Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

CT Chest w/ Contrast

Facility

$1,210.00

Service Code	CPT 71260
Hospital Charge Code	4500796
Hospital Revenue Code	352
Min. Negotiated Rate	$847.00
Max. Negotiated Rate	$1,089.00
Rate for Payer: Aetna of IA Commercial	$1,089.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,089.00
Rate for Payer: Cash Price	$968.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$907.50
Rate for Payer: Medical Associates Commercial	$907.50
Rate for Payer: Midlands Choice Commercial	$847.00
Rate for Payer: United Healthcare Commercial	$1,089.00

CT Chest w/o Contrast

Facility

$1,137.00

Service Code	CPT 71250
Hospital Charge Code	4500799
Hospital Revenue Code	352
Min. Negotiated Rate	$795.90
Max. Negotiated Rate	$1,023.30
Rate for Payer: Aetna of IA Commercial	$1,023.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,023.30
Rate for Payer: Cash Price	$909.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$852.75
Rate for Payer: Medical Associates Commercial	$852.75
Rate for Payer: Midlands Choice Commercial	$795.90
Rate for Payer: United Healthcare Commercial	$1,023.30

CT Chest w/o Contrast

Facility

$1,137.00

Service Code	CPT 71250
Hospital Charge Code	4500799
Hospital Revenue Code	352
Min. Negotiated Rate	$480.50
Max. Negotiated Rate	$1,023.30
Rate for Payer: Aetna of IA Commercial	$1,023.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,023.30
Rate for Payer: Aetna of IA Medicare	$648.09
Rate for Payer: Amerigroup Medicaid	$573.84
Rate for Payer: Amerigroup Medicare	$574.18
Rate for Payer: Cash Price	$909.60
Rate for Payer: Cash Price	$909.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$852.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$568.50
Rate for Payer: Iowa Total Care Managed Medicaid	$568.27
Rate for Payer: Medical Associates Commercial	$852.75
Rate for Payer: Medical Associates Managed Medicare	$568.50
Rate for Payer: Midlands Choice Commercial	$795.90
Rate for Payer: Molina Healthcare Managed Medicaid	$577.03
Rate for Payer: Molina Healthcare Managed Medicare	$576.69
Rate for Payer: Oscar Health of IA Commercial	$852.75
Rate for Payer: Partners Health Alliance Commercial	$852.75
Rate for Payer: United Healthcare Commercial	$1,023.30
Rate for Payer: United Healthcare Managed Medicare	$670.83
Rate for Payer: Wellmark IA HMO	$480.50
Rate for Payer: Wellmark IA PPO	$528.55

CT Chest w/ + w/o Contrast

Facility

$1,672.00

Service Code	CPT 71270
Hospital Charge Code	4500793
Hospital Revenue Code	352
Min. Negotiated Rate	$1,170.40
Max. Negotiated Rate	$1,504.80
Rate for Payer: Aetna of IA Commercial	$1,504.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,504.80
Rate for Payer: Cash Price	$1,337.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,254.00
Rate for Payer: Medical Associates Commercial	$1,254.00
Rate for Payer: Midlands Choice Commercial	$1,170.40
Rate for Payer: United Healthcare Commercial	$1,504.80

CT Chest w/ + w/o Contrast

Facility

$1,672.00

Service Code	CPT 71270
Hospital Charge Code	4500793
Hospital Revenue Code	352
Min. Negotiated Rate	$835.67
Max. Negotiated Rate	$1,504.80
Rate for Payer: Aetna of IA Commercial	$1,504.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,504.80
Rate for Payer: Aetna of IA Medicare	$953.04
Rate for Payer: Amerigroup Medicaid	$843.86
Rate for Payer: Amerigroup Medicare	$844.36
Rate for Payer: Cash Price	$1,337.60
Rate for Payer: Cash Price	$1,337.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,254.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$836.00
Rate for Payer: Iowa Total Care Managed Medicaid	$835.67
Rate for Payer: Medical Associates Commercial	$1,254.00
Rate for Payer: Medical Associates Managed Medicare	$836.00
Rate for Payer: Midlands Choice Commercial	$1,170.40
Rate for Payer: Molina Healthcare Managed Medicaid	$848.54
Rate for Payer: Molina Healthcare Managed Medicare	$848.04
Rate for Payer: Oscar Health of IA Commercial	$1,254.00
Rate for Payer: Partners Health Alliance Commercial	$1,254.00
Rate for Payer: United Healthcare Commercial	$1,504.80
Rate for Payer: United Healthcare Managed Medicare	$986.48
Rate for Payer: Wellmark IA HMO	$1,042.22
Rate for Payer: Wellmark IA PPO	$1,146.44

CT Elbow w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73201
Hospital Charge Code	1167996
Hospital Revenue Code	350
Min. Negotiated Rate	$1,005.20
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: United Healthcare Commercial	$1,292.40

CT Elbow w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73201
Hospital Charge Code	1167996
Hospital Revenue Code	350
Min. Negotiated Rate	$717.71
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Aetna of IA Medicare	$818.52
Rate for Payer: Amerigroup Medicaid	$724.75
Rate for Payer: Amerigroup Medicare	$725.18
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$718.00
Rate for Payer: Iowa Total Care Managed Medicaid	$717.71
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Medical Associates Managed Medicare	$718.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: Molina Healthcare Managed Medicaid	$728.77
Rate for Payer: Molina Healthcare Managed Medicare	$728.34
Rate for Payer: Oscar Health of IA Commercial	$1,077.00
Rate for Payer: Partners Health Alliance Commercial	$1,077.00
Rate for Payer: United Healthcare Commercial	$1,292.40
Rate for Payer: United Healthcare Managed Medicare	$847.24
Rate for Payer: Wellmark IA HMO	$1,042.22
Rate for Payer: Wellmark IA PPO	$1,146.44

CT Elbow w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73201
Hospital Charge Code	1167998
Hospital Revenue Code	350
Min. Negotiated Rate	$717.71
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Aetna of IA Medicare	$818.52
Rate for Payer: Amerigroup Medicaid	$724.75
Rate for Payer: Amerigroup Medicare	$725.18
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$718.00
Rate for Payer: Iowa Total Care Managed Medicaid	$717.71
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Medical Associates Managed Medicare	$718.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: Molina Healthcare Managed Medicaid	$728.77
Rate for Payer: Molina Healthcare Managed Medicare	$728.34
Rate for Payer: Oscar Health of IA Commercial	$1,077.00
Rate for Payer: Partners Health Alliance Commercial	$1,077.00
Rate for Payer: United Healthcare Commercial	$1,292.40
Rate for Payer: United Healthcare Managed Medicare	$847.24
Rate for Payer: Wellmark IA HMO	$1,042.22
Rate for Payer: Wellmark IA PPO	$1,146.44

CT Elbow w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73201
Hospital Charge Code	1167998
Hospital Revenue Code	350
Min. Negotiated Rate	$1,005.20
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: United Healthcare Commercial	$1,292.40

CT Elbow w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73200
Hospital Charge Code	1168002
Hospital Revenue Code	350
Min. Negotiated Rate	$480.50
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Aetna of IA Medicare	$638.97
Rate for Payer: Amerigroup Medicaid	$565.77
Rate for Payer: Amerigroup Medicare	$566.10
Rate for Payer: Cash Price	$896.80
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$560.50
Rate for Payer: Iowa Total Care Managed Medicaid	$560.28
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Medical Associates Managed Medicare	$560.50
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: Molina Healthcare Managed Medicaid	$568.91
Rate for Payer: Molina Healthcare Managed Medicare	$568.57
Rate for Payer: Oscar Health of IA Commercial	$840.75
Rate for Payer: Partners Health Alliance Commercial	$840.75
Rate for Payer: United Healthcare Commercial	$1,008.90
Rate for Payer: United Healthcare Managed Medicare	$661.39
Rate for Payer: Wellmark IA HMO	$480.50
Rate for Payer: Wellmark IA PPO	$528.55

CT Elbow w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73200
Hospital Charge Code	1168002
Hospital Revenue Code	350
Min. Negotiated Rate	$784.70
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: United Healthcare Commercial	$1,008.90

CT Elbow w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73200
Hospital Charge Code	1168004
Hospital Revenue Code	350
Min. Negotiated Rate	$784.70
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: United Healthcare Commercial	$1,008.90

CT Elbow w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73200
Hospital Charge Code	1168004
Hospital Revenue Code	350
Min. Negotiated Rate	$480.50
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Aetna of IA Medicare	$638.97
Rate for Payer: Amerigroup Medicaid	$565.77
Rate for Payer: Amerigroup Medicare	$566.10
Rate for Payer: Cash Price	$896.80
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$560.50
Rate for Payer: Iowa Total Care Managed Medicaid	$560.28
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Medical Associates Managed Medicare	$560.50
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: Molina Healthcare Managed Medicaid	$568.91
Rate for Payer: Molina Healthcare Managed Medicare	$568.57
Rate for Payer: Oscar Health of IA Commercial	$840.75
Rate for Payer: Partners Health Alliance Commercial	$840.75
Rate for Payer: United Healthcare Commercial	$1,008.90
Rate for Payer: United Healthcare Managed Medicare	$661.39
Rate for Payer: Wellmark IA HMO	$480.50
Rate for Payer: Wellmark IA PPO	$528.55

CT Elbow w/ + w/o Contrast Left

Facility

$1,321.00

Service Code	CPT 73202
Hospital Charge Code	1167990
Hospital Revenue Code	352
Min. Negotiated Rate	$660.24
Max. Negotiated Rate	$1,188.90
Rate for Payer: Aetna of IA Commercial	$1,188.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,188.90
Rate for Payer: Aetna of IA Medicare	$752.97
Rate for Payer: Amerigroup Medicaid	$666.71
Rate for Payer: Amerigroup Medicare	$667.10
Rate for Payer: Cash Price	$1,056.80
Rate for Payer: Cash Price	$1,056.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$990.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$660.50
Rate for Payer: Iowa Total Care Managed Medicaid	$660.24
Rate for Payer: Medical Associates Commercial	$990.75
Rate for Payer: Medical Associates Managed Medicare	$660.50
Rate for Payer: Midlands Choice Commercial	$924.70
Rate for Payer: Molina Healthcare Managed Medicaid	$670.41
Rate for Payer: Molina Healthcare Managed Medicare	$670.01
Rate for Payer: Oscar Health of IA Commercial	$990.75
Rate for Payer: Partners Health Alliance Commercial	$990.75
Rate for Payer: United Healthcare Commercial	$1,188.90
Rate for Payer: United Healthcare Managed Medicare	$779.39
Rate for Payer: Wellmark IA HMO	$1,042.22
Rate for Payer: Wellmark IA PPO	$1,146.44

CT Elbow w/ + w/o Contrast Left

Facility

$1,321.00

Service Code	CPT 73202
Hospital Charge Code	1167990
Hospital Revenue Code	352
Min. Negotiated Rate	$924.70
Max. Negotiated Rate	$1,188.90
Rate for Payer: Aetna of IA Commercial	$1,188.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,188.90
Rate for Payer: Cash Price	$1,056.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$990.75
Rate for Payer: Medical Associates Commercial	$990.75
Rate for Payer: Midlands Choice Commercial	$924.70
Rate for Payer: United Healthcare Commercial	$1,188.90

CT Elbow w/ + w/o Contrast Right

Facility

$1,321.00

Service Code	CPT 73202
Hospital Charge Code	1167992
Hospital Revenue Code	352
Min. Negotiated Rate	$924.70
Max. Negotiated Rate	$1,188.90
Rate for Payer: Aetna of IA Commercial	$1,188.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,188.90
Rate for Payer: Cash Price	$1,056.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$990.75
Rate for Payer: Medical Associates Commercial	$990.75
Rate for Payer: Midlands Choice Commercial	$924.70
Rate for Payer: United Healthcare Commercial	$1,188.90

CT Elbow w/ + w/o Contrast Right

Facility

$1,321.00

Service Code	CPT 73202
Hospital Charge Code	1167992
Hospital Revenue Code	352
Min. Negotiated Rate	$660.24
Max. Negotiated Rate	$1,188.90
Rate for Payer: Aetna of IA Commercial	$1,188.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,188.90
Rate for Payer: Aetna of IA Medicare	$752.97
Rate for Payer: Amerigroup Medicaid	$666.71
Rate for Payer: Amerigroup Medicare	$667.10
Rate for Payer: Cash Price	$1,056.80
Rate for Payer: Cash Price	$1,056.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$990.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$660.50
Rate for Payer: Iowa Total Care Managed Medicaid	$660.24
Rate for Payer: Medical Associates Commercial	$990.75
Rate for Payer: Medical Associates Managed Medicare	$660.50
Rate for Payer: Midlands Choice Commercial	$924.70
Rate for Payer: Molina Healthcare Managed Medicaid	$670.41
Rate for Payer: Molina Healthcare Managed Medicare	$670.01
Rate for Payer: Oscar Health of IA Commercial	$990.75
Rate for Payer: Partners Health Alliance Commercial	$990.75
Rate for Payer: United Healthcare Commercial	$1,188.90
Rate for Payer: United Healthcare Managed Medicare	$779.39
Rate for Payer: Wellmark IA HMO	$1,042.22
Rate for Payer: Wellmark IA PPO	$1,146.44

CT Femur w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73701
Hospital Charge Code	1168014
Hospital Revenue Code	352
Min. Negotiated Rate	$1,005.20
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: United Healthcare Commercial	$1,292.40

CT Femur w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73701
Hospital Charge Code	1168014
Hospital Revenue Code	352
Min. Negotiated Rate	$717.71
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Aetna of IA Medicare	$818.52
Rate for Payer: Amerigroup Medicaid	$724.75
Rate for Payer: Amerigroup Medicare	$725.18
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$718.00
Rate for Payer: Iowa Total Care Managed Medicaid	$717.71
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Medical Associates Managed Medicare	$718.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: Molina Healthcare Managed Medicaid	$728.77
Rate for Payer: Molina Healthcare Managed Medicare	$728.34
Rate for Payer: Oscar Health of IA Commercial	$1,077.00
Rate for Payer: Partners Health Alliance Commercial	$1,077.00
Rate for Payer: United Healthcare Commercial	$1,292.40
Rate for Payer: United Healthcare Managed Medicare	$847.24
Rate for Payer: Wellmark IA HMO	$1,042.22
Rate for Payer: Wellmark IA PPO	$1,146.44

CT Femur w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73701
Hospital Charge Code	1168016
Hospital Revenue Code	352
Min. Negotiated Rate	$1,005.20
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: United Healthcare Commercial	$1,292.40

CT Femur w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73701
Hospital Charge Code	1168016
Hospital Revenue Code	352
Min. Negotiated Rate	$717.71
Max. Negotiated Rate	$1,292.40
Rate for Payer: Aetna of IA Commercial	$1,292.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,292.40
Rate for Payer: Aetna of IA Medicare	$818.52
Rate for Payer: Amerigroup Medicaid	$724.75
Rate for Payer: Amerigroup Medicare	$725.18
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Cash Price	$1,148.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,077.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$718.00
Rate for Payer: Iowa Total Care Managed Medicaid	$717.71
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Medical Associates Managed Medicare	$718.00
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: Molina Healthcare Managed Medicaid	$728.77
Rate for Payer: Molina Healthcare Managed Medicare	$728.34
Rate for Payer: Oscar Health of IA Commercial	$1,077.00
Rate for Payer: Partners Health Alliance Commercial	$1,077.00
Rate for Payer: United Healthcare Commercial	$1,292.40
Rate for Payer: United Healthcare Managed Medicare	$847.24
Rate for Payer: Wellmark IA HMO	$1,042.22
Rate for Payer: Wellmark IA PPO	$1,146.44

CT Femur w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73700
Hospital Charge Code	1168020
Hospital Revenue Code	352
Min. Negotiated Rate	$480.50
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Aetna of IA Medicare	$638.97
Rate for Payer: Amerigroup Medicaid	$565.77
Rate for Payer: Amerigroup Medicare	$566.10
Rate for Payer: Cash Price	$896.80
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$560.50
Rate for Payer: Iowa Total Care Managed Medicaid	$560.28
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Medical Associates Managed Medicare	$560.50
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: Molina Healthcare Managed Medicaid	$568.91
Rate for Payer: Molina Healthcare Managed Medicare	$568.57
Rate for Payer: Oscar Health of IA Commercial	$840.75
Rate for Payer: Partners Health Alliance Commercial	$840.75
Rate for Payer: United Healthcare Commercial	$1,008.90
Rate for Payer: United Healthcare Managed Medicare	$661.39
Rate for Payer: Wellmark IA HMO	$480.50
Rate for Payer: Wellmark IA PPO	$528.55

CT Femur w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73700
Hospital Charge Code	1168020
Hospital Revenue Code	352
Min. Negotiated Rate	$784.70
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: United Healthcare Commercial	$1,008.90

CT Femur w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73700
Hospital Charge Code	1168022
Hospital Revenue Code	352
Min. Negotiated Rate	$784.70
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: United Healthcare Commercial	$1,008.90

CT Femur w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73700
Hospital Charge Code	1168022
Hospital Revenue Code	352
Min. Negotiated Rate	$480.50
Max. Negotiated Rate	$1,008.90
Rate for Payer: Aetna of IA Commercial	$1,008.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.90
Rate for Payer: Aetna of IA Medicare	$638.97
Rate for Payer: Amerigroup Medicaid	$565.77
Rate for Payer: Amerigroup Medicare	$566.10
Rate for Payer: Cash Price	$896.80
Rate for Payer: Cash Price	$896.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$560.50
Rate for Payer: Iowa Total Care Managed Medicaid	$560.28
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Medical Associates Managed Medicare	$560.50
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: Molina Healthcare Managed Medicaid	$568.91
Rate for Payer: Molina Healthcare Managed Medicare	$568.57
Rate for Payer: Oscar Health of IA Commercial	$840.75
Rate for Payer: Partners Health Alliance Commercial	$840.75
Rate for Payer: United Healthcare Commercial	$1,008.90
Rate for Payer: United Healthcare Managed Medicare	$661.39
Rate for Payer: Wellmark IA HMO	$480.50
Rate for Payer: Wellmark IA PPO	$528.55

Know your out-of-pocket cost for care.

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