Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

E4526 Aph RBC ACDA AS1 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8053739
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4526 Aph RBC ACDA AS1 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8053739
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4527 Aph RBC ACDA AS1 LR Irr 1

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8053741
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4527 Aph RBC ACDA AS1 LR Irr 1

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8053741
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4528 Aph RBC ACDA AS1 LR Irr 2

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8053742
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4528 Aph RBC ACDA AS1 LR Irr 2

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8053742
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4531 Aph RBC ACDA AS1 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8053736
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4531 Aph RBC ACDA AS1 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8053736
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4532 Aph RBC ACDA AS1 LR 1

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8053738
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4532 Aph RBC ACDA AS1 LR 1

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8053738
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4533 Aph RBC ACDA AS1 LR 2

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8053740
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4533 Aph RBC ACDA AS1 LR 2

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8053740
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4538 Aph RBC Trima AS3 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8018879
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4538 Aph RBC Trima AS3 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8018879
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4539 Aph RBC Trima AS3 LR Irr 1

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8018885
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4539 Aph RBC Trima AS3 LR Irr 1

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8018885
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4540 Aph RBC Trima AS3 LR Irr 2

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8018883
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4540 Aph RBC Trima AS3 LR Irr 2

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	8018883
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4543 Aph RBC Trima AS3 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8018887
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4543 Aph RBC Trima AS3 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8018887
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4544 Aph RBC Trima AS3 LR 1

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8018888
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4544 Aph RBC Trima AS3 LR 1

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8018888
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4545 Aph RBC Trima AS3 LR 2

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8018891
Hospital Revenue Code	390
Min. Negotiated Rate	$372.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: United Healthcare Commercial	$478.80

E4545 Aph RBC Trima AS3 LR 2

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	8018891
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$478.80
Rate for Payer: Aetna of IA Commercial	$478.80
Rate for Payer: Aetna of IA Medical Rental Products	$478.80
Rate for Payer: Aetna of IA Medicare	$303.24
Rate for Payer: Amerigroup Medicaid	$306.86
Rate for Payer: Amerigroup Medicare	$241.79
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$399.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$239.40
Rate for Payer: Iowa Total Care Managed Medicaid	$303.88
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Medical Associates Managed Medicare	$239.40
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$308.35
Rate for Payer: Partners Health Alliance Commercial	$275.31
Rate for Payer: United Healthcare Commercial	$478.80
Rate for Payer: United Healthcare Managed Medicare	$313.88

E4713 Thawed Aph FFP ACDA 1

Facility

$196.00

Service Code	HCPCS P9017
Hospital Charge Code	6702792
Hospital Revenue Code	390
Min. Negotiated Rate	$137.20
Max. Negotiated Rate	$176.40
Rate for Payer: Aetna of IA Commercial	$176.40
Rate for Payer: Aetna of IA Medical Rental Products	$176.40
Rate for Payer: Cash Price	$156.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$147.00
Rate for Payer: Medical Associates Commercial	$147.00
Rate for Payer: Midlands Choice Commercial	$137.20
Rate for Payer: United Healthcare Commercial	$176.40

Know your out-of-pocket cost for care.

All Charges