Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Knee Standing AP Bilateral

Facility

$139.00

Service Code	CPT 73565 50
Hospital Charge Code	1170291
Hospital Revenue Code	320
Min. Negotiated Rate	$62.55
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: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$80.18
Rate for Payer: Amerigroup Medicare	$63.18
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.55
Rate for Payer: Iowa Total Care Managed Medicaid	$79.40
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$62.55
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$80.56
Rate for Payer: Partners Health Alliance Commercial	$71.93
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Mandible Complete Minimum 4 Views

Facility

$180.00

Service Code	CPT 70110
Hospital Charge Code	1170301
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 Mandible Complete Minimum 4 Views

Facility

$180.00

Service Code	CPT 70110
Hospital Charge Code	1170301
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 Mastoids Complete Bilateral

Facility

$176.00

Service Code	CPT 70130 50
Hospital Charge Code	1170313
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 Mastoids Complete Bilateral

Facility

$176.00

Service Code	CPT 70130 50
Hospital Charge Code	1170313
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 Myelography Cervical Spine

Facility

$1,211.00

Service Code	CPT 72240
Hospital Charge Code	1170319
Hospital Revenue Code	320
Min. Negotiated Rate	$544.95
Max. Negotiated Rate	$1,537.01
Rate for Payer: Aetna of IA Commercial	$1,089.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,089.90
Rate for Payer: Aetna of IA Medicare	$690.27
Rate for Payer: Amerigroup Medicaid	$698.50
Rate for Payer: Amerigroup Medicare	$550.40
Rate for Payer: Cash Price	$968.80
Rate for Payer: Cash Price	$968.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$908.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$544.95
Rate for Payer: Iowa Total Care Managed Medicaid	$691.72
Rate for Payer: Medical Associates Commercial	$908.25
Rate for Payer: Medical Associates Managed Medicare	$544.95
Rate for Payer: Midlands Choice Commercial	$847.70
Rate for Payer: Molina Healthcare Managed Medicaid	$701.90
Rate for Payer: Partners Health Alliance Commercial	$626.69
Rate for Payer: United Healthcare Commercial	$1,089.90
Rate for Payer: United Healthcare Managed Medicare	$714.49
Rate for Payer: Wellmark IA HMO WHPI	$1,395.31
Rate for Payer: Wellmark IA PPO	$1,537.01

XR Myelography Cervical Spine

Facility

$1,211.00

Service Code	CPT 72240
Hospital Charge Code	1170319
Hospital Revenue Code	320
Min. Negotiated Rate	$847.70
Max. Negotiated Rate	$1,089.90
Rate for Payer: Aetna of IA Commercial	$1,089.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,089.90
Rate for Payer: Cash Price	$968.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$908.25
Rate for Payer: Medical Associates Commercial	$908.25
Rate for Payer: Midlands Choice Commercial	$847.70
Rate for Payer: United Healthcare Commercial	$1,089.90

XR Myelography Lumbosacral

Facility

$1,187.00

Service Code	CPT 72265
Hospital Charge Code	1170321
Hospital Revenue Code	320
Min. Negotiated Rate	$830.90
Max. Negotiated Rate	$1,068.30
Rate for Payer: Aetna of IA Commercial	$1,068.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,068.30
Rate for Payer: Cash Price	$949.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$890.25
Rate for Payer: Medical Associates Commercial	$890.25
Rate for Payer: Midlands Choice Commercial	$830.90
Rate for Payer: United Healthcare Commercial	$1,068.30

XR Myelography Lumbosacral

Facility

$1,187.00

Service Code	CPT 72265
Hospital Charge Code	1170321
Hospital Revenue Code	320
Min. Negotiated Rate	$534.15
Max. Negotiated Rate	$1,537.01
Rate for Payer: Aetna of IA Commercial	$1,068.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,068.30
Rate for Payer: Aetna of IA Medicare	$676.59
Rate for Payer: Amerigroup Medicaid	$684.66
Rate for Payer: Amerigroup Medicare	$539.49
Rate for Payer: Cash Price	$949.60
Rate for Payer: Cash Price	$949.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$890.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$534.15
Rate for Payer: Iowa Total Care Managed Medicaid	$678.01
Rate for Payer: Medical Associates Commercial	$890.25
Rate for Payer: Medical Associates Managed Medicare	$534.15
Rate for Payer: Midlands Choice Commercial	$830.90
Rate for Payer: Molina Healthcare Managed Medicaid	$687.99
Rate for Payer: Partners Health Alliance Commercial	$614.27
Rate for Payer: United Healthcare Commercial	$1,068.30
Rate for Payer: United Healthcare Managed Medicare	$700.33
Rate for Payer: Wellmark IA HMO WHPI	$1,395.31
Rate for Payer: Wellmark IA PPO	$1,537.01

XR Nasal Bones Minimum 3 Views

Facility

$180.00

Service Code	CPT 70160
Hospital Charge Code	1170329
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 Nasal Bones Minimum 3 Views

Facility

$180.00

Service Code	CPT 70160
Hospital Charge Code	1170329
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 Neck Soft Tissue

Facility

$180.00

Service Code	CPT 70360
Hospital Charge Code	1170331
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 Neck Soft Tissue

Facility

$180.00

Service Code	CPT 70360
Hospital Charge Code	1170331
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 Optic Foramina Left

Facility

$151.00

Service Code	CPT 70190 LT
Hospital Charge Code	1170333
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 Optic Foramina Left

Facility

$151.00

Service Code	CPT 70190 LT
Hospital Charge Code	1170333
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 Optic Foramina Right

Facility

$151.00

Service Code	CPT 70190 RT
Hospital Charge Code	1170335
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 Optic Foramina Right

Facility

$151.00

Service Code	CPT 70190 RT
Hospital Charge Code	1170335
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 Orbits Complete Bilateral

Facility

$227.00

Service Code	CPT 70200 50
Hospital Charge Code	1170337
Hospital Revenue Code	320
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of IA Commercial	$204.30
Rate for Payer: Aetna of IA Medical Rental Products	$204.30
Rate for Payer: Aetna of IA Medicare	$129.39
Rate for Payer: Amerigroup Medicaid	$130.93
Rate for Payer: Amerigroup Medicare	$103.17
Rate for Payer: Cash Price	$181.60
Rate for Payer: Cash Price	$181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$102.15
Rate for Payer: Iowa Total Care Managed Medicaid	$129.66
Rate for Payer: Medical Associates Commercial	$170.25
Rate for Payer: Medical Associates Managed Medicare	$102.15
Rate for Payer: Midlands Choice Commercial	$158.90
Rate for Payer: Molina Healthcare Managed Medicaid	$131.57
Rate for Payer: Partners Health Alliance Commercial	$117.47
Rate for Payer: United Healthcare Commercial	$204.30
Rate for Payer: United Healthcare Managed Medicare	$133.93
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Orbits Complete Bilateral

Facility

$227.00

Service Code	CPT 70200 50
Hospital Charge Code	1170337
Hospital Revenue Code	320
Min. Negotiated Rate	$158.90
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of IA Commercial	$204.30
Rate for Payer: Aetna of IA Medical Rental Products	$204.30
Rate for Payer: Cash Price	$181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.25
Rate for Payer: Medical Associates Commercial	$170.25
Rate for Payer: Midlands Choice Commercial	$158.90
Rate for Payer: United Healthcare Commercial	$204.30

XR Orbits Complete Left

Facility

$227.00

Service Code	CPT 70200 LT
Hospital Charge Code	1170339
Hospital Revenue Code	320
Min. Negotiated Rate	$158.90
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of IA Commercial	$204.30
Rate for Payer: Aetna of IA Medical Rental Products	$204.30
Rate for Payer: Cash Price	$181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.25
Rate for Payer: Medical Associates Commercial	$170.25
Rate for Payer: Midlands Choice Commercial	$158.90
Rate for Payer: United Healthcare Commercial	$204.30

XR Orbits Complete Left

Facility

$227.00

Service Code	CPT 70200 LT
Hospital Charge Code	1170339
Hospital Revenue Code	320
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of IA Commercial	$204.30
Rate for Payer: Aetna of IA Medical Rental Products	$204.30
Rate for Payer: Aetna of IA Medicare	$129.39
Rate for Payer: Amerigroup Medicaid	$130.93
Rate for Payer: Amerigroup Medicare	$103.17
Rate for Payer: Cash Price	$181.60
Rate for Payer: Cash Price	$181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$102.15
Rate for Payer: Iowa Total Care Managed Medicaid	$129.66
Rate for Payer: Medical Associates Commercial	$170.25
Rate for Payer: Medical Associates Managed Medicare	$102.15
Rate for Payer: Midlands Choice Commercial	$158.90
Rate for Payer: Molina Healthcare Managed Medicaid	$131.57
Rate for Payer: Partners Health Alliance Commercial	$117.47
Rate for Payer: United Healthcare Commercial	$204.30
Rate for Payer: United Healthcare Managed Medicare	$133.93
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Orbits Complete Right

Facility

$227.00

Service Code	CPT 70200 RT
Hospital Charge Code	1170341
Hospital Revenue Code	320
Min. Negotiated Rate	$158.90
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of IA Commercial	$204.30
Rate for Payer: Aetna of IA Medical Rental Products	$204.30
Rate for Payer: Cash Price	$181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.25
Rate for Payer: Medical Associates Commercial	$170.25
Rate for Payer: Midlands Choice Commercial	$158.90
Rate for Payer: United Healthcare Commercial	$204.30

XR Orbits Complete Right

Facility

$227.00

Service Code	CPT 70200 RT
Hospital Charge Code	1170341
Hospital Revenue Code	320
Min. Negotiated Rate	$102.15
Max. Negotiated Rate	$204.30
Rate for Payer: Aetna of IA Commercial	$204.30
Rate for Payer: Aetna of IA Medical Rental Products	$204.30
Rate for Payer: Aetna of IA Medicare	$129.39
Rate for Payer: Amerigroup Medicaid	$130.93
Rate for Payer: Amerigroup Medicare	$103.17
Rate for Payer: Cash Price	$181.60
Rate for Payer: Cash Price	$181.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$102.15
Rate for Payer: Iowa Total Care Managed Medicaid	$129.66
Rate for Payer: Medical Associates Commercial	$170.25
Rate for Payer: Medical Associates Managed Medicare	$102.15
Rate for Payer: Midlands Choice Commercial	$158.90
Rate for Payer: Molina Healthcare Managed Medicaid	$131.57
Rate for Payer: Partners Health Alliance Commercial	$117.47
Rate for Payer: United Healthcare Commercial	$204.30
Rate for Payer: United Healthcare Managed Medicare	$133.93
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Pelvis 1 or 2 Views

Facility

$150.00

Service Code	CPT 72170
Hospital Charge Code	1170351
Hospital Revenue Code	320
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: United Healthcare Commercial	$135.00

XR Pelvis 1 or 2 Views

Facility

$150.00

Service Code	CPT 72170
Hospital Charge Code	1170351
Hospital Revenue Code	320
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Aetna of IA Medicare	$85.50
Rate for Payer: Amerigroup Medicaid	$86.52
Rate for Payer: Amerigroup Medicare	$68.18
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.50
Rate for Payer: Iowa Total Care Managed Medicaid	$85.68
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Medical Associates Managed Medicare	$67.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: Molina Healthcare Managed Medicaid	$86.94
Rate for Payer: Partners Health Alliance Commercial	$77.62
Rate for Payer: United Healthcare Commercial	$135.00
Rate for Payer: United Healthcare Managed Medicare	$88.50
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

Know your out-of-pocket cost for care.

All Charges