Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE MR FOOT RT WO CONTRAST

Professional

Both

$190.00

Service Code	CPT 73718
Hospital Charge Code	50002125
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 RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73720
Hospital Charge Code	50002124
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 FOREARM LT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73219
Hospital Charge Code	50002126
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 FOREARM LT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73218
Hospital Charge Code	50002128
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 FOREARM LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73220
Hospital Charge Code	50002127
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 FOREARM RT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73219
Hospital Charge Code	50002129
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 FOREARM RT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73218
Hospital Charge Code	50002131
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 FOREARM RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73220
Hospital Charge Code	50002130
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 HAND LT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73219
Hospital Charge Code	50002132
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 HAND LT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73218
Hospital Charge Code	50002134
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 HAND LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73220
Hospital Charge Code	50002133
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 HAND RT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73219
Hospital Charge Code	50002135
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 HAND RT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73218
Hospital Charge Code	50002137
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 HAND RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73220
Hospital Charge Code	50002136
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 HIP LT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002138
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 HIP LT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002140
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 HIP LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002139
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 HIP RT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002141
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 HIP RT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002143
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 HIP RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002142
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 HUMERUS LT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73219
Hospital Charge Code	50002144
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 HUMERUS LT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73218
Hospital Charge Code	50002146
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 HUMERUS LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73220
Hospital Charge Code	50002145
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 HUMERUS RT W CONTRAST

Professional

Both

$228.00

Service Code	CPT 73219
Hospital Charge Code	50002147
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 HUMERUS RT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73218
Hospital Charge Code	50002149
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

Know your out-of-pocket cost for care.

All Charges