Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE US EXAM OF EYE THICKNESS

Professional

Both

$30.00

Service Code	HCPCS 76514 26
Hospital Charge Code	50002406
Hospital Revenue Code	972
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$29.10
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

PROFEE US GI ENDOSCOPIC ULTRASOUND

Professional

Both

$133.00

Service Code	HCPCS 76975 26
Hospital Charge Code	50002402
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 US INTRACRANIAL LIMITED STUDY

Professional

Both

$139.00

Service Code	HCPCS 93888 26
Hospital Charge Code	50002435
Hospital Revenue Code	972
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$134.83
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: Aetna Medicare	$125.10
Rate for Payer: Cash Price	$125.10
Rate for Payer: Medicaid All Medicaid	$127.88
Rate for Payer: Medicare All Medicare	$97.30
Rate for Payer: Monida Allegiance	$132.05
Rate for Payer: Monida First Choice Health	$134.83
Rate for Payer: Monida Montana Health Co-op	$132.05
Rate for Payer: Monida PacificSource	$132.05

PROFEE US LOWER EXTR STUDY UNILATERAL

Professional

Both

$87.00

Service Code	HCPCS 93926 26
Hospital Charge Code	50002404
Hospital Revenue Code	972
Min. Negotiated Rate	$60.90
Max. Negotiated Rate	$84.39
Rate for Payer: Aetna Commercial	$82.65
Rate for Payer: Aetna Medicare	$78.30
Rate for Payer: Cash Price	$78.30
Rate for Payer: Medicaid All Medicaid	$80.04
Rate for Payer: Medicare All Medicare	$60.90
Rate for Payer: Monida Allegiance	$82.65
Rate for Payer: Monida First Choice Health	$84.39
Rate for Payer: Monida Montana Health Co-op	$82.65
Rate for Payer: Monida PacificSource	$82.65

PROFEE US LOWER EXT STUDY BILATERAL

Professional

Both

$144.00

Service Code	HCPCS 93925 26
Hospital Charge Code	50002403
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 US NTRACRANIAL COMPLETE STUDY

Professional

Both

$175.00

Service Code	HCPCS 93886 26
Hospital Charge Code	50002434
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 US OF BONE DENSITY MEASUREMENT

Professional

Both

$8.00

Service Code	HCPCS 76977 26
Hospital Charge Code	50002405
Hospital Revenue Code	972
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$7.76
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: Cash Price	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

PROFEE US OF EYE DISEASE OR GROWTH

Professional

Both

$138.00

Service Code	HCPCS 76511 26
Hospital Charge Code	50002407
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 US OF EYE FORGN BODY LOCALIZATION

Professional

Both

$122.00

Service Code	HCPCS 76529 26
Hospital Charge Code	50002410
Hospital Revenue Code	972
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$118.34
Rate for Payer: Aetna Commercial	$115.90
Rate for Payer: Aetna Medicare	$109.80
Rate for Payer: Cash Price	$109.80
Rate for Payer: Medicaid All Medicaid	$112.24
Rate for Payer: Medicare All Medicare	$85.40
Rate for Payer: Monida Allegiance	$115.90
Rate for Payer: Monida First Choice Health	$118.34
Rate for Payer: Monida Montana Health Co-op	$115.90
Rate for Payer: Monida PacificSource	$115.90

PROFEE US OF EYE TISSUE AND STRUCTURES

Professional

Both

$88.00

Service Code	HCPCS 76516 26
Hospital Charge Code	50002411
Hospital Revenue Code	972
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$85.36
Rate for Payer: Aetna Commercial	$83.60
Rate for Payer: Aetna Medicare	$79.20
Rate for Payer: Cash Price	$79.20
Rate for Payer: Medicaid All Medicaid	$80.96
Rate for Payer: Medicare All Medicare	$61.60
Rate for Payer: Monida Allegiance	$83.60
Rate for Payer: Monida First Choice Health	$85.36
Rate for Payer: Monida Montana Health Co-op	$83.60
Rate for Payer: Monida PacificSource	$83.60

PROFEE US OF EYE USING WATER BATH METHOD

Professional

Both

$126.00

Service Code	HCPCS 76513 26
Hospital Charge Code	50002412
Hospital Revenue Code	972
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$122.22
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: Aetna Medicare	$113.40
Rate for Payer: Cash Price	$113.40
Rate for Payer: Medicaid All Medicaid	$115.92
Rate for Payer: Medicare All Medicare	$88.20
Rate for Payer: Monida Allegiance	$119.70
Rate for Payer: Monida First Choice Health	$122.22
Rate for Payer: Monida Montana Health Co-op	$119.70
Rate for Payer: Monida PacificSource	$119.70

PROFEE US OF FETAL BRAIN ARTERY

Professional

Both

$129.00

Service Code	HCPCS 76821 26
Hospital Charge Code	50002413
Hospital Revenue Code	972
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$125.13
Rate for Payer: Aetna Commercial	$122.55
Rate for Payer: Aetna Medicare	$116.10
Rate for Payer: Cash Price	$116.10
Rate for Payer: Medicaid All Medicaid	$118.68
Rate for Payer: Medicare All Medicare	$90.30
Rate for Payer: Monida Allegiance	$122.55
Rate for Payer: Monida First Choice Health	$125.13
Rate for Payer: Monida Montana Health Co-op	$122.55
Rate for Payer: Monida PacificSource	$122.55

PROFEE US OF FETAL UMBILICAL ARTERY FLO

Professional

Both

$91.00

Service Code	HCPCS 76820 26
Hospital Charge Code	50002414
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 OF HIPS, INFANT

Professional

Both

$115.00

Service Code	HCPCS 76886 26
Hospital Charge Code	50002415
Hospital Revenue Code	972
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$111.55
Rate for Payer: Aetna Commercial	$109.25
Rate for Payer: Aetna Medicare	$103.50
Rate for Payer: Cash Price	$103.50
Rate for Payer: Medicaid All Medicaid	$105.80
Rate for Payer: Medicare All Medicare	$80.50
Rate for Payer: Monida Allegiance	$109.25
Rate for Payer: Monida First Choice Health	$111.55
Rate for Payer: Monida Montana Health Co-op	$109.25
Rate for Payer: Monida PacificSource	$109.25

PROFEE US OPH DX B-SCAN

Professional

Both

$118.00

Service Code	HCPCS 76512 26
Hospital Charge Code	50002408
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

PROFEE US PELVIC COMP NON OB

Professional

Both

$127.00

Service Code	HCPCS 76856 26
Hospital Charge Code	50002416
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 PELVIC LMT NON OB

Professional

Both

$91.00

Service Code	HCPCS 76857 26
Hospital Charge Code	50002418
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 PELVIS BUNDLED

Professional

Both

$127.00

Service Code	HCPCS 76856 26
Hospital Charge Code	50002417
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 POST VOID RESIDUAL

Professional

Both

$47.00

Service Code	HCPCS 51798 26
Hospital Charge Code	50002419
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 RETROPERITONEAL COMP RENALS

Professional

Both

$136.00

Service Code	HCPCS 76770 26
Hospital Charge Code	50002421
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

PROFEE US RETROPERITONEAL LMT AORTA

Professional

Both

$107.00

Service Code	HCPCS 76775 26
Hospital Charge Code	50002422
Hospital Revenue Code	972
Min. Negotiated Rate	$74.90
Max. Negotiated Rate	$103.79
Rate for Payer: Aetna Commercial	$101.65
Rate for Payer: Aetna Medicare	$96.30
Rate for Payer: Cash Price	$96.30
Rate for Payer: Medicaid All Medicaid	$98.44
Rate for Payer: Medicare All Medicare	$74.90
Rate for Payer: Monida Allegiance	$101.65
Rate for Payer: Monida First Choice Health	$103.79
Rate for Payer: Monida Montana Health Co-op	$101.65
Rate for Payer: Monida PacificSource	$101.65

PROFEE US SOFT TISSUE ABDOMEN

Professional

Both

$108.00

Service Code	HCPCS 76705 26
Hospital Charge Code	50002423
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 SOFT TISSUE CHEST

Professional

Both

$106.00

Service Code	HCPCS 76604 26
Hospital Charge Code	50002424
Hospital Revenue Code	972
Min. Negotiated Rate	$74.20
Max. Negotiated Rate	$102.82
Rate for Payer: Aetna Commercial	$100.70
Rate for Payer: Aetna Medicare	$95.40
Rate for Payer: Cash Price	$95.40
Rate for Payer: Medicaid All Medicaid	$97.52
Rate for Payer: Medicare All Medicare	$74.20
Rate for Payer: Monida Allegiance	$100.70
Rate for Payer: Monida First Choice Health	$102.82
Rate for Payer: Monida Montana Health Co-op	$100.70
Rate for Payer: Monida PacificSource	$100.70

PROFEE US SOFT TISSUE EXTREMITY LMT

Professional

Both

$128.00

Service Code	HCPCS 76882 26
Hospital Charge Code	50002425
Hospital Revenue Code	972
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$124.16
Rate for Payer: Aetna Commercial	$121.60
Rate for Payer: Aetna Medicare	$115.20
Rate for Payer: Cash Price	$115.20
Rate for Payer: Medicaid All Medicaid	$117.76
Rate for Payer: Medicare All Medicare	$89.60
Rate for Payer: Monida Allegiance	$121.60
Rate for Payer: Monida First Choice Health	$124.16
Rate for Payer: Monida Montana Health Co-op	$121.60
Rate for Payer: Monida PacificSource	$121.60

PROFEE US SOFT TISSUE PELVIS

Professional

Both

$91.00

Service Code	HCPCS 76857 26
Hospital Charge Code	50002426
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

Know your out-of-pocket cost for care.

All Charges