Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Clavicle Left

Facility

$151.00

Service Code	CPT 73000 LT
Hospital Charge Code	1170075
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

XR Clavicle Right

Facility

$151.00

Service Code	CPT 73000 RT
Hospital Charge Code	1170077
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

XR Clavicle Right

Facility

$151.00

Service Code	CPT 73000 RT
Hospital Charge Code	1170077
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Cystography

Facility

$347.00

Service Code	CPT 74430
Hospital Charge Code	1170083
Hospital Revenue Code	320
Min. Negotiated Rate	$156.15
Max. Negotiated Rate	$328.80
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	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Cystography

Facility

$347.00

Service Code	CPT 74430
Hospital Charge Code	1170083
Hospital Revenue Code	320
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

XR Elbow 2 Views Left

Facility

$145.00

Service Code	CPT 73070 LT
Hospital Charge Code	1170121
Hospital Revenue Code	320
Min. Negotiated Rate	$65.25
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna of IA Commercial	$130.50
Rate for Payer: Aetna of IA Medical Rental Products	$130.50
Rate for Payer: Aetna of IA Medicare	$82.65
Rate for Payer: Amerigroup Medicaid	$83.64
Rate for Payer: Amerigroup Medicare	$65.90
Rate for Payer: Cash Price	$116.00
Rate for Payer: Cash Price	$116.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.25
Rate for Payer: Iowa Total Care Managed Medicaid	$82.82
Rate for Payer: Medical Associates Commercial	$108.75
Rate for Payer: Medical Associates Managed Medicare	$65.25
Rate for Payer: Midlands Choice Commercial	$101.50
Rate for Payer: Molina Healthcare Managed Medicaid	$84.04
Rate for Payer: Partners Health Alliance Commercial	$75.04
Rate for Payer: United Healthcare Commercial	$130.50
Rate for Payer: United Healthcare Managed Medicare	$85.55
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Elbow 2 Views Left

Facility

$145.00

Service Code	CPT 73070 LT
Hospital Charge Code	1170121
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna of IA Commercial	$130.50
Rate for Payer: Aetna of IA Medical Rental Products	$130.50
Rate for Payer: Cash Price	$116.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.75
Rate for Payer: Medical Associates Commercial	$108.75
Rate for Payer: Midlands Choice Commercial	$101.50
Rate for Payer: United Healthcare Commercial	$130.50

XR Elbow 2 Views Right

Facility

$145.00

Service Code	CPT 73070 RT
Hospital Charge Code	1170123
Hospital Revenue Code	320
Min. Negotiated Rate	$101.50
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna of IA Commercial	$130.50
Rate for Payer: Aetna of IA Medical Rental Products	$130.50
Rate for Payer: Cash Price	$116.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.75
Rate for Payer: Medical Associates Commercial	$108.75
Rate for Payer: Midlands Choice Commercial	$101.50
Rate for Payer: United Healthcare Commercial	$130.50

XR Elbow 2 Views Right

Facility

$145.00

Service Code	CPT 73070 RT
Hospital Charge Code	1170123
Hospital Revenue Code	320
Min. Negotiated Rate	$65.25
Max. Negotiated Rate	$130.50
Rate for Payer: Aetna of IA Commercial	$130.50
Rate for Payer: Aetna of IA Medical Rental Products	$130.50
Rate for Payer: Aetna of IA Medicare	$82.65
Rate for Payer: Amerigroup Medicaid	$83.64
Rate for Payer: Amerigroup Medicare	$65.90
Rate for Payer: Cash Price	$116.00
Rate for Payer: Cash Price	$116.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.25
Rate for Payer: Iowa Total Care Managed Medicaid	$82.82
Rate for Payer: Medical Associates Commercial	$108.75
Rate for Payer: Medical Associates Managed Medicare	$65.25
Rate for Payer: Midlands Choice Commercial	$101.50
Rate for Payer: Molina Healthcare Managed Medicaid	$84.04
Rate for Payer: Partners Health Alliance Commercial	$75.04
Rate for Payer: United Healthcare Commercial	$130.50
Rate for Payer: United Healthcare Managed Medicare	$85.55
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Elbow Complete Left

Facility

$151.00

Service Code	CPT 73080 LT
Hospital Charge Code	1170127
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

XR Elbow Complete Left

Facility

$151.00

Service Code	CPT 73080 LT
Hospital Charge Code	1170127
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Elbow Complete Right

Facility

$151.00

Service Code	CPT 73080 RT
Hospital Charge Code	1170129
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Elbow Complete Right

Facility

$151.00

Service Code	CPT 73080 RT
Hospital Charge Code	1170129
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

XR Esophagus

Facility

$279.00

Service Code	CPT 74220
Hospital Charge Code	1170137
Hospital Revenue Code	320
Min. Negotiated Rate	$103.51
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Aetna of IA Medicare	$159.03
Rate for Payer: Amerigroup Medicaid	$160.93
Rate for Payer: Amerigroup Medicare	$126.81
Rate for Payer: Cash Price	$223.20
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$125.55
Rate for Payer: Iowa Total Care Managed Medicaid	$159.36
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Medical Associates Managed Medicare	$125.55
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: Molina Healthcare Managed Medicaid	$161.71
Rate for Payer: Partners Health Alliance Commercial	$144.38
Rate for Payer: United Healthcare Commercial	$251.10
Rate for Payer: United Healthcare Managed Medicare	$164.61
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Esophagus

Facility

$279.00

Service Code	CPT 74220
Hospital Charge Code	1170137
Hospital Revenue Code	320
Min. Negotiated Rate	$195.30
Max. Negotiated Rate	$251.10
Rate for Payer: Aetna of IA Commercial	$251.10
Rate for Payer: Aetna of IA Medical Rental Products	$251.10
Rate for Payer: Cash Price	$223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$209.25
Rate for Payer: Medical Associates Commercial	$209.25
Rate for Payer: Midlands Choice Commercial	$195.30
Rate for Payer: United Healthcare Commercial	$251.10

XR Facial Bones < 3 Views

Facility

$151.00

Service Code	CPT 70140
Hospital Charge Code	1170139
Hospital Revenue Code	320
Min. Negotiated Rate	$105.70
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: United Healthcare Commercial	$135.90

XR Facial Bones < 3 Views

Facility

$151.00

Service Code	CPT 70140
Hospital Charge Code	1170139
Hospital Revenue Code	320
Min. Negotiated Rate	$67.95
Max. Negotiated Rate	$135.90
Rate for Payer: Aetna of IA Commercial	$135.90
Rate for Payer: Aetna of IA Medical Rental Products	$135.90
Rate for Payer: Aetna of IA Medicare	$86.07
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Amerigroup Medicare	$68.63
Rate for Payer: Cash Price	$120.80
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.95
Rate for Payer: Iowa Total Care Managed Medicaid	$86.25
Rate for Payer: Medical Associates Commercial	$113.25
Rate for Payer: Medical Associates Managed Medicare	$67.95
Rate for Payer: Midlands Choice Commercial	$105.70
Rate for Payer: Molina Healthcare Managed Medicaid	$87.52
Rate for Payer: Partners Health Alliance Commercial	$78.14
Rate for Payer: United Healthcare Commercial	$135.90
Rate for Payer: United Healthcare Managed Medicare	$89.09
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Facial Bones Minimum 3 Views

Facility

$180.00

Service Code	CPT 70150
Hospital Charge Code	1170141
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Facial Bones Minimum 3 Views

Facility

$180.00

Service Code	CPT 70150
Hospital Charge Code	1170141
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 Femur 1 View Lt

Facility

$147.00

Service Code	CPT 73551 LT
Hospital Charge Code	8025358
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Femur 1 View Lt

Facility

$147.00

Service Code	CPT 73551 LT
Hospital Charge Code	8025358
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 Femur 1 View Rt

Facility

$147.00

Service Code	CPT 73551 RT
Hospital Charge Code	8025361
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Femur 1 View Rt

Facility

$147.00

Service Code	CPT 73551 RT
Hospital Charge Code	8025361
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 Femur Min 2 Views Lt

Facility

$147.00

Service Code	CPT 73552 LT
Hospital Charge Code	8025364
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Femur Min 2 Views Lt

Facility

$147.00

Service Code	CPT 73552 LT
Hospital Charge Code	8025364
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

Know your out-of-pocket cost for care.

All Charges