Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MOUTH PROCEDURES WITH CC/MCC

Facility

$10,632.60

Service Code	MSDRG 137
Min. Negotiated Rate	$10,478.50
Max. Negotiated Rate	$10,632.60
Rate for Payer: Amerigroup Medicaid	$10,581.23
Rate for Payer: Iowa Total Care Managed Medicaid	$10,478.50
Rate for Payer: Molina Healthcare Managed Medicaid	$10,632.60

MOUTH PROCEDURES WITHOUT CC/MCC

Facility

$8,533.78

Service Code	MSDRG 138
Min. Negotiated Rate	$8,410.10
Max. Negotiated Rate	$8,533.78
Rate for Payer: Amerigroup Medicaid	$8,492.55
Rate for Payer: Iowa Total Care Managed Medicaid	$8,410.10
Rate for Payer: Molina Healthcare Managed Medicaid	$8,533.78

moxifloxacin 0.5% Ophth Sol [VDMC]

Facility

$48.36

Service Code	HCPCS A9270
Hospital Charge Code	10436319
Hospital Revenue Code	259
Min. Negotiated Rate	$33.85
Max. Negotiated Rate	$43.52
Rate for Payer: Aetna of IA Commercial	$43.52
Rate for Payer: Aetna of IA Medical Rental Products	$43.52
Rate for Payer: Cash Price	$38.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.27
Rate for Payer: Medical Associates Commercial	$36.27
Rate for Payer: Midlands Choice Commercial	$33.85
Rate for Payer: United Healthcare Commercial	$43.52

moxifloxacin 0.5% Ophth Sol [VDMC]

Facility

$48.36

Service Code	HCPCS A9270
Hospital Charge Code	10436319
Hospital Revenue Code	259
Min. Negotiated Rate	$21.76
Max. Negotiated Rate	$43.52
Rate for Payer: Aetna of IA Commercial	$43.52
Rate for Payer: Aetna of IA Medical Rental Products	$43.52
Rate for Payer: Aetna of IA Medicare	$27.57
Rate for Payer: Amerigroup Medicaid	$27.89
Rate for Payer: Amerigroup Medicare	$21.98
Rate for Payer: Cash Price	$38.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.76
Rate for Payer: Iowa Total Care Managed Medicaid	$27.62
Rate for Payer: Medical Associates Commercial	$36.27
Rate for Payer: Medical Associates Managed Medicare	$21.76
Rate for Payer: Midlands Choice Commercial	$33.85
Rate for Payer: Molina Healthcare Managed Medicaid	$28.03
Rate for Payer: Partners Health Alliance Commercial	$25.03
Rate for Payer: United Healthcare Commercial	$43.52
Rate for Payer: United Healthcare Managed Medicare	$28.53

Moxifloxacin 1.6 mg/1ml Opht Syringe [VDMC]

Facility

$47.96

Service Code	HCPCS A9270
Hospital Charge Code	23137854
Hospital Revenue Code	259
Min. Negotiated Rate	$21.58
Max. Negotiated Rate	$43.16
Rate for Payer: Aetna of IA Commercial	$43.16
Rate for Payer: Aetna of IA Medical Rental Products	$43.16
Rate for Payer: Aetna of IA Medicare	$27.34
Rate for Payer: Amerigroup Medicaid	$27.66
Rate for Payer: Amerigroup Medicare	$21.80
Rate for Payer: Cash Price	$38.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.97
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.58
Rate for Payer: Iowa Total Care Managed Medicaid	$27.39
Rate for Payer: Medical Associates Commercial	$35.97
Rate for Payer: Medical Associates Managed Medicare	$21.58
Rate for Payer: Midlands Choice Commercial	$33.57
Rate for Payer: Molina Healthcare Managed Medicaid	$27.80
Rate for Payer: Partners Health Alliance Commercial	$24.82
Rate for Payer: United Healthcare Commercial	$43.16
Rate for Payer: United Healthcare Managed Medicare	$28.30

Moxifloxacin 1.6 mg/1ml Opht Syringe [VDMC]

Facility

$47.96

Service Code	HCPCS A9270
Hospital Charge Code	23137854
Hospital Revenue Code	259
Min. Negotiated Rate	$33.57
Max. Negotiated Rate	$43.16
Rate for Payer: Aetna of IA Commercial	$43.16
Rate for Payer: Aetna of IA Medical Rental Products	$43.16
Rate for Payer: Cash Price	$38.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.97
Rate for Payer: Medical Associates Commercial	$35.97
Rate for Payer: Midlands Choice Commercial	$33.57
Rate for Payer: United Healthcare Commercial	$43.16

MRA Abdomen

Facility

$1,594.00

Service Code	CPT 74185
Hospital Charge Code	1168633
Hospital Revenue Code	618
Min. Negotiated Rate	$1,115.80
Max. Negotiated Rate	$1,434.60
Rate for Payer: Aetna of IA Commercial	$1,434.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,434.60
Rate for Payer: Cash Price	$1,275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,195.50
Rate for Payer: Medical Associates Commercial	$1,195.50
Rate for Payer: Midlands Choice Commercial	$1,115.80
Rate for Payer: United Healthcare Commercial	$1,434.60

MRA Abdomen

Facility

$1,594.00

Service Code	CPT 74185
Hospital Charge Code	1168633
Hospital Revenue Code	618
Min. Negotiated Rate	$652.99
Max. Negotiated Rate	$1,434.60
Rate for Payer: Aetna of IA Commercial	$1,434.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,434.60
Rate for Payer: Aetna of IA Medicare	$908.58
Rate for Payer: Amerigroup Medicaid	$919.42
Rate for Payer: Amerigroup Medicare	$724.47
Rate for Payer: Cash Price	$1,275.20
Rate for Payer: Cash Price	$1,275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,195.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$717.30
Rate for Payer: Iowa Total Care Managed Medicaid	$910.49
Rate for Payer: Medical Associates Commercial	$1,195.50
Rate for Payer: Medical Associates Managed Medicare	$717.30
Rate for Payer: Midlands Choice Commercial	$1,115.80
Rate for Payer: Molina Healthcare Managed Medicaid	$923.88
Rate for Payer: Partners Health Alliance Commercial	$824.90
Rate for Payer: United Healthcare Commercial	$1,434.60
Rate for Payer: United Healthcare Managed Medicare	$940.46
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Chest

Facility

$905.00

Service Code	CPT 71555
Hospital Charge Code	1168641
Hospital Revenue Code	618
Min. Negotiated Rate	$407.25
Max. Negotiated Rate	$814.50
Rate for Payer: Aetna of IA Commercial	$814.50
Rate for Payer: Aetna of IA Medical Rental Products	$814.50
Rate for Payer: Aetna of IA Medicare	$515.85
Rate for Payer: Amerigroup Medicaid	$522.00
Rate for Payer: Amerigroup Medicare	$411.32
Rate for Payer: Cash Price	$724.00
Rate for Payer: Cash Price	$724.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$678.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$407.25
Rate for Payer: Iowa Total Care Managed Medicaid	$516.94
Rate for Payer: Medical Associates Commercial	$678.75
Rate for Payer: Medical Associates Managed Medicare	$407.25
Rate for Payer: Midlands Choice Commercial	$633.50
Rate for Payer: Molina Healthcare Managed Medicaid	$524.54
Rate for Payer: Partners Health Alliance Commercial	$468.34
Rate for Payer: United Healthcare Commercial	$814.50
Rate for Payer: United Healthcare Managed Medicare	$533.95
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Chest

Facility

$905.00

Service Code	CPT 71555
Hospital Charge Code	1168641
Hospital Revenue Code	618
Min. Negotiated Rate	$633.50
Max. Negotiated Rate	$814.50
Rate for Payer: Aetna of IA Commercial	$814.50
Rate for Payer: Aetna of IA Medical Rental Products	$814.50
Rate for Payer: Cash Price	$724.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$678.75
Rate for Payer: Medical Associates Commercial	$678.75
Rate for Payer: Midlands Choice Commercial	$633.50
Rate for Payer: United Healthcare Commercial	$814.50

MRA Head w/ Contrast

Facility

$1,147.00

Service Code	CPT 70545
Hospital Charge Code	1168651
Hospital Revenue Code	610
Min. Negotiated Rate	$802.90
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: United Healthcare Commercial	$1,032.30

MRA Head w/ Contrast

Facility

$1,147.00

Service Code	CPT 70545
Hospital Charge Code	1168651
Hospital Revenue Code	610
Min. Negotiated Rate	$516.15
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Aetna of IA Medicare	$653.79
Rate for Payer: Amerigroup Medicaid	$661.59
Rate for Payer: Amerigroup Medicare	$521.31
Rate for Payer: Cash Price	$917.60
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$516.15
Rate for Payer: Iowa Total Care Managed Medicaid	$655.17
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Medical Associates Managed Medicare	$516.15
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: Molina Healthcare Managed Medicaid	$664.80
Rate for Payer: Partners Health Alliance Commercial	$593.57
Rate for Payer: United Healthcare Commercial	$1,032.30
Rate for Payer: United Healthcare Managed Medicare	$676.73
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Head w/o Contrast

Facility

$1,070.00

Service Code	CPT 70544
Hospital Charge Code	1168653
Hospital Revenue Code	610
Min. Negotiated Rate	$481.50
Max. Negotiated Rate	$963.00
Rate for Payer: Aetna of IA Commercial	$963.00
Rate for Payer: Aetna of IA Medical Rental Products	$963.00
Rate for Payer: Aetna of IA Medicare	$609.90
Rate for Payer: Amerigroup Medicaid	$617.18
Rate for Payer: Amerigroup Medicare	$486.32
Rate for Payer: Cash Price	$856.00
Rate for Payer: Cash Price	$856.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$802.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$481.50
Rate for Payer: Iowa Total Care Managed Medicaid	$611.18
Rate for Payer: Medical Associates Commercial	$802.50
Rate for Payer: Medical Associates Managed Medicare	$481.50
Rate for Payer: Midlands Choice Commercial	$749.00
Rate for Payer: Molina Healthcare Managed Medicaid	$620.17
Rate for Payer: Partners Health Alliance Commercial	$553.72
Rate for Payer: United Healthcare Commercial	$963.00
Rate for Payer: United Healthcare Managed Medicare	$631.30
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Head w/o Contrast

Facility

$1,070.00

Service Code	CPT 70544
Hospital Charge Code	1168653
Hospital Revenue Code	610
Min. Negotiated Rate	$749.00
Max. Negotiated Rate	$963.00
Rate for Payer: Aetna of IA Commercial	$963.00
Rate for Payer: Aetna of IA Medical Rental Products	$963.00
Rate for Payer: Cash Price	$856.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$802.50
Rate for Payer: Medical Associates Commercial	$802.50
Rate for Payer: Midlands Choice Commercial	$749.00
Rate for Payer: United Healthcare Commercial	$963.00

MRA Head w/ + w/o Contrast

Facility

$1,147.00

Service Code	CPT 70546
Hospital Charge Code	1168649
Hospital Revenue Code	610
Min. Negotiated Rate	$802.90
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: United Healthcare Commercial	$1,032.30

MRA Head w/ + w/o Contrast

Facility

$1,147.00

Service Code	CPT 70546
Hospital Charge Code	1168649
Hospital Revenue Code	610
Min. Negotiated Rate	$516.15
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Aetna of IA Medicare	$653.79
Rate for Payer: Amerigroup Medicaid	$661.59
Rate for Payer: Amerigroup Medicare	$521.31
Rate for Payer: Cash Price	$917.60
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$516.15
Rate for Payer: Iowa Total Care Managed Medicaid	$655.17
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Medical Associates Managed Medicare	$516.15
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: Molina Healthcare Managed Medicaid	$664.80
Rate for Payer: Partners Health Alliance Commercial	$593.57
Rate for Payer: United Healthcare Commercial	$1,032.30
Rate for Payer: United Healthcare Managed Medicare	$676.73
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Neck w/ Contrast

Facility

$1,147.00

Service Code	CPT 70548
Hospital Charge Code	1168681
Hospital Revenue Code	610
Min. Negotiated Rate	$802.90
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: United Healthcare Commercial	$1,032.30

MRA Neck w/ Contrast

Facility

$1,147.00

Service Code	CPT 70548
Hospital Charge Code	1168681
Hospital Revenue Code	610
Min. Negotiated Rate	$516.15
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Aetna of IA Medicare	$653.79
Rate for Payer: Amerigroup Medicaid	$661.59
Rate for Payer: Amerigroup Medicare	$521.31
Rate for Payer: Cash Price	$917.60
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$516.15
Rate for Payer: Iowa Total Care Managed Medicaid	$655.17
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Medical Associates Managed Medicare	$516.15
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: Molina Healthcare Managed Medicaid	$664.80
Rate for Payer: Partners Health Alliance Commercial	$593.57
Rate for Payer: United Healthcare Commercial	$1,032.30
Rate for Payer: United Healthcare Managed Medicare	$676.73
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Neck w/o Contrast

Facility

$1,070.00

Service Code	CPT 70547
Hospital Charge Code	1168683
Hospital Revenue Code	610
Min. Negotiated Rate	$749.00
Max. Negotiated Rate	$963.00
Rate for Payer: Aetna of IA Commercial	$963.00
Rate for Payer: Aetna of IA Medical Rental Products	$963.00
Rate for Payer: Cash Price	$856.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$802.50
Rate for Payer: Medical Associates Commercial	$802.50
Rate for Payer: Midlands Choice Commercial	$749.00
Rate for Payer: United Healthcare Commercial	$963.00

MRA Neck w/o Contrast

Facility

$1,070.00

Service Code	CPT 70547
Hospital Charge Code	1168683
Hospital Revenue Code	610
Min. Negotiated Rate	$481.50
Max. Negotiated Rate	$963.00
Rate for Payer: Aetna of IA Commercial	$963.00
Rate for Payer: Aetna of IA Medical Rental Products	$963.00
Rate for Payer: Aetna of IA Medicare	$609.90
Rate for Payer: Amerigroup Medicaid	$617.18
Rate for Payer: Amerigroup Medicare	$486.32
Rate for Payer: Cash Price	$856.00
Rate for Payer: Cash Price	$856.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$802.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$481.50
Rate for Payer: Iowa Total Care Managed Medicaid	$611.18
Rate for Payer: Medical Associates Commercial	$802.50
Rate for Payer: Medical Associates Managed Medicare	$481.50
Rate for Payer: Midlands Choice Commercial	$749.00
Rate for Payer: Molina Healthcare Managed Medicaid	$620.17
Rate for Payer: Partners Health Alliance Commercial	$553.72
Rate for Payer: United Healthcare Commercial	$963.00
Rate for Payer: United Healthcare Managed Medicare	$631.30
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Neck w/ + w/o Contrast

Facility

$1,147.00

Service Code	CPT 70549
Hospital Charge Code	1168679
Hospital Revenue Code	610
Min. Negotiated Rate	$516.15
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Aetna of IA Medicare	$653.79
Rate for Payer: Amerigroup Medicaid	$661.59
Rate for Payer: Amerigroup Medicare	$521.31
Rate for Payer: Cash Price	$917.60
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$516.15
Rate for Payer: Iowa Total Care Managed Medicaid	$655.17
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Medical Associates Managed Medicare	$516.15
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: Molina Healthcare Managed Medicaid	$664.80
Rate for Payer: Partners Health Alliance Commercial	$593.57
Rate for Payer: United Healthcare Commercial	$1,032.30
Rate for Payer: United Healthcare Managed Medicare	$676.73
Rate for Payer: Wellmark IA HMO WHPI	$652.99
Rate for Payer: Wellmark IA PPO	$719.30

MRA Neck w/ + w/o Contrast

Facility

$1,147.00

Service Code	CPT 70549
Hospital Charge Code	1168679
Hospital Revenue Code	610
Min. Negotiated Rate	$802.90
Max. Negotiated Rate	$1,032.30
Rate for Payer: Aetna of IA Commercial	$1,032.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,032.30
Rate for Payer: Cash Price	$917.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$860.25
Rate for Payer: Medical Associates Commercial	$860.25
Rate for Payer: Midlands Choice Commercial	$802.90
Rate for Payer: United Healthcare Commercial	$1,032.30

MRI Abdomen w/ Contrast

Facility

$1,708.00

Service Code	CPT 74182
Hospital Charge Code	1168732
Hospital Revenue Code	610
Min. Negotiated Rate	$1,195.60
Max. Negotiated Rate	$1,537.20
Rate for Payer: Aetna of IA Commercial	$1,537.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,537.20
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,281.00
Rate for Payer: Medical Associates Commercial	$1,281.00
Rate for Payer: Midlands Choice Commercial	$1,195.60
Rate for Payer: United Healthcare Commercial	$1,537.20

MRI Abdomen w/ Contrast

Facility

$1,708.00

Service Code	CPT 74182
Hospital Charge Code	1168732
Hospital Revenue Code	610
Min. Negotiated Rate	$768.60
Max. Negotiated Rate	$1,537.20
Rate for Payer: Aetna of IA Commercial	$1,537.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,537.20
Rate for Payer: Aetna of IA Medicare	$973.56
Rate for Payer: Amerigroup Medicaid	$985.17
Rate for Payer: Amerigroup Medicare	$776.29
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,281.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$768.60
Rate for Payer: Iowa Total Care Managed Medicaid	$975.61
Rate for Payer: Medical Associates Commercial	$1,281.00
Rate for Payer: Medical Associates Managed Medicare	$768.60
Rate for Payer: Midlands Choice Commercial	$1,195.60
Rate for Payer: Molina Healthcare Managed Medicaid	$989.96
Rate for Payer: Partners Health Alliance Commercial	$883.89
Rate for Payer: United Healthcare Commercial	$1,537.20
Rate for Payer: United Healthcare Managed Medicare	$1,007.72
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI Abdomen w/o Contrast

Facility

$1,594.00

Service Code	CPT 74181
Hospital Charge Code	1168734
Hospital Revenue Code	610
Min. Negotiated Rate	$1,115.80
Max. Negotiated Rate	$1,434.60
Rate for Payer: Aetna of IA Commercial	$1,434.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,434.60
Rate for Payer: Cash Price	$1,275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,195.50
Rate for Payer: Medical Associates Commercial	$1,195.50
Rate for Payer: Midlands Choice Commercial	$1,115.80
Rate for Payer: United Healthcare Commercial	$1,434.60

Know your out-of-pocket cost for care.

All Charges