Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

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

ER REPAIR SIMPLE FACE/EAR/LIP 5.1-7.5

Facility

$445.00

Service Code	CPT 12014
Hospital Charge Code	1012014
Hospital Revenue Code	450
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

ER REPAIR SIMPLE FACE/EAR/LIP 5.1-7.5

Facility

$445.00

Service Code	CPT 12014
Hospital Charge Code	1012014
Hospital Revenue Code	450
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

ER REPAIR SIMPLE FACE,EARS 2.5 CM/LESS

Facility

$445.00

Service Code	CPT 12011
Hospital Charge Code	1012011
Hospital Revenue Code	450
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

ER REPAIR SIMPLE FACE,EARS 2.5 CM/LESS

Facility

$445.00

Service Code	CPT 12011
Hospital Charge Code	1012011
Hospital Revenue Code	450
Min. Negotiated Rate	$311.50
Max. Negotiated Rate	$445.00
Rate for Payer: Aetna Commercial	$422.75
Rate for Payer: Aetna Medicare	$400.50
Rate for Payer: BCBS MT CHIP	$400.50
Rate for Payer: BCBS MT Closed Plan Network	$422.75
Rate for Payer: BCBS MT HealthLink	$400.50
Rate for Payer: BCBS MT Medicare	$400.50
Rate for Payer: BCBS MT POS	$422.75
Rate for Payer: BCBS MT Traditional	$445.00
Rate for Payer: Cash Price	$400.50
Rate for Payer: Cigna Commercial	$422.75
Rate for Payer: Cigna Medicare	$400.50
Rate for Payer: Medicaid All Medicaid	$409.40
Rate for Payer: Medicare All Medicare	$311.50
Rate for Payer: Monida Allegiance	$422.75
Rate for Payer: Monida First Choice Health	$431.65
Rate for Payer: Monida Montana Health Co-op	$422.75
Rate for Payer: Monida PacificSource	$422.75

ER REPAIR SIMPLE FACE,EARS 2.6 TO 5.0 CM

Facility

$424.00

Service Code	CPT 12013
Hospital Charge Code	1012013
Hospital Revenue Code	450
Min. Negotiated Rate	$296.80
Max. Negotiated Rate	$424.00
Rate for Payer: Aetna Commercial	$402.80
Rate for Payer: Aetna Medicare	$381.60
Rate for Payer: BCBS MT CHIP	$381.60
Rate for Payer: BCBS MT Closed Plan Network	$402.80
Rate for Payer: BCBS MT HealthLink	$381.60
Rate for Payer: BCBS MT Medicare	$381.60
Rate for Payer: BCBS MT POS	$402.80
Rate for Payer: BCBS MT Traditional	$424.00
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cigna Commercial	$402.80
Rate for Payer: Cigna Medicare	$381.60
Rate for Payer: Medicaid All Medicaid	$390.08
Rate for Payer: Medicare All Medicare	$296.80
Rate for Payer: Monida Allegiance	$402.80
Rate for Payer: Monida First Choice Health	$411.28
Rate for Payer: Monida Montana Health Co-op	$402.80
Rate for Payer: Monida PacificSource	$402.80

ER REPAIR SIMPLE FACE,EARS 2.6 TO 5.0 CM

Facility

$424.00

Service Code	CPT 12013
Hospital Charge Code	1012013
Hospital Revenue Code	450
Min. Negotiated Rate	$296.80
Max. Negotiated Rate	$424.00
Rate for Payer: Aetna Commercial	$402.80
Rate for Payer: Aetna Medicare	$381.60
Rate for Payer: BCBS MT CHIP	$381.60
Rate for Payer: BCBS MT Closed Plan Network	$402.80
Rate for Payer: BCBS MT HealthLink	$381.60
Rate for Payer: BCBS MT Medicare	$381.60
Rate for Payer: BCBS MT POS	$402.80
Rate for Payer: BCBS MT Traditional	$424.00
Rate for Payer: Cash Price	$381.60
Rate for Payer: Cigna Commercial	$402.80
Rate for Payer: Cigna Medicare	$381.60
Rate for Payer: Medicaid All Medicaid	$390.08
Rate for Payer: Medicare All Medicare	$296.80
Rate for Payer: Monida Allegiance	$402.80
Rate for Payer: Monida First Choice Health	$411.28
Rate for Payer: Monida Montana Health Co-op	$402.80
Rate for Payer: Monida PacificSource	$402.80

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

Facility

$510.00

Service Code	CPT 12015
Hospital Charge Code	1012015
Hospital Revenue Code	450
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

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

Facility

$510.00

Service Code	CPT 12015
Hospital Charge Code	1012015
Hospital Revenue Code	450
Min. Negotiated Rate	$357.00
Max. Negotiated Rate	$510.00
Rate for Payer: Aetna Commercial	$484.50
Rate for Payer: Aetna Medicare	$459.00
Rate for Payer: BCBS MT CHIP	$459.00
Rate for Payer: BCBS MT Closed Plan Network	$484.50
Rate for Payer: BCBS MT HealthLink	$459.00
Rate for Payer: BCBS MT Medicare	$459.00
Rate for Payer: BCBS MT POS	$484.50
Rate for Payer: BCBS MT Traditional	$510.00
Rate for Payer: Cash Price	$459.00
Rate for Payer: Cigna Commercial	$484.50
Rate for Payer: Cigna Medicare	$459.00
Rate for Payer: Medicaid All Medicaid	$469.20
Rate for Payer: Medicare All Medicare	$357.00
Rate for Payer: Monida Allegiance	$484.50
Rate for Payer: Monida First Choice Health	$494.70
Rate for Payer: Monida Montana Health Co-op	$484.50
Rate for Payer: Monida PacificSource	$484.50

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

Facility

$428.00

Service Code	CPT 12007
Hospital Charge Code	1012007
Hospital Revenue Code	450
Min. Negotiated Rate	$299.60
Max. Negotiated Rate	$428.00
Rate for Payer: Aetna Commercial	$406.60
Rate for Payer: Aetna Medicare	$385.20
Rate for Payer: BCBS MT CHIP	$385.20
Rate for Payer: BCBS MT Closed Plan Network	$406.60
Rate for Payer: BCBS MT HealthLink	$385.20
Rate for Payer: BCBS MT Medicare	$385.20
Rate for Payer: BCBS MT POS	$406.60
Rate for Payer: BCBS MT Traditional	$428.00
Rate for Payer: Cash Price	$385.20
Rate for Payer: Cigna Commercial	$406.60
Rate for Payer: Cigna Medicare	$385.20
Rate for Payer: Medicaid All Medicaid	$393.76
Rate for Payer: Medicare All Medicare	$299.60
Rate for Payer: Monida Allegiance	$406.60
Rate for Payer: Monida First Choice Health	$415.16
Rate for Payer: Monida Montana Health Co-op	$406.60
Rate for Payer: Monida PacificSource	$406.60

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

Facility

$428.00

Service Code	CPT 12007
Hospital Charge Code	1012007
Hospital Revenue Code	450
Min. Negotiated Rate	$299.60
Max. Negotiated Rate	$428.00
Rate for Payer: Aetna Commercial	$406.60
Rate for Payer: Aetna Medicare	$385.20
Rate for Payer: BCBS MT CHIP	$385.20
Rate for Payer: BCBS MT Closed Plan Network	$406.60
Rate for Payer: BCBS MT HealthLink	$385.20
Rate for Payer: BCBS MT Medicare	$385.20
Rate for Payer: BCBS MT POS	$406.60
Rate for Payer: BCBS MT Traditional	$428.00
Rate for Payer: Cash Price	$385.20
Rate for Payer: Cigna Commercial	$406.60
Rate for Payer: Cigna Medicare	$385.20
Rate for Payer: Medicaid All Medicaid	$393.76
Rate for Payer: Medicare All Medicare	$299.60
Rate for Payer: Monida Allegiance	$406.60
Rate for Payer: Monida First Choice Health	$415.16
Rate for Payer: Monida Montana Health Co-op	$406.60
Rate for Payer: Monida PacificSource	$406.60

ER REPAIR SIMPLE S/N/A/HF 20.1-30CM

Facility

$423.00

Service Code	CPT 12006
Hospital Charge Code	1012006
Hospital Revenue Code	450
Min. Negotiated Rate	$296.10
Max. Negotiated Rate	$423.00
Rate for Payer: Aetna Commercial	$401.85
Rate for Payer: Aetna Medicare	$380.70
Rate for Payer: BCBS MT CHIP	$380.70
Rate for Payer: BCBS MT Closed Plan Network	$401.85
Rate for Payer: BCBS MT HealthLink	$380.70
Rate for Payer: BCBS MT Medicare	$380.70
Rate for Payer: BCBS MT POS	$401.85
Rate for Payer: BCBS MT Traditional	$423.00
Rate for Payer: Cash Price	$380.70
Rate for Payer: Cigna Commercial	$401.85
Rate for Payer: Cigna Medicare	$380.70
Rate for Payer: Medicaid All Medicaid	$389.16
Rate for Payer: Medicare All Medicare	$296.10
Rate for Payer: Monida Allegiance	$401.85
Rate for Payer: Monida First Choice Health	$410.31
Rate for Payer: Monida Montana Health Co-op	$401.85
Rate for Payer: Monida PacificSource	$401.85

ER REPAIR SIMPLE S/N/A/HF 20.1-30CM

Facility

$423.00

Service Code	CPT 12006
Hospital Charge Code	1012006
Hospital Revenue Code	450
Min. Negotiated Rate	$296.10
Max. Negotiated Rate	$423.00
Rate for Payer: Aetna Commercial	$401.85
Rate for Payer: Aetna Medicare	$380.70
Rate for Payer: BCBS MT CHIP	$380.70
Rate for Payer: BCBS MT Closed Plan Network	$401.85
Rate for Payer: BCBS MT HealthLink	$380.70
Rate for Payer: BCBS MT Medicare	$380.70
Rate for Payer: BCBS MT POS	$401.85
Rate for Payer: BCBS MT Traditional	$423.00
Rate for Payer: Cash Price	$380.70
Rate for Payer: Cigna Commercial	$401.85
Rate for Payer: Cigna Medicare	$380.70
Rate for Payer: Medicaid All Medicaid	$389.16
Rate for Payer: Medicare All Medicare	$296.10
Rate for Payer: Monida Allegiance	$401.85
Rate for Payer: Monida First Choice Health	$410.31
Rate for Payer: Monida Montana Health Co-op	$401.85
Rate for Payer: Monida PacificSource	$401.85

ER REPAIR SIM,S/N/T/HF 12.6 TO 20CM

Facility

$400.00

Service Code	CPT 12005
Hospital Charge Code	1012005
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 SIM,S/N/T/HF 12.6 TO 20CM

Facility

$400.00

Service Code	CPT 12005
Hospital Charge Code	1012005
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 ROOM/OPO EVALUATION FROM CLINIC

Facility

$94.00

Service Code	CPT 99211
Hospital Charge Code	1010111
Hospital Revenue Code	760
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

ER ROOM/OPO EVALUATION FROM CLINIC

Facility

$94.00

Service Code	CPT 99211
Hospital Charge Code	1010111
Hospital Revenue Code	760
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$94.00
Rate for Payer: Aetna Commercial	$89.30
Rate for Payer: Aetna Medicare	$84.60
Rate for Payer: BCBS MT CHIP	$84.60
Rate for Payer: BCBS MT Closed Plan Network	$89.30
Rate for Payer: BCBS MT HealthLink	$84.60
Rate for Payer: BCBS MT Medicare	$84.60
Rate for Payer: BCBS MT POS	$89.30
Rate for Payer: BCBS MT Traditional	$94.00
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cigna Commercial	$89.30
Rate for Payer: Cigna Medicare	$84.60
Rate for Payer: Medicaid All Medicaid	$86.48
Rate for Payer: Medicare All Medicare	$65.80
Rate for Payer: Monida Allegiance	$89.30
Rate for Payer: Monida First Choice Health	$91.18
Rate for Payer: Monida Montana Health Co-op	$89.30
Rate for Payer: Monida PacificSource	$89.30

ER ROOM/OP ROOM BRIEF 99281

Facility

$279.00

Service Code	CPT 99281
Hospital Charge Code	1010107
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 ROOM/OP ROOM BRIEF 99281

Facility

$279.00

Service Code	CPT 99281
Hospital Charge Code	1010107
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 ROOM/OP ROOM COMPREHENSIVE 99285

Facility

$1,823.00

Service Code	CPT 99285
Hospital Charge Code	1010106
Hospital Revenue Code	450
Min. Negotiated Rate	$1,276.10
Max. Negotiated Rate	$1,823.00
Rate for Payer: Aetna Commercial	$1,731.85
Rate for Payer: Aetna Medicare	$1,640.70
Rate for Payer: BCBS MT CHIP	$1,640.70
Rate for Payer: BCBS MT Closed Plan Network	$1,731.85
Rate for Payer: BCBS MT HealthLink	$1,640.70
Rate for Payer: BCBS MT Medicare	$1,640.70
Rate for Payer: BCBS MT POS	$1,731.85
Rate for Payer: BCBS MT Traditional	$1,823.00
Rate for Payer: Cash Price	$1,640.70
Rate for Payer: Cigna Commercial	$1,731.85
Rate for Payer: Cigna Medicare	$1,640.70
Rate for Payer: Medicaid All Medicaid	$1,677.16
Rate for Payer: Medicare All Medicare	$1,276.10
Rate for Payer: Monida Allegiance	$1,731.85
Rate for Payer: Monida First Choice Health	$1,768.31
Rate for Payer: Monida Montana Health Co-op	$1,731.85
Rate for Payer: Monida PacificSource	$1,731.85

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