Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

ER REMOVE FOREIGN BODY

Facility

$527.00

Service Code	CPT 10120
Hospital Charge Code	1010120
Hospital Revenue Code	450
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$527.00
Rate for Payer: Aetna Commercial	$500.65
Rate for Payer: Aetna Medicare	$474.30
Rate for Payer: BCBS MT CHIP	$474.30
Rate for Payer: BCBS MT Closed Plan Network	$500.65
Rate for Payer: BCBS MT HealthLink	$474.30
Rate for Payer: BCBS MT Medicare	$474.30
Rate for Payer: BCBS MT POS	$500.65
Rate for Payer: BCBS MT Traditional	$527.00
Rate for Payer: Cash Price	$474.30
Rate for Payer: Cigna Commercial	$500.65
Rate for Payer: Cigna Medicare	$474.30
Rate for Payer: Medicaid All Medicaid	$484.84
Rate for Payer: Medicare All Medicare	$368.90
Rate for Payer: Monida Allegiance	$500.65
Rate for Payer: Monida First Choice Health	$511.19
Rate for Payer: Monida Montana Health Co-op	$500.65
Rate for Payer: Monida PacificSource	$500.65

ER REMOVE FOREIGN BODY

Facility

$527.00

Service Code	CPT 10120
Hospital Charge Code	1010120
Hospital Revenue Code	450
Min. Negotiated Rate	$368.90
Max. Negotiated Rate	$527.00
Rate for Payer: Aetna Commercial	$500.65
Rate for Payer: Aetna Medicare	$474.30
Rate for Payer: BCBS MT CHIP	$474.30
Rate for Payer: BCBS MT Closed Plan Network	$500.65
Rate for Payer: BCBS MT HealthLink	$474.30
Rate for Payer: BCBS MT Medicare	$474.30
Rate for Payer: BCBS MT POS	$500.65
Rate for Payer: BCBS MT Traditional	$527.00
Rate for Payer: Cash Price	$474.30
Rate for Payer: Cigna Commercial	$500.65
Rate for Payer: Cigna Medicare	$474.30
Rate for Payer: Medicaid All Medicaid	$484.84
Rate for Payer: Medicare All Medicare	$368.90
Rate for Payer: Monida Allegiance	$500.65
Rate for Payer: Monida First Choice Health	$511.19
Rate for Payer: Monida Montana Health Co-op	$500.65
Rate for Payer: Monida PacificSource	$500.65

ER REMOVE FOREIGN BODY EYELID EXT CONJ

Facility

$235.00

Service Code	CPT 65205
Hospital Charge Code	1065205
Hospital Revenue Code	450
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

ER REMOVE FOREIGN BODY EYELID EXT CONJ

Facility

$235.00

Service Code	CPT 65205
Hospital Charge Code	1065205
Hospital Revenue Code	450
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$235.00
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: BCBS MT CHIP	$211.50
Rate for Payer: BCBS MT Closed Plan Network	$223.25
Rate for Payer: BCBS MT HealthLink	$211.50
Rate for Payer: BCBS MT Medicare	$211.50
Rate for Payer: BCBS MT POS	$223.25
Rate for Payer: BCBS MT Traditional	$235.00
Rate for Payer: Cash Price	$211.50
Rate for Payer: Cigna Commercial	$223.25
Rate for Payer: Cigna Medicare	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

ER REMOVE NASAL FOREIGN BODY

Facility

$342.00

Service Code	CPT 30300
Hospital Charge Code	1030300
Hospital Revenue Code	450
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

ER REMOVE NASAL FOREIGN BODY

Facility

$342.00

Service Code	CPT 30300
Hospital Charge Code	1030300
Hospital Revenue Code	450
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna Commercial	$324.90
Rate for Payer: Aetna Medicare	$307.80
Rate for Payer: BCBS MT CHIP	$307.80
Rate for Payer: BCBS MT Closed Plan Network	$324.90
Rate for Payer: BCBS MT HealthLink	$307.80
Rate for Payer: BCBS MT Medicare	$307.80
Rate for Payer: BCBS MT POS	$324.90
Rate for Payer: BCBS MT Traditional	$342.00
Rate for Payer: Cash Price	$307.80
Rate for Payer: Cigna Commercial	$324.90
Rate for Payer: Cigna Medicare	$307.80
Rate for Payer: Medicaid All Medicaid	$314.64
Rate for Payer: Medicare All Medicare	$239.40
Rate for Payer: Monida Allegiance	$324.90
Rate for Payer: Monida First Choice Health	$331.74
Rate for Payer: Monida Montana Health Co-op	$324.90
Rate for Payer: Monida PacificSource	$324.90

ER REMOV FOREIGN BODY EMBEDED EYLID EXT

Facility

$550.00

Service Code	CPT 67938
Hospital Charge Code	1067938
Hospital Revenue Code	450
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

ER REMOV FOREIGN BODY EMBEDED EYLID EXT

Facility

$550.00

Service Code	CPT 67938
Hospital Charge Code	1067938
Hospital Revenue Code	450
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$550.00
Rate for Payer: Aetna Commercial	$522.50
Rate for Payer: Aetna Medicare	$495.00
Rate for Payer: BCBS MT CHIP	$495.00
Rate for Payer: BCBS MT Closed Plan Network	$522.50
Rate for Payer: BCBS MT HealthLink	$495.00
Rate for Payer: BCBS MT Medicare	$495.00
Rate for Payer: BCBS MT POS	$522.50
Rate for Payer: BCBS MT Traditional	$550.00
Rate for Payer: Cash Price	$495.00
Rate for Payer: Cigna Commercial	$522.50
Rate for Payer: Cigna Medicare	$495.00
Rate for Payer: Medicaid All Medicaid	$506.00
Rate for Payer: Medicare All Medicare	$385.00
Rate for Payer: Monida Allegiance	$522.50
Rate for Payer: Monida First Choice Health	$533.50
Rate for Payer: Monida Montana Health Co-op	$522.50
Rate for Payer: Monida PacificSource	$522.50

ER REPAIR COMPLEX 1.1-2.5 CM

Facility

$734.00

Service Code	CPT 13131
Hospital Charge Code	1013131
Hospital Revenue Code	450
Min. Negotiated Rate	$513.80
Max. Negotiated Rate	$734.00
Rate for Payer: Aetna Commercial	$697.30
Rate for Payer: Aetna Medicare	$660.60
Rate for Payer: BCBS MT CHIP	$660.60
Rate for Payer: BCBS MT Closed Plan Network	$697.30
Rate for Payer: BCBS MT HealthLink	$660.60
Rate for Payer: BCBS MT Medicare	$660.60
Rate for Payer: BCBS MT POS	$697.30
Rate for Payer: BCBS MT Traditional	$734.00
Rate for Payer: Cash Price	$660.60
Rate for Payer: Cigna Commercial	$697.30
Rate for Payer: Cigna Medicare	$660.60
Rate for Payer: Medicaid All Medicaid	$675.28
Rate for Payer: Medicare All Medicare	$513.80
Rate for Payer: Monida Allegiance	$697.30
Rate for Payer: Monida First Choice Health	$711.98
Rate for Payer: Monida Montana Health Co-op	$697.30
Rate for Payer: Monida PacificSource	$697.30

ER REPAIR COMPLEX 1.1-2.5 CM

Facility

$734.00

Service Code	CPT 13131
Hospital Charge Code	1013131
Hospital Revenue Code	450
Min. Negotiated Rate	$513.80
Max. Negotiated Rate	$734.00
Rate for Payer: Aetna Commercial	$697.30
Rate for Payer: Aetna Medicare	$660.60
Rate for Payer: BCBS MT CHIP	$660.60
Rate for Payer: BCBS MT Closed Plan Network	$697.30
Rate for Payer: BCBS MT HealthLink	$660.60
Rate for Payer: BCBS MT Medicare	$660.60
Rate for Payer: BCBS MT POS	$697.30
Rate for Payer: BCBS MT Traditional	$734.00
Rate for Payer: Cash Price	$660.60
Rate for Payer: Cigna Commercial	$697.30
Rate for Payer: Cigna Medicare	$660.60
Rate for Payer: Medicaid All Medicaid	$675.28
Rate for Payer: Medicare All Medicare	$513.80
Rate for Payer: Monida Allegiance	$697.30
Rate for Payer: Monida First Choice Health	$711.98
Rate for Payer: Monida Montana Health Co-op	$697.30
Rate for Payer: Monida PacificSource	$697.30

ER REPAIR COMPLEX 1.1CM TO 2.5 SCALP, AR

Facility

$714.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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

Know your out-of-pocket cost for care.

All Charges