Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

CT Head or Brain w/ + w/o Contrast

Facility

$1,629.00

Service Code	CPT 70470
Hospital Charge Code	1168090
Hospital Revenue Code	351
Min. Negotiated Rate	$1,140.30
Max. Negotiated Rate	$1,466.10
Rate for Payer: Aetna of IA Commercial	$1,466.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,466.10
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,221.75
Rate for Payer: Medical Associates Commercial	$1,221.75
Rate for Payer: Midlands Choice Commercial	$1,140.30
Rate for Payer: United Healthcare Commercial	$1,466.10

CT Hip w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73701 LT
Hospital Charge Code	1168110
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 Hip w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73701 LT
Hospital Charge Code	1168110
Hospital Revenue Code	352
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Hip w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73701 RT
Hospital Charge Code	1168112
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 Hip w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73701 RT
Hospital Charge Code	1168112
Hospital Revenue Code	352
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Hip w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73700 LT
Hospital Charge Code	1168116
Hospital Revenue Code	352
Min. Negotiated Rate	$312.67
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$312.67
Rate for Payer: Wellmark IA PPO	$344.42

CT Hip w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73700 LT
Hospital Charge Code	1168116
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 Hip w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73700 RT
Hospital Charge Code	1168118
Hospital Revenue Code	352
Min. Negotiated Rate	$312.67
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$312.67
Rate for Payer: Wellmark IA PPO	$344.42

CT Hip w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73700 RT
Hospital Charge Code	1168118
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 Hip w/ + w/o Contrast Left

Facility

$1,592.00

Service Code	CPT 73702 LT
Hospital Charge Code	1168104
Hospital Revenue Code	352
Min. Negotiated Rate	$716.40
Max. Negotiated Rate	$1,432.80
Rate for Payer: Aetna of IA Commercial	$1,432.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,432.80
Rate for Payer: Aetna of IA Medicare	$907.44
Rate for Payer: Amerigroup Medicaid	$918.27
Rate for Payer: Amerigroup Medicare	$723.56
Rate for Payer: Cash Price	$1,273.60
Rate for Payer: Cash Price	$1,273.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,194.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$716.40
Rate for Payer: Iowa Total Care Managed Medicaid	$909.35
Rate for Payer: Medical Associates Commercial	$1,194.00
Rate for Payer: Medical Associates Managed Medicare	$716.40
Rate for Payer: Midlands Choice Commercial	$1,114.40
Rate for Payer: Molina Healthcare Managed Medicaid	$922.72
Rate for Payer: Partners Health Alliance Commercial	$823.86
Rate for Payer: United Healthcare Commercial	$1,432.80
Rate for Payer: United Healthcare Managed Medicare	$939.28
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Hip w/ + w/o Contrast Left

Facility

$1,592.00

Service Code	CPT 73702 LT
Hospital Charge Code	1168104
Hospital Revenue Code	352
Min. Negotiated Rate	$1,114.40
Max. Negotiated Rate	$1,432.80
Rate for Payer: Aetna of IA Commercial	$1,432.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,432.80
Rate for Payer: Cash Price	$1,273.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,194.00
Rate for Payer: Medical Associates Commercial	$1,194.00
Rate for Payer: Midlands Choice Commercial	$1,114.40
Rate for Payer: United Healthcare Commercial	$1,432.80

CT Hip w/ + w/o Contrast Right

Facility

$1,592.00

Service Code	CPT 73702 RT
Hospital Charge Code	1168106
Hospital Revenue Code	352
Min. Negotiated Rate	$1,114.40
Max. Negotiated Rate	$1,432.80
Rate for Payer: Aetna of IA Commercial	$1,432.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,432.80
Rate for Payer: Cash Price	$1,273.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,194.00
Rate for Payer: Medical Associates Commercial	$1,194.00
Rate for Payer: Midlands Choice Commercial	$1,114.40
Rate for Payer: United Healthcare Commercial	$1,432.80

CT Hip w/ + w/o Contrast Right

Facility

$1,592.00

Service Code	CPT 73702 RT
Hospital Charge Code	1168106
Hospital Revenue Code	352
Min. Negotiated Rate	$716.40
Max. Negotiated Rate	$1,432.80
Rate for Payer: Aetna of IA Commercial	$1,432.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,432.80
Rate for Payer: Aetna of IA Medicare	$907.44
Rate for Payer: Amerigroup Medicaid	$918.27
Rate for Payer: Amerigroup Medicare	$723.56
Rate for Payer: Cash Price	$1,273.60
Rate for Payer: Cash Price	$1,273.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,194.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$716.40
Rate for Payer: Iowa Total Care Managed Medicaid	$909.35
Rate for Payer: Medical Associates Commercial	$1,194.00
Rate for Payer: Medical Associates Managed Medicare	$716.40
Rate for Payer: Midlands Choice Commercial	$1,114.40
Rate for Payer: Molina Healthcare Managed Medicaid	$922.72
Rate for Payer: Partners Health Alliance Commercial	$823.86
Rate for Payer: United Healthcare Commercial	$1,432.80
Rate for Payer: United Healthcare Managed Medicare	$939.28
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Humerus w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73201 LT
Hospital Charge Code	1168128
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Humerus w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73201 LT
Hospital Charge Code	1168128
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 Humerus w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73201 RT
Hospital Charge Code	1168130
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Humerus w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73201 RT
Hospital Charge Code	1168130
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 Humerus w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73200 LT
Hospital Charge Code	1168134
Hospital Revenue Code	350
Min. Negotiated Rate	$312.67
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$312.67
Rate for Payer: Wellmark IA PPO	$344.42

CT Humerus w/o Contrast Left

Facility

$1,121.00

Service Code	CPT 73200 LT
Hospital Charge Code	1168134
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 Humerus w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73200 RT
Hospital Charge Code	1168136
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 Humerus w/o Contrast Right

Facility

$1,121.00

Service Code	CPT 73200 RT
Hospital Charge Code	1168136
Hospital Revenue Code	350
Min. Negotiated Rate	$312.67
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$312.67
Rate for Payer: Wellmark IA PPO	$344.42

CT Humerus w/ + w/o Contrast Left

Facility

$1,321.00

Service Code	CPT 73202 LT
Hospital Charge Code	1168122
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Humerus w/ + w/o Contrast Left

Facility

$1,321.00

Service Code	CPT 73202 LT
Hospital Charge Code	1168122
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 Humerus w/ + w/o Contrast Right

Facility

$1,321.00

Service Code	CPT 73202 RT
Hospital Charge Code	1168124
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Humerus w/ + w/o Contrast Right

Facility

$1,321.00

Service Code	CPT 73202 RT
Hospital Charge Code	1168124
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

Know your out-of-pocket cost for care.

All Charges