Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

E9257 Aph Plt ACDA LR Irr 1 BTD6

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758125
Hospital Revenue Code	390
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Aetna of IA Medicare	$502.17
Rate for Payer: Amerigroup Medicaid	$508.16
Rate for Payer: Amerigroup Medicare	$400.41
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$396.45
Rate for Payer: Iowa Total Care Managed Medicaid	$503.23
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Medical Associates Managed Medicare	$396.45
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: Molina Healthcare Managed Medicaid	$510.63
Rate for Payer: Partners Health Alliance Commercial	$455.92
Rate for Payer: United Healthcare Commercial	$792.90
Rate for Payer: United Healthcare Managed Medicare	$519.79
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

E9257 Aph Plt ACDA LR Irr 1 BTD6

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758125
Hospital Revenue Code	390
Min. Negotiated Rate	$616.70
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: United Healthcare Commercial	$792.90

E9258 Aph Plt ACDA LR Irr 2 BTD6

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758113
Hospital Revenue Code	390
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Aetna of IA Medicare	$502.17
Rate for Payer: Amerigroup Medicaid	$508.16
Rate for Payer: Amerigroup Medicare	$400.41
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$396.45
Rate for Payer: Iowa Total Care Managed Medicaid	$503.23
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Medical Associates Managed Medicare	$396.45
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: Molina Healthcare Managed Medicaid	$510.63
Rate for Payer: Partners Health Alliance Commercial	$455.92
Rate for Payer: United Healthcare Commercial	$792.90
Rate for Payer: United Healthcare Managed Medicare	$519.79
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

E9258 Aph Plt ACDA LR Irr 2 BTD6

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758113
Hospital Revenue Code	390
Min. Negotiated Rate	$616.70
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: United Healthcare Commercial	$792.90

E9259 Aph Plt ACDA LR Irr 3 BTD6

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758110
Hospital Revenue Code	390
Min. Negotiated Rate	$616.70
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: United Healthcare Commercial	$792.90

E9259 Aph Plt ACDA LR Irr 3 BTD6

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758110
Hospital Revenue Code	390
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Aetna of IA Medicare	$502.17
Rate for Payer: Amerigroup Medicaid	$508.16
Rate for Payer: Amerigroup Medicare	$400.41
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$396.45
Rate for Payer: Iowa Total Care Managed Medicaid	$503.23
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Medical Associates Managed Medicare	$396.45
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: Molina Healthcare Managed Medicaid	$510.63
Rate for Payer: Partners Health Alliance Commercial	$455.92
Rate for Payer: United Healthcare Commercial	$792.90
Rate for Payer: United Healthcare Managed Medicare	$519.79
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

E9260 Aph Plt ACDA LR Irr BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758105
Hospital Revenue Code	390
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Aetna of IA Medicare	$502.17
Rate for Payer: Amerigroup Medicaid	$508.16
Rate for Payer: Amerigroup Medicare	$400.41
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$396.45
Rate for Payer: Iowa Total Care Managed Medicaid	$503.23
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Medical Associates Managed Medicare	$396.45
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: Molina Healthcare Managed Medicaid	$510.63
Rate for Payer: Partners Health Alliance Commercial	$455.92
Rate for Payer: United Healthcare Commercial	$792.90
Rate for Payer: United Healthcare Managed Medicare	$519.79
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

E9260 Aph Plt ACDA LR Irr BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758105
Hospital Revenue Code	390
Min. Negotiated Rate	$616.70
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: United Healthcare Commercial	$792.90

E9261 Aph Plt ACDA LR Irr 1 BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758118
Hospital Revenue Code	390
Min. Negotiated Rate	$616.70
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: United Healthcare Commercial	$792.90

E9261 Aph Plt ACDA LR Irr 1 BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758118
Hospital Revenue Code	390
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Aetna of IA Medicare	$502.17
Rate for Payer: Amerigroup Medicaid	$508.16
Rate for Payer: Amerigroup Medicare	$400.41
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$396.45
Rate for Payer: Iowa Total Care Managed Medicaid	$503.23
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Medical Associates Managed Medicare	$396.45
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: Molina Healthcare Managed Medicaid	$510.63
Rate for Payer: Partners Health Alliance Commercial	$455.92
Rate for Payer: United Healthcare Commercial	$792.90
Rate for Payer: United Healthcare Managed Medicare	$519.79
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

E9262 Aph Plt ACDA LR Irr 2 BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758123
Hospital Revenue Code	390
Min. Negotiated Rate	$616.70
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: United Healthcare Commercial	$792.90

E9262 Aph Plt ACDA LR Irr 2 BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758123
Hospital Revenue Code	390
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Aetna of IA Medicare	$502.17
Rate for Payer: Amerigroup Medicaid	$508.16
Rate for Payer: Amerigroup Medicare	$400.41
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$396.45
Rate for Payer: Iowa Total Care Managed Medicaid	$503.23
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Medical Associates Managed Medicare	$396.45
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: Molina Healthcare Managed Medicaid	$510.63
Rate for Payer: Partners Health Alliance Commercial	$455.92
Rate for Payer: United Healthcare Commercial	$792.90
Rate for Payer: United Healthcare Managed Medicare	$519.79
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

E9263 Aph Plt ACDA LR Irr 3 BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758117
Hospital Revenue Code	390
Min. Negotiated Rate	$616.70
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: United Healthcare Commercial	$792.90

E9263 Aph Plt ACDA LR Irr 3 BTD7

Facility

$881.00

Service Code	HCPCS P9037
Hospital Charge Code	8758117
Hospital Revenue Code	390
Min. Negotiated Rate	$396.45
Max. Negotiated Rate	$792.90
Rate for Payer: Aetna of IA Commercial	$792.90
Rate for Payer: Aetna of IA Medical Rental Products	$792.90
Rate for Payer: Aetna of IA Medicare	$502.17
Rate for Payer: Amerigroup Medicaid	$508.16
Rate for Payer: Amerigroup Medicare	$400.41
Rate for Payer: Cash Price	$704.80
Rate for Payer: Cash Price	$704.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$660.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$396.45
Rate for Payer: Iowa Total Care Managed Medicaid	$503.23
Rate for Payer: Medical Associates Commercial	$660.75
Rate for Payer: Medical Associates Managed Medicare	$396.45
Rate for Payer: Midlands Choice Commercial	$616.70
Rate for Payer: Molina Healthcare Managed Medicaid	$510.63
Rate for Payer: Partners Health Alliance Commercial	$455.92
Rate for Payer: United Healthcare Commercial	$792.90
Rate for Payer: United Healthcare Managed Medicare	$519.79
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH CC

Facility

$14,653.46

Service Code	MSDRG 147
Min. Negotiated Rate	$14,441.09
Max. Negotiated Rate	$14,653.46
Rate for Payer: Amerigroup Medicaid	$14,582.67
Rate for Payer: Iowa Total Care Managed Medicaid	$14,441.09
Rate for Payer: Molina Healthcare Managed Medicaid	$14,653.46

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITH MCC

Facility

$22,897.87

Service Code	MSDRG 146
Min. Negotiated Rate	$22,566.01
Max. Negotiated Rate	$22,897.87
Rate for Payer: Amerigroup Medicaid	$22,787.24
Rate for Payer: Iowa Total Care Managed Medicaid	$22,566.01
Rate for Payer: Molina Healthcare Managed Medicaid	$22,897.87

EAR, NOSE, MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC

Facility

$8,855.81

Service Code	MSDRG 148
Min. Negotiated Rate	$8,727.46
Max. Negotiated Rate	$8,855.81
Rate for Payer: Amerigroup Medicaid	$8,813.02
Rate for Payer: Iowa Total Care Managed Medicaid	$8,727.46
Rate for Payer: Molina Healthcare Managed Medicaid	$8,855.81

EBV capsid antibody

Facility

$114.00

Service Code	CPT 86665
Hospital Charge Code	8819615
Hospital Revenue Code	301
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

EBV capsid antibody

Facility

$114.00

Service Code	CPT 86665
Hospital Charge Code	8819615
Hospital Revenue Code	301
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$59.00
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

ECG 12 Lead

Facility

$161.00

Service Code	CPT 93005
Hospital Charge Code	7719908
Hospital Revenue Code	730
Min. Negotiated Rate	$72.45
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Aetna of IA Medicare	$91.77
Rate for Payer: Amerigroup Medicaid	$92.86
Rate for Payer: Amerigroup Medicare	$73.17
Rate for Payer: Cash Price	$128.80
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.45
Rate for Payer: Iowa Total Care Managed Medicaid	$91.96
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Medical Associates Managed Medicare	$72.45
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: Molina Healthcare Managed Medicaid	$93.32
Rate for Payer: Partners Health Alliance Commercial	$83.32
Rate for Payer: United Healthcare Commercial	$144.90
Rate for Payer: United Healthcare Managed Medicare	$94.99
Rate for Payer: Wellmark IA HMO WHPI	$75.15
Rate for Payer: Wellmark IA PPO	$82.79

ECG 12 Lead

Facility

$161.00

Service Code	CPT 93005
Hospital Charge Code	7719908
Hospital Revenue Code	730
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: United Healthcare Commercial	$144.90

ECG 12 LEAD

Facility

$161.00

Service Code	CPT 93005
Hospital Charge Code	6892782
Hospital Revenue Code	730
Min. Negotiated Rate	$72.45
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Aetna of IA Medicare	$91.77
Rate for Payer: Amerigroup Medicaid	$92.86
Rate for Payer: Amerigroup Medicare	$73.17
Rate for Payer: Cash Price	$128.80
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.45
Rate for Payer: Iowa Total Care Managed Medicaid	$91.96
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Medical Associates Managed Medicare	$72.45
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: Molina Healthcare Managed Medicaid	$93.32
Rate for Payer: Partners Health Alliance Commercial	$83.32
Rate for Payer: United Healthcare Commercial	$144.90
Rate for Payer: United Healthcare Managed Medicare	$94.99
Rate for Payer: Wellmark IA HMO WHPI	$75.15
Rate for Payer: Wellmark IA PPO	$82.79

ECG 12 LEAD

Facility

$161.00

Service Code	CPT 93005
Hospital Charge Code	6892782
Hospital Revenue Code	730
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: United Healthcare Commercial	$144.90

ECG 12 LEAD - INTERP AND REPORT

Professional

Both

$19.00

Service Code	CPT 93010
Hospital Charge Code	8101314
Hospital Revenue Code	983
Min. Negotiated Rate	$7.74
Max. Negotiated Rate	$18.10
Rate for Payer: Amerigroup Medicaid	$7.82
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cash Price	$15.20
Rate for Payer: Iowa Total Care Managed Medicaid	$7.74
Rate for Payer: Medical Associates Commercial	$14.25
Rate for Payer: Midlands Choice Commercial	$13.30
Rate for Payer: Molina Healthcare Managed Medicaid	$7.78
Rate for Payer: Partners Health Alliance Commercial	$14.25
Rate for Payer: United Healthcare Commercial	$13.20
Rate for Payer: Wellmark IA HMO WHPI	$15.40
Rate for Payer: Wellmark IA PPO	$18.10

ECG Monitor/Record <= 48 hrs Charge

Facility

$375.00

Service Code	CPT 93224
Hospital Charge Code	4850266
Hospital Revenue Code	731
Min. Negotiated Rate	$262.50
Max. Negotiated Rate	$337.50
Rate for Payer: Aetna of IA Commercial	$337.50
Rate for Payer: Aetna of IA Medical Rental Products	$337.50
Rate for Payer: Cash Price	$300.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$281.25
Rate for Payer: Medical Associates Commercial	$281.25
Rate for Payer: Midlands Choice Commercial	$262.50
Rate for Payer: United Healthcare Commercial	$337.50

Know your out-of-pocket cost for care.

All Charges