Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Level 3: Normal Newborn

Facility

$2,844.46

Service Code	MS-DRG 7957
Hospital Charge Code	691
Min. Negotiated Rate	$2,803.24
Max. Negotiated Rate	$2,844.46
Rate for Payer: Amerigroup Medicaid	$2,830.72
Rate for Payer: Iowa Total Care Managed Medicaid	$2,803.24
Rate for Payer: Molina Healthcare Managed Medicaid	$2,844.46

Level 3: Prematurity W Major Problems

Facility

$37,116.74

Service Code	MS-DRG 7917
Hospital Charge Code	683
Min. Negotiated Rate	$36,578.81
Max. Negotiated Rate	$37,116.74
Rate for Payer: Amerigroup Medicaid	$36,937.43
Rate for Payer: Iowa Total Care Managed Medicaid	$36,578.81
Rate for Payer: Molina Healthcare Managed Medicaid	$37,116.74

Level 3: Prematurity W/O Major Problems

Facility

$12,759.71

Service Code	MS-DRG 7927
Hospital Charge Code	685
Min. Negotiated Rate	$12,574.78
Max. Negotiated Rate	$12,759.71
Rate for Payer: Amerigroup Medicaid	$12,698.07
Rate for Payer: Iowa Total Care Managed Medicaid	$12,574.78
Rate for Payer: Molina Healthcare Managed Medicaid	$12,759.71

LEVEL 4

Facility

$711.00

Service Code	CPT 99284 25
Hospital Charge Code	6922788
Hospital Revenue Code	450
Min. Negotiated Rate	$355.36
Max. Negotiated Rate	$639.90
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Aetna of IA Medicare	$405.27
Rate for Payer: Amerigroup Medicaid	$358.84
Rate for Payer: Amerigroup Medicare	$359.06
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$355.50
Rate for Payer: Iowa Total Care Managed Medicaid	$355.36
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Medical Associates Managed Medicare	$355.50
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: Molina Healthcare Managed Medicaid	$360.83
Rate for Payer: Molina Healthcare Managed Medicare	$360.62
Rate for Payer: Oscar Health of IA Commercial	$533.25
Rate for Payer: Partners Health Alliance Commercial	$533.25
Rate for Payer: United Healthcare Commercial	$639.90
Rate for Payer: United Healthcare Managed Medicare	$419.49

LEVEL 4

Facility

$711.00

Service Code	CPT 99284 25
Hospital Charge Code	6922788
Hospital Revenue Code	450
Min. Negotiated Rate	$497.70
Max. Negotiated Rate	$639.90
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: United Healthcare Commercial	$639.90

LEVEL 4

Professional

Both

$359.00

Service Code	CPT 99284
Hospital Charge Code	7982752
Hospital Revenue Code	981
Min. Negotiated Rate	$110.80
Max. Negotiated Rate	$199.44
Rate for Payer: Aetna of IA Medicare	$110.80
Rate for Payer: Amerigroup Medicaid	$114.57
Rate for Payer: Cash Price	$287.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.96
Rate for Payer: Iowa Total Care Managed Medicaid	$113.02
Rate for Payer: Medical Associates Commercial	$199.44
Rate for Payer: Medical Associates Managed Medicare	$110.80
Rate for Payer: Midlands Choice Commercial	$178.34
Rate for Payer: Oscar Health of IA Commercial	$188.36
Rate for Payer: Partners Health Alliance Commercial	$166.20
Rate for Payer: United Healthcare Commercial	$129.49

LEVEL 5

Facility

$1,042.00

Service Code	CPT 99285 25
Hospital Charge Code	6922790
Hospital Revenue Code	450
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$937.80
Rate for Payer: Aetna of IA Commercial	$937.80
Rate for Payer: Aetna of IA Medical Rental Products	$937.80
Rate for Payer: Cash Price	$833.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$781.50
Rate for Payer: Medical Associates Commercial	$781.50
Rate for Payer: Midlands Choice Commercial	$729.40
Rate for Payer: United Healthcare Commercial	$937.80

LEVEL 5

Professional

Both

$529.00

Service Code	CPT 99285
Hospital Charge Code	7982751
Hospital Revenue Code	981
Min. Negotiated Rate	$160.58
Max. Negotiated Rate	$289.04
Rate for Payer: Aetna of IA Medicare	$160.58
Rate for Payer: Amerigroup Medicaid	$166.04
Rate for Payer: Cash Price	$423.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$192.70
Rate for Payer: Iowa Total Care Managed Medicaid	$163.79
Rate for Payer: Medical Associates Commercial	$289.04
Rate for Payer: Medical Associates Managed Medicare	$160.58
Rate for Payer: Midlands Choice Commercial	$259.53
Rate for Payer: Oscar Health of IA Commercial	$272.99
Rate for Payer: Partners Health Alliance Commercial	$240.87
Rate for Payer: United Healthcare Commercial	$202.69

LEVEL 5

Facility

$1,042.00

Service Code	CPT 99285 25
Hospital Charge Code	6922790
Hospital Revenue Code	450
Min. Negotiated Rate	$520.79
Max. Negotiated Rate	$937.80
Rate for Payer: Aetna of IA Commercial	$937.80
Rate for Payer: Aetna of IA Medical Rental Products	$937.80
Rate for Payer: Aetna of IA Medicare	$593.94
Rate for Payer: Amerigroup Medicaid	$525.90
Rate for Payer: Amerigroup Medicare	$526.21
Rate for Payer: Cash Price	$833.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$781.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$521.00
Rate for Payer: Iowa Total Care Managed Medicaid	$520.79
Rate for Payer: Medical Associates Commercial	$781.50
Rate for Payer: Medical Associates Managed Medicare	$521.00
Rate for Payer: Midlands Choice Commercial	$729.40
Rate for Payer: Molina Healthcare Managed Medicaid	$528.82
Rate for Payer: Molina Healthcare Managed Medicare	$528.50
Rate for Payer: Oscar Health of IA Commercial	$781.50
Rate for Payer: Partners Health Alliance Commercial	$781.50
Rate for Payer: United Healthcare Commercial	$937.80
Rate for Payer: United Healthcare Managed Medicare	$614.78

levETIRAcetam 100 mg/mL 5ml cup Oral Sol [VDMC]

Facility

$13.70

Service Code	HCPCS A9270
Hospital Charge Code	10399512
Hospital Revenue Code	259
Min. Negotiated Rate	$9.59
Max. Negotiated Rate	$12.33
Rate for Payer: Aetna of IA Commercial	$12.33
Rate for Payer: Aetna of IA Medical Rental Products	$12.33
Rate for Payer: Cash Price	$10.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.28
Rate for Payer: Medical Associates Commercial	$10.28
Rate for Payer: Midlands Choice Commercial	$9.59
Rate for Payer: United Healthcare Commercial	$12.33

levETIRAcetam 100 mg/mL 5ml cup Oral Sol [VDMC]

Facility

$13.70

Service Code	HCPCS A9270
Hospital Charge Code	10399512
Hospital Revenue Code	259
Min. Negotiated Rate	$6.85
Max. Negotiated Rate	$12.33
Rate for Payer: Aetna of IA Commercial	$12.33
Rate for Payer: Aetna of IA Medical Rental Products	$12.33
Rate for Payer: Aetna of IA Medicare	$7.81
Rate for Payer: Amerigroup Medicaid	$6.91
Rate for Payer: Amerigroup Medicare	$6.92
Rate for Payer: Cash Price	$10.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.85
Rate for Payer: Iowa Total Care Managed Medicaid	$6.85
Rate for Payer: Medical Associates Commercial	$10.28
Rate for Payer: Medical Associates Managed Medicare	$6.85
Rate for Payer: Midlands Choice Commercial	$9.59
Rate for Payer: Molina Healthcare Managed Medicaid	$6.95
Rate for Payer: Molina Healthcare Managed Medicare	$6.95
Rate for Payer: Oscar Health of IA Commercial	$10.28
Rate for Payer: Partners Health Alliance Commercial	$10.28
Rate for Payer: United Healthcare Commercial	$12.33
Rate for Payer: United Healthcare Managed Medicare	$8.08

levETIRAcetam 500 mg/5ml Vial [VDMC]

Facility

$24.92

Service Code	HCPCS J1953
Hospital Charge Code	11263874
Hospital Revenue Code	259
Min. Negotiated Rate	$12.46
Max. Negotiated Rate	$22.43
Rate for Payer: Aetna of IA Commercial	$22.43
Rate for Payer: Aetna of IA Medical Rental Products	$22.43
Rate for Payer: Aetna of IA Medicare	$14.20
Rate for Payer: Amerigroup Medicaid	$12.58
Rate for Payer: Amerigroup Medicare	$12.58
Rate for Payer: Cash Price	$19.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.69
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.46
Rate for Payer: Iowa Total Care Managed Medicaid	$12.46
Rate for Payer: Medical Associates Commercial	$18.69
Rate for Payer: Medical Associates Managed Medicare	$12.46
Rate for Payer: Midlands Choice Commercial	$17.44
Rate for Payer: Molina Healthcare Managed Medicaid	$12.65
Rate for Payer: Molina Healthcare Managed Medicare	$12.64
Rate for Payer: Oscar Health of IA Commercial	$18.69
Rate for Payer: Partners Health Alliance Commercial	$18.69
Rate for Payer: United Healthcare Commercial	$22.43
Rate for Payer: United Healthcare Managed Medicare	$14.70

levETIRAcetam 500 mg/5ml Vial [VDMC]

Facility

$24.92

Service Code	HCPCS J1953
Hospital Charge Code	11263874
Hospital Revenue Code	259
Min. Negotiated Rate	$17.44
Max. Negotiated Rate	$22.43
Rate for Payer: Aetna of IA Commercial	$22.43
Rate for Payer: Aetna of IA Medical Rental Products	$22.43
Rate for Payer: Cash Price	$19.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.69
Rate for Payer: Medical Associates Commercial	$18.69
Rate for Payer: Midlands Choice Commercial	$17.44
Rate for Payer: United Healthcare Commercial	$22.43

levETIRAcetam 500 mg Tab [VDMC]

Facility

$1.53

Service Code	HCPCS A9270
Hospital Charge Code	10399579
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.38
Rate for Payer: Aetna of IA Commercial	$1.38
Rate for Payer: Aetna of IA Medical Rental Products	$1.38
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.15
Rate for Payer: Medical Associates Commercial	$1.15
Rate for Payer: Midlands Choice Commercial	$1.07
Rate for Payer: United Healthcare Commercial	$1.38

levETIRAcetam 500 mg Tab [VDMC]

Facility

$1.53

Service Code	HCPCS A9270
Hospital Charge Code	10399579
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.38
Rate for Payer: Aetna of IA Commercial	$1.38
Rate for Payer: Aetna of IA Medical Rental Products	$1.38
Rate for Payer: Aetna of IA Medicare	$0.87
Rate for Payer: Amerigroup Medicaid	$0.77
Rate for Payer: Amerigroup Medicare	$0.77
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.77
Rate for Payer: Iowa Total Care Managed Medicaid	$0.76
Rate for Payer: Medical Associates Commercial	$1.15
Rate for Payer: Medical Associates Managed Medicare	$0.77
Rate for Payer: Midlands Choice Commercial	$1.07
Rate for Payer: Molina Healthcare Managed Medicaid	$0.78
Rate for Payer: Molina Healthcare Managed Medicare	$0.78
Rate for Payer: Oscar Health of IA Commercial	$1.15
Rate for Payer: Partners Health Alliance Commercial	$1.15
Rate for Payer: United Healthcare Commercial	$1.38
Rate for Payer: United Healthcare Managed Medicare	$0.90

levofloxacin 250 mg/50 mL IV Sol [VDMC]

Facility

$55.11

Service Code	HCPCS J1956
Hospital Charge Code	10399648
Hospital Revenue Code	259
Min. Negotiated Rate	$27.54
Max. Negotiated Rate	$49.60
Rate for Payer: Aetna of IA Commercial	$49.60
Rate for Payer: Aetna of IA Medical Rental Products	$49.60
Rate for Payer: Aetna of IA Medicare	$31.41
Rate for Payer: Amerigroup Medicaid	$27.81
Rate for Payer: Amerigroup Medicare	$27.83
Rate for Payer: Cash Price	$44.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$41.33
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.56
Rate for Payer: Iowa Total Care Managed Medicaid	$27.54
Rate for Payer: Medical Associates Commercial	$41.33
Rate for Payer: Medical Associates Managed Medicare	$27.56
Rate for Payer: Midlands Choice Commercial	$38.58
Rate for Payer: Molina Healthcare Managed Medicaid	$27.97
Rate for Payer: Molina Healthcare Managed Medicare	$27.95
Rate for Payer: Oscar Health of IA Commercial	$41.33
Rate for Payer: Partners Health Alliance Commercial	$41.33
Rate for Payer: United Healthcare Commercial	$49.60
Rate for Payer: United Healthcare Managed Medicare	$32.51

levofloxacin 250 mg/50 mL IV Sol [VDMC]

Facility

$55.11

Service Code	HCPCS J1956
Hospital Charge Code	10399648
Hospital Revenue Code	259
Min. Negotiated Rate	$38.58
Max. Negotiated Rate	$49.60
Rate for Payer: Aetna of IA Commercial	$49.60
Rate for Payer: Aetna of IA Medical Rental Products	$49.60
Rate for Payer: Cash Price	$44.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$41.33
Rate for Payer: Medical Associates Commercial	$41.33
Rate for Payer: Midlands Choice Commercial	$38.58
Rate for Payer: United Healthcare Commercial	$49.60

levofloxacin 500 mg/100 mL IV Sol [VDMC]

Facility

$56.87

Service Code	HCPCS J1956
Hospital Charge Code	10399719
Hospital Revenue Code	259
Min. Negotiated Rate	$28.42
Max. Negotiated Rate	$51.18
Rate for Payer: Aetna of IA Commercial	$51.18
Rate for Payer: Aetna of IA Medical Rental Products	$51.18
Rate for Payer: Aetna of IA Medicare	$32.42
Rate for Payer: Amerigroup Medicaid	$28.70
Rate for Payer: Amerigroup Medicare	$28.72
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.65
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.44
Rate for Payer: Iowa Total Care Managed Medicaid	$28.42
Rate for Payer: Medical Associates Commercial	$42.65
Rate for Payer: Medical Associates Managed Medicare	$28.44
Rate for Payer: Midlands Choice Commercial	$39.81
Rate for Payer: Molina Healthcare Managed Medicaid	$28.86
Rate for Payer: Molina Healthcare Managed Medicare	$28.84
Rate for Payer: Oscar Health of IA Commercial	$42.65
Rate for Payer: Partners Health Alliance Commercial	$42.65
Rate for Payer: United Healthcare Commercial	$51.18
Rate for Payer: United Healthcare Managed Medicare	$33.55

levofloxacin 500 mg/100 mL IV Sol [VDMC]

Facility

$56.87

Service Code	HCPCS J1956
Hospital Charge Code	10399719
Hospital Revenue Code	259
Min. Negotiated Rate	$39.81
Max. Negotiated Rate	$51.18
Rate for Payer: Aetna of IA Commercial	$51.18
Rate for Payer: Aetna of IA Medical Rental Products	$51.18
Rate for Payer: Cash Price	$45.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.65
Rate for Payer: Medical Associates Commercial	$42.65
Rate for Payer: Midlands Choice Commercial	$39.81
Rate for Payer: United Healthcare Commercial	$51.18

levofloxacin 500 mg Tab UD [VDMC]

Facility

$1.78

Service Code	HCPCS A9270
Hospital Charge Code	11224623
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of IA Commercial	$1.60
Rate for Payer: Aetna of IA Medical Rental Products	$1.60
Rate for Payer: Aetna of IA Medicare	$1.01
Rate for Payer: Amerigroup Medicaid	$0.90
Rate for Payer: Amerigroup Medicare	$0.90
Rate for Payer: Cash Price	$1.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.89
Rate for Payer: Iowa Total Care Managed Medicaid	$0.89
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Medical Associates Managed Medicare	$0.89
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: Molina Healthcare Managed Medicaid	$0.90
Rate for Payer: Molina Healthcare Managed Medicare	$0.90
Rate for Payer: Oscar Health of IA Commercial	$1.34
Rate for Payer: Partners Health Alliance Commercial	$1.34
Rate for Payer: United Healthcare Commercial	$1.60
Rate for Payer: United Healthcare Managed Medicare	$1.05

levofloxacin 500 mg Tab UD [VDMC]

Facility

$1.78

Service Code	HCPCS A9270
Hospital Charge Code	11224623
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of IA Commercial	$1.60
Rate for Payer: Aetna of IA Medical Rental Products	$1.60
Rate for Payer: Cash Price	$1.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: United Healthcare Commercial	$1.60

levofloxacin 750 mg/150 mL IV Sol [VDMC]

Facility

$57.20

Service Code	HCPCS J1956
Hospital Charge Code	10399790
Hospital Revenue Code	259
Min. Negotiated Rate	$28.59
Max. Negotiated Rate	$51.48
Rate for Payer: Aetna of IA Commercial	$51.48
Rate for Payer: Aetna of IA Medical Rental Products	$51.48
Rate for Payer: Aetna of IA Medicare	$32.60
Rate for Payer: Amerigroup Medicaid	$28.87
Rate for Payer: Amerigroup Medicare	$28.89
Rate for Payer: Cash Price	$45.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.60
Rate for Payer: Iowa Total Care Managed Medicaid	$28.59
Rate for Payer: Medical Associates Commercial	$42.90
Rate for Payer: Medical Associates Managed Medicare	$28.60
Rate for Payer: Midlands Choice Commercial	$40.04
Rate for Payer: Molina Healthcare Managed Medicaid	$29.03
Rate for Payer: Molina Healthcare Managed Medicare	$29.01
Rate for Payer: Oscar Health of IA Commercial	$42.90
Rate for Payer: Partners Health Alliance Commercial	$42.90
Rate for Payer: United Healthcare Commercial	$51.48
Rate for Payer: United Healthcare Managed Medicare	$33.75

levofloxacin 750 mg/150 mL IV Sol [VDMC]

Facility

$57.20

Service Code	HCPCS J1956
Hospital Charge Code	10399790
Hospital Revenue Code	259
Min. Negotiated Rate	$40.04
Max. Negotiated Rate	$51.48
Rate for Payer: Aetna of IA Commercial	$51.48
Rate for Payer: Aetna of IA Medical Rental Products	$51.48
Rate for Payer: Cash Price	$45.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.90
Rate for Payer: Medical Associates Commercial	$42.90
Rate for Payer: Midlands Choice Commercial	$40.04
Rate for Payer: United Healthcare Commercial	$51.48

LEVOleucovorin 10 mg/mL 25ml [VDMC]

Facility

$673.20

Service Code	HCPCS J0641
Hospital Charge Code	14142550
Hospital Revenue Code	259
Min. Negotiated Rate	$336.47
Max. Negotiated Rate	$605.88
Rate for Payer: Aetna of IA Commercial	$605.88
Rate for Payer: Aetna of IA Medical Rental Products	$605.88
Rate for Payer: Aetna of IA Medicare	$383.72
Rate for Payer: Amerigroup Medicaid	$339.76
Rate for Payer: Amerigroup Medicare	$339.97
Rate for Payer: Cash Price	$538.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$504.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$336.60
Rate for Payer: Iowa Total Care Managed Medicaid	$336.47
Rate for Payer: Medical Associates Commercial	$504.90
Rate for Payer: Medical Associates Managed Medicare	$336.60
Rate for Payer: Midlands Choice Commercial	$471.24
Rate for Payer: Molina Healthcare Managed Medicaid	$341.65
Rate for Payer: Molina Healthcare Managed Medicare	$341.45
Rate for Payer: Oscar Health of IA Commercial	$504.90
Rate for Payer: Partners Health Alliance Commercial	$504.90
Rate for Payer: United Healthcare Commercial	$605.88
Rate for Payer: United Healthcare Managed Medicare	$397.19

LEVOleucovorin 10 mg/mL 25ml [VDMC]

Facility

$673.20

Service Code	HCPCS J0641
Hospital Charge Code	14142550
Hospital Revenue Code	259
Min. Negotiated Rate	$471.24
Max. Negotiated Rate	$605.88
Rate for Payer: Aetna of IA Commercial	$605.88
Rate for Payer: Aetna of IA Medical Rental Products	$605.88
Rate for Payer: Cash Price	$538.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$504.90
Rate for Payer: Medical Associates Commercial	$504.90
Rate for Payer: Midlands Choice Commercial	$471.24
Rate for Payer: United Healthcare Commercial	$605.88

Know your out-of-pocket cost for care.

All Charges