Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MRI Pelvis w/ + w/o Contrast

Facility

$1,640.00

Service Code	CPT 72197
Hospital Charge Code	1169024
Hospital Revenue Code	610
Min. Negotiated Rate	$738.00
Max. Negotiated Rate	$1,476.00
Rate for Payer: Aetna of IA Commercial	$1,476.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,476.00
Rate for Payer: Aetna of IA Medicare	$934.80
Rate for Payer: Amerigroup Medicaid	$945.95
Rate for Payer: Amerigroup Medicare	$745.38
Rate for Payer: Cash Price	$1,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,230.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$738.00
Rate for Payer: Iowa Total Care Managed Medicaid	$936.77
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Medical Associates Managed Medicare	$738.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: Molina Healthcare Managed Medicaid	$950.54
Rate for Payer: Partners Health Alliance Commercial	$848.70
Rate for Payer: United Healthcare Commercial	$1,476.00
Rate for Payer: United Healthcare Managed Medicare	$967.60

MRI Shoulder w/ Contrast Left

Facility

$1,025.00

Service Code	CPT 73222 LT
Hospital Charge Code	1169038
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Aetna of IA Medicare	$584.25
Rate for Payer: Amerigroup Medicaid	$591.22
Rate for Payer: Amerigroup Medicare	$465.86
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$461.25
Rate for Payer: Iowa Total Care Managed Medicaid	$585.48
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Medical Associates Managed Medicare	$461.25
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Molina Healthcare Managed Medicaid	$594.09
Rate for Payer: Partners Health Alliance Commercial	$530.44
Rate for Payer: United Healthcare Commercial	$922.50
Rate for Payer: United Healthcare Managed Medicare	$604.75

MRI Shoulder w/ Contrast Left

Facility

$1,025.00

Service Code	CPT 73222 LT
Hospital Charge Code	1169038
Hospital Revenue Code	610
Min. Negotiated Rate	$717.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: United Healthcare Commercial	$922.50

MRI Shoulder w/ Contrast Right

Facility

$1,025.00

Service Code	CPT 73222 RT
Hospital Charge Code	1169040
Hospital Revenue Code	610
Min. Negotiated Rate	$717.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: United Healthcare Commercial	$922.50

MRI Shoulder w/ Contrast Right

Facility

$1,025.00

Service Code	CPT 73222 RT
Hospital Charge Code	1169040
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Aetna of IA Medicare	$584.25
Rate for Payer: Amerigroup Medicaid	$591.22
Rate for Payer: Amerigroup Medicare	$465.86
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$461.25
Rate for Payer: Iowa Total Care Managed Medicaid	$585.48
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Medical Associates Managed Medicare	$461.25
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Molina Healthcare Managed Medicaid	$594.09
Rate for Payer: Partners Health Alliance Commercial	$530.44
Rate for Payer: United Healthcare Commercial	$922.50
Rate for Payer: United Healthcare Managed Medicare	$604.75

MRI Shoulder w/o Contrast Left

Facility

$1,021.00

Service Code	CPT 73221 LT
Hospital Charge Code	1169044
Hospital Revenue Code	610
Min. Negotiated Rate	$459.45
Max. Negotiated Rate	$918.90
Rate for Payer: Aetna of IA Commercial	$918.90
Rate for Payer: Aetna of IA Medical Rental Products	$918.90
Rate for Payer: Aetna of IA Medicare	$581.97
Rate for Payer: Amerigroup Medicaid	$588.91
Rate for Payer: Amerigroup Medicare	$464.04
Rate for Payer: Cash Price	$816.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$765.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$459.45
Rate for Payer: Iowa Total Care Managed Medicaid	$583.20
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Medical Associates Managed Medicare	$459.45
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: Molina Healthcare Managed Medicaid	$591.77
Rate for Payer: Partners Health Alliance Commercial	$528.37
Rate for Payer: United Healthcare Commercial	$918.90
Rate for Payer: United Healthcare Managed Medicare	$602.39

MRI Shoulder w/o Contrast Left

Facility

$1,021.00

Service Code	CPT 73221 LT
Hospital Charge Code	1169044
Hospital Revenue Code	610
Min. Negotiated Rate	$714.70
Max. Negotiated Rate	$918.90
Rate for Payer: Aetna of IA Commercial	$918.90
Rate for Payer: Aetna of IA Medical Rental Products	$918.90
Rate for Payer: Cash Price	$816.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$765.75
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: United Healthcare Commercial	$918.90

MRI Shoulder w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73221 RT
Hospital Charge Code	1169046
Hospital Revenue Code	610
Min. Negotiated Rate	$714.70
Max. Negotiated Rate	$918.90
Rate for Payer: Aetna of IA Commercial	$918.90
Rate for Payer: Aetna of IA Medical Rental Products	$918.90
Rate for Payer: Cash Price	$816.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$765.75
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: United Healthcare Commercial	$918.90

MRI Shoulder w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73221 RT
Hospital Charge Code	1169046
Hospital Revenue Code	610
Min. Negotiated Rate	$459.45
Max. Negotiated Rate	$918.90
Rate for Payer: Aetna of IA Commercial	$918.90
Rate for Payer: Aetna of IA Medical Rental Products	$918.90
Rate for Payer: Aetna of IA Medicare	$581.97
Rate for Payer: Amerigroup Medicaid	$588.91
Rate for Payer: Amerigroup Medicare	$464.04
Rate for Payer: Cash Price	$816.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$765.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$459.45
Rate for Payer: Iowa Total Care Managed Medicaid	$583.20
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Medical Associates Managed Medicare	$459.45
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: Molina Healthcare Managed Medicaid	$591.77
Rate for Payer: Partners Health Alliance Commercial	$528.37
Rate for Payer: United Healthcare Commercial	$918.90
Rate for Payer: United Healthcare Managed Medicare	$602.39

MRI Shoulder w/ + w/o Contrast Left

Facility

$1,025.00

Service Code	CPT 73223 LT
Hospital Charge Code	1169032
Hospital Revenue Code	610
Min. Negotiated Rate	$717.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: United Healthcare Commercial	$922.50

MRI Shoulder w/ + w/o Contrast Left

Facility

$1,025.00

Service Code	CPT 73223 LT
Hospital Charge Code	1169032
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Aetna of IA Medicare	$584.25
Rate for Payer: Amerigroup Medicaid	$591.22
Rate for Payer: Amerigroup Medicare	$465.86
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$461.25
Rate for Payer: Iowa Total Care Managed Medicaid	$585.48
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Medical Associates Managed Medicare	$461.25
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Molina Healthcare Managed Medicaid	$594.09
Rate for Payer: Partners Health Alliance Commercial	$530.44
Rate for Payer: United Healthcare Commercial	$922.50
Rate for Payer: United Healthcare Managed Medicare	$604.75

MRI Shoulder w/ + w/o Contrast Right

Facility

$1,025.00

Service Code	CPT 73223 RT
Hospital Charge Code	1169034
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Aetna of IA Medicare	$584.25
Rate for Payer: Amerigroup Medicaid	$591.22
Rate for Payer: Amerigroup Medicare	$465.86
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$461.25
Rate for Payer: Iowa Total Care Managed Medicaid	$585.48
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Medical Associates Managed Medicare	$461.25
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Molina Healthcare Managed Medicaid	$594.09
Rate for Payer: Partners Health Alliance Commercial	$530.44
Rate for Payer: United Healthcare Commercial	$922.50
Rate for Payer: United Healthcare Managed Medicare	$604.75

MRI Shoulder w/ + w/o Contrast Right

Facility

$1,025.00

Service Code	CPT 73223 RT
Hospital Charge Code	1169034
Hospital Revenue Code	610
Min. Negotiated Rate	$717.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: United Healthcare Commercial	$922.50

MRI Spine Cervical w/ Contrast

Facility

$956.00

Service Code	CPT 72142
Hospital Charge Code	1169052
Hospital Revenue Code	612
Min. Negotiated Rate	$669.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: United Healthcare Commercial	$860.40

MRI Spine Cervical w/ Contrast

Facility

$956.00

Service Code	CPT 72142
Hospital Charge Code	1169052
Hospital Revenue Code	612
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Aetna of IA Medicare	$544.92
Rate for Payer: Amerigroup Medicaid	$551.42
Rate for Payer: Amerigroup Medicare	$434.50
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$430.20
Rate for Payer: Iowa Total Care Managed Medicaid	$546.07
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Medical Associates Managed Medicare	$430.20
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: Molina Healthcare Managed Medicaid	$554.10
Rate for Payer: Partners Health Alliance Commercial	$494.73
Rate for Payer: United Healthcare Commercial	$860.40
Rate for Payer: United Healthcare Managed Medicare	$564.04

MRI Spine Cervical w/o Contrast

Facility

$894.00

Service Code	CPT 72141
Hospital Charge Code	1169054
Hospital Revenue Code	612
Min. Negotiated Rate	$402.30
Max. Negotiated Rate	$804.60
Rate for Payer: Aetna of IA Commercial	$804.60
Rate for Payer: Aetna of IA Medical Rental Products	$804.60
Rate for Payer: Aetna of IA Medicare	$509.58
Rate for Payer: Amerigroup Medicaid	$515.66
Rate for Payer: Amerigroup Medicare	$406.32
Rate for Payer: Cash Price	$715.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$670.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$402.30
Rate for Payer: Iowa Total Care Managed Medicaid	$510.65
Rate for Payer: Medical Associates Commercial	$670.50
Rate for Payer: Medical Associates Managed Medicare	$402.30
Rate for Payer: Midlands Choice Commercial	$625.80
Rate for Payer: Molina Healthcare Managed Medicaid	$518.16
Rate for Payer: Partners Health Alliance Commercial	$462.64
Rate for Payer: United Healthcare Commercial	$804.60
Rate for Payer: United Healthcare Managed Medicare	$527.46

MRI Spine Cervical w/o Contrast

Facility

$894.00

Service Code	CPT 72141
Hospital Charge Code	1169054
Hospital Revenue Code	612
Min. Negotiated Rate	$625.80
Max. Negotiated Rate	$804.60
Rate for Payer: Aetna of IA Commercial	$804.60
Rate for Payer: Aetna of IA Medical Rental Products	$804.60
Rate for Payer: Cash Price	$715.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$670.50
Rate for Payer: Medical Associates Commercial	$670.50
Rate for Payer: Midlands Choice Commercial	$625.80
Rate for Payer: United Healthcare Commercial	$804.60

MRI Spine Cervical w/ + w/o Contrast

Facility

$956.00

Service Code	CPT 72156
Hospital Charge Code	1169050
Hospital Revenue Code	612
Min. Negotiated Rate	$669.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: United Healthcare Commercial	$860.40

MRI Spine Cervical w/ + w/o Contrast

Facility

$956.00

Service Code	CPT 72156
Hospital Charge Code	1169050
Hospital Revenue Code	612
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Aetna of IA Medicare	$544.92
Rate for Payer: Amerigroup Medicaid	$551.42
Rate for Payer: Amerigroup Medicare	$434.50
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$430.20
Rate for Payer: Iowa Total Care Managed Medicaid	$546.07
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Medical Associates Managed Medicare	$430.20
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: Molina Healthcare Managed Medicaid	$554.10
Rate for Payer: Partners Health Alliance Commercial	$494.73
Rate for Payer: United Healthcare Commercial	$860.40
Rate for Payer: United Healthcare Managed Medicare	$564.04

MRI Spine Lumbar w/ Contrast

Facility

$956.00

Service Code	CPT 72149
Hospital Charge Code	1169058
Hospital Revenue Code	612
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Aetna of IA Medicare	$544.92
Rate for Payer: Amerigroup Medicaid	$551.42
Rate for Payer: Amerigroup Medicare	$434.50
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$430.20
Rate for Payer: Iowa Total Care Managed Medicaid	$546.07
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Medical Associates Managed Medicare	$430.20
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: Molina Healthcare Managed Medicaid	$554.10
Rate for Payer: Partners Health Alliance Commercial	$494.73
Rate for Payer: United Healthcare Commercial	$860.40
Rate for Payer: United Healthcare Managed Medicare	$564.04

MRI Spine Lumbar w/ Contrast

Facility

$956.00

Service Code	CPT 72149
Hospital Charge Code	1169058
Hospital Revenue Code	612
Min. Negotiated Rate	$669.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: United Healthcare Commercial	$860.40

MRI Spine Lumbar w/o Contrast

Facility

$892.00

Service Code	CPT 72148
Hospital Charge Code	1169060
Hospital Revenue Code	612
Min. Negotiated Rate	$624.40
Max. Negotiated Rate	$802.80
Rate for Payer: Aetna of IA Commercial	$802.80
Rate for Payer: Aetna of IA Medical Rental Products	$802.80
Rate for Payer: Cash Price	$713.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$669.00
Rate for Payer: Medical Associates Commercial	$669.00
Rate for Payer: Midlands Choice Commercial	$624.40
Rate for Payer: United Healthcare Commercial	$802.80

MRI Spine Lumbar w/o Contrast

Facility

$892.00

Service Code	CPT 72148
Hospital Charge Code	1169060
Hospital Revenue Code	612
Min. Negotiated Rate	$401.40
Max. Negotiated Rate	$802.80
Rate for Payer: Aetna of IA Commercial	$802.80
Rate for Payer: Aetna of IA Medical Rental Products	$802.80
Rate for Payer: Aetna of IA Medicare	$508.44
Rate for Payer: Amerigroup Medicaid	$514.51
Rate for Payer: Amerigroup Medicare	$405.41
Rate for Payer: Cash Price	$713.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$669.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$401.40
Rate for Payer: Iowa Total Care Managed Medicaid	$509.51
Rate for Payer: Medical Associates Commercial	$669.00
Rate for Payer: Medical Associates Managed Medicare	$401.40
Rate for Payer: Midlands Choice Commercial	$624.40
Rate for Payer: Molina Healthcare Managed Medicaid	$517.00
Rate for Payer: Partners Health Alliance Commercial	$461.61
Rate for Payer: United Healthcare Commercial	$802.80
Rate for Payer: United Healthcare Managed Medicare	$526.28

MRI Spine Lumbar w/ + w/o Contrast

Facility

$956.00

Service Code	CPT 72158
Hospital Charge Code	1169056
Hospital Revenue Code	612
Min. Negotiated Rate	$669.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: United Healthcare Commercial	$860.40

MRI Spine Lumbar w/ + w/o Contrast

Facility

$956.00

Service Code	CPT 72158
Hospital Charge Code	1169056
Hospital Revenue Code	612
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$860.40
Rate for Payer: Aetna of IA Commercial	$860.40
Rate for Payer: Aetna of IA Medical Rental Products	$860.40
Rate for Payer: Aetna of IA Medicare	$544.92
Rate for Payer: Amerigroup Medicaid	$551.42
Rate for Payer: Amerigroup Medicare	$434.50
Rate for Payer: Cash Price	$764.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$717.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$430.20
Rate for Payer: Iowa Total Care Managed Medicaid	$546.07
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Medical Associates Managed Medicare	$430.20
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: Molina Healthcare Managed Medicaid	$554.10
Rate for Payer: Partners Health Alliance Commercial	$494.73
Rate for Payer: United Healthcare Commercial	$860.40
Rate for Payer: United Healthcare Managed Medicare	$564.04

Know your out-of-pocket cost for care.

All Charges