Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

famotidine 20 mg Tab [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	10388019
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Aetna of IA Medicare	$0.80
Rate for Payer: Amerigroup Medicaid	$0.81
Rate for Payer: Amerigroup Medicare	$0.64
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.63
Rate for Payer: Iowa Total Care Managed Medicaid	$0.80
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Medical Associates Managed Medicare	$0.63
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: Molina Healthcare Managed Medicaid	$0.81
Rate for Payer: Partners Health Alliance Commercial	$0.73
Rate for Payer: United Healthcare Commercial	$1.26
Rate for Payer: United Healthcare Managed Medicare	$0.83

famotidine 20 mg Tab [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	10388019
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.26

Fat Emul, 20% IV 250 mL [VDMC]

Facility

$102.11

Service Code	NDC 65219-0533-25
Hospital Charge Code	10434518
Hospital Revenue Code	259
Min. Negotiated Rate	$71.48
Max. Negotiated Rate	$91.90
Rate for Payer: Aetna of IA Commercial	$91.90
Rate for Payer: Aetna of IA Medical Rental Products	$91.90
Rate for Payer: Cash Price	$81.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$76.58
Rate for Payer: Medical Associates Commercial	$76.58
Rate for Payer: Midlands Choice Commercial	$71.48
Rate for Payer: United Healthcare Commercial	$91.90

Fat Emul, 20% IV 250 mL [VDMC]

Facility

$102.11

Service Code	NDC 65219-0533-25
Hospital Charge Code	10434518
Hospital Revenue Code	259
Min. Negotiated Rate	$45.95
Max. Negotiated Rate	$91.90
Rate for Payer: Aetna of IA Commercial	$91.90
Rate for Payer: Aetna of IA Medical Rental Products	$91.90
Rate for Payer: Aetna of IA Medicare	$58.20
Rate for Payer: Amerigroup Medicaid	$58.90
Rate for Payer: Amerigroup Medicare	$46.41
Rate for Payer: Cash Price	$81.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$76.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.95
Rate for Payer: Iowa Total Care Managed Medicaid	$58.33
Rate for Payer: Medical Associates Commercial	$76.58
Rate for Payer: Medical Associates Managed Medicare	$45.95
Rate for Payer: Midlands Choice Commercial	$71.48
Rate for Payer: Molina Healthcare Managed Medicaid	$59.18
Rate for Payer: Partners Health Alliance Commercial	$52.84
Rate for Payer: United Healthcare Commercial	$91.90
Rate for Payer: United Healthcare Managed Medicare	$60.24

febuxostat 40 mg Tab [VDMC]

Facility

$2.68

Service Code	HCPCS A9270
Hospital Charge Code	10388088
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$2.41
Rate for Payer: Aetna of IA Commercial	$2.41
Rate for Payer: Aetna of IA Medical Rental Products	$2.41
Rate for Payer: Aetna of IA Medicare	$1.53
Rate for Payer: Amerigroup Medicaid	$1.54
Rate for Payer: Amerigroup Medicare	$1.22
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.01
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.20
Rate for Payer: Iowa Total Care Managed Medicaid	$1.53
Rate for Payer: Medical Associates Commercial	$2.01
Rate for Payer: Medical Associates Managed Medicare	$1.20
Rate for Payer: Midlands Choice Commercial	$1.87
Rate for Payer: Molina Healthcare Managed Medicaid	$1.55
Rate for Payer: Partners Health Alliance Commercial	$1.39
Rate for Payer: United Healthcare Commercial	$2.41
Rate for Payer: United Healthcare Managed Medicare	$1.58

febuxostat 40 mg Tab [VDMC]

Facility

$2.68

Service Code	HCPCS A9270
Hospital Charge Code	10388088
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$2.41
Rate for Payer: Aetna of IA Commercial	$2.41
Rate for Payer: Aetna of IA Medical Rental Products	$2.41
Rate for Payer: Cash Price	$2.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.01
Rate for Payer: Medical Associates Commercial	$2.01
Rate for Payer: Midlands Choice Commercial	$1.87
Rate for Payer: United Healthcare Commercial	$2.41

felodipine 5 mg ER Tab [VDMC]

Facility

$1.43

Service Code	HCPCS A9270
Hospital Charge Code	10388157
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Aetna of IA Medicare	$0.82
Rate for Payer: Amerigroup Medicaid	$0.83
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.82
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Managed Medicare	$0.85

felodipine 5 mg ER Tab [VDMC]

Facility

$1.43

Service Code	HCPCS A9270
Hospital Charge Code	10388157
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: United Healthcare Commercial	$1.29

FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES

Facility

$11,930.85

Service Code	MSDRG 748
Min. Negotiated Rate	$11,757.94
Max. Negotiated Rate	$11,930.85
Rate for Payer: Amerigroup Medicaid	$11,873.21
Rate for Payer: Iowa Total Care Managed Medicaid	$11,757.94
Rate for Payer: Molina Healthcare Managed Medicaid	$11,930.85

FEMORAL DISTAL FIXATION PEG

Facility

$1,013.00

Service Code	HCPCS C1713
Hospital Charge Code	8046884
Hospital Revenue Code	278
Min. Negotiated Rate	$709.10
Max. Negotiated Rate	$911.70
Rate for Payer: Aetna of IA Commercial	$911.70
Rate for Payer: Aetna of IA Medical Rental Products	$911.70
Rate for Payer: Cash Price	$810.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$759.75
Rate for Payer: Medical Associates Commercial	$759.75
Rate for Payer: Midlands Choice Commercial	$709.10
Rate for Payer: United Healthcare Commercial	$911.70

FEMORAL DISTAL FIXATION PEG

Facility

$1,013.00

Service Code	HCPCS C1713
Hospital Charge Code	8046884
Hospital Revenue Code	278
Min. Negotiated Rate	$455.85
Max. Negotiated Rate	$911.70
Rate for Payer: Aetna of IA Commercial	$911.70
Rate for Payer: Aetna of IA Medical Rental Products	$911.70
Rate for Payer: Aetna of IA Medicare	$577.41
Rate for Payer: Amerigroup Medicaid	$584.30
Rate for Payer: Amerigroup Medicare	$460.41
Rate for Payer: Cash Price	$810.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$759.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$455.85
Rate for Payer: Iowa Total Care Managed Medicaid	$578.63
Rate for Payer: Medical Associates Commercial	$759.75
Rate for Payer: Medical Associates Managed Medicare	$455.85
Rate for Payer: Midlands Choice Commercial	$709.10
Rate for Payer: Molina Healthcare Managed Medicaid	$587.13
Rate for Payer: Partners Health Alliance Commercial	$524.23
Rate for Payer: United Healthcare Commercial	$911.70
Rate for Payer: United Healthcare Managed Medicare	$597.67

FEMORAL HEAD 28

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026262
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: United Healthcare Commercial	$1,656.00

FEMORAL HEAD 28

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026262
Hospital Revenue Code	278
Min. Negotiated Rate	$828.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Aetna of IA Medicare	$1,048.80
Rate for Payer: Amerigroup Medicaid	$1,061.31
Rate for Payer: Amerigroup Medicare	$836.28
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$828.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,051.01
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Medical Associates Managed Medicare	$828.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,066.46
Rate for Payer: Partners Health Alliance Commercial	$952.20
Rate for Payer: United Healthcare Commercial	$1,656.00
Rate for Payer: United Healthcare Managed Medicare	$1,085.60

FEMORAL HEAD C-TAPER 36MM +5MM C-TPR

Facility

$4,573.00

Service Code	HCPCS C1776
Hospital Charge Code	8025964
Hospital Revenue Code	278
Min. Negotiated Rate	$2,057.85
Max. Negotiated Rate	$4,115.70
Rate for Payer: Aetna of IA Commercial	$4,115.70
Rate for Payer: Aetna of IA Medical Rental Products	$4,115.70
Rate for Payer: Aetna of IA Medicare	$2,606.61
Rate for Payer: Amerigroup Medicaid	$2,637.71
Rate for Payer: Amerigroup Medicare	$2,078.43
Rate for Payer: Cash Price	$3,658.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,429.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,057.85
Rate for Payer: Iowa Total Care Managed Medicaid	$2,612.10
Rate for Payer: Medical Associates Commercial	$3,429.75
Rate for Payer: Medical Associates Managed Medicare	$2,057.85
Rate for Payer: Midlands Choice Commercial	$3,201.10
Rate for Payer: Molina Healthcare Managed Medicaid	$2,650.51
Rate for Payer: Partners Health Alliance Commercial	$2,366.53
Rate for Payer: United Healthcare Commercial	$4,115.70
Rate for Payer: United Healthcare Managed Medicare	$2,698.07

FEMORAL HEAD C-TAPER 36MM +5MM C-TPR

Facility

$4,573.00

Service Code	HCPCS C1776
Hospital Charge Code	8025964
Hospital Revenue Code	278
Min. Negotiated Rate	$3,201.10
Max. Negotiated Rate	$4,115.70
Rate for Payer: Aetna of IA Commercial	$4,115.70
Rate for Payer: Aetna of IA Medical Rental Products	$4,115.70
Rate for Payer: Cash Price	$3,658.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,429.75
Rate for Payer: Medical Associates Commercial	$3,429.75
Rate for Payer: Midlands Choice Commercial	$3,201.10
Rate for Payer: United Healthcare Commercial	$4,115.70

FEMORAL HEAD HIP 26MM+0MM

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026254
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: United Healthcare Commercial	$1,656.00

FEMORAL HEAD HIP 26MM+0MM

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026254
Hospital Revenue Code	278
Min. Negotiated Rate	$828.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Aetna of IA Medicare	$1,048.80
Rate for Payer: Amerigroup Medicaid	$1,061.31
Rate for Payer: Amerigroup Medicare	$836.28
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$828.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,051.01
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Medical Associates Managed Medicare	$828.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,066.46
Rate for Payer: Partners Health Alliance Commercial	$952.20
Rate for Payer: United Healthcare Commercial	$1,656.00
Rate for Payer: United Healthcare Managed Medicare	$1,085.60

FEMORAL HEAD HIP 26MM +12MM V40

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8046931
Hospital Revenue Code	278
Min. Negotiated Rate	$828.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Aetna of IA Medicare	$1,048.80
Rate for Payer: Amerigroup Medicaid	$1,061.31
Rate for Payer: Amerigroup Medicare	$836.28
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$828.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,051.01
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Medical Associates Managed Medicare	$828.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,066.46
Rate for Payer: Partners Health Alliance Commercial	$952.20
Rate for Payer: United Healthcare Commercial	$1,656.00
Rate for Payer: United Healthcare Managed Medicare	$1,085.60

FEMORAL HEAD HIP 26MM +12MM V40

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8046931
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: United Healthcare Commercial	$1,656.00

FEMORAL HEAD HIP 26MM+4MM

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026257
Hospital Revenue Code	278
Min. Negotiated Rate	$828.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Aetna of IA Medicare	$1,048.80
Rate for Payer: Amerigroup Medicaid	$1,061.31
Rate for Payer: Amerigroup Medicare	$836.28
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$828.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,051.01
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Medical Associates Managed Medicare	$828.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,066.46
Rate for Payer: Partners Health Alliance Commercial	$952.20
Rate for Payer: United Healthcare Commercial	$1,656.00
Rate for Payer: United Healthcare Managed Medicare	$1,085.60

FEMORAL HEAD HIP 26MM+4MM

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026257
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: United Healthcare Commercial	$1,656.00

FEMORAL HEAD HIP 26MM +8MM V40

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026259
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: United Healthcare Commercial	$1,656.00

FEMORAL HEAD HIP 26MM +8MM V40

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026259
Hospital Revenue Code	278
Min. Negotiated Rate	$828.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Aetna of IA Medicare	$1,048.80
Rate for Payer: Amerigroup Medicaid	$1,061.31
Rate for Payer: Amerigroup Medicare	$836.28
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$828.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,051.01
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Medical Associates Managed Medicare	$828.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,066.46
Rate for Payer: Partners Health Alliance Commercial	$952.20
Rate for Payer: United Healthcare Commercial	$1,656.00
Rate for Payer: United Healthcare Managed Medicare	$1,085.60

FEMORAL HEAD HIP 28MM+0MM

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026255
Hospital Revenue Code	278
Min. Negotiated Rate	$828.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Aetna of IA Medicare	$1,048.80
Rate for Payer: Amerigroup Medicaid	$1,061.31
Rate for Payer: Amerigroup Medicare	$836.28
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$828.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,051.01
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Medical Associates Managed Medicare	$828.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,066.46
Rate for Payer: Partners Health Alliance Commercial	$952.20
Rate for Payer: United Healthcare Commercial	$1,656.00
Rate for Payer: United Healthcare Managed Medicare	$1,085.60

FEMORAL HEAD HIP 28MM+0MM

Facility

$1,840.00

Service Code	HCPCS C1776
Hospital Charge Code	8026255
Hospital Revenue Code	278
Min. Negotiated Rate	$1,288.00
Max. Negotiated Rate	$1,656.00
Rate for Payer: Aetna of IA Commercial	$1,656.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,656.00
Rate for Payer: Cash Price	$1,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,380.00
Rate for Payer: Medical Associates Commercial	$1,380.00
Rate for Payer: Midlands Choice Commercial	$1,288.00
Rate for Payer: United Healthcare Commercial	$1,656.00

Know your out-of-pocket cost for care.

All Charges