Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

PROFEE XR SKULL COMPLETE 4 VIEWS

Professional

Both

$39.00

Service Code	CPT 70260
Hospital Charge Code	50002346
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 SOFT TISSUE NECK

Professional

Both

$26.00

Service Code	CPT 70360
Hospital Charge Code	50002347
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 STERNUM

Professional

Both

$27.00

Service Code	CPT 71120
Hospital Charge Code	50002348
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 THORACIC SPINE 1 VIEW

Professional

Both

$23.00

Service Code	CPT 72020
Hospital Charge Code	50002349
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 THORACIC SPINE 2 VIEWS

Professional

Both

$28.00

Service Code	CPT 72070
Hospital Charge Code	50002350
Hospital Revenue Code	972
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$27.16
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: Cash Price	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

PROFEE XR THORACIC SPINE 3 VIEWS

Professional

Both

$31.00

Service Code	CPT 72072
Hospital Charge Code	50002351
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 THORACIC SPINE 4 VIEWS

Professional

Both

$34.00

Service Code	CPT 72074
Hospital Charge Code	50002352
Hospital Revenue Code	972
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$32.98
Rate for Payer: Aetna Commercial	$32.30
Rate for Payer: Aetna Medicare	$30.60
Rate for Payer: Cash Price	$30.60
Rate for Payer: Medicaid All Medicaid	$31.28
Rate for Payer: Medicare All Medicare	$23.80
Rate for Payer: Monida Allegiance	$32.30
Rate for Payer: Monida First Choice Health	$32.98
Rate for Payer: Monida Montana Health Co-op	$32.30
Rate for Payer: Monida PacificSource	$32.30

PROFEE XR THORACOLUMBAR JUNCTION 2 VIEWS

Professional

Both

$29.00

Service Code	CPT 72080
Hospital Charge Code	50002353
Hospital Revenue Code	972
Min. Negotiated Rate	$20.30
Max. Negotiated Rate	$28.13
Rate for Payer: Aetna Commercial	$27.55
Rate for Payer: Aetna Medicare	$26.10
Rate for Payer: Cash Price	$26.10
Rate for Payer: Medicaid All Medicaid	$26.68
Rate for Payer: Medicare All Medicare	$20.30
Rate for Payer: Monida Allegiance	$27.55
Rate for Payer: Monida First Choice Health	$28.13
Rate for Payer: Monida Montana Health Co-op	$27.55
Rate for Payer: Monida PacificSource	$27.55

PROFEE XR TIB FIB BILATERAL

Professional

Both

$23.00

Service Code	CPT 73590
Hospital Charge Code	50002354
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 TIB FIB LT

Professional

Both

$23.00

Service Code	CPT 73590
Hospital Charge Code	50002355
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 TIB FIB RT

Professional

Both

$23.00

Service Code	CPT 73590
Hospital Charge Code	50002356
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 TMJ

Professional

Both

$26.00

Service Code	CPT 70328
Hospital Charge Code	50002357
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 TMJ LT

Professional

Both

$33.00

Service Code	CPT 70330
Hospital Charge Code	50002358
Hospital Revenue Code	972
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$32.01
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: Cash Price	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

PROFEE XR TMJ RT

Professional

Both

$33.00

Service Code	CPT 70330
Hospital Charge Code	50002359
Hospital Revenue Code	972
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$32.01
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: Cash Price	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

PROFEE XR TOES BILATERAL

Professional

Both

$19.00

Service Code	CPT 73660
Hospital Charge Code	50002360
Hospital Revenue Code	972
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$18.43
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

PROFEE XR TOES LT

Professional

Both

$19.00

Service Code	CPT 73660
Hospital Charge Code	50002361
Hospital Revenue Code	972
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$18.43
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

PROFEE XR TOES RT

Professional

Both

$19.00

Service Code	CPT 73660
Hospital Charge Code	50002362
Hospital Revenue Code	972
Min. Negotiated Rate	$13.30
Max. Negotiated Rate	$18.43
Rate for Payer: Aetna Commercial	$18.05
Rate for Payer: Aetna Medicare	$17.10
Rate for Payer: Cash Price	$17.10
Rate for Payer: Medicaid All Medicaid	$17.48
Rate for Payer: Medicare All Medicare	$13.30
Rate for Payer: Monida Allegiance	$18.05
Rate for Payer: Monida First Choice Health	$18.43
Rate for Payer: Monida Montana Health Co-op	$18.05
Rate for Payer: Monida PacificSource	$18.05

PROFEE XR UPPER EXTREMITY LT INFANT

Professional

Both

$23.00

Service Code	CPT 73092
Hospital Charge Code	50002363
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 UPPER EXTREMITY RT INFANT

Professional

Both

$23.00

Service Code	CPT 73092
Hospital Charge Code	50002364
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 WRIST BILATERAL 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73100
Hospital Charge Code	50002365
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 WRIST BILATERAL 3 VIEWS

Professional

Both

$25.00

Service Code	CPT 73110
Hospital Charge Code	50002366
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 WRIST LT 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73100
Hospital Charge Code	50002367
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 WRIST LT COMPLETE

Professional

Both

$25.00

Service Code	CPT 73110
Hospital Charge Code	50002368
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 WRIST RT 2 VIEWS

Professional

Both

$24.00

Service Code	CPT 73100
Hospital Charge Code	50002369
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 WRIST RT COMPLETE

Professional

Both

$25.00

Service Code	CPT 73110
Hospital Charge Code	50002370
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

Know your out-of-pocket cost for care.

All Charges