Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE CTA PELVIS

Professional

Both

$261.00

Service Code	CPT 72191
Hospital Charge Code	50002085
Hospital Revenue Code	972
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$253.17
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: Cash Price	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

PROFEE CTA THORACIC AORTA

Professional

Both

$265.00

Service Code	CPT 71275
Hospital Charge Code	50002086
Hospital Revenue Code	972
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$257.05
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

PROFEE CTA THORACIC PE STUDY

Professional

Both

$265.00

Service Code	CPT 71275
Hospital Charge Code	50002087
Hospital Revenue Code	972
Min. Negotiated Rate	$185.50
Max. Negotiated Rate	$257.05
Rate for Payer: Aetna Commercial	$251.75
Rate for Payer: Aetna Medicare	$238.50
Rate for Payer: Cash Price	$238.50
Rate for Payer: Medicaid All Medicaid	$243.80
Rate for Payer: Medicare All Medicare	$185.50
Rate for Payer: Monida Allegiance	$251.75
Rate for Payer: Monida First Choice Health	$257.05
Rate for Payer: Monida Montana Health Co-op	$251.75
Rate for Payer: Monida PacificSource	$251.75

PROFEE CTA UPPER EXTREMITY LT W WO

Professional

Both

$261.00

Service Code	CPT 73206
Hospital Charge Code	50002088
Hospital Revenue Code	972
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$253.17
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: Cash Price	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

PROFEE CTA UPPER EXTREMITY RT W WO

Professional

Both

$261.00

Service Code	CPT 73206
Hospital Charge Code	50002089
Hospital Revenue Code	972
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$253.17
Rate for Payer: Aetna Commercial	$247.95
Rate for Payer: Aetna Medicare	$234.90
Rate for Payer: Cash Price	$234.90
Rate for Payer: Medicaid All Medicaid	$240.12
Rate for Payer: Medicare All Medicare	$182.70
Rate for Payer: Monida Allegiance	$247.95
Rate for Payer: Monida First Choice Health	$253.17
Rate for Payer: Monida Montana Health Co-op	$247.95
Rate for Payer: Monida PacificSource	$247.95

PROFEE CT BONE DENSITY

Professional

Both

$36.00

Service Code	CPT 77078
Hospital Charge Code	50002029
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

PROFEE CT BONE LENGTH STUDY SCANOGRAM

Professional

Both

$38.00

Service Code	CPT 77073
Hospital Charge Code	50002030
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 CT CERVICAL SPINE W CONTRAST

Professional

Both

$176.00

Service Code	CPT 72126
Hospital Charge Code	50002031
Hospital Revenue Code	972
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$170.72
Rate for Payer: Aetna Commercial	$167.20
Rate for Payer: Aetna Medicare	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Medicaid All Medicaid	$161.92
Rate for Payer: Medicare All Medicare	$123.20
Rate for Payer: Monida Allegiance	$167.20
Rate for Payer: Monida First Choice Health	$170.72
Rate for Payer: Monida Montana Health Co-op	$167.20
Rate for Payer: Monida PacificSource	$167.20

PROFEE CT CERVICAL SPINE WO CONTRAST

Professional

Both

$144.00

Service Code	CPT 72125
Hospital Charge Code	50002033
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 CT CERVICAL SPINE W WO CONTRAST

Professional

Both

$184.00

Service Code	CPT 72127
Hospital Charge Code	50002032
Hospital Revenue Code	972
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$178.48
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

PROFEE CT CHEST W CONTRAST

Professional

Both

$169.00

Service Code	CPT 71260
Hospital Charge Code	50002034
Hospital Revenue Code	972
Min. Negotiated Rate	$118.30
Max. Negotiated Rate	$163.93
Rate for Payer: Aetna Commercial	$160.55
Rate for Payer: Aetna Medicare	$152.10
Rate for Payer: Cash Price	$152.10
Rate for Payer: Medicaid All Medicaid	$155.48
Rate for Payer: Medicare All Medicare	$118.30
Rate for Payer: Monida Allegiance	$160.55
Rate for Payer: Monida First Choice Health	$163.93
Rate for Payer: Monida Montana Health Co-op	$160.55
Rate for Payer: Monida PacificSource	$160.55

PROFEE CT CHEST WO CONTRAST

Professional

Both

$157.00

Service Code	CPT 71250
Hospital Charge Code	50002036
Hospital Revenue Code	972
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$152.29
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: Cash Price	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

PROFEE CT CHEST W WO CONTRAST

Professional

Both

$182.00

Service Code	CPT 71270
Hospital Charge Code	50002035
Hospital Revenue Code	972
Min. Negotiated Rate	$127.40
Max. Negotiated Rate	$176.54
Rate for Payer: Aetna Commercial	$172.90
Rate for Payer: Aetna Medicare	$163.80
Rate for Payer: Cash Price	$163.80
Rate for Payer: Medicaid All Medicaid	$167.44
Rate for Payer: Medicare All Medicare	$127.40
Rate for Payer: Monida Allegiance	$172.90
Rate for Payer: Monida First Choice Health	$176.54
Rate for Payer: Monida Montana Health Co-op	$172.90
Rate for Payer: Monida PacificSource	$172.90

PROFEE CT FACIAL BONES W CONTRAST

Professional

Both

$164.00

Service Code	CPT 70487
Hospital Charge Code	50002039
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

PROFEE CT FACIAL BONES WO CONTRAST

Professional

Both

$125.00

Service Code	CPT 70486
Hospital Charge Code	50002041
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 CT FACIAL BONES W WO CONTRAST

Professional

Both

$184.00

Service Code	CPT 70488
Hospital Charge Code	50002040
Hospital Revenue Code	972
Min. Negotiated Rate	$128.80
Max. Negotiated Rate	$178.48
Rate for Payer: Aetna Commercial	$174.80
Rate for Payer: Aetna Medicare	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Medicaid All Medicaid	$169.28
Rate for Payer: Medicare All Medicare	$128.80
Rate for Payer: Monida Allegiance	$174.80
Rate for Payer: Monida First Choice Health	$178.48
Rate for Payer: Monida Montana Health Co-op	$174.80
Rate for Payer: Monida PacificSource	$174.80

PROFEE CT HEAD W CONTRAST

Professional

Both

$164.00

Service Code	CPT 70460
Hospital Charge Code	50002042
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

PROFEE CT HEAD WO CONTRAST

Professional

Both

$124.00

Service Code	CPT 70450
Hospital Charge Code	50002044
Hospital Revenue Code	972
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$120.28
Rate for Payer: Aetna Commercial	$117.80
Rate for Payer: Aetna Medicare	$111.60
Rate for Payer: Cash Price	$111.60
Rate for Payer: Medicaid All Medicaid	$114.08
Rate for Payer: Medicare All Medicare	$86.80
Rate for Payer: Monida Allegiance	$117.80
Rate for Payer: Monida First Choice Health	$120.28
Rate for Payer: Monida Montana Health Co-op	$117.80
Rate for Payer: Monida PacificSource	$117.80

PROFEE CT HEAD W WO CONTRAST

Professional

Both

$185.00

Service Code	CPT 70470
Hospital Charge Code	50002043
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 HIGH REZ CHEST

Professional

Both

$157.00

Service Code	CPT 71250
Hospital Charge Code	50002045
Hospital Revenue Code	972
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$152.29
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: Cash Price	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

PROFEE CT LIMITED FOLLOW-UP

Professional

Both

$138.00

Service Code	CPT 76380
Hospital Charge Code	50002046
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 CT LIMITED ORBITS FOR MRI

Professional

Both

$187.00

Service Code	CPT 70480
Hospital Charge Code	50002047
Hospital Revenue Code	972
Min. Negotiated Rate	$130.90
Max. Negotiated Rate	$181.39
Rate for Payer: Aetna Commercial	$177.65
Rate for Payer: Aetna Medicare	$168.30
Rate for Payer: Cash Price	$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 CT LOW DOSE LUNG SCREEN

Professional

Both

$157.00

Service Code	CPT 71271
Hospital Charge Code	50002048
Hospital Revenue Code	972
Min. Negotiated Rate	$109.90
Max. Negotiated Rate	$152.29
Rate for Payer: Aetna Commercial	$149.15
Rate for Payer: Aetna Medicare	$141.30
Rate for Payer: Cash Price	$141.30
Rate for Payer: Medicaid All Medicaid	$144.44
Rate for Payer: Medicare All Medicare	$109.90
Rate for Payer: Monida Allegiance	$149.15
Rate for Payer: Monida First Choice Health	$152.29
Rate for Payer: Monida Montana Health Co-op	$149.15
Rate for Payer: Monida PacificSource	$149.15

PROFEE CT LOWER EXTREMITY LT W CONTRAST

Professional

Both

$168.00

Service Code	CPT 73701
Hospital Charge Code	50002049
Hospital Revenue Code	972
Min. Negotiated Rate	$117.60
Max. Negotiated Rate	$162.96
Rate for Payer: Aetna Commercial	$159.60
Rate for Payer: Aetna Medicare	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Medicaid All Medicaid	$154.56
Rate for Payer: Medicare All Medicare	$117.60
Rate for Payer: Monida Allegiance	$159.60
Rate for Payer: Monida First Choice Health	$162.96
Rate for Payer: Monida Montana Health Co-op	$159.60
Rate for Payer: Monida PacificSource	$159.60

PROFEE CT LOWER EXTREMITY LT WO CONTRAST

Professional

Both

$144.00

Service Code	CPT 73700
Hospital Charge Code	50002051
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

Know your out-of-pocket cost for care.

All Charges