Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE MR KNEE LT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73722 26
Hospital Charge Code	50002162
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 KNEE LT WO CONTRAST

Professional

Both

$191.00

Service Code	HCPCS 73721 26
Hospital Charge Code	50002164
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 KNEE LT W WO CONTRAST

Professional

Both

$306.00

Service Code	HCPCS 73723 26
Hospital Charge Code	50002163
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 KNEE RT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73722 26
Hospital Charge Code	50002165
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 KNEE RT WO CONTRAST

Professional

Both

$191.00

Service Code	HCPCS 73721 26
Hospital Charge Code	50002167
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 KNEE RT W WO CONTRAST

Professional

Both

$306.00

Service Code	HCPCS 73723 26
Hospital Charge Code	50002166
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 LUMBAR SPINE W CONTRAST

Professional

Both

$254.00

Service Code	HCPCS 72149 26
Hospital Charge Code	50002168
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 LUMBAR SPINE WO CONTRAST

Professional

Both

$209.00

Service Code	HCPCS 72148 26
Hospital Charge Code	50002170
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 LUMBAR SPINE W WO CONTRAST

Professional

Both

$326.00

Service Code	HCPCS 72158 26
Hospital Charge Code	50002169
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 LWR EXT W CON LT

Professional

Both

$228.00

Service Code	HCPCS 73719 26
Hospital Charge Code	50002171
Hospital Revenue Code	972
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$221.16
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

PROFEE MR LWR EXT W CON RT

Professional

Both

$228.00

Service Code	HCPCS 73719 26
Hospital Charge Code	50002172
Hospital Revenue Code	972
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$221.16
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

PROFEE MR LWR XT WO CON LT

Professional

Both

$190.00

Service Code	HCPCS 73718 26
Hospital Charge Code	50002173
Hospital Revenue Code	972
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$184.30
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

PROFEE MR LWR XT WO CON RT

Professional

Both

$190.00

Service Code	HCPCS 73718 26
Hospital Charge Code	50002174
Hospital Revenue Code	972
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$184.30
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

PROFEE MR LWR XT WO&W CON LT

Professional

Both

$306.00

Service Code	HCPCS 73720 26
Hospital Charge Code	50002175
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 LWR XT WO&W CON RT

Professional

Both

$306.00

Service Code	HCPCS 73720 26
Hospital Charge Code	50002176
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 ORBIT FACE NECK W CONTRAST

Professional

Both

$228.00

Service Code	HCPCS 70542 26
Hospital Charge Code	50002177
Hospital Revenue Code	972
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$221.16
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

PROFEE MR ORBIT FACE NECK WO CONTRAST

Professional

Both

$189.00

Service Code	HCPCS 70540 26
Hospital Charge Code	50002179
Hospital Revenue Code	972
Min. Negotiated Rate	$132.30
Max. Negotiated Rate	$183.33
Rate for Payer: Aetna Commercial	$179.55
Rate for Payer: Aetna Medicare	$170.10
Rate for Payer: Cash Price	$170.10
Rate for Payer: Medicaid All Medicaid	$173.88
Rate for Payer: Medicare All Medicare	$132.30
Rate for Payer: Monida Allegiance	$179.55
Rate for Payer: Monida First Choice Health	$183.33
Rate for Payer: Monida Montana Health Co-op	$179.55
Rate for Payer: Monida PacificSource	$179.55

PROFEE MR ORBIT FACE NECK W WO CONTRAST

Professional

Both

$305.00

Service Code	HCPCS 70543 26
Hospital Charge Code	50002178
Hospital Revenue Code	972
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$295.85
Rate for Payer: Aetna Commercial	$289.75
Rate for Payer: Aetna Medicare	$274.50
Rate for Payer: Cash Price	$274.50
Rate for Payer: Medicaid All Medicaid	$280.60
Rate for Payer: Medicare All Medicare	$213.50
Rate for Payer: Monida Allegiance	$289.75
Rate for Payer: Monida First Choice Health	$295.85
Rate for Payer: Monida Montana Health Co-op	$289.75
Rate for Payer: Monida PacificSource	$289.75

PROFEE MR PELVIS W CONTRAST

Professional

Both

$243.00

Service Code	HCPCS 72196 26
Hospital Charge Code	50002180
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 PELVIS WO CONTRAST

Professional

Both

$206.00

Service Code	HCPCS 72195 26
Hospital Charge Code	50002182
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 PELVIS W WO CONTRAST

Professional

Both

$312.00

Service Code	HCPCS 72197 26
Hospital Charge Code	50002181
Hospital Revenue Code	972
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$302.64
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

PROFEE MR SHOULDER LT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73222 26
Hospital Charge Code	50002183
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 SHOULDER LT WO CONTRAST

Professional

Both

$191.00

Service Code	HCPCS 73221 26
Hospital Charge Code	50002185
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 SHOULDER LT W WO CONTRAST

Professional

Both

$306.00

Service Code	HCPCS 73223 26
Hospital Charge Code	50002184
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 SHOULDER RT W CONTRAST

Professional

Both

$229.00

Service Code	HCPCS 73222 26
Hospital Charge Code	50002186
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