Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

RESPIRATORY PANEL, NAD

Facility

$578.00

Service Code	HCPCS 0202U
Hospital Charge Code	4050202
Hospital Revenue Code	300
Min. Negotiated Rate	$404.60
Max. Negotiated Rate	$578.00
Rate for Payer: Aetna Commercial	$549.10
Rate for Payer: Aetna Medicare	$520.20
Rate for Payer: BCBS MT CHIP	$520.20
Rate for Payer: BCBS MT Closed Plan Network	$549.10
Rate for Payer: BCBS MT HealthLink	$520.20
Rate for Payer: BCBS MT Medicare	$520.20
Rate for Payer: BCBS MT POS	$549.10
Rate for Payer: BCBS MT Traditional	$578.00
Rate for Payer: Cash Price	$520.20
Rate for Payer: Cigna Commercial	$549.10
Rate for Payer: Cigna Medicare	$520.20
Rate for Payer: Medicaid All Medicaid	$531.76
Rate for Payer: Medicare All Medicare	$404.60
Rate for Payer: Monida Allegiance	$549.10
Rate for Payer: Monida First Choice Health	$560.66
Rate for Payer: Monida Montana Health Co-op	$549.10
Rate for Payer: Monida PacificSource	$549.10

RESPITE CARE

Facility

$420.00

Hospital Charge Code	800001
Hospital Revenue Code	120
Min. Negotiated Rate	$294.00
Max. Negotiated Rate	$420.00
Rate for Payer: Aetna Commercial	$399.00
Rate for Payer: Aetna Medicare	$378.00
Rate for Payer: BCBS MT CHIP	$378.00
Rate for Payer: BCBS MT Closed Plan Network	$399.00
Rate for Payer: BCBS MT HealthLink	$378.00
Rate for Payer: BCBS MT Medicare	$378.00
Rate for Payer: BCBS MT POS	$399.00
Rate for Payer: BCBS MT Traditional	$420.00
Rate for Payer: Cash Price	$378.00
Rate for Payer: Cigna Commercial	$399.00
Rate for Payer: Cigna Medicare	$378.00
Rate for Payer: Medicaid All Medicaid	$386.40
Rate for Payer: Medicare All Medicare	$294.00
Rate for Payer: Monida Allegiance	$399.00
Rate for Payer: Monida First Choice Health	$407.40
Rate for Payer: Monida Montana Health Co-op	$399.00
Rate for Payer: Monida PacificSource	$399.00

RESUSCITATOR INFANT

Facility

$152.00

Hospital Charge Code	80030011
Hospital Revenue Code	270
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

RESUSCITATOR INFANT

Facility

$152.00

Hospital Charge Code	80030011
Hospital Revenue Code	270
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$152.00
Rate for Payer: Aetna Commercial	$144.40
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: BCBS MT CHIP	$136.80
Rate for Payer: BCBS MT Closed Plan Network	$144.40
Rate for Payer: BCBS MT HealthLink	$136.80
Rate for Payer: BCBS MT Medicare	$136.80
Rate for Payer: BCBS MT POS	$144.40
Rate for Payer: BCBS MT Traditional	$152.00
Rate for Payer: Cash Price	$136.80
Rate for Payer: Cigna Commercial	$144.40
Rate for Payer: Cigna Medicare	$136.80
Rate for Payer: Medicaid All Medicaid	$139.84
Rate for Payer: Medicare All Medicare	$106.40
Rate for Payer: Monida Allegiance	$144.40
Rate for Payer: Monida First Choice Health	$147.44
Rate for Payer: Monida Montana Health Co-op	$144.40
Rate for Payer: Monida PacificSource	$144.40

RETICULOCYTE COUNT (005280)

Facility

$13.00

Service Code	HCPCS 85045
Hospital Charge Code	4085046
Hospital Revenue Code	300
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

RETICULOCYTE COUNT (005280)

Facility

$13.00

Service Code	HCPCS 85045
Hospital Charge Code	4085046
Hospital Revenue Code	300
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

RF ABLTJ NRV NRVTG SI JT W/I 64625

Facility

$4,767.00

Service Code	HCPCS 64625
Hospital Charge Code	1564625
Hospital Revenue Code	761
Min. Negotiated Rate	$3,336.90
Max. Negotiated Rate	$4,767.00
Rate for Payer: Aetna Commercial	$4,528.65
Rate for Payer: Aetna Medicare	$4,290.30
Rate for Payer: BCBS MT CHIP	$4,290.30
Rate for Payer: BCBS MT Closed Plan Network	$4,528.65
Rate for Payer: BCBS MT HealthLink	$4,290.30
Rate for Payer: BCBS MT Medicare	$4,290.30
Rate for Payer: BCBS MT POS	$4,528.65
Rate for Payer: BCBS MT Traditional	$4,767.00
Rate for Payer: Cash Price	$4,290.30
Rate for Payer: Cigna Commercial	$4,528.65
Rate for Payer: Cigna Medicare	$4,290.30
Rate for Payer: Medicaid All Medicaid	$4,385.64
Rate for Payer: Medicare All Medicare	$3,336.90
Rate for Payer: Monida Allegiance	$4,528.65
Rate for Payer: Monida First Choice Health	$4,623.99
Rate for Payer: Monida Montana Health Co-op	$4,528.65
Rate for Payer: Monida PacificSource	$4,528.65

RF ABLTJ NRV NRVTG SI JT W/I 64625

Facility

$4,767.00

Service Code	HCPCS 64625
Hospital Charge Code	1564625
Hospital Revenue Code	761
Min. Negotiated Rate	$3,336.90
Max. Negotiated Rate	$4,767.00
Rate for Payer: Aetna Commercial	$4,528.65
Rate for Payer: Aetna Medicare	$4,290.30
Rate for Payer: BCBS MT CHIP	$4,290.30
Rate for Payer: BCBS MT Closed Plan Network	$4,528.65
Rate for Payer: BCBS MT HealthLink	$4,290.30
Rate for Payer: BCBS MT Medicare	$4,290.30
Rate for Payer: BCBS MT POS	$4,528.65
Rate for Payer: BCBS MT Traditional	$4,767.00
Rate for Payer: Cash Price	$4,290.30
Rate for Payer: Cigna Commercial	$4,528.65
Rate for Payer: Cigna Medicare	$4,290.30
Rate for Payer: Medicaid All Medicaid	$4,385.64
Rate for Payer: Medicare All Medicare	$3,336.90
Rate for Payer: Monida Allegiance	$4,528.65
Rate for Payer: Monida First Choice Health	$4,623.99
Rate for Payer: Monida Montana Health Co-op	$4,528.65
Rate for Payer: Monida PacificSource	$4,528.65

RHEUMATOID FACTOR (006502)

Facility

$13.00

Service Code	HCPCS 86431
Hospital Charge Code	4086431
Hospital Revenue Code	300
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

RHEUMATOID FACTOR (006502)

Facility

$13.00

Service Code	HCPCS 86431
Hospital Charge Code	4086431
Hospital Revenue Code	300
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$13.00
Rate for Payer: Aetna Commercial	$12.35
Rate for Payer: Aetna Medicare	$11.70
Rate for Payer: BCBS MT CHIP	$11.70
Rate for Payer: BCBS MT Closed Plan Network	$12.35
Rate for Payer: BCBS MT HealthLink	$11.70
Rate for Payer: BCBS MT Medicare	$11.70
Rate for Payer: BCBS MT POS	$12.35
Rate for Payer: BCBS MT Traditional	$13.00
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cigna Commercial	$12.35
Rate for Payer: Cigna Medicare	$11.70
Rate for Payer: Medicaid All Medicaid	$11.96
Rate for Payer: Medicare All Medicare	$9.10
Rate for Payer: Monida Allegiance	$12.35
Rate for Payer: Monida First Choice Health	$12.61
Rate for Payer: Monida Montana Health Co-op	$12.35
Rate for Payer: Monida PacificSource	$12.35

RH TYPE

Facility

$85.00

Service Code	HCPCS 86901
Hospital Charge Code	4086901
Hospital Revenue Code	300
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$80.75
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS MT CHIP	$76.50
Rate for Payer: BCBS MT Closed Plan Network	$80.75
Rate for Payer: BCBS MT HealthLink	$76.50
Rate for Payer: BCBS MT Medicare	$76.50
Rate for Payer: BCBS MT POS	$80.75
Rate for Payer: BCBS MT Traditional	$85.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Cigna Medicare	$76.50
Rate for Payer: Medicaid All Medicaid	$78.20
Rate for Payer: Medicare All Medicare	$59.50
Rate for Payer: Monida Allegiance	$80.75
Rate for Payer: Monida First Choice Health	$82.45
Rate for Payer: Monida Montana Health Co-op	$80.75
Rate for Payer: Monida PacificSource	$80.75

RH TYPE

Facility

$85.00

Service Code	HCPCS 86901
Hospital Charge Code	4086901
Hospital Revenue Code	300
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$85.00
Rate for Payer: Aetna Commercial	$80.75
Rate for Payer: Aetna Medicare	$76.50
Rate for Payer: BCBS MT CHIP	$76.50
Rate for Payer: BCBS MT Closed Plan Network	$80.75
Rate for Payer: BCBS MT HealthLink	$76.50
Rate for Payer: BCBS MT Medicare	$76.50
Rate for Payer: BCBS MT POS	$80.75
Rate for Payer: BCBS MT Traditional	$85.00
Rate for Payer: Cash Price	$76.50
Rate for Payer: Cigna Commercial	$80.75
Rate for Payer: Cigna Medicare	$76.50
Rate for Payer: Medicaid All Medicaid	$78.20
Rate for Payer: Medicare All Medicare	$59.50
Rate for Payer: Monida Allegiance	$80.75
Rate for Payer: Monida First Choice Health	$82.45
Rate for Payer: Monida Montana Health Co-op	$80.75
Rate for Payer: Monida PacificSource	$80.75

RHYTHM STRIPS

Facility

$82.00

Service Code	HCPCS 93041
Hospital Charge Code	114002
Hospital Revenue Code	730
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

RHYTHM STRIPS

Facility

$82.00

Service Code	HCPCS 93041
Hospital Charge Code	114002
Hospital Revenue Code	730
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$82.00
Rate for Payer: Aetna Commercial	$77.90
Rate for Payer: Aetna Medicare	$73.80
Rate for Payer: BCBS MT CHIP	$73.80
Rate for Payer: BCBS MT Closed Plan Network	$77.90
Rate for Payer: BCBS MT HealthLink	$73.80
Rate for Payer: BCBS MT Medicare	$73.80
Rate for Payer: BCBS MT POS	$77.90
Rate for Payer: BCBS MT Traditional	$82.00
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cigna Commercial	$77.90
Rate for Payer: Cigna Medicare	$73.80
Rate for Payer: Medicaid All Medicaid	$75.44
Rate for Payer: Medicare All Medicare	$57.40
Rate for Payer: Monida Allegiance	$77.90
Rate for Payer: Monida First Choice Health	$79.54
Rate for Payer: Monida Montana Health Co-op	$77.90
Rate for Payer: Monida PacificSource	$77.90

RIB BELT

Facility

$246.00

Service Code	HCPCS L0220
Hospital Charge Code	8000210
Hospital Revenue Code	290
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

RIB BELT

Facility

$246.00

Service Code	HCPCS L0220
Hospital Charge Code	8000210
Hospital Revenue Code	290
Min. Negotiated Rate	$172.20
Max. Negotiated Rate	$246.00
Rate for Payer: Aetna Commercial	$233.70
Rate for Payer: Aetna Medicare	$221.40
Rate for Payer: BCBS MT CHIP	$221.40
Rate for Payer: BCBS MT Closed Plan Network	$233.70
Rate for Payer: BCBS MT HealthLink	$221.40
Rate for Payer: BCBS MT Medicare	$221.40
Rate for Payer: BCBS MT POS	$233.70
Rate for Payer: BCBS MT Traditional	$246.00
Rate for Payer: Cash Price	$221.40
Rate for Payer: Cigna Commercial	$233.70
Rate for Payer: Cigna Medicare	$221.40
Rate for Payer: Medicaid All Medicaid	$226.32
Rate for Payer: Medicare All Medicare	$172.20
Rate for Payer: Monida Allegiance	$233.70
Rate for Payer: Monida First Choice Health	$238.62
Rate for Payer: Monida Montana Health Co-op	$233.70
Rate for Payer: Monida PacificSource	$233.70

RIB BELT MALE LG

Facility

$21.00

Hospital Charge Code	2893488
Hospital Revenue Code	290
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

RIB BELT MALE LG

Facility

$21.00

Hospital Charge Code	2893488
Hospital Revenue Code	290
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

RIB BELT MALE SM

Facility

$21.00

Hospital Charge Code	2893487
Hospital Revenue Code	290
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

RIB BELT MALE SM

Facility

$21.00

Hospital Charge Code	2893487
Hospital Revenue Code	290
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

RIB BELT MALE UNIV

Facility

$21.00

Hospital Charge Code	2820019
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

RIB BELT MALE UNIV

Facility

$21.00

Hospital Charge Code	2820019
Hospital Revenue Code	270
Min. Negotiated Rate	$14.70
Max. Negotiated Rate	$21.00
Rate for Payer: Aetna Commercial	$19.95
Rate for Payer: Aetna Medicare	$18.90
Rate for Payer: BCBS MT CHIP	$18.90
Rate for Payer: BCBS MT Closed Plan Network	$19.95
Rate for Payer: BCBS MT HealthLink	$18.90
Rate for Payer: BCBS MT Medicare	$18.90
Rate for Payer: BCBS MT POS	$19.95
Rate for Payer: BCBS MT Traditional	$21.00
Rate for Payer: Cash Price	$18.90
Rate for Payer: Cigna Commercial	$19.95
Rate for Payer: Cigna Medicare	$18.90
Rate for Payer: Medicaid All Medicaid	$19.32
Rate for Payer: Medicare All Medicare	$14.70
Rate for Payer: Monida Allegiance	$19.95
Rate for Payer: Monida First Choice Health	$20.37
Rate for Payer: Monida Montana Health Co-op	$19.95
Rate for Payer: Monida PacificSource	$19.95

RIB BELT MALE XLG DELUXE

Facility

$24.00

Hospital Charge Code	2893489
Hospital Revenue Code	290
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

RIB BELT MALE XLG DELUXE

Facility

$24.00

Hospital Charge Code	2893489
Hospital Revenue Code	290
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$24.00
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: BCBS MT CHIP	$21.60
Rate for Payer: BCBS MT Closed Plan Network	$22.80
Rate for Payer: BCBS MT HealthLink	$21.60
Rate for Payer: BCBS MT Medicare	$21.60
Rate for Payer: BCBS MT POS	$22.80
Rate for Payer: BCBS MT Traditional	$24.00
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cigna Commercial	$22.80
Rate for Payer: Cigna Medicare	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

RIFAMPIN 300 MG CAPSULE-NF

Facility

$15.00

Service Code	NDC 68180065907
Hospital Charge Code	3007239
Hospital Revenue Code	250
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$15.00
Rate for Payer: Aetna Commercial	$14.25
Rate for Payer: Aetna Medicare	$13.50
Rate for Payer: BCBS MT CHIP	$13.50
Rate for Payer: BCBS MT Closed Plan Network	$14.25
Rate for Payer: BCBS MT HealthLink	$13.50
Rate for Payer: BCBS MT Medicare	$13.50
Rate for Payer: BCBS MT POS	$14.25
Rate for Payer: BCBS MT Traditional	$15.00
Rate for Payer: Cash Price	$13.50
Rate for Payer: Cigna Commercial	$14.25
Rate for Payer: Cigna Medicare	$13.50
Rate for Payer: Medicaid All Medicaid	$13.80
Rate for Payer: Medicare All Medicare	$10.50
Rate for Payer: Monida Allegiance	$14.25
Rate for Payer: Monida First Choice Health	$14.55
Rate for Payer: Monida Montana Health Co-op	$14.25
Rate for Payer: Monida PacificSource	$14.25

Know your out-of-pocket cost for care.

All Charges