Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE CT LOWER EXTREMITY RT W CONTRAST

Professional

Both

$168.00

Service Code	CPT 73701
Hospital Charge Code	50002052
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 RT WO CONTRAST

Professional

Both

$144.00

Service Code	CPT 73700
Hospital Charge Code	50002054
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 LOWER EXTR LT W WO CONTRAST

Professional

Both

$175.00

Service Code	CPT 73702
Hospital Charge Code	50002050
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 CT LOWER EXTR RT W WO CONTRAST

Professional

Both

$175.00

Service Code	CPT 73702
Hospital Charge Code	50002053
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 CT LUMBAR SPINE W CONTRAST

Professional

Both

$176.00

Service Code	CPT 72132
Hospital Charge Code	50002055
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 LUMBAR SPINE WO CONTRAST

Professional

Both

$144.00

Service Code	CPT 72131
Hospital Charge Code	50002057
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 LUMBAR SPINE W WO CONTRAST

Professional

Both

$184.00

Service Code	CPT 72133
Hospital Charge Code	50002056
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 ORBIT EAR FOSSA W WO CONTRAST

Professional

Both

$184.00

Service Code	CPT 70482
Hospital Charge Code	50002058
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 ORBITS SELLA FOSSA WO CONTRAST

Professional

Both

$187.00

Service Code	CPT 70480
Hospital Charge Code	50002059
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 PELVIS W CONTRAST

Professional

Both

$168.00

Service Code	CPT 72193
Hospital Charge Code	50002060
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 PELVIS WO CONTRAST

Professional

Both

$158.00

Service Code	CPT 72192
Hospital Charge Code	50002062
Hospital Revenue Code	972
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$153.26
Rate for Payer: Aetna Commercial	$150.10
Rate for Payer: Aetna Medicare	$142.20
Rate for Payer: Cash Price	$142.20
Rate for Payer: Medicaid All Medicaid	$145.36
Rate for Payer: Medicare All Medicare	$110.60
Rate for Payer: Monida Allegiance	$150.10
Rate for Payer: Monida First Choice Health	$153.26
Rate for Payer: Monida Montana Health Co-op	$150.10
Rate for Payer: Monida PacificSource	$150.10

PROFEE CT PELVIS W WO CONTRAST

Professional

Both

$176.00

Service Code	CPT 72194
Hospital Charge Code	50002061
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 SINUS STUDY WO CONTRAST

Professional

Both

$125.00

Service Code	CPT 70486
Hospital Charge Code	50002063
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 SOFT TISSUE NECK W CONTRAST

Professional

Both

$200.00

Service Code	CPT 70491
Hospital Charge Code	50002064
Hospital Revenue Code	972
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$194.00
Rate for Payer: Aetna Commercial	$190.00
Rate for Payer: Aetna Medicare	$180.00
Rate for Payer: Cash Price	$180.00
Rate for Payer: Medicaid All Medicaid	$184.00
Rate for Payer: Medicare All Medicare	$140.00
Rate for Payer: Monida Allegiance	$190.00
Rate for Payer: Monida First Choice Health	$194.00
Rate for Payer: Monida Montana Health Co-op	$190.00
Rate for Payer: Monida PacificSource	$190.00

PROFEE CT SOFT TISSUE NECK WO CONTRAST

Professional

Both

$187.00

Service Code	CPT 70490
Hospital Charge Code	50002066
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 SOFT TISSUE NECK W WO CONTRAST

Professional

Both

$234.00

Service Code	CPT 70492
Hospital Charge Code	50002065
Hospital Revenue Code	972
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$226.98
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: Cash Price	$210.60
Rate for Payer: Medicaid All Medicaid	$215.28
Rate for Payer: Medicare All Medicare	$163.80
Rate for Payer: Monida Allegiance	$222.30
Rate for Payer: Monida First Choice Health	$226.98
Rate for Payer: Monida Montana Health Co-op	$222.30
Rate for Payer: Monida PacificSource	$222.30

PROFEE CT THORACIC SPINE W CONTRAST

Professional

Both

$177.00

Service Code	CPT 72129
Hospital Charge Code	50002067
Hospital Revenue Code	972
Min. Negotiated Rate	$123.90
Max. Negotiated Rate	$171.69
Rate for Payer: Aetna Commercial	$168.15
Rate for Payer: Aetna Medicare	$159.30
Rate for Payer: Cash Price	$159.30
Rate for Payer: Medicaid All Medicaid	$162.84
Rate for Payer: Medicare All Medicare	$123.90
Rate for Payer: Monida Allegiance	$168.15
Rate for Payer: Monida First Choice Health	$171.69
Rate for Payer: Monida Montana Health Co-op	$168.15
Rate for Payer: Monida PacificSource	$168.15

PROFEE CT THORACIC SPINE WO CONTRAST

Professional

Both

$144.00

Service Code	CPT 72128
Hospital Charge Code	50002069
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 THORACIC SPINE W WO CONTRAST

Professional

Both

$185.00

Service Code	CPT 72130
Hospital Charge Code	50002068
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 UPPER EXTREMITY LT W CONTRAST

Professional

Both

$168.00

Service Code	CPT 73201
Hospital Charge Code	50002070
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 UPPER EXTREMITY LT WO CONTRAST

Professional

Both

$144.00

Service Code	CPT 73200
Hospital Charge Code	50002072
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 UPPER EXTREMITY RT W CONTRAST

Professional

Both

$168.00

Service Code	CPT 73201
Hospital Charge Code	50002073
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 UPPER EXTREMITY RT WO CONTRAST

Professional

Both

$144.00

Service Code	CPT 73200
Hospital Charge Code	50002075
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 UPPER EXTR LT W WO CONTRAST

Professional

Both

$175.00

Service Code	CPT 73202
Hospital Charge Code	50002071
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 CT UPPER EXTR RT W WO CONTRAST

Professional

Both

$175.00

Service Code	CPT 73202
Hospital Charge Code	50002074
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

Know your out-of-pocket cost for care.

All Charges