Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

US Art/Vein Abd/Pelvis/Scrotal Complete

Facility

$508.00

Service Code	CPT 93975 TC
Hospital Charge Code	1169581
Hospital Revenue Code	921
Min. Negotiated Rate	$355.60
Max. Negotiated Rate	$457.20
Rate for Payer: Aetna of IA Commercial	$457.20
Rate for Payer: Aetna of IA Medical Rental Products	$457.20
Rate for Payer: Cash Price	$406.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$381.00
Rate for Payer: Medical Associates Commercial	$381.00
Rate for Payer: Midlands Choice Commercial	$355.60
Rate for Payer: United Healthcare Commercial	$457.20

US Art/Vein Abd/Pelvis/Scrotal Complete

Facility

$508.00

Service Code	CPT 93975 TC
Hospital Charge Code	1169581
Hospital Revenue Code	921
Min. Negotiated Rate	$228.60
Max. Negotiated Rate	$457.20
Rate for Payer: Aetna of IA Commercial	$457.20
Rate for Payer: Aetna of IA Medical Rental Products	$457.20
Rate for Payer: Aetna of IA Medicare	$289.56
Rate for Payer: Amerigroup Medicaid	$293.01
Rate for Payer: Amerigroup Medicare	$230.89
Rate for Payer: Cash Price	$406.40
Rate for Payer: Cash Price	$406.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$381.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$228.60
Rate for Payer: Iowa Total Care Managed Medicaid	$290.17
Rate for Payer: Medical Associates Commercial	$381.00
Rate for Payer: Medical Associates Managed Medicare	$228.60
Rate for Payer: Midlands Choice Commercial	$355.60
Rate for Payer: Molina Healthcare Managed Medicaid	$294.44
Rate for Payer: Partners Health Alliance Commercial	$262.89
Rate for Payer: United Healthcare Commercial	$457.20
Rate for Payer: United Healthcare Managed Medicare	$299.72
Rate for Payer: Wellmark IA HMO WHPI	$375.06
Rate for Payer: Wellmark IA PPO	$413.15

US Art/Vein Abd/Pelvis/Scrotal Limited

Facility

$361.00

Service Code	CPT 93976
Hospital Charge Code	1169583
Hospital Revenue Code	921
Min. Negotiated Rate	$252.70
Max. Negotiated Rate	$324.90
Rate for Payer: Aetna of IA Commercial	$324.90
Rate for Payer: Aetna of IA Medical Rental Products	$324.90
Rate for Payer: Cash Price	$288.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.75
Rate for Payer: Medical Associates Commercial	$270.75
Rate for Payer: Midlands Choice Commercial	$252.70
Rate for Payer: United Healthcare Commercial	$324.90

US Art/Vein Abd/Pelvis/Scrotal Limited

Facility

$361.00

Service Code	CPT 93976
Hospital Charge Code	1169583
Hospital Revenue Code	921
Min. Negotiated Rate	$162.45
Max. Negotiated Rate	$413.15
Rate for Payer: Aetna of IA Commercial	$324.90
Rate for Payer: Aetna of IA Medical Rental Products	$324.90
Rate for Payer: Aetna of IA Medicare	$205.77
Rate for Payer: Amerigroup Medicaid	$208.22
Rate for Payer: Amerigroup Medicare	$164.07
Rate for Payer: Cash Price	$288.80
Rate for Payer: Cash Price	$288.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$162.45
Rate for Payer: Iowa Total Care Managed Medicaid	$206.20
Rate for Payer: Medical Associates Commercial	$270.75
Rate for Payer: Medical Associates Managed Medicare	$162.45
Rate for Payer: Midlands Choice Commercial	$252.70
Rate for Payer: Molina Healthcare Managed Medicaid	$209.24
Rate for Payer: Partners Health Alliance Commercial	$186.82
Rate for Payer: United Healthcare Commercial	$324.90
Rate for Payer: United Healthcare Managed Medicare	$212.99
Rate for Payer: Wellmark IA HMO WHPI	$375.06
Rate for Payer: Wellmark IA PPO	$413.15

US Aspiration/Inject/Biopsy Bilateral

Facility

$511.00

Service Code	CPT 76942 50
Hospital Charge Code	1169585
Hospital Revenue Code	402
Min. Negotiated Rate	$229.95
Max. Negotiated Rate	$764.60
Rate for Payer: Aetna of IA Commercial	$459.90
Rate for Payer: Aetna of IA Medical Rental Products	$459.90
Rate for Payer: Aetna of IA Medicare	$291.27
Rate for Payer: Amerigroup Medicaid	$294.74
Rate for Payer: Amerigroup Medicare	$232.25
Rate for Payer: Cash Price	$408.80
Rate for Payer: Cash Price	$408.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$383.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$229.95
Rate for Payer: Iowa Total Care Managed Medicaid	$291.88
Rate for Payer: Medical Associates Commercial	$383.25
Rate for Payer: Medical Associates Managed Medicare	$229.95
Rate for Payer: Midlands Choice Commercial	$357.70
Rate for Payer: Molina Healthcare Managed Medicaid	$296.18
Rate for Payer: Partners Health Alliance Commercial	$264.44
Rate for Payer: United Healthcare Commercial	$459.90
Rate for Payer: United Healthcare Managed Medicare	$301.49
Rate for Payer: Wellmark IA HMO WHPI	$694.11
Rate for Payer: Wellmark IA PPO	$764.60

US Aspiration/Inject/Biopsy Bilateral

Facility

$511.00

Service Code	CPT 76942 50
Hospital Charge Code	1169585
Hospital Revenue Code	402
Min. Negotiated Rate	$357.70
Max. Negotiated Rate	$459.90
Rate for Payer: Aetna of IA Commercial	$459.90
Rate for Payer: Aetna of IA Medical Rental Products	$459.90
Rate for Payer: Cash Price	$408.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$383.25
Rate for Payer: Medical Associates Commercial	$383.25
Rate for Payer: Midlands Choice Commercial	$357.70
Rate for Payer: United Healthcare Commercial	$459.90

US Aspiration/Inject/Biopsy Left

Facility

$511.00

Service Code	CPT 76942 LT
Hospital Charge Code	1169587
Hospital Revenue Code	402
Min. Negotiated Rate	$229.95
Max. Negotiated Rate	$764.60
Rate for Payer: Aetna of IA Commercial	$459.90
Rate for Payer: Aetna of IA Medical Rental Products	$459.90
Rate for Payer: Aetna of IA Medicare	$291.27
Rate for Payer: Amerigroup Medicaid	$294.74
Rate for Payer: Amerigroup Medicare	$232.25
Rate for Payer: Cash Price	$408.80
Rate for Payer: Cash Price	$408.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$383.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$229.95
Rate for Payer: Iowa Total Care Managed Medicaid	$291.88
Rate for Payer: Medical Associates Commercial	$383.25
Rate for Payer: Medical Associates Managed Medicare	$229.95
Rate for Payer: Midlands Choice Commercial	$357.70
Rate for Payer: Molina Healthcare Managed Medicaid	$296.18
Rate for Payer: Partners Health Alliance Commercial	$264.44
Rate for Payer: United Healthcare Commercial	$459.90
Rate for Payer: United Healthcare Managed Medicare	$301.49
Rate for Payer: Wellmark IA HMO WHPI	$694.11
Rate for Payer: Wellmark IA PPO	$764.60

US Aspiration/Inject/Biopsy Left

Facility

$511.00

Service Code	CPT 76942 LT
Hospital Charge Code	1169587
Hospital Revenue Code	402
Min. Negotiated Rate	$357.70
Max. Negotiated Rate	$459.90
Rate for Payer: Aetna of IA Commercial	$459.90
Rate for Payer: Aetna of IA Medical Rental Products	$459.90
Rate for Payer: Cash Price	$408.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$383.25
Rate for Payer: Medical Associates Commercial	$383.25
Rate for Payer: Midlands Choice Commercial	$357.70
Rate for Payer: United Healthcare Commercial	$459.90

US Aspiration/Inject/Biopsy Right

Facility

$511.00

Service Code	CPT 76942 RT
Hospital Charge Code	1169589
Hospital Revenue Code	402
Min. Negotiated Rate	$357.70
Max. Negotiated Rate	$459.90
Rate for Payer: Aetna of IA Commercial	$459.90
Rate for Payer: Aetna of IA Medical Rental Products	$459.90
Rate for Payer: Cash Price	$408.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$383.25
Rate for Payer: Medical Associates Commercial	$383.25
Rate for Payer: Midlands Choice Commercial	$357.70
Rate for Payer: United Healthcare Commercial	$459.90

US Aspiration/Inject/Biopsy Right

Facility

$511.00

Service Code	CPT 76942 RT
Hospital Charge Code	1169589
Hospital Revenue Code	402
Min. Negotiated Rate	$229.95
Max. Negotiated Rate	$764.60
Rate for Payer: Aetna of IA Commercial	$459.90
Rate for Payer: Aetna of IA Medical Rental Products	$459.90
Rate for Payer: Aetna of IA Medicare	$291.27
Rate for Payer: Amerigroup Medicaid	$294.74
Rate for Payer: Amerigroup Medicare	$232.25
Rate for Payer: Cash Price	$408.80
Rate for Payer: Cash Price	$408.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$383.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$229.95
Rate for Payer: Iowa Total Care Managed Medicaid	$291.88
Rate for Payer: Medical Associates Commercial	$383.25
Rate for Payer: Medical Associates Managed Medicare	$229.95
Rate for Payer: Midlands Choice Commercial	$357.70
Rate for Payer: Molina Healthcare Managed Medicaid	$296.18
Rate for Payer: Partners Health Alliance Commercial	$264.44
Rate for Payer: United Healthcare Commercial	$459.90
Rate for Payer: United Healthcare Managed Medicare	$301.49
Rate for Payer: Wellmark IA HMO WHPI	$694.11
Rate for Payer: Wellmark IA PPO	$764.60

US Breast Bilateral

Facility

$360.00

Service Code	CPT 76641 50
Hospital Charge Code	6800927
Hospital Revenue Code	402
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of IA Commercial	$324.00
Rate for Payer: Aetna of IA Medical Rental Products	$324.00
Rate for Payer: Aetna of IA Medicare	$205.20
Rate for Payer: Amerigroup Medicaid	$207.65
Rate for Payer: Amerigroup Medicare	$163.62
Rate for Payer: Cash Price	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$162.00
Rate for Payer: Iowa Total Care Managed Medicaid	$205.63
Rate for Payer: Medical Associates Commercial	$270.00
Rate for Payer: Medical Associates Managed Medicare	$162.00
Rate for Payer: Midlands Choice Commercial	$252.00
Rate for Payer: Molina Healthcare Managed Medicaid	$208.66
Rate for Payer: Partners Health Alliance Commercial	$186.30
Rate for Payer: United Healthcare Commercial	$324.00
Rate for Payer: United Healthcare Managed Medicare	$212.40
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Breast Bilateral

Facility

$360.00

Service Code	CPT 76641 50
Hospital Charge Code	6800927
Hospital Revenue Code	402
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of IA Commercial	$324.00
Rate for Payer: Aetna of IA Medical Rental Products	$324.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.00
Rate for Payer: Medical Associates Commercial	$270.00
Rate for Payer: Midlands Choice Commercial	$252.00
Rate for Payer: United Healthcare Commercial	$324.00

US Breast Bilateral.

Facility

$252.00

Service Code	CPT 76642 50
Hospital Charge Code	1169621
Hospital Revenue Code	402
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$265.54
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Aetna of IA Medicare	$143.64
Rate for Payer: Amerigroup Medicaid	$145.35
Rate for Payer: Amerigroup Medicare	$114.53
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$113.40
Rate for Payer: Iowa Total Care Managed Medicaid	$143.94
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Medical Associates Managed Medicare	$113.40
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: Molina Healthcare Managed Medicaid	$146.06
Rate for Payer: Partners Health Alliance Commercial	$130.41
Rate for Payer: United Healthcare Commercial	$226.80
Rate for Payer: United Healthcare Managed Medicare	$148.68
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Breast Bilateral.

Facility

$252.00

Service Code	CPT 76642 50
Hospital Charge Code	1169621
Hospital Revenue Code	402
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$226.80
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: United Healthcare Commercial	$226.80

US Breast Left

Facility

$360.00

Service Code	CPT 76641 LT
Hospital Charge Code	6800930
Hospital Revenue Code	402
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of IA Commercial	$324.00
Rate for Payer: Aetna of IA Medical Rental Products	$324.00
Rate for Payer: Aetna of IA Medicare	$205.20
Rate for Payer: Amerigroup Medicaid	$207.65
Rate for Payer: Amerigroup Medicare	$163.62
Rate for Payer: Cash Price	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$162.00
Rate for Payer: Iowa Total Care Managed Medicaid	$205.63
Rate for Payer: Medical Associates Commercial	$270.00
Rate for Payer: Medical Associates Managed Medicare	$162.00
Rate for Payer: Midlands Choice Commercial	$252.00
Rate for Payer: Molina Healthcare Managed Medicaid	$208.66
Rate for Payer: Partners Health Alliance Commercial	$186.30
Rate for Payer: United Healthcare Commercial	$324.00
Rate for Payer: United Healthcare Managed Medicare	$212.40
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Breast Left

Facility

$360.00

Service Code	CPT 76641 LT
Hospital Charge Code	6800930
Hospital Revenue Code	402
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of IA Commercial	$324.00
Rate for Payer: Aetna of IA Medical Rental Products	$324.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.00
Rate for Payer: Medical Associates Commercial	$270.00
Rate for Payer: Midlands Choice Commercial	$252.00
Rate for Payer: United Healthcare Commercial	$324.00

US Breast Left.

Facility

$360.00

Service Code	CPT 76641 LT
Hospital Charge Code	1169623
Hospital Revenue Code	402
Min. Negotiated Rate	$252.00
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of IA Commercial	$324.00
Rate for Payer: Aetna of IA Medical Rental Products	$324.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.00
Rate for Payer: Medical Associates Commercial	$270.00
Rate for Payer: Midlands Choice Commercial	$252.00
Rate for Payer: United Healthcare Commercial	$324.00

US Breast Left.

Facility

$360.00

Service Code	CPT 76641 LT
Hospital Charge Code	1169623
Hospital Revenue Code	402
Min. Negotiated Rate	$162.00
Max. Negotiated Rate	$324.00
Rate for Payer: Aetna of IA Commercial	$324.00
Rate for Payer: Aetna of IA Medical Rental Products	$324.00
Rate for Payer: Aetna of IA Medicare	$205.20
Rate for Payer: Amerigroup Medicaid	$207.65
Rate for Payer: Amerigroup Medicare	$163.62
Rate for Payer: Cash Price	$288.00
Rate for Payer: Cash Price	$288.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$270.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$162.00
Rate for Payer: Iowa Total Care Managed Medicaid	$205.63
Rate for Payer: Medical Associates Commercial	$270.00
Rate for Payer: Medical Associates Managed Medicare	$162.00
Rate for Payer: Midlands Choice Commercial	$252.00
Rate for Payer: Molina Healthcare Managed Medicaid	$208.66
Rate for Payer: Partners Health Alliance Commercial	$186.30
Rate for Payer: United Healthcare Commercial	$324.00
Rate for Payer: United Healthcare Managed Medicare	$212.40
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Breast Limited Left

Facility

$252.00

Service Code	CPT 76642 LT
Hospital Charge Code	6800933
Hospital Revenue Code	402
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$226.80
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: United Healthcare Commercial	$226.80

US Breast Limited Left

Facility

$252.00

Service Code	CPT 76642 LT
Hospital Charge Code	6800933
Hospital Revenue Code	402
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$265.54
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Aetna of IA Medicare	$143.64
Rate for Payer: Amerigroup Medicaid	$145.35
Rate for Payer: Amerigroup Medicare	$114.53
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$113.40
Rate for Payer: Iowa Total Care Managed Medicaid	$143.94
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Medical Associates Managed Medicare	$113.40
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: Molina Healthcare Managed Medicaid	$146.06
Rate for Payer: Partners Health Alliance Commercial	$130.41
Rate for Payer: United Healthcare Commercial	$226.80
Rate for Payer: United Healthcare Managed Medicare	$148.68
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Breast Limited Left.

Facility

$252.00

Service Code	CPT 76642 LT
Hospital Charge Code	5052788
Hospital Revenue Code	402
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$226.80
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: United Healthcare Commercial	$226.80

US Breast Limited Left.

Facility

$252.00

Service Code	CPT 76642 LT
Hospital Charge Code	5052788
Hospital Revenue Code	402
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$265.54
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Aetna of IA Medicare	$143.64
Rate for Payer: Amerigroup Medicaid	$145.35
Rate for Payer: Amerigroup Medicare	$114.53
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$113.40
Rate for Payer: Iowa Total Care Managed Medicaid	$143.94
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Medical Associates Managed Medicare	$113.40
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: Molina Healthcare Managed Medicaid	$146.06
Rate for Payer: Partners Health Alliance Commercial	$130.41
Rate for Payer: United Healthcare Commercial	$226.80
Rate for Payer: United Healthcare Managed Medicare	$148.68
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Breast Limited Right

Facility

$252.00

Service Code	CPT 76642 RT
Hospital Charge Code	6800936
Hospital Revenue Code	402
Min. Negotiated Rate	$176.40
Max. Negotiated Rate	$226.80
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: United Healthcare Commercial	$226.80

US Breast Limited Right

Facility

$252.00

Service Code	CPT 76642 RT
Hospital Charge Code	6800936
Hospital Revenue Code	402
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$265.54
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Aetna of IA Medicare	$143.64
Rate for Payer: Amerigroup Medicaid	$145.35
Rate for Payer: Amerigroup Medicare	$114.53
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$113.40
Rate for Payer: Iowa Total Care Managed Medicaid	$143.94
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Medical Associates Managed Medicare	$113.40
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: Molina Healthcare Managed Medicaid	$146.06
Rate for Payer: Partners Health Alliance Commercial	$130.41
Rate for Payer: United Healthcare Commercial	$226.80
Rate for Payer: United Healthcare Managed Medicare	$148.68
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Breast Limited Right.

Facility

$252.00

Service Code	CPT 76642 RT
Hospital Charge Code	5052791
Hospital Revenue Code	402
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$265.54
Rate for Payer: Aetna of IA Commercial	$226.80
Rate for Payer: Aetna of IA Medical Rental Products	$226.80
Rate for Payer: Aetna of IA Medicare	$143.64
Rate for Payer: Amerigroup Medicaid	$145.35
Rate for Payer: Amerigroup Medicare	$114.53
Rate for Payer: Cash Price	$201.60
Rate for Payer: Cash Price	$201.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$189.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$113.40
Rate for Payer: Iowa Total Care Managed Medicaid	$143.94
Rate for Payer: Medical Associates Commercial	$189.00
Rate for Payer: Medical Associates Managed Medicare	$113.40
Rate for Payer: Midlands Choice Commercial	$176.40
Rate for Payer: Molina Healthcare Managed Medicaid	$146.06
Rate for Payer: Partners Health Alliance Commercial	$130.41
Rate for Payer: United Healthcare Commercial	$226.80
Rate for Payer: United Healthcare Managed Medicare	$148.68
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

Know your out-of-pocket cost for care.

All Charges