Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Foreign Body Loc Eye Bilateral

Facility

$154.00

Service Code	CPT 70030 50
Hospital Charge Code	1170201
Hospital Revenue Code	320
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna of IA Commercial	$138.60
Rate for Payer: Aetna of IA Medical Rental Products	$138.60
Rate for Payer: Cash Price	$123.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$115.50
Rate for Payer: Medical Associates Commercial	$115.50
Rate for Payer: Midlands Choice Commercial	$107.80
Rate for Payer: United Healthcare Commercial	$138.60

XR Foreign Body Loc Eye Bilateral

Facility

$154.00

Service Code	CPT 70030 50
Hospital Charge Code	1170201
Hospital Revenue Code	320
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$138.60
Rate for Payer: Aetna of IA Commercial	$138.60
Rate for Payer: Aetna of IA Medical Rental Products	$138.60
Rate for Payer: Aetna of IA Medicare	$87.78
Rate for Payer: Amerigroup Medicaid	$88.83
Rate for Payer: Amerigroup Medicare	$69.99
Rate for Payer: Cash Price	$123.20
Rate for Payer: Cash Price	$123.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$115.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.30
Rate for Payer: Iowa Total Care Managed Medicaid	$87.96
Rate for Payer: Medical Associates Commercial	$115.50
Rate for Payer: Medical Associates Managed Medicare	$69.30
Rate for Payer: Midlands Choice Commercial	$107.80
Rate for Payer: Molina Healthcare Managed Medicaid	$89.26
Rate for Payer: Partners Health Alliance Commercial	$79.70
Rate for Payer: United Healthcare Commercial	$138.60
Rate for Payer: United Healthcare Managed Medicare	$90.86
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Gastrografin Enema

Facility

$718.00

Service Code	CPT 74270
Hospital Charge Code	1170209
Hospital Revenue Code	320
Min. Negotiated Rate	$502.60
Max. Negotiated Rate	$646.20
Rate for Payer: Aetna of IA Commercial	$646.20
Rate for Payer: Aetna of IA Medical Rental Products	$646.20
Rate for Payer: Cash Price	$574.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$538.50
Rate for Payer: Medical Associates Commercial	$538.50
Rate for Payer: Midlands Choice Commercial	$502.60
Rate for Payer: United Healthcare Commercial	$646.20

XR Gastrografin Enema

Facility

$718.00

Service Code	CPT 74270
Hospital Charge Code	1170209
Hospital Revenue Code	320
Min. Negotiated Rate	$298.49
Max. Negotiated Rate	$646.20
Rate for Payer: Aetna of IA Commercial	$646.20
Rate for Payer: Aetna of IA Medical Rental Products	$646.20
Rate for Payer: Aetna of IA Medicare	$409.26
Rate for Payer: Amerigroup Medicaid	$414.14
Rate for Payer: Amerigroup Medicare	$326.33
Rate for Payer: Cash Price	$574.40
Rate for Payer: Cash Price	$574.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$538.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$323.10
Rate for Payer: Iowa Total Care Managed Medicaid	$410.12
Rate for Payer: Medical Associates Commercial	$538.50
Rate for Payer: Medical Associates Managed Medicare	$323.10
Rate for Payer: Midlands Choice Commercial	$502.60
Rate for Payer: Molina Healthcare Managed Medicaid	$416.15
Rate for Payer: Partners Health Alliance Commercial	$371.56
Rate for Payer: United Healthcare Commercial	$646.20
Rate for Payer: United Healthcare Managed Medicare	$423.62
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR GI Tube Inj for Placement

Facility

$432.00

Service Code	CPT 49465
Hospital Charge Code	7960844
Hospital Revenue Code	320
Min. Negotiated Rate	$194.40
Max. Negotiated Rate	$388.80
Rate for Payer: Aetna of IA Commercial	$388.80
Rate for Payer: Aetna of IA Medical Rental Products	$388.80
Rate for Payer: Aetna of IA Medicare	$246.24
Rate for Payer: Amerigroup Medicaid	$249.18
Rate for Payer: Amerigroup Medicare	$196.34
Rate for Payer: Cash Price	$345.60
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$324.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$194.40
Rate for Payer: Iowa Total Care Managed Medicaid	$246.76
Rate for Payer: Medical Associates Commercial	$324.00
Rate for Payer: Medical Associates Managed Medicare	$194.40
Rate for Payer: Midlands Choice Commercial	$302.40
Rate for Payer: Molina Healthcare Managed Medicaid	$250.39
Rate for Payer: Partners Health Alliance Commercial	$223.56
Rate for Payer: United Healthcare Commercial	$388.80
Rate for Payer: United Healthcare Managed Medicare	$254.88
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR GI Tube Inj for Placement

Facility

$432.00

Service Code	CPT 49465
Hospital Charge Code	7960844
Hospital Revenue Code	320
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$388.80
Rate for Payer: Aetna of IA Commercial	$388.80
Rate for Payer: Aetna of IA Medical Rental Products	$388.80
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$324.00
Rate for Payer: Medical Associates Commercial	$324.00
Rate for Payer: Midlands Choice Commercial	$302.40
Rate for Payer: United Healthcare Commercial	$388.80

XR Hand 2 Views Left

Facility

$127.00

Service Code	CPT 73120 LT
Hospital Charge Code	1170215
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 Hand 2 Views Left

Facility

$127.00

Service Code	CPT 73120 LT
Hospital Charge Code	1170215
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 Hand 2 Views Right

Facility

$127.00

Service Code	CPT 73120 RT
Hospital Charge Code	1170217
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 Hand 2 Views Right

Facility

$127.00

Service Code	CPT 73120 RT
Hospital Charge Code	1170217
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 Hand Complete Left

Facility

$201.00

Service Code	CPT 73130 LT
Hospital Charge Code	1170221
Hospital Revenue Code	320
Min. Negotiated Rate	$90.45
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Aetna of IA Medicare	$114.57
Rate for Payer: Amerigroup Medicaid	$115.94
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.45
Rate for Payer: Iowa Total Care Managed Medicaid	$114.81
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Medical Associates Managed Medicare	$90.45
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$116.50
Rate for Payer: Partners Health Alliance Commercial	$104.02
Rate for Payer: United Healthcare Commercial	$180.90
Rate for Payer: United Healthcare Managed Medicare	$118.59
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Hand Complete Left

Facility

$201.00

Service Code	CPT 73130 LT
Hospital Charge Code	1170221
Hospital Revenue Code	320
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: United Healthcare Commercial	$180.90

XR Hand Complete Right

Facility

$201.00

Service Code	CPT 73130 RT
Hospital Charge Code	1170223
Hospital Revenue Code	320
Min. Negotiated Rate	$90.45
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Aetna of IA Medicare	$114.57
Rate for Payer: Amerigroup Medicaid	$115.94
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.45
Rate for Payer: Iowa Total Care Managed Medicaid	$114.81
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Medical Associates Managed Medicare	$90.45
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$116.50
Rate for Payer: Partners Health Alliance Commercial	$104.02
Rate for Payer: United Healthcare Commercial	$180.90
Rate for Payer: United Healthcare Managed Medicare	$118.59
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Hand Complete Right

Facility

$201.00

Service Code	CPT 73130 RT
Hospital Charge Code	1170223
Hospital Revenue Code	320
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: United Healthcare Commercial	$180.90

XR Hip 1 View Left

Facility

$163.00

Service Code	CPT 73501 LT
Hospital Charge Code	1170225
Hospital Revenue Code	320
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: United Healthcare Commercial	$146.70

XR Hip 1 View Left

Facility

$163.00

Service Code	CPT 73501 LT
Hospital Charge Code	1170225
Hospital Revenue Code	320
Min. Negotiated Rate	$73.35
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Aetna of IA Medicare	$92.91
Rate for Payer: Amerigroup Medicaid	$94.02
Rate for Payer: Amerigroup Medicare	$74.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.35
Rate for Payer: Iowa Total Care Managed Medicaid	$93.11
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Medical Associates Managed Medicare	$73.35
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: Molina Healthcare Managed Medicaid	$94.47
Rate for Payer: Partners Health Alliance Commercial	$84.35
Rate for Payer: United Healthcare Commercial	$146.70
Rate for Payer: United Healthcare Managed Medicare	$96.17
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Hip 1 View Lt w/ Pelvis

Facility

$163.00

Service Code	CPT 73501 LT
Hospital Charge Code	8025370
Hospital Revenue Code	320
Min. Negotiated Rate	$73.35
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Aetna of IA Medicare	$92.91
Rate for Payer: Amerigroup Medicaid	$94.02
Rate for Payer: Amerigroup Medicare	$74.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.35
Rate for Payer: Iowa Total Care Managed Medicaid	$93.11
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Medical Associates Managed Medicare	$73.35
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: Molina Healthcare Managed Medicaid	$94.47
Rate for Payer: Partners Health Alliance Commercial	$84.35
Rate for Payer: United Healthcare Commercial	$146.70
Rate for Payer: United Healthcare Managed Medicare	$96.17
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Hip 1 View Lt w/ Pelvis

Facility

$163.00

Service Code	CPT 73501 LT
Hospital Charge Code	8025370
Hospital Revenue Code	320
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: United Healthcare Commercial	$146.70

XR Hip 1 View Right

Facility

$163.00

Service Code	CPT 73501 RT
Hospital Charge Code	1170227
Hospital Revenue Code	320
Min. Negotiated Rate	$73.35
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Aetna of IA Medicare	$92.91
Rate for Payer: Amerigroup Medicaid	$94.02
Rate for Payer: Amerigroup Medicare	$74.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.35
Rate for Payer: Iowa Total Care Managed Medicaid	$93.11
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Medical Associates Managed Medicare	$73.35
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: Molina Healthcare Managed Medicaid	$94.47
Rate for Payer: Partners Health Alliance Commercial	$84.35
Rate for Payer: United Healthcare Commercial	$146.70
Rate for Payer: United Healthcare Managed Medicare	$96.17
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Hip 1 View Right

Facility

$163.00

Service Code	CPT 73501 RT
Hospital Charge Code	1170227
Hospital Revenue Code	320
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: United Healthcare Commercial	$146.70

XR Hip 1 View Rt w/ Pelvis

Facility

$163.00

Service Code	CPT 73501 RT
Hospital Charge Code	8025373
Hospital Revenue Code	320
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: United Healthcare Commercial	$146.70

XR Hip 1 View Rt w/ Pelvis

Facility

$163.00

Service Code	CPT 73501 RT
Hospital Charge Code	8025373
Hospital Revenue Code	320
Min. Negotiated Rate	$73.35
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Aetna of IA Medicare	$92.91
Rate for Payer: Amerigroup Medicaid	$94.02
Rate for Payer: Amerigroup Medicare	$74.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.35
Rate for Payer: Iowa Total Care Managed Medicaid	$93.11
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Medical Associates Managed Medicare	$73.35
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: Molina Healthcare Managed Medicaid	$94.47
Rate for Payer: Partners Health Alliance Commercial	$84.35
Rate for Payer: United Healthcare Commercial	$146.70
Rate for Payer: United Healthcare Managed Medicare	$96.17
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Hip 2-3 Views Lt w/ Pelvis

Facility

$163.00

Service Code	CPT 73502 LT
Hospital Charge Code	8025376
Hospital Revenue Code	320
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: United Healthcare Commercial	$146.70

XR Hip 2-3 Views Lt w/ Pelvis

Facility

$163.00

Service Code	CPT 73502 LT
Hospital Charge Code	8025376
Hospital Revenue Code	320
Min. Negotiated Rate	$73.35
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Aetna of IA Medicare	$92.91
Rate for Payer: Amerigroup Medicaid	$94.02
Rate for Payer: Amerigroup Medicare	$74.08
Rate for Payer: Cash Price	$130.40
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.35
Rate for Payer: Iowa Total Care Managed Medicaid	$93.11
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Medical Associates Managed Medicare	$73.35
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: Molina Healthcare Managed Medicaid	$94.47
Rate for Payer: Partners Health Alliance Commercial	$84.35
Rate for Payer: United Healthcare Commercial	$146.70
Rate for Payer: United Healthcare Managed Medicare	$96.17
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Hip 2-3 Views Rt w/ Pelvis

Facility

$163.00

Service Code	CPT 73502 RT
Hospital Charge Code	8025379
Hospital Revenue Code	320
Min. Negotiated Rate	$114.10
Max. Negotiated Rate	$146.70
Rate for Payer: Aetna of IA Commercial	$146.70
Rate for Payer: Aetna of IA Medical Rental Products	$146.70
Rate for Payer: Cash Price	$130.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.25
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Midlands Choice Commercial	$114.10
Rate for Payer: United Healthcare Commercial	$146.70

Know your out-of-pocket cost for care.

All Charges