Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

KNEE SLEEVE XLG

Facility

$28.00

Hospital Charge Code	2893371
Hospital Revenue Code	290
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

KNEE SPLINT 18 - 20'' UNIVERSA

Facility

$64.00

Hospital Charge Code	2820013
Hospital Revenue Code	270
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

KNEE SPLINT 18 - 20'' UNIVERSA

Facility

$64.00

Hospital Charge Code	2820013
Hospital Revenue Code	270
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$64.00
Rate for Payer: Aetna Commercial	$60.80
Rate for Payer: Aetna Medicare	$57.60
Rate for Payer: BCBS MT CHIP	$57.60
Rate for Payer: BCBS MT Closed Plan Network	$60.80
Rate for Payer: BCBS MT HealthLink	$57.60
Rate for Payer: BCBS MT Medicare	$57.60
Rate for Payer: BCBS MT POS	$60.80
Rate for Payer: BCBS MT Traditional	$64.00
Rate for Payer: Cash Price	$57.60
Rate for Payer: Cigna Commercial	$60.80
Rate for Payer: Cigna Medicare	$57.60
Rate for Payer: Medicaid All Medicaid	$58.88
Rate for Payer: Medicare All Medicare	$44.80
Rate for Payer: Monida Allegiance	$60.80
Rate for Payer: Monida First Choice Health	$62.08
Rate for Payer: Monida Montana Health Co-op	$60.80
Rate for Payer: Monida PacificSource	$60.80

KNEE SPLINT 20' XL

Facility

$54.00

Hospital Charge Code	2893362
Hospital Revenue Code	290
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

KNEE SPLINT 20' XL

Facility

$54.00

Hospital Charge Code	2893362
Hospital Revenue Code	290
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

KNEE SPLINT 20'' XXL

Facility

$54.00

Hospital Charge Code	2893363
Hospital Revenue Code	290
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

KNEE SPLINT 20'' XXL

Facility

$54.00

Hospital Charge Code	2893363
Hospital Revenue Code	290
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna Commercial	$51.30
Rate for Payer: Aetna Medicare	$48.60
Rate for Payer: BCBS MT CHIP	$48.60
Rate for Payer: BCBS MT Closed Plan Network	$51.30
Rate for Payer: BCBS MT HealthLink	$48.60
Rate for Payer: BCBS MT Medicare	$48.60
Rate for Payer: BCBS MT POS	$51.30
Rate for Payer: BCBS MT Traditional	$54.00
Rate for Payer: Cash Price	$48.60
Rate for Payer: Cigna Commercial	$51.30
Rate for Payer: Cigna Medicare	$48.60
Rate for Payer: Medicaid All Medicaid	$49.68
Rate for Payer: Medicare All Medicare	$37.80
Rate for Payer: Monida Allegiance	$51.30
Rate for Payer: Monida First Choice Health	$52.38
Rate for Payer: Monida Montana Health Co-op	$51.30
Rate for Payer: Monida PacificSource	$51.30

KNEE SPLINT 22' LG

Facility

$63.00

Hospital Charge Code	2893365
Hospital Revenue Code	290
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

KNEE SPLINT 22' LG

Facility

$63.00

Hospital Charge Code	2893365
Hospital Revenue Code	290
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

KNEE SPLINT 22' MED

Facility

$63.00

Hospital Charge Code	2893364
Hospital Revenue Code	290
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

KNEE SPLINT 22' MED

Facility

$63.00

Hospital Charge Code	2893364
Hospital Revenue Code	290
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$63.00
Rate for Payer: Aetna Commercial	$59.85
Rate for Payer: Aetna Medicare	$56.70
Rate for Payer: BCBS MT CHIP	$56.70
Rate for Payer: BCBS MT Closed Plan Network	$59.85
Rate for Payer: BCBS MT HealthLink	$56.70
Rate for Payer: BCBS MT Medicare	$56.70
Rate for Payer: BCBS MT POS	$59.85
Rate for Payer: BCBS MT Traditional	$63.00
Rate for Payer: Cash Price	$56.70
Rate for Payer: Cigna Commercial	$59.85
Rate for Payer: Cigna Medicare	$56.70
Rate for Payer: Medicaid All Medicaid	$57.96
Rate for Payer: Medicare All Medicare	$44.10
Rate for Payer: Monida Allegiance	$59.85
Rate for Payer: Monida First Choice Health	$61.11
Rate for Payer: Monida Montana Health Co-op	$59.85
Rate for Payer: Monida PacificSource	$59.85

KNEE SPORT SLEEVE

Facility

$289.00

Service Code	HCPCS L1820
Hospital Charge Code	8001800
Hospital Revenue Code	290
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

KNEE SPORT SLEEVE

Facility

$289.00

Service Code	HCPCS L1820
Hospital Charge Code	8001800
Hospital Revenue Code	290
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

KNEE STABILIZER LG LONG

Facility

$81.00

Hospital Charge Code	2893366
Hospital Revenue Code	290
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

KNEE STABILIZER LG LONG

Facility

$81.00

Hospital Charge Code	2893366
Hospital Revenue Code	290
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

KNEE STABILIZER MED LONG

Facility

$95.00

Hospital Charge Code	2820012
Hospital Revenue Code	270
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

KNEE STABILIZER MED LONG

Facility

$95.00

Hospital Charge Code	2820012
Hospital Revenue Code	270
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$95.00
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: BCBS MT CHIP	$85.50
Rate for Payer: BCBS MT Closed Plan Network	$90.25
Rate for Payer: BCBS MT HealthLink	$85.50
Rate for Payer: BCBS MT Medicare	$85.50
Rate for Payer: BCBS MT POS	$90.25
Rate for Payer: BCBS MT Traditional	$95.00
Rate for Payer: Cash Price	$85.50
Rate for Payer: Cigna Commercial	$90.25
Rate for Payer: Cigna Medicare	$85.50
Rate for Payer: Medicaid All Medicaid	$87.40
Rate for Payer: Medicare All Medicare	$66.50
Rate for Payer: Monida Allegiance	$90.25
Rate for Payer: Monida First Choice Health	$92.15
Rate for Payer: Monida Montana Health Co-op	$90.25
Rate for Payer: Monida PacificSource	$90.25

KNEE STABILIZER SM

Facility

$81.00

Hospital Charge Code	2893368
Hospital Revenue Code	290
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

KNEE STABILIZER SM

Facility

$81.00

Hospital Charge Code	2893368
Hospital Revenue Code	290
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

KNEE STABILIZER XL LONG

Facility

$81.00

Hospital Charge Code	2893367
Hospital Revenue Code	290
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

KNEE STABILIZER XL LONG

Facility

$81.00

Hospital Charge Code	2893367
Hospital Revenue Code	290
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$81.00
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: BCBS MT CHIP	$72.90
Rate for Payer: BCBS MT Closed Plan Network	$76.95
Rate for Payer: BCBS MT HealthLink	$72.90
Rate for Payer: BCBS MT Medicare	$72.90
Rate for Payer: BCBS MT POS	$76.95
Rate for Payer: BCBS MT Traditional	$81.00
Rate for Payer: Cash Price	$72.90
Rate for Payer: Cigna Commercial	$76.95
Rate for Payer: Cigna Medicare	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

KNEE SUPPORT W/PATELLA

Facility

$289.00

Service Code	HCPCS L1820
Hospital Charge Code	8001820
Hospital Revenue Code	290
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

KNEE SUPPORT W/PATELLA

Facility

$289.00

Service Code	HCPCS L1820
Hospital Charge Code	8001820
Hospital Revenue Code	290
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$289.00
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: BCBS MT CHIP	$260.10
Rate for Payer: BCBS MT Closed Plan Network	$274.55
Rate for Payer: BCBS MT HealthLink	$260.10
Rate for Payer: BCBS MT Medicare	$260.10
Rate for Payer: BCBS MT POS	$274.55
Rate for Payer: BCBS MT Traditional	$289.00
Rate for Payer: Cash Price	$260.10
Rate for Payer: Cigna Commercial	$274.55
Rate for Payer: Cigna Medicare	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

KNEE WRAP HINGED LG

Facility

$196.00

Hospital Charge Code	2893374
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

KNEE WRAP HINGED LG

Facility

$196.00

Hospital Charge Code	2893374
Hospital Revenue Code	290
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna Commercial	$186.20
Rate for Payer: Aetna Medicare	$176.40
Rate for Payer: BCBS MT CHIP	$176.40
Rate for Payer: BCBS MT Closed Plan Network	$186.20
Rate for Payer: BCBS MT HealthLink	$176.40
Rate for Payer: BCBS MT Medicare	$176.40
Rate for Payer: BCBS MT POS	$186.20
Rate for Payer: BCBS MT Traditional	$196.00
Rate for Payer: Cash Price	$176.40
Rate for Payer: Cigna Commercial	$186.20
Rate for Payer: Cigna Medicare	$176.40
Rate for Payer: Medicaid All Medicaid	$180.32
Rate for Payer: Medicare All Medicare	$137.20
Rate for Payer: Monida Allegiance	$186.20
Rate for Payer: Monida First Choice Health	$190.12
Rate for Payer: Monida Montana Health Co-op	$186.20
Rate for Payer: Monida PacificSource	$186.20

Know your out-of-pocket cost for care.

All Charges