Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

ER REPAIR INT S/A/T/E 2.6-7.5CM

Facility

$612.00

Service Code	HCPCS 12032
Hospital Charge Code	1012032
Hospital Revenue Code	450
Min. Negotiated Rate	$428.40
Max. Negotiated Rate	$612.00
Rate for Payer: Aetna Commercial	$581.40
Rate for Payer: Aetna Medicare	$550.80
Rate for Payer: BCBS MT CHIP	$550.80
Rate for Payer: BCBS MT Closed Plan Network	$581.40
Rate for Payer: BCBS MT HealthLink	$550.80
Rate for Payer: BCBS MT Medicare	$550.80
Rate for Payer: BCBS MT POS	$581.40
Rate for Payer: BCBS MT Traditional	$612.00
Rate for Payer: Cash Price	$550.80
Rate for Payer: Cigna Commercial	$581.40
Rate for Payer: Cigna Medicare	$550.80
Rate for Payer: Medicaid All Medicaid	$563.04
Rate for Payer: Medicare All Medicare	$428.40
Rate for Payer: Monida Allegiance	$581.40
Rate for Payer: Monida First Choice Health	$593.64
Rate for Payer: Monida Montana Health Co-op	$581.40
Rate for Payer: Monida PacificSource	$581.40

ER REPAIR INT S/A/T/E 2.6-7.5CM

Facility

$612.00

Service Code	HCPCS 12032
Hospital Charge Code	1012032
Hospital Revenue Code	450
Min. Negotiated Rate	$428.40
Max. Negotiated Rate	$612.00
Rate for Payer: Aetna Commercial	$581.40
Rate for Payer: Aetna Medicare	$550.80
Rate for Payer: BCBS MT CHIP	$550.80
Rate for Payer: BCBS MT Closed Plan Network	$581.40
Rate for Payer: BCBS MT HealthLink	$550.80
Rate for Payer: BCBS MT Medicare	$550.80
Rate for Payer: BCBS MT POS	$581.40
Rate for Payer: BCBS MT Traditional	$612.00
Rate for Payer: Cash Price	$550.80
Rate for Payer: Cigna Commercial	$581.40
Rate for Payer: Cigna Medicare	$550.80
Rate for Payer: Medicaid All Medicaid	$563.04
Rate for Payer: Medicare All Medicare	$428.40
Rate for Payer: Monida Allegiance	$581.40
Rate for Payer: Monida First Choice Health	$593.64
Rate for Payer: Monida Montana Health Co-op	$581.40
Rate for Payer: Monida PacificSource	$581.40

ER REPAIR INT S/A/T/E 7.6-12CM

Facility

$690.00

Service Code	HCPCS 12034
Hospital Charge Code	1012034
Hospital Revenue Code	450
Min. Negotiated Rate	$483.00
Max. Negotiated Rate	$690.00
Rate for Payer: Aetna Commercial	$655.50
Rate for Payer: Aetna Medicare	$621.00
Rate for Payer: BCBS MT CHIP	$621.00
Rate for Payer: BCBS MT Closed Plan Network	$655.50
Rate for Payer: BCBS MT HealthLink	$621.00
Rate for Payer: BCBS MT Medicare	$621.00
Rate for Payer: BCBS MT POS	$655.50
Rate for Payer: BCBS MT Traditional	$690.00
Rate for Payer: Cash Price	$621.00
Rate for Payer: Cigna Commercial	$655.50
Rate for Payer: Cigna Medicare	$621.00
Rate for Payer: Medicaid All Medicaid	$634.80
Rate for Payer: Medicare All Medicare	$483.00
Rate for Payer: Monida Allegiance	$655.50
Rate for Payer: Monida First Choice Health	$669.30
Rate for Payer: Monida Montana Health Co-op	$655.50
Rate for Payer: Monida PacificSource	$655.50

ER REPAIR INT S/A/T/E 7.6-12CM

Facility

$690.00

Service Code	HCPCS 12034
Hospital Charge Code	1012034
Hospital Revenue Code	450
Min. Negotiated Rate	$483.00
Max. Negotiated Rate	$690.00
Rate for Payer: Aetna Commercial	$655.50
Rate for Payer: Aetna Medicare	$621.00
Rate for Payer: BCBS MT CHIP	$621.00
Rate for Payer: BCBS MT Closed Plan Network	$655.50
Rate for Payer: BCBS MT HealthLink	$621.00
Rate for Payer: BCBS MT Medicare	$621.00
Rate for Payer: BCBS MT POS	$655.50
Rate for Payer: BCBS MT Traditional	$690.00
Rate for Payer: Cash Price	$621.00
Rate for Payer: Cigna Commercial	$655.50
Rate for Payer: Cigna Medicare	$621.00
Rate for Payer: Medicaid All Medicaid	$634.80
Rate for Payer: Medicare All Medicare	$483.00
Rate for Payer: Monida Allegiance	$655.50
Rate for Payer: Monida First Choice Health	$669.30
Rate for Payer: Monida Montana Health Co-op	$655.50
Rate for Payer: Monida PacificSource	$655.50

ER REPAIR LACERATION OF PALATE UP 2CM

Facility

$516.00

Service Code	HCPCS 42180
Hospital Charge Code	1042180
Hospital Revenue Code	450
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

ER REPAIR LACERATION OF PALATE UP 2CM

Facility

$516.00

Service Code	HCPCS 42180
Hospital Charge Code	1042180
Hospital Revenue Code	450
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$516.00
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: BCBS MT CHIP	$464.40
Rate for Payer: BCBS MT Closed Plan Network	$490.20
Rate for Payer: BCBS MT HealthLink	$464.40
Rate for Payer: BCBS MT Medicare	$464.40
Rate for Payer: BCBS MT POS	$490.20
Rate for Payer: BCBS MT Traditional	$516.00
Rate for Payer: Cash Price	$464.40
Rate for Payer: Cigna Commercial	$490.20
Rate for Payer: Cigna Medicare	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

ER REPAIR SIMPLE =<2.5CM

Facility

$328.00

Service Code	HCPCS 12001
Hospital Charge Code	1012001
Hospital Revenue Code	450
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

ER REPAIR SIMPLE =<2.5CM

Facility

$328.00

Service Code	HCPCS 12001
Hospital Charge Code	1012001
Hospital Revenue Code	450
Min. Negotiated Rate	$229.60
Max. Negotiated Rate	$328.00
Rate for Payer: Aetna Commercial	$311.60
Rate for Payer: Aetna Medicare	$295.20
Rate for Payer: BCBS MT CHIP	$295.20
Rate for Payer: BCBS MT Closed Plan Network	$311.60
Rate for Payer: BCBS MT HealthLink	$295.20
Rate for Payer: BCBS MT Medicare	$295.20
Rate for Payer: BCBS MT POS	$311.60
Rate for Payer: BCBS MT Traditional	$328.00
Rate for Payer: Cash Price	$295.20
Rate for Payer: Cigna Commercial	$311.60
Rate for Payer: Cigna Medicare	$295.20
Rate for Payer: Medicaid All Medicaid	$301.76
Rate for Payer: Medicare All Medicare	$229.60
Rate for Payer: Monida Allegiance	$311.60
Rate for Payer: Monida First Choice Health	$318.16
Rate for Payer: Monida Montana Health Co-op	$311.60
Rate for Payer: Monida PacificSource	$311.60

ER REPAIR SIMPLE 2.6-7.5CM

Facility

$338.00

Service Code	HCPCS 12002
Hospital Charge Code	1012002
Hospital Revenue Code	450
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

ER REPAIR SIMPLE 2.6-7.5CM

Facility

$338.00

Service Code	HCPCS 12002
Hospital Charge Code	1012002
Hospital Revenue Code	450
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$338.00
Rate for Payer: Aetna Commercial	$321.10
Rate for Payer: Aetna Medicare	$304.20
Rate for Payer: BCBS MT CHIP	$304.20
Rate for Payer: BCBS MT Closed Plan Network	$321.10
Rate for Payer: BCBS MT HealthLink	$304.20
Rate for Payer: BCBS MT Medicare	$304.20
Rate for Payer: BCBS MT POS	$321.10
Rate for Payer: BCBS MT Traditional	$338.00
Rate for Payer: Cash Price	$304.20
Rate for Payer: Cigna Commercial	$321.10
Rate for Payer: Cigna Medicare	$304.20
Rate for Payer: Medicaid All Medicaid	$310.96
Rate for Payer: Medicare All Medicare	$236.60
Rate for Payer: Monida Allegiance	$321.10
Rate for Payer: Monida First Choice Health	$327.86
Rate for Payer: Monida Montana Health Co-op	$321.10
Rate for Payer: Monida PacificSource	$321.10

ER REPAIR SIMPLE 7.6-12.5CM

Facility

$355.00

Service Code	HCPCS 12004
Hospital Charge Code	1012004
Hospital Revenue Code	450
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

ER REPAIR SIMPLE 7.6-12.5CM

Facility

$355.00

Service Code	HCPCS 12004
Hospital Charge Code	1012004
Hospital Revenue Code	450
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$355.00
Rate for Payer: Aetna Commercial	$337.25
Rate for Payer: Aetna Medicare	$319.50
Rate for Payer: BCBS MT CHIP	$319.50
Rate for Payer: BCBS MT Closed Plan Network	$337.25
Rate for Payer: BCBS MT HealthLink	$319.50
Rate for Payer: BCBS MT Medicare	$319.50
Rate for Payer: BCBS MT POS	$337.25
Rate for Payer: BCBS MT Traditional	$355.00
Rate for Payer: Cash Price	$319.50
Rate for Payer: Cigna Commercial	$337.25
Rate for Payer: Cigna Medicare	$319.50
Rate for Payer: Medicaid All Medicaid	$326.60
Rate for Payer: Medicare All Medicare	$248.50
Rate for Payer: Monida Allegiance	$337.25
Rate for Payer: Monida First Choice Health	$344.35
Rate for Payer: Monida Montana Health Co-op	$337.25
Rate for Payer: Monida PacificSource	$337.25

ER REPAIR SIMPLE CLOSURE BY ADHESIVE

Facility

$198.00

Service Code	HCPCS G0168
Hospital Charge Code	1010168
Hospital Revenue Code	450
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna Commercial	$188.10
Rate for Payer: Aetna Medicare	$178.20
Rate for Payer: BCBS MT CHIP	$178.20
Rate for Payer: BCBS MT Closed Plan Network	$188.10
Rate for Payer: BCBS MT HealthLink	$178.20
Rate for Payer: BCBS MT Medicare	$178.20
Rate for Payer: BCBS MT POS	$188.10
Rate for Payer: BCBS MT Traditional	$198.00
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cigna Commercial	$188.10
Rate for Payer: Cigna Medicare	$178.20
Rate for Payer: Medicaid All Medicaid	$182.16
Rate for Payer: Medicare All Medicare	$138.60
Rate for Payer: Monida Allegiance	$188.10
Rate for Payer: Monida First Choice Health	$192.06
Rate for Payer: Monida Montana Health Co-op	$188.10
Rate for Payer: Monida PacificSource	$188.10

ER REPAIR SIMPLE CLOSURE BY ADHESIVE

Facility

$198.00

Service Code	HCPCS G0168
Hospital Charge Code	1010168
Hospital Revenue Code	450
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna Commercial	$188.10
Rate for Payer: Aetna Medicare	$178.20
Rate for Payer: BCBS MT CHIP	$178.20
Rate for Payer: BCBS MT Closed Plan Network	$188.10
Rate for Payer: BCBS MT HealthLink	$178.20
Rate for Payer: BCBS MT Medicare	$178.20
Rate for Payer: BCBS MT POS	$188.10
Rate for Payer: BCBS MT Traditional	$198.00
Rate for Payer: Cash Price	$178.20
Rate for Payer: Cigna Commercial	$188.10
Rate for Payer: Cigna Medicare	$178.20
Rate for Payer: Medicaid All Medicaid	$182.16
Rate for Payer: Medicare All Medicare	$138.60
Rate for Payer: Monida Allegiance	$188.10
Rate for Payer: Monida First Choice Health	$192.06
Rate for Payer: Monida Montana Health Co-op	$188.10
Rate for Payer: Monida PacificSource	$188.10

ER REPAIR SIMPLE FACE/EAR/LIP 5.1-7.5

Facility

$420.00

Service Code	HCPCS 12014
Hospital Charge Code	1012014
Hospital Revenue Code	450
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

ER REPAIR SIMPLE FACE/EAR/LIP 5.1-7.5

Facility

$420.00

Service Code	HCPCS 12014
Hospital Charge Code	1012014
Hospital Revenue Code	450
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

ER REPAIR SIMPLE FACE,EARS 2.5 CM/LESS

Facility

$420.00

Service Code	HCPCS 12011
Hospital Charge Code	1012011
Hospital Revenue Code	450
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

ER REPAIR SIMPLE FACE,EARS 2.5 CM/LESS

Facility

$420.00

Service Code	HCPCS 12011
Hospital Charge Code	1012011
Hospital Revenue Code	450
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

ER REPAIR SIMPLE FACE,EARS 2.6 TO 5.0 CM

Facility

$400.00

Service Code	HCPCS 12013
Hospital Charge Code	1012013
Hospital Revenue Code	450
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

ER REPAIR SIMPLE FACE,EARS 2.6 TO 5.0 CM

Facility

$400.00

Service Code	HCPCS 12013
Hospital Charge Code	1012013
Hospital Revenue Code	450
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$400.00
Rate for Payer: Aetna Commercial	$380.00
Rate for Payer: Aetna Medicare	$360.00
Rate for Payer: BCBS MT CHIP	$360.00
Rate for Payer: BCBS MT Closed Plan Network	$380.00
Rate for Payer: BCBS MT HealthLink	$360.00
Rate for Payer: BCBS MT Medicare	$360.00
Rate for Payer: BCBS MT POS	$380.00
Rate for Payer: BCBS MT Traditional	$400.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cigna Commercial	$380.00
Rate for Payer: Cigna Medicare	$360.00
Rate for Payer: Medicaid All Medicaid	$368.00
Rate for Payer: Medicare All Medicare	$280.00
Rate for Payer: Monida Allegiance	$380.00
Rate for Payer: Monida First Choice Health	$388.00
Rate for Payer: Monida Montana Health Co-op	$380.00
Rate for Payer: Monida PacificSource	$380.00

ER REPAIR SIMPLE FACE,EARS...7.6-12.5CM

Facility

$481.00

Service Code	HCPCS 12015
Hospital Charge Code	1012015
Hospital Revenue Code	450
Min. Negotiated Rate	$336.70
Max. Negotiated Rate	$481.00
Rate for Payer: Aetna Commercial	$456.95
Rate for Payer: Aetna Medicare	$432.90
Rate for Payer: BCBS MT CHIP	$432.90
Rate for Payer: BCBS MT Closed Plan Network	$456.95
Rate for Payer: BCBS MT HealthLink	$432.90
Rate for Payer: BCBS MT Medicare	$432.90
Rate for Payer: BCBS MT POS	$456.95
Rate for Payer: BCBS MT Traditional	$481.00
Rate for Payer: Cash Price	$432.90
Rate for Payer: Cigna Commercial	$456.95
Rate for Payer: Cigna Medicare	$432.90
Rate for Payer: Medicaid All Medicaid	$442.52
Rate for Payer: Medicare All Medicare	$336.70
Rate for Payer: Monida Allegiance	$456.95
Rate for Payer: Monida First Choice Health	$466.57
Rate for Payer: Monida Montana Health Co-op	$456.95
Rate for Payer: Monida PacificSource	$456.95

ER REPAIR SIMPLE FACE,EARS...7.6-12.5CM

Facility

$481.00

Service Code	HCPCS 12015
Hospital Charge Code	1012015
Hospital Revenue Code	450
Min. Negotiated Rate	$336.70
Max. Negotiated Rate	$481.00
Rate for Payer: Aetna Commercial	$456.95
Rate for Payer: Aetna Medicare	$432.90
Rate for Payer: BCBS MT CHIP	$432.90
Rate for Payer: BCBS MT Closed Plan Network	$456.95
Rate for Payer: BCBS MT HealthLink	$432.90
Rate for Payer: BCBS MT Medicare	$432.90
Rate for Payer: BCBS MT POS	$456.95
Rate for Payer: BCBS MT Traditional	$481.00
Rate for Payer: Cash Price	$432.90
Rate for Payer: Cigna Commercial	$456.95
Rate for Payer: Cigna Medicare	$432.90
Rate for Payer: Medicaid All Medicaid	$442.52
Rate for Payer: Medicare All Medicare	$336.70
Rate for Payer: Monida Allegiance	$456.95
Rate for Payer: Monida First Choice Health	$466.57
Rate for Payer: Monida Montana Health Co-op	$456.95
Rate for Payer: Monida PacificSource	$456.95

ER REPAIR SIMPLE S/N/A/E/T<30CM

Facility

$404.00

Service Code	HCPCS 12007
Hospital Charge Code	1012007
Hospital Revenue Code	450
Min. Negotiated Rate	$282.80
Max. Negotiated Rate	$404.00
Rate for Payer: Aetna Commercial	$383.80
Rate for Payer: Aetna Medicare	$363.60
Rate for Payer: BCBS MT CHIP	$363.60
Rate for Payer: BCBS MT Closed Plan Network	$383.80
Rate for Payer: BCBS MT HealthLink	$363.60
Rate for Payer: BCBS MT Medicare	$363.60
Rate for Payer: BCBS MT POS	$383.80
Rate for Payer: BCBS MT Traditional	$404.00
Rate for Payer: Cash Price	$363.60
Rate for Payer: Cigna Commercial	$383.80
Rate for Payer: Cigna Medicare	$363.60
Rate for Payer: Medicaid All Medicaid	$371.68
Rate for Payer: Medicare All Medicare	$282.80
Rate for Payer: Monida Allegiance	$383.80
Rate for Payer: Monida First Choice Health	$391.88
Rate for Payer: Monida Montana Health Co-op	$383.80
Rate for Payer: Monida PacificSource	$383.80

ER REPAIR SIMPLE S/N/A/E/T<30CM

Facility

$404.00

Service Code	HCPCS 12007
Hospital Charge Code	1012007
Hospital Revenue Code	450
Min. Negotiated Rate	$282.80
Max. Negotiated Rate	$404.00
Rate for Payer: Aetna Commercial	$383.80
Rate for Payer: Aetna Medicare	$363.60
Rate for Payer: BCBS MT CHIP	$363.60
Rate for Payer: BCBS MT Closed Plan Network	$383.80
Rate for Payer: BCBS MT HealthLink	$363.60
Rate for Payer: BCBS MT Medicare	$363.60
Rate for Payer: BCBS MT POS	$383.80
Rate for Payer: BCBS MT Traditional	$404.00
Rate for Payer: Cash Price	$363.60
Rate for Payer: Cigna Commercial	$383.80
Rate for Payer: Cigna Medicare	$363.60
Rate for Payer: Medicaid All Medicaid	$371.68
Rate for Payer: Medicare All Medicare	$282.80
Rate for Payer: Monida Allegiance	$383.80
Rate for Payer: Monida First Choice Health	$391.88
Rate for Payer: Monida Montana Health Co-op	$383.80
Rate for Payer: Monida PacificSource	$383.80

Know your out-of-pocket cost for care.

All Charges