Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE CTA AORTA ILIAC RUNOFF

Professional

Both

$344.00

Service Code	HCPCS 75635 26
Hospital Charge Code	50002078
Hospital Revenue Code	972
Min. Negotiated Rate	$240.80
Max. Negotiated Rate	$333.68
Rate for Payer: Aetna Commercial	$326.80
Rate for Payer: Aetna Medicare	$309.60
Rate for Payer: Cash Price	$309.60
Rate for Payer: Medicaid All Medicaid	$316.48
Rate for Payer: Medicare All Medicare	$240.80
Rate for Payer: Monida Allegiance	$326.80
Rate for Payer: Monida First Choice Health	$333.68
Rate for Payer: Monida Montana Health Co-op	$326.80
Rate for Payer: Monida PacificSource	$326.80

PROFEE CT ABDOMEN PELVIS W CONTRAST

Professional

Both

$266.00

Service Code	HCPCS 74177 26
Hospital Charge Code	50002023
Hospital Revenue Code	972
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$258.02
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: Cash Price	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

PROFEE CT ABDOMEN PELVIS WO CONTRAST

Professional

Both

$253.00

Service Code	HCPCS 74176 26
Hospital Charge Code	50002025
Hospital Revenue Code	972
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$245.41
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: Cash Price	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

PROFEE CT ABDOMEN PELVIS W WO CONTRAST

Professional

Both

$292.00

Service Code	HCPCS 74178 26
Hospital Charge Code	50002024
Hospital Revenue Code	972
Min. Negotiated Rate	$204.40
Max. Negotiated Rate	$283.24
Rate for Payer: Aetna Commercial	$277.40
Rate for Payer: Aetna Medicare	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Medicaid All Medicaid	$268.64
Rate for Payer: Medicare All Medicare	$204.40
Rate for Payer: Monida Allegiance	$277.40
Rate for Payer: Monida First Choice Health	$283.24
Rate for Payer: Monida Montana Health Co-op	$277.40
Rate for Payer: Monida PacificSource	$277.40

PROFEE CT ABDOMEN W CONTRAST

Professional

Both

$185.00

Service Code	HCPCS 74160 26
Hospital Charge Code	50002026
Hospital Revenue Code	972
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$179.45
Rate for Payer: Aetna Commercial	$175.75
Rate for Payer: Aetna Medicare	$166.50
Rate for Payer: Cash Price	$166.50
Rate for Payer: Medicaid All Medicaid	$170.20
Rate for Payer: Medicare All Medicare	$129.50
Rate for Payer: Monida Allegiance	$175.75
Rate for Payer: Monida First Choice Health	$179.45
Rate for Payer: Monida Montana Health Co-op	$175.75
Rate for Payer: Monida PacificSource	$175.75

PROFEE CT ABDOMEN WO CONTRAST

Professional

Both

$172.00

Service Code	HCPCS 74150 26
Hospital Charge Code	50002028
Hospital Revenue Code	972
Min. Negotiated Rate	$120.40
Max. Negotiated Rate	$166.84
Rate for Payer: Aetna Commercial	$163.40
Rate for Payer: Aetna Medicare	$154.80
Rate for Payer: Cash Price	$154.80
Rate for Payer: Medicaid All Medicaid	$158.24
Rate for Payer: Medicare All Medicare	$120.40
Rate for Payer: Monida Allegiance	$163.40
Rate for Payer: Monida First Choice Health	$166.84
Rate for Payer: Monida Montana Health Co-op	$163.40
Rate for Payer: Monida PacificSource	$163.40

PROFEE CT ABDOMEN W WO CONTRAST

Professional

Both

$202.00

Service Code	HCPCS 74170 26
Hospital Charge Code	50002027
Hospital Revenue Code	972
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$195.94
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

PROFEE CT ABD/PELVIS/CHEST W/O

Professional

Both

$253.00

Service Code	HCPCS 74176 26
Hospital Charge Code	50002022
Hospital Revenue Code	972
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$245.41
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: Cash Price	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

PROFEE CTA CAROTID ARTERIES

Professional

Both

$254.00

Service Code	HCPCS 70498 26
Hospital Charge Code	50002079
Hospital Revenue Code	972
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$246.38
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: Cash Price	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

PROFEE CTA CHEST PE STUDY

Professional

Both

$516.00

Service Code	HCPCS 71275 26
Hospital Charge Code	50002442
Hospital Revenue Code	972
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$500.52
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: Cash Price	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

PROFEE CTA HEAD CIRCLE OF WILLIS

Professional

Both

$254.00

Service Code	HCPCS 70496 26
Hospital Charge Code	50002082
Hospital Revenue Code	972
Min. Negotiated Rate	$177.80
Max. Negotiated Rate	$246.38
Rate for Payer: Aetna Commercial	$241.30
Rate for Payer: Aetna Medicare	$228.60
Rate for Payer: Cash Price	$228.60
Rate for Payer: Medicaid All Medicaid	$233.68
Rate for Payer: Medicare All Medicare	$177.80
Rate for Payer: Monida Allegiance	$241.30
Rate for Payer: Monida First Choice Health	$246.38
Rate for Payer: Monida Montana Health Co-op	$241.30
Rate for Payer: Monida PacificSource	$241.30

PROFEE CTA LOWER EXT BILAT W CONTRAST

Professional

Both

$274.00

Service Code	HCPCS 73706 26
Hospital Charge Code	50002444
Hospital Revenue Code	972
Min. Negotiated Rate	$191.80
Max. Negotiated Rate	$265.78
Rate for Payer: Aetna Commercial	$260.30
Rate for Payer: Aetna Medicare	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Medicaid All Medicaid	$252.08
Rate for Payer: Medicare All Medicare	$191.80
Rate for Payer: Monida Allegiance	$260.30
Rate for Payer: Monida First Choice Health	$265.78
Rate for Payer: Monida Montana Health Co-op	$260.30
Rate for Payer: Monida PacificSource	$260.30

PROFEE CTA LOWER EXT BILAT W WO CONTRAST

Professional

Both

$274.00

Service Code	HCPCS 73706 26
Hospital Charge Code	50002083
Hospital Revenue Code	972
Min. Negotiated Rate	$191.80
Max. Negotiated Rate	$265.78
Rate for Payer: Aetna Commercial	$260.30
Rate for Payer: Aetna Medicare	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Medicaid All Medicaid	$252.08
Rate for Payer: Medicare All Medicare	$191.80
Rate for Payer: Monida Allegiance	$260.30
Rate for Payer: Monida First Choice Health	$265.78
Rate for Payer: Monida Montana Health Co-op	$260.30
Rate for Payer: Monida PacificSource	$260.30

PROFEE CTA ORBIT EAR FOSSA W CONTRAST

Professional

Both

$164.00

Service Code	HCPCS 70481 26
Hospital Charge Code	50002084
Hospital Revenue Code	972
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$159.08
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$147.60
Rate for Payer: Cash Price	$147.60
Rate for Payer: Medicaid All Medicaid	$150.88
Rate for Payer: Medicare All Medicare	$114.80
Rate for Payer: Monida Allegiance	$155.80
Rate for Payer: Monida First Choice Health	$159.08
Rate for Payer: Monida Montana Health Co-op	$155.80
Rate for Payer: Monida PacificSource	$155.80

PROFEE CTA PELVIS

Professional

Both

$261.00

Service Code	HCPCS 72191 26
Hospital Charge Code	50002085
Hospital Revenue Code	972
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$253.17
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: Cash Price	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

PROFEE CTA THORACIC AORTA

Professional

Both

$265.00

Service Code	HCPCS 71275 26
Hospital Charge Code	50002086
Hospital Revenue Code	972
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$257.05
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

PROFEE CTA THORACIC PE STUDY

Professional

Both

$265.00

Service Code	HCPCS 71275 26
Hospital Charge Code	50002087
Hospital Revenue Code	972
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$257.05
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

PROFEE CTA UPPER EXTREMITY LT W WO

Professional

Both

$261.00

Service Code	HCPCS 73206 26
Hospital Charge Code	50002088
Hospital Revenue Code	972
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$253.17
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: Cash Price	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

PROFEE CTA UPPER EXTREMITY RT W WO

Professional

Both

$261.00

Service Code	HCPCS 73206 26
Hospital Charge Code	50002089
Hospital Revenue Code	972
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$253.17
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: Cash Price	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

PROFEE CT BONE DENSITY

Professional

Both

$36.00

Service Code	HCPCS 77078 26
Hospital Charge Code	50002029
Hospital Revenue Code	972
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$34.92
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: Cash Price	$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

PROFEE CT BONE LENGTH STUDY SCANOGRAM

Professional

Both

$38.00

Service Code	HCPCS 77073 26
Hospital Charge Code	50002030
Hospital Revenue Code	972
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: Cash Price	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

PROFEE CT CERVICAL SPINE W CONTRAST

Professional

Both

$176.00

Service Code	HCPCS 72126 26
Hospital Charge Code	50002031
Hospital Revenue Code	972
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$170.72
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Medicaid All Medicaid	$161.92
Rate for Payer: Medicare All Medicare	$123.20
Rate for Payer: Monida Allegiance	$167.20
Rate for Payer: Monida First Choice Health	$170.72
Rate for Payer: Monida Montana Health Co-op	$167.20
Rate for Payer: Monida PacificSource	$167.20

PROFEE CT CERVICAL SPINE WO CONTRAST

Professional

Both

$144.00

Service Code	HCPCS 72125 26
Hospital Charge Code	50002033
Hospital Revenue Code	972
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$139.68
Rate for Payer: Aetna Commercial	$136.80
Rate for Payer: Aetna Medicare	$129.60
Rate for Payer: Cash Price	$129.60
Rate for Payer: Medicaid All Medicaid	$132.48
Rate for Payer: Medicare All Medicare	$100.80
Rate for Payer: Monida Allegiance	$136.80
Rate for Payer: Monida First Choice Health	$139.68
Rate for Payer: Monida Montana Health Co-op	$136.80
Rate for Payer: Monida PacificSource	$136.80

PROFEE CT CERVICAL SPINE W WO CONTRAST

Professional

Both

$184.00

Service Code	HCPCS 72127 26
Hospital Charge Code	50002032
Hospital Revenue Code	972
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$178.48
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

PROFEE CT CHEST W CONTRAST

Professional

Both

$169.00

Service Code	HCPCS 71260 26
Hospital Charge Code	50002034
Hospital Revenue Code	972
Min. Negotiated Rate	$118.30
Max. Negotiated Rate	$163.93
Rate for Payer: Aetna Commercial	$160.55
Rate for Payer: Aetna Medicare	$152.10
Rate for Payer: Cash Price	$152.10
Rate for Payer: Medicaid All Medicaid	$155.48
Rate for Payer: Medicare All Medicare	$118.30
Rate for Payer: Monida Allegiance	$160.55
Rate for Payer: Monida First Choice Health	$163.93
Rate for Payer: Monida Montana Health Co-op	$160.55
Rate for Payer: Monida PacificSource	$160.55

Know your out-of-pocket cost for care.

All Charges