Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

TB INTRADERMAL TEST

Facility

$36.00

Service Code	HCPCS J3490
Hospital Charge Code	186580
Hospital Revenue Code	302
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

TB INTRADERMAL TEST

Facility

$36.00

Service Code	HCPCS J3490
Hospital Charge Code	186580
Hospital Revenue Code	302
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$36.00
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: BCBS MT CHIP	$32.40
Rate for Payer: BCBS MT Closed Plan Network	$34.20
Rate for Payer: BCBS MT HealthLink	$32.40
Rate for Payer: BCBS MT Medicare	$32.40
Rate for Payer: BCBS MT POS	$34.20
Rate for Payer: BCBS MT Traditional	$36.00
Rate for Payer: Cash Price	$32.40
Rate for Payer: Cigna Commercial	$34.20
Rate for Payer: Cigna Medicare	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

.T CELLS, TOTAL COUNT

Facility

$125.00

Service Code	CPT 86359
Hospital Charge Code	4086359
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

.T CELLS, TOTAL COUNT

Facility

$125.00

Service Code	CPT 86359
Hospital Charge Code	4086359
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$125.00
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: BCBS MT CHIP	$112.50
Rate for Payer: BCBS MT Closed Plan Network	$118.75
Rate for Payer: BCBS MT HealthLink	$112.50
Rate for Payer: BCBS MT Medicare	$112.50
Rate for Payer: BCBS MT POS	$118.75
Rate for Payer: BCBS MT Traditional	$125.00
Rate for Payer: Cash Price	$112.50
Rate for Payer: Cigna Commercial	$118.75
Rate for Payer: Cigna Medicare	$112.50
Rate for Payer: Medicaid All Medicaid	$115.00
Rate for Payer: Medicare All Medicare	$87.50
Rate for Payer: Monida Allegiance	$118.75
Rate for Payer: Monida First Choice Health	$121.25
Rate for Payer: Monida Montana Health Co-op	$118.75
Rate for Payer: Monida PacificSource	$118.75

TED HOSE KNEE HIGH LG LONG

Facility

$14.00

Hospital Charge Code	2893598
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH LG LONG

Facility

$14.00

Hospital Charge Code	2893598
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH LG REG

Facility

$14.00

Hospital Charge Code	2893597
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH LG REG

Facility

$14.00

Hospital Charge Code	2893597
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH LG SHORT

Facility

$14.00

Hospital Charge Code	2893596
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH LG SHORT

Facility

$14.00

Hospital Charge Code	2893596
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH MD REG

Facility

$14.00

Hospital Charge Code	2893594
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH MD REG

Facility

$14.00

Hospital Charge Code	2893594
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH MD SHORT

Facility

$14.00

Hospital Charge Code	2893593
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH MD SHORT

Facility

$14.00

Hospital Charge Code	2893593
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH SM LONG

Facility

$14.00

Hospital Charge Code	2893592
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH SM LONG

Facility

$14.00

Hospital Charge Code	2893592
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH SM REG

Facility

$14.00

Hospital Charge Code	2893591
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH SM REG

Facility

$14.00

Hospital Charge Code	2893591
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH SM SHORT

Facility

$16.00

Hospital Charge Code	2830290
Hospital Revenue Code	270
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

TED HOSE KNEE HIGH SM SHORT

Facility

$16.00

Hospital Charge Code	2830290
Hospital Revenue Code	270
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$16.00
Rate for Payer: Aetna Commercial	$15.20
Rate for Payer: Aetna Medicare	$14.40
Rate for Payer: BCBS MT CHIP	$14.40
Rate for Payer: BCBS MT Closed Plan Network	$15.20
Rate for Payer: BCBS MT HealthLink	$14.40
Rate for Payer: BCBS MT Medicare	$14.40
Rate for Payer: BCBS MT POS	$15.20
Rate for Payer: BCBS MT Traditional	$16.00
Rate for Payer: Cash Price	$14.40
Rate for Payer: Cigna Commercial	$15.20
Rate for Payer: Cigna Medicare	$14.40
Rate for Payer: Medicaid All Medicaid	$14.72
Rate for Payer: Medicare All Medicare	$11.20
Rate for Payer: Monida Allegiance	$15.20
Rate for Payer: Monida First Choice Health	$15.52
Rate for Payer: Monida Montana Health Co-op	$15.20
Rate for Payer: Monida PacificSource	$15.20

TED HOSE KNEE HIGH XL LONG

Facility

$14.00

Hospital Charge Code	2893601
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH XL LONG

Facility

$14.00

Hospital Charge Code	2893601
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH XL REG

Facility

$14.00

Hospital Charge Code	2893600
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH XL REG

Facility

$14.00

Hospital Charge Code	2893600
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

TED HOSE KNEE HIGH XL SHORT

Facility

$14.00

Hospital Charge Code	2893599
Hospital Revenue Code	290
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.00
Rate for Payer: Aetna Commercial	$13.30
Rate for Payer: Aetna Medicare	$12.60
Rate for Payer: BCBS MT CHIP	$12.60
Rate for Payer: BCBS MT Closed Plan Network	$13.30
Rate for Payer: BCBS MT HealthLink	$12.60
Rate for Payer: BCBS MT Medicare	$12.60
Rate for Payer: BCBS MT POS	$13.30
Rate for Payer: BCBS MT Traditional	$14.00
Rate for Payer: Cash Price	$12.60
Rate for Payer: Cigna Commercial	$13.30
Rate for Payer: Cigna Medicare	$12.60
Rate for Payer: Medicaid All Medicaid	$12.88
Rate for Payer: Medicare All Medicare	$9.80
Rate for Payer: Monida Allegiance	$13.30
Rate for Payer: Monida First Choice Health	$13.58
Rate for Payer: Monida Montana Health Co-op	$13.30
Rate for Payer: Monida PacificSource	$13.30

Know your out-of-pocket cost for care.

All Charges