Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE MRA HEAD WO CONTRAST

Professional

Both

$168.00

Service Code	HCPCS 70544 26
Hospital Charge Code	50002215
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 MRA HEAD W WO CONTRAST

Professional

Both

$208.00

Service Code	HCPCS 70546 26
Hospital Charge Code	50002214
Hospital Revenue Code	972
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$201.76
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: Cash Price	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

PROFEE MRA NECK W CONTRAST

Professional

Both

$211.00

Service Code	HCPCS 70548 26
Hospital Charge Code	50002216
Hospital Revenue Code	972
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$204.67
Rate for Payer: Aetna Commercial	$200.45
Rate for Payer: Aetna Medicare	$189.90
Rate for Payer: Cash Price	$189.90
Rate for Payer: Medicaid All Medicaid	$194.12
Rate for Payer: Medicare All Medicare	$147.70
Rate for Payer: Monida Allegiance	$200.45
Rate for Payer: Monida First Choice Health	$204.67
Rate for Payer: Monida Montana Health Co-op	$200.45
Rate for Payer: Monida PacificSource	$200.45

PROFEE MRA NECK WO CONTRAST

Professional

Both

$169.00

Service Code	HCPCS 70547 SD
Hospital Charge Code	50002218
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

PROFEE MRA NECK W WO CONTRAST

Professional

Both

$254.00

Service Code	HCPCS 70549 26
Hospital Charge Code	50002217
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 MR ANKLE LT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73722 26
Hospital Charge Code	50002093
Hospital Revenue Code	972
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$222.13
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: Cash Price	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

PROFEE MR ANKLE LT WO CONTRAST

Professional

Both

$191.00

Service Code	HCPCS 73721 26
Hospital Charge Code	50002095
Hospital Revenue Code	972
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$185.27
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: Cash Price	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

PROFEE MR ANKLE LT W WO CONTRAST

Professional

Both

$306.00

Service Code	HCPCS 73723 26
Hospital Charge Code	50002094
Hospital Revenue Code	972
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$296.82
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: Cash Price	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

PROFEE MR ANKLE RT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73722 26
Hospital Charge Code	50002096
Hospital Revenue Code	972
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$222.13
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: Cash Price	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

PROFEE MR ANKLE RT WO CONTRAST

Professional

Both

$191.00

Service Code	HCPCS 73721 26
Hospital Charge Code	50002098
Hospital Revenue Code	972
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$185.27
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: Cash Price	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

PROFEE MR ANKLE RT W WO CONTRAST

Professional

Both

$306.00

Service Code	HCPCS 73723 26
Hospital Charge Code	50002097
Hospital Revenue Code	972
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$296.82
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: Cash Price	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

PROFEE MR BRAIN AND IAC W WO CONTRAST

Professional

Both

$325.00

Service Code	HCPCS 70553 26
Hospital Charge Code	50002445
Hospital Revenue Code	972
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$315.25
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

PROFEE MR BRAIN W CONTRAST

Professional

Both

$252.00

Service Code	HCPCS 70552 26
Hospital Charge Code	50002099
Hospital Revenue Code	972
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$244.44
Rate for Payer: Aetna Commercial	$239.40
Rate for Payer: Aetna Medicare	$226.80
Rate for Payer: Cash Price	$226.80
Rate for Payer: Medicaid All Medicaid	$231.84
Rate for Payer: Medicare All Medicare	$176.40
Rate for Payer: Monida Allegiance	$239.40
Rate for Payer: Monida First Choice Health	$244.44
Rate for Payer: Monida Montana Health Co-op	$239.40
Rate for Payer: Monida PacificSource	$239.40

PROFEE MR BRAIN WO CONTRAST

Professional

Both

$208.00

Service Code	HCPCS 70551 26
Hospital Charge Code	50002101
Hospital Revenue Code	972
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$201.76
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: Cash Price	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

PROFEE MR BRAIN W WO CONTRAST

Professional

Both

$325.00

Service Code	HCPCS 70553 26
Hospital Charge Code	50002100
Hospital Revenue Code	972
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$315.25
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

PROFEE MR CERVICAL SPINE W CONTRAST

Professional

Both

$255.00

Service Code	HCPCS 72142 26
Hospital Charge Code	50002102
Hospital Revenue Code	972
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$247.35
Rate for Payer: Aetna Commercial	$242.25
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: Medicaid All Medicaid	$234.60
Rate for Payer: Medicare All Medicare	$178.50
Rate for Payer: Monida Allegiance	$242.25
Rate for Payer: Monida First Choice Health	$247.35
Rate for Payer: Monida Montana Health Co-op	$242.25
Rate for Payer: Monida PacificSource	$242.25

PROFEE MR CERVICAL SPINE WO CONTRAST

Professional

Both

$209.00

Service Code	HCPCS 72141 26
Hospital Charge Code	50002104
Hospital Revenue Code	972
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$202.73
Rate for Payer: Aetna Commercial	$198.55
Rate for Payer: Aetna Medicare	$188.10
Rate for Payer: Cash Price	$188.10
Rate for Payer: Medicaid All Medicaid	$192.28
Rate for Payer: Medicare All Medicare	$146.30
Rate for Payer: Monida Allegiance	$198.55
Rate for Payer: Monida First Choice Health	$202.73
Rate for Payer: Monida Montana Health Co-op	$198.55
Rate for Payer: Monida PacificSource	$198.55

PROFEE MR CERVICAL SPINE W WO CONTRAST

Professional

Both

$326.00

Service Code	HCPCS 72156 26
Hospital Charge Code	50002103
Hospital Revenue Code	972
Min. Negotiated Rate	$228.20
Max. Negotiated Rate	$316.22
Rate for Payer: Aetna Commercial	$309.70
Rate for Payer: Aetna Medicare	$293.40
Rate for Payer: Cash Price	$293.40
Rate for Payer: Medicaid All Medicaid	$299.92
Rate for Payer: Medicare All Medicare	$228.20
Rate for Payer: Monida Allegiance	$309.70
Rate for Payer: Monida First Choice Health	$316.22
Rate for Payer: Monida Montana Health Co-op	$309.70
Rate for Payer: Monida PacificSource	$309.70

PROFEE MR CHEST W CONTRAST

Professional

Both

$243.00

Service Code	HCPCS 71551 26
Hospital Charge Code	50002105
Hospital Revenue Code	972
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$235.71
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: Cash Price	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

PROFEE MR CHEST WO CONTRAST

Professional

Both

$206.00

Service Code	HCPCS 71550 26
Hospital Charge Code	50002107
Hospital Revenue Code	972
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$199.82
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: Cash Price	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

PROFEE MR CHEST W WO CONTRAST

Professional

Both

$321.00

Service Code	HCPCS 71552 26
Hospital Charge Code	50002106
Hospital Revenue Code	972
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$311.37
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: Cash Price	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

PROFEE MR ELBOW LT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73222 26
Hospital Charge Code	50002108
Hospital Revenue Code	972
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$222.13
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: Cash Price	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

PROFEE MR ELBOW LT WO CONTRAST

Professional

Both

$191.00

Service Code	HCPCS 73221 26
Hospital Charge Code	50002110
Hospital Revenue Code	972
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$185.27
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: Cash Price	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

PROFEE MR ELBOW LT W WO CONTRAST

Professional

Both

$306.00

Service Code	HCPCS 73223 26
Hospital Charge Code	50002109
Hospital Revenue Code	972
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$296.82
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: Cash Price	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

PROFEE MR ELBOW RT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73222 26
Hospital Charge Code	50002111
Hospital Revenue Code	972
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$222.13
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: Cash Price	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

Know your out-of-pocket cost for care.

All Charges