Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PRO FEE OPO SAME DAY ADMIT/D/CLOW

Professional

Both

$278.00

Service Code	CPT 99234
Hospital Charge Code	739234
Hospital Revenue Code	982
Min. Negotiated Rate	$194.60
Max. Negotiated Rate	$269.66
Rate for Payer: Aetna Commercial	$264.10
Rate for Payer: Aetna Medicare	$250.20
Rate for Payer: Cash Price	$250.20
Rate for Payer: Medicaid All Medicaid	$255.76
Rate for Payer: Medicare All Medicare	$194.60
Rate for Payer: Monida Allegiance	$264.10
Rate for Payer: Monida First Choice Health	$269.66
Rate for Payer: Monida Montana Health Co-op	$264.10
Rate for Payer: Monida PacificSource	$264.10

PRO FEE OPO SAME DAY ADMIT HIGH

Professional

Both

$457.00

Service Code	CPT 99236
Hospital Charge Code	799236
Hospital Revenue Code	982
Min. Negotiated Rate	$319.90
Max. Negotiated Rate	$443.29
Rate for Payer: Aetna Commercial	$434.15
Rate for Payer: Aetna Medicare	$411.30
Rate for Payer: Cash Price	$411.30
Rate for Payer: Medicaid All Medicaid	$420.44
Rate for Payer: Medicare All Medicare	$319.90
Rate for Payer: Monida Allegiance	$434.15
Rate for Payer: Monida First Choice Health	$443.29
Rate for Payer: Monida Montana Health Co-op	$434.15
Rate for Payer: Monida PacificSource	$434.15

PRO FEE OPO SAME DAY ADMIT MOD

Professional

Both

$352.00

Service Code	CPT 99235
Hospital Charge Code	739235
Hospital Revenue Code	982
Min. Negotiated Rate	$246.40
Max. Negotiated Rate	$341.44
Rate for Payer: Aetna Commercial	$334.40
Rate for Payer: Aetna Medicare	$316.80
Rate for Payer: Cash Price	$316.80
Rate for Payer: Medicaid All Medicaid	$323.84
Rate for Payer: Medicare All Medicare	$246.40
Rate for Payer: Monida Allegiance	$334.40
Rate for Payer: Monida First Choice Health	$341.44
Rate for Payer: Monida Montana Health Co-op	$334.40
Rate for Payer: Monida PacificSource	$334.40

PRO FEE OPO SEPARATE DAY DISCHARGE>30MI

Professional

Both

$320.00

Service Code	CPT 99239
Hospital Charge Code	799239
Hospital Revenue Code	982
Min. Negotiated Rate	$224.00
Max. Negotiated Rate	$310.40
Rate for Payer: Aetna Commercial	$304.00
Rate for Payer: Aetna Medicare	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Medicaid All Medicaid	$294.40
Rate for Payer: Medicare All Medicare	$224.00
Rate for Payer: Monida Allegiance	$304.00
Rate for Payer: Monida First Choice Health	$310.40
Rate for Payer: Monida Montana Health Co-op	$304.00
Rate for Payer: Monida PacificSource	$304.00

PRO FEE OPO SEPARATE DAY DISCHARGE 99217

Professional

Both

$189.00

Service Code	CPT 99217
Hospital Charge Code	799217
Hospital Revenue Code	982
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$183.33
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: Cash Price	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

PRO FEE OP PMGT INJ TRIGEM NRV BLC 64400

Professional

Both

$271.00

Service Code	CPT 64400
Hospital Charge Code	764400
Hospital Revenue Code	964
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$271.00
Rate for Payer: Aetna Commercial	$257.45
Rate for Payer: Aetna Medicare	$243.90
Rate for Payer: BCBS MT CHIP	$243.90
Rate for Payer: BCBS MT Closed Plan Network	$257.45
Rate for Payer: BCBS MT HealthLink	$243.90
Rate for Payer: BCBS MT Medicare	$243.90
Rate for Payer: BCBS MT POS	$257.45
Rate for Payer: BCBS MT Traditional	$271.00
Rate for Payer: Cash Price	$243.90
Rate for Payer: Cigna Commercial	$257.45
Rate for Payer: Cigna Medicare	$243.90
Rate for Payer: Medicaid All Medicaid	$249.32
Rate for Payer: Medicare All Medicare	$189.70
Rate for Payer: Monida Allegiance	$257.45
Rate for Payer: Monida First Choice Health	$262.87
Rate for Payer: Monida Montana Health Co-op	$257.45
Rate for Payer: Monida PacificSource	$257.45

PRO FEE OP UNLISTED PROCEDURE 64999

Professional

Both

$449.00

Service Code	CPT 64999
Hospital Charge Code	764999
Hospital Revenue Code	964
Min. Negotiated Rate	$314.30
Max. Negotiated Rate	$449.00
Rate for Payer: Aetna Commercial	$426.55
Rate for Payer: Aetna Medicare	$404.10
Rate for Payer: BCBS MT CHIP	$404.10
Rate for Payer: BCBS MT Closed Plan Network	$426.55
Rate for Payer: BCBS MT HealthLink	$404.10
Rate for Payer: BCBS MT Medicare	$404.10
Rate for Payer: BCBS MT POS	$426.55
Rate for Payer: BCBS MT Traditional	$449.00
Rate for Payer: Cash Price	$404.10
Rate for Payer: Cigna Commercial	$426.55
Rate for Payer: Cigna Medicare	$404.10
Rate for Payer: Medicaid All Medicaid	$413.08
Rate for Payer: Medicare All Medicare	$314.30
Rate for Payer: Monida Allegiance	$426.55
Rate for Payer: Monida First Choice Health	$435.53
Rate for Payer: Monida Montana Health Co-op	$426.55
Rate for Payer: Monida PacificSource	$426.55

PRO FEE PARAVERT SYMP BLOCK T/L 64520

Professional

Both

$439.00

Service Code	CPT 64520
Hospital Charge Code	764520
Hospital Revenue Code	964
Min. Negotiated Rate	$307.30
Max. Negotiated Rate	$439.00
Rate for Payer: Aetna Commercial	$417.05
Rate for Payer: Aetna Medicare	$395.10
Rate for Payer: BCBS MT CHIP	$395.10
Rate for Payer: BCBS MT Closed Plan Network	$417.05
Rate for Payer: BCBS MT HealthLink	$395.10
Rate for Payer: BCBS MT Medicare	$395.10
Rate for Payer: BCBS MT POS	$417.05
Rate for Payer: BCBS MT Traditional	$439.00
Rate for Payer: Cash Price	$395.10
Rate for Payer: Cigna Commercial	$417.05
Rate for Payer: Cigna Medicare	$395.10
Rate for Payer: Medicaid All Medicaid	$403.88
Rate for Payer: Medicare All Medicare	$307.30
Rate for Payer: Monida Allegiance	$417.05
Rate for Payer: Monida First Choice Health	$425.83
Rate for Payer: Monida Montana Health Co-op	$417.05
Rate for Payer: Monida PacificSource	$417.05

PRO FEE PLEURAL DRNG, PERC,W/INS OF CATH

Professional

Both

$122.00

Service Code	CPT 32556
Hospital Charge Code	732556
Hospital Revenue Code	981
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$122.00
Rate for Payer: Aetna Commercial	$115.90
Rate for Payer: Aetna Medicare	$109.80
Rate for Payer: BCBS MT CHIP	$109.80
Rate for Payer: BCBS MT Closed Plan Network	$115.90
Rate for Payer: BCBS MT HealthLink	$109.80
Rate for Payer: BCBS MT Medicare	$109.80
Rate for Payer: BCBS MT POS	$115.90
Rate for Payer: BCBS MT Traditional	$122.00
Rate for Payer: Cash Price	$109.80
Rate for Payer: Cigna Commercial	$115.90
Rate for Payer: Cigna Medicare	$109.80
Rate for Payer: Medicaid All Medicaid	$112.24
Rate for Payer: Medicare All Medicare	$85.40
Rate for Payer: Monida Allegiance	$115.90
Rate for Payer: Monida First Choice Health	$118.34
Rate for Payer: Monida Montana Health Co-op	$115.90
Rate for Payer: Monida PacificSource	$115.90

PRO FEE PVB THORACIC 1ST LEVEL

Professional

Both

$394.00

Service Code	CPT 64461
Hospital Charge Code	764461
Hospital Revenue Code	964
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$394.00
Rate for Payer: Aetna Commercial	$374.30
Rate for Payer: Aetna Medicare	$354.60
Rate for Payer: BCBS MT CHIP	$354.60
Rate for Payer: BCBS MT Closed Plan Network	$374.30
Rate for Payer: BCBS MT HealthLink	$354.60
Rate for Payer: BCBS MT Medicare	$354.60
Rate for Payer: BCBS MT POS	$374.30
Rate for Payer: BCBS MT Traditional	$394.00
Rate for Payer: Cash Price	$354.60
Rate for Payer: Cigna Commercial	$374.30
Rate for Payer: Cigna Medicare	$354.60
Rate for Payer: Medicaid All Medicaid	$362.48
Rate for Payer: Medicare All Medicare	$275.80
Rate for Payer: Monida Allegiance	$374.30
Rate for Payer: Monida First Choice Health	$382.18
Rate for Payer: Monida Montana Health Co-op	$374.30
Rate for Payer: Monida PacificSource	$374.30

PRO FEE PVB THORACIC ADD ON LEVEL

Professional

Both

$244.00

Service Code	CPT 64462
Hospital Charge Code	764462
Hospital Revenue Code	964
Min. Negotiated Rate	$170.80
Max. Negotiated Rate	$244.00
Rate for Payer: Aetna Commercial	$231.80
Rate for Payer: Aetna Medicare	$219.60
Rate for Payer: BCBS MT CHIP	$219.60
Rate for Payer: BCBS MT Closed Plan Network	$231.80
Rate for Payer: BCBS MT HealthLink	$219.60
Rate for Payer: BCBS MT Medicare	$219.60
Rate for Payer: BCBS MT POS	$231.80
Rate for Payer: BCBS MT Traditional	$244.00
Rate for Payer: Cash Price	$219.60
Rate for Payer: Cigna Commercial	$231.80
Rate for Payer: Cigna Medicare	$219.60
Rate for Payer: Medicaid All Medicaid	$224.48
Rate for Payer: Medicare All Medicare	$170.80
Rate for Payer: Monida Allegiance	$231.80
Rate for Payer: Monida First Choice Health	$236.68
Rate for Payer: Monida Montana Health Co-op	$231.80
Rate for Payer: Monida PacificSource	$231.80

PRO FEE REDUCTION DISTAL FRACTURE RAD

Professional

Both

$2,497.00

Service Code	CPT 25505
Hospital Charge Code	782505
Hospital Revenue Code	964
Min. Negotiated Rate	$1,747.90
Max. Negotiated Rate	$2,497.00
Rate for Payer: Aetna Commercial	$2,372.15
Rate for Payer: Aetna Medicare	$2,247.30
Rate for Payer: BCBS MT CHIP	$2,247.30
Rate for Payer: BCBS MT Closed Plan Network	$2,372.15
Rate for Payer: BCBS MT HealthLink	$2,247.30
Rate for Payer: BCBS MT Medicare	$2,247.30
Rate for Payer: BCBS MT POS	$2,372.15
Rate for Payer: BCBS MT Traditional	$2,497.00
Rate for Payer: Cash Price	$2,247.30
Rate for Payer: Cigna Commercial	$2,372.15
Rate for Payer: Cigna Medicare	$2,247.30
Rate for Payer: Medicaid All Medicaid	$2,297.24
Rate for Payer: Medicare All Medicare	$1,747.90
Rate for Payer: Monida Allegiance	$2,372.15
Rate for Payer: Monida First Choice Health	$2,422.09
Rate for Payer: Monida Montana Health Co-op	$2,372.15
Rate for Payer: Monida PacificSource	$2,372.15

PRO FEE REMOVAL OF NAIL BED

Professional

Both

$102.00

Service Code	CPT 11730
Hospital Charge Code	711730
Hospital Revenue Code	981
Min. Negotiated Rate	$71.40
Max. Negotiated Rate	$102.00
Rate for Payer: Aetna Commercial	$96.90
Rate for Payer: Aetna Medicare	$91.80
Rate for Payer: BCBS MT CHIP	$91.80
Rate for Payer: BCBS MT Closed Plan Network	$96.90
Rate for Payer: BCBS MT HealthLink	$91.80
Rate for Payer: BCBS MT Medicare	$91.80
Rate for Payer: BCBS MT POS	$96.90
Rate for Payer: BCBS MT Traditional	$102.00
Rate for Payer: Cash Price	$91.80
Rate for Payer: Cigna Commercial	$96.90
Rate for Payer: Cigna Medicare	$91.80
Rate for Payer: Medicaid All Medicaid	$93.84
Rate for Payer: Medicare All Medicare	$71.40
Rate for Payer: Monida Allegiance	$96.90
Rate for Payer: Monida First Choice Health	$98.94
Rate for Payer: Monida Montana Health Co-op	$96.90
Rate for Payer: Monida PacificSource	$96.90

PRO FEE REPAIR F/E/E/N/LNTERM 2.6-5.0CM

Professional

Both

$382.00

Service Code	CPT 12052
Hospital Charge Code	712052
Hospital Revenue Code	981
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$382.00
Rate for Payer: Aetna Commercial	$362.90
Rate for Payer: Aetna Medicare	$343.80
Rate for Payer: BCBS MT CHIP	$343.80
Rate for Payer: BCBS MT Closed Plan Network	$362.90
Rate for Payer: BCBS MT HealthLink	$343.80
Rate for Payer: BCBS MT Medicare	$343.80
Rate for Payer: BCBS MT POS	$362.90
Rate for Payer: BCBS MT Traditional	$382.00
Rate for Payer: Cash Price	$343.80
Rate for Payer: Cigna Commercial	$362.90
Rate for Payer: Cigna Medicare	$343.80
Rate for Payer: Medicaid All Medicaid	$351.44
Rate for Payer: Medicare All Medicare	$267.40
Rate for Payer: Monida Allegiance	$362.90
Rate for Payer: Monida First Choice Health	$370.54
Rate for Payer: Monida Montana Health Co-op	$362.90
Rate for Payer: Monida PacificSource	$362.90

PRO FEE REPAIR INT =< 2.5CM

Professional

Both

$279.00

Service Code	CPT 12041
Hospital Charge Code	712041
Hospital Revenue Code	981
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

PRO FEE REPAIR INTF/E/E/N/L 12.6-20.0CM

Professional

Both

$576.00

Service Code	CPT 12055
Hospital Charge Code	712055
Hospital Revenue Code	981
Min. Negotiated Rate	$403.20
Max. Negotiated Rate	$576.00
Rate for Payer: Aetna Commercial	$547.20
Rate for Payer: Aetna Medicare	$518.40
Rate for Payer: BCBS MT CHIP	$518.40
Rate for Payer: BCBS MT Closed Plan Network	$547.20
Rate for Payer: BCBS MT HealthLink	$518.40
Rate for Payer: BCBS MT Medicare	$518.40
Rate for Payer: BCBS MT POS	$547.20
Rate for Payer: BCBS MT Traditional	$576.00
Rate for Payer: Cash Price	$518.40
Rate for Payer: Cigna Commercial	$547.20
Rate for Payer: Cigna Medicare	$518.40
Rate for Payer: Medicaid All Medicaid	$529.92
Rate for Payer: Medicare All Medicare	$403.20
Rate for Payer: Monida Allegiance	$547.20
Rate for Payer: Monida First Choice Health	$558.72
Rate for Payer: Monida Montana Health Co-op	$547.20
Rate for Payer: Monida PacificSource	$547.20

PRO FEE REPAIR INT F/E/E/N/L 5.1-7.5CM

Professional

Both

$412.00

Service Code	CPT 12053
Hospital Charge Code	712053
Hospital Revenue Code	981
Min. Negotiated Rate	$288.40
Max. Negotiated Rate	$412.00
Rate for Payer: Aetna Commercial	$391.40
Rate for Payer: Aetna Medicare	$370.80
Rate for Payer: BCBS MT CHIP	$370.80
Rate for Payer: BCBS MT Closed Plan Network	$391.40
Rate for Payer: BCBS MT HealthLink	$370.80
Rate for Payer: BCBS MT Medicare	$370.80
Rate for Payer: BCBS MT POS	$391.40
Rate for Payer: BCBS MT Traditional	$412.00
Rate for Payer: Cash Price	$370.80
Rate for Payer: Cigna Commercial	$391.40
Rate for Payer: Cigna Medicare	$370.80
Rate for Payer: Medicaid All Medicaid	$379.04
Rate for Payer: Medicare All Medicare	$288.40
Rate for Payer: Monida Allegiance	$391.40
Rate for Payer: Monida First Choice Health	$399.64
Rate for Payer: Monida Montana Health Co-op	$391.40
Rate for Payer: Monida PacificSource	$391.40

PRO FEE REPAIR INT F/E/E/N/L 7.6-12.5CM

Professional

Both

$420.00

Service Code	CPT 12054
Hospital Charge Code	712054
Hospital Revenue Code	981
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$420.00
Rate for Payer: Aetna Commercial	$399.00
Rate for Payer: Aetna Medicare	$378.00
Rate for Payer: BCBS MT CHIP	$378.00
Rate for Payer: BCBS MT Closed Plan Network	$399.00
Rate for Payer: BCBS MT HealthLink	$378.00
Rate for Payer: BCBS MT Medicare	$378.00
Rate for Payer: BCBS MT POS	$399.00
Rate for Payer: BCBS MT Traditional	$420.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cigna Commercial	$399.00
Rate for Payer: Cigna Medicare	$378.00
Rate for Payer: Medicaid All Medicaid	$386.40
Rate for Payer: Medicare All Medicare	$294.00
Rate for Payer: Monida Allegiance	$399.00
Rate for Payer: Monida First Choice Health	$407.40
Rate for Payer: Monida Montana Health Co-op	$399.00
Rate for Payer: Monida PacificSource	$399.00

PRO FEE REPAIR INT N/H/F/EXTG 7.6-12.5CM

Professional

Both

$412.00

Service Code	CPT 12044
Hospital Charge Code	712044
Hospital Revenue Code	981
Min. Negotiated Rate	$288.40
Max. Negotiated Rate	$412.00
Rate for Payer: Aetna Commercial	$391.40
Rate for Payer: Aetna Medicare	$370.80
Rate for Payer: BCBS MT CHIP	$370.80
Rate for Payer: BCBS MT Closed Plan Network	$391.40
Rate for Payer: BCBS MT HealthLink	$370.80
Rate for Payer: BCBS MT Medicare	$370.80
Rate for Payer: BCBS MT POS	$391.40
Rate for Payer: BCBS MT Traditional	$412.00
Rate for Payer: Cash Price	$370.80
Rate for Payer: Cigna Commercial	$391.40
Rate for Payer: Cigna Medicare	$370.80
Rate for Payer: Medicaid All Medicaid	$379.04
Rate for Payer: Medicare All Medicare	$288.40
Rate for Payer: Monida Allegiance	$391.40
Rate for Payer: Monida First Choice Health	$399.64
Rate for Payer: Monida Montana Health Co-op	$391.40
Rate for Payer: Monida PacificSource	$391.40

PRO FEE REPAIR INT N/H/F/G 2.5-7.5CM

Professional

Both

$375.00

Service Code	CPT 12042
Hospital Charge Code	712042
Hospital Revenue Code	981
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$375.00
Rate for Payer: Aetna Commercial	$356.25
Rate for Payer: Aetna Medicare	$337.50
Rate for Payer: BCBS MT CHIP	$337.50
Rate for Payer: BCBS MT Closed Plan Network	$356.25
Rate for Payer: BCBS MT HealthLink	$337.50
Rate for Payer: BCBS MT Medicare	$337.50
Rate for Payer: BCBS MT POS	$356.25
Rate for Payer: BCBS MT Traditional	$375.00
Rate for Payer: Cash Price	$337.50
Rate for Payer: Cigna Commercial	$356.25
Rate for Payer: Cigna Medicare	$337.50
Rate for Payer: Medicaid All Medicaid	$345.00
Rate for Payer: Medicare All Medicare	$262.50
Rate for Payer: Monida Allegiance	$356.25
Rate for Payer: Monida First Choice Health	$363.75
Rate for Payer: Monida Montana Health Co-op	$356.25
Rate for Payer: Monida PacificSource	$356.25

PRO FEE REPAIR INT S/A/T/E 12.6-20.CM

Professional

Both

$463.00

Service Code	CPT 12035
Hospital Charge Code	712035
Hospital Revenue Code	981
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

PRO FEE REPAIR INT S/A/T/E<2.5CM

Professional

Both

$291.00

Service Code	CPT 12031
Hospital Charge Code	712031
Hospital Revenue Code	981
Min. Negotiated Rate	$203.70
Max. Negotiated Rate	$291.00
Rate for Payer: Aetna Commercial	$276.45
Rate for Payer: Aetna Medicare	$261.90
Rate for Payer: BCBS MT CHIP	$261.90
Rate for Payer: BCBS MT Closed Plan Network	$276.45
Rate for Payer: BCBS MT HealthLink	$261.90
Rate for Payer: BCBS MT Medicare	$261.90
Rate for Payer: BCBS MT POS	$276.45
Rate for Payer: BCBS MT Traditional	$291.00
Rate for Payer: Cash Price	$261.90
Rate for Payer: Cigna Commercial	$276.45
Rate for Payer: Cigna Medicare	$261.90
Rate for Payer: Medicaid All Medicaid	$267.72
Rate for Payer: Medicare All Medicare	$203.70
Rate for Payer: Monida Allegiance	$276.45
Rate for Payer: Monida First Choice Health	$282.27
Rate for Payer: Monida Montana Health Co-op	$276.45
Rate for Payer: Monida PacificSource	$276.45

PRO FEE REPAIR INT S/A/T/E 2.6-7.5CM

Professional

Both

$366.00

Service Code	CPT 12032
Hospital Charge Code	712032
Hospital Revenue Code	981
Min. Negotiated Rate	$256.20
Max. Negotiated Rate	$366.00
Rate for Payer: Aetna Commercial	$347.70
Rate for Payer: Aetna Medicare	$329.40
Rate for Payer: BCBS MT CHIP	$329.40
Rate for Payer: BCBS MT Closed Plan Network	$347.70
Rate for Payer: BCBS MT HealthLink	$329.40
Rate for Payer: BCBS MT Medicare	$329.40
Rate for Payer: BCBS MT POS	$347.70
Rate for Payer: BCBS MT Traditional	$366.00
Rate for Payer: Cash Price	$329.40
Rate for Payer: Cigna Commercial	$347.70
Rate for Payer: Cigna Medicare	$329.40
Rate for Payer: Medicaid All Medicaid	$336.72
Rate for Payer: Medicare All Medicare	$256.20
Rate for Payer: Monida Allegiance	$347.70
Rate for Payer: Monida First Choice Health	$355.02
Rate for Payer: Monida Montana Health Co-op	$347.70
Rate for Payer: Monida PacificSource	$347.70

PRO FEE REPAIR INT S/A/T/E 7.6-12.5CM

Professional

Both

$393.00

Service Code	CPT 12034
Hospital Charge Code	712034
Hospital Revenue Code	981
Min. Negotiated Rate	$275.10
Max. Negotiated Rate	$393.00
Rate for Payer: Aetna Commercial	$373.35
Rate for Payer: Aetna Medicare	$353.70
Rate for Payer: BCBS MT CHIP	$353.70
Rate for Payer: BCBS MT Closed Plan Network	$373.35
Rate for Payer: BCBS MT HealthLink	$353.70
Rate for Payer: BCBS MT Medicare	$353.70
Rate for Payer: BCBS MT POS	$373.35
Rate for Payer: BCBS MT Traditional	$393.00
Rate for Payer: Cash Price	$353.70
Rate for Payer: Cigna Commercial	$373.35
Rate for Payer: Cigna Medicare	$353.70
Rate for Payer: Medicaid All Medicaid	$361.56
Rate for Payer: Medicare All Medicare	$275.10
Rate for Payer: Monida Allegiance	$373.35
Rate for Payer: Monida First Choice Health	$381.21
Rate for Payer: Monida Montana Health Co-op	$373.35
Rate for Payer: Monida PacificSource	$373.35

PRO FEE REPAIR SIMPLE FACE...7.6-12.5

Professional

Both

$176.00

Service Code	CPT 12015
Hospital Charge Code	712015
Hospital Revenue Code	981
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$176.00
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$158.40
Rate for Payer: BCBS MT CHIP	$158.40
Rate for Payer: BCBS MT Closed Plan Network	$167.20
Rate for Payer: BCBS MT HealthLink	$158.40
Rate for Payer: BCBS MT Medicare	$158.40
Rate for Payer: BCBS MT POS	$167.20
Rate for Payer: BCBS MT Traditional	$176.00
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cigna Commercial	$167.20
Rate for Payer: Cigna Medicare	$158.40
Rate for Payer: Medicaid All Medicaid	$161.92
Rate for Payer: Medicare All Medicare	$123.20
Rate for Payer: Monida Allegiance	$167.20
Rate for Payer: Monida First Choice Health	$170.72
Rate for Payer: Monida Montana Health Co-op	$167.20
Rate for Payer: Monida PacificSource	$167.20

Know your out-of-pocket cost for care.

All Charges