Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE MR HUMERUS RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73220
Hospital Charge Code	50002148
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 JNT LWR EXT W CON LT

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002150
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 JNT LWR EXT W CON RT

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002151
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 JNT LWR EXT W/O CON LT

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002152
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 JNT LWR XT WO CON RT

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002153
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 JNT LWR XT WO&W CON L

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002154
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 JNT LWR XT WO&W CON R

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002155
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 JNT UPPR EXT W CON LT

Professional

Both

$229.00

Service Code	CPT 73222
Hospital Charge Code	50002156
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 JNT UPPR EXT W CON RT

Professional

Both

$229.00

Service Code	CPT 73222
Hospital Charge Code	50002157
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 JNT UPPR EXT WO CO LT

Professional

Both

$191.00

Service Code	CPT 73221
Hospital Charge Code	50002158
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 JNT UPPR EXT WO CON R

Professional

Both

$191.00

Service Code	CPT 73221
Hospital Charge Code	50002159
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 JNT UPPR EXT WO&W CN LT

Professional

Both

$306.00

Service Code	CPT 73223
Hospital Charge Code	50002160
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 JNT UPPR EXT WO&W CN RT

Professional

Both

$306.00

Service Code	CPT 73223
Hospital Charge Code	50002161
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 KNEE LT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002162
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 KNEE LT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002164
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 KNEE LT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002163
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 KNEE RT W CONTRAST

Professional

Both

$229.00

Service Code	CPT 73722
Hospital Charge Code	50002165
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 KNEE RT WO CONTRAST

Professional

Both

$191.00

Service Code	CPT 73721
Hospital Charge Code	50002167
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 KNEE RT W WO CONTRAST

Professional

Both

$306.00

Service Code	CPT 73723
Hospital Charge Code	50002166
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 LUMBAR SPINE W CONTRAST

Professional

Both

$254.00

Service Code	CPT 72149
Hospital Charge Code	50002168
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 LUMBAR SPINE WO CONTRAST

Professional

Both

$209.00

Service Code	CPT 72148
Hospital Charge Code	50002170
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 LUMBAR SPINE W WO CONTRAST

Professional

Both

$326.00

Service Code	CPT 72158
Hospital Charge Code	50002169
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 LWR EXT W CON LT

Professional

Both

$228.00

Service Code	CPT 73719
Hospital Charge Code	50002171
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 LWR EXT W CON RT

Professional

Both

$228.00

Service Code	CPT 73719
Hospital Charge Code	50002172
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 LWR XT WO CON LT

Professional

Both

$190.00

Service Code	CPT 73718
Hospital Charge Code	50002173
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

Know your out-of-pocket cost for care.

All Charges