Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER REPAIR COMPLEX 1.1CM TO 2.5 SCALP, AR

Facility

$714.00

Service Code	HCPCS 13120
Hospital Charge Code	1013120
Hospital Revenue Code	450
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$714.00
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna Medicare	$642.60
Rate for Payer: BCBS MT CHIP	$642.60
Rate for Payer: BCBS MT Closed Plan Network	$678.30
Rate for Payer: BCBS MT HealthLink	$642.60
Rate for Payer: BCBS MT Medicare	$642.60
Rate for Payer: BCBS MT POS	$678.30
Rate for Payer: BCBS MT Traditional	$714.00
Rate for Payer: Cash Price	$642.60
Rate for Payer: Cigna Commercial	$678.30
Rate for Payer: Cigna Medicare	$642.60
Rate for Payer: Medicaid All Medicaid	$656.88
Rate for Payer: Medicare All Medicare	$499.80
Rate for Payer: Monida Allegiance	$678.30
Rate for Payer: Monida First Choice Health	$692.58
Rate for Payer: Monida Montana Health Co-op	$678.30
Rate for Payer: Monida PacificSource	$678.30

ER REPAIR COMPLEX 1.1CM TO 2.5 SCALP, AR

Facility

$714.00

Service Code	HCPCS 13120
Hospital Charge Code	1013120
Hospital Revenue Code	450
Min. Negotiated Rate	$499.80
Max. Negotiated Rate	$714.00
Rate for Payer: Aetna Commercial	$678.30
Rate for Payer: Aetna Medicare	$642.60
Rate for Payer: BCBS MT CHIP	$642.60
Rate for Payer: BCBS MT Closed Plan Network	$678.30
Rate for Payer: BCBS MT HealthLink	$642.60
Rate for Payer: BCBS MT Medicare	$642.60
Rate for Payer: BCBS MT POS	$678.30
Rate for Payer: BCBS MT Traditional	$714.00
Rate for Payer: Cash Price	$642.60
Rate for Payer: Cigna Commercial	$678.30
Rate for Payer: Cigna Medicare	$642.60
Rate for Payer: Medicaid All Medicaid	$656.88
Rate for Payer: Medicare All Medicare	$499.80
Rate for Payer: Monida Allegiance	$678.30
Rate for Payer: Monida First Choice Health	$692.58
Rate for Payer: Monida Montana Health Co-op	$678.30
Rate for Payer: Monida PacificSource	$678.30

ER REPAIR COMPLEX 2.6CM TO 7.5CM

Facility

$899.00

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

ER REPAIR COMPLEX 2.6CM TO 7.5CM

Facility

$899.00

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

ER REPAIR COMPLEX EA ADDTL 5CM OR LESS

Facility

$899.00

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

ER REPAIR COMPLEX EA ADDTL 5CM OR LESS

Facility

$899.00

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

ER REPAIR COMPLEX FC/HN 2.6 TO 7.5CM

Facility

$981.00

Service Code	HCPCS 13132
Hospital Charge Code	1013132
Hospital Revenue Code	450
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

ER REPAIR COMPLEX FC/HN 2.6 TO 7.5CM

Facility

$981.00

Service Code	HCPCS 13132
Hospital Charge Code	1013132
Hospital Revenue Code	450
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

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

Facility

$572.00

Service Code	HCPCS 13133
Hospital Charge Code	1013133
Hospital Revenue Code	450
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

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

Facility

$572.00

Service Code	HCPCS 13133
Hospital Charge Code	1013133
Hospital Revenue Code	450
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

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

Facility

$605.00

Service Code	HCPCS 12052
Hospital Charge Code	1012052
Hospital Revenue Code	450
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

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

Facility

$605.00

Service Code	HCPCS 12052
Hospital Charge Code	1012052
Hospital Revenue Code	450
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

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

Facility

$279.00

Service Code	HCPCS 12053
Hospital Charge Code	1012053
Hospital Revenue Code	450
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

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

Facility

$279.00

Service Code	HCPCS 12053
Hospital Charge Code	1012053
Hospital Revenue Code	450
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

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

Facility

$660.00

Service Code	HCPCS 12054
Hospital Charge Code	1012054
Hospital Revenue Code	450
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

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

Facility

$660.00

Service Code	HCPCS 12054
Hospital Charge Code	1012054
Hospital Revenue Code	450
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

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

Facility

$568.00

Service Code	HCPCS 12051
Hospital Charge Code	1012051
Hospital Revenue Code	450
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

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

Facility

$568.00

Service Code	HCPCS 12051
Hospital Charge Code	1012051
Hospital Revenue Code	450
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

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

Facility

$483.00

Service Code	HCPCS 12041
Hospital Charge Code	1012041
Hospital Revenue Code	450
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

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

Facility

$483.00

Service Code	HCPCS 12041
Hospital Charge Code	1012041
Hospital Revenue Code	450
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

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

Facility

$530.00

Service Code	HCPCS 12042
Hospital Charge Code	1012042
Hospital Revenue Code	450
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

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

Facility

$530.00

Service Code	HCPCS 12042
Hospital Charge Code	1012042
Hospital Revenue Code	450
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

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

Facility

$805.00

Service Code	HCPCS 12035
Hospital Charge Code	1012035
Hospital Revenue Code	450
Min. Negotiated Rate	$563.50
Max. Negotiated Rate	$805.00
Rate for Payer: Aetna Commercial	$764.75
Rate for Payer: Aetna Medicare	$724.50
Rate for Payer: BCBS MT CHIP	$724.50
Rate for Payer: BCBS MT Closed Plan Network	$764.75
Rate for Payer: BCBS MT HealthLink	$724.50
Rate for Payer: BCBS MT Medicare	$724.50
Rate for Payer: BCBS MT POS	$764.75
Rate for Payer: BCBS MT Traditional	$805.00
Rate for Payer: Cash Price	$724.50
Rate for Payer: Cigna Commercial	$764.75
Rate for Payer: Cigna Medicare	$724.50
Rate for Payer: Medicaid All Medicaid	$740.60
Rate for Payer: Medicare All Medicare	$563.50
Rate for Payer: Monida Allegiance	$764.75
Rate for Payer: Monida First Choice Health	$780.85
Rate for Payer: Monida Montana Health Co-op	$764.75
Rate for Payer: Monida PacificSource	$764.75

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

Facility

$805.00

Service Code	HCPCS 12035
Hospital Charge Code	1012035
Hospital Revenue Code	450
Min. Negotiated Rate	$563.50
Max. Negotiated Rate	$805.00
Rate for Payer: Aetna Commercial	$764.75
Rate for Payer: Aetna Medicare	$724.50
Rate for Payer: BCBS MT CHIP	$724.50
Rate for Payer: BCBS MT Closed Plan Network	$764.75
Rate for Payer: BCBS MT HealthLink	$724.50
Rate for Payer: BCBS MT Medicare	$724.50
Rate for Payer: BCBS MT POS	$764.75
Rate for Payer: BCBS MT Traditional	$805.00
Rate for Payer: Cash Price	$724.50
Rate for Payer: Cigna Commercial	$764.75
Rate for Payer: Cigna Medicare	$724.50
Rate for Payer: Medicaid All Medicaid	$740.60
Rate for Payer: Medicare All Medicare	$563.50
Rate for Payer: Monida Allegiance	$764.75
Rate for Payer: Monida First Choice Health	$780.85
Rate for Payer: Monida Montana Health Co-op	$764.75
Rate for Payer: Monida PacificSource	$764.75

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

Facility

$590.00

Service Code	HCPCS 12031
Hospital Charge Code	1012031
Hospital Revenue Code	450
Min. Negotiated Rate	$413.00
Max. Negotiated Rate	$590.00
Rate for Payer: Aetna Commercial	$560.50
Rate for Payer: Aetna Medicare	$531.00
Rate for Payer: BCBS MT CHIP	$531.00
Rate for Payer: BCBS MT Closed Plan Network	$560.50
Rate for Payer: BCBS MT HealthLink	$531.00
Rate for Payer: BCBS MT Medicare	$531.00
Rate for Payer: BCBS MT POS	$560.50
Rate for Payer: BCBS MT Traditional	$590.00
Rate for Payer: Cash Price	$531.00
Rate for Payer: Cigna Commercial	$560.50
Rate for Payer: Cigna Medicare	$531.00
Rate for Payer: Medicaid All Medicaid	$542.80
Rate for Payer: Medicare All Medicare	$413.00
Rate for Payer: Monida Allegiance	$560.50
Rate for Payer: Monida First Choice Health	$572.30
Rate for Payer: Monida Montana Health Co-op	$560.50
Rate for Payer: Monida PacificSource	$560.50

Know your out-of-pocket cost for care.

All Charges