Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE XR KNEES BILATERAL 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73560
Hospital Charge Code	50002296
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 KNEES BILATERAL COMPLETE

Professional

Both

$32.00

Service Code	CPT 73564
Hospital Charge Code	50002297
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 STAND AP

Professional

Both

$25.00

Service Code	CPT 73565
Hospital Charge Code	50002298
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 LOWER EXTREMITY LT INFANT

Professional

Both

$23.00

Service Code	CPT 73592
Hospital Charge Code	50002299
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 LOWER EXTREMITY RT INFANT

Professional

Both

$23.00

Service Code	CPT 73592
Hospital Charge Code	50002300
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 LUMBAR SPINE 2 OR 3 VIEWS

Professional

Both

$31.00

Service Code	CPT 72100
Hospital Charge Code	50002301
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 LUMBAR SPINE 3 VIEWS

Professional

Both

$31.00

Service Code	CPT 72100
Hospital Charge Code	50002302
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 LUMBAR SPINE BEND ONLY

Professional

Both

$31.00

Service Code	CPT 72120
Hospital Charge Code	50002303
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 LUMBAR SPINE COMPLETE 4 VIEWS

Professional

Both

$37.00

Service Code	CPT 72110
Hospital Charge Code	50002304
Hospital Revenue Code	972
Min. Negotiated Rate	$25.90
Max. Negotiated Rate	$35.89
Rate for Payer: Aetna Commercial	$35.15
Rate for Payer: Aetna Medicare	$33.30
Rate for Payer: Cash Price	$33.30
Rate for Payer: Medicaid All Medicaid	$34.04
Rate for Payer: Medicare All Medicare	$25.90
Rate for Payer: Monida Allegiance	$35.15
Rate for Payer: Monida First Choice Health	$35.89
Rate for Payer: Monida Montana Health Co-op	$35.15
Rate for Payer: Monida PacificSource	$35.15

PROFEE XR LUMBOSACRAL WITH FLEX AND EXT

Professional

Both

$43.00

Service Code	CPT 72114
Hospital Charge Code	50002305
Hospital Revenue Code	972
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$41.71
Rate for Payer: Aetna Commercial	$40.85
Rate for Payer: Aetna Medicare	$38.70
Rate for Payer: Cash Price	$38.70
Rate for Payer: Medicaid All Medicaid	$39.56
Rate for Payer: Medicare All Medicare	$30.10
Rate for Payer: Monida Allegiance	$40.85
Rate for Payer: Monida First Choice Health	$41.71
Rate for Payer: Monida Montana Health Co-op	$40.85
Rate for Payer: Monida PacificSource	$40.85

PROFEE XR MANDIBLE 4 VIEWS

Professional

Both

$35.00

Service Code	CPT 70110
Hospital Charge Code	50002306
Hospital Revenue Code	972
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$33.95
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: Cash Price	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

PROFEE XR MANDIBLE BILATERAL 1 OR 2 VIEW

Professional

Both

$26.00

Service Code	CPT 70100
Hospital Charge Code	50002307
Hospital Revenue Code	972
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$25.22
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

PROFEE XR MANDIBLE LT 1-2 VIEW

Professional

Both

$26.00

Service Code	CPT 70100
Hospital Charge Code	50002308
Hospital Revenue Code	972
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$25.22
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

PROFEE XR MANDIBLE RT 1-2 VIEW

Professional

Both

$26.00

Service Code	CPT 70100
Hospital Charge Code	50002309
Hospital Revenue Code	972
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$25.22
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

PROFEEXR MASTOIDS GREATER THN 3 PER SIDE

Professional

Both

$48.00

Service Code	CPT 70130
Hospital Charge Code	50002310
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 MASTOIDS LESS THAN 3 PER SIDE

Professional

Both

$26.00

Service Code	CPT 70120
Hospital Charge Code	50002311
Hospital Revenue Code	972
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$25.22
Rate for Payer: Aetna Commercial	$24.70
Rate for Payer: Aetna Medicare	$23.40
Rate for Payer: Cash Price	$23.40
Rate for Payer: Medicaid All Medicaid	$23.92
Rate for Payer: Medicare All Medicare	$18.20
Rate for Payer: Monida Allegiance	$24.70
Rate for Payer: Monida First Choice Health	$25.22
Rate for Payer: Monida Montana Health Co-op	$24.70
Rate for Payer: Monida PacificSource	$24.70

PROFEE XR NASAL BONES 3 VIEWS

Professional

Both

$25.00

Service Code	CPT 70160
Hospital Charge Code	50002312
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 OP MAJOR JOINT INJ W/US 20611

Professional

Both

$304.00

Service Code	CPT 20611
Hospital Charge Code	50002313
Hospital Revenue Code	972
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$294.88
Rate for Payer: Aetna Commercial	$288.80
Rate for Payer: Aetna Medicare	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Medicaid All Medicaid	$279.68
Rate for Payer: Medicare All Medicare	$212.80
Rate for Payer: Monida Allegiance	$288.80
Rate for Payer: Monida First Choice Health	$294.88
Rate for Payer: Monida Montana Health Co-op	$288.80
Rate for Payer: Monida PacificSource	$288.80

PROFEE XR ORBITS 1 VIEW

Professional

Both

$31.00

Service Code	CPT 70190
Hospital Charge Code	50002314
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 ORBITS COMPLETE 4 VIEWS

Professional

Both

$39.00

Service Code	CPT 70200
Hospital Charge Code	50002315
Hospital Revenue Code	972
Min. Negotiated Rate	$27.30
Max. Negotiated Rate	$37.83
Rate for Payer: Aetna Commercial	$37.05
Rate for Payer: Aetna Medicare	$35.10
Rate for Payer: Cash Price	$35.10
Rate for Payer: Medicaid All Medicaid	$35.88
Rate for Payer: Medicare All Medicare	$27.30
Rate for Payer: Monida Allegiance	$37.05
Rate for Payer: Monida First Choice Health	$37.83
Rate for Payer: Monida Montana Health Co-op	$37.05
Rate for Payer: Monida PacificSource	$37.05

PROFEE XR PELVIS 1 VIEW

Professional

Both

$25.00

Service Code	CPT 72170
Hospital Charge Code	50002316
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 PELVIS 2 VIEWS

Professional

Both

$25.00

Service Code	CPT 72170
Hospital Charge Code	50002317
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 PELVIS 3 VIEWS

Professional

Both

$35.00

Service Code	CPT 72190
Hospital Charge Code	50002318
Hospital Revenue Code	972
Min. Negotiated Rate	$24.50
Max. Negotiated Rate	$33.95
Rate for Payer: Aetna Commercial	$33.25
Rate for Payer: Aetna Medicare	$31.50
Rate for Payer: Cash Price	$31.50
Rate for Payer: Medicaid All Medicaid	$32.20
Rate for Payer: Medicare All Medicare	$24.50
Rate for Payer: Monida Allegiance	$33.25
Rate for Payer: Monida First Choice Health	$33.95
Rate for Payer: Monida Montana Health Co-op	$33.25
Rate for Payer: Monida PacificSource	$33.25

PROFEE XR RIBS BILATERAL 3 VIEWS

Professional

Both

$40.00

Service Code	CPT 71110
Hospital Charge Code	50002319
Hospital Revenue Code	972
Min. Negotiated Rate	$28.00
Max. Negotiated Rate	$38.80
Rate for Payer: Aetna Commercial	$38.00
Rate for Payer: Aetna Medicare	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Medicaid All Medicaid	$36.80
Rate for Payer: Medicare All Medicare	$28.00
Rate for Payer: Monida Allegiance	$38.00
Rate for Payer: Monida First Choice Health	$38.80
Rate for Payer: Monida Montana Health Co-op	$38.00
Rate for Payer: Monida PacificSource	$38.00

PROFEE XR RIBS LT 2 VIEWS

Professional

Both

$31.00

Service Code	CPT 71100
Hospital Charge Code	50002321
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

Know your out-of-pocket cost for care.

All Charges