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/ Contrast

Facility

$956.00

Service Code	CPT 72149
Hospital Charge Code	1169058
Hospital Revenue Code	612
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

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: 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
Rate for Payer: Wellmark IA HMO WHPI	$724.60
Rate for Payer: Wellmark IA PPO	$798.18

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/ + 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	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI Spine Thoracic w/ Contrast

Facility

$956.00

Service Code	CPT 72147
Hospital Charge Code	1169064
Hospital Revenue Code	612
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

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/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	$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: 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
Rate for Payer: Wellmark IA HMO WHPI	$724.60
Rate for Payer: Wellmark IA PPO	$798.18

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 Spine Thoracic w/ + w/o Contrast

Facility

$956.00

Service Code	CPT 72157
Hospital Charge Code	1169062
Hospital Revenue Code	612
Min. Negotiated Rate	$430.20
Max. Negotiated Rate	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI Tibia/Fibula w/ Contrast Left

Facility

$1,640.00

Service Code	CPT 73719 LT
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 Left

Facility

$1,640.00

Service Code	CPT 73719 LT
Hospital Charge Code	1169078
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI Tibia/Fibula w/ Contrast Right

Facility

$1,530.00

Service Code	CPT 73719 RT
Hospital Charge Code	1169080
Hospital Revenue Code	610
Min. Negotiated Rate	$688.50
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	$882.50
Rate for Payer: Amerigroup Medicare	$695.38
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	$688.50
Rate for Payer: Iowa Total Care Managed Medicaid	$873.94
Rate for Payer: Medical Associates Commercial	$1,147.50
Rate for Payer: Medical Associates Managed Medicare	$688.50
Rate for Payer: Midlands Choice Commercial	$1,071.00
Rate for Payer: Molina Healthcare Managed Medicaid	$886.79
Rate for Payer: Partners Health Alliance Commercial	$791.78
Rate for Payer: United Healthcare Commercial	$1,377.00
Rate for Payer: United Healthcare Managed Medicare	$902.70
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI Tibia/Fibula w/ Contrast Right

Facility

$1,530.00

Service Code	CPT 73719 RT
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/o Contrast Left

Facility

$1,530.00

Service Code	CPT 73718 LT
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 LT
Hospital Charge Code	1169084
Hospital Revenue Code	610
Min. Negotiated Rate	$688.50
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	$882.50
Rate for Payer: Amerigroup Medicare	$695.38
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	$688.50
Rate for Payer: Iowa Total Care Managed Medicaid	$873.94
Rate for Payer: Medical Associates Commercial	$1,147.50
Rate for Payer: Medical Associates Managed Medicare	$688.50
Rate for Payer: Midlands Choice Commercial	$1,071.00
Rate for Payer: Molina Healthcare Managed Medicaid	$886.79
Rate for Payer: Partners Health Alliance Commercial	$791.78
Rate for Payer: United Healthcare Commercial	$1,377.00
Rate for Payer: United Healthcare Managed Medicare	$902.70
Rate for Payer: Wellmark IA HMO WHPI	$724.60
Rate for Payer: Wellmark IA PPO	$798.18

MRI Tibia/Fibula w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73718 RT
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/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73718 RT
Hospital Charge Code	1169086
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$724.60
Rate for Payer: Wellmark IA PPO	$798.18

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

Facility

$1,640.00

Service Code	CPT 73720 LT
Hospital Charge Code	1169072
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

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

Facility

$1,640.00

Service Code	CPT 73720 LT
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 Right

Facility

$1,640.00

Service Code	CPT 73720 RT
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 Tibia/Fibula w/ + w/o Contrast Right

Facility

$1,640.00

Service Code	CPT 73720 RT
Hospital Charge Code	1169074
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI TMJ

Facility

$1,640.00

Service Code	CPT 70336
Hospital Charge Code	1169068
Hospital Revenue Code	610
Min. Negotiated Rate	$724.60
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$724.60
Rate for Payer: Wellmark IA PPO	$798.18

Know your out-of-pocket cost for care.

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