Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Fluoro Cath Placement

Facility

$549.00

Service Code	CPT 77001
Hospital Charge Code	7960838
Hospital Revenue Code	320
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of IA Commercial	$494.10
Rate for Payer: Aetna of IA Medical Rental Products	$494.10
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$411.75
Rate for Payer: Medical Associates Commercial	$411.75
Rate for Payer: Midlands Choice Commercial	$384.30
Rate for Payer: United Healthcare Commercial	$494.10

XR Fluoro GI Tube Placement

Facility

$830.00

Service Code	CPT 74340
Hospital Charge Code	7960841
Hospital Revenue Code	320
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Aetna of IA Medicare	$473.10
Rate for Payer: Amerigroup Medicaid	$478.74
Rate for Payer: Amerigroup Medicare	$377.24
Rate for Payer: Cash Price	$664.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$373.50
Rate for Payer: Iowa Total Care Managed Medicaid	$474.10
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Medical Associates Managed Medicare	$373.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: Molina Healthcare Managed Medicaid	$481.07
Rate for Payer: Partners Health Alliance Commercial	$429.52
Rate for Payer: United Healthcare Commercial	$747.00
Rate for Payer: United Healthcare Managed Medicare	$489.70
Rate for Payer: Wellmark IA HMO WHPI	$463.69
Rate for Payer: Wellmark IA PPO	$510.77

XR Fluoro GI Tube Placement

Facility

$830.00

Service Code	CPT 74340
Hospital Charge Code	7960841
Hospital Revenue Code	320
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: United Healthcare Commercial	$747.00

XR Fluoro Guidance Needle Loc Spine

Facility

$437.00

Service Code	CPT 77003
Hospital Charge Code	1170173
Hospital Revenue Code	320
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$393.30
Rate for Payer: Aetna of IA Commercial	$393.30
Rate for Payer: Aetna of IA Medical Rental Products	$393.30
Rate for Payer: Cash Price	$349.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$327.75
Rate for Payer: Medical Associates Commercial	$327.75
Rate for Payer: Midlands Choice Commercial	$305.90
Rate for Payer: United Healthcare Commercial	$393.30

XR Fluoro Guidance Needle Loc Spine

Facility

$437.00

Service Code	CPT 77003
Hospital Charge Code	1170173
Hospital Revenue Code	320
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$510.77
Rate for Payer: Aetna of IA Commercial	$393.30
Rate for Payer: Aetna of IA Medical Rental Products	$393.30
Rate for Payer: Aetna of IA Medicare	$249.09
Rate for Payer: Amerigroup Medicaid	$252.06
Rate for Payer: Amerigroup Medicare	$198.62
Rate for Payer: Cash Price	$349.60
Rate for Payer: Cash Price	$349.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$327.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$196.65
Rate for Payer: Iowa Total Care Managed Medicaid	$249.61
Rate for Payer: Medical Associates Commercial	$327.75
Rate for Payer: Medical Associates Managed Medicare	$196.65
Rate for Payer: Midlands Choice Commercial	$305.90
Rate for Payer: Molina Healthcare Managed Medicaid	$253.29
Rate for Payer: Partners Health Alliance Commercial	$226.15
Rate for Payer: United Healthcare Commercial	$393.30
Rate for Payer: United Healthcare Managed Medicare	$257.83
Rate for Payer: Wellmark IA HMO WHPI	$463.69
Rate for Payer: Wellmark IA PPO	$510.77

XR Fluoro Guidance Needle Placement

Facility

$735.00

Service Code	CPT 77002
Hospital Charge Code	1170175
Hospital Revenue Code	320
Min. Negotiated Rate	$330.75
Max. Negotiated Rate	$661.50
Rate for Payer: Aetna of IA Commercial	$661.50
Rate for Payer: Aetna of IA Medical Rental Products	$661.50
Rate for Payer: Aetna of IA Medicare	$418.95
Rate for Payer: Amerigroup Medicaid	$423.95
Rate for Payer: Amerigroup Medicare	$334.06
Rate for Payer: Cash Price	$588.00
Rate for Payer: Cash Price	$588.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$551.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$330.75
Rate for Payer: Iowa Total Care Managed Medicaid	$419.83
Rate for Payer: Medical Associates Commercial	$551.25
Rate for Payer: Medical Associates Managed Medicare	$330.75
Rate for Payer: Midlands Choice Commercial	$514.50
Rate for Payer: Molina Healthcare Managed Medicaid	$426.01
Rate for Payer: Partners Health Alliance Commercial	$380.36
Rate for Payer: United Healthcare Commercial	$661.50
Rate for Payer: United Healthcare Managed Medicare	$433.65
Rate for Payer: Wellmark IA HMO WHPI	$463.69
Rate for Payer: Wellmark IA PPO	$510.77

XR Fluoro Guidance Needle Placement

Facility

$735.00

Service Code	CPT 77002
Hospital Charge Code	1170175
Hospital Revenue Code	320
Min. Negotiated Rate	$514.50
Max. Negotiated Rate	$661.50
Rate for Payer: Aetna of IA Commercial	$661.50
Rate for Payer: Aetna of IA Medical Rental Products	$661.50
Rate for Payer: Cash Price	$588.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$551.25
Rate for Payer: Medical Associates Commercial	$551.25
Rate for Payer: Midlands Choice Commercial	$514.50
Rate for Payer: United Healthcare Commercial	$661.50

XR Fluoroscopy Over 1 Hour Non Rad

Facility

$354.00

Service Code	CPT 76001
Hospital Charge Code	1170177
Hospital Revenue Code	320
Min. Negotiated Rate	$159.30
Max. Negotiated Rate	$318.60
Rate for Payer: Aetna of IA Commercial	$318.60
Rate for Payer: Aetna of IA Medical Rental Products	$318.60
Rate for Payer: Aetna of IA Medicare	$201.78
Rate for Payer: Amerigroup Medicaid	$204.19
Rate for Payer: Amerigroup Medicare	$160.89
Rate for Payer: Cash Price	$283.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$265.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$159.30
Rate for Payer: Iowa Total Care Managed Medicaid	$202.20
Rate for Payer: Medical Associates Commercial	$265.50
Rate for Payer: Medical Associates Managed Medicare	$159.30
Rate for Payer: Midlands Choice Commercial	$247.80
Rate for Payer: Molina Healthcare Managed Medicaid	$205.18
Rate for Payer: Partners Health Alliance Commercial	$183.20
Rate for Payer: United Healthcare Commercial	$318.60
Rate for Payer: United Healthcare Managed Medicare	$208.86

XR Fluoroscopy Over 1 Hour Non Rad

Facility

$354.00

Service Code	CPT 76001
Hospital Charge Code	1170177
Hospital Revenue Code	320
Min. Negotiated Rate	$247.80
Max. Negotiated Rate	$318.60
Rate for Payer: Aetna of IA Commercial	$318.60
Rate for Payer: Aetna of IA Medical Rental Products	$318.60
Rate for Payer: Cash Price	$283.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$265.50
Rate for Payer: Medical Associates Commercial	$265.50
Rate for Payer: Midlands Choice Commercial	$247.80
Rate for Payer: United Healthcare Commercial	$318.60

XR Fluoroscopy Up to 1 Hour

Facility

$221.00

Service Code	CPT 76000
Hospital Charge Code	1170181
Hospital Revenue Code	320
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: United Healthcare Commercial	$198.90

XR Fluoroscopy Up to 1 Hour

Facility

$221.00

Service Code	CPT 76000
Hospital Charge Code	1170181
Hospital Revenue Code	320
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$328.80
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Aetna of IA Medicare	$125.97
Rate for Payer: Amerigroup Medicaid	$127.47
Rate for Payer: Amerigroup Medicare	$100.44
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.45
Rate for Payer: Iowa Total Care Managed Medicaid	$126.24
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Medical Associates Managed Medicare	$99.45
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: Molina Healthcare Managed Medicaid	$128.09
Rate for Payer: Partners Health Alliance Commercial	$114.37
Rate for Payer: United Healthcare Commercial	$198.90
Rate for Payer: United Healthcare Managed Medicare	$130.39
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Fluoroscopy Up to 1 Hour NR

Facility

$221.00

Service Code	CPT 76000
Hospital Charge Code	5702788
Hospital Revenue Code	320
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$328.80
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Aetna of IA Medicare	$125.97
Rate for Payer: Amerigroup Medicaid	$127.47
Rate for Payer: Amerigroup Medicare	$100.44
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.45
Rate for Payer: Iowa Total Care Managed Medicaid	$126.24
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Medical Associates Managed Medicare	$99.45
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: Molina Healthcare Managed Medicaid	$128.09
Rate for Payer: Partners Health Alliance Commercial	$114.37
Rate for Payer: United Healthcare Commercial	$198.90
Rate for Payer: United Healthcare Managed Medicare	$130.39
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Fluoroscopy Up to 1 Hour NR

Facility

$221.00

Service Code	CPT 76000
Hospital Charge Code	5702788
Hospital Revenue Code	320
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: United Healthcare Commercial	$198.90

XR Foot 2 Views Left

Facility

$127.00

Service Code	CPT 73620 LT
Hospital Charge Code	1170185
Hospital Revenue Code	320
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: United Healthcare Commercial	$114.30

XR Foot 2 Views Left

Facility

$127.00

Service Code	CPT 73620 LT
Hospital Charge Code	1170185
Hospital Revenue Code	320
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Aetna of IA Medicare	$72.39
Rate for Payer: Amerigroup Medicaid	$73.25
Rate for Payer: Amerigroup Medicare	$57.72
Rate for Payer: Cash Price	$101.60
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.15
Rate for Payer: Iowa Total Care Managed Medicaid	$72.54
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Medical Associates Managed Medicare	$57.15
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: Molina Healthcare Managed Medicaid	$73.61
Rate for Payer: Partners Health Alliance Commercial	$65.72
Rate for Payer: United Healthcare Commercial	$114.30
Rate for Payer: United Healthcare Managed Medicare	$74.93
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Foot 2 Views Right

Facility

$127.00

Service Code	CPT 73620 RT
Hospital Charge Code	1170187
Hospital Revenue Code	320
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Aetna of IA Medicare	$72.39
Rate for Payer: Amerigroup Medicaid	$73.25
Rate for Payer: Amerigroup Medicare	$57.72
Rate for Payer: Cash Price	$101.60
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.15
Rate for Payer: Iowa Total Care Managed Medicaid	$72.54
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Medical Associates Managed Medicare	$57.15
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: Molina Healthcare Managed Medicaid	$73.61
Rate for Payer: Partners Health Alliance Commercial	$65.72
Rate for Payer: United Healthcare Commercial	$114.30
Rate for Payer: United Healthcare Managed Medicare	$74.93
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Foot 2 Views Right

Facility

$127.00

Service Code	CPT 73620 RT
Hospital Charge Code	1170187
Hospital Revenue Code	320
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: United Healthcare Commercial	$114.30

XR Foot Complete Left

Facility

$146.00

Service Code	CPT 73630 LT
Hospital Charge Code	1170191
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 Foot Complete Left

Facility

$146.00

Service Code	CPT 73630 LT
Hospital Charge Code	1170191
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 Foot Complete Right

Facility

$146.00

Service Code	CPT 73630 RT
Hospital Charge Code	1170193
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 Foot Complete Right

Facility

$146.00

Service Code	CPT 73630 RT
Hospital Charge Code	1170193
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 Forearm 2 Views Left

Facility

$132.00

Service Code	CPT 73090 LT
Hospital Charge Code	1170197
Hospital Revenue Code	320
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of IA Commercial	$118.80
Rate for Payer: Aetna of IA Medical Rental Products	$118.80
Rate for Payer: Aetna of IA Medicare	$75.24
Rate for Payer: Amerigroup Medicaid	$76.14
Rate for Payer: Amerigroup Medicare	$59.99
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$59.40
Rate for Payer: Iowa Total Care Managed Medicaid	$75.40
Rate for Payer: Medical Associates Commercial	$99.00
Rate for Payer: Medical Associates Managed Medicare	$59.40
Rate for Payer: Midlands Choice Commercial	$92.40
Rate for Payer: Molina Healthcare Managed Medicaid	$76.51
Rate for Payer: Partners Health Alliance Commercial	$68.31
Rate for Payer: United Healthcare Commercial	$118.80
Rate for Payer: United Healthcare Managed Medicare	$77.88
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Forearm 2 Views Left

Facility

$132.00

Service Code	CPT 73090 LT
Hospital Charge Code	1170197
Hospital Revenue Code	320
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of IA Commercial	$118.80
Rate for Payer: Aetna of IA Medical Rental Products	$118.80
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.00
Rate for Payer: Medical Associates Commercial	$99.00
Rate for Payer: Midlands Choice Commercial	$92.40
Rate for Payer: United Healthcare Commercial	$118.80

XR Forearm 2 Views Right

Facility

$132.00

Service Code	CPT 73090 RT
Hospital Charge Code	1170199
Hospital Revenue Code	320
Min. Negotiated Rate	$59.40
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of IA Commercial	$118.80
Rate for Payer: Aetna of IA Medical Rental Products	$118.80
Rate for Payer: Aetna of IA Medicare	$75.24
Rate for Payer: Amerigroup Medicaid	$76.14
Rate for Payer: Amerigroup Medicare	$59.99
Rate for Payer: Cash Price	$105.60
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$59.40
Rate for Payer: Iowa Total Care Managed Medicaid	$75.40
Rate for Payer: Medical Associates Commercial	$99.00
Rate for Payer: Medical Associates Managed Medicare	$59.40
Rate for Payer: Midlands Choice Commercial	$92.40
Rate for Payer: Molina Healthcare Managed Medicaid	$76.51
Rate for Payer: Partners Health Alliance Commercial	$68.31
Rate for Payer: United Healthcare Commercial	$118.80
Rate for Payer: United Healthcare Managed Medicare	$77.88
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Forearm 2 Views Right

Facility

$132.00

Service Code	CPT 73090 RT
Hospital Charge Code	1170199
Hospital Revenue Code	320
Min. Negotiated Rate	$92.40
Max. Negotiated Rate	$118.80
Rate for Payer: Aetna of IA Commercial	$118.80
Rate for Payer: Aetna of IA Medical Rental Products	$118.80
Rate for Payer: Cash Price	$105.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.00
Rate for Payer: Medical Associates Commercial	$99.00
Rate for Payer: Midlands Choice Commercial	$92.40
Rate for Payer: United Healthcare Commercial	$118.80

Know your out-of-pocket cost for care.

All Charges