Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE CT CHEST WO CONTRAST

Professional

Both

$157.00

Service Code	HCPCS 71250 26
Hospital Charge Code	50002036
Hospital Revenue Code	972
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$152.29
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: Cash Price	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

PROFEE CT CHEST W WO CONTRAST

Professional

Both

$182.00

Service Code	HCPCS 71270 26
Hospital Charge Code	50002035
Hospital Revenue Code	972
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$176.54
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

PROFEE CT FACIAL BONES W CONTRAST

Professional

Both

$164.00

Service Code	HCPCS 70487 26
Hospital Charge Code	50002039
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 CT FACIAL BONES WO CONTRAST

Professional

Both

$125.00

Service Code	HCPCS 70486 26
Hospital Charge Code	50002041
Hospital Revenue Code	972
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$121.25
Rate for Payer: Aetna Commercial	$118.75
Rate for Payer: Aetna Medicare	$112.50
Rate for Payer: Cash Price	$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

PROFEE CT FACIAL BONES W WO CONTRAST

Professional

Both

$184.00

Service Code	HCPCS 70488 26
Hospital Charge Code	50002040
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 HEAD W CONTRAST

Professional

Both

$164.00

Service Code	HCPCS 70460 26
Hospital Charge Code	50002042
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 CT HEAD WO CONTRAST

Professional

Both

$124.00

Service Code	HCPCS 70450 26
Hospital Charge Code	50002044
Hospital Revenue Code	972
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$120.28
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: Cash Price	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

PROFEE CT HEAD W WO CONTRAST

Professional

Both

$185.00

Service Code	HCPCS 70470 26
Hospital Charge Code	50002043
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 HIGH REZ CHEST

Professional

Both

$157.00

Service Code	HCPCS 71250 26
Hospital Charge Code	50002045
Hospital Revenue Code	972
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$152.29
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: Cash Price	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

PROFEE CT LIMITED FOLLOW-UP

Professional

Both

$138.00

Service Code	HCPCS 76380 26
Hospital Charge Code	50002046
Hospital Revenue Code	972
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$133.86
Rate for Payer: Aetna Commercial	$131.10
Rate for Payer: Aetna Medicare	$124.20
Rate for Payer: Cash Price	$124.20
Rate for Payer: Medicaid All Medicaid	$126.96
Rate for Payer: Medicare All Medicare	$96.60
Rate for Payer: Monida Allegiance	$131.10
Rate for Payer: Monida First Choice Health	$133.86
Rate for Payer: Monida Montana Health Co-op	$131.10
Rate for Payer: Monida PacificSource	$131.10

PROFEE CT LIMITED ORBITS FOR MRI

Professional

Both

$187.00

Service Code	HCPCS 70480 26
Hospital Charge Code	50002047
Hospital Revenue Code	972
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$181.39
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: Cash Price	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

PROFEE CT LOW DOSE LUNG SCREEN

Professional

Both

$157.00

Service Code	HCPCS 71271 26
Hospital Charge Code	50002048
Hospital Revenue Code	972
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$152.29
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: Cash Price	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

PROFEE CT LOWER EXTREMITY LT W CONTRAST

Professional

Both

$168.00

Service Code	HCPCS 73701 26
Hospital Charge Code	50002049
Hospital Revenue Code	972
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$162.96
Rate for Payer: Aetna Commercial	$159.60
Rate for Payer: Aetna Medicare	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Medicaid All Medicaid	$154.56
Rate for Payer: Medicare All Medicare	$117.60
Rate for Payer: Monida Allegiance	$159.60
Rate for Payer: Monida First Choice Health	$162.96
Rate for Payer: Monida Montana Health Co-op	$159.60
Rate for Payer: Monida PacificSource	$159.60

PROFEE CT LOWER EXTREMITY LT WO CONTRAST

Professional

Both

$144.00

Service Code	HCPCS 73700 26
Hospital Charge Code	50002051
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 LOWER EXTREMITY RT W CONTRAST

Professional

Both

$168.00

Service Code	HCPCS 73701 26
Hospital Charge Code	50002052
Hospital Revenue Code	972
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$162.96
Rate for Payer: Aetna Commercial	$159.60
Rate for Payer: Aetna Medicare	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Medicaid All Medicaid	$154.56
Rate for Payer: Medicare All Medicare	$117.60
Rate for Payer: Monida Allegiance	$159.60
Rate for Payer: Monida First Choice Health	$162.96
Rate for Payer: Monida Montana Health Co-op	$159.60
Rate for Payer: Monida PacificSource	$159.60

PROFEE CT LOWER EXTREMITY RT WO CONTRAST

Professional

Both

$144.00

Service Code	HCPCS 73700 26
Hospital Charge Code	50002054
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 LOWER EXTR LT W WO CONTRAST

Professional

Both

$175.00

Service Code	HCPCS 73702 26
Hospital Charge Code	50002050
Hospital Revenue Code	972
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$169.75
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

PROFEE CT LOWER EXTR RT W WO CONTRAST

Professional

Both

$175.00

Service Code	HCPCS 73702 26
Hospital Charge Code	50002053
Hospital Revenue Code	972
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$169.75
Rate for Payer: Aetna Commercial	$166.25
Rate for Payer: Aetna Medicare	$157.50
Rate for Payer: Cash Price	$157.50
Rate for Payer: Medicaid All Medicaid	$161.00
Rate for Payer: Medicare All Medicare	$122.50
Rate for Payer: Monida Allegiance	$166.25
Rate for Payer: Monida First Choice Health	$169.75
Rate for Payer: Monida Montana Health Co-op	$166.25
Rate for Payer: Monida PacificSource	$166.25

PROFEE CT LUMBAR SPINE W CONTRAST

Professional

Both

$176.00

Service Code	HCPCS 72132 26
Hospital Charge Code	50002055
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 LUMBAR SPINE WO CONTRAST

Professional

Both

$144.00

Service Code	HCPCS 72131 26
Hospital Charge Code	50002057
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 LUMBAR SPINE W WO CONTRAST

Professional

Both

$184.00

Service Code	HCPCS 72133 26
Hospital Charge Code	50002056
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 ORBIT EAR FOSSA W WO CONTRAST

Professional

Both

$184.00

Service Code	HCPCS 70482 26
Hospital Charge Code	50002058
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 ORBITS SELLA FOSSA WO CONTRAST

Professional

Both

$187.00

Service Code	HCPCS 70480 26
Hospital Charge Code	50002059
Hospital Revenue Code	972
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$181.39
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: Cash Price	$168.30
Rate for Payer: Medicaid All Medicaid	$172.04
Rate for Payer: Medicare All Medicare	$130.90
Rate for Payer: Monida Allegiance	$177.65
Rate for Payer: Monida First Choice Health	$181.39
Rate for Payer: Monida Montana Health Co-op	$177.65
Rate for Payer: Monida PacificSource	$177.65

PROFEE CT PELVIS W CONTRAST

Professional

Both

$168.00

Service Code	HCPCS 72193 26
Hospital Charge Code	50002060
Hospital Revenue Code	972
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$162.96
Rate for Payer: Aetna Commercial	$159.60
Rate for Payer: Aetna Medicare	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Medicaid All Medicaid	$154.56
Rate for Payer: Medicare All Medicare	$117.60
Rate for Payer: Monida Allegiance	$159.60
Rate for Payer: Monida First Choice Health	$162.96
Rate for Payer: Monida Montana Health Co-op	$159.60
Rate for Payer: Monida PacificSource	$159.60

PROFEE CT PELVIS WO CONTRAST

Professional

Both

$158.00

Service Code	HCPCS 72192 26
Hospital Charge Code	50002062
Hospital Revenue Code	972
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$153.26
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: Cash Price	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

Know your out-of-pocket cost for care.

All Charges