Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

LAC REPAIR COMP 2.6-7.5CM

Facility

$899.00

Service Code	CPT 13121
Hospital Charge Code	8013121
Hospital Revenue Code	521
Min. Negotiated Rate	$629.30
Max. Negotiated Rate	$899.00
Rate for Payer: Aetna Commercial	$854.05
Rate for Payer: Aetna Medicare	$809.10
Rate for Payer: BCBS MT CHIP	$809.10
Rate for Payer: BCBS MT Closed Plan Network	$854.05
Rate for Payer: BCBS MT HealthLink	$809.10
Rate for Payer: BCBS MT Medicare	$809.10
Rate for Payer: BCBS MT POS	$854.05
Rate for Payer: BCBS MT Traditional	$899.00
Rate for Payer: Cash Price	$809.10
Rate for Payer: Cigna Commercial	$854.05
Rate for Payer: Cigna Medicare	$809.10
Rate for Payer: Medicaid All Medicaid	$827.08
Rate for Payer: Medicare All Medicare	$629.30
Rate for Payer: Monida Allegiance	$854.05
Rate for Payer: Monida First Choice Health	$872.03
Rate for Payer: Monida Montana Health Co-op	$854.05
Rate for Payer: Monida PacificSource	$854.05

LAC REPAIR COMP 2.6-7.5CM

Facility

$899.00

Service Code	CPT 13121
Hospital Charge Code	8013121
Hospital Revenue Code	521
Min. Negotiated Rate	$629.30
Max. Negotiated Rate	$899.00
Rate for Payer: Aetna Commercial	$854.05
Rate for Payer: Aetna Medicare	$809.10
Rate for Payer: BCBS MT CHIP	$809.10
Rate for Payer: BCBS MT Closed Plan Network	$854.05
Rate for Payer: BCBS MT HealthLink	$809.10
Rate for Payer: BCBS MT Medicare	$809.10
Rate for Payer: BCBS MT POS	$854.05
Rate for Payer: BCBS MT Traditional	$899.00
Rate for Payer: Cash Price	$809.10
Rate for Payer: Cigna Commercial	$854.05
Rate for Payer: Cigna Medicare	$809.10
Rate for Payer: Medicaid All Medicaid	$827.08
Rate for Payer: Medicare All Medicare	$629.30
Rate for Payer: Monida Allegiance	$854.05
Rate for Payer: Monida First Choice Health	$872.03
Rate for Payer: Monida Montana Health Co-op	$854.05
Rate for Payer: Monida PacificSource	$854.05

LAC REPAIR COMP ADD SCALP/ARM/LEGS

Facility

$290.00

Service Code	CPT 13122
Hospital Charge Code	8013122
Hospital Revenue Code	521
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

LAC REPAIR COMP ADD SCALP/ARM/LEGS

Facility

$290.00

Service Code	CPT 13122
Hospital Charge Code	8013122
Hospital Revenue Code	521
Min. Negotiated Rate	$203.00
Max. Negotiated Rate	$290.00
Rate for Payer: Aetna Commercial	$275.50
Rate for Payer: Aetna Medicare	$261.00
Rate for Payer: BCBS MT CHIP	$261.00
Rate for Payer: BCBS MT Closed Plan Network	$275.50
Rate for Payer: BCBS MT HealthLink	$261.00
Rate for Payer: BCBS MT Medicare	$261.00
Rate for Payer: BCBS MT POS	$275.50
Rate for Payer: BCBS MT Traditional	$290.00
Rate for Payer: Cash Price	$261.00
Rate for Payer: Cigna Commercial	$275.50
Rate for Payer: Cigna Medicare	$261.00
Rate for Payer: Medicaid All Medicaid	$266.80
Rate for Payer: Medicare All Medicare	$203.00
Rate for Payer: Monida Allegiance	$275.50
Rate for Payer: Monida First Choice Health	$281.30
Rate for Payer: Monida Montana Health Co-op	$275.50
Rate for Payer: Monida PacificSource	$275.50

LAC REPAIR COMPLEXFC/HND/FT ADD ON =<5CM

Facility

$572.00

Service Code	CPT 13133
Hospital Charge Code	8013133
Hospital Revenue Code	521
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

LAC REPAIR COMPLEXFC/HND/FT ADD ON =<5CM

Facility

$572.00

Service Code	CPT 13133
Hospital Charge Code	8013133
Hospital Revenue Code	521
Min. Negotiated Rate	$400.40
Max. Negotiated Rate	$572.00
Rate for Payer: Aetna Commercial	$543.40
Rate for Payer: Aetna Medicare	$514.80
Rate for Payer: BCBS MT CHIP	$514.80
Rate for Payer: BCBS MT Closed Plan Network	$543.40
Rate for Payer: BCBS MT HealthLink	$514.80
Rate for Payer: BCBS MT Medicare	$514.80
Rate for Payer: BCBS MT POS	$543.40
Rate for Payer: BCBS MT Traditional	$572.00
Rate for Payer: Cash Price	$514.80
Rate for Payer: Cigna Commercial	$543.40
Rate for Payer: Cigna Medicare	$514.80
Rate for Payer: Medicaid All Medicaid	$526.24
Rate for Payer: Medicare All Medicare	$400.40
Rate for Payer: Monida Allegiance	$543.40
Rate for Payer: Monida First Choice Health	$554.84
Rate for Payer: Monida Montana Health Co-op	$543.40
Rate for Payer: Monida PacificSource	$543.40

LAC REPAIR COMPLEX FC/HN/FT 2.6-7.5CM

Facility

$981.00

Service Code	CPT 13132
Hospital Charge Code	8013132
Hospital Revenue Code	521
Min. Negotiated Rate	$686.70
Max. Negotiated Rate	$981.00
Rate for Payer: Aetna Commercial	$931.95
Rate for Payer: Aetna Medicare	$882.90
Rate for Payer: BCBS MT CHIP	$882.90
Rate for Payer: BCBS MT Closed Plan Network	$931.95
Rate for Payer: BCBS MT HealthLink	$882.90
Rate for Payer: BCBS MT Medicare	$882.90
Rate for Payer: BCBS MT POS	$931.95
Rate for Payer: BCBS MT Traditional	$981.00
Rate for Payer: Cash Price	$882.90
Rate for Payer: Cigna Commercial	$931.95
Rate for Payer: Cigna Medicare	$882.90
Rate for Payer: Medicaid All Medicaid	$902.52
Rate for Payer: Medicare All Medicare	$686.70
Rate for Payer: Monida Allegiance	$931.95
Rate for Payer: Monida First Choice Health	$951.57
Rate for Payer: Monida Montana Health Co-op	$931.95
Rate for Payer: Monida PacificSource	$931.95

LAC REPAIR COMPLEX FC/HN/FT 2.6-7.5CM

Facility

$981.00

Service Code	CPT 13132
Hospital Charge Code	8013132
Hospital Revenue Code	521
Min. Negotiated Rate	$686.70
Max. Negotiated Rate	$981.00
Rate for Payer: Aetna Commercial	$931.95
Rate for Payer: Aetna Medicare	$882.90
Rate for Payer: BCBS MT CHIP	$882.90
Rate for Payer: BCBS MT Closed Plan Network	$931.95
Rate for Payer: BCBS MT HealthLink	$882.90
Rate for Payer: BCBS MT Medicare	$882.90
Rate for Payer: BCBS MT POS	$931.95
Rate for Payer: BCBS MT Traditional	$981.00
Rate for Payer: Cash Price	$882.90
Rate for Payer: Cigna Commercial	$931.95
Rate for Payer: Cigna Medicare	$882.90
Rate for Payer: Medicaid All Medicaid	$902.52
Rate for Payer: Medicare All Medicare	$686.70
Rate for Payer: Monida Allegiance	$931.95
Rate for Payer: Monida First Choice Health	$951.57
Rate for Payer: Monida Montana Health Co-op	$931.95
Rate for Payer: Monida PacificSource	$931.95

LAC REPAIR COMPL FAC/GENIT/H/F 1.1-2.5CM

Facility

$1,558.00

Service Code	CPT 13131
Hospital Charge Code	8013131
Hospital Revenue Code	521
Min. Negotiated Rate	$1,090.60
Max. Negotiated Rate	$1,558.00
Rate for Payer: Aetna Commercial	$1,480.10
Rate for Payer: Aetna Medicare	$1,402.20
Rate for Payer: BCBS MT CHIP	$1,402.20
Rate for Payer: BCBS MT Closed Plan Network	$1,480.10
Rate for Payer: BCBS MT HealthLink	$1,402.20
Rate for Payer: BCBS MT Medicare	$1,402.20
Rate for Payer: BCBS MT POS	$1,480.10
Rate for Payer: BCBS MT Traditional	$1,558.00
Rate for Payer: Cash Price	$1,402.20
Rate for Payer: Cigna Commercial	$1,480.10
Rate for Payer: Cigna Medicare	$1,402.20
Rate for Payer: Medicaid All Medicaid	$1,433.36
Rate for Payer: Medicare All Medicare	$1,090.60
Rate for Payer: Monida Allegiance	$1,480.10
Rate for Payer: Monida First Choice Health	$1,511.26
Rate for Payer: Monida Montana Health Co-op	$1,480.10
Rate for Payer: Monida PacificSource	$1,480.10

LAC REPAIR COMPL FAC/GENIT/H/F 1.1-2.5CM

Facility

$1,558.00

Service Code	CPT 13131
Hospital Charge Code	8013131
Hospital Revenue Code	521
Min. Negotiated Rate	$1,090.60
Max. Negotiated Rate	$1,558.00
Rate for Payer: Aetna Commercial	$1,480.10
Rate for Payer: Aetna Medicare	$1,402.20
Rate for Payer: BCBS MT CHIP	$1,402.20
Rate for Payer: BCBS MT Closed Plan Network	$1,480.10
Rate for Payer: BCBS MT HealthLink	$1,402.20
Rate for Payer: BCBS MT Medicare	$1,402.20
Rate for Payer: BCBS MT POS	$1,480.10
Rate for Payer: BCBS MT Traditional	$1,558.00
Rate for Payer: Cash Price	$1,402.20
Rate for Payer: Cigna Commercial	$1,480.10
Rate for Payer: Cigna Medicare	$1,402.20
Rate for Payer: Medicaid All Medicaid	$1,433.36
Rate for Payer: Medicare All Medicare	$1,090.60
Rate for Payer: Monida Allegiance	$1,480.10
Rate for Payer: Monida First Choice Health	$1,511.26
Rate for Payer: Monida Montana Health Co-op	$1,480.10
Rate for Payer: Monida PacificSource	$1,480.10

LAC REPAIR IN F/E/E/N/L 2.6-5.0CM

Facility

$605.00

Service Code	CPT 12052
Hospital Charge Code	8012052
Hospital Revenue Code	521
Min. Negotiated Rate	$423.50
Max. Negotiated Rate	$605.00
Rate for Payer: Aetna Commercial	$574.75
Rate for Payer: Aetna Medicare	$544.50
Rate for Payer: BCBS MT CHIP	$544.50
Rate for Payer: BCBS MT Closed Plan Network	$574.75
Rate for Payer: BCBS MT HealthLink	$544.50
Rate for Payer: BCBS MT Medicare	$544.50
Rate for Payer: BCBS MT POS	$574.75
Rate for Payer: BCBS MT Traditional	$605.00
Rate for Payer: Cash Price	$544.50
Rate for Payer: Cigna Commercial	$574.75
Rate for Payer: Cigna Medicare	$544.50
Rate for Payer: Medicaid All Medicaid	$556.60
Rate for Payer: Medicare All Medicare	$423.50
Rate for Payer: Monida Allegiance	$574.75
Rate for Payer: Monida First Choice Health	$586.85
Rate for Payer: Monida Montana Health Co-op	$574.75
Rate for Payer: Monida PacificSource	$574.75

LAC REPAIR IN F/E/E/N/L 2.6-5.0CM

Facility

$605.00

Service Code	CPT 12052
Hospital Charge Code	8012052
Hospital Revenue Code	521
Min. Negotiated Rate	$423.50
Max. Negotiated Rate	$605.00
Rate for Payer: Aetna Commercial	$574.75
Rate for Payer: Aetna Medicare	$544.50
Rate for Payer: BCBS MT CHIP	$544.50
Rate for Payer: BCBS MT Closed Plan Network	$574.75
Rate for Payer: BCBS MT HealthLink	$544.50
Rate for Payer: BCBS MT Medicare	$544.50
Rate for Payer: BCBS MT POS	$574.75
Rate for Payer: BCBS MT Traditional	$605.00
Rate for Payer: Cash Price	$544.50
Rate for Payer: Cigna Commercial	$574.75
Rate for Payer: Cigna Medicare	$544.50
Rate for Payer: Medicaid All Medicaid	$556.60
Rate for Payer: Medicare All Medicare	$423.50
Rate for Payer: Monida Allegiance	$574.75
Rate for Payer: Monida First Choice Health	$586.85
Rate for Payer: Monida Montana Health Co-op	$574.75
Rate for Payer: Monida PacificSource	$574.75

LAC REPAIR INTERM S/A/T/E 2.6CM-7.5CM

Facility

$649.00

Service Code	CPT 12032
Hospital Charge Code	8012032
Hospital Revenue Code	521
Min. Negotiated Rate	$454.30
Max. Negotiated Rate	$649.00
Rate for Payer: Aetna Commercial	$616.55
Rate for Payer: Aetna Medicare	$584.10
Rate for Payer: BCBS MT CHIP	$584.10
Rate for Payer: BCBS MT Closed Plan Network	$616.55
Rate for Payer: BCBS MT HealthLink	$584.10
Rate for Payer: BCBS MT Medicare	$584.10
Rate for Payer: BCBS MT POS	$616.55
Rate for Payer: BCBS MT Traditional	$649.00
Rate for Payer: Cash Price	$584.10
Rate for Payer: Cigna Commercial	$616.55
Rate for Payer: Cigna Medicare	$584.10
Rate for Payer: Medicaid All Medicaid	$597.08
Rate for Payer: Medicare All Medicare	$454.30
Rate for Payer: Monida Allegiance	$616.55
Rate for Payer: Monida First Choice Health	$629.53
Rate for Payer: Monida Montana Health Co-op	$616.55
Rate for Payer: Monida PacificSource	$616.55

LAC REPAIR INTERM S/A/T/E 2.6CM-7.5CM

Facility

$649.00

Service Code	CPT 12032
Hospital Charge Code	8012032
Hospital Revenue Code	521
Min. Negotiated Rate	$454.30
Max. Negotiated Rate	$649.00
Rate for Payer: Aetna Commercial	$616.55
Rate for Payer: Aetna Medicare	$584.10
Rate for Payer: BCBS MT CHIP	$584.10
Rate for Payer: BCBS MT Closed Plan Network	$616.55
Rate for Payer: BCBS MT HealthLink	$584.10
Rate for Payer: BCBS MT Medicare	$584.10
Rate for Payer: BCBS MT POS	$616.55
Rate for Payer: BCBS MT Traditional	$649.00
Rate for Payer: Cash Price	$584.10
Rate for Payer: Cigna Commercial	$616.55
Rate for Payer: Cigna Medicare	$584.10
Rate for Payer: Medicaid All Medicaid	$597.08
Rate for Payer: Medicare All Medicare	$454.30
Rate for Payer: Monida Allegiance	$616.55
Rate for Payer: Monida First Choice Health	$629.53
Rate for Payer: Monida Montana Health Co-op	$616.55
Rate for Payer: Monida PacificSource	$616.55

LAC REPAIR INT F/E/E/N/L 5.1-7.5CM

Facility

$279.00

Service Code	CPT 12053
Hospital Charge Code	8012053
Hospital Revenue Code	521
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

LAC REPAIR INT F/E/E/N/L 5.1-7.5CM

Facility

$279.00

Service Code	CPT 12053
Hospital Charge Code	8012053
Hospital Revenue Code	521
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna Commercial	$265.05
Rate for Payer: Aetna Medicare	$251.10
Rate for Payer: BCBS MT CHIP	$251.10
Rate for Payer: BCBS MT Closed Plan Network	$265.05
Rate for Payer: BCBS MT HealthLink	$251.10
Rate for Payer: BCBS MT Medicare	$251.10
Rate for Payer: BCBS MT POS	$265.05
Rate for Payer: BCBS MT Traditional	$279.00
Rate for Payer: Cash Price	$251.10
Rate for Payer: Cigna Commercial	$265.05
Rate for Payer: Cigna Medicare	$251.10
Rate for Payer: Medicaid All Medicaid	$256.68
Rate for Payer: Medicare All Medicare	$195.30
Rate for Payer: Monida Allegiance	$265.05
Rate for Payer: Monida First Choice Health	$270.63
Rate for Payer: Monida Montana Health Co-op	$265.05
Rate for Payer: Monida PacificSource	$265.05

LAC REPAIR INT F/E/E/N/L 7.6-12.5CM

Facility

$660.00

Service Code	CPT 12054
Hospital Charge Code	8012054
Hospital Revenue Code	521
Min. Negotiated Rate	$462.00
Max. Negotiated Rate	$660.00
Rate for Payer: Aetna Commercial	$627.00
Rate for Payer: Aetna Medicare	$594.00
Rate for Payer: BCBS MT CHIP	$594.00
Rate for Payer: BCBS MT Closed Plan Network	$627.00
Rate for Payer: BCBS MT HealthLink	$594.00
Rate for Payer: BCBS MT Medicare	$594.00
Rate for Payer: BCBS MT POS	$627.00
Rate for Payer: BCBS MT Traditional	$660.00
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cigna Commercial	$627.00
Rate for Payer: Cigna Medicare	$594.00
Rate for Payer: Medicaid All Medicaid	$607.20
Rate for Payer: Medicare All Medicare	$462.00
Rate for Payer: Monida Allegiance	$627.00
Rate for Payer: Monida First Choice Health	$640.20
Rate for Payer: Monida Montana Health Co-op	$627.00
Rate for Payer: Monida PacificSource	$627.00

LAC REPAIR INT F/E/E/N/L 7.6-12.5CM

Facility

$660.00

Service Code	CPT 12054
Hospital Charge Code	8012054
Hospital Revenue Code	521
Min. Negotiated Rate	$462.00
Max. Negotiated Rate	$660.00
Rate for Payer: Aetna Commercial	$627.00
Rate for Payer: Aetna Medicare	$594.00
Rate for Payer: BCBS MT CHIP	$594.00
Rate for Payer: BCBS MT Closed Plan Network	$627.00
Rate for Payer: BCBS MT HealthLink	$594.00
Rate for Payer: BCBS MT Medicare	$594.00
Rate for Payer: BCBS MT POS	$627.00
Rate for Payer: BCBS MT Traditional	$660.00
Rate for Payer: Cash Price	$594.00
Rate for Payer: Cigna Commercial	$627.00
Rate for Payer: Cigna Medicare	$594.00
Rate for Payer: Medicaid All Medicaid	$607.20
Rate for Payer: Medicare All Medicare	$462.00
Rate for Payer: Monida Allegiance	$627.00
Rate for Payer: Monida First Choice Health	$640.20
Rate for Payer: Monida Montana Health Co-op	$627.00
Rate for Payer: Monida PacificSource	$627.00

LAC REPAIR INT F/E/E/N/L/M =<2.5CM

Facility

$568.00

Service Code	CPT 12051
Hospital Charge Code	8012051
Hospital Revenue Code	521
Min. Negotiated Rate	$397.60
Max. Negotiated Rate	$568.00
Rate for Payer: Aetna Commercial	$539.60
Rate for Payer: Aetna Medicare	$511.20
Rate for Payer: BCBS MT CHIP	$511.20
Rate for Payer: BCBS MT Closed Plan Network	$539.60
Rate for Payer: BCBS MT HealthLink	$511.20
Rate for Payer: BCBS MT Medicare	$511.20
Rate for Payer: BCBS MT POS	$539.60
Rate for Payer: BCBS MT Traditional	$568.00
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cigna Commercial	$539.60
Rate for Payer: Cigna Medicare	$511.20
Rate for Payer: Medicaid All Medicaid	$522.56
Rate for Payer: Medicare All Medicare	$397.60
Rate for Payer: Monida Allegiance	$539.60
Rate for Payer: Monida First Choice Health	$550.96
Rate for Payer: Monida Montana Health Co-op	$539.60
Rate for Payer: Monida PacificSource	$539.60

LAC REPAIR INT F/E/E/N/L/M =<2.5CM

Facility

$568.00

Service Code	CPT 12051
Hospital Charge Code	8012051
Hospital Revenue Code	521
Min. Negotiated Rate	$397.60
Max. Negotiated Rate	$568.00
Rate for Payer: Aetna Commercial	$539.60
Rate for Payer: Aetna Medicare	$511.20
Rate for Payer: BCBS MT CHIP	$511.20
Rate for Payer: BCBS MT Closed Plan Network	$539.60
Rate for Payer: BCBS MT HealthLink	$511.20
Rate for Payer: BCBS MT Medicare	$511.20
Rate for Payer: BCBS MT POS	$539.60
Rate for Payer: BCBS MT Traditional	$568.00
Rate for Payer: Cash Price	$511.20
Rate for Payer: Cigna Commercial	$539.60
Rate for Payer: Cigna Medicare	$511.20
Rate for Payer: Medicaid All Medicaid	$522.56
Rate for Payer: Medicare All Medicare	$397.60
Rate for Payer: Monida Allegiance	$539.60
Rate for Payer: Monida First Choice Health	$550.96
Rate for Payer: Monida Montana Health Co-op	$539.60
Rate for Payer: Monida PacificSource	$539.60

LAC REPAIR INT N/H/F/G =<2.5CM

Facility

$483.00

Service Code	CPT 12041
Hospital Charge Code	8012041
Hospital Revenue Code	521
Min. Negotiated Rate	$338.10
Max. Negotiated Rate	$483.00
Rate for Payer: Aetna Commercial	$458.85
Rate for Payer: Aetna Medicare	$434.70
Rate for Payer: BCBS MT CHIP	$434.70
Rate for Payer: BCBS MT Closed Plan Network	$458.85
Rate for Payer: BCBS MT HealthLink	$434.70
Rate for Payer: BCBS MT Medicare	$434.70
Rate for Payer: BCBS MT POS	$458.85
Rate for Payer: BCBS MT Traditional	$483.00
Rate for Payer: Cash Price	$434.70
Rate for Payer: Cigna Commercial	$458.85
Rate for Payer: Cigna Medicare	$434.70
Rate for Payer: Medicaid All Medicaid	$444.36
Rate for Payer: Medicare All Medicare	$338.10
Rate for Payer: Monida Allegiance	$458.85
Rate for Payer: Monida First Choice Health	$468.51
Rate for Payer: Monida Montana Health Co-op	$458.85
Rate for Payer: Monida PacificSource	$458.85

LAC REPAIR INT N/H/F/G =<2.5CM

Facility

$483.00

Service Code	CPT 12041
Hospital Charge Code	8012041
Hospital Revenue Code	521
Min. Negotiated Rate	$338.10
Max. Negotiated Rate	$483.00
Rate for Payer: Aetna Commercial	$458.85
Rate for Payer: Aetna Medicare	$434.70
Rate for Payer: BCBS MT CHIP	$434.70
Rate for Payer: BCBS MT Closed Plan Network	$458.85
Rate for Payer: BCBS MT HealthLink	$434.70
Rate for Payer: BCBS MT Medicare	$434.70
Rate for Payer: BCBS MT POS	$458.85
Rate for Payer: BCBS MT Traditional	$483.00
Rate for Payer: Cash Price	$434.70
Rate for Payer: Cigna Commercial	$458.85
Rate for Payer: Cigna Medicare	$434.70
Rate for Payer: Medicaid All Medicaid	$444.36
Rate for Payer: Medicare All Medicare	$338.10
Rate for Payer: Monida Allegiance	$458.85
Rate for Payer: Monida First Choice Health	$468.51
Rate for Payer: Monida Montana Health Co-op	$458.85
Rate for Payer: Monida PacificSource	$458.85

LAC REPAIR INT N/H/F/G 2.6-7.5CM

Facility

$530.00

Service Code	CPT 12042
Hospital Charge Code	8012042
Hospital Revenue Code	521
Min. Negotiated Rate	$371.00
Max. Negotiated Rate	$530.00
Rate for Payer: Aetna Commercial	$503.50
Rate for Payer: Aetna Medicare	$477.00
Rate for Payer: BCBS MT CHIP	$477.00
Rate for Payer: BCBS MT Closed Plan Network	$503.50
Rate for Payer: BCBS MT HealthLink	$477.00
Rate for Payer: BCBS MT Medicare	$477.00
Rate for Payer: BCBS MT POS	$503.50
Rate for Payer: BCBS MT Traditional	$530.00
Rate for Payer: Cash Price	$477.00
Rate for Payer: Cigna Commercial	$503.50
Rate for Payer: Cigna Medicare	$477.00
Rate for Payer: Medicaid All Medicaid	$487.60
Rate for Payer: Medicare All Medicare	$371.00
Rate for Payer: Monida Allegiance	$503.50
Rate for Payer: Monida First Choice Health	$514.10
Rate for Payer: Monida Montana Health Co-op	$503.50
Rate for Payer: Monida PacificSource	$503.50

LAC REPAIR INT N/H/F/G 2.6-7.5CM

Facility

$530.00

Service Code	CPT 12042
Hospital Charge Code	8012042
Hospital Revenue Code	521
Min. Negotiated Rate	$371.00
Max. Negotiated Rate	$530.00
Rate for Payer: Aetna Commercial	$503.50
Rate for Payer: Aetna Medicare	$477.00
Rate for Payer: BCBS MT CHIP	$477.00
Rate for Payer: BCBS MT Closed Plan Network	$503.50
Rate for Payer: BCBS MT HealthLink	$477.00
Rate for Payer: BCBS MT Medicare	$477.00
Rate for Payer: BCBS MT POS	$503.50
Rate for Payer: BCBS MT Traditional	$530.00
Rate for Payer: Cash Price	$477.00
Rate for Payer: Cigna Commercial	$503.50
Rate for Payer: Cigna Medicare	$477.00
Rate for Payer: Medicaid All Medicaid	$487.60
Rate for Payer: Medicare All Medicare	$371.00
Rate for Payer: Monida Allegiance	$503.50
Rate for Payer: Monida First Choice Health	$514.10
Rate for Payer: Monida Montana Health Co-op	$503.50
Rate for Payer: Monida PacificSource	$503.50

LAC REPAIR INT N/H/F/XTG 7.6-12.5CM

Facility

$665.00

Service Code	CPT 12044
Hospital Charge Code	8012044
Hospital Revenue Code	521
Min. Negotiated Rate	$465.50
Max. Negotiated Rate	$665.00
Rate for Payer: Aetna Commercial	$631.75
Rate for Payer: Aetna Medicare	$598.50
Rate for Payer: BCBS MT CHIP	$598.50
Rate for Payer: BCBS MT Closed Plan Network	$631.75
Rate for Payer: BCBS MT HealthLink	$598.50
Rate for Payer: BCBS MT Medicare	$598.50
Rate for Payer: BCBS MT POS	$631.75
Rate for Payer: BCBS MT Traditional	$665.00
Rate for Payer: Cash Price	$598.50
Rate for Payer: Cigna Commercial	$631.75
Rate for Payer: Cigna Medicare	$598.50
Rate for Payer: Medicaid All Medicaid	$611.80
Rate for Payer: Medicare All Medicare	$465.50
Rate for Payer: Monida Allegiance	$631.75
Rate for Payer: Monida First Choice Health	$645.05
Rate for Payer: Monida Montana Health Co-op	$631.75
Rate for Payer: Monida PacificSource	$631.75

Know your out-of-pocket cost for care.

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