Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PRO FEE LAC REPAIR CMPL FC/HNADD ON =>5C

Professional

Both

$236.00

Service Code	CPT 13133
Hospital Charge Code	713133
Hospital Revenue Code	981
Min. Negotiated Rate	$165.20
Max. Negotiated Rate	$236.00
Rate for Payer: Aetna Commercial	$224.20
Rate for Payer: Aetna Medicare	$212.40
Rate for Payer: BCBS MT CHIP	$212.40
Rate for Payer: BCBS MT Closed Plan Network	$224.20
Rate for Payer: BCBS MT HealthLink	$212.40
Rate for Payer: BCBS MT Medicare	$212.40
Rate for Payer: BCBS MT POS	$224.20
Rate for Payer: BCBS MT Traditional	$236.00
Rate for Payer: Cash Price	$212.40
Rate for Payer: Cigna Commercial	$224.20
Rate for Payer: Cigna Medicare	$212.40
Rate for Payer: Medicaid All Medicaid	$217.12
Rate for Payer: Medicare All Medicare	$165.20
Rate for Payer: Monida Allegiance	$224.20
Rate for Payer: Monida First Choice Health	$228.92
Rate for Payer: Monida Montana Health Co-op	$224.20
Rate for Payer: Monida PacificSource	$224.20

PRO FEE LAC REPAIR COMPLEX 2.6-7.5CM

Professional

Both

$574.00

Service Code	CPT 13132
Hospital Charge Code	713132
Hospital Revenue Code	981
Min. Negotiated Rate	$401.80
Max. Negotiated Rate	$574.00
Rate for Payer: Aetna Commercial	$545.30
Rate for Payer: Aetna Medicare	$516.60
Rate for Payer: BCBS MT CHIP	$516.60
Rate for Payer: BCBS MT Closed Plan Network	$545.30
Rate for Payer: BCBS MT HealthLink	$516.60
Rate for Payer: BCBS MT Medicare	$516.60
Rate for Payer: BCBS MT POS	$545.30
Rate for Payer: BCBS MT Traditional	$574.00
Rate for Payer: Cash Price	$516.60
Rate for Payer: Cigna Commercial	$545.30
Rate for Payer: Cigna Medicare	$516.60
Rate for Payer: Medicaid All Medicaid	$528.08
Rate for Payer: Medicare All Medicare	$401.80
Rate for Payer: Monida Allegiance	$545.30
Rate for Payer: Monida First Choice Health	$556.78
Rate for Payer: Monida Montana Health Co-op	$545.30
Rate for Payer: Monida PacificSource	$545.30

PRO FEE LAC REPAIR COMPLEX 2.6-7.5CM

Professional

Both

$491.00

Service Code	CPT 13121
Hospital Charge Code	713121
Hospital Revenue Code	981
Min. Negotiated Rate	$343.70
Max. Negotiated Rate	$491.00
Rate for Payer: Aetna Commercial	$466.45
Rate for Payer: Aetna Medicare	$441.90
Rate for Payer: BCBS MT CHIP	$441.90
Rate for Payer: BCBS MT Closed Plan Network	$466.45
Rate for Payer: BCBS MT HealthLink	$441.90
Rate for Payer: BCBS MT Medicare	$441.90
Rate for Payer: BCBS MT POS	$466.45
Rate for Payer: BCBS MT Traditional	$491.00
Rate for Payer: Cash Price	$441.90
Rate for Payer: Cigna Commercial	$466.45
Rate for Payer: Cigna Medicare	$441.90
Rate for Payer: Medicaid All Medicaid	$451.72
Rate for Payer: Medicare All Medicare	$343.70
Rate for Payer: Monida Allegiance	$466.45
Rate for Payer: Monida First Choice Health	$476.27
Rate for Payer: Monida Montana Health Co-op	$466.45
Rate for Payer: Monida PacificSource	$466.45

PRO FEE LAC REPAIR SIMPLE=<2.5CM

Professional

Both

$84.00

Service Code	CPT 12001
Hospital Charge Code	712001
Hospital Revenue Code	981
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$84.00
Rate for Payer: Aetna Commercial	$79.80
Rate for Payer: Aetna Medicare	$75.60
Rate for Payer: BCBS MT CHIP	$75.60
Rate for Payer: BCBS MT Closed Plan Network	$79.80
Rate for Payer: BCBS MT HealthLink	$75.60
Rate for Payer: BCBS MT Medicare	$75.60
Rate for Payer: BCBS MT POS	$79.80
Rate for Payer: BCBS MT Traditional	$84.00
Rate for Payer: Cash Price	$75.60
Rate for Payer: Cigna Commercial	$79.80
Rate for Payer: Cigna Medicare	$75.60
Rate for Payer: Medicaid All Medicaid	$77.28
Rate for Payer: Medicare All Medicare	$58.80
Rate for Payer: Monida Allegiance	$79.80
Rate for Payer: Monida First Choice Health	$81.48
Rate for Payer: Monida Montana Health Co-op	$79.80
Rate for Payer: Monida PacificSource	$79.80

PRO FEE LAC REPAIR SIMPLE 2.6-7.5CM

Professional

Both

$111.00

Service Code	CPT 12002
Hospital Charge Code	712002
Hospital Revenue Code	981
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$111.00
Rate for Payer: Aetna Commercial	$105.45
Rate for Payer: Aetna Medicare	$99.90
Rate for Payer: BCBS MT CHIP	$99.90
Rate for Payer: BCBS MT Closed Plan Network	$105.45
Rate for Payer: BCBS MT HealthLink	$99.90
Rate for Payer: BCBS MT Medicare	$99.90
Rate for Payer: BCBS MT POS	$105.45
Rate for Payer: BCBS MT Traditional	$111.00
Rate for Payer: Cash Price	$99.90
Rate for Payer: Cigna Commercial	$105.45
Rate for Payer: Cigna Medicare	$99.90
Rate for Payer: Medicaid All Medicaid	$102.12
Rate for Payer: Medicare All Medicare	$77.70
Rate for Payer: Monida Allegiance	$105.45
Rate for Payer: Monida First Choice Health	$107.67
Rate for Payer: Monida Montana Health Co-op	$105.45
Rate for Payer: Monida PacificSource	$105.45

PRO FEE LAC REPAIR SIMPLE 7.6-12.5CM

Professional

Both

$138.00

Service Code	CPT 12004
Hospital Charge Code	712004
Hospital Revenue Code	981
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$138.00
Rate for Payer: Aetna Commercial	$131.10
Rate for Payer: Aetna Medicare	$124.20
Rate for Payer: BCBS MT CHIP	$124.20
Rate for Payer: BCBS MT Closed Plan Network	$131.10
Rate for Payer: BCBS MT HealthLink	$124.20
Rate for Payer: BCBS MT Medicare	$124.20
Rate for Payer: BCBS MT POS	$131.10
Rate for Payer: BCBS MT Traditional	$138.00
Rate for Payer: Cash Price	$124.20
Rate for Payer: Cigna Commercial	$131.10
Rate for Payer: Cigna Medicare	$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

PRO FEE MAJOR JOINT INJ W/O US 20610

Professional

Both

$234.00

Service Code	CPT 20610
Hospital Charge Code	720610
Hospital Revenue Code	964
Min. Negotiated Rate	$163.80
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna Commercial	$222.30
Rate for Payer: Aetna Medicare	$210.60
Rate for Payer: BCBS MT CHIP	$210.60
Rate for Payer: BCBS MT Closed Plan Network	$222.30
Rate for Payer: BCBS MT HealthLink	$210.60
Rate for Payer: BCBS MT Medicare	$210.60
Rate for Payer: BCBS MT POS	$222.30
Rate for Payer: BCBS MT Traditional	$234.00
Rate for Payer: Cash Price	$210.60
Rate for Payer: Cigna Commercial	$222.30
Rate for Payer: Cigna Medicare	$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 MRA ABDOMEN W WO CONTRAST

Professional

Both

$252.00

Service Code	CPT 74185
Hospital Charge Code	50002211
Hospital Revenue Code	972
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$244.44
Rate for Payer: Aetna Commercial	$239.40
Rate for Payer: Aetna Medicare	$226.80
Rate for Payer: Cash Price	$226.80
Rate for Payer: Medicaid All Medicaid	$231.84
Rate for Payer: Medicare All Medicare	$176.40
Rate for Payer: Monida Allegiance	$239.40
Rate for Payer: Monida First Choice Health	$244.44
Rate for Payer: Monida Montana Health Co-op	$239.40
Rate for Payer: Monida PacificSource	$239.40

PROFEE MR ABDOMEN W CONTRAST

Professional

Both

$243.00

Service Code	CPT 74182
Hospital Charge Code	50002090
Hospital Revenue Code	972
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$235.71
Rate for Payer: Aetna Commercial	$230.85
Rate for Payer: Aetna Medicare	$218.70
Rate for Payer: Cash Price	$218.70
Rate for Payer: Medicaid All Medicaid	$223.56
Rate for Payer: Medicare All Medicare	$170.10
Rate for Payer: Monida Allegiance	$230.85
Rate for Payer: Monida First Choice Health	$235.71
Rate for Payer: Monida Montana Health Co-op	$230.85
Rate for Payer: Monida PacificSource	$230.85

PROFEE MR ABDOMEN WO CONTRAST

Professional

Both

$205.00

Service Code	CPT 74181
Hospital Charge Code	50002092
Hospital Revenue Code	972
Min. Negotiated Rate	$143.50
Max. Negotiated Rate	$198.85
Rate for Payer: Aetna Commercial	$194.75
Rate for Payer: Aetna Medicare	$184.50
Rate for Payer: Cash Price	$184.50
Rate for Payer: Medicaid All Medicaid	$188.60
Rate for Payer: Medicare All Medicare	$143.50
Rate for Payer: Monida Allegiance	$194.75
Rate for Payer: Monida First Choice Health	$198.85
Rate for Payer: Monida Montana Health Co-op	$194.75
Rate for Payer: Monida PacificSource	$194.75

PROFEE MR ABDOMEN W WO CONTRAST

Professional

Both

$312.00

Service Code	CPT 74183
Hospital Charge Code	50002091
Hospital Revenue Code	972
Min. Negotiated Rate	$218.40
Max. Negotiated Rate	$302.64
Rate for Payer: Aetna Commercial	$296.40
Rate for Payer: Aetna Medicare	$280.80
Rate for Payer: Cash Price	$280.80
Rate for Payer: Medicaid All Medicaid	$287.04
Rate for Payer: Medicare All Medicare	$218.40
Rate for Payer: Monida Allegiance	$296.40
Rate for Payer: Monida First Choice Health	$302.64
Rate for Payer: Monida Montana Health Co-op	$296.40
Rate for Payer: Monida PacificSource	$296.40

PROFEE MRA CHEST W WO CONTRAST

Professional

Both

$252.00

Service Code	CPT 71555
Hospital Charge Code	50002212
Hospital Revenue Code	972
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$244.44
Rate for Payer: Aetna Commercial	$239.40
Rate for Payer: Aetna Medicare	$226.80
Rate for Payer: Cash Price	$226.80
Rate for Payer: Medicaid All Medicaid	$231.84
Rate for Payer: Medicare All Medicare	$176.40
Rate for Payer: Monida Allegiance	$239.40
Rate for Payer: Monida First Choice Health	$244.44
Rate for Payer: Monida Montana Health Co-op	$239.40
Rate for Payer: Monida PacificSource	$239.40

PROFEE MRA HEAD W CONTRAST

Professional

Both

$168.00

Service Code	CPT 70545
Hospital Charge Code	50002213
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 MRA HEAD WO CONTRAST

Professional

Both

$168.00

Service Code	CPT 70544
Hospital Charge Code	50002215
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 MRA HEAD W WO CONTRAST

Professional

Both

$208.00

Service Code	CPT 70546
Hospital Charge Code	50002214
Hospital Revenue Code	972
Min. Negotiated Rate	$145.60
Max. Negotiated Rate	$201.76
Rate for Payer: Aetna Commercial	$197.60
Rate for Payer: Aetna Medicare	$187.20
Rate for Payer: Cash Price	$187.20
Rate for Payer: Medicaid All Medicaid	$191.36
Rate for Payer: Medicare All Medicare	$145.60
Rate for Payer: Monida Allegiance	$197.60
Rate for Payer: Monida First Choice Health	$201.76
Rate for Payer: Monida Montana Health Co-op	$197.60
Rate for Payer: Monida PacificSource	$197.60

PROFEE MRA NECK W CONTRAST

Professional

Both

$211.00

Service Code	CPT 70548
Hospital Charge Code	50002216
Hospital Revenue Code	972
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$204.67
Rate for Payer: Aetna Commercial	$200.45
Rate for Payer: Aetna Medicare	$189.90
Rate for Payer: Cash Price	$189.90
Rate for Payer: Medicaid All Medicaid	$194.12
Rate for Payer: Medicare All Medicare	$147.70
Rate for Payer: Monida Allegiance	$200.45
Rate for Payer: Monida First Choice Health	$204.67
Rate for Payer: Monida Montana Health Co-op	$200.45
Rate for Payer: Monida PacificSource	$200.45

PROFEE MRA NECK WO CONTRAST

Professional

Both

$169.00

Service Code	CPT 70547
Hospital Charge Code	50002218
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 MRA NECK W WO CONTRAST

Professional

Both

$254.00

Service Code	CPT 70549
Hospital Charge Code	50002217
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 MR ANKLE LT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002093
Hospital Revenue Code	972
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$222.13
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: Cash Price	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

PROFEE MR ANKLE LT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002095
Hospital Revenue Code	972
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$185.27
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: Cash Price	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

PROFEE MR ANKLE LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002094
Hospital Revenue Code	972
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$296.82
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: Cash Price	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

PROFEE MR ANKLE RT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002096
Hospital Revenue Code	972
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$222.13
Rate for Payer: Aetna Commercial	$217.55
Rate for Payer: Aetna Medicare	$206.10
Rate for Payer: Cash Price	$206.10
Rate for Payer: Medicaid All Medicaid	$210.68
Rate for Payer: Medicare All Medicare	$160.30
Rate for Payer: Monida Allegiance	$217.55
Rate for Payer: Monida First Choice Health	$222.13
Rate for Payer: Monida Montana Health Co-op	$217.55
Rate for Payer: Monida PacificSource	$217.55

PROFEE MR ANKLE RT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002098
Hospital Revenue Code	972
Min. Negotiated Rate	$133.70
Max. Negotiated Rate	$185.27
Rate for Payer: Aetna Commercial	$181.45
Rate for Payer: Aetna Medicare	$171.90
Rate for Payer: Cash Price	$171.90
Rate for Payer: Medicaid All Medicaid	$175.72
Rate for Payer: Medicare All Medicare	$133.70
Rate for Payer: Monida Allegiance	$181.45
Rate for Payer: Monida First Choice Health	$185.27
Rate for Payer: Monida Montana Health Co-op	$181.45
Rate for Payer: Monida PacificSource	$181.45

PROFEE MR ANKLE RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002097
Hospital Revenue Code	972
Min. Negotiated Rate	$214.20
Max. Negotiated Rate	$296.82
Rate for Payer: Aetna Commercial	$290.70
Rate for Payer: Aetna Medicare	$275.40
Rate for Payer: Cash Price	$275.40
Rate for Payer: Medicaid All Medicaid	$281.52
Rate for Payer: Medicare All Medicare	$214.20
Rate for Payer: Monida Allegiance	$290.70
Rate for Payer: Monida First Choice Health	$296.82
Rate for Payer: Monida Montana Health Co-op	$290.70
Rate for Payer: Monida PacificSource	$290.70

PROFEE MR BRAIN AND IAC W WO CONTRAST

Professional

Both

$325.00

Service Code	CPT 70553
Hospital Charge Code	50002445
Hospital Revenue Code	972
Min. Negotiated Rate	$227.50
Max. Negotiated Rate	$315.25
Rate for Payer: Aetna Commercial	$308.75
Rate for Payer: Aetna Medicare	$292.50
Rate for Payer: Cash Price	$292.50
Rate for Payer: Medicaid All Medicaid	$299.00
Rate for Payer: Medicare All Medicare	$227.50
Rate for Payer: Monida Allegiance	$308.75
Rate for Payer: Monida First Choice Health	$315.25
Rate for Payer: Monida Montana Health Co-op	$308.75
Rate for Payer: Monida PacificSource	$308.75

Know your out-of-pocket cost for care.

All Charges