Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER REPAIR COMPLEX 1.1CM TO 2.5 SCALP, AR

Facility

$674.00

Service Code	HCPCS 13120
Hospital Charge Code	1013120
Hospital Revenue Code	450
Min. Negotiated Rate	$471.80
Max. Negotiated Rate	$674.00
Rate for Payer: Aetna Commercial	$640.30
Rate for Payer: Aetna Medicare	$606.60
Rate for Payer: BCBS MT CHIP	$606.60
Rate for Payer: BCBS MT Closed Plan Network	$640.30
Rate for Payer: BCBS MT HealthLink	$606.60
Rate for Payer: BCBS MT Medicare	$606.60
Rate for Payer: BCBS MT POS	$640.30
Rate for Payer: BCBS MT Traditional	$674.00
Rate for Payer: Cash Price	$606.60
Rate for Payer: Cigna Commercial	$640.30
Rate for Payer: Cigna Medicare	$606.60
Rate for Payer: Medicaid All Medicaid	$620.08
Rate for Payer: Medicare All Medicare	$471.80
Rate for Payer: Monida Allegiance	$640.30
Rate for Payer: Monida First Choice Health	$653.78
Rate for Payer: Monida Montana Health Co-op	$640.30
Rate for Payer: Monida PacificSource	$640.30

ER REPAIR COMPLEX 1.1CM TO 2.5 SCALP, AR

Facility

$674.00

Service Code	HCPCS 13120
Hospital Charge Code	1013120
Hospital Revenue Code	450
Min. Negotiated Rate	$471.80
Max. Negotiated Rate	$674.00
Rate for Payer: Aetna Commercial	$640.30
Rate for Payer: Aetna Medicare	$606.60
Rate for Payer: BCBS MT CHIP	$606.60
Rate for Payer: BCBS MT Closed Plan Network	$640.30
Rate for Payer: BCBS MT HealthLink	$606.60
Rate for Payer: BCBS MT Medicare	$606.60
Rate for Payer: BCBS MT POS	$640.30
Rate for Payer: BCBS MT Traditional	$674.00
Rate for Payer: Cash Price	$606.60
Rate for Payer: Cigna Commercial	$640.30
Rate for Payer: Cigna Medicare	$606.60
Rate for Payer: Medicaid All Medicaid	$620.08
Rate for Payer: Medicare All Medicare	$471.80
Rate for Payer: Monida Allegiance	$640.30
Rate for Payer: Monida First Choice Health	$653.78
Rate for Payer: Monida Montana Health Co-op	$640.30
Rate for Payer: Monida PacificSource	$640.30

ER REPAIR COMPLEX 2.6CM TO 7.5CM

Facility

$848.00

Service Code	HCPCS 13121
Hospital Charge Code	1013121
Hospital Revenue Code	450
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

ER REPAIR COMPLEX 2.6CM TO 7.5CM

Facility

$848.00

Service Code	HCPCS 13121
Hospital Charge Code	1013121
Hospital Revenue Code	450
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

ER REPAIR COMPLEX EA ADDTL 5CM OR LESS

Facility

$848.00

Service Code	HCPCS 13122
Hospital Charge Code	1013122
Hospital Revenue Code	450
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

ER REPAIR COMPLEX EA ADDTL 5CM OR LESS

Facility

$848.00

Service Code	HCPCS 13122
Hospital Charge Code	1013122
Hospital Revenue Code	450
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

ER REPAIR COMPLEX FC/HN 2.6 TO 7.5CM

Facility

$925.00

Service Code	HCPCS 13132
Hospital Charge Code	1013132
Hospital Revenue Code	450
Min. Negotiated Rate	$647.50
Max. Negotiated Rate	$925.00
Rate for Payer: Aetna Commercial	$878.75
Rate for Payer: Aetna Medicare	$832.50
Rate for Payer: BCBS MT CHIP	$832.50
Rate for Payer: BCBS MT Closed Plan Network	$878.75
Rate for Payer: BCBS MT HealthLink	$832.50
Rate for Payer: BCBS MT Medicare	$832.50
Rate for Payer: BCBS MT POS	$878.75
Rate for Payer: BCBS MT Traditional	$925.00
Rate for Payer: Cash Price	$832.50
Rate for Payer: Cigna Commercial	$878.75
Rate for Payer: Cigna Medicare	$832.50
Rate for Payer: Medicaid All Medicaid	$851.00
Rate for Payer: Medicare All Medicare	$647.50
Rate for Payer: Monida Allegiance	$878.75
Rate for Payer: Monida First Choice Health	$897.25
Rate for Payer: Monida Montana Health Co-op	$878.75
Rate for Payer: Monida PacificSource	$878.75

ER REPAIR COMPLEX FC/HN 2.6 TO 7.5CM

Facility

$925.00

Service Code	HCPCS 13132
Hospital Charge Code	1013132
Hospital Revenue Code	450
Min. Negotiated Rate	$647.50
Max. Negotiated Rate	$925.00
Rate for Payer: Aetna Commercial	$878.75
Rate for Payer: Aetna Medicare	$832.50
Rate for Payer: BCBS MT CHIP	$832.50
Rate for Payer: BCBS MT Closed Plan Network	$878.75
Rate for Payer: BCBS MT HealthLink	$832.50
Rate for Payer: BCBS MT Medicare	$832.50
Rate for Payer: BCBS MT POS	$878.75
Rate for Payer: BCBS MT Traditional	$925.00
Rate for Payer: Cash Price	$832.50
Rate for Payer: Cigna Commercial	$878.75
Rate for Payer: Cigna Medicare	$832.50
Rate for Payer: Medicaid All Medicaid	$851.00
Rate for Payer: Medicare All Medicare	$647.50
Rate for Payer: Monida Allegiance	$878.75
Rate for Payer: Monida First Choice Health	$897.25
Rate for Payer: Monida Montana Health Co-op	$878.75
Rate for Payer: Monida PacificSource	$878.75

ER REPAIR COMPLEX FC/HNDS/FTADD ON =<5CM

Facility

$540.00

Service Code	HCPCS 13133
Hospital Charge Code	1013133
Hospital Revenue Code	450
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna Commercial	$513.00
Rate for Payer: Aetna Medicare	$486.00
Rate for Payer: BCBS MT CHIP	$486.00
Rate for Payer: BCBS MT Closed Plan Network	$513.00
Rate for Payer: BCBS MT HealthLink	$486.00
Rate for Payer: BCBS MT Medicare	$486.00
Rate for Payer: BCBS MT POS	$513.00
Rate for Payer: BCBS MT Traditional	$540.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna Commercial	$513.00
Rate for Payer: Cigna Medicare	$486.00
Rate for Payer: Medicaid All Medicaid	$496.80
Rate for Payer: Medicare All Medicare	$378.00
Rate for Payer: Monida Allegiance	$513.00
Rate for Payer: Monida First Choice Health	$523.80
Rate for Payer: Monida Montana Health Co-op	$513.00
Rate for Payer: Monida PacificSource	$513.00

ER REPAIR COMPLEX FC/HNDS/FTADD ON =<5CM

Facility

$540.00

Service Code	HCPCS 13133
Hospital Charge Code	1013133
Hospital Revenue Code	450
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$540.00
Rate for Payer: Aetna Commercial	$513.00
Rate for Payer: Aetna Medicare	$486.00
Rate for Payer: BCBS MT CHIP	$486.00
Rate for Payer: BCBS MT Closed Plan Network	$513.00
Rate for Payer: BCBS MT HealthLink	$486.00
Rate for Payer: BCBS MT Medicare	$486.00
Rate for Payer: BCBS MT POS	$513.00
Rate for Payer: BCBS MT Traditional	$540.00
Rate for Payer: Cash Price	$486.00
Rate for Payer: Cigna Commercial	$513.00
Rate for Payer: Cigna Medicare	$486.00
Rate for Payer: Medicaid All Medicaid	$496.80
Rate for Payer: Medicare All Medicare	$378.00
Rate for Payer: Monida Allegiance	$513.00
Rate for Payer: Monida First Choice Health	$523.80
Rate for Payer: Monida Montana Health Co-op	$513.00
Rate for Payer: Monida PacificSource	$513.00

ER REPAIR INT F,E,E,N,L 2.5 TO 5CM

Facility

$571.00

Service Code	HCPCS 12052
Hospital Charge Code	1012052
Hospital Revenue Code	450
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

ER REPAIR INT F,E,E,N,L 2.5 TO 5CM

Facility

$571.00

Service Code	HCPCS 12052
Hospital Charge Code	1012052
Hospital Revenue Code	450
Min. Negotiated Rate	$399.70
Max. Negotiated Rate	$571.00
Rate for Payer: Aetna Commercial	$542.45
Rate for Payer: Aetna Medicare	$513.90
Rate for Payer: BCBS MT CHIP	$513.90
Rate for Payer: BCBS MT Closed Plan Network	$542.45
Rate for Payer: BCBS MT HealthLink	$513.90
Rate for Payer: BCBS MT Medicare	$513.90
Rate for Payer: BCBS MT POS	$542.45
Rate for Payer: BCBS MT Traditional	$571.00
Rate for Payer: Cash Price	$513.90
Rate for Payer: Cigna Commercial	$542.45
Rate for Payer: Cigna Medicare	$513.90
Rate for Payer: Medicaid All Medicaid	$525.32
Rate for Payer: Medicare All Medicare	$399.70
Rate for Payer: Monida Allegiance	$542.45
Rate for Payer: Monida First Choice Health	$553.87
Rate for Payer: Monida Montana Health Co-op	$542.45
Rate for Payer: Monida PacificSource	$542.45

ER REPAIR INT, F/E/E/N/L 5.1-7.5CM

Facility

$263.00

Service Code	HCPCS 12053
Hospital Charge Code	1012053
Hospital Revenue Code	450
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

ER REPAIR INT, F/E/E/N/L 5.1-7.5CM

Facility

$263.00

Service Code	HCPCS 12053
Hospital Charge Code	1012053
Hospital Revenue Code	450
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$263.00
Rate for Payer: Aetna Commercial	$249.85
Rate for Payer: Aetna Medicare	$236.70
Rate for Payer: BCBS MT CHIP	$236.70
Rate for Payer: BCBS MT Closed Plan Network	$249.85
Rate for Payer: BCBS MT HealthLink	$236.70
Rate for Payer: BCBS MT Medicare	$236.70
Rate for Payer: BCBS MT POS	$249.85
Rate for Payer: BCBS MT Traditional	$263.00
Rate for Payer: Cash Price	$236.70
Rate for Payer: Cigna Commercial	$249.85
Rate for Payer: Cigna Medicare	$236.70
Rate for Payer: Medicaid All Medicaid	$241.96
Rate for Payer: Medicare All Medicare	$184.10
Rate for Payer: Monida Allegiance	$249.85
Rate for Payer: Monida First Choice Health	$255.11
Rate for Payer: Monida Montana Health Co-op	$249.85
Rate for Payer: Monida PacificSource	$249.85

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

Facility

$623.00

Service Code	HCPCS 12054
Hospital Charge Code	1012054
Hospital Revenue Code	450
Min. Negotiated Rate	$436.10
Max. Negotiated Rate	$623.00
Rate for Payer: Aetna Commercial	$591.85
Rate for Payer: Aetna Medicare	$560.70
Rate for Payer: BCBS MT CHIP	$560.70
Rate for Payer: BCBS MT Closed Plan Network	$591.85
Rate for Payer: BCBS MT HealthLink	$560.70
Rate for Payer: BCBS MT Medicare	$560.70
Rate for Payer: BCBS MT POS	$591.85
Rate for Payer: BCBS MT Traditional	$623.00
Rate for Payer: Cash Price	$560.70
Rate for Payer: Cigna Commercial	$591.85
Rate for Payer: Cigna Medicare	$560.70
Rate for Payer: Medicaid All Medicaid	$573.16
Rate for Payer: Medicare All Medicare	$436.10
Rate for Payer: Monida Allegiance	$591.85
Rate for Payer: Monida First Choice Health	$604.31
Rate for Payer: Monida Montana Health Co-op	$591.85
Rate for Payer: Monida PacificSource	$591.85

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

Facility

$623.00

Service Code	HCPCS 12054
Hospital Charge Code	1012054
Hospital Revenue Code	450
Min. Negotiated Rate	$436.10
Max. Negotiated Rate	$623.00
Rate for Payer: Aetna Commercial	$591.85
Rate for Payer: Aetna Medicare	$560.70
Rate for Payer: BCBS MT CHIP	$560.70
Rate for Payer: BCBS MT Closed Plan Network	$591.85
Rate for Payer: BCBS MT HealthLink	$560.70
Rate for Payer: BCBS MT Medicare	$560.70
Rate for Payer: BCBS MT POS	$591.85
Rate for Payer: BCBS MT Traditional	$623.00
Rate for Payer: Cash Price	$560.70
Rate for Payer: Cigna Commercial	$591.85
Rate for Payer: Cigna Medicare	$560.70
Rate for Payer: Medicaid All Medicaid	$573.16
Rate for Payer: Medicare All Medicare	$436.10
Rate for Payer: Monida Allegiance	$591.85
Rate for Payer: Monida First Choice Health	$604.31
Rate for Payer: Monida Montana Health Co-op	$591.85
Rate for Payer: Monida PacificSource	$591.85

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

Facility

$536.00

Service Code	HCPCS 12051
Hospital Charge Code	1012051
Hospital Revenue Code	450
Min. Negotiated Rate	$375.20
Max. Negotiated Rate	$536.00
Rate for Payer: Aetna Commercial	$509.20
Rate for Payer: Aetna Medicare	$482.40
Rate for Payer: BCBS MT CHIP	$482.40
Rate for Payer: BCBS MT Closed Plan Network	$509.20
Rate for Payer: BCBS MT HealthLink	$482.40
Rate for Payer: BCBS MT Medicare	$482.40
Rate for Payer: BCBS MT POS	$509.20
Rate for Payer: BCBS MT Traditional	$536.00
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cigna Commercial	$509.20
Rate for Payer: Cigna Medicare	$482.40
Rate for Payer: Medicaid All Medicaid	$493.12
Rate for Payer: Medicare All Medicare	$375.20
Rate for Payer: Monida Allegiance	$509.20
Rate for Payer: Monida First Choice Health	$519.92
Rate for Payer: Monida Montana Health Co-op	$509.20
Rate for Payer: Monida PacificSource	$509.20

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

Facility

$536.00

Service Code	HCPCS 12051
Hospital Charge Code	1012051
Hospital Revenue Code	450
Min. Negotiated Rate	$375.20
Max. Negotiated Rate	$536.00
Rate for Payer: Aetna Commercial	$509.20
Rate for Payer: Aetna Medicare	$482.40
Rate for Payer: BCBS MT CHIP	$482.40
Rate for Payer: BCBS MT Closed Plan Network	$509.20
Rate for Payer: BCBS MT HealthLink	$482.40
Rate for Payer: BCBS MT Medicare	$482.40
Rate for Payer: BCBS MT POS	$509.20
Rate for Payer: BCBS MT Traditional	$536.00
Rate for Payer: Cash Price	$482.40
Rate for Payer: Cigna Commercial	$509.20
Rate for Payer: Cigna Medicare	$482.40
Rate for Payer: Medicaid All Medicaid	$493.12
Rate for Payer: Medicare All Medicare	$375.20
Rate for Payer: Monida Allegiance	$509.20
Rate for Payer: Monida First Choice Health	$519.92
Rate for Payer: Monida Montana Health Co-op	$509.20
Rate for Payer: Monida PacificSource	$509.20

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

Facility

$456.00

Service Code	HCPCS 12041
Hospital Charge Code	1012041
Hospital Revenue Code	450
Min. Negotiated Rate	$319.20
Max. Negotiated Rate	$456.00
Rate for Payer: Aetna Commercial	$433.20
Rate for Payer: Aetna Medicare	$410.40
Rate for Payer: BCBS MT CHIP	$410.40
Rate for Payer: BCBS MT Closed Plan Network	$433.20
Rate for Payer: BCBS MT HealthLink	$410.40
Rate for Payer: BCBS MT Medicare	$410.40
Rate for Payer: BCBS MT POS	$433.20
Rate for Payer: BCBS MT Traditional	$456.00
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cigna Commercial	$433.20
Rate for Payer: Cigna Medicare	$410.40
Rate for Payer: Medicaid All Medicaid	$419.52
Rate for Payer: Medicare All Medicare	$319.20
Rate for Payer: Monida Allegiance	$433.20
Rate for Payer: Monida First Choice Health	$442.32
Rate for Payer: Monida Montana Health Co-op	$433.20
Rate for Payer: Monida PacificSource	$433.20

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

Facility

$456.00

Service Code	HCPCS 12041
Hospital Charge Code	1012041
Hospital Revenue Code	450
Min. Negotiated Rate	$319.20
Max. Negotiated Rate	$456.00
Rate for Payer: Aetna Commercial	$433.20
Rate for Payer: Aetna Medicare	$410.40
Rate for Payer: BCBS MT CHIP	$410.40
Rate for Payer: BCBS MT Closed Plan Network	$433.20
Rate for Payer: BCBS MT HealthLink	$410.40
Rate for Payer: BCBS MT Medicare	$410.40
Rate for Payer: BCBS MT POS	$433.20
Rate for Payer: BCBS MT Traditional	$456.00
Rate for Payer: Cash Price	$410.40
Rate for Payer: Cigna Commercial	$433.20
Rate for Payer: Cigna Medicare	$410.40
Rate for Payer: Medicaid All Medicaid	$419.52
Rate for Payer: Medicare All Medicare	$319.20
Rate for Payer: Monida Allegiance	$433.20
Rate for Payer: Monida First Choice Health	$442.32
Rate for Payer: Monida Montana Health Co-op	$433.20
Rate for Payer: Monida PacificSource	$433.20

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

Facility

$500.00

Service Code	HCPCS 12042
Hospital Charge Code	1012042
Hospital Revenue Code	450
Min. Negotiated Rate	$350.00
Max. Negotiated Rate	$500.00
Rate for Payer: Aetna Commercial	$475.00
Rate for Payer: Aetna Medicare	$450.00
Rate for Payer: BCBS MT CHIP	$450.00
Rate for Payer: BCBS MT Closed Plan Network	$475.00
Rate for Payer: BCBS MT HealthLink	$450.00
Rate for Payer: BCBS MT Medicare	$450.00
Rate for Payer: BCBS MT POS	$475.00
Rate for Payer: BCBS MT Traditional	$500.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial	$475.00
Rate for Payer: Cigna Medicare	$450.00
Rate for Payer: Medicaid All Medicaid	$460.00
Rate for Payer: Medicare All Medicare	$350.00
Rate for Payer: Monida Allegiance	$475.00
Rate for Payer: Monida First Choice Health	$485.00
Rate for Payer: Monida Montana Health Co-op	$475.00
Rate for Payer: Monida PacificSource	$475.00

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

Facility

$500.00

Service Code	HCPCS 12042
Hospital Charge Code	1012042
Hospital Revenue Code	450
Min. Negotiated Rate	$350.00
Max. Negotiated Rate	$500.00
Rate for Payer: Aetna Commercial	$475.00
Rate for Payer: Aetna Medicare	$450.00
Rate for Payer: BCBS MT CHIP	$450.00
Rate for Payer: BCBS MT Closed Plan Network	$475.00
Rate for Payer: BCBS MT HealthLink	$450.00
Rate for Payer: BCBS MT Medicare	$450.00
Rate for Payer: BCBS MT POS	$475.00
Rate for Payer: BCBS MT Traditional	$500.00
Rate for Payer: Cash Price	$450.00
Rate for Payer: Cigna Commercial	$475.00
Rate for Payer: Cigna Medicare	$450.00
Rate for Payer: Medicaid All Medicaid	$460.00
Rate for Payer: Medicare All Medicare	$350.00
Rate for Payer: Monida Allegiance	$475.00
Rate for Payer: Monida First Choice Health	$485.00
Rate for Payer: Monida Montana Health Co-op	$475.00
Rate for Payer: Monida PacificSource	$475.00

ER REPAIR INT S/A/T/E 12.6-20CM

Facility

$759.00

Service Code	HCPCS 12035
Hospital Charge Code	1012035
Hospital Revenue Code	450
Min. Negotiated Rate	$531.30
Max. Negotiated Rate	$759.00
Rate for Payer: Aetna Commercial	$721.05
Rate for Payer: Aetna Medicare	$683.10
Rate for Payer: BCBS MT CHIP	$683.10
Rate for Payer: BCBS MT Closed Plan Network	$721.05
Rate for Payer: BCBS MT HealthLink	$683.10
Rate for Payer: BCBS MT Medicare	$683.10
Rate for Payer: BCBS MT POS	$721.05
Rate for Payer: BCBS MT Traditional	$759.00
Rate for Payer: Cash Price	$683.10
Rate for Payer: Cigna Commercial	$721.05
Rate for Payer: Cigna Medicare	$683.10
Rate for Payer: Medicaid All Medicaid	$698.28
Rate for Payer: Medicare All Medicare	$531.30
Rate for Payer: Monida Allegiance	$721.05
Rate for Payer: Monida First Choice Health	$736.23
Rate for Payer: Monida Montana Health Co-op	$721.05
Rate for Payer: Monida PacificSource	$721.05

ER REPAIR INT S/A/T/E 12.6-20CM

Facility

$759.00

Service Code	HCPCS 12035
Hospital Charge Code	1012035
Hospital Revenue Code	450
Min. Negotiated Rate	$531.30
Max. Negotiated Rate	$759.00
Rate for Payer: Aetna Commercial	$721.05
Rate for Payer: Aetna Medicare	$683.10
Rate for Payer: BCBS MT CHIP	$683.10
Rate for Payer: BCBS MT Closed Plan Network	$721.05
Rate for Payer: BCBS MT HealthLink	$683.10
Rate for Payer: BCBS MT Medicare	$683.10
Rate for Payer: BCBS MT POS	$721.05
Rate for Payer: BCBS MT Traditional	$759.00
Rate for Payer: Cash Price	$683.10
Rate for Payer: Cigna Commercial	$721.05
Rate for Payer: Cigna Medicare	$683.10
Rate for Payer: Medicaid All Medicaid	$698.28
Rate for Payer: Medicare All Medicare	$531.30
Rate for Payer: Monida Allegiance	$721.05
Rate for Payer: Monida First Choice Health	$736.23
Rate for Payer: Monida Montana Health Co-op	$721.05
Rate for Payer: Monida PacificSource	$721.05

ER REPAIR INT S/A/T/E =<2.5CM

Facility

$557.00

Service Code	HCPCS 12031
Hospital Charge Code	1012031
Hospital Revenue Code	450
Min. Negotiated Rate	$389.90
Max. Negotiated Rate	$557.00
Rate for Payer: Aetna Commercial	$529.15
Rate for Payer: Aetna Medicare	$501.30
Rate for Payer: BCBS MT CHIP	$501.30
Rate for Payer: BCBS MT Closed Plan Network	$529.15
Rate for Payer: BCBS MT HealthLink	$501.30
Rate for Payer: BCBS MT Medicare	$501.30
Rate for Payer: BCBS MT POS	$529.15
Rate for Payer: BCBS MT Traditional	$557.00
Rate for Payer: Cash Price	$501.30
Rate for Payer: Cigna Commercial	$529.15
Rate for Payer: Cigna Medicare	$501.30
Rate for Payer: Medicaid All Medicaid	$512.44
Rate for Payer: Medicare All Medicare	$389.90
Rate for Payer: Monida Allegiance	$529.15
Rate for Payer: Monida First Choice Health	$540.29
Rate for Payer: Monida Montana Health Co-op	$529.15
Rate for Payer: Monida PacificSource	$529.15

Know your out-of-pocket cost for care.

All Charges