Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR IVP

Facility

$459.00

Service Code	CPT 74400
Hospital Charge Code	1170251
Hospital Revenue Code	320
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Aetna of IA Medicare	$261.63
Rate for Payer: Amerigroup Medicaid	$264.75
Rate for Payer: Amerigroup Medicare	$208.62
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$206.55
Rate for Payer: Iowa Total Care Managed Medicaid	$262.18
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Medical Associates Managed Medicare	$206.55
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: Molina Healthcare Managed Medicaid	$266.04
Rate for Payer: Partners Health Alliance Commercial	$237.53
Rate for Payer: United Healthcare Commercial	$413.10
Rate for Payer: United Healthcare Managed Medicare	$270.81

XR Knee 1 or 2 Views Left

Facility

$138.00

Service Code	CPT 73560 LT
Hospital Charge Code	1170263
Hospital Revenue Code	320
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: United Healthcare Commercial	$124.20

XR Knee 1 or 2 Views Left

Facility

$138.00

Service Code	CPT 73560 LT
Hospital Charge Code	1170263
Hospital Revenue Code	320
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Aetna of IA Medicare	$78.66
Rate for Payer: Amerigroup Medicaid	$79.60
Rate for Payer: Amerigroup Medicare	$62.72
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.10
Rate for Payer: Iowa Total Care Managed Medicaid	$78.83
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Medical Associates Managed Medicare	$62.10
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: Molina Healthcare Managed Medicaid	$79.98
Rate for Payer: Partners Health Alliance Commercial	$71.42
Rate for Payer: United Healthcare Commercial	$124.20
Rate for Payer: United Healthcare Managed Medicare	$81.42

XR Knee 1 or 2 Views Right

Facility

$138.00

Service Code	CPT 73560 RT
Hospital Charge Code	1170265
Hospital Revenue Code	320
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Aetna of IA Medicare	$78.66
Rate for Payer: Amerigroup Medicaid	$79.60
Rate for Payer: Amerigroup Medicare	$62.72
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.10
Rate for Payer: Iowa Total Care Managed Medicaid	$78.83
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Medical Associates Managed Medicare	$62.10
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: Molina Healthcare Managed Medicaid	$79.98
Rate for Payer: Partners Health Alliance Commercial	$71.42
Rate for Payer: United Healthcare Commercial	$124.20
Rate for Payer: United Healthcare Managed Medicare	$81.42

XR Knee 1 or 2 Views Right

Facility

$138.00

Service Code	CPT 73560 RT
Hospital Charge Code	1170265
Hospital Revenue Code	320
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: United Healthcare Commercial	$124.20

XR Knee 3 Views Left

Facility

$147.00

Service Code	CPT 73562 LT
Hospital Charge Code	1170269
Hospital Revenue Code	320
Min. Negotiated Rate	$66.15
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Aetna of IA Medicare	$83.79
Rate for Payer: Amerigroup Medicaid	$84.79
Rate for Payer: Amerigroup Medicare	$66.81
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$66.15
Rate for Payer: Iowa Total Care Managed Medicaid	$83.97
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Medical Associates Managed Medicare	$66.15
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: Molina Healthcare Managed Medicaid	$85.20
Rate for Payer: Partners Health Alliance Commercial	$76.07
Rate for Payer: United Healthcare Commercial	$132.30
Rate for Payer: United Healthcare Managed Medicare	$86.73

XR Knee 3 Views Left

Facility

$147.00

Service Code	CPT 73562 LT
Hospital Charge Code	1170269
Hospital Revenue Code	320
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: United Healthcare Commercial	$132.30

XR Knee 3 Views Right

Facility

$147.00

Service Code	CPT 73562 RT
Hospital Charge Code	1170271
Hospital Revenue Code	320
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: United Healthcare Commercial	$132.30

XR Knee 3 Views Right

Facility

$147.00

Service Code	CPT 73562 RT
Hospital Charge Code	1170271
Hospital Revenue Code	320
Min. Negotiated Rate	$66.15
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Aetna of IA Medicare	$83.79
Rate for Payer: Amerigroup Medicaid	$84.79
Rate for Payer: Amerigroup Medicare	$66.81
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$66.15
Rate for Payer: Iowa Total Care Managed Medicaid	$83.97
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Medical Associates Managed Medicare	$66.15
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: Molina Healthcare Managed Medicaid	$85.20
Rate for Payer: Partners Health Alliance Commercial	$76.07
Rate for Payer: United Healthcare Commercial	$132.30
Rate for Payer: United Healthcare Managed Medicare	$86.73

XR Knee 4 Views w/ Patella Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170273
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84

XR Knee 4 Views w/ Patella Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170273
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Patella Right

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170276
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84

XR Knee 4 Views w/ Patella Right

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170276
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Tunnel + Sunrise Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170279
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84

XR Knee 4 Views w/ Tunnel + Sunrise Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170279
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Tunnel + Sunrise Righ

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170282
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Tunnel + Sunrise Righ

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170282
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84

XR Knee Standing AP Bilateral

Facility

$139.00

Service Code	CPT 73565 50
Hospital Charge Code	1170291
Hospital Revenue Code	320
Min. Negotiated Rate	$62.55
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$80.18
Rate for Payer: Amerigroup Medicare	$63.18
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.55
Rate for Payer: Iowa Total Care Managed Medicaid	$79.40
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$62.55
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$80.56
Rate for Payer: Partners Health Alliance Commercial	$71.93
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01

XR Knee Standing AP Bilateral

Facility

$139.00

Service Code	CPT 73565 50
Hospital Charge Code	1170291
Hospital Revenue Code	320
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

XR Mandible Complete Minimum 4 Views

Facility

$180.00

Service Code	CPT 70110
Hospital Charge Code	1170301
Hospital Revenue Code	320
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

XR Mandible Complete Minimum 4 Views

Facility

$180.00

Service Code	CPT 70110
Hospital Charge Code	1170301
Hospital Revenue Code	320
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

XR Mastoids Complete Bilateral

Facility

$176.00

Service Code	CPT 70130 50
Hospital Charge Code	1170313
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84

XR Mastoids Complete Bilateral

Facility

$176.00

Service Code	CPT 70130 50
Hospital Charge Code	1170313
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Myelography Cervical Spine

Facility

$1,211.00

Service Code	CPT 72240
Hospital Charge Code	1170319
Hospital Revenue Code	320
Min. Negotiated Rate	$847.70
Max. Negotiated Rate	$1,089.90
Rate for Payer: Aetna of IA Commercial	$1,089.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,089.90
Rate for Payer: Cash Price	$968.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$908.25
Rate for Payer: Medical Associates Commercial	$908.25
Rate for Payer: Midlands Choice Commercial	$847.70
Rate for Payer: United Healthcare Commercial	$1,089.90

XR Myelography Cervical Spine

Facility

$1,211.00

Service Code	CPT 72240
Hospital Charge Code	1170319
Hospital Revenue Code	320
Min. Negotiated Rate	$544.95
Max. Negotiated Rate	$1,089.90
Rate for Payer: Aetna of IA Commercial	$1,089.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,089.90
Rate for Payer: Aetna of IA Medicare	$690.27
Rate for Payer: Amerigroup Medicaid	$698.50
Rate for Payer: Amerigroup Medicare	$550.40
Rate for Payer: Cash Price	$968.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$908.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$544.95
Rate for Payer: Iowa Total Care Managed Medicaid	$691.72
Rate for Payer: Medical Associates Commercial	$908.25
Rate for Payer: Medical Associates Managed Medicare	$544.95
Rate for Payer: Midlands Choice Commercial	$847.70
Rate for Payer: Molina Healthcare Managed Medicaid	$701.90
Rate for Payer: Partners Health Alliance Commercial	$626.69
Rate for Payer: United Healthcare Commercial	$1,089.90
Rate for Payer: United Healthcare Managed Medicare	$714.49

Know your out-of-pocket cost for care.

All Charges