Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE CT PELVIS W WO CONTRAST

Professional

Both

$176.00

Service Code	HCPCS 72194 26
Hospital Charge Code	50002061
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 SINUS STUDY WO CONTRAST

Professional

Both

$125.00

Service Code	HCPCS 70486 26
Hospital Charge Code	50002063
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 SOFT TISSUE NECK W CONTRAST

Professional

Both

$200.00

Service Code	HCPCS 70491 26
Hospital Charge Code	50002064
Hospital Revenue Code	972
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

PROFEE CT SOFT TISSUE NECK WO CONTRAST

Professional

Both

$187.00

Service Code	HCPCS 70490 26
Hospital Charge Code	50002066
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 SOFT TISSUE NECK W WO CONTRAST

Professional

Both

$234.00

Service Code	HCPCS 70492 26
Hospital Charge Code	50002065
Hospital Revenue Code	972
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$226.98
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

PROFEE CT THORACIC SPINE W CONTRAST

Professional

Both

$177.00

Service Code	HCPCS 72129 26
Hospital Charge Code	50002067
Hospital Revenue Code	972
Min. Negotiated Rate	$123.90
Max. Negotiated Rate	$171.69
Rate for Payer: Aetna Commercial	$168.15
Rate for Payer: Aetna Medicare	$159.30
Rate for Payer: Cash Price	$159.30
Rate for Payer: Medicaid All Medicaid	$162.84
Rate for Payer: Medicare All Medicare	$123.90
Rate for Payer: Monida Allegiance	$168.15
Rate for Payer: Monida First Choice Health	$171.69
Rate for Payer: Monida Montana Health Co-op	$168.15
Rate for Payer: Monida PacificSource	$168.15

PROFEE CT THORACIC SPINE WO CONTRAST

Professional

Both

$144.00

Service Code	HCPCS 72128 26
Hospital Charge Code	50002069
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 THORACIC SPINE W WO CONTRAST

Professional

Both

$185.00

Service Code	HCPCS 72130 26
Hospital Charge Code	50002068
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 UPPER EXTREMITY LT W CONTRAST

Professional

Both

$168.00

Service Code	HCPCS 73201 26
Hospital Charge Code	50002070
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 UPPER EXTREMITY LT WO CONTRAST

Professional

Both

$144.00

Service Code	HCPCS 73200 26
Hospital Charge Code	50002072
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 UPPER EXTREMITY RT W CONTRAST

Professional

Both

$168.00

Service Code	HCPCS 73201 26
Hospital Charge Code	50002073
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 UPPER EXTREMITY RT WO CONTRAST

Professional

Both

$144.00

Service Code	HCPCS 73200 26
Hospital Charge Code	50002075
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 UPPER EXTR LT W WO CONTRAST

Professional

Both

$175.00

Service Code	HCPCS 73202 26
Hospital Charge Code	50002071
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 UPPER EXTR RT W WO CONTRAST

Professional

Both

$175.00

Service Code	HCPCS 73202 26
Hospital Charge Code	50002074
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

PRO FEE DEBRIDEMENT 20SQCM OR LESS 97597

Professional

Both

$66.00

Service Code	HCPCS 97597
Hospital Charge Code	797597
Hospital Revenue Code	960
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$64.02
Rate for Payer: Aetna Commercial	$62.70
Rate for Payer: Aetna Medicare	$59.40
Rate for Payer: Cash Price	$59.40
Rate for Payer: Medicaid All Medicaid	$60.72
Rate for Payer: Medicare All Medicare	$46.20
Rate for Payer: Monida Allegiance	$62.70
Rate for Payer: Monida First Choice Health	$64.02
Rate for Payer: Monida Montana Health Co-op	$62.70
Rate for Payer: Monida PacificSource	$62.70

PRO FEE DEBRIDEMENT EA ADD 20SQCM 97598

Professional

Both

$45.00

Service Code	HCPCS 97598
Hospital Charge Code	797598
Hospital Revenue Code	982
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$43.65
Rate for Payer: Aetna Commercial	$42.75
Rate for Payer: Aetna Medicare	$40.50
Rate for Payer: Cash Price	$40.50
Rate for Payer: Medicaid All Medicaid	$41.40
Rate for Payer: Medicare All Medicare	$31.50
Rate for Payer: Monida Allegiance	$42.75
Rate for Payer: Monida First Choice Health	$43.65
Rate for Payer: Monida Montana Health Co-op	$42.75
Rate for Payer: Monida PacificSource	$42.75

PRO FEE DEBRIDE NON-SELECT W/O ANES97602

Professional

Both

$100.00

Service Code	HCPCS 97602
Hospital Charge Code	797602
Hospital Revenue Code	982
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$97.00
Rate for Payer: Aetna Commercial	$95.00
Rate for Payer: Aetna Medicare	$90.00
Rate for Payer: Cash Price	$90.00
Rate for Payer: Medicaid All Medicaid	$92.00
Rate for Payer: Medicare All Medicare	$70.00
Rate for Payer: Monida Allegiance	$95.00
Rate for Payer: Monida First Choice Health	$97.00
Rate for Payer: Monida Montana Health Co-op	$95.00
Rate for Payer: Monida PacificSource	$95.00

PRO FEE DESTRUCTION NEUROLYTIC AGT GENI

Professional

Both

$759.00

Service Code	HCPCS 64624
Hospital Charge Code	7664624
Hospital Revenue Code	964
Min. Negotiated Rate	$531.30
Max. Negotiated Rate	$759.00
Rate for Payer: Aetna Commercial	$721.05
Rate for Payer: Aetna Medicare	$683.10
Rate for Payer: BCBS MT CHIP	$683.10
Rate for Payer: BCBS MT Closed Plan Network	$721.05
Rate for Payer: BCBS MT HealthLink	$683.10
Rate for Payer: BCBS MT Medicare	$683.10
Rate for Payer: BCBS MT POS	$721.05
Rate for Payer: BCBS MT Traditional	$759.00
Rate for Payer: Cash Price	$683.10
Rate for Payer: Cigna Commercial	$721.05
Rate for Payer: Cigna Medicare	$683.10
Rate for Payer: Medicaid All Medicaid	$698.28
Rate for Payer: Medicare All Medicare	$531.30
Rate for Payer: Monida Allegiance	$721.05
Rate for Payer: Monida First Choice Health	$736.23
Rate for Payer: Monida Montana Health Co-op	$721.05
Rate for Payer: Monida PacificSource	$721.05

PRO FEE DRAIN ABSCESS, CYST DENTO 41800

Professional

Both

$63.00

Service Code	HCPCS 41800 AQ
Hospital Charge Code	741800
Hospital Revenue Code	981
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

PRO FEE DRAIN/INJ JOINT/BURSA W/US 20604

Professional

Both

$238.00

Service Code	HCPCS 20604
Hospital Charge Code	720604
Hospital Revenue Code	964
Min. Negotiated Rate	$166.60
Max. Negotiated Rate	$238.00
Rate for Payer: Aetna Commercial	$226.10
Rate for Payer: Aetna Medicare	$214.20
Rate for Payer: BCBS MT CHIP	$214.20
Rate for Payer: BCBS MT Closed Plan Network	$226.10
Rate for Payer: BCBS MT HealthLink	$214.20
Rate for Payer: BCBS MT Medicare	$214.20
Rate for Payer: BCBS MT POS	$226.10
Rate for Payer: BCBS MT Traditional	$238.00
Rate for Payer: Cash Price	$214.20
Rate for Payer: Cigna Commercial	$226.10
Rate for Payer: Cigna Medicare	$214.20
Rate for Payer: Medicaid All Medicaid	$218.96
Rate for Payer: Medicare All Medicare	$166.60
Rate for Payer: Monida Allegiance	$226.10
Rate for Payer: Monida First Choice Health	$230.86
Rate for Payer: Monida Montana Health Co-op	$226.10
Rate for Payer: Monida PacificSource	$226.10

PROFEE ECHO BUBBLE STUDY

Professional

Both

$264.00

Service Code	HCPCS 93306 26
Hospital Charge Code	50002391
Hospital Revenue Code	972
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$256.08
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Medicaid All Medicaid	$242.88
Rate for Payer: Medicare All Medicare	$184.80
Rate for Payer: Monida Allegiance	$250.80
Rate for Payer: Monida First Choice Health	$256.08
Rate for Payer: Monida Montana Health Co-op	$250.80
Rate for Payer: Monida PacificSource	$250.80

PROFEE ECHO COMPLETE

Professional

Both

$264.00

Service Code	HCPCS 93306 26
Hospital Charge Code	50002392
Hospital Revenue Code	972
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$256.08
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Medicaid All Medicaid	$242.88
Rate for Payer: Medicare All Medicare	$184.80
Rate for Payer: Monida Allegiance	$250.80
Rate for Payer: Monida First Choice Health	$256.08
Rate for Payer: Monida Montana Health Co-op	$250.80
Rate for Payer: Monida PacificSource	$250.80

PROFEE ECHO EXAM OF FETAL HEART

Professional

Both

$304.00

Service Code	HCPCS 76825 26
Hospital Charge Code	50002393
Hospital Revenue Code	972
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$294.88
Rate for Payer: Aetna Commercial	$288.80
Rate for Payer: Aetna Medicare	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Medicaid All Medicaid	$279.68
Rate for Payer: Medicare All Medicare	$212.80
Rate for Payer: Monida Allegiance	$288.80
Rate for Payer: Monida First Choice Health	$294.88
Rate for Payer: Monida Montana Health Co-op	$288.80
Rate for Payer: Monida PacificSource	$288.80

PROFEE ECHO EXAM UTERUS

Professional

Both

$133.00

Service Code	HCPCS 76831 26
Hospital Charge Code	50002394
Hospital Revenue Code	972
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$129.01
Rate for Payer: Aetna Commercial	$126.35
Rate for Payer: Aetna Medicare	$119.70
Rate for Payer: Cash Price	$119.70
Rate for Payer: Medicaid All Medicaid	$122.36
Rate for Payer: Medicare All Medicare	$93.10
Rate for Payer: Monida Allegiance	$126.35
Rate for Payer: Monida First Choice Health	$129.01
Rate for Payer: Monida Montana Health Co-op	$126.35
Rate for Payer: Monida PacificSource	$126.35

PROFEE ECHO LIMITED

Professional

Both

$95.00

Service Code	HCPCS 93308 26
Hospital Charge Code	50002395
Hospital Revenue Code	972
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$92.15
Rate for Payer: Aetna Commercial	$90.25
Rate for Payer: Aetna Medicare	$85.50
Rate for Payer: Cash Price	$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

Know your out-of-pocket cost for care.

All Charges