Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

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

Facility

$568.00

Service Code	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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	CPT 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

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

Facility

$590.00

Service Code	CPT 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

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

Facility

$649.00

Service Code	CPT 12032
Hospital Charge Code	1012032
Hospital Revenue Code	450
Min. Negotiated Rate	$454.30
Max. Negotiated Rate	$649.00
Rate for Payer: Aetna Commercial	$616.55
Rate for Payer: Aetna Medicare	$584.10
Rate for Payer: BCBS MT CHIP	$584.10
Rate for Payer: BCBS MT Closed Plan Network	$616.55
Rate for Payer: BCBS MT HealthLink	$584.10
Rate for Payer: BCBS MT Medicare	$584.10
Rate for Payer: BCBS MT POS	$616.55
Rate for Payer: BCBS MT Traditional	$649.00
Rate for Payer: Cash Price	$584.10
Rate for Payer: Cigna Commercial	$616.55
Rate for Payer: Cigna Medicare	$584.10
Rate for Payer: Medicaid All Medicaid	$597.08
Rate for Payer: Medicare All Medicare	$454.30
Rate for Payer: Monida Allegiance	$616.55
Rate for Payer: Monida First Choice Health	$629.53
Rate for Payer: Monida Montana Health Co-op	$616.55
Rate for Payer: Monida PacificSource	$616.55

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

Facility

$649.00

Service Code	CPT 12032
Hospital Charge Code	1012032
Hospital Revenue Code	450
Min. Negotiated Rate	$454.30
Max. Negotiated Rate	$649.00
Rate for Payer: Aetna Commercial	$616.55
Rate for Payer: Aetna Medicare	$584.10
Rate for Payer: BCBS MT CHIP	$584.10
Rate for Payer: BCBS MT Closed Plan Network	$616.55
Rate for Payer: BCBS MT HealthLink	$584.10
Rate for Payer: BCBS MT Medicare	$584.10
Rate for Payer: BCBS MT POS	$616.55
Rate for Payer: BCBS MT Traditional	$649.00
Rate for Payer: Cash Price	$584.10
Rate for Payer: Cigna Commercial	$616.55
Rate for Payer: Cigna Medicare	$584.10
Rate for Payer: Medicaid All Medicaid	$597.08
Rate for Payer: Medicare All Medicare	$454.30
Rate for Payer: Monida Allegiance	$616.55
Rate for Payer: Monida First Choice Health	$629.53
Rate for Payer: Monida Montana Health Co-op	$616.55
Rate for Payer: Monida PacificSource	$616.55

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

Facility

$731.00

Service Code	CPT 12034
Hospital Charge Code	1012034
Hospital Revenue Code	450
Min. Negotiated Rate	$511.70
Max. Negotiated Rate	$731.00
Rate for Payer: Aetna Commercial	$694.45
Rate for Payer: Aetna Medicare	$657.90
Rate for Payer: BCBS MT CHIP	$657.90
Rate for Payer: BCBS MT Closed Plan Network	$694.45
Rate for Payer: BCBS MT HealthLink	$657.90
Rate for Payer: BCBS MT Medicare	$657.90
Rate for Payer: BCBS MT POS	$694.45
Rate for Payer: BCBS MT Traditional	$731.00
Rate for Payer: Cash Price	$657.90
Rate for Payer: Cigna Commercial	$694.45
Rate for Payer: Cigna Medicare	$657.90
Rate for Payer: Medicaid All Medicaid	$672.52
Rate for Payer: Medicare All Medicare	$511.70
Rate for Payer: Monida Allegiance	$694.45
Rate for Payer: Monida First Choice Health	$709.07
Rate for Payer: Monida Montana Health Co-op	$694.45
Rate for Payer: Monida PacificSource	$694.45

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

Facility

$731.00

Service Code	CPT 12034
Hospital Charge Code	1012034
Hospital Revenue Code	450
Min. Negotiated Rate	$511.70
Max. Negotiated Rate	$731.00
Rate for Payer: Aetna Commercial	$694.45
Rate for Payer: Aetna Medicare	$657.90
Rate for Payer: BCBS MT CHIP	$657.90
Rate for Payer: BCBS MT Closed Plan Network	$694.45
Rate for Payer: BCBS MT HealthLink	$657.90
Rate for Payer: BCBS MT Medicare	$657.90
Rate for Payer: BCBS MT POS	$694.45
Rate for Payer: BCBS MT Traditional	$731.00
Rate for Payer: Cash Price	$657.90
Rate for Payer: Cigna Commercial	$694.45
Rate for Payer: Cigna Medicare	$657.90
Rate for Payer: Medicaid All Medicaid	$672.52
Rate for Payer: Medicare All Medicare	$511.70
Rate for Payer: Monida Allegiance	$694.45
Rate for Payer: Monida First Choice Health	$709.07
Rate for Payer: Monida Montana Health Co-op	$694.45
Rate for Payer: Monida PacificSource	$694.45

ER REPAIR LACERATION OF PALATE UP 2CM

Facility

$547.00

Service Code	CPT 42180
Hospital Charge Code	1042180
Hospital Revenue Code	450
Min. Negotiated Rate	$382.90
Max. Negotiated Rate	$547.00
Rate for Payer: Aetna Commercial	$519.65
Rate for Payer: Aetna Medicare	$492.30
Rate for Payer: BCBS MT CHIP	$492.30
Rate for Payer: BCBS MT Closed Plan Network	$519.65
Rate for Payer: BCBS MT HealthLink	$492.30
Rate for Payer: BCBS MT Medicare	$492.30
Rate for Payer: BCBS MT POS	$519.65
Rate for Payer: BCBS MT Traditional	$547.00
Rate for Payer: Cash Price	$492.30
Rate for Payer: Cigna Commercial	$519.65
Rate for Payer: Cigna Medicare	$492.30
Rate for Payer: Medicaid All Medicaid	$503.24
Rate for Payer: Medicare All Medicare	$382.90
Rate for Payer: Monida Allegiance	$519.65
Rate for Payer: Monida First Choice Health	$530.59
Rate for Payer: Monida Montana Health Co-op	$519.65
Rate for Payer: Monida PacificSource	$519.65

ER REPAIR LACERATION OF PALATE UP 2CM

Facility

$547.00

Service Code	CPT 42180
Hospital Charge Code	1042180
Hospital Revenue Code	450
Min. Negotiated Rate	$382.90
Max. Negotiated Rate	$547.00
Rate for Payer: Aetna Commercial	$519.65
Rate for Payer: Aetna Medicare	$492.30
Rate for Payer: BCBS MT CHIP	$492.30
Rate for Payer: BCBS MT Closed Plan Network	$519.65
Rate for Payer: BCBS MT HealthLink	$492.30
Rate for Payer: BCBS MT Medicare	$492.30
Rate for Payer: BCBS MT POS	$519.65
Rate for Payer: BCBS MT Traditional	$547.00
Rate for Payer: Cash Price	$492.30
Rate for Payer: Cigna Commercial	$519.65
Rate for Payer: Cigna Medicare	$492.30
Rate for Payer: Medicaid All Medicaid	$503.24
Rate for Payer: Medicare All Medicare	$382.90
Rate for Payer: Monida Allegiance	$519.65
Rate for Payer: Monida First Choice Health	$530.59
Rate for Payer: Monida Montana Health Co-op	$519.65
Rate for Payer: Monida PacificSource	$519.65

ER REPAIR SIMPLE =<2.5CM

Facility

$348.00

Service Code	CPT 12001
Hospital Charge Code	1012001
Hospital Revenue Code	450
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

ER REPAIR SIMPLE =<2.5CM

Facility

$348.00

Service Code	CPT 12001
Hospital Charge Code	1012001
Hospital Revenue Code	450
Min. Negotiated Rate	$243.60
Max. Negotiated Rate	$348.00
Rate for Payer: Aetna Commercial	$330.60
Rate for Payer: Aetna Medicare	$313.20
Rate for Payer: BCBS MT CHIP	$313.20
Rate for Payer: BCBS MT Closed Plan Network	$330.60
Rate for Payer: BCBS MT HealthLink	$313.20
Rate for Payer: BCBS MT Medicare	$313.20
Rate for Payer: BCBS MT POS	$330.60
Rate for Payer: BCBS MT Traditional	$348.00
Rate for Payer: Cash Price	$313.20
Rate for Payer: Cigna Commercial	$330.60
Rate for Payer: Cigna Medicare	$313.20
Rate for Payer: Medicaid All Medicaid	$320.16
Rate for Payer: Medicare All Medicare	$243.60
Rate for Payer: Monida Allegiance	$330.60
Rate for Payer: Monida First Choice Health	$337.56
Rate for Payer: Monida Montana Health Co-op	$330.60
Rate for Payer: Monida PacificSource	$330.60

ER REPAIR SIMPLE 2.6-7.5CM

Facility

$358.00

Service Code	CPT 12002
Hospital Charge Code	1012002
Hospital Revenue Code	450
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

ER REPAIR SIMPLE 2.6-7.5CM

Facility

$358.00

Service Code	CPT 12002
Hospital Charge Code	1012002
Hospital Revenue Code	450
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$358.00
Rate for Payer: Aetna Commercial	$340.10
Rate for Payer: Aetna Medicare	$322.20
Rate for Payer: BCBS MT CHIP	$322.20
Rate for Payer: BCBS MT Closed Plan Network	$340.10
Rate for Payer: BCBS MT HealthLink	$322.20
Rate for Payer: BCBS MT Medicare	$322.20
Rate for Payer: BCBS MT POS	$340.10
Rate for Payer: BCBS MT Traditional	$358.00
Rate for Payer: Cash Price	$322.20
Rate for Payer: Cigna Commercial	$340.10
Rate for Payer: Cigna Medicare	$322.20
Rate for Payer: Medicaid All Medicaid	$329.36
Rate for Payer: Medicare All Medicare	$250.60
Rate for Payer: Monida Allegiance	$340.10
Rate for Payer: Monida First Choice Health	$347.26
Rate for Payer: Monida Montana Health Co-op	$340.10
Rate for Payer: Monida PacificSource	$340.10

ER REPAIR SIMPLE 7.6-12.5CM

Facility

$376.00

Service Code	CPT 12004
Hospital Charge Code	1012004
Hospital Revenue Code	450
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

ER REPAIR SIMPLE 7.6-12.5CM

Facility

$376.00

Service Code	CPT 12004
Hospital Charge Code	1012004
Hospital Revenue Code	450
Min. Negotiated Rate	$263.20
Max. Negotiated Rate	$376.00
Rate for Payer: Aetna Commercial	$357.20
Rate for Payer: Aetna Medicare	$338.40
Rate for Payer: BCBS MT CHIP	$338.40
Rate for Payer: BCBS MT Closed Plan Network	$357.20
Rate for Payer: BCBS MT HealthLink	$338.40
Rate for Payer: BCBS MT Medicare	$338.40
Rate for Payer: BCBS MT POS	$357.20
Rate for Payer: BCBS MT Traditional	$376.00
Rate for Payer: Cash Price	$338.40
Rate for Payer: Cigna Commercial	$357.20
Rate for Payer: Cigna Medicare	$338.40
Rate for Payer: Medicaid All Medicaid	$345.92
Rate for Payer: Medicare All Medicare	$263.20
Rate for Payer: Monida Allegiance	$357.20
Rate for Payer: Monida First Choice Health	$364.72
Rate for Payer: Monida Montana Health Co-op	$357.20
Rate for Payer: Monida PacificSource	$357.20

ER REPAIR SIMPLE CLOSURE BY ADHESIVE

Facility

$210.00

Service Code	HCPCS G0168
Hospital Charge Code	1010168
Hospital Revenue Code	450
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare	$189.00
Rate for Payer: BCBS MT CHIP	$189.00
Rate for Payer: BCBS MT Closed Plan Network	$199.50
Rate for Payer: BCBS MT HealthLink	$189.00
Rate for Payer: BCBS MT Medicare	$189.00
Rate for Payer: BCBS MT POS	$199.50
Rate for Payer: BCBS MT Traditional	$210.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial	$199.50
Rate for Payer: Cigna Medicare	$189.00
Rate for Payer: Medicaid All Medicaid	$193.20
Rate for Payer: Medicare All Medicare	$147.00
Rate for Payer: Monida Allegiance	$199.50
Rate for Payer: Monida First Choice Health	$203.70
Rate for Payer: Monida Montana Health Co-op	$199.50
Rate for Payer: Monida PacificSource	$199.50

ER REPAIR SIMPLE CLOSURE BY ADHESIVE

Facility

$210.00

Service Code	HCPCS G0168
Hospital Charge Code	1010168
Hospital Revenue Code	450
Min. Negotiated Rate	$147.00
Max. Negotiated Rate	$210.00
Rate for Payer: Aetna Commercial	$199.50
Rate for Payer: Aetna Medicare	$189.00
Rate for Payer: BCBS MT CHIP	$189.00
Rate for Payer: BCBS MT Closed Plan Network	$199.50
Rate for Payer: BCBS MT HealthLink	$189.00
Rate for Payer: BCBS MT Medicare	$189.00
Rate for Payer: BCBS MT POS	$199.50
Rate for Payer: BCBS MT Traditional	$210.00
Rate for Payer: Cash Price	$189.00
Rate for Payer: Cigna Commercial	$199.50
Rate for Payer: Cigna Medicare	$189.00
Rate for Payer: Medicaid All Medicaid	$193.20
Rate for Payer: Medicare All Medicare	$147.00
Rate for Payer: Monida Allegiance	$199.50
Rate for Payer: Monida First Choice Health	$203.70
Rate for Payer: Monida Montana Health Co-op	$199.50
Rate for Payer: Monida PacificSource	$199.50

Know your out-of-pocket cost for care.

All Charges