Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

US Breast Limited Right.

Facility

$252.00

Service Code	CPT 76642 RT
Hospital Charge Code	5052791
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 Right

Facility

$360.00

Service Code	CPT 76641 RT
Hospital Charge Code	6800939
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 Right

Facility

$360.00

Service Code	CPT 76641 RT
Hospital Charge Code	6800939
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 Right.

Facility

$360.00

Service Code	CPT 76641 RT
Hospital Charge Code	1169625
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 Right.

Facility

$360.00

Service Code	CPT 76641 RT
Hospital Charge Code	1169625
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 Carotid Doppler Bilateral

Facility

$716.00

Service Code	CPT 93880 50\|TC
Hospital Charge Code	1169627
Hospital Revenue Code	921
Min. Negotiated Rate	$501.20
Max. Negotiated Rate	$644.40
Rate for Payer: Aetna of IA Commercial	$644.40
Rate for Payer: Aetna of IA Medical Rental Products	$644.40
Rate for Payer: Cash Price	$572.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$537.00
Rate for Payer: Medical Associates Commercial	$537.00
Rate for Payer: Midlands Choice Commercial	$501.20
Rate for Payer: United Healthcare Commercial	$644.40

US Carotid Doppler Bilateral

Facility

$716.00

Service Code	CPT 93880 50\|TC
Hospital Charge Code	1169627
Hospital Revenue Code	921
Min. Negotiated Rate	$322.20
Max. Negotiated Rate	$644.40
Rate for Payer: Aetna of IA Commercial	$644.40
Rate for Payer: Aetna of IA Medical Rental Products	$644.40
Rate for Payer: Aetna of IA Medicare	$408.12
Rate for Payer: Amerigroup Medicaid	$412.99
Rate for Payer: Amerigroup Medicare	$325.42
Rate for Payer: Cash Price	$572.80
Rate for Payer: Cash Price	$572.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$537.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$322.20
Rate for Payer: Iowa Total Care Managed Medicaid	$408.98
Rate for Payer: Medical Associates Commercial	$537.00
Rate for Payer: Medical Associates Managed Medicare	$322.20
Rate for Payer: Midlands Choice Commercial	$501.20
Rate for Payer: Molina Healthcare Managed Medicaid	$414.99
Rate for Payer: Partners Health Alliance Commercial	$370.53
Rate for Payer: United Healthcare Commercial	$644.40
Rate for Payer: United Healthcare Managed Medicare	$422.44
Rate for Payer: Wellmark IA HMO WHPI	$375.06
Rate for Payer: Wellmark IA PPO	$413.15

US Carotid Duplex Bilateral

Facility

$716.00

Service Code	CPT 93880 50\|TC
Hospital Charge Code	1169629
Hospital Revenue Code	921
Min. Negotiated Rate	$501.20
Max. Negotiated Rate	$644.40
Rate for Payer: Aetna of IA Commercial	$644.40
Rate for Payer: Aetna of IA Medical Rental Products	$644.40
Rate for Payer: Cash Price	$572.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$537.00
Rate for Payer: Medical Associates Commercial	$537.00
Rate for Payer: Midlands Choice Commercial	$501.20
Rate for Payer: United Healthcare Commercial	$644.40

US Carotid Duplex Bilateral

Facility

$716.00

Service Code	CPT 93880 50\|TC
Hospital Charge Code	1169629
Hospital Revenue Code	921
Min. Negotiated Rate	$322.20
Max. Negotiated Rate	$644.40
Rate for Payer: Aetna of IA Commercial	$644.40
Rate for Payer: Aetna of IA Medical Rental Products	$644.40
Rate for Payer: Aetna of IA Medicare	$408.12
Rate for Payer: Amerigroup Medicaid	$412.99
Rate for Payer: Amerigroup Medicare	$325.42
Rate for Payer: Cash Price	$572.80
Rate for Payer: Cash Price	$572.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$537.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$322.20
Rate for Payer: Iowa Total Care Managed Medicaid	$408.98
Rate for Payer: Medical Associates Commercial	$537.00
Rate for Payer: Medical Associates Managed Medicare	$322.20
Rate for Payer: Midlands Choice Commercial	$501.20
Rate for Payer: Molina Healthcare Managed Medicaid	$414.99
Rate for Payer: Partners Health Alliance Commercial	$370.53
Rate for Payer: United Healthcare Commercial	$644.40
Rate for Payer: United Healthcare Managed Medicare	$422.44
Rate for Payer: Wellmark IA HMO WHPI	$375.06
Rate for Payer: Wellmark IA PPO	$413.15

US Carotid Duplex Left

Facility

$500.00

Service Code	CPT 93882
Hospital Charge Code	1169631
Hospital Revenue Code	921
Min. Negotiated Rate	$350.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna of IA Commercial	$450.00
Rate for Payer: Aetna of IA Medical Rental Products	$450.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$375.00
Rate for Payer: Medical Associates Commercial	$375.00
Rate for Payer: Midlands Choice Commercial	$350.00
Rate for Payer: United Healthcare Commercial	$450.00

US Carotid Duplex Left

Facility

$500.00

Service Code	CPT 93882
Hospital Charge Code	1169631
Hospital Revenue Code	921
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna of IA Commercial	$450.00
Rate for Payer: Aetna of IA Medical Rental Products	$450.00
Rate for Payer: Aetna of IA Medicare	$285.00
Rate for Payer: Amerigroup Medicaid	$288.40
Rate for Payer: Amerigroup Medicare	$227.25
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$375.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$225.00
Rate for Payer: Iowa Total Care Managed Medicaid	$285.60
Rate for Payer: Medical Associates Commercial	$375.00
Rate for Payer: Medical Associates Managed Medicare	$225.00
Rate for Payer: Midlands Choice Commercial	$350.00
Rate for Payer: Molina Healthcare Managed Medicaid	$289.80
Rate for Payer: Partners Health Alliance Commercial	$258.75
Rate for Payer: United Healthcare Commercial	$450.00
Rate for Payer: United Healthcare Managed Medicare	$295.00
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Carotid Duplex Right

Facility

$500.00

Service Code	CPT 93882
Hospital Charge Code	1169633
Hospital Revenue Code	921
Min. Negotiated Rate	$350.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna of IA Commercial	$450.00
Rate for Payer: Aetna of IA Medical Rental Products	$450.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$375.00
Rate for Payer: Medical Associates Commercial	$375.00
Rate for Payer: Midlands Choice Commercial	$350.00
Rate for Payer: United Healthcare Commercial	$450.00

US Carotid Duplex Right

Facility

$500.00

Service Code	CPT 93882
Hospital Charge Code	1169633
Hospital Revenue Code	921
Min. Negotiated Rate	$225.00
Max. Negotiated Rate	$450.00
Rate for Payer: Aetna of IA Commercial	$450.00
Rate for Payer: Aetna of IA Medical Rental Products	$450.00
Rate for Payer: Aetna of IA Medicare	$285.00
Rate for Payer: Amerigroup Medicaid	$288.40
Rate for Payer: Amerigroup Medicare	$227.25
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$375.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$225.00
Rate for Payer: Iowa Total Care Managed Medicaid	$285.60
Rate for Payer: Medical Associates Commercial	$375.00
Rate for Payer: Medical Associates Managed Medicare	$225.00
Rate for Payer: Midlands Choice Commercial	$350.00
Rate for Payer: Molina Healthcare Managed Medicaid	$289.80
Rate for Payer: Partners Health Alliance Commercial	$258.75
Rate for Payer: United Healthcare Commercial	$450.00
Rate for Payer: United Healthcare Managed Medicare	$295.00
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US CHEST

Facility

$360.00

Service Code	CPT 76604 TC
Hospital Charge Code	1169635
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 CHEST

Facility

$360.00

Service Code	CPT 76604 TC
Hospital Charge Code	1169635
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 Drainage Abscess or Cyst

Facility

$897.00

Service Code	CPT 75989 TC
Hospital Charge Code	1169645
Hospital Revenue Code	402
Min. Negotiated Rate	$627.90
Max. Negotiated Rate	$807.30
Rate for Payer: Aetna of IA Commercial	$807.30
Rate for Payer: Aetna of IA Medical Rental Products	$807.30
Rate for Payer: Cash Price	$717.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$672.75
Rate for Payer: Medical Associates Commercial	$672.75
Rate for Payer: Midlands Choice Commercial	$627.90
Rate for Payer: United Healthcare Commercial	$807.30

US Drainage Abscess or Cyst

Facility

$897.00

Service Code	CPT 75989 TC
Hospital Charge Code	1169645
Hospital Revenue Code	402
Min. Negotiated Rate	$403.65
Max. Negotiated Rate	$807.30
Rate for Payer: Aetna of IA Commercial	$807.30
Rate for Payer: Aetna of IA Medical Rental Products	$807.30
Rate for Payer: Aetna of IA Medicare	$511.29
Rate for Payer: Amerigroup Medicaid	$517.39
Rate for Payer: Amerigroup Medicare	$407.69
Rate for Payer: Cash Price	$717.60
Rate for Payer: Cash Price	$717.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$672.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$403.65
Rate for Payer: Iowa Total Care Managed Medicaid	$512.37
Rate for Payer: Medical Associates Commercial	$672.75
Rate for Payer: Medical Associates Managed Medicare	$403.65
Rate for Payer: Midlands Choice Commercial	$627.90
Rate for Payer: Molina Healthcare Managed Medicaid	$519.90
Rate for Payer: Partners Health Alliance Commercial	$464.20
Rate for Payer: United Healthcare Commercial	$807.30
Rate for Payer: United Healthcare Managed Medicare	$529.23
Rate for Payer: Wellmark IA HMO WHPI	$463.69
Rate for Payer: Wellmark IA PPO	$510.77

US Echocardiogram

Facility

$1,338.00

Service Code	CPT 93306 TC
Hospital Charge Code	1844784
Hospital Revenue Code	480
Min. Negotiated Rate	$936.60
Max. Negotiated Rate	$1,204.20
Rate for Payer: Aetna of IA Commercial	$1,204.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,204.20
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,003.50
Rate for Payer: Medical Associates Commercial	$1,003.50
Rate for Payer: Midlands Choice Commercial	$936.60
Rate for Payer: United Healthcare Commercial	$1,204.20

US Echocardiogram

Facility

$1,338.00

Service Code	CPT 93306 TC
Hospital Charge Code	1844784
Hospital Revenue Code	480
Min. Negotiated Rate	$602.10
Max. Negotiated Rate	$1,204.20
Rate for Payer: Aetna of IA Commercial	$1,204.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,204.20
Rate for Payer: Aetna of IA Medicare	$762.66
Rate for Payer: Amerigroup Medicaid	$771.76
Rate for Payer: Amerigroup Medicare	$608.12
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Cash Price	$1,070.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,003.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$602.10
Rate for Payer: Iowa Total Care Managed Medicaid	$764.27
Rate for Payer: Medical Associates Commercial	$1,003.50
Rate for Payer: Medical Associates Managed Medicare	$602.10
Rate for Payer: Midlands Choice Commercial	$936.60
Rate for Payer: Molina Healthcare Managed Medicaid	$775.50
Rate for Payer: Partners Health Alliance Commercial	$692.42
Rate for Payer: United Healthcare Commercial	$1,204.20
Rate for Payer: United Healthcare Managed Medicare	$789.42
Rate for Payer: Wellmark IA HMO WHPI	$901.85
Rate for Payer: Wellmark IA PPO	$993.43

US Echocardiogram Limited

Facility

$518.00

Service Code	CPT 93308 TC
Hospital Charge Code	7960820
Hospital Revenue Code	480
Min. Negotiated Rate	$362.60
Max. Negotiated Rate	$466.20
Rate for Payer: Aetna of IA Commercial	$466.20
Rate for Payer: Aetna of IA Medical Rental Products	$466.20
Rate for Payer: Cash Price	$414.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$388.50
Rate for Payer: Medical Associates Commercial	$388.50
Rate for Payer: Midlands Choice Commercial	$362.60
Rate for Payer: United Healthcare Commercial	$466.20

US Echocardiogram Limited

Facility

$518.00

Service Code	CPT 93308 TC
Hospital Charge Code	7960820
Hospital Revenue Code	480
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$993.43
Rate for Payer: Aetna of IA Commercial	$466.20
Rate for Payer: Aetna of IA Medical Rental Products	$466.20
Rate for Payer: Aetna of IA Medicare	$295.26
Rate for Payer: Amerigroup Medicaid	$298.78
Rate for Payer: Amerigroup Medicare	$235.43
Rate for Payer: Cash Price	$414.40
Rate for Payer: Cash Price	$414.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$388.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$233.10
Rate for Payer: Iowa Total Care Managed Medicaid	$295.88
Rate for Payer: Medical Associates Commercial	$388.50
Rate for Payer: Medical Associates Managed Medicare	$233.10
Rate for Payer: Midlands Choice Commercial	$362.60
Rate for Payer: Molina Healthcare Managed Medicaid	$300.23
Rate for Payer: Partners Health Alliance Commercial	$268.06
Rate for Payer: United Healthcare Commercial	$466.20
Rate for Payer: United Healthcare Managed Medicare	$305.62
Rate for Payer: Wellmark IA HMO WHPI	$901.85
Rate for Payer: Wellmark IA PPO	$993.43

US Extremity Non Vascular Left

Facility

$347.00

Service Code	CPT 76882 LT
Hospital Charge Code	1169683
Hospital Revenue Code	402
Min. Negotiated Rate	$242.90
Max. Negotiated Rate	$312.30
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: United Healthcare Commercial	$312.30

US Extremity Non Vascular Left

Facility

$347.00

Service Code	CPT 76882 LT
Hospital Charge Code	1169683
Hospital Revenue Code	402
Min. Negotiated Rate	$156.15
Max. Negotiated Rate	$312.30
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Aetna of IA Medicare	$197.79
Rate for Payer: Amerigroup Medicaid	$200.15
Rate for Payer: Amerigroup Medicare	$157.71
Rate for Payer: Cash Price	$277.60
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$156.15
Rate for Payer: Iowa Total Care Managed Medicaid	$198.21
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Medical Associates Managed Medicare	$156.15
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: Molina Healthcare Managed Medicaid	$201.12
Rate for Payer: Partners Health Alliance Commercial	$179.57
Rate for Payer: United Healthcare Commercial	$312.30
Rate for Payer: United Healthcare Managed Medicare	$204.73
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Extremity Non Vascular Right

Facility

$347.00

Service Code	CPT 76882 RT
Hospital Charge Code	1169685
Hospital Revenue Code	402
Min. Negotiated Rate	$156.15
Max. Negotiated Rate	$312.30
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Aetna of IA Medicare	$197.79
Rate for Payer: Amerigroup Medicaid	$200.15
Rate for Payer: Amerigroup Medicare	$157.71
Rate for Payer: Cash Price	$277.60
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$156.15
Rate for Payer: Iowa Total Care Managed Medicaid	$198.21
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Medical Associates Managed Medicare	$156.15
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: Molina Healthcare Managed Medicaid	$201.12
Rate for Payer: Partners Health Alliance Commercial	$179.57
Rate for Payer: United Healthcare Commercial	$312.30
Rate for Payer: United Healthcare Managed Medicare	$204.73
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Extremity Non Vascular Right

Facility

$347.00

Service Code	CPT 76882 RT
Hospital Charge Code	1169685
Hospital Revenue Code	402
Min. Negotiated Rate	$242.90
Max. Negotiated Rate	$312.30
Rate for Payer: Aetna of IA Commercial	$312.30
Rate for Payer: Aetna of IA Medical Rental Products	$312.30
Rate for Payer: Cash Price	$277.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.25
Rate for Payer: Medical Associates Commercial	$260.25
Rate for Payer: Midlands Choice Commercial	$242.90
Rate for Payer: United Healthcare Commercial	$312.30

Know your out-of-pocket cost for care.

All Charges