Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

MRI UE Joint w/ Contrast Left

Facility

$1,025.00

Service Code	CPT 73222 LT
Hospital Charge Code	1169096
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 UE Joint w/ Contrast Left

Facility

$1,025.00

Service Code	CPT 73222 LT
Hospital Charge Code	1169096
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI UE Joint w/ Contrast Right

Facility

$1,025.00

Service Code	CPT 73222 RT
Hospital Charge Code	1169098
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI UE Joint w/ Contrast Right

Facility

$1,025.00

Service Code	CPT 73222 RT
Hospital Charge Code	1169098
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 UE Joint w/o Contrast Left

Facility

$1,021.00

Service Code	CPT 73221 LT
Hospital Charge Code	1169102
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 UE Joint w/o Contrast Left

Facility

$1,021.00

Service Code	CPT 73221 LT
Hospital Charge Code	1169102
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 UE Joint w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73221 RT
Hospital Charge Code	1169104
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 UE Joint w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73221 RT
Hospital Charge Code	1169104
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 UE Joint w/ + w/o Contrast Left

Facility

$1,025.00

Service Code	CPT 73223 LT
Hospital Charge Code	1169090
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI UE Joint w/ + w/o Contrast Left

Facility

$1,025.00

Service Code	CPT 73223 LT
Hospital Charge Code	1169090
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 UE Joint w/ + w/o Contrast Right

Facility

$1,025.00

Service Code	CPT 73223 RT
Hospital Charge Code	1169092
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$1,116.05
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,013.16
Rate for Payer: Wellmark IA PPO	$1,116.05

MRI UE Joint w/ + w/o Contrast Right

Facility

$1,025.00

Service Code	CPT 73223 RT
Hospital Charge Code	1169092
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 UE Non Joint w/ Contrast Left

Facility

$1,640.00

Service Code	CPT 73219 LT
Hospital Charge Code	1169114
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 UE Non Joint w/ Contrast Left

Facility

$1,640.00

Service Code	CPT 73219 LT
Hospital Charge Code	1169114
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 UE Non Joint w/ Contrast Right

Facility

$1,640.00

Service Code	CPT 73219 RT
Hospital Charge Code	1169116
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 UE Non Joint w/ Contrast Right

Facility

$1,640.00

Service Code	CPT 73219 RT
Hospital Charge Code	1169116
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 UE Non Joint w/o Contrast Left

Facility

$1,530.00

Service Code	CPT 73218 LT
Hospital Charge Code	1169120
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 UE Non Joint w/o Contrast Left

Facility

$1,530.00

Service Code	CPT 73218 LT
Hospital Charge Code	1169120
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 UE Non Joint w/o Contrast Right

Facility

$1,530.00

Service Code	CPT 73218 RT
Hospital Charge Code	1169122
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 UE Non Joint w/o Contrast Right

Facility

$1,530.00

Service Code	CPT 73218 RT
Hospital Charge Code	1169122
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 UE Non Joint w/ + w/o Contrast Left

Facility

$1,640.00

Service Code	CPT 73220 LT
Hospital Charge Code	1169108
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 UE Non Joint w/ + w/o Contrast Left

Facility

$1,640.00

Service Code	CPT 73220 LT
Hospital Charge Code	1169108
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 UE Non Joint w/ + w/o Contrast Right

Facility

$1,640.00

Service Code	CPT 73220 RT
Hospital Charge Code	1169110
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 UE Non Joint w/ + w/o Contrast Right

Facility

$1,640.00

Service Code	CPT 73220 RT
Hospital Charge Code	1169110
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

Know your out-of-pocket cost for care.

All Charges