Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE XR BONE AGE STUDY

Professional

Both

$26.00

Service Code	HCPCS 77072 26
Hospital Charge Code	50002232
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 BONE LENGTH STUDY

Professional

Both

$38.00

Service Code	HCPCS 77073 26
Hospital Charge Code	50002233
Hospital Revenue Code	972
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: Cash Price	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

PROFEE XR CALCANEUS BILATERAL 2 VIEWS

Professional

Both

$23.00

Service Code	HCPCS 73650 26
Hospital Charge Code	50002234
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 CALCANEUS LT 2 VIEWS

Professional

Both

$23.00

Service Code	HCPCS 73650 26
Hospital Charge Code	50002235
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 CALCANEUS RT 2 VIEWS

Professional

Both

$23.00

Service Code	HCPCS 73650 26
Hospital Charge Code	50002236
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 CERVICAL SPINE 2 TO 3 VIEWS

Professional

Both

$31.00

Service Code	HCPCS 72040 26
Hospital Charge Code	50002237
Hospital Revenue Code	972
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$30.07
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

PROFEE XR CERVICAL SPINE COMPLETE

Professional

Both

$38.00

Service Code	HCPCS 72050 26
Hospital Charge Code	50002238
Hospital Revenue Code	972
Min. Negotiated Rate	$26.60
Max. Negotiated Rate	$36.86
Rate for Payer: Aetna Commercial	$36.10
Rate for Payer: Aetna Medicare	$34.20
Rate for Payer: Cash Price	$34.20
Rate for Payer: Medicaid All Medicaid	$34.96
Rate for Payer: Medicare All Medicare	$26.60
Rate for Payer: Monida Allegiance	$36.10
Rate for Payer: Monida First Choice Health	$36.86
Rate for Payer: Monida Montana Health Co-op	$36.10
Rate for Payer: Monida PacificSource	$36.10

PROFEEXR CERVICAL SPINE COMP W/ FLEX/EXT

Professional

Both

$42.00

Service Code	HCPCS 72052 26
Hospital Charge Code	50002239
Hospital Revenue Code	972
Min. Negotiated Rate	$29.40
Max. Negotiated Rate	$40.74
Rate for Payer: Aetna Commercial	$39.90
Rate for Payer: Aetna Medicare	$37.80
Rate for Payer: Cash Price	$37.80
Rate for Payer: Medicaid All Medicaid	$38.64
Rate for Payer: Medicare All Medicare	$29.40
Rate for Payer: Monida Allegiance	$39.90
Rate for Payer: Monida First Choice Health	$40.74
Rate for Payer: Monida Montana Health Co-op	$39.90
Rate for Payer: Monida PacificSource	$39.90

PROFEE XR CHEST 1 VIEW

Professional

Both

$26.00

Service Code	HCPCS 71045 26
Hospital Charge Code	50002240
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 CHEST 2 VIEWS

Professional

Both

$30.00

Service Code	HCPCS 71046 26
Hospital Charge Code	50002241
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 XR CHEST CHILD 1 VIEW

Professional

Both

$26.00

Service Code	HCPCS 71045 26
Hospital Charge Code	50002242
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 CHEST/RIBS 4/> VIEWS

Professional

Both

$45.00

Service Code	HCPCS 71111 26
Hospital Charge Code	50002244
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 CHEST SINGLE VIEW

Professional

Both

$26.00

Service Code	HCPCS 71045 26
Hospital Charge Code	50002243
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 CINE/VIDEO THROAT/ESOPH

Professional

Both

$74.00

Service Code	HCPCS 74230 26
Hospital Charge Code	50002245
Hospital Revenue Code	972
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$71.78
Rate for Payer: Aetna Commercial	$70.30
Rate for Payer: Aetna Medicare	$66.60
Rate for Payer: Cash Price	$66.60
Rate for Payer: Medicaid All Medicaid	$68.08
Rate for Payer: Medicare All Medicare	$51.80
Rate for Payer: Monida Allegiance	$70.30
Rate for Payer: Monida First Choice Health	$71.78
Rate for Payer: Monida Montana Health Co-op	$70.30
Rate for Payer: Monida PacificSource	$70.30

PROFEE XR CLAVICLE BILATERAL COMPLETE

Professional

Both

$24.00

Service Code	HCPCS 73000 26
Hospital Charge Code	50002246
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

PROFEE XR CLAVICLE LT COMPLETE

Professional

Both

$24.00

Service Code	HCPCS 73000 26
Hospital Charge Code	50002247
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

PROFEE XR CLAVICLE RT COMPLETE

Professional

Both

$24.00

Service Code	HCPCS 73000 26
Hospital Charge Code	50002249
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

PROFEE XR ELBOW BILATERAL 2 VIEWS

Professional

Both

$24.00

Service Code	HCPCS 73070 26
Hospital Charge Code	50002250
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

PROFEE XR ELBOW LT 2 VIEWS

Professional

Both

$24.00

Service Code	HCPCS 73070 26
Hospital Charge Code	50002251
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

PROFEE XR ELBOW LT 3-4 VIEWS

Professional

Both

$25.00

Service Code	HCPCS 73080 26
Hospital Charge Code	50002252
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 ELBOW RT 2 VIEWS

Professional

Both

$24.00

Service Code	HCPCS 73070 26
Hospital Charge Code	50002253
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

PROFEE XR ELBOW RT 3-4 VIEWS

Professional

Both

$25.00

Service Code	HCPCS 73080 26
Hospital Charge Code	50002254
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 ENTIRE SPINE W SKULL 4 OR 5

Professional

Both

$50.00

Service Code	HCPCS 72083 26
Hospital Charge Code	50002256
Hospital Revenue Code	972
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$48.50
Rate for Payer: Aetna Commercial	$47.50
Rate for Payer: Aetna Medicare	$45.00
Rate for Payer: Cash Price	$45.00
Rate for Payer: Medicaid All Medicaid	$46.00
Rate for Payer: Medicare All Medicare	$35.00
Rate for Payer: Monida Allegiance	$47.50
Rate for Payer: Monida First Choice Health	$48.50
Rate for Payer: Monida Montana Health Co-op	$47.50
Rate for Payer: Monida PacificSource	$47.50

PROFEE XR EYE FOREIGN BODY

Professional

Both

$26.00

Service Code	HCPCS 70030 26
Hospital Charge Code	50002257
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 FACIAL BONES COMPLETE 3 VIEWS

Professional

Both

$36.00

Service Code	HCPCS 70150 26
Hospital Charge Code	50002258
Hospital Revenue Code	972
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$34.92
Rate for Payer: Aetna Commercial	$34.20
Rate for Payer: Aetna Medicare	$32.40
Rate for Payer: Cash Price	$32.40
Rate for Payer: Medicaid All Medicaid	$33.12
Rate for Payer: Medicare All Medicare	$25.20
Rate for Payer: Monida Allegiance	$34.20
Rate for Payer: Monida First Choice Health	$34.92
Rate for Payer: Monida Montana Health Co-op	$34.20
Rate for Payer: Monida PacificSource	$34.20

Know your out-of-pocket cost for care.

All Charges