Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PRO FEE TRIG PT INJ 1-2 GRPS 20552(SIJ)

Professional

Both

$187.00

Service Code	HCPCS 20552
Hospital Charge Code	720552
Hospital Revenue Code	964
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$187.00
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: BCBS MT CHIP	$168.30
Rate for Payer: BCBS MT Closed Plan Network	$177.65
Rate for Payer: BCBS MT HealthLink	$168.30
Rate for Payer: BCBS MT Medicare	$168.30
Rate for Payer: BCBS MT POS	$177.65
Rate for Payer: BCBS MT Traditional	$187.00
Rate for Payer: Cash Price	$168.30
Rate for Payer: Cigna Commercial	$177.65
Rate for Payer: Cigna Medicare	$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 US 3D REND W/INTERP&POSTPRC DIFF

Professional

Both

$110.00

Service Code	HCPCS 76377 26
Hospital Charge Code	50002371
Hospital Revenue Code	972
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$106.70
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

PROFEE US 3D REND W/INTERPRET POST PROCE

Professional

Both

$29.00

Service Code	HCPCS 76376 26
Hospital Charge Code	50002372
Hospital Revenue Code	972
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$28.13
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: Cash Price	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

PROFEE US ABD AORTA REAL TME SCREEN STUD

Professional

Both

$101.00

Service Code	HCPCS 76706 26
Hospital Charge Code	50002376
Hospital Revenue Code	972
Min. Negotiated Rate	$70.70
Max. Negotiated Rate	$97.97
Rate for Payer: Aetna Commercial	$95.95
Rate for Payer: Aetna Medicare	$90.90
Rate for Payer: Cash Price	$90.90
Rate for Payer: Medicaid All Medicaid	$92.92
Rate for Payer: Medicare All Medicare	$70.70
Rate for Payer: Monida Allegiance	$95.95
Rate for Payer: Monida First Choice Health	$97.97
Rate for Payer: Monida Montana Health Co-op	$95.95
Rate for Payer: Monida PacificSource	$95.95

PROFEE US ABDOMEN COMPLETE

Professional

Both

$149.00

Service Code	HCPCS 76700 26
Hospital Charge Code	50002373
Hospital Revenue Code	972
Min. Negotiated Rate	$104.30
Max. Negotiated Rate	$144.53
Rate for Payer: Aetna Commercial	$141.55
Rate for Payer: Aetna Medicare	$134.10
Rate for Payer: Cash Price	$134.10
Rate for Payer: Medicaid All Medicaid	$137.08
Rate for Payer: Medicare All Medicare	$104.30
Rate for Payer: Monida Allegiance	$141.55
Rate for Payer: Monida First Choice Health	$144.53
Rate for Payer: Monida Montana Health Co-op	$141.55
Rate for Payer: Monida PacificSource	$141.55

PROFEE US ABDOMEN DOPP LMT

Professional

Both

$146.00

Service Code	HCPCS 93976 26
Hospital Charge Code	50002374
Hospital Revenue Code	972
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$141.62
Rate for Payer: Aetna Commercial	$138.70
Rate for Payer: Aetna Medicare	$131.40
Rate for Payer: Cash Price	$131.40
Rate for Payer: Medicaid All Medicaid	$134.32
Rate for Payer: Medicare All Medicare	$102.20
Rate for Payer: Monida Allegiance	$138.70
Rate for Payer: Monida First Choice Health	$141.62
Rate for Payer: Monida Montana Health Co-op	$138.70
Rate for Payer: Monida PacificSource	$138.70

PROFEE US ABDOMEN LIMITED

Professional

Both

$108.00

Service Code	HCPCS 76705 26
Hospital Charge Code	50002375
Hospital Revenue Code	972
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$104.76
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Aetna Medicare	$97.20
Rate for Payer: Cash Price	$97.20
Rate for Payer: Medicaid All Medicaid	$99.36
Rate for Payer: Medicare All Medicare	$75.60
Rate for Payer: Monida Allegiance	$102.60
Rate for Payer: Monida First Choice Health	$104.76
Rate for Payer: Monida Montana Health Co-op	$102.60
Rate for Payer: Monida PacificSource	$102.60

PROFEE US ABI

Professional

Both

$46.00

Service Code	HCPCS 93922 26
Hospital Charge Code	50002377
Hospital Revenue Code	972
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$44.62
Rate for Payer: Aetna Commercial	$43.70
Rate for Payer: Aetna Medicare	$41.40
Rate for Payer: Cash Price	$41.40
Rate for Payer: Medicaid All Medicaid	$42.32
Rate for Payer: Medicare All Medicare	$32.20
Rate for Payer: Monida Allegiance	$43.70
Rate for Payer: Monida First Choice Health	$44.62
Rate for Payer: Monida Montana Health Co-op	$43.70
Rate for Payer: Monida PacificSource	$43.70

PROFEE US ABSCESS DRAINAGE

Professional

Both

$104.00

Service Code	HCPCS 75989 26
Hospital Charge Code	50002420
Hospital Revenue Code	972
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$100.88
Rate for Payer: Aetna Commercial	$98.80
Rate for Payer: Aetna Medicare	$93.60
Rate for Payer: Cash Price	$93.60
Rate for Payer: Medicaid All Medicaid	$95.68
Rate for Payer: Medicare All Medicare	$72.80
Rate for Payer: Monida Allegiance	$98.80
Rate for Payer: Monida First Choice Health	$100.88
Rate for Payer: Monida Montana Health Co-op	$98.80
Rate for Payer: Monida PacificSource	$98.80

PROFEE US AORTA SCREEN/MC

Professional

Both

$90.00

Service Code	HCPCS 93979 26
Hospital Charge Code	50002378
Hospital Revenue Code	972
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

PROFEE US ARTERY BYPASS GRAFT

Professional

Both

$90.00

Service Code	HCPCS 93979 26
Hospital Charge Code	50002379
Hospital Revenue Code	972
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

PROFEE US BLADDER PRE/POST

Professional

Both

$91.00

Service Code	HCPCS 76857 26
Hospital Charge Code	50002380
Hospital Revenue Code	972
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$88.27
Rate for Payer: Aetna Commercial	$86.45
Rate for Payer: Aetna Medicare	$81.90
Rate for Payer: Cash Price	$81.90
Rate for Payer: Medicaid All Medicaid	$83.72
Rate for Payer: Medicare All Medicare	$63.70
Rate for Payer: Monida Allegiance	$86.45
Rate for Payer: Monida First Choice Health	$88.27
Rate for Payer: Monida Montana Health Co-op	$86.45
Rate for Payer: Monida PacificSource	$86.45

PROFEE US BLADDER SCANNER POST

Professional

Both

$47.00

Service Code	HCPCS 51798 26
Hospital Charge Code	50002381
Hospital Revenue Code	972
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$45.59
Rate for Payer: Aetna Commercial	$44.65
Rate for Payer: Aetna Medicare	$42.30
Rate for Payer: Cash Price	$42.30
Rate for Payer: Medicaid All Medicaid	$43.24
Rate for Payer: Medicare All Medicare	$32.90
Rate for Payer: Monida Allegiance	$44.65
Rate for Payer: Monida First Choice Health	$45.59
Rate for Payer: Monida Montana Health Co-op	$44.65
Rate for Payer: Monida PacificSource	$44.65

PROFEE US BREAST

Professional

Both

$136.00

Service Code	HCPCS 76641 26
Hospital Charge Code	50002382
Hospital Revenue Code	972
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$131.92
Rate for Payer: Aetna Commercial	$129.20
Rate for Payer: Aetna Medicare	$122.40
Rate for Payer: Cash Price	$122.40
Rate for Payer: Medicaid All Medicaid	$125.12
Rate for Payer: Medicare All Medicare	$95.20
Rate for Payer: Monida Allegiance	$129.20
Rate for Payer: Monida First Choice Health	$131.92
Rate for Payer: Monida Montana Health Co-op	$129.20
Rate for Payer: Monida PacificSource	$129.20

PROFEEUS BRST UNI REAL TIME W IMAGE LIMT

Professional

Both

$127.00

Service Code	HCPCS 76642 26
Hospital Charge Code	50002383
Hospital Revenue Code	972
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$123.19
Rate for Payer: Aetna Commercial	$120.65
Rate for Payer: Aetna Medicare	$114.30
Rate for Payer: Cash Price	$114.30
Rate for Payer: Medicaid All Medicaid	$116.84
Rate for Payer: Medicare All Medicare	$88.90
Rate for Payer: Monida Allegiance	$120.65
Rate for Payer: Monida First Choice Health	$123.19
Rate for Payer: Monida Montana Health Co-op	$120.65
Rate for Payer: Monida PacificSource	$120.65

PROFEE US CAROTID BILATERAL

Professional

Both

$146.00

Service Code	HCPCS 93880 26
Hospital Charge Code	50002384
Hospital Revenue Code	972
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$141.62
Rate for Payer: Aetna Commercial	$138.70
Rate for Payer: Aetna Medicare	$131.40
Rate for Payer: Cash Price	$131.40
Rate for Payer: Medicaid All Medicaid	$134.32
Rate for Payer: Medicare All Medicare	$102.20
Rate for Payer: Monida Allegiance	$138.70
Rate for Payer: Monida First Choice Health	$141.62
Rate for Payer: Monida Montana Health Co-op	$138.70
Rate for Payer: Monida PacificSource	$138.70

PROFEE US CAROTID UNILATERAL

Professional

Both

$90.00

Service Code	HCPCS 93882 26
Hospital Charge Code	50002385
Hospital Revenue Code	972
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

PROFEE US COMPL JOINT R-T W/IMAGE DOC

Professional

Both

$167.00

Service Code	HCPCS 76881 26
Hospital Charge Code	50002386
Hospital Revenue Code	972
Min. Negotiated Rate	$116.90
Max. Negotiated Rate	$161.99
Rate for Payer: Aetna Commercial	$158.65
Rate for Payer: Aetna Medicare	$150.30
Rate for Payer: Cash Price	$150.30
Rate for Payer: Medicaid All Medicaid	$153.64
Rate for Payer: Medicare All Medicare	$116.90
Rate for Payer: Monida Allegiance	$158.65
Rate for Payer: Monida First Choice Health	$161.99
Rate for Payer: Monida Montana Health Co-op	$158.65
Rate for Payer: Monida PacificSource	$158.65

PROFEE US COMP TTHRC ECHO CONGENI CARD A

Professional

Both

$235.00

Service Code	HCPCS 93303 26
Hospital Charge Code	50002387
Hospital Revenue Code	972
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$227.95
Rate for Payer: Aetna Commercial	$223.25
Rate for Payer: Aetna Medicare	$211.50
Rate for Payer: Cash Price	$211.50
Rate for Payer: Medicaid All Medicaid	$216.20
Rate for Payer: Medicare All Medicare	$164.50
Rate for Payer: Monida Allegiance	$223.25
Rate for Payer: Monida First Choice Health	$227.95
Rate for Payer: Monida Montana Health Co-op	$223.25
Rate for Payer: Monida PacificSource	$223.25

PROFEE US DOPPLER COLOR FLOW ADD-ON

Professional

Both

$12.00

Service Code	HCPCS 93325 26
Hospital Charge Code	50002389
Hospital Revenue Code	972
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$11.64
Rate for Payer: Aetna Commercial	$11.40
Rate for Payer: Aetna Medicare	$10.80
Rate for Payer: Cash Price	$10.80
Rate for Payer: Medicaid All Medicaid	$11.04
Rate for Payer: Medicare All Medicare	$8.40
Rate for Payer: Monida Allegiance	$11.40
Rate for Payer: Monida First Choice Health	$11.64
Rate for Payer: Monida Montana Health Co-op	$11.40
Rate for Payer: Monida PacificSource	$11.40

PROFEE US ELASTOGRAPHY 1ST TARGET LESION

Professional

Both

$110.00

Service Code	HCPCS 76982 26
Hospital Charge Code	50002398
Hospital Revenue Code	972
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$106.70
Rate for Payer: Aetna Commercial	$104.50
Rate for Payer: Aetna Medicare	$99.00
Rate for Payer: Cash Price	$99.00
Rate for Payer: Medicaid All Medicaid	$101.20
Rate for Payer: Medicare All Medicare	$77.00
Rate for Payer: Monida Allegiance	$104.50
Rate for Payer: Monida First Choice Health	$106.70
Rate for Payer: Monida Montana Health Co-op	$104.50
Rate for Payer: Monida PacificSource	$104.50

PROFEE US ELASTOGRAPHY EA ADDL TAGET LE

Professional

Both

$90.00

Service Code	HCPCS 76983 26
Hospital Charge Code	50002397
Hospital Revenue Code	972
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$87.30
Rate for Payer: Aetna Commercial	$85.50
Rate for Payer: Aetna Medicare	$81.00
Rate for Payer: Cash Price	$81.00
Rate for Payer: Medicaid All Medicaid	$82.80
Rate for Payer: Medicare All Medicare	$63.00
Rate for Payer: Monida Allegiance	$85.50
Rate for Payer: Monida First Choice Health	$87.30
Rate for Payer: Monida Montana Health Co-op	$85.50
Rate for Payer: Monida PacificSource	$85.50

PROFEE US ELASTOGRAPHY OF ORGAN TISSUE

Professional

Both

$111.00

Service Code	HCPCS 76981 26
Hospital Charge Code	50002399
Hospital Revenue Code	972
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$107.67
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: Cash Price	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

PROFEE US EXAM K TRANSPL W/DOPPLER

Professional

Both

$140.00

Service Code	HCPCS 76776 26
Hospital Charge Code	50002439
Hospital Revenue Code	972
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$135.80
Rate for Payer: Aetna Commercial	$133.00
Rate for Payer: Aetna Medicare	$126.00
Rate for Payer: Cash Price	$126.00
Rate for Payer: Medicaid All Medicaid	$128.80
Rate for Payer: Medicare All Medicare	$98.00
Rate for Payer: Monida Allegiance	$133.00
Rate for Payer: Monida First Choice Health	$135.80
Rate for Payer: Monida Montana Health Co-op	$133.00
Rate for Payer: Monida PacificSource	$133.00

PROFEE US EXAM OF EYE

Professional

Both

$118.00

Service Code	HCPCS 76519 26
Hospital Charge Code	50002409
Hospital Revenue Code	972
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$114.46
Rate for Payer: Aetna Commercial	$112.10
Rate for Payer: Aetna Medicare	$106.20
Rate for Payer: Cash Price	$106.20
Rate for Payer: Medicaid All Medicaid	$108.56
Rate for Payer: Medicare All Medicare	$82.60
Rate for Payer: Monida Allegiance	$112.10
Rate for Payer: Monida First Choice Health	$114.46
Rate for Payer: Monida Montana Health Co-op	$112.10
Rate for Payer: Monida PacificSource	$112.10

Know your out-of-pocket cost for care.

All Charges