Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$445.82
Max. Negotiated Rate	$1,081.65
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	$450.19
Rate for Payer: Amerigroup Medicare	$450.46
Rate for Payer: Cash Price	$713.60
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	$446.00
Rate for Payer: Iowa Total Care Managed Medicaid	$445.82
Rate for Payer: Medical Associates Commercial	$669.00
Rate for Payer: Medical Associates Managed Medicare	$446.00
Rate for Payer: Midlands Choice Commercial	$624.40
Rate for Payer: Molina Healthcare Managed Medicaid	$452.69
Rate for Payer: Molina Healthcare Managed Medicare	$452.42
Rate for Payer: Oscar Health of IA Commercial	$669.00
Rate for Payer: Partners Health Alliance Commercial	$669.00
Rate for Payer: United Healthcare Commercial	$802.80
Rate for Payer: United Healthcare Managed Medicare	$526.28
Rate for Payer: Wellmark IA HMO	$983.32
Rate for Payer: Wellmark IA PPO	$1,081.65

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	$477.81
Max. Negotiated Rate	$1,357.18
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	$482.49
Rate for Payer: Amerigroup Medicare	$482.78
Rate for Payer: Cash Price	$764.80
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	$478.00
Rate for Payer: Iowa Total Care Managed Medicaid	$477.81
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Medical Associates Managed Medicare	$478.00
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: Molina Healthcare Managed Medicaid	$485.17
Rate for Payer: Molina Healthcare Managed Medicare	$484.88
Rate for Payer: Oscar Health of IA Commercial	$717.00
Rate for Payer: Partners Health Alliance Commercial	$717.00
Rate for Payer: United Healthcare Commercial	$860.40
Rate for Payer: United Healthcare Managed Medicare	$564.04
Rate for Payer: Wellmark IA HMO	$1,233.80
Rate for Payer: Wellmark IA PPO	$1,357.18

MRI Spine Thoracic w/ Contrast

Facility

$956.00

Service Code	CPT 72147
Hospital Charge Code	1169064
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 Thoracic w/ Contrast

Facility

$956.00

Service Code	CPT 72147
Hospital Charge Code	1169064
Hospital Revenue Code	612
Min. Negotiated Rate	$477.81
Max. Negotiated Rate	$1,357.18
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	$482.49
Rate for Payer: Amerigroup Medicare	$482.78
Rate for Payer: Cash Price	$764.80
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	$478.00
Rate for Payer: Iowa Total Care Managed Medicaid	$477.81
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Medical Associates Managed Medicare	$478.00
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: Molina Healthcare Managed Medicaid	$485.17
Rate for Payer: Molina Healthcare Managed Medicare	$484.88
Rate for Payer: Oscar Health of IA Commercial	$717.00
Rate for Payer: Partners Health Alliance Commercial	$717.00
Rate for Payer: United Healthcare Commercial	$860.40
Rate for Payer: United Healthcare Managed Medicare	$564.04
Rate for Payer: Wellmark IA HMO	$1,233.80
Rate for Payer: Wellmark IA PPO	$1,357.18

MRI Spine Thoracic w/o Contrast

Facility

$892.00

Service Code	CPT 72146
Hospital Charge Code	1169066
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 Thoracic w/o Contrast

Facility

$892.00

Service Code	CPT 72146
Hospital Charge Code	1169066
Hospital Revenue Code	612
Min. Negotiated Rate	$445.82
Max. Negotiated Rate	$1,081.65
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	$450.19
Rate for Payer: Amerigroup Medicare	$450.46
Rate for Payer: Cash Price	$713.60
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	$446.00
Rate for Payer: Iowa Total Care Managed Medicaid	$445.82
Rate for Payer: Medical Associates Commercial	$669.00
Rate for Payer: Medical Associates Managed Medicare	$446.00
Rate for Payer: Midlands Choice Commercial	$624.40
Rate for Payer: Molina Healthcare Managed Medicaid	$452.69
Rate for Payer: Molina Healthcare Managed Medicare	$452.42
Rate for Payer: Oscar Health of IA Commercial	$669.00
Rate for Payer: Partners Health Alliance Commercial	$669.00
Rate for Payer: United Healthcare Commercial	$802.80
Rate for Payer: United Healthcare Managed Medicare	$526.28
Rate for Payer: Wellmark IA HMO	$983.32
Rate for Payer: Wellmark IA PPO	$1,081.65

MRI Spine Thoracic w/ + w/o Contrast

Facility

$956.00

Service Code	CPT 72157
Hospital Charge Code	1169062
Hospital Revenue Code	612
Min. Negotiated Rate	$477.81
Max. Negotiated Rate	$1,357.18
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	$482.49
Rate for Payer: Amerigroup Medicare	$482.78
Rate for Payer: Cash Price	$764.80
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	$478.00
Rate for Payer: Iowa Total Care Managed Medicaid	$477.81
Rate for Payer: Medical Associates Commercial	$717.00
Rate for Payer: Medical Associates Managed Medicare	$478.00
Rate for Payer: Midlands Choice Commercial	$669.20
Rate for Payer: Molina Healthcare Managed Medicaid	$485.17
Rate for Payer: Molina Healthcare Managed Medicare	$484.88
Rate for Payer: Oscar Health of IA Commercial	$717.00
Rate for Payer: Partners Health Alliance Commercial	$717.00
Rate for Payer: United Healthcare Commercial	$860.40
Rate for Payer: United Healthcare Managed Medicare	$564.04
Rate for Payer: Wellmark IA HMO	$1,233.80
Rate for Payer: Wellmark IA PPO	$1,357.18

MRI Spine Thoracic w/ + w/o Contrast

Facility

$956.00

Service Code	CPT 72157
Hospital Charge Code	1169062
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 Tibia/Fibula w/ Contrast Left

Facility

$1,640.00

Service Code	CPT 73719
Hospital Charge Code	1169078
Hospital Revenue Code	610
Min. Negotiated Rate	$819.67
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	$827.71
Rate for Payer: Amerigroup Medicare	$828.20
Rate for Payer: Cash Price	$1,312.00
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	$820.00
Rate for Payer: Iowa Total Care Managed Medicaid	$819.67
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Medical Associates Managed Medicare	$820.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: Molina Healthcare Managed Medicaid	$832.30
Rate for Payer: Molina Healthcare Managed Medicare	$831.81
Rate for Payer: Oscar Health of IA Commercial	$1,230.00
Rate for Payer: Partners Health Alliance Commercial	$1,230.00
Rate for Payer: United Healthcare Commercial	$1,476.00
Rate for Payer: United Healthcare Managed Medicare	$967.60
Rate for Payer: Wellmark IA HMO	$1,233.80
Rate for Payer: Wellmark IA PPO	$1,357.18

MRI Tibia/Fibula w/ Contrast Left

Facility

$1,640.00

Service Code	CPT 73719
Hospital Charge Code	1169078
Hospital Revenue Code	610
Min. Negotiated Rate	$1,148.00
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: Cash Price	$1,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,230.00
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: United Healthcare Commercial	$1,476.00

MRI Tibia/Fibula w/ Contrast Right

Facility

$1,530.00

Service Code	CPT 73719
Hospital Charge Code	1169080
Hospital Revenue Code	610
Min. Negotiated Rate	$1,071.00
Max. Negotiated Rate	$1,377.00
Rate for Payer: Aetna of IA Commercial	$1,377.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,377.00
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,147.50
Rate for Payer: Medical Associates Commercial	$1,147.50
Rate for Payer: Midlands Choice Commercial	$1,071.00
Rate for Payer: United Healthcare Commercial	$1,377.00

MRI Tibia/Fibula w/ Contrast Right

Facility

$1,530.00

Service Code	CPT 73719
Hospital Charge Code	1169080
Hospital Revenue Code	610
Min. Negotiated Rate	$764.69
Max. Negotiated Rate	$1,377.00
Rate for Payer: Aetna of IA Commercial	$1,377.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,377.00
Rate for Payer: Aetna of IA Medicare	$872.10
Rate for Payer: Amerigroup Medicaid	$772.19
Rate for Payer: Amerigroup Medicare	$772.65
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,147.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$765.00
Rate for Payer: Iowa Total Care Managed Medicaid	$764.69
Rate for Payer: Medical Associates Commercial	$1,147.50
Rate for Payer: Medical Associates Managed Medicare	$765.00
Rate for Payer: Midlands Choice Commercial	$1,071.00
Rate for Payer: Molina Healthcare Managed Medicaid	$776.48
Rate for Payer: Molina Healthcare Managed Medicare	$776.02
Rate for Payer: Oscar Health of IA Commercial	$1,147.50
Rate for Payer: Partners Health Alliance Commercial	$1,147.50
Rate for Payer: United Healthcare Commercial	$1,377.00
Rate for Payer: United Healthcare Managed Medicare	$902.70
Rate for Payer: Wellmark IA HMO	$1,233.80
Rate for Payer: Wellmark IA PPO	$1,357.18

MRI Tibia/Fibula w/o Contrast Left

Facility

$1,530.00

Service Code	CPT 73718
Hospital Charge Code	1169084
Hospital Revenue Code	610
Min. Negotiated Rate	$1,071.00
Max. Negotiated Rate	$1,377.00
Rate for Payer: Aetna of IA Commercial	$1,377.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,377.00
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,147.50
Rate for Payer: Medical Associates Commercial	$1,147.50
Rate for Payer: Midlands Choice Commercial	$1,071.00
Rate for Payer: United Healthcare Commercial	$1,377.00

MRI Tibia/Fibula w/o Contrast Left

Facility

$1,530.00

Service Code	CPT 73718
Hospital Charge Code	1169084
Hospital Revenue Code	610
Min. Negotiated Rate	$764.69
Max. Negotiated Rate	$1,377.00
Rate for Payer: Aetna of IA Commercial	$1,377.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,377.00
Rate for Payer: Aetna of IA Medicare	$872.10
Rate for Payer: Amerigroup Medicaid	$772.19
Rate for Payer: Amerigroup Medicare	$772.65
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Cash Price	$1,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,147.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$765.00
Rate for Payer: Iowa Total Care Managed Medicaid	$764.69
Rate for Payer: Medical Associates Commercial	$1,147.50
Rate for Payer: Medical Associates Managed Medicare	$765.00
Rate for Payer: Midlands Choice Commercial	$1,071.00
Rate for Payer: Molina Healthcare Managed Medicaid	$776.48
Rate for Payer: Molina Healthcare Managed Medicare	$776.02
Rate for Payer: Oscar Health of IA Commercial	$1,147.50
Rate for Payer: Partners Health Alliance Commercial	$1,147.50
Rate for Payer: United Healthcare Commercial	$1,377.00
Rate for Payer: United Healthcare Managed Medicare	$902.70
Rate for Payer: Wellmark IA HMO	$983.32
Rate for Payer: Wellmark IA PPO	$1,081.65

MRI Tibia/Fibula w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73718
Hospital Charge Code	1169086
Hospital Revenue Code	610
Min. Negotiated Rate	$510.30
Max. Negotiated Rate	$1,081.65
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	$515.30
Rate for Payer: Amerigroup Medicare	$515.60
Rate for Payer: Cash Price	$816.80
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	$510.50
Rate for Payer: Iowa Total Care Managed Medicaid	$510.30
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Medical Associates Managed Medicare	$510.50
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: Molina Healthcare Managed Medicaid	$518.16
Rate for Payer: Molina Healthcare Managed Medicare	$517.85
Rate for Payer: Oscar Health of IA Commercial	$765.75
Rate for Payer: Partners Health Alliance Commercial	$765.75
Rate for Payer: United Healthcare Commercial	$918.90
Rate for Payer: United Healthcare Managed Medicare	$602.39
Rate for Payer: Wellmark IA HMO	$983.32
Rate for Payer: Wellmark IA PPO	$1,081.65

MRI Tibia/Fibula w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73718
Hospital Charge Code	1169086
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 Tibia/Fibula w/ + w/o Contrast Left

Facility

$1,640.00

Service Code	CPT 73720
Hospital Charge Code	1169072
Hospital Revenue Code	610
Min. Negotiated Rate	$1,148.00
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: Cash Price	$1,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,230.00
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: United Healthcare Commercial	$1,476.00

MRI Tibia/Fibula w/ + w/o Contrast Left

Facility

$1,640.00

Service Code	CPT 73720
Hospital Charge Code	1169072
Hospital Revenue Code	610
Min. Negotiated Rate	$819.67
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	$827.71
Rate for Payer: Amerigroup Medicare	$828.20
Rate for Payer: Cash Price	$1,312.00
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	$820.00
Rate for Payer: Iowa Total Care Managed Medicaid	$819.67
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Medical Associates Managed Medicare	$820.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: Molina Healthcare Managed Medicaid	$832.30
Rate for Payer: Molina Healthcare Managed Medicare	$831.81
Rate for Payer: Oscar Health of IA Commercial	$1,230.00
Rate for Payer: Partners Health Alliance Commercial	$1,230.00
Rate for Payer: United Healthcare Commercial	$1,476.00
Rate for Payer: United Healthcare Managed Medicare	$967.60
Rate for Payer: Wellmark IA HMO	$1,233.80
Rate for Payer: Wellmark IA PPO	$1,357.18

MRI Tibia/Fibula w/ + w/o Contrast Right

Facility

$1,640.00

Service Code	CPT 73720
Hospital Charge Code	1169074
Hospital Revenue Code	610
Min. Negotiated Rate	$819.67
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	$827.71
Rate for Payer: Amerigroup Medicare	$828.20
Rate for Payer: Cash Price	$1,312.00
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	$820.00
Rate for Payer: Iowa Total Care Managed Medicaid	$819.67
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Medical Associates Managed Medicare	$820.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: Molina Healthcare Managed Medicaid	$832.30
Rate for Payer: Molina Healthcare Managed Medicare	$831.81
Rate for Payer: Oscar Health of IA Commercial	$1,230.00
Rate for Payer: Partners Health Alliance Commercial	$1,230.00
Rate for Payer: United Healthcare Commercial	$1,476.00
Rate for Payer: United Healthcare Managed Medicare	$967.60
Rate for Payer: Wellmark IA HMO	$1,233.80
Rate for Payer: Wellmark IA PPO	$1,357.18

MRI Tibia/Fibula w/ + w/o Contrast Right

Facility

$1,640.00

Service Code	CPT 73720
Hospital Charge Code	1169074
Hospital Revenue Code	610
Min. Negotiated Rate	$1,148.00
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: Cash Price	$1,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,230.00
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: United Healthcare Commercial	$1,476.00

MRI TMJ

Facility

$1,640.00

Service Code	CPT 70336
Hospital Charge Code	1169068
Hospital Revenue Code	610
Min. Negotiated Rate	$819.67
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	$827.71
Rate for Payer: Amerigroup Medicare	$828.20
Rate for Payer: Cash Price	$1,312.00
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	$820.00
Rate for Payer: Iowa Total Care Managed Medicaid	$819.67
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Medical Associates Managed Medicare	$820.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: Molina Healthcare Managed Medicaid	$832.30
Rate for Payer: Molina Healthcare Managed Medicare	$831.81
Rate for Payer: Oscar Health of IA Commercial	$1,230.00
Rate for Payer: Partners Health Alliance Commercial	$1,230.00
Rate for Payer: United Healthcare Commercial	$1,476.00
Rate for Payer: United Healthcare Managed Medicare	$967.60
Rate for Payer: Wellmark IA HMO	$983.32
Rate for Payer: Wellmark IA PPO	$1,081.65

MRI TMJ

Facility

$1,640.00

Service Code	CPT 70336
Hospital Charge Code	1169068
Hospital Revenue Code	610
Min. Negotiated Rate	$1,148.00
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: Cash Price	$1,312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,230.00
Rate for Payer: Medical Associates Commercial	$1,230.00
Rate for Payer: Midlands Choice Commercial	$1,148.00
Rate for Payer: United Healthcare Commercial	$1,476.00

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