Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Ankle 2 Views Right

Facility

$133.00

Service Code	CPT 73600 RT
Hospital Charge Code	1169938
Hospital Revenue Code	320
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: United Healthcare Commercial	$119.70

XR Ankle Complete Left

Facility

$146.00

Service Code	CPT 73610 LT
Hospital Charge Code	1169942
Hospital Revenue Code	320
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Aetna of IA Medicare	$83.22
Rate for Payer: Amerigroup Medicaid	$84.21
Rate for Payer: Amerigroup Medicare	$66.36
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.70
Rate for Payer: Iowa Total Care Managed Medicaid	$83.40
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Medical Associates Managed Medicare	$65.70
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: Molina Healthcare Managed Medicaid	$84.62
Rate for Payer: Partners Health Alliance Commercial	$75.56
Rate for Payer: United Healthcare Commercial	$131.40
Rate for Payer: United Healthcare Managed Medicare	$86.14
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Ankle Complete Left

Facility

$146.00

Service Code	CPT 73610 LT
Hospital Charge Code	1169942
Hospital Revenue Code	320
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: United Healthcare Commercial	$131.40

XR Ankle Complete Right

Facility

$146.00

Service Code	CPT 73610 RT
Hospital Charge Code	1169944
Hospital Revenue Code	320
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Aetna of IA Medicare	$83.22
Rate for Payer: Amerigroup Medicaid	$84.21
Rate for Payer: Amerigroup Medicare	$66.36
Rate for Payer: Cash Price	$116.80
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.70
Rate for Payer: Iowa Total Care Managed Medicaid	$83.40
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Medical Associates Managed Medicare	$65.70
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: Molina Healthcare Managed Medicaid	$84.62
Rate for Payer: Partners Health Alliance Commercial	$75.56
Rate for Payer: United Healthcare Commercial	$131.40
Rate for Payer: United Healthcare Managed Medicare	$86.14
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Ankle Complete Right

Facility

$146.00

Service Code	CPT 73610 RT
Hospital Charge Code	1169944
Hospital Revenue Code	320
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: United Healthcare Commercial	$131.40

XR Arthrogram Knee Left

Facility

$723.00

Service Code	CPT 73580 LT
Hospital Charge Code	1169970
Hospital Revenue Code	322
Min. Negotiated Rate	$506.10
Max. Negotiated Rate	$650.70
Rate for Payer: Aetna of IA Commercial	$650.70
Rate for Payer: Aetna of IA Medical Rental Products	$650.70
Rate for Payer: Cash Price	$578.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$542.25
Rate for Payer: Medical Associates Commercial	$542.25
Rate for Payer: Midlands Choice Commercial	$506.10
Rate for Payer: United Healthcare Commercial	$650.70

XR Arthrogram Knee Left

Facility

$723.00

Service Code	CPT 73580 LT
Hospital Charge Code	1169970
Hospital Revenue Code	322
Min. Negotiated Rate	$298.49
Max. Negotiated Rate	$650.70
Rate for Payer: Aetna of IA Commercial	$650.70
Rate for Payer: Aetna of IA Medical Rental Products	$650.70
Rate for Payer: Aetna of IA Medicare	$412.11
Rate for Payer: Amerigroup Medicaid	$417.03
Rate for Payer: Amerigroup Medicare	$328.60
Rate for Payer: Cash Price	$578.40
Rate for Payer: Cash Price	$578.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$542.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$325.35
Rate for Payer: Iowa Total Care Managed Medicaid	$412.98
Rate for Payer: Medical Associates Commercial	$542.25
Rate for Payer: Medical Associates Managed Medicare	$325.35
Rate for Payer: Midlands Choice Commercial	$506.10
Rate for Payer: Molina Healthcare Managed Medicaid	$419.05
Rate for Payer: Partners Health Alliance Commercial	$374.15
Rate for Payer: United Healthcare Commercial	$650.70
Rate for Payer: United Healthcare Managed Medicare	$426.57
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Arthrogram Knee Right

Facility

$723.00

Service Code	CPT 73580 RT
Hospital Charge Code	1169972
Hospital Revenue Code	322
Min. Negotiated Rate	$506.10
Max. Negotiated Rate	$650.70
Rate for Payer: Aetna of IA Commercial	$650.70
Rate for Payer: Aetna of IA Medical Rental Products	$650.70
Rate for Payer: Cash Price	$578.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$542.25
Rate for Payer: Medical Associates Commercial	$542.25
Rate for Payer: Midlands Choice Commercial	$506.10
Rate for Payer: United Healthcare Commercial	$650.70

XR Arthrogram Knee Right

Facility

$723.00

Service Code	CPT 73580 RT
Hospital Charge Code	1169972
Hospital Revenue Code	322
Min. Negotiated Rate	$298.49
Max. Negotiated Rate	$650.70
Rate for Payer: Aetna of IA Commercial	$650.70
Rate for Payer: Aetna of IA Medical Rental Products	$650.70
Rate for Payer: Aetna of IA Medicare	$412.11
Rate for Payer: Amerigroup Medicaid	$417.03
Rate for Payer: Amerigroup Medicare	$328.60
Rate for Payer: Cash Price	$578.40
Rate for Payer: Cash Price	$578.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$542.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$325.35
Rate for Payer: Iowa Total Care Managed Medicaid	$412.98
Rate for Payer: Medical Associates Commercial	$542.25
Rate for Payer: Medical Associates Managed Medicare	$325.35
Rate for Payer: Midlands Choice Commercial	$506.10
Rate for Payer: Molina Healthcare Managed Medicaid	$419.05
Rate for Payer: Partners Health Alliance Commercial	$374.15
Rate for Payer: United Healthcare Commercial	$650.70
Rate for Payer: United Healthcare Managed Medicare	$426.57
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Arthrogram Shoulder Left

Facility

$772.00

Service Code	CPT 73040 LT
Hospital Charge Code	1169984
Hospital Revenue Code	322
Min. Negotiated Rate	$298.49
Max. Negotiated Rate	$694.80
Rate for Payer: Aetna of IA Commercial	$694.80
Rate for Payer: Aetna of IA Medical Rental Products	$694.80
Rate for Payer: Aetna of IA Medicare	$440.04
Rate for Payer: Amerigroup Medicaid	$445.29
Rate for Payer: Amerigroup Medicare	$350.87
Rate for Payer: Cash Price	$617.60
Rate for Payer: Cash Price	$617.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$579.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$347.40
Rate for Payer: Iowa Total Care Managed Medicaid	$440.97
Rate for Payer: Medical Associates Commercial	$579.00
Rate for Payer: Medical Associates Managed Medicare	$347.40
Rate for Payer: Midlands Choice Commercial	$540.40
Rate for Payer: Molina Healthcare Managed Medicaid	$447.45
Rate for Payer: Partners Health Alliance Commercial	$399.51
Rate for Payer: United Healthcare Commercial	$694.80
Rate for Payer: United Healthcare Managed Medicare	$455.48
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Arthrogram Shoulder Left

Facility

$772.00

Service Code	CPT 73040 LT
Hospital Charge Code	1169984
Hospital Revenue Code	322
Min. Negotiated Rate	$540.40
Max. Negotiated Rate	$694.80
Rate for Payer: Aetna of IA Commercial	$694.80
Rate for Payer: Aetna of IA Medical Rental Products	$694.80
Rate for Payer: Cash Price	$617.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$579.00
Rate for Payer: Medical Associates Commercial	$579.00
Rate for Payer: Midlands Choice Commercial	$540.40
Rate for Payer: United Healthcare Commercial	$694.80

XR Arthrogram Shoulder Right

Facility

$772.00

Service Code	CPT 73040 RT
Hospital Charge Code	1169986
Hospital Revenue Code	322
Min. Negotiated Rate	$298.49
Max. Negotiated Rate	$694.80
Rate for Payer: Aetna of IA Commercial	$694.80
Rate for Payer: Aetna of IA Medical Rental Products	$694.80
Rate for Payer: Aetna of IA Medicare	$440.04
Rate for Payer: Amerigroup Medicaid	$445.29
Rate for Payer: Amerigroup Medicare	$350.87
Rate for Payer: Cash Price	$617.60
Rate for Payer: Cash Price	$617.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$579.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$347.40
Rate for Payer: Iowa Total Care Managed Medicaid	$440.97
Rate for Payer: Medical Associates Commercial	$579.00
Rate for Payer: Medical Associates Managed Medicare	$347.40
Rate for Payer: Midlands Choice Commercial	$540.40
Rate for Payer: Molina Healthcare Managed Medicaid	$447.45
Rate for Payer: Partners Health Alliance Commercial	$399.51
Rate for Payer: United Healthcare Commercial	$694.80
Rate for Payer: United Healthcare Managed Medicare	$455.48
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Arthrogram Shoulder Right

Facility

$772.00

Service Code	CPT 73040 RT
Hospital Charge Code	1169986
Hospital Revenue Code	322
Min. Negotiated Rate	$540.40
Max. Negotiated Rate	$694.80
Rate for Payer: Aetna of IA Commercial	$694.80
Rate for Payer: Aetna of IA Medical Rental Products	$694.80
Rate for Payer: Cash Price	$617.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$579.00
Rate for Payer: Medical Associates Commercial	$579.00
Rate for Payer: Midlands Choice Commercial	$540.40
Rate for Payer: United Healthcare Commercial	$694.80

XR Arthrogram Wrist Left

Facility

$759.00

Service Code	CPT 73115 LT
Hospital Charge Code	1169996
Hospital Revenue Code	322
Min. Negotiated Rate	$298.49
Max. Negotiated Rate	$683.10
Rate for Payer: Aetna of IA Commercial	$683.10
Rate for Payer: Aetna of IA Medical Rental Products	$683.10
Rate for Payer: Aetna of IA Medicare	$432.63
Rate for Payer: Amerigroup Medicaid	$437.79
Rate for Payer: Amerigroup Medicare	$344.97
Rate for Payer: Cash Price	$607.20
Rate for Payer: Cash Price	$607.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$569.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$341.55
Rate for Payer: Iowa Total Care Managed Medicaid	$433.54
Rate for Payer: Medical Associates Commercial	$569.25
Rate for Payer: Medical Associates Managed Medicare	$341.55
Rate for Payer: Midlands Choice Commercial	$531.30
Rate for Payer: Molina Healthcare Managed Medicaid	$439.92
Rate for Payer: Partners Health Alliance Commercial	$392.78
Rate for Payer: United Healthcare Commercial	$683.10
Rate for Payer: United Healthcare Managed Medicare	$447.81
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Arthrogram Wrist Left

Facility

$759.00

Service Code	CPT 73115 LT
Hospital Charge Code	1169996
Hospital Revenue Code	322
Min. Negotiated Rate	$531.30
Max. Negotiated Rate	$683.10
Rate for Payer: Aetna of IA Commercial	$683.10
Rate for Payer: Aetna of IA Medical Rental Products	$683.10
Rate for Payer: Cash Price	$607.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$569.25
Rate for Payer: Medical Associates Commercial	$569.25
Rate for Payer: Midlands Choice Commercial	$531.30
Rate for Payer: United Healthcare Commercial	$683.10

XR Arthrogram Wrist Right

Facility

$759.00

Service Code	CPT 73115 RT
Hospital Charge Code	1169998
Hospital Revenue Code	322
Min. Negotiated Rate	$298.49
Max. Negotiated Rate	$683.10
Rate for Payer: Aetna of IA Commercial	$683.10
Rate for Payer: Aetna of IA Medical Rental Products	$683.10
Rate for Payer: Aetna of IA Medicare	$432.63
Rate for Payer: Amerigroup Medicaid	$437.79
Rate for Payer: Amerigroup Medicare	$344.97
Rate for Payer: Cash Price	$607.20
Rate for Payer: Cash Price	$607.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$569.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$341.55
Rate for Payer: Iowa Total Care Managed Medicaid	$433.54
Rate for Payer: Medical Associates Commercial	$569.25
Rate for Payer: Medical Associates Managed Medicare	$341.55
Rate for Payer: Midlands Choice Commercial	$531.30
Rate for Payer: Molina Healthcare Managed Medicaid	$439.92
Rate for Payer: Partners Health Alliance Commercial	$392.78
Rate for Payer: United Healthcare Commercial	$683.10
Rate for Payer: United Healthcare Managed Medicare	$447.81
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Arthrogram Wrist Right

Facility

$759.00

Service Code	CPT 73115 RT
Hospital Charge Code	1169998
Hospital Revenue Code	322
Min. Negotiated Rate	$531.30
Max. Negotiated Rate	$683.10
Rate for Payer: Aetna of IA Commercial	$683.10
Rate for Payer: Aetna of IA Medical Rental Products	$683.10
Rate for Payer: Cash Price	$607.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$569.25
Rate for Payer: Medical Associates Commercial	$569.25
Rate for Payer: Midlands Choice Commercial	$531.30
Rate for Payer: United Healthcare Commercial	$683.10

XR Barium Enema Complete

Facility

$474.00

Service Code	CPT 74270
Hospital Charge Code	1170002
Hospital Revenue Code	320
Min. Negotiated Rate	$331.80
Max. Negotiated Rate	$426.60
Rate for Payer: Aetna of IA Commercial	$426.60
Rate for Payer: Aetna of IA Medical Rental Products	$426.60
Rate for Payer: Cash Price	$379.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$355.50
Rate for Payer: Medical Associates Commercial	$355.50
Rate for Payer: Midlands Choice Commercial	$331.80
Rate for Payer: United Healthcare Commercial	$426.60

XR Barium Enema Complete

Facility

$474.00

Service Code	CPT 74270
Hospital Charge Code	1170002
Hospital Revenue Code	320
Min. Negotiated Rate	$213.30
Max. Negotiated Rate	$426.60
Rate for Payer: Aetna of IA Commercial	$426.60
Rate for Payer: Aetna of IA Medical Rental Products	$426.60
Rate for Payer: Aetna of IA Medicare	$270.18
Rate for Payer: Amerigroup Medicaid	$273.40
Rate for Payer: Amerigroup Medicare	$215.43
Rate for Payer: Cash Price	$379.20
Rate for Payer: Cash Price	$379.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$355.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$213.30
Rate for Payer: Iowa Total Care Managed Medicaid	$270.75
Rate for Payer: Medical Associates Commercial	$355.50
Rate for Payer: Medical Associates Managed Medicare	$213.30
Rate for Payer: Midlands Choice Commercial	$331.80
Rate for Payer: Molina Healthcare Managed Medicaid	$274.73
Rate for Payer: Partners Health Alliance Commercial	$245.30
Rate for Payer: United Healthcare Commercial	$426.60
Rate for Payer: United Healthcare Managed Medicare	$279.66
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Barium Enema w/ Air Complete

Facility

$547.00

Service Code	CPT 74280
Hospital Charge Code	1170006
Hospital Revenue Code	320
Min. Negotiated Rate	$246.15
Max. Negotiated Rate	$492.30
Rate for Payer: Aetna of IA Commercial	$492.30
Rate for Payer: Aetna of IA Medical Rental Products	$492.30
Rate for Payer: Aetna of IA Medicare	$311.79
Rate for Payer: Amerigroup Medicaid	$315.51
Rate for Payer: Amerigroup Medicare	$248.61
Rate for Payer: Cash Price	$437.60
Rate for Payer: Cash Price	$437.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$410.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$246.15
Rate for Payer: Iowa Total Care Managed Medicaid	$312.45
Rate for Payer: Medical Associates Commercial	$410.25
Rate for Payer: Medical Associates Managed Medicare	$246.15
Rate for Payer: Midlands Choice Commercial	$382.90
Rate for Payer: Molina Healthcare Managed Medicaid	$317.04
Rate for Payer: Partners Health Alliance Commercial	$283.07
Rate for Payer: United Healthcare Commercial	$492.30
Rate for Payer: United Healthcare Managed Medicare	$322.73
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Barium Enema w/ Air Complete

Facility

$547.00

Service Code	CPT 74280
Hospital Charge Code	1170006
Hospital Revenue Code	320
Min. Negotiated Rate	$382.90
Max. Negotiated Rate	$492.30
Rate for Payer: Aetna of IA Commercial	$492.30
Rate for Payer: Aetna of IA Medical Rental Products	$492.30
Rate for Payer: Cash Price	$437.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$410.25
Rate for Payer: Medical Associates Commercial	$410.25
Rate for Payer: Midlands Choice Commercial	$382.90
Rate for Payer: United Healthcare Commercial	$492.30

XR Bone Age Studies

Facility

$134.00

Service Code	CPT 77072
Hospital Charge Code	1170014
Hospital Revenue Code	320
Min. Negotiated Rate	$93.80
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: United Healthcare Commercial	$120.60

XR Bone Age Studies

Facility

$134.00

Service Code	CPT 77072
Hospital Charge Code	1170014
Hospital Revenue Code	320
Min. Negotiated Rate	$60.30
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Aetna of IA Medicare	$76.38
Rate for Payer: Amerigroup Medicaid	$77.29
Rate for Payer: Amerigroup Medicare	$60.90
Rate for Payer: Cash Price	$107.20
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$60.30
Rate for Payer: Iowa Total Care Managed Medicaid	$76.54
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Medical Associates Managed Medicare	$60.30
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: Molina Healthcare Managed Medicaid	$77.67
Rate for Payer: Partners Health Alliance Commercial	$69.34
Rate for Payer: United Healthcare Commercial	$120.60
Rate for Payer: United Healthcare Managed Medicare	$79.06
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Bone Survey Complete (Mets)

Facility

$552.00

Service Code	CPT 77075
Hospital Charge Code	1170018
Hospital Revenue Code	320
Min. Negotiated Rate	$248.40
Max. Negotiated Rate	$496.80
Rate for Payer: Aetna of IA Commercial	$496.80
Rate for Payer: Aetna of IA Medical Rental Products	$496.80
Rate for Payer: Aetna of IA Medicare	$314.64
Rate for Payer: Amerigroup Medicaid	$318.39
Rate for Payer: Amerigroup Medicare	$250.88
Rate for Payer: Cash Price	$441.60
Rate for Payer: Cash Price	$441.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$414.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$248.40
Rate for Payer: Iowa Total Care Managed Medicaid	$315.30
Rate for Payer: Medical Associates Commercial	$414.00
Rate for Payer: Medical Associates Managed Medicare	$248.40
Rate for Payer: Midlands Choice Commercial	$386.40
Rate for Payer: Molina Healthcare Managed Medicaid	$319.94
Rate for Payer: Partners Health Alliance Commercial	$285.66
Rate for Payer: United Healthcare Commercial	$496.80
Rate for Payer: United Healthcare Managed Medicare	$325.68
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Bone Survey Complete (Mets)

Facility

$552.00

Service Code	CPT 77075
Hospital Charge Code	1170018
Hospital Revenue Code	320
Min. Negotiated Rate	$386.40
Max. Negotiated Rate	$496.80
Rate for Payer: Aetna of IA Commercial	$496.80
Rate for Payer: Aetna of IA Medical Rental Products	$496.80
Rate for Payer: Cash Price	$441.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$414.00
Rate for Payer: Medical Associates Commercial	$414.00
Rate for Payer: Midlands Choice Commercial	$386.40
Rate for Payer: United Healthcare Commercial	$496.80

Know your out-of-pocket cost for care.

All Charges