Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE MR BRAIN W CONTRAST

Professional

Both

$252.00

Service Code	CPT 70552
Hospital Charge Code	50002099
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 BRAIN WO CONTRAST

Professional

Both

$208.00

Service Code	CPT 70551
Hospital Charge Code	50002101
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 MR BRAIN W WO CONTRAST

Professional

Both

$325.00

Service Code	CPT 70553
Hospital Charge Code	50002100
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

PROFEE MR CERVICAL SPINE W CONTRAST

Professional

Both

$255.00

Service Code	CPT 72142
Hospital Charge Code	50002102
Hospital Revenue Code	972
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$247.35
Rate for Payer: Aetna Commercial	$242.25
Rate for Payer: Aetna Medicare	$229.50
Rate for Payer: Cash Price	$229.50
Rate for Payer: Medicaid All Medicaid	$234.60
Rate for Payer: Medicare All Medicare	$178.50
Rate for Payer: Monida Allegiance	$242.25
Rate for Payer: Monida First Choice Health	$247.35
Rate for Payer: Monida Montana Health Co-op	$242.25
Rate for Payer: Monida PacificSource	$242.25

PROFEE MR CERVICAL SPINE WO CONTRAST

Professional

Both

$209.00

Service Code	CPT 72141
Hospital Charge Code	50002104
Hospital Revenue Code	972
Min. Negotiated Rate	$146.30
Max. Negotiated Rate	$202.73
Rate for Payer: Aetna Commercial	$198.55
Rate for Payer: Aetna Medicare	$188.10
Rate for Payer: Cash Price	$188.10
Rate for Payer: Medicaid All Medicaid	$192.28
Rate for Payer: Medicare All Medicare	$146.30
Rate for Payer: Monida Allegiance	$198.55
Rate for Payer: Monida First Choice Health	$202.73
Rate for Payer: Monida Montana Health Co-op	$198.55
Rate for Payer: Monida PacificSource	$198.55

PROFEE MR CERVICAL SPINE W WO CONTRAST

Professional

Both

$326.00

Service Code	CPT 72156
Hospital Charge Code	50002103
Hospital Revenue Code	972
Min. Negotiated Rate	$228.20
Max. Negotiated Rate	$316.22
Rate for Payer: Aetna Commercial	$309.70
Rate for Payer: Aetna Medicare	$293.40
Rate for Payer: Cash Price	$293.40
Rate for Payer: Medicaid All Medicaid	$299.92
Rate for Payer: Medicare All Medicare	$228.20
Rate for Payer: Monida Allegiance	$309.70
Rate for Payer: Monida First Choice Health	$316.22
Rate for Payer: Monida Montana Health Co-op	$309.70
Rate for Payer: Monida PacificSource	$309.70

PROFEE MR CHEST W CONTRAST

Professional

Both

$243.00

Service Code	CPT 71551
Hospital Charge Code	50002105
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 CHEST WO CONTRAST

Professional

Both

$206.00

Service Code	CPT 71550
Hospital Charge Code	50002107
Hospital Revenue Code	972
Min. Negotiated Rate	$144.20
Max. Negotiated Rate	$199.82
Rate for Payer: Aetna Commercial	$195.70
Rate for Payer: Aetna Medicare	$185.40
Rate for Payer: Cash Price	$185.40
Rate for Payer: Medicaid All Medicaid	$189.52
Rate for Payer: Medicare All Medicare	$144.20
Rate for Payer: Monida Allegiance	$195.70
Rate for Payer: Monida First Choice Health	$199.82
Rate for Payer: Monida Montana Health Co-op	$195.70
Rate for Payer: Monida PacificSource	$195.70

PROFEE MR CHEST W WO CONTRAST

Professional

Both

$321.00

Service Code	CPT 71552
Hospital Charge Code	50002106
Hospital Revenue Code	972
Min. Negotiated Rate	$224.70
Max. Negotiated Rate	$311.37
Rate for Payer: Aetna Commercial	$304.95
Rate for Payer: Aetna Medicare	$288.90
Rate for Payer: Cash Price	$288.90
Rate for Payer: Medicaid All Medicaid	$295.32
Rate for Payer: Medicare All Medicare	$224.70
Rate for Payer: Monida Allegiance	$304.95
Rate for Payer: Monida First Choice Health	$311.37
Rate for Payer: Monida Montana Health Co-op	$304.95
Rate for Payer: Monida PacificSource	$304.95

PROFEE MR ELBOW LT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73222
Hospital Charge Code	50002108
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 ELBOW LT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73221
Hospital Charge Code	50002110
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 ELBOW LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73223
Hospital Charge Code	50002109
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 ELBOW RT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73222
Hospital Charge Code	50002111
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 ELBOW RT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73221
Hospital Charge Code	50002113
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 ELBOW RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73223
Hospital Charge Code	50002112
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 FEMUR LT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73719
Hospital Charge Code	50002114
Hospital Revenue Code	972
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$221.16
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

PROFEE MR FEMUR LT WO CONTRAST

Professional

Both

$190.00

Service Code	CPT 73718
Hospital Charge Code	50002116
Hospital Revenue Code	972
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$184.30
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

PROFEE MR FEMUR LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73720
Hospital Charge Code	50002115
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 FEMUR RT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73719
Hospital Charge Code	50002117
Hospital Revenue Code	972
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$221.16
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

PROFEE MR FEMUR RT WO CONTRAST

Professional

Both

$190.00

Service Code	CPT 73718
Hospital Charge Code	50002119
Hospital Revenue Code	972
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$184.30
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

PROFEE MR FEMUR RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73720
Hospital Charge Code	50002118
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 FOOT LT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73719
Hospital Charge Code	50002120
Hospital Revenue Code	972
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$221.16
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

PROFEE MR FOOT LT WO CONTRAST

Professional

Both

$190.00

Service Code	CPT 73718
Hospital Charge Code	50002122
Hospital Revenue Code	972
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$184.30
Rate for Payer: Aetna Commercial	$180.50
Rate for Payer: Aetna Medicare	$171.00
Rate for Payer: Cash Price	$171.00
Rate for Payer: Medicaid All Medicaid	$174.80
Rate for Payer: Medicare All Medicare	$133.00
Rate for Payer: Monida Allegiance	$180.50
Rate for Payer: Monida First Choice Health	$184.30
Rate for Payer: Monida Montana Health Co-op	$180.50
Rate for Payer: Monida PacificSource	$180.50

PROFEE MR FOOT LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73720
Hospital Charge Code	50002121
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 FOOT RT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73719
Hospital Charge Code	50002123
Hospital Revenue Code	972
Min. Negotiated Rate	$159.60
Max. Negotiated Rate	$221.16
Rate for Payer: Aetna Commercial	$216.60
Rate for Payer: Aetna Medicare	$205.20
Rate for Payer: Cash Price	$205.20
Rate for Payer: Medicaid All Medicaid	$209.76
Rate for Payer: Medicare All Medicare	$159.60
Rate for Payer: Monida Allegiance	$216.60
Rate for Payer: Monida First Choice Health	$221.16
Rate for Payer: Monida Montana Health Co-op	$216.60
Rate for Payer: Monida PacificSource	$216.60

Know your out-of-pocket cost for care.

All Charges