Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

CT Pelvis w/ Contrast

Facility

$1,210.00

Service Code	CPT 72193
Hospital Charge Code	1168196
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 Pelvis w/o Contrast

Facility

$1,146.00

Service Code	CPT 72192
Hospital Charge Code	1168198
Hospital Revenue Code	352
Min. Negotiated Rate	$802.20
Max. Negotiated Rate	$1,031.40
Rate for Payer: Aetna of IA Commercial	$1,031.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,031.40
Rate for Payer: Cash Price	$916.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$859.50
Rate for Payer: Medical Associates Commercial	$859.50
Rate for Payer: Midlands Choice Commercial	$802.20
Rate for Payer: United Healthcare Commercial	$1,031.40

CT Pelvis w/o Contrast

Facility

$1,146.00

Service Code	CPT 72192
Hospital Charge Code	1168198
Hospital Revenue Code	352
Min. Negotiated Rate	$515.70
Max. Negotiated Rate	$1,031.40
Rate for Payer: Aetna of IA Commercial	$1,031.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,031.40
Rate for Payer: Aetna of IA Medicare	$653.22
Rate for Payer: Amerigroup Medicaid	$661.01
Rate for Payer: Amerigroup Medicare	$520.86
Rate for Payer: Cash Price	$916.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$859.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$515.70
Rate for Payer: Iowa Total Care Managed Medicaid	$654.60
Rate for Payer: Medical Associates Commercial	$859.50
Rate for Payer: Medical Associates Managed Medicare	$515.70
Rate for Payer: Midlands Choice Commercial	$802.20
Rate for Payer: Molina Healthcare Managed Medicaid	$664.22
Rate for Payer: Partners Health Alliance Commercial	$593.05
Rate for Payer: United Healthcare Commercial	$1,031.40
Rate for Payer: United Healthcare Managed Medicare	$676.14

CT Pelvis w/ + w/o Contrast

Facility

$1,672.00

Service Code	CPT 72194
Hospital Charge Code	1168194
Hospital Revenue Code	352
Min. Negotiated Rate	$752.40
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: Aetna of IA Medicare	$953.04
Rate for Payer: Amerigroup Medicaid	$964.41
Rate for Payer: Amerigroup Medicare	$759.92
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	$752.40
Rate for Payer: Iowa Total Care Managed Medicaid	$955.05
Rate for Payer: Medical Associates Commercial	$1,254.00
Rate for Payer: Medical Associates Managed Medicare	$752.40
Rate for Payer: Midlands Choice Commercial	$1,170.40
Rate for Payer: Molina Healthcare Managed Medicaid	$969.09
Rate for Payer: Partners Health Alliance Commercial	$865.26
Rate for Payer: United Healthcare Commercial	$1,504.80
Rate for Payer: United Healthcare Managed Medicare	$986.48

CT Pelvis w/ + w/o Contrast

Facility

$1,672.00

Service Code	CPT 72194
Hospital Charge Code	1168194
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

C. trach N. gonorrhea DNA DMCL

Facility

$142.00

Service Code	CPT 87491
Hospital Charge Code	8037504
Hospital Revenue Code	306
Min. Negotiated Rate	$99.40
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of IA Commercial	$127.80
Rate for Payer: Aetna of IA Medical Rental Products	$127.80
Rate for Payer: Cash Price	$113.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$106.50
Rate for Payer: Medical Associates Commercial	$106.50
Rate for Payer: Midlands Choice Commercial	$99.40
Rate for Payer: United Healthcare Commercial	$127.80

C. trach N. gonorrhea DNA DMCL

Facility

$142.00

Service Code	CPT 87491
Hospital Charge Code	8037504
Hospital Revenue Code	306
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$127.80
Rate for Payer: Aetna of IA Commercial	$127.80
Rate for Payer: Aetna of IA Medical Rental Products	$127.80
Rate for Payer: Aetna of IA Medicare	$80.94
Rate for Payer: Amerigroup Medicaid	$81.91
Rate for Payer: Amerigroup Medicare	$64.54
Rate for Payer: Cash Price	$113.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$106.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$63.90
Rate for Payer: Iowa Total Care Managed Medicaid	$81.11
Rate for Payer: Medical Associates Commercial	$106.50
Rate for Payer: Medical Associates Managed Medicare	$63.90
Rate for Payer: Midlands Choice Commercial	$99.40
Rate for Payer: Molina Healthcare Managed Medicaid	$82.30
Rate for Payer: Partners Health Alliance Commercial	$73.48
Rate for Payer: United Healthcare Commercial	$127.80
Rate for Payer: United Healthcare Managed Medicare	$83.78

CT Shoulder w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73201 LT
Hospital Charge Code	1168214
Hospital Revenue Code	350
Min. Negotiated Rate	$646.20
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: Aetna of IA Medicare	$818.52
Rate for Payer: Amerigroup Medicaid	$828.28
Rate for Payer: Amerigroup Medicare	$652.66
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	$646.20
Rate for Payer: Iowa Total Care Managed Medicaid	$820.24
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Medical Associates Managed Medicare	$646.20
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: Molina Healthcare Managed Medicaid	$832.31
Rate for Payer: Partners Health Alliance Commercial	$743.13
Rate for Payer: United Healthcare Commercial	$1,292.40
Rate for Payer: United Healthcare Managed Medicare	$847.24

CT Shoulder w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73201 LT
Hospital Charge Code	1168214
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 Shoulder w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73201 RT
Hospital Charge Code	1168216
Hospital Revenue Code	350
Min. Negotiated Rate	$646.20
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: Aetna of IA Medicare	$818.52
Rate for Payer: Amerigroup Medicaid	$828.28
Rate for Payer: Amerigroup Medicare	$652.66
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	$646.20
Rate for Payer: Iowa Total Care Managed Medicaid	$820.24
Rate for Payer: Medical Associates Commercial	$1,077.00
Rate for Payer: Medical Associates Managed Medicare	$646.20
Rate for Payer: Midlands Choice Commercial	$1,005.20
Rate for Payer: Molina Healthcare Managed Medicaid	$832.31
Rate for Payer: Partners Health Alliance Commercial	$743.13
Rate for Payer: United Healthcare Commercial	$1,292.40
Rate for Payer: United Healthcare Managed Medicare	$847.24

CT Shoulder w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73201 RT
Hospital Charge Code	1168216
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 Shoulder w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73200 LT
Hospital Charge Code	1168220
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 Shoulder w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73200 LT
Hospital Charge Code	1168220
Hospital Revenue Code	350
Min. Negotiated Rate	$504.45
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	$646.59
Rate for Payer: Amerigroup Medicare	$509.49
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	$504.45
Rate for Payer: Iowa Total Care Managed Medicaid	$640.32
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Medical Associates Managed Medicare	$504.45
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: Molina Healthcare Managed Medicaid	$649.73
Rate for Payer: Partners Health Alliance Commercial	$580.12
Rate for Payer: United Healthcare Commercial	$1,008.90
Rate for Payer: United Healthcare Managed Medicare	$661.39

CT Shoulder w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73200 RT
Hospital Charge Code	1168222
Hospital Revenue Code	350
Min. Negotiated Rate	$504.45
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	$646.59
Rate for Payer: Amerigroup Medicare	$509.49
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	$504.45
Rate for Payer: Iowa Total Care Managed Medicaid	$640.32
Rate for Payer: Medical Associates Commercial	$840.75
Rate for Payer: Medical Associates Managed Medicare	$504.45
Rate for Payer: Midlands Choice Commercial	$784.70
Rate for Payer: Molina Healthcare Managed Medicaid	$649.73
Rate for Payer: Partners Health Alliance Commercial	$580.12
Rate for Payer: United Healthcare Commercial	$1,008.90
Rate for Payer: United Healthcare Managed Medicare	$661.39

CT Shoulder w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73200 RT
Hospital Charge Code	1168222
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 Shoulder w/ + w/o Contrast Left

Facility

$1,321.00

Service Code	CPT 73202 LT
Hospital Charge Code	1168208
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 Shoulder w/ + w/o Contrast Left

Facility

$1,321.00

Service Code	CPT 73202 LT
Hospital Charge Code	1168208
Hospital Revenue Code	352
Min. Negotiated Rate	$594.45
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	$761.95
Rate for Payer: Amerigroup Medicare	$600.39
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	$594.45
Rate for Payer: Iowa Total Care Managed Medicaid	$754.56
Rate for Payer: Medical Associates Commercial	$990.75
Rate for Payer: Medical Associates Managed Medicare	$594.45
Rate for Payer: Midlands Choice Commercial	$924.70
Rate for Payer: Molina Healthcare Managed Medicaid	$765.65
Rate for Payer: Partners Health Alliance Commercial	$683.62
Rate for Payer: United Healthcare Commercial	$1,188.90
Rate for Payer: United Healthcare Managed Medicare	$779.39

CT Shoulder w/ + w/o Contrast Right

Facility

$1,321.00

Service Code	CPT 73202 RT
Hospital Charge Code	1168210
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 Shoulder w/ + w/o Contrast Right

Facility

$1,321.00

Service Code	CPT 73202 RT
Hospital Charge Code	1168210
Hospital Revenue Code	352
Min. Negotiated Rate	$594.45
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	$761.95
Rate for Payer: Amerigroup Medicare	$600.39
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	$594.45
Rate for Payer: Iowa Total Care Managed Medicaid	$754.56
Rate for Payer: Medical Associates Commercial	$990.75
Rate for Payer: Medical Associates Managed Medicare	$594.45
Rate for Payer: Midlands Choice Commercial	$924.70
Rate for Payer: Molina Healthcare Managed Medicaid	$765.65
Rate for Payer: Partners Health Alliance Commercial	$683.62
Rate for Payer: United Healthcare Commercial	$1,188.90
Rate for Payer: United Healthcare Managed Medicare	$779.39

CT Sinus w/ Contrast

Facility

$1,540.00

Service Code	CPT 70487
Hospital Charge Code	1168226
Hospital Revenue Code	351
Min. Negotiated Rate	$1,078.00
Max. Negotiated Rate	$1,386.00
Rate for Payer: Aetna of IA Commercial	$1,386.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,386.00
Rate for Payer: Cash Price	$1,232.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,155.00
Rate for Payer: Medical Associates Commercial	$1,155.00
Rate for Payer: Midlands Choice Commercial	$1,078.00
Rate for Payer: United Healthcare Commercial	$1,386.00

CT Sinus w/ Contrast

Facility

$1,540.00

Service Code	CPT 70487
Hospital Charge Code	1168226
Hospital Revenue Code	351
Min. Negotiated Rate	$693.00
Max. Negotiated Rate	$1,386.00
Rate for Payer: Aetna of IA Commercial	$1,386.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,386.00
Rate for Payer: Aetna of IA Medicare	$877.80
Rate for Payer: Amerigroup Medicaid	$888.27
Rate for Payer: Amerigroup Medicare	$699.93
Rate for Payer: Cash Price	$1,232.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,155.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$693.00
Rate for Payer: Iowa Total Care Managed Medicaid	$879.65
Rate for Payer: Medical Associates Commercial	$1,155.00
Rate for Payer: Medical Associates Managed Medicare	$693.00
Rate for Payer: Midlands Choice Commercial	$1,078.00
Rate for Payer: Molina Healthcare Managed Medicaid	$892.58
Rate for Payer: Partners Health Alliance Commercial	$796.95
Rate for Payer: United Healthcare Commercial	$1,386.00
Rate for Payer: United Healthcare Managed Medicare	$908.60

CT Sinus w/o Contrast

Facility

$1,180.00

Service Code	CPT 70486
Hospital Charge Code	1168228
Hospital Revenue Code	351
Min. Negotiated Rate	$826.00
Max. Negotiated Rate	$1,062.00
Rate for Payer: Aetna of IA Commercial	$1,062.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,062.00
Rate for Payer: Cash Price	$944.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$885.00
Rate for Payer: Medical Associates Commercial	$885.00
Rate for Payer: Midlands Choice Commercial	$826.00
Rate for Payer: United Healthcare Commercial	$1,062.00

CT Sinus w/o Contrast

Facility

$1,180.00

Service Code	CPT 70486
Hospital Charge Code	1168228
Hospital Revenue Code	351
Min. Negotiated Rate	$531.00
Max. Negotiated Rate	$1,062.00
Rate for Payer: Aetna of IA Commercial	$1,062.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,062.00
Rate for Payer: Aetna of IA Medicare	$672.60
Rate for Payer: Amerigroup Medicaid	$680.62
Rate for Payer: Amerigroup Medicare	$536.31
Rate for Payer: Cash Price	$944.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$885.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$531.00
Rate for Payer: Iowa Total Care Managed Medicaid	$674.02
Rate for Payer: Medical Associates Commercial	$885.00
Rate for Payer: Medical Associates Managed Medicare	$531.00
Rate for Payer: Midlands Choice Commercial	$826.00
Rate for Payer: Molina Healthcare Managed Medicaid	$683.93
Rate for Payer: Partners Health Alliance Commercial	$610.65
Rate for Payer: United Healthcare Commercial	$1,062.00
Rate for Payer: United Healthcare Managed Medicare	$696.20

CT Sinus w/ + w/o Contrast

Facility

$1,503.00

Service Code	CPT 70488
Hospital Charge Code	1168224
Hospital Revenue Code	351
Min. Negotiated Rate	$1,052.10
Max. Negotiated Rate	$1,352.70
Rate for Payer: Aetna of IA Commercial	$1,352.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,352.70
Rate for Payer: Cash Price	$1,202.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,127.25
Rate for Payer: Medical Associates Commercial	$1,127.25
Rate for Payer: Midlands Choice Commercial	$1,052.10
Rate for Payer: United Healthcare Commercial	$1,352.70

CT Sinus w/ + w/o Contrast

Facility

$1,503.00

Service Code	CPT 70488
Hospital Charge Code	1168224
Hospital Revenue Code	351
Min. Negotiated Rate	$676.35
Max. Negotiated Rate	$1,352.70
Rate for Payer: Aetna of IA Commercial	$1,352.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,352.70
Rate for Payer: Aetna of IA Medicare	$856.71
Rate for Payer: Amerigroup Medicaid	$866.93
Rate for Payer: Amerigroup Medicare	$683.11
Rate for Payer: Cash Price	$1,202.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,127.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$676.35
Rate for Payer: Iowa Total Care Managed Medicaid	$858.51
Rate for Payer: Medical Associates Commercial	$1,127.25
Rate for Payer: Medical Associates Managed Medicare	$676.35
Rate for Payer: Midlands Choice Commercial	$1,052.10
Rate for Payer: Molina Healthcare Managed Medicaid	$871.14
Rate for Payer: Partners Health Alliance Commercial	$777.80
Rate for Payer: United Healthcare Commercial	$1,352.70
Rate for Payer: United Healthcare Managed Medicare	$886.77

Know your out-of-pocket cost for care.

All Charges