Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

dutasteride 0.5 mg Cap [VDMC]

Facility

$1.64

Service Code	HCPCS A9270
Hospital Charge Code	10385354
Hospital Revenue Code	259
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of IA Commercial	$1.48
Rate for Payer: Aetna of IA Medical Rental Products	$1.48
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.23
Rate for Payer: Medical Associates Commercial	$1.23
Rate for Payer: Midlands Choice Commercial	$1.15
Rate for Payer: United Healthcare Commercial	$1.48

dutasteride 0.5 mg Cap [VDMC]

Facility

$1.64

Service Code	HCPCS A9270
Hospital Charge Code	10385354
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of IA Commercial	$1.48
Rate for Payer: Aetna of IA Medical Rental Products	$1.48
Rate for Payer: Aetna of IA Medicare	$0.94
Rate for Payer: Amerigroup Medicaid	$0.95
Rate for Payer: Amerigroup Medicare	$0.75
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.74
Rate for Payer: Iowa Total Care Managed Medicaid	$0.94
Rate for Payer: Medical Associates Commercial	$1.23
Rate for Payer: Medical Associates Managed Medicare	$0.74
Rate for Payer: Midlands Choice Commercial	$1.15
Rate for Payer: Molina Healthcare Managed Medicaid	$0.95
Rate for Payer: Partners Health Alliance Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.48
Rate for Payer: United Healthcare Managed Medicare	$0.97

DU TUBE

Facility

$52.00

Service Code	CPT 86905
Hospital Charge Code	7912828
Hospital Revenue Code	302
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$55.45
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Aetna of IA Medicare	$29.64
Rate for Payer: Amerigroup Medicaid	$29.99
Rate for Payer: Amerigroup Medicare	$23.63
Rate for Payer: Cash Price	$41.60
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.40
Rate for Payer: Iowa Total Care Managed Medicaid	$29.70
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Medical Associates Managed Medicare	$23.40
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: Molina Healthcare Managed Medicaid	$30.14
Rate for Payer: Partners Health Alliance Commercial	$26.91
Rate for Payer: United Healthcare Commercial	$46.80
Rate for Payer: United Healthcare Managed Medicare	$30.68
Rate for Payer: Wellmark IA HMO WHPI	$50.34
Rate for Payer: Wellmark IA PPO	$55.45

DU TUBE

Facility

$52.00

Service Code	CPT 86905
Hospital Charge Code	7912828
Hospital Revenue Code	302
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: United Healthcare Commercial	$46.80

DXA BONE DENSITY AXIAL 1+ SITES

Facility

$355.00

Service Code	CPT 77080
Hospital Charge Code	8401513
Hospital Revenue Code	320
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of IA Commercial	$319.50
Rate for Payer: Aetna of IA Medical Rental Products	$319.50
Rate for Payer: Cash Price	$284.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$266.25
Rate for Payer: Medical Associates Commercial	$266.25
Rate for Payer: Midlands Choice Commercial	$248.50
Rate for Payer: United Healthcare Commercial	$319.50

DXA BONE DENSITY AXIAL 1+ SITES

Facility

$355.00

Service Code	CPT 77080
Hospital Charge Code	8401513
Hospital Revenue Code	320
Min. Negotiated Rate	$159.75
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of IA Commercial	$319.50
Rate for Payer: Aetna of IA Medical Rental Products	$319.50
Rate for Payer: Aetna of IA Medicare	$202.35
Rate for Payer: Amerigroup Medicaid	$204.76
Rate for Payer: Amerigroup Medicare	$161.35
Rate for Payer: Cash Price	$284.00
Rate for Payer: Cash Price	$284.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$266.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$159.75
Rate for Payer: Iowa Total Care Managed Medicaid	$202.78
Rate for Payer: Medical Associates Commercial	$266.25
Rate for Payer: Medical Associates Managed Medicare	$159.75
Rate for Payer: Midlands Choice Commercial	$248.50
Rate for Payer: Molina Healthcare Managed Medicaid	$205.76
Rate for Payer: Partners Health Alliance Commercial	$183.71
Rate for Payer: United Healthcare Commercial	$319.50
Rate for Payer: United Healthcare Managed Medicare	$209.45
Rate for Payer: Wellmark IA HMO WHPI	$221.21
Rate for Payer: Wellmark IA PPO	$243.67

DXA BONE DENSITY/PERIPHERAL 1+ SITES

Facility

$355.00

Service Code	CPT 77081
Hospital Charge Code	8401514
Hospital Revenue Code	320
Min. Negotiated Rate	$159.75
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of IA Commercial	$319.50
Rate for Payer: Aetna of IA Medical Rental Products	$319.50
Rate for Payer: Aetna of IA Medicare	$202.35
Rate for Payer: Amerigroup Medicaid	$204.76
Rate for Payer: Amerigroup Medicare	$161.35
Rate for Payer: Cash Price	$284.00
Rate for Payer: Cash Price	$284.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$266.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$159.75
Rate for Payer: Iowa Total Care Managed Medicaid	$202.78
Rate for Payer: Medical Associates Commercial	$266.25
Rate for Payer: Medical Associates Managed Medicare	$159.75
Rate for Payer: Midlands Choice Commercial	$248.50
Rate for Payer: Molina Healthcare Managed Medicaid	$205.76
Rate for Payer: Partners Health Alliance Commercial	$183.71
Rate for Payer: United Healthcare Commercial	$319.50
Rate for Payer: United Healthcare Managed Medicare	$209.45
Rate for Payer: Wellmark IA HMO WHPI	$221.21
Rate for Payer: Wellmark IA PPO	$243.67

DXA BONE DENSITY/PERIPHERAL 1+ SITES

Facility

$355.00

Service Code	CPT 77081
Hospital Charge Code	8401514
Hospital Revenue Code	320
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of IA Commercial	$319.50
Rate for Payer: Aetna of IA Medical Rental Products	$319.50
Rate for Payer: Cash Price	$284.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$266.25
Rate for Payer: Medical Associates Commercial	$266.25
Rate for Payer: Midlands Choice Commercial	$248.50
Rate for Payer: United Healthcare Commercial	$319.50

DX FIBERTAK SUTURE ANCHOR, ST NDLS

Facility

$837.00

Service Code	HCPCS C1713
Hospital Charge Code	8783236
Hospital Revenue Code	278
Min. Negotiated Rate	$585.90
Max. Negotiated Rate	$753.30
Rate for Payer: Aetna of IA Commercial	$753.30
Rate for Payer: Aetna of IA Medical Rental Products	$753.30
Rate for Payer: Cash Price	$669.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$627.75
Rate for Payer: Medical Associates Commercial	$627.75
Rate for Payer: Midlands Choice Commercial	$585.90
Rate for Payer: United Healthcare Commercial	$753.30

DX FIBERTAK SUTURE ANCHOR, ST NDLS

Facility

$837.00

Service Code	HCPCS C1713
Hospital Charge Code	8783236
Hospital Revenue Code	278
Min. Negotiated Rate	$376.65
Max. Negotiated Rate	$753.30
Rate for Payer: Aetna of IA Commercial	$753.30
Rate for Payer: Aetna of IA Medical Rental Products	$753.30
Rate for Payer: Aetna of IA Medicare	$477.09
Rate for Payer: Amerigroup Medicaid	$482.78
Rate for Payer: Amerigroup Medicare	$380.42
Rate for Payer: Cash Price	$669.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$627.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$376.65
Rate for Payer: Iowa Total Care Managed Medicaid	$478.09
Rate for Payer: Medical Associates Commercial	$627.75
Rate for Payer: Medical Associates Managed Medicare	$376.65
Rate for Payer: Midlands Choice Commercial	$585.90
Rate for Payer: Molina Healthcare Managed Medicaid	$485.13
Rate for Payer: Partners Health Alliance Commercial	$433.15
Rate for Payer: United Healthcare Commercial	$753.30
Rate for Payer: United Healthcare Managed Medicare	$493.83

DYSEQUILIBRIUM

Facility

$6,975.43

Service Code	MSDRG 149
Min. Negotiated Rate	$6,874.33
Max. Negotiated Rate	$6,975.43
Rate for Payer: Amerigroup Medicaid	$6,941.73
Rate for Payer: Iowa Total Care Managed Medicaid	$6,874.33
Rate for Payer: Molina Healthcare Managed Medicaid	$6,975.43

E0332 RBC CPD AS1 500 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702794
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$505.31
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

E0332 RBC CPD AS1 500 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702794
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

E0336 RBC CPD AS1 500 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	6702786
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$505.31
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

E0336 RBC CPD AS1 500 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	6702786
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

E0379 RBC CP2D AS3 500 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702804
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$505.31
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

E0379 RBC CP2D AS3 500 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702804
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

E0382 RBC CP2D AS3 500 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	6702782
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$505.31
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

E0382 RBC CP2D AS3 500 LR

Facility

$532.00

Service Code	HCPCS P9016
Hospital Charge Code	6702782
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

E0661 Aph RBC CP2D AS3 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702817
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$505.31
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

E0661 Aph RBC CP2D AS3 LR Irr

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702817
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

E0668 Aph RBC CP2D AS3 LR Irr 1

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702814
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

E0668 Aph RBC CP2D AS3 LR Irr 1

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702814
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$505.31
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

E0669 Aph RBC CP2D AS3 LR Irr 2

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702785
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

E0669 Aph RBC CP2D AS3 LR Irr 2

Facility

$532.00

Service Code	HCPCS P9040
Hospital Charge Code	6702785
Hospital Revenue Code	390
Min. Negotiated Rate	$239.40
Max. Negotiated Rate	$505.31
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

Know your out-of-pocket cost for care.

All Charges