Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Hysterosalpingography

Facility

$830.00

Service Code	CPT 74740
Hospital Charge Code	1170249
Hospital Revenue Code	320
Min. Negotiated Rate	$298.49
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	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Hysterosalpingography

Facility

$830.00

Service Code	CPT 74740
Hospital Charge Code	1170249
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 Inj Arthrogram Shoulder LT

Facility

$218.00

Service Code	CPT 23350
Hospital Charge Code	7820769
Hospital Revenue Code	761
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$447.51
Rate for Payer: Aetna of IA Commercial	$196.20
Rate for Payer: Aetna of IA Medical Rental Products	$196.20
Rate for Payer: Aetna of IA Medicare	$124.26
Rate for Payer: Amerigroup Medicaid	$125.74
Rate for Payer: Amerigroup Medicare	$99.08
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cash Price	$174.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$163.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$98.10
Rate for Payer: Iowa Total Care Managed Medicaid	$124.52
Rate for Payer: Medical Associates Commercial	$163.50
Rate for Payer: Medical Associates Managed Medicare	$98.10
Rate for Payer: Midlands Choice Commercial	$152.60
Rate for Payer: Molina Healthcare Managed Medicaid	$126.35
Rate for Payer: Partners Health Alliance Commercial	$112.82
Rate for Payer: United Healthcare Commercial	$196.20
Rate for Payer: United Healthcare Managed Medicare	$128.62
Rate for Payer: Wellmark IA HMO WHPI	$406.26
Rate for Payer: Wellmark IA PPO	$447.51

XR Inj Arthrogram Shoulder LT

Facility

$218.00

Service Code	CPT 23350
Hospital Charge Code	7820769
Hospital Revenue Code	761
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$196.20
Rate for Payer: Aetna of IA Commercial	$196.20
Rate for Payer: Aetna of IA Medical Rental Products	$196.20
Rate for Payer: Cash Price	$174.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$163.50
Rate for Payer: Medical Associates Commercial	$163.50
Rate for Payer: Midlands Choice Commercial	$152.60
Rate for Payer: United Healthcare Commercial	$196.20

XR Inj Arthrogram Shoulder RT

Facility

$218.00

Service Code	CPT 23350
Hospital Charge Code	7820772
Hospital Revenue Code	761
Min. Negotiated Rate	$98.10
Max. Negotiated Rate	$447.51
Rate for Payer: Aetna of IA Commercial	$196.20
Rate for Payer: Aetna of IA Medical Rental Products	$196.20
Rate for Payer: Aetna of IA Medicare	$124.26
Rate for Payer: Amerigroup Medicaid	$125.74
Rate for Payer: Amerigroup Medicare	$99.08
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cash Price	$174.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$163.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$98.10
Rate for Payer: Iowa Total Care Managed Medicaid	$124.52
Rate for Payer: Medical Associates Commercial	$163.50
Rate for Payer: Medical Associates Managed Medicare	$98.10
Rate for Payer: Midlands Choice Commercial	$152.60
Rate for Payer: Molina Healthcare Managed Medicaid	$126.35
Rate for Payer: Partners Health Alliance Commercial	$112.82
Rate for Payer: United Healthcare Commercial	$196.20
Rate for Payer: United Healthcare Managed Medicare	$128.62
Rate for Payer: Wellmark IA HMO WHPI	$406.26
Rate for Payer: Wellmark IA PPO	$447.51

XR Inj Arthrogram Shoulder RT

Facility

$218.00

Service Code	CPT 23350
Hospital Charge Code	7820772
Hospital Revenue Code	761
Min. Negotiated Rate	$152.60
Max. Negotiated Rate	$196.20
Rate for Payer: Aetna of IA Commercial	$196.20
Rate for Payer: Aetna of IA Medical Rental Products	$196.20
Rate for Payer: Cash Price	$174.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$163.50
Rate for Payer: Medical Associates Commercial	$163.50
Rate for Payer: Midlands Choice Commercial	$152.60
Rate for Payer: United Healthcare Commercial	$196.20

XR IVP

Facility

$459.00

Service Code	CPT 74400
Hospital Charge Code	1170251
Hospital Revenue Code	320
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: United Healthcare Commercial	$413.10

XR IVP

Facility

$459.00

Service Code	CPT 74400
Hospital Charge Code	1170251
Hospital Revenue Code	320
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Aetna of IA Medicare	$261.63
Rate for Payer: Amerigroup Medicaid	$264.75
Rate for Payer: Amerigroup Medicare	$208.62
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$206.55
Rate for Payer: Iowa Total Care Managed Medicaid	$262.18
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Medical Associates Managed Medicare	$206.55
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: Molina Healthcare Managed Medicaid	$266.04
Rate for Payer: Partners Health Alliance Commercial	$237.53
Rate for Payer: United Healthcare Commercial	$413.10
Rate for Payer: United Healthcare Managed Medicare	$270.81
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

XR Knee 1 or 2 Views Left

Facility

$138.00

Service Code	CPT 73560 LT
Hospital Charge Code	1170263
Hospital Revenue Code	320
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Aetna of IA Medicare	$78.66
Rate for Payer: Amerigroup Medicaid	$79.60
Rate for Payer: Amerigroup Medicare	$62.72
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.10
Rate for Payer: Iowa Total Care Managed Medicaid	$78.83
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Medical Associates Managed Medicare	$62.10
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: Molina Healthcare Managed Medicaid	$79.98
Rate for Payer: Partners Health Alliance Commercial	$71.42
Rate for Payer: United Healthcare Commercial	$124.20
Rate for Payer: United Healthcare Managed Medicare	$81.42
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Knee 1 or 2 Views Left

Facility

$138.00

Service Code	CPT 73560 LT
Hospital Charge Code	1170263
Hospital Revenue Code	320
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: United Healthcare Commercial	$124.20

XR Knee 1 or 2 Views Right

Facility

$138.00

Service Code	CPT 73560 RT
Hospital Charge Code	1170265
Hospital Revenue Code	320
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: United Healthcare Commercial	$124.20

XR Knee 1 or 2 Views Right

Facility

$138.00

Service Code	CPT 73560 RT
Hospital Charge Code	1170265
Hospital Revenue Code	320
Min. Negotiated Rate	$62.10
Max. Negotiated Rate	$124.20
Rate for Payer: Aetna of IA Commercial	$124.20
Rate for Payer: Aetna of IA Medical Rental Products	$124.20
Rate for Payer: Aetna of IA Medicare	$78.66
Rate for Payer: Amerigroup Medicaid	$79.60
Rate for Payer: Amerigroup Medicare	$62.72
Rate for Payer: Cash Price	$110.40
Rate for Payer: Cash Price	$110.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.10
Rate for Payer: Iowa Total Care Managed Medicaid	$78.83
Rate for Payer: Medical Associates Commercial	$103.50
Rate for Payer: Medical Associates Managed Medicare	$62.10
Rate for Payer: Midlands Choice Commercial	$96.60
Rate for Payer: Molina Healthcare Managed Medicaid	$79.98
Rate for Payer: Partners Health Alliance Commercial	$71.42
Rate for Payer: United Healthcare Commercial	$124.20
Rate for Payer: United Healthcare Managed Medicare	$81.42
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Knee 3 Views Left

Facility

$147.00

Service Code	CPT 73562 LT
Hospital Charge Code	1170269
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 Knee 3 Views Left

Facility

$147.00

Service Code	CPT 73562 LT
Hospital Charge Code	1170269
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 Knee 3 Views Right

Facility

$147.00

Service Code	CPT 73562 RT
Hospital Charge Code	1170271
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 Knee 3 Views Right

Facility

$147.00

Service Code	CPT 73562 RT
Hospital Charge Code	1170271
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 Knee 4 Views w/ Patella Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170273
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Patella Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170273
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Knee 4 Views w/ Patella Right

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170276
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Knee 4 Views w/ Patella Right

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170276
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Tunnel + Sunrise Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170279
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Tunnel + Sunrise Left

Facility

$176.00

Service Code	CPT 73564 LT
Hospital Charge Code	1170279
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Knee 4 Views w/ Tunnel + Sunrise Righ

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170282
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Knee 4 Views w/ Tunnel + Sunrise Righ

Facility

$176.00

Service Code	CPT 73564 RT
Hospital Charge Code	1170282
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Knee Standing AP Bilateral

Facility

$139.00

Service Code	CPT 73565 50
Hospital Charge Code	1170291
Hospital Revenue Code	320
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

Know your out-of-pocket cost for care.

All Charges