Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

CT Soft Tissue Neck w/o Contrast

Facility

$1,180.00

Service Code	CPT 70490
Hospital Charge Code	1168234
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 Soft Tissue Neck w/ + w/o Contrast

Facility

$1,656.00

Service Code	CPT 70492
Hospital Charge Code	1168230
Hospital Revenue Code	351
Min. Negotiated Rate	$1,159.20
Max. Negotiated Rate	$1,490.40
Rate for Payer: Aetna of IA Commercial	$1,490.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,490.40
Rate for Payer: Cash Price	$1,324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,242.00
Rate for Payer: Medical Associates Commercial	$1,242.00
Rate for Payer: Midlands Choice Commercial	$1,159.20
Rate for Payer: United Healthcare Commercial	$1,490.40

CT Soft Tissue Neck w/ + w/o Contrast

Facility

$1,656.00

Service Code	CPT 70492
Hospital Charge Code	1168230
Hospital Revenue Code	351
Min. Negotiated Rate	$745.20
Max. Negotiated Rate	$1,490.40
Rate for Payer: Aetna of IA Commercial	$1,490.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,490.40
Rate for Payer: Aetna of IA Medicare	$943.92
Rate for Payer: Amerigroup Medicaid	$955.18
Rate for Payer: Amerigroup Medicare	$752.65
Rate for Payer: Cash Price	$1,324.80
Rate for Payer: Cash Price	$1,324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,242.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$745.20
Rate for Payer: Iowa Total Care Managed Medicaid	$945.91
Rate for Payer: Medical Associates Commercial	$1,242.00
Rate for Payer: Medical Associates Managed Medicare	$745.20
Rate for Payer: Midlands Choice Commercial	$1,159.20
Rate for Payer: Molina Healthcare Managed Medicaid	$959.82
Rate for Payer: Partners Health Alliance Commercial	$856.98
Rate for Payer: United Healthcare Commercial	$1,490.40
Rate for Payer: United Healthcare Managed Medicare	$977.04
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Spine Cervical w/ Contrast

Facility

$1,557.00

Service Code	CPT 72126
Hospital Charge Code	1168238
Hospital Revenue Code	352
Min. Negotiated Rate	$700.65
Max. Negotiated Rate	$1,401.30
Rate for Payer: Aetna of IA Commercial	$1,401.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,401.30
Rate for Payer: Aetna of IA Medicare	$887.49
Rate for Payer: Amerigroup Medicaid	$898.08
Rate for Payer: Amerigroup Medicare	$707.66
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,167.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$700.65
Rate for Payer: Iowa Total Care Managed Medicaid	$889.36
Rate for Payer: Medical Associates Commercial	$1,167.75
Rate for Payer: Medical Associates Managed Medicare	$700.65
Rate for Payer: Midlands Choice Commercial	$1,089.90
Rate for Payer: Molina Healthcare Managed Medicaid	$902.44
Rate for Payer: Partners Health Alliance Commercial	$805.75
Rate for Payer: United Healthcare Commercial	$1,401.30
Rate for Payer: United Healthcare Managed Medicare	$918.63
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Spine Cervical w/ Contrast

Facility

$1,557.00

Service Code	CPT 72126
Hospital Charge Code	1168238
Hospital Revenue Code	352
Min. Negotiated Rate	$1,089.90
Max. Negotiated Rate	$1,401.30
Rate for Payer: Aetna of IA Commercial	$1,401.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,401.30
Rate for Payer: Cash Price	$1,245.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,167.75
Rate for Payer: Medical Associates Commercial	$1,167.75
Rate for Payer: Midlands Choice Commercial	$1,089.90
Rate for Payer: United Healthcare Commercial	$1,401.30

CT Spine Cervical w/o Contrast

Facility

$1,438.00

Service Code	CPT 72125
Hospital Charge Code	1168240
Hospital Revenue Code	352
Min. Negotiated Rate	$312.67
Max. Negotiated Rate	$1,294.20
Rate for Payer: Aetna of IA Commercial	$1,294.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,294.20
Rate for Payer: Aetna of IA Medicare	$819.66
Rate for Payer: Amerigroup Medicaid	$829.44
Rate for Payer: Amerigroup Medicare	$653.57
Rate for Payer: Cash Price	$1,150.40
Rate for Payer: Cash Price	$1,150.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,078.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$647.10
Rate for Payer: Iowa Total Care Managed Medicaid	$821.39
Rate for Payer: Medical Associates Commercial	$1,078.50
Rate for Payer: Medical Associates Managed Medicare	$647.10
Rate for Payer: Midlands Choice Commercial	$1,006.60
Rate for Payer: Molina Healthcare Managed Medicaid	$833.46
Rate for Payer: Partners Health Alliance Commercial	$744.16
Rate for Payer: United Healthcare Commercial	$1,294.20
Rate for Payer: United Healthcare Managed Medicare	$848.42
Rate for Payer: Wellmark IA HMO WHPI	$312.67
Rate for Payer: Wellmark IA PPO	$344.42

CT Spine Cervical w/o Contrast

Facility

$1,438.00

Service Code	CPT 72125
Hospital Charge Code	1168240
Hospital Revenue Code	352
Min. Negotiated Rate	$1,006.60
Max. Negotiated Rate	$1,294.20
Rate for Payer: Aetna of IA Commercial	$1,294.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,294.20
Rate for Payer: Cash Price	$1,150.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,078.50
Rate for Payer: Medical Associates Commercial	$1,078.50
Rate for Payer: Midlands Choice Commercial	$1,006.60
Rate for Payer: United Healthcare Commercial	$1,294.20

CT Spine Cervical w/ + w/o Contrast

Facility

$1,809.00

Service Code	CPT 72127
Hospital Charge Code	1168236
Hospital Revenue Code	352
Min. Negotiated Rate	$814.05
Max. Negotiated Rate	$1,628.10
Rate for Payer: Aetna of IA Commercial	$1,628.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,628.10
Rate for Payer: Aetna of IA Medicare	$1,031.13
Rate for Payer: Amerigroup Medicaid	$1,043.43
Rate for Payer: Amerigroup Medicare	$822.19
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,356.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$814.05
Rate for Payer: Iowa Total Care Managed Medicaid	$1,033.30
Rate for Payer: Medical Associates Commercial	$1,356.75
Rate for Payer: Medical Associates Managed Medicare	$814.05
Rate for Payer: Midlands Choice Commercial	$1,266.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1,048.50
Rate for Payer: Partners Health Alliance Commercial	$936.16
Rate for Payer: United Healthcare Commercial	$1,628.10
Rate for Payer: United Healthcare Managed Medicare	$1,067.31
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Spine Cervical w/ + w/o Contrast

Facility

$1,809.00

Service Code	CPT 72127
Hospital Charge Code	1168236
Hospital Revenue Code	352
Min. Negotiated Rate	$1,266.30
Max. Negotiated Rate	$1,628.10
Rate for Payer: Aetna of IA Commercial	$1,628.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,628.10
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,356.75
Rate for Payer: Medical Associates Commercial	$1,356.75
Rate for Payer: Midlands Choice Commercial	$1,266.30
Rate for Payer: United Healthcare Commercial	$1,628.10

CT Spine Lumbar w/ Contrast

Facility

$1,708.00

Service Code	CPT 72132
Hospital Charge Code	1168244
Hospital Revenue Code	352
Min. Negotiated Rate	$768.60
Max. Negotiated Rate	$1,537.20
Rate for Payer: Aetna of IA Commercial	$1,537.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,537.20
Rate for Payer: Aetna of IA Medicare	$973.56
Rate for Payer: Amerigroup Medicaid	$985.17
Rate for Payer: Amerigroup Medicare	$776.29
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,281.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$768.60
Rate for Payer: Iowa Total Care Managed Medicaid	$975.61
Rate for Payer: Medical Associates Commercial	$1,281.00
Rate for Payer: Medical Associates Managed Medicare	$768.60
Rate for Payer: Midlands Choice Commercial	$1,195.60
Rate for Payer: Molina Healthcare Managed Medicaid	$989.96
Rate for Payer: Partners Health Alliance Commercial	$883.89
Rate for Payer: United Healthcare Commercial	$1,537.20
Rate for Payer: United Healthcare Managed Medicare	$1,007.72
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Spine Lumbar w/ Contrast

Facility

$1,708.00

Service Code	CPT 72132
Hospital Charge Code	1168244
Hospital Revenue Code	352
Min. Negotiated Rate	$1,195.60
Max. Negotiated Rate	$1,537.20
Rate for Payer: Aetna of IA Commercial	$1,537.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,537.20
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,281.00
Rate for Payer: Medical Associates Commercial	$1,281.00
Rate for Payer: Midlands Choice Commercial	$1,195.60
Rate for Payer: United Healthcare Commercial	$1,537.20

CT Spine Lumbar w/o Contrast

Facility

$1,440.00

Service Code	CPT 72131
Hospital Charge Code	1168246
Hospital Revenue Code	352
Min. Negotiated Rate	$1,008.00
Max. Negotiated Rate	$1,296.00
Rate for Payer: Aetna of IA Commercial	$1,296.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,296.00
Rate for Payer: Cash Price	$1,152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,080.00
Rate for Payer: Medical Associates Commercial	$1,080.00
Rate for Payer: Midlands Choice Commercial	$1,008.00
Rate for Payer: United Healthcare Commercial	$1,296.00

CT Spine Lumbar w/o Contrast

Facility

$1,440.00

Service Code	CPT 72131
Hospital Charge Code	1168246
Hospital Revenue Code	352
Min. Negotiated Rate	$312.67
Max. Negotiated Rate	$1,296.00
Rate for Payer: Aetna of IA Commercial	$1,296.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,296.00
Rate for Payer: Aetna of IA Medicare	$820.80
Rate for Payer: Amerigroup Medicaid	$830.59
Rate for Payer: Amerigroup Medicare	$654.48
Rate for Payer: Cash Price	$1,152.00
Rate for Payer: Cash Price	$1,152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,080.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$648.00
Rate for Payer: Iowa Total Care Managed Medicaid	$822.53
Rate for Payer: Medical Associates Commercial	$1,080.00
Rate for Payer: Medical Associates Managed Medicare	$648.00
Rate for Payer: Midlands Choice Commercial	$1,008.00
Rate for Payer: Molina Healthcare Managed Medicaid	$834.62
Rate for Payer: Partners Health Alliance Commercial	$745.20
Rate for Payer: United Healthcare Commercial	$1,296.00
Rate for Payer: United Healthcare Managed Medicare	$849.60
Rate for Payer: Wellmark IA HMO WHPI	$312.67
Rate for Payer: Wellmark IA PPO	$344.42

CT Spine Lumbar w/ + w/o Contrast

Facility

$1,809.00

Service Code	CPT 72133
Hospital Charge Code	1168242
Hospital Revenue Code	352
Min. Negotiated Rate	$814.05
Max. Negotiated Rate	$1,628.10
Rate for Payer: Aetna of IA Commercial	$1,628.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,628.10
Rate for Payer: Aetna of IA Medicare	$1,031.13
Rate for Payer: Amerigroup Medicaid	$1,043.43
Rate for Payer: Amerigroup Medicare	$822.19
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,356.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$814.05
Rate for Payer: Iowa Total Care Managed Medicaid	$1,033.30
Rate for Payer: Medical Associates Commercial	$1,356.75
Rate for Payer: Medical Associates Managed Medicare	$814.05
Rate for Payer: Midlands Choice Commercial	$1,266.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1,048.50
Rate for Payer: Partners Health Alliance Commercial	$936.16
Rate for Payer: United Healthcare Commercial	$1,628.10
Rate for Payer: United Healthcare Managed Medicare	$1,067.31
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Spine Lumbar w/ + w/o Contrast

Facility

$1,809.00

Service Code	CPT 72133
Hospital Charge Code	1168242
Hospital Revenue Code	352
Min. Negotiated Rate	$1,266.30
Max. Negotiated Rate	$1,628.10
Rate for Payer: Aetna of IA Commercial	$1,628.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,628.10
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,356.75
Rate for Payer: Medical Associates Commercial	$1,356.75
Rate for Payer: Midlands Choice Commercial	$1,266.30
Rate for Payer: United Healthcare Commercial	$1,628.10

CT Spine Thoracic w/ Contrast

Facility

$1,708.00

Service Code	CPT 72129
Hospital Charge Code	1168250
Hospital Revenue Code	352
Min. Negotiated Rate	$768.60
Max. Negotiated Rate	$1,537.20
Rate for Payer: Aetna of IA Commercial	$1,537.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,537.20
Rate for Payer: Aetna of IA Medicare	$973.56
Rate for Payer: Amerigroup Medicaid	$985.17
Rate for Payer: Amerigroup Medicare	$776.29
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,281.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$768.60
Rate for Payer: Iowa Total Care Managed Medicaid	$975.61
Rate for Payer: Medical Associates Commercial	$1,281.00
Rate for Payer: Medical Associates Managed Medicare	$768.60
Rate for Payer: Midlands Choice Commercial	$1,195.60
Rate for Payer: Molina Healthcare Managed Medicaid	$989.96
Rate for Payer: Partners Health Alliance Commercial	$883.89
Rate for Payer: United Healthcare Commercial	$1,537.20
Rate for Payer: United Healthcare Managed Medicare	$1,007.72
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Spine Thoracic w/ Contrast

Facility

$1,708.00

Service Code	CPT 72129
Hospital Charge Code	1168250
Hospital Revenue Code	352
Min. Negotiated Rate	$1,195.60
Max. Negotiated Rate	$1,537.20
Rate for Payer: Aetna of IA Commercial	$1,537.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,537.20
Rate for Payer: Cash Price	$1,366.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,281.00
Rate for Payer: Medical Associates Commercial	$1,281.00
Rate for Payer: Midlands Choice Commercial	$1,195.60
Rate for Payer: United Healthcare Commercial	$1,537.20

CT Spine Thoracic w/o Contrast

Facility

$1,426.00

Service Code	CPT 72128
Hospital Charge Code	1168252
Hospital Revenue Code	352
Min. Negotiated Rate	$312.67
Max. Negotiated Rate	$1,283.40
Rate for Payer: Aetna of IA Commercial	$1,283.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,283.40
Rate for Payer: Aetna of IA Medicare	$812.82
Rate for Payer: Amerigroup Medicaid	$822.52
Rate for Payer: Amerigroup Medicare	$648.12
Rate for Payer: Cash Price	$1,140.80
Rate for Payer: Cash Price	$1,140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,069.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$641.70
Rate for Payer: Iowa Total Care Managed Medicaid	$814.53
Rate for Payer: Medical Associates Commercial	$1,069.50
Rate for Payer: Medical Associates Managed Medicare	$641.70
Rate for Payer: Midlands Choice Commercial	$998.20
Rate for Payer: Molina Healthcare Managed Medicaid	$826.51
Rate for Payer: Partners Health Alliance Commercial	$737.96
Rate for Payer: United Healthcare Commercial	$1,283.40
Rate for Payer: United Healthcare Managed Medicare	$841.34
Rate for Payer: Wellmark IA HMO WHPI	$312.67
Rate for Payer: Wellmark IA PPO	$344.42

CT Spine Thoracic w/o Contrast

Facility

$1,426.00

Service Code	CPT 72128
Hospital Charge Code	1168252
Hospital Revenue Code	352
Min. Negotiated Rate	$998.20
Max. Negotiated Rate	$1,283.40
Rate for Payer: Aetna of IA Commercial	$1,283.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,283.40
Rate for Payer: Cash Price	$1,140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,069.50
Rate for Payer: Medical Associates Commercial	$1,069.50
Rate for Payer: Midlands Choice Commercial	$998.20
Rate for Payer: United Healthcare Commercial	$1,283.40

CT Spine Thoracic w/ + w/o Contrast

Facility

$1,809.00

Service Code	CPT 72130
Hospital Charge Code	1168248
Hospital Revenue Code	352
Min. Negotiated Rate	$814.05
Max. Negotiated Rate	$1,628.10
Rate for Payer: Aetna of IA Commercial	$1,628.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,628.10
Rate for Payer: Aetna of IA Medicare	$1,031.13
Rate for Payer: Amerigroup Medicaid	$1,043.43
Rate for Payer: Amerigroup Medicare	$822.19
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,356.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$814.05
Rate for Payer: Iowa Total Care Managed Medicaid	$1,033.30
Rate for Payer: Medical Associates Commercial	$1,356.75
Rate for Payer: Medical Associates Managed Medicare	$814.05
Rate for Payer: Midlands Choice Commercial	$1,266.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1,048.50
Rate for Payer: Partners Health Alliance Commercial	$936.16
Rate for Payer: United Healthcare Commercial	$1,628.10
Rate for Payer: United Healthcare Managed Medicare	$1,067.31
Rate for Payer: Wellmark IA HMO WHPI	$832.37
Rate for Payer: Wellmark IA PPO	$916.89

CT Spine Thoracic w/ + w/o Contrast

Facility

$1,809.00

Service Code	CPT 72130
Hospital Charge Code	1168248
Hospital Revenue Code	352
Min. Negotiated Rate	$1,266.30
Max. Negotiated Rate	$1,628.10
Rate for Payer: Aetna of IA Commercial	$1,628.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,628.10
Rate for Payer: Cash Price	$1,447.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,356.75
Rate for Payer: Medical Associates Commercial	$1,356.75
Rate for Payer: Midlands Choice Commercial	$1,266.30
Rate for Payer: United Healthcare Commercial	$1,628.10

CT Tibia/Fibula w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73701 LT
Hospital Charge Code	1168297
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 Tibia/Fibula w/ Contrast Left

Facility

$1,436.00

Service Code	CPT 73701 LT
Hospital Charge Code	1168297
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 Tibia/Fibula w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73701 RT
Hospital Charge Code	1168299
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 Tibia/Fibula w/ Contrast Right

Facility

$1,436.00

Service Code	CPT 73701 RT
Hospital Charge Code	1168299
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

Know your out-of-pocket cost for care.

All Charges