Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

3DMax Mesh, Large Right, 4X6 in

Facility

$570.00

Service Code	HCPCS C1713
Hospital Charge Code	8993115
Hospital Revenue Code	278
Min. Negotiated Rate	$399.00
Max. Negotiated Rate	$513.00
Rate for Payer: Aetna of IA Commercial	$513.00
Rate for Payer: Aetna of IA Medical Rental Products	$513.00
Rate for Payer: Cash Price	$456.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$427.50
Rate for Payer: Medical Associates Commercial	$427.50
Rate for Payer: Midlands Choice Commercial	$399.00
Rate for Payer: United Healthcare Commercial	$513.00

4.00X54MM GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8780889
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Aetna of IA Medicare	$287.28
Rate for Payer: Amerigroup Medicaid	$290.71
Rate for Payer: Amerigroup Medicare	$229.07
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$226.80
Rate for Payer: Iowa Total Care Managed Medicaid	$287.88
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Medical Associates Managed Medicare	$226.80
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: Molina Healthcare Managed Medicaid	$292.12
Rate for Payer: Partners Health Alliance Commercial	$260.82
Rate for Payer: United Healthcare Commercial	$453.60
Rate for Payer: United Healthcare Managed Medicare	$297.36

4.00X54MM GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8780889
Hospital Revenue Code	278
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: United Healthcare Commercial	$453.60

4.0MMX40MM GL LP SYNDESMOTIC SCREW

Facility

$531.00

Service Code	HCPCS C1713
Hospital Charge Code	8977183
Hospital Revenue Code	278
Min. Negotiated Rate	$238.95
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Aetna of IA Medicare	$302.67
Rate for Payer: Amerigroup Medicaid	$306.28
Rate for Payer: Amerigroup Medicare	$241.34
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$238.95
Rate for Payer: Iowa Total Care Managed Medicaid	$303.31
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Medical Associates Managed Medicare	$238.95
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: Molina Healthcare Managed Medicaid	$307.77
Rate for Payer: Partners Health Alliance Commercial	$274.79
Rate for Payer: United Healthcare Commercial	$477.90
Rate for Payer: United Healthcare Managed Medicare	$313.29

4.0MMX40MM GL LP SYNDESMOTIC SCREW

Facility

$531.00

Service Code	HCPCS C1713
Hospital Charge Code	8977183
Hospital Revenue Code	278
Min. Negotiated Rate	$371.70
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: United Healthcare Commercial	$477.90

4.0MMX46 GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8758438
Hospital Revenue Code	278
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: United Healthcare Commercial	$453.60

4.0MMX46 GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8758438
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Aetna of IA Medicare	$287.28
Rate for Payer: Amerigroup Medicaid	$290.71
Rate for Payer: Amerigroup Medicare	$229.07
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$226.80
Rate for Payer: Iowa Total Care Managed Medicaid	$287.88
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Medical Associates Managed Medicare	$226.80
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: Molina Healthcare Managed Medicaid	$292.12
Rate for Payer: Partners Health Alliance Commercial	$260.82
Rate for Payer: United Healthcare Commercial	$453.60
Rate for Payer: United Healthcare Managed Medicare	$297.36

4.0MMX46MM TIGER CANNULATED SCREW

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8749761
Hospital Revenue Code	278
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

4.0MMX46MM TIGER CANNULATED SCREW

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8749761
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

4.0MMX48MM GL LP SYNDESMOTIC SCREW

Facility

$531.00

Service Code	HCPCS C1713
Hospital Charge Code	8985010
Hospital Revenue Code	278
Min. Negotiated Rate	$371.70
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: United Healthcare Commercial	$477.90

4.0MMX48MM GL LP SYNDESMOTIC SCREW

Facility

$531.00

Service Code	HCPCS C1713
Hospital Charge Code	8985010
Hospital Revenue Code	278
Min. Negotiated Rate	$238.95
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Aetna of IA Medicare	$302.67
Rate for Payer: Amerigroup Medicaid	$306.28
Rate for Payer: Amerigroup Medicare	$241.34
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$238.95
Rate for Payer: Iowa Total Care Managed Medicaid	$303.31
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Medical Associates Managed Medicare	$238.95
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: Molina Healthcare Managed Medicaid	$307.77
Rate for Payer: Partners Health Alliance Commercial	$274.79
Rate for Payer: United Healthcare Commercial	$477.90
Rate for Payer: United Healthcare Managed Medicare	$313.29

4.0MMX48MM TIGER CANNULATED SCREW

Facility

$297.00

Service Code	HCPCS C1713
Hospital Charge Code	8986275
Hospital Revenue Code	278
Min. Negotiated Rate	$133.65
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Aetna of IA Medicare	$169.29
Rate for Payer: Amerigroup Medicaid	$171.31
Rate for Payer: Amerigroup Medicare	$134.99
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$133.65
Rate for Payer: Iowa Total Care Managed Medicaid	$169.65
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Medical Associates Managed Medicare	$133.65
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: Molina Healthcare Managed Medicaid	$172.14
Rate for Payer: Partners Health Alliance Commercial	$153.70
Rate for Payer: United Healthcare Commercial	$267.30
Rate for Payer: United Healthcare Managed Medicare	$175.23

4.0MMX48MM TIGER CANNULATED SCREW

Facility

$297.00

Service Code	HCPCS C1713
Hospital Charge Code	8986275
Hospital Revenue Code	278
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: United Healthcare Commercial	$267.30

4.0MMX50MM GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8758440
Hospital Revenue Code	278
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: United Healthcare Commercial	$453.60

4.0MMX50MM GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8758440
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Aetna of IA Medicare	$287.28
Rate for Payer: Amerigroup Medicaid	$290.71
Rate for Payer: Amerigroup Medicare	$229.07
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$226.80
Rate for Payer: Iowa Total Care Managed Medicaid	$287.88
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Medical Associates Managed Medicare	$226.80
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: Molina Healthcare Managed Medicaid	$292.12
Rate for Payer: Partners Health Alliance Commercial	$260.82
Rate for Payer: United Healthcare Commercial	$453.60
Rate for Payer: United Healthcare Managed Medicare	$297.36

4.0MMX52MM GL LP SYNDESMOTIC SCREW

Facility

$531.00

Service Code	HCPCS C1713
Hospital Charge Code	8985012
Hospital Revenue Code	278
Min. Negotiated Rate	$238.95
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Aetna of IA Medicare	$302.67
Rate for Payer: Amerigroup Medicaid	$306.28
Rate for Payer: Amerigroup Medicare	$241.34
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$238.95
Rate for Payer: Iowa Total Care Managed Medicaid	$303.31
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Medical Associates Managed Medicare	$238.95
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: Molina Healthcare Managed Medicaid	$307.77
Rate for Payer: Partners Health Alliance Commercial	$274.79
Rate for Payer: United Healthcare Commercial	$477.90
Rate for Payer: United Healthcare Managed Medicare	$313.29

4.0MMX52MM GL LP SYNDESMOTIC SCREW

Facility

$531.00

Service Code	HCPCS C1713
Hospital Charge Code	8985012
Hospital Revenue Code	278
Min. Negotiated Rate	$371.70
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: United Healthcare Commercial	$477.90

4.0MMX56 GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8760641
Hospital Revenue Code	278
Min. Negotiated Rate	$352.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: United Healthcare Commercial	$453.60

4.0MMX56 GL ANKLE SYNDESMOTIC SCREW LOW PROFILE

Facility

$504.00

Service Code	HCPCS C1713
Hospital Charge Code	8760641
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$453.60
Rate for Payer: Aetna of IA Commercial	$453.60
Rate for Payer: Aetna of IA Medical Rental Products	$453.60
Rate for Payer: Aetna of IA Medicare	$287.28
Rate for Payer: Amerigroup Medicaid	$290.71
Rate for Payer: Amerigroup Medicare	$229.07
Rate for Payer: Cash Price	$403.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$378.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$226.80
Rate for Payer: Iowa Total Care Managed Medicaid	$287.88
Rate for Payer: Medical Associates Commercial	$378.00
Rate for Payer: Medical Associates Managed Medicare	$226.80
Rate for Payer: Midlands Choice Commercial	$352.80
Rate for Payer: Molina Healthcare Managed Medicaid	$292.12
Rate for Payer: Partners Health Alliance Commercial	$260.82
Rate for Payer: United Healthcare Commercial	$453.60
Rate for Payer: United Healthcare Managed Medicare	$297.36

43235 EGD DX BRUSHWASH (NO BX)

Professional

Both

$849.00

Service Code	CPT 43235
Hospital Charge Code	8069022
Hospital Revenue Code	975
Min. Negotiated Rate	$286.61
Max. Negotiated Rate	$650.70
Rate for Payer: Amerigroup Medicaid	$289.42
Rate for Payer: Cash Price	$679.20
Rate for Payer: Cash Price	$679.20
Rate for Payer: Iowa Total Care Managed Medicaid	$286.61
Rate for Payer: Medical Associates Commercial	$636.75
Rate for Payer: Midlands Choice Commercial	$594.30
Rate for Payer: Molina Healthcare Managed Medicaid	$288.01
Rate for Payer: Partners Health Alliance Commercial	$636.75
Rate for Payer: United Healthcare Commercial	$421.90
Rate for Payer: Wellmark IA HMO WHPI	$553.10
Rate for Payer: Wellmark IA PPO	$650.70

43239 EGD W/ BX (COLD FORCEPS)

Professional

Both

$1,135.00

Service Code	CPT 43239
Hospital Charge Code	8069041
Hospital Revenue Code	975
Min. Negotiated Rate	$365.74
Max. Negotiated Rate	$851.25
Rate for Payer: Amerigroup Medicaid	$369.33
Rate for Payer: Cash Price	$908.00
Rate for Payer: Cash Price	$908.00
Rate for Payer: Iowa Total Care Managed Medicaid	$365.74
Rate for Payer: Medical Associates Commercial	$851.25
Rate for Payer: Midlands Choice Commercial	$794.50
Rate for Payer: Molina Healthcare Managed Medicaid	$367.53
Rate for Payer: Partners Health Alliance Commercial	$851.25
Rate for Payer: United Healthcare Commercial	$561.76
Rate for Payer: Wellmark IA HMO WHPI	$722.90
Rate for Payer: Wellmark IA PPO	$850.50

43241 EGD W/ INSERTION OF INTRALUMINAL TUB OR CATHETER

Professional

Both

$489.00

Service Code	CPT 43241
Hospital Charge Code	8069121
Hospital Revenue Code	975
Min. Negotiated Rate	$142.73
Max. Negotiated Rate	$366.75
Rate for Payer: Amerigroup Medicaid	$144.13
Rate for Payer: Cash Price	$391.20
Rate for Payer: Cash Price	$391.20
Rate for Payer: Iowa Total Care Managed Medicaid	$142.73
Rate for Payer: Medical Associates Commercial	$366.75
Rate for Payer: Midlands Choice Commercial	$342.30
Rate for Payer: Molina Healthcare Managed Medicaid	$143.43
Rate for Payer: Partners Health Alliance Commercial	$366.75
Rate for Payer: United Healthcare Commercial	$219.78
Rate for Payer: Wellmark IA HMO WHPI	$269.80
Rate for Payer: Wellmark IA PPO	$317.40

43245 EGD W/ DILATION OF GASTRIC/DUODENAL STRICTURE W/ BALLO

Professional

Both

$1,828.00

Service Code	CPT 43245
Hospital Charge Code	8069065
Hospital Revenue Code	975
Min. Negotiated Rate	$561.82
Max. Negotiated Rate	$1,371.00
Rate for Payer: Amerigroup Medicaid	$567.32
Rate for Payer: Cash Price	$1,462.40
Rate for Payer: Cash Price	$1,462.40
Rate for Payer: Iowa Total Care Managed Medicaid	$561.82
Rate for Payer: Medical Associates Commercial	$1,371.00
Rate for Payer: Midlands Choice Commercial	$1,279.60
Rate for Payer: Molina Healthcare Managed Medicaid	$564.57
Rate for Payer: Partners Health Alliance Commercial	$1,371.00
Rate for Payer: United Healthcare Commercial	$884.45
Rate for Payer: Wellmark IA HMO WHPI	$1,135.70
Rate for Payer: Wellmark IA PPO	$1,336.10

43247 EGD WITH REMOVAL OF FOREIGN BODY

Professional

Both

$1,159.00

Service Code	CPT 43247
Hospital Charge Code	8069093
Hospital Revenue Code	975
Min. Negotiated Rate	$373.78
Max. Negotiated Rate	$869.25
Rate for Payer: Amerigroup Medicaid	$377.44
Rate for Payer: Cash Price	$927.20
Rate for Payer: Cash Price	$927.20
Rate for Payer: Iowa Total Care Managed Medicaid	$373.78
Rate for Payer: Medical Associates Commercial	$869.25
Rate for Payer: Midlands Choice Commercial	$811.30
Rate for Payer: Molina Healthcare Managed Medicaid	$375.61
Rate for Payer: Partners Health Alliance Commercial	$869.25
Rate for Payer: United Healthcare Commercial	$559.68
Rate for Payer: Wellmark IA HMO WHPI	$736.40
Rate for Payer: Wellmark IA PPO	$866.30

43248 EGD W/ DILATION INSERT GUIDEWIRE W/ PASSAGE OF DILATO

Professional

Both

$1,161.00

Service Code	CPT 43248
Hospital Charge Code	8069064
Hospital Revenue Code	975
Min. Negotiated Rate	$377.54
Max. Negotiated Rate	$933.50
Rate for Payer: Amerigroup Medicaid	$381.24
Rate for Payer: Cash Price	$928.80
Rate for Payer: Cash Price	$928.80
Rate for Payer: Iowa Total Care Managed Medicaid	$377.54
Rate for Payer: Medical Associates Commercial	$870.75
Rate for Payer: Midlands Choice Commercial	$812.70
Rate for Payer: Molina Healthcare Managed Medicaid	$379.39
Rate for Payer: Partners Health Alliance Commercial	$870.75
Rate for Payer: United Healthcare Commercial	$586.48
Rate for Payer: Wellmark IA HMO WHPI	$793.40
Rate for Payer: Wellmark IA PPO	$933.50

Know your out-of-pocket cost for care.

All Charges