Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE COLONOSCOPY-SNARE TECHNQ 45385

Professional

Both

$830.00

Service Code	CPT 45385
Hospital Charge Code	5840012
Hospital Revenue Code	960
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$805.10
Rate for Payer: Aetna Commercial	$788.50
Rate for Payer: Aetna Medicare	$747.00
Rate for Payer: Cash Price	$747.00
Rate for Payer: Medicaid All Medicaid	$763.60
Rate for Payer: Medicare All Medicare	$581.00
Rate for Payer: Monida Allegiance	$788.50
Rate for Payer: Monida First Choice Health	$805.10
Rate for Payer: Monida Montana Health Co-op	$788.50
Rate for Payer: Monida PacificSource	$788.50

PROFEE COLONOSCOPY W/ABLATION 45388

Professional

Both

$883.00

Service Code	CPT 45388
Hospital Charge Code	5840010
Hospital Revenue Code	960
Min. Negotiated Rate	$618.10
Max. Negotiated Rate	$856.51
Rate for Payer: Aetna Commercial	$838.85
Rate for Payer: Aetna Medicare	$794.70
Rate for Payer: Cash Price	$794.70
Rate for Payer: Medicaid All Medicaid	$812.36
Rate for Payer: Medicare All Medicare	$618.10
Rate for Payer: Monida Allegiance	$838.85
Rate for Payer: Monida First Choice Health	$856.51
Rate for Payer: Monida Montana Health Co-op	$838.85
Rate for Payer: Monida PacificSource	$838.85

PROFEE COLONOSCOPY W/ BIOPSY 45380

Professional

Both

$659.00

Service Code	CPT 45380
Hospital Charge Code	5840003
Hospital Revenue Code	960
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$639.23
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: Cash Price	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

PROFEE COLONOSCOPY W/CNTRL BLDNG 45382

Professional

Both

$846.00

Service Code	CPT 45382
Hospital Charge Code	5840009
Hospital Revenue Code	960
Min. Negotiated Rate	$592.20
Max. Negotiated Rate	$820.62
Rate for Payer: Aetna Commercial	$803.70
Rate for Payer: Aetna Medicare	$761.40
Rate for Payer: Cash Price	$761.40
Rate for Payer: Medicaid All Medicaid	$778.32
Rate for Payer: Medicare All Medicare	$592.20
Rate for Payer: Monida Allegiance	$803.70
Rate for Payer: Monida First Choice Health	$820.62
Rate for Payer: Monida Montana Health Co-op	$803.70
Rate for Payer: Monida PacificSource	$803.70

PROFEE COLONOSCOPY W/DRCT SUBM INJ 45381

Professional

Both

$659.00

Service Code	CPT 45381
Hospital Charge Code	5840013
Hospital Revenue Code	960
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$639.23
Rate for Payer: Aetna Commercial	$626.05
Rate for Payer: Aetna Medicare	$593.10
Rate for Payer: Cash Price	$593.10
Rate for Payer: Medicaid All Medicaid	$606.28
Rate for Payer: Medicare All Medicare	$461.30
Rate for Payer: Monida Allegiance	$626.05
Rate for Payer: Monida First Choice Health	$639.23
Rate for Payer: Monida Montana Health Co-op	$626.05
Rate for Payer: Monida PacificSource	$626.05

PROFEE COLONOSCOPY W/HT BPSY FCPS 45384

Professional

Both

$749.00

Service Code	CPT 45384
Hospital Charge Code	5840011
Hospital Revenue Code	960
Min. Negotiated Rate	$524.30
Max. Negotiated Rate	$726.53
Rate for Payer: Aetna Commercial	$711.55
Rate for Payer: Aetna Medicare	$674.10
Rate for Payer: Cash Price	$674.10
Rate for Payer: Medicaid All Medicaid	$689.08
Rate for Payer: Medicare All Medicare	$524.30
Rate for Payer: Monida Allegiance	$711.55
Rate for Payer: Monida First Choice Health	$726.53
Rate for Payer: Monida Montana Health Co-op	$711.55
Rate for Payer: Monida PacificSource	$711.55

PRO FEE CRITICAL CARE EA ADD 30 MIN

Facility

$272.00

Service Code	CPT 99292
Hospital Charge Code	709292
Hospital Revenue Code	521
Min. Negotiated Rate	$190.40
Max. Negotiated Rate	$272.00
Rate for Payer: Aetna Commercial	$258.40
Rate for Payer: Aetna Medicare	$244.80
Rate for Payer: BCBS MT CHIP	$244.80
Rate for Payer: BCBS MT Closed Plan Network	$258.40
Rate for Payer: BCBS MT HealthLink	$244.80
Rate for Payer: BCBS MT Medicare	$244.80
Rate for Payer: BCBS MT POS	$258.40
Rate for Payer: BCBS MT Traditional	$272.00
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna Commercial	$258.40
Rate for Payer: Cigna Medicare	$244.80
Rate for Payer: Medicaid All Medicaid	$250.24
Rate for Payer: Medicare All Medicare	$190.40
Rate for Payer: Monida Allegiance	$258.40
Rate for Payer: Monida First Choice Health	$263.84
Rate for Payer: Monida Montana Health Co-op	$258.40
Rate for Payer: Monida PacificSource	$258.40

PRO FEE CRITICAL CARE EA ADD 30 MIN

Facility

$272.00

Service Code	CPT 99292
Hospital Charge Code	709292
Hospital Revenue Code	521
Min. Negotiated Rate	$190.40
Max. Negotiated Rate	$272.00
Rate for Payer: Aetna Commercial	$258.40
Rate for Payer: Aetna Medicare	$244.80
Rate for Payer: BCBS MT CHIP	$244.80
Rate for Payer: BCBS MT Closed Plan Network	$258.40
Rate for Payer: BCBS MT HealthLink	$244.80
Rate for Payer: BCBS MT Medicare	$244.80
Rate for Payer: BCBS MT POS	$258.40
Rate for Payer: BCBS MT Traditional	$272.00
Rate for Payer: Cash Price	$244.80
Rate for Payer: Cigna Commercial	$258.40
Rate for Payer: Cigna Medicare	$244.80
Rate for Payer: Medicaid All Medicaid	$250.24
Rate for Payer: Medicare All Medicare	$190.40
Rate for Payer: Monida Allegiance	$258.40
Rate for Payer: Monida First Choice Health	$263.84
Rate for Payer: Monida Montana Health Co-op	$258.40
Rate for Payer: Monida PacificSource	$258.40

PROFEE CT 3D RECONSTRUCTION

Professional

Both

$29.00

Service Code	CPT 76376
Hospital Charge Code	50002021
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 CTA ABDOMEN GENERAL

Professional

Both

$264.00

Service Code	CPT 74175
Hospital Charge Code	50002076
Hospital Revenue Code	972
Min. Negotiated Rate	$184.80
Max. Negotiated Rate	$256.08
Rate for Payer: Aetna Commercial	$250.80
Rate for Payer: Aetna Medicare	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Medicaid All Medicaid	$242.88
Rate for Payer: Medicare All Medicare	$184.80
Rate for Payer: Monida Allegiance	$250.80
Rate for Payer: Monida First Choice Health	$256.08
Rate for Payer: Monida Montana Health Co-op	$250.80
Rate for Payer: Monida PacificSource	$250.80

PROFEE CTA ABDOMEN PELVIS W WO CONTRAST

Professional

Both

$320.00

Service Code	CPT 74174
Hospital Charge Code	50002077
Hospital Revenue Code	972
Min. Negotiated Rate	$224.00
Max. Negotiated Rate	$310.40
Rate for Payer: Aetna Commercial	$304.00
Rate for Payer: Aetna Medicare	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Medicaid All Medicaid	$294.40
Rate for Payer: Medicare All Medicare	$224.00
Rate for Payer: Monida Allegiance	$304.00
Rate for Payer: Monida First Choice Health	$310.40
Rate for Payer: Monida Montana Health Co-op	$304.00
Rate for Payer: Monida PacificSource	$304.00

PROFEE CTA AORTA ILIAC RUNOFF

Professional

Both

$344.00

Service Code	CPT 75635
Hospital Charge Code	50002078
Hospital Revenue Code	972
Min. Negotiated Rate	$240.80
Max. Negotiated Rate	$333.68
Rate for Payer: Aetna Commercial	$326.80
Rate for Payer: Aetna Medicare	$309.60
Rate for Payer: Cash Price	$309.60
Rate for Payer: Medicaid All Medicaid	$316.48
Rate for Payer: Medicare All Medicare	$240.80
Rate for Payer: Monida Allegiance	$326.80
Rate for Payer: Monida First Choice Health	$333.68
Rate for Payer: Monida Montana Health Co-op	$326.80
Rate for Payer: Monida PacificSource	$326.80

PROFEE CT ABDOMEN PELVIS W CONTRAST

Professional

Both

$266.00

Service Code	CPT 74177
Hospital Charge Code	50002023
Hospital Revenue Code	972
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$258.02
Rate for Payer: Aetna Commercial	$252.70
Rate for Payer: Aetna Medicare	$239.40
Rate for Payer: Cash Price	$239.40
Rate for Payer: Medicaid All Medicaid	$244.72
Rate for Payer: Medicare All Medicare	$186.20
Rate for Payer: Monida Allegiance	$252.70
Rate for Payer: Monida First Choice Health	$258.02
Rate for Payer: Monida Montana Health Co-op	$252.70
Rate for Payer: Monida PacificSource	$252.70

PROFEE CT ABDOMEN PELVIS WO CONTRAST

Professional

Both

$253.00

Service Code	CPT 74176
Hospital Charge Code	50002025
Hospital Revenue Code	972
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$245.41
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: Cash Price	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

PROFEE CT ABDOMEN PELVIS W WO CONTRAST

Professional

Both

$292.00

Service Code	CPT 74178
Hospital Charge Code	50002024
Hospital Revenue Code	972
Min. Negotiated Rate	$204.40
Max. Negotiated Rate	$283.24
Rate for Payer: Aetna Commercial	$277.40
Rate for Payer: Aetna Medicare	$262.80
Rate for Payer: Cash Price	$262.80
Rate for Payer: Medicaid All Medicaid	$268.64
Rate for Payer: Medicare All Medicare	$204.40
Rate for Payer: Monida Allegiance	$277.40
Rate for Payer: Monida First Choice Health	$283.24
Rate for Payer: Monida Montana Health Co-op	$277.40
Rate for Payer: Monida PacificSource	$277.40

PROFEE CT ABDOMEN W CONTRAST

Professional

Both

$185.00

Service Code	CPT 74160
Hospital Charge Code	50002026
Hospital Revenue Code	972
Min. Negotiated Rate	$129.50
Max. Negotiated Rate	$179.45
Rate for Payer: Aetna Commercial	$175.75
Rate for Payer: Aetna Medicare	$166.50
Rate for Payer: Cash Price	$166.50
Rate for Payer: Medicaid All Medicaid	$170.20
Rate for Payer: Medicare All Medicare	$129.50
Rate for Payer: Monida Allegiance	$175.75
Rate for Payer: Monida First Choice Health	$179.45
Rate for Payer: Monida Montana Health Co-op	$175.75
Rate for Payer: Monida PacificSource	$175.75

PROFEE CT ABDOMEN WO CONTRAST

Professional

Both

$172.00

Service Code	CPT 74150
Hospital Charge Code	50002028
Hospital Revenue Code	972
Min. Negotiated Rate	$120.40
Max. Negotiated Rate	$166.84
Rate for Payer: Aetna Commercial	$163.40
Rate for Payer: Aetna Medicare	$154.80
Rate for Payer: Cash Price	$154.80
Rate for Payer: Medicaid All Medicaid	$158.24
Rate for Payer: Medicare All Medicare	$120.40
Rate for Payer: Monida Allegiance	$163.40
Rate for Payer: Monida First Choice Health	$166.84
Rate for Payer: Monida Montana Health Co-op	$163.40
Rate for Payer: Monida PacificSource	$163.40

PROFEE CT ABDOMEN W WO CONTRAST

Professional

Both

$202.00

Service Code	CPT 74170
Hospital Charge Code	50002027
Hospital Revenue Code	972
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$195.94
Rate for Payer: Aetna Commercial	$191.90
Rate for Payer: Aetna Medicare	$181.80
Rate for Payer: Cash Price	$181.80
Rate for Payer: Medicaid All Medicaid	$185.84
Rate for Payer: Medicare All Medicare	$141.40
Rate for Payer: Monida Allegiance	$191.90
Rate for Payer: Monida First Choice Health	$195.94
Rate for Payer: Monida Montana Health Co-op	$191.90
Rate for Payer: Monida PacificSource	$191.90

PROFEE CT ABD/PELVIS/CHEST W/O

Professional

Both

$253.00

Service Code	CPT 74176
Hospital Charge Code	50002022
Hospital Revenue Code	972
Min. Negotiated Rate	$177.10
Max. Negotiated Rate	$245.41
Rate for Payer: Aetna Commercial	$240.35
Rate for Payer: Aetna Medicare	$227.70
Rate for Payer: Cash Price	$227.70
Rate for Payer: Medicaid All Medicaid	$232.76
Rate for Payer: Medicare All Medicare	$177.10
Rate for Payer: Monida Allegiance	$240.35
Rate for Payer: Monida First Choice Health	$245.41
Rate for Payer: Monida Montana Health Co-op	$240.35
Rate for Payer: Monida PacificSource	$240.35

PROFEE CTA CAROTID ARTERIES

Professional

Both

$254.00

Service Code	CPT 70498
Hospital Charge Code	50002079
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 CTA CHEST PE STUDY

Professional

Both

$516.00

Service Code	CPT 71275
Hospital Charge Code	50002442
Hospital Revenue Code	972
Min. Negotiated Rate	$361.20
Max. Negotiated Rate	$500.52
Rate for Payer: Aetna Commercial	$490.20
Rate for Payer: Aetna Medicare	$464.40
Rate for Payer: Cash Price	$464.40
Rate for Payer: Medicaid All Medicaid	$474.72
Rate for Payer: Medicare All Medicare	$361.20
Rate for Payer: Monida Allegiance	$490.20
Rate for Payer: Monida First Choice Health	$500.52
Rate for Payer: Monida Montana Health Co-op	$490.20
Rate for Payer: Monida PacificSource	$490.20

PROFEE CTA HEAD CIRCLE OF WILLIS

Professional

Both

$254.00

Service Code	CPT 70496
Hospital Charge Code	50002082
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 CTA LOWER EXT BILAT W CONTRAST

Professional

Both

$274.00

Service Code	CPT 73706
Hospital Charge Code	50002444
Hospital Revenue Code	972
Min. Negotiated Rate	$191.80
Max. Negotiated Rate	$265.78
Rate for Payer: Aetna Commercial	$260.30
Rate for Payer: Aetna Medicare	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Medicaid All Medicaid	$252.08
Rate for Payer: Medicare All Medicare	$191.80
Rate for Payer: Monida Allegiance	$260.30
Rate for Payer: Monida First Choice Health	$265.78
Rate for Payer: Monida Montana Health Co-op	$260.30
Rate for Payer: Monida PacificSource	$260.30

PROFEE CTA LOWER EXT BILAT W WO CONTRAST

Professional

Both

$274.00

Service Code	CPT 73706
Hospital Charge Code	50002083
Hospital Revenue Code	972
Min. Negotiated Rate	$191.80
Max. Negotiated Rate	$265.78
Rate for Payer: Aetna Commercial	$260.30
Rate for Payer: Aetna Medicare	$246.60
Rate for Payer: Cash Price	$246.60
Rate for Payer: Medicaid All Medicaid	$252.08
Rate for Payer: Medicare All Medicare	$191.80
Rate for Payer: Monida Allegiance	$260.30
Rate for Payer: Monida First Choice Health	$265.78
Rate for Payer: Monida Montana Health Co-op	$260.30
Rate for Payer: Monida PacificSource	$260.30

PROFEE CTA ORBIT EAR FOSSA W CONTRAST

Professional

Both

$164.00

Service Code	CPT 70481
Hospital Charge Code	50002084
Hospital Revenue Code	972
Min. Negotiated Rate	$114.80
Max. Negotiated Rate	$159.08
Rate for Payer: Aetna Commercial	$155.80
Rate for Payer: Aetna Medicare	$147.60
Rate for Payer: Cash Price	$147.60
Rate for Payer: Medicaid All Medicaid	$150.88
Rate for Payer: Medicare All Medicare	$114.80
Rate for Payer: Monida Allegiance	$155.80
Rate for Payer: Monida First Choice Health	$159.08
Rate for Payer: Monida Montana Health Co-op	$155.80
Rate for Payer: Monida PacificSource	$155.80

Know your out-of-pocket cost for care.

All Charges