Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE US TCD EMBOLI DETECT W/O INJ

Professional

Both

$226.00

Service Code	HCPCS 93892 26
Hospital Charge Code	50002436
Hospital Revenue Code	972
Min. Negotiated Rate	$158.20
Max. Negotiated Rate	$219.22
Rate for Payer: Aetna Commercial	$214.70
Rate for Payer: Aetna Medicare	$203.40
Rate for Payer: Cash Price	$203.40
Rate for Payer: Medicaid All Medicaid	$207.92
Rate for Payer: Medicare All Medicare	$158.20
Rate for Payer: Monida Allegiance	$214.70
Rate for Payer: Monida First Choice Health	$219.22
Rate for Payer: Monida Montana Health Co-op	$214.70
Rate for Payer: Monida PacificSource	$214.70

PROFEE US TESTICULAR SCROTUM

Professional

Both

$118.00

Service Code	HCPCS 76870 26
Hospital Charge Code	50002429
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 THYROID

Professional

Both

$105.00

Service Code	HCPCS 76536 26
Hospital Charge Code	50002430
Hospital Revenue Code	972
Min. Negotiated Rate	$73.50
Max. Negotiated Rate	$101.85
Rate for Payer: Aetna Commercial	$99.75
Rate for Payer: Aetna Medicare	$94.50
Rate for Payer: Cash Price	$94.50
Rate for Payer: Medicaid All Medicaid	$96.60
Rate for Payer: Medicare All Medicare	$73.50
Rate for Payer: Monida Allegiance	$99.75
Rate for Payer: Monida First Choice Health	$101.85
Rate for Payer: Monida Montana Health Co-op	$99.75
Rate for Payer: Monida PacificSource	$99.75

PROFEE US TO DETERMINE LENGTH FROM CORN

Professional

Both

$88.00

Service Code	HCPCS 76516 26
Hospital Charge Code	50002431
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 TRANSVAGINAL US NON-OB

Professional

Both

$128.00

Service Code	HCPCS 76830 26
Hospital Charge Code	50002437
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 TRANSVAGINAL US OBSTETRIC

Professional

Both

$139.00

Service Code	HCPCS 76817 26
Hospital Charge Code	50002438
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 TRANS VAG LMT

Professional

Both

$91.00

Service Code	HCPCS 76857 26
Hospital Charge Code	50002432
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 UMBILICAL CORD OCCLUD W/US

Professional

Both

$289.00

Service Code	HCPCS 59072 26
Hospital Charge Code	50002401
Hospital Revenue Code	972
Min. Negotiated Rate	$202.30
Max. Negotiated Rate	$280.33
Rate for Payer: Aetna Commercial	$274.55
Rate for Payer: Aetna Medicare	$260.10
Rate for Payer: Cash Price	$260.10
Rate for Payer: Medicaid All Medicaid	$265.88
Rate for Payer: Medicare All Medicare	$202.30
Rate for Payer: Monida Allegiance	$274.55
Rate for Payer: Monida First Choice Health	$280.33
Rate for Payer: Monida Montana Health Co-op	$274.55
Rate for Payer: Monida PacificSource	$274.55

PROFEE US UPPER EXT ARTERIAL DUPLEX BILA

Professional

Both

$146.00

Service Code	HCPCS 93930 26
Hospital Charge Code	50002443
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 VENOUS DOPP BILATERAL

Professional

Both

$125.00

Service Code	HCPCS 93970 26
Hospital Charge Code	50002440
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 US VENOUS DOPP SINGLE

Professional

Both

$81.00

Service Code	HCPCS 93971 26
Hospital Charge Code	50002441
Hospital Revenue Code	972
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$78.57
Rate for Payer: Aetna Commercial	$76.95
Rate for Payer: Aetna Medicare	$72.90
Rate for Payer: Cash Price	$72.90
Rate for Payer: Medicaid All Medicaid	$74.52
Rate for Payer: Medicare All Medicare	$56.70
Rate for Payer: Monida Allegiance	$76.95
Rate for Payer: Monida First Choice Health	$78.57
Rate for Payer: Monida Montana Health Co-op	$76.95
Rate for Payer: Monida PacificSource	$76.95

PROFEE VASCULAR STUDY

Professional

Both

$212.00

Service Code	HCPCS 93975 26
Hospital Charge Code	50002390
Hospital Revenue Code	972
Min. Negotiated Rate	$148.40
Max. Negotiated Rate	$205.64
Rate for Payer: Aetna Commercial	$201.40
Rate for Payer: Aetna Medicare	$190.80
Rate for Payer: Cash Price	$190.80
Rate for Payer: Medicaid All Medicaid	$195.04
Rate for Payer: Medicare All Medicare	$148.40
Rate for Payer: Monida Allegiance	$201.40
Rate for Payer: Monida First Choice Health	$205.64
Rate for Payer: Monida Montana Health Co-op	$201.40
Rate for Payer: Monida PacificSource	$201.40

PROFEE XR ABDOMEN 1 VIEW

Professional

Both

$26.00

Service Code	HCPCS 74018 26
Hospital Charge Code	50002219
Hospital Revenue Code	972
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$25.22
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

PROFEE XR ABDOMEN 2 VIEWS

Professional

Both

$32.00

Service Code	HCPCS 74019 26
Hospital Charge Code	50002220
Hospital Revenue Code	972
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$31.04
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

PROFEE XR ABDOMEN ACUTE

Professional

Both

$45.00

Service Code	HCPCS 74022 26
Hospital Charge Code	50002221
Hospital Revenue Code	972
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

PROFEE XR AC JOINTS W WO WEIGHTS

Professional

Both

$27.00

Service Code	HCPCS 73050 26
Hospital Charge Code	50002222
Hospital Revenue Code	972
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$26.19
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

PROFEE XR ANKLE 2 VIEWS BILATERAL

Professional

Both

$23.00

Service Code	HCPCS 73600 26
Hospital Charge Code	50002223
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR ANKLE 3 VIEWS BILATERAL

Professional

Both

$25.00

Service Code	HCPCS 73610 26
Hospital Charge Code	50002224
Hospital Revenue Code	972
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$24.25
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

PROFEE XR ANKLE LT 1 VIEW

Professional

Both

$23.00

Service Code	HCPCS 73600 26
Hospital Charge Code	50002225
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR ANKLE LT 2 VIEWS

Professional

Both

$23.00

Service Code	HCPCS 73600 26
Hospital Charge Code	50002226
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR ANKLE LT 3 VIEWS

Professional

Both

$25.00

Service Code	HCPCS 73610 26
Hospital Charge Code	50002227
Hospital Revenue Code	972
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$24.25
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

PROFEE XR ANKLE RT 1 VIEW

Professional

Both

$23.00

Service Code	HCPCS 73600 26
Hospital Charge Code	50002228
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR ANKLE RT 2 VIEWS

Professional

Both

$23.00

Service Code	HCPCS 73600 26
Hospital Charge Code	50002229
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR ANKLE RT 3 VIEWS

Professional

Both

$25.00

Service Code	HCPCS 73610 26
Hospital Charge Code	50002230
Hospital Revenue Code	972
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$24.25
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

PROFEE XR BALL CATCHERS

Professional

Both

$24.00

Service Code	HCPCS 73120 26
Hospital Charge Code	50002231
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

Know your out-of-pocket cost for care.

All Charges