS MT Traditional	$40.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cigna Commercial	$38.00
Rate for Payer: Cigna Medicare	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

Know your out-of-pocket cost for care.

All Charges