Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE XR FOREARM, LEFT AP/LATERAL VIEW

Professional

Both

$23.00

Service Code	CPT 73090
Hospital Charge Code	50002271
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR FOREARM, RIGHT AP/LATERAL VIEW

Professional

Both

$23.00

Service Code	CPT 73090
Hospital Charge Code	50002272
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR GUIDANCE SPINAL INJ 77003

Professional

Both

$144.00

Service Code	CPT 77003
Hospital Charge Code	50002273
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 XR HAND LT 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73120
Hospital Charge Code	50002274
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PROFEE XR HAND LT 3 VIEWS

Professional

Both

$25.00

Service Code	CPT 73130
Hospital Charge Code	50002275
Hospital Revenue Code	972
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$24.25
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

PROFEE XR HAND RT 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73120
Hospital Charge Code	50002276
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PROFEE XR HAND RT 3 VIEWS

Professional

Both

$25.00

Service Code	CPT 73130
Hospital Charge Code	50002277
Hospital Revenue Code	972
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$24.25
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

PROFEE XR HANDS BILATERAL 1 VIEW

Professional

Both

$24.00

Service Code	CPT 73120
Hospital Charge Code	50002278
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PROFEE XR HANDS BILATERAL 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73120
Hospital Charge Code	50002279
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PROFEE XR HANDS BILATERAL 3 VIEWS

Professional

Both

$25.00

Service Code	CPT 73130
Hospital Charge Code	50002280
Hospital Revenue Code	972
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$24.25
Rate for Payer: Aetna Commercial	$23.75
Rate for Payer: Aetna Medicare	$22.50
Rate for Payer: Cash Price	$22.50
Rate for Payer: Medicaid All Medicaid	$23.00
Rate for Payer: Medicare All Medicare	$17.50
Rate for Payer: Monida Allegiance	$23.75
Rate for Payer: Monida First Choice Health	$24.25
Rate for Payer: Monida Montana Health Co-op	$23.75
Rate for Payer: Monida PacificSource	$23.75

PROFEE XR HIP LT 1 VIEW

Professional

Both

$27.00

Service Code	CPT 73501
Hospital Charge Code	50002281
Hospital Revenue Code	972
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$26.19
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

PROFEE XR HIP LT 2 VIEWS

Professional

Both

$31.00

Service Code	CPT 73502
Hospital Charge Code	50002282
Hospital Revenue Code	972
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$30.07
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

PROFEE XR HIP RT 1 VIEW

Professional

Both

$27.00

Service Code	CPT 73501
Hospital Charge Code	50002283
Hospital Revenue Code	972
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$26.19
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

PROFEE XR HIP RT 2 VIEWS

Professional

Both

$31.00

Service Code	CPT 73502
Hospital Charge Code	50002284
Hospital Revenue Code	972
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$30.07
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

PROFEE XR HIPS BILAT 2 VIEWS W PELVIS

Professional

Both

$31.00

Service Code	CPT 73521
Hospital Charge Code	50002285
Hospital Revenue Code	972
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$30.07
Rate for Payer: Aetna Commercial	$29.45
Rate for Payer: Aetna Medicare	$27.90
Rate for Payer: Cash Price	$27.90
Rate for Payer: Medicaid All Medicaid	$28.52
Rate for Payer: Medicare All Medicare	$21.70
Rate for Payer: Monida Allegiance	$29.45
Rate for Payer: Monida First Choice Health	$30.07
Rate for Payer: Monida Montana Health Co-op	$29.45
Rate for Payer: Monida PacificSource	$29.45

PROFEE XR HUMERUS LT 2 VIEWS

Professional

Both

$23.00

Service Code	CPT 73060
Hospital Charge Code	50002286
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR HUMERUS RT 2 VIEWS

Professional

Both

$23.00

Service Code	CPT 73060
Hospital Charge Code	50002287
Hospital Revenue Code	972
Min. Negotiated Rate	$16.10
Max. Negotiated Rate	$22.31
Rate for Payer: Aetna Commercial	$21.85
Rate for Payer: Aetna Medicare	$20.70
Rate for Payer: Cash Price	$20.70
Rate for Payer: Medicaid All Medicaid	$21.16
Rate for Payer: Medicare All Medicare	$16.10
Rate for Payer: Monida Allegiance	$21.85
Rate for Payer: Monida First Choice Health	$22.31
Rate for Payer: Monida Montana Health Co-op	$21.85
Rate for Payer: Monida PacificSource	$21.85

PROFEE XR JOINT SURVEY BILATERAL 2 VIEWS

Professional

Both

$48.00

Service Code	CPT 77077
Hospital Charge Code	50002288
Hospital Revenue Code	972
Min. Negotiated Rate	$33.60
Max. Negotiated Rate	$46.56
Rate for Payer: Aetna Commercial	$45.60
Rate for Payer: Aetna Medicare	$43.20
Rate for Payer: Cash Price	$43.20
Rate for Payer: Medicaid All Medicaid	$44.16
Rate for Payer: Medicare All Medicare	$33.60
Rate for Payer: Monida Allegiance	$45.60
Rate for Payer: Monida First Choice Health	$46.56
Rate for Payer: Monida Montana Health Co-op	$45.60
Rate for Payer: Monida PacificSource	$45.60

PROFEE XR KNEE LT 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73560
Hospital Charge Code	50002289
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PROFEE XR KNEE LT 3 VIEWS

Professional

Both

$27.00

Service Code	CPT 73562
Hospital Charge Code	50002290
Hospital Revenue Code	972
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$26.19
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

PROFEE XR KNEE LT COMPLETE

Professional

Both

$32.00

Service Code	CPT 73564
Hospital Charge Code	50002291
Hospital Revenue Code	972
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$31.04
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

PROFEE XR KNEE RT 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73560
Hospital Charge Code	50002292
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

PROFEE XR KNEE RT 3 VIEWS

Professional

Both

$27.00

Service Code	CPT 73562
Hospital Charge Code	50002293
Hospital Revenue Code	972
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$26.19
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: Cash Price	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

PROFEE XR KNEE RT COMPLETE

Professional

Both

$32.00

Service Code	CPT 73564
Hospital Charge Code	50002294
Hospital Revenue Code	972
Min. Negotiated Rate	$22.40
Max. Negotiated Rate	$31.04
Rate for Payer: Aetna Commercial	$30.40
Rate for Payer: Aetna Medicare	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Medicaid All Medicaid	$29.44
Rate for Payer: Medicare All Medicare	$22.40
Rate for Payer: Monida Allegiance	$30.40
Rate for Payer: Monida First Choice Health	$31.04
Rate for Payer: Monida Montana Health Co-op	$30.40
Rate for Payer: Monida PacificSource	$30.40

PROFEE XR KNEES BILATERAL 1 VIEW

Professional

Both

$24.00

Service Code	CPT 73560
Hospital Charge Code	50002295
Hospital Revenue Code	972
Min. Negotiated Rate	$16.80
Max. Negotiated Rate	$23.28
Rate for Payer: Aetna Commercial	$22.80
Rate for Payer: Aetna Medicare	$21.60
Rate for Payer: Cash Price	$21.60
Rate for Payer: Medicaid All Medicaid	$22.08
Rate for Payer: Medicare All Medicare	$16.80
Rate for Payer: Monida Allegiance	$22.80
Rate for Payer: Monida First Choice Health	$23.28
Rate for Payer: Monida Montana Health Co-op	$22.80
Rate for Payer: Monida PacificSource	$22.80

Know your out-of-pocket cost for care.

All Charges