Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625 KX
Hospital Charge Code	7702164
Hospital Revenue Code	948
Min. Negotiated Rate	$107.55
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Aetna of IA Medicare	$136.23
Rate for Payer: Amerigroup Medicaid	$137.86
Rate for Payer: Amerigroup Medicare	$108.63
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$107.55
Rate for Payer: Iowa Total Care Managed Medicaid	$136.52
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Medical Associates Managed Medicare	$107.55
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: Molina Healthcare Managed Medicaid	$138.52
Rate for Payer: Partners Health Alliance Commercial	$123.68
Rate for Payer: United Healthcare Commercial	$215.10
Rate for Payer: United Healthcare Managed Medicare	$141.01

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625
Hospital Charge Code	7702165
Hospital Revenue Code	948
Min. Negotiated Rate	$107.55
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Aetna of IA Medicare	$136.23
Rate for Payer: Amerigroup Medicaid	$137.86
Rate for Payer: Amerigroup Medicare	$108.63
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$107.55
Rate for Payer: Iowa Total Care Managed Medicaid	$136.52
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Medical Associates Managed Medicare	$107.55
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: Molina Healthcare Managed Medicaid	$138.52
Rate for Payer: Partners Health Alliance Commercial	$123.68
Rate for Payer: United Healthcare Commercial	$215.10
Rate for Payer: United Healthcare Managed Medicare	$141.01

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625
Hospital Charge Code	7827004
Hospital Revenue Code	948
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: United Healthcare Commercial	$215.10

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625 KX
Hospital Charge Code	7827005
Hospital Revenue Code	948
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: United Healthcare Commercial	$215.10

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625 KX
Hospital Charge Code	7702164
Hospital Revenue Code	948
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: United Healthcare Commercial	$215.10

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625
Hospital Charge Code	7827004
Hospital Revenue Code	948
Min. Negotiated Rate	$107.55
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Aetna of IA Medicare	$136.23
Rate for Payer: Amerigroup Medicaid	$137.86
Rate for Payer: Amerigroup Medicare	$108.63
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$107.55
Rate for Payer: Iowa Total Care Managed Medicaid	$136.52
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Medical Associates Managed Medicare	$107.55
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: Molina Healthcare Managed Medicaid	$138.52
Rate for Payer: Partners Health Alliance Commercial	$123.68
Rate for Payer: United Healthcare Commercial	$215.10
Rate for Payer: United Healthcare Managed Medicare	$141.01

Pulmonary Rehab TherEx Charge

Facility

$99.00

Service Code	HCPCS G0237
Hospital Charge Code	8058999
Hospital Revenue Code	410
Min. Negotiated Rate	$44.55
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of IA Commercial	$89.10
Rate for Payer: Aetna of IA Medical Rental Products	$89.10
Rate for Payer: Aetna of IA Medicare	$56.43
Rate for Payer: Amerigroup Medicaid	$57.10
Rate for Payer: Amerigroup Medicare	$45.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.55
Rate for Payer: Iowa Total Care Managed Medicaid	$56.55
Rate for Payer: Medical Associates Commercial	$74.25
Rate for Payer: Medical Associates Managed Medicare	$44.55
Rate for Payer: Midlands Choice Commercial	$69.30
Rate for Payer: Molina Healthcare Managed Medicaid	$57.38
Rate for Payer: Partners Health Alliance Commercial	$51.23
Rate for Payer: United Healthcare Commercial	$89.10
Rate for Payer: United Healthcare Managed Medicare	$58.41

Pulmonary Rehab TherEx Charge

Facility

$99.00

Service Code	HCPCS G0237
Hospital Charge Code	8058999
Hospital Revenue Code	410
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of IA Commercial	$89.10
Rate for Payer: Aetna of IA Medical Rental Products	$89.10
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.25
Rate for Payer: Medical Associates Commercial	$74.25
Rate for Payer: Midlands Choice Commercial	$69.30
Rate for Payer: United Healthcare Commercial	$89.10

Pulm Rehab w Continuos Oximetry

Facility

$329.00

Service Code	CPT 94626
Hospital Charge Code	8873992
Hospital Revenue Code	948
Min. Negotiated Rate	$148.05
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna of IA Commercial	$296.10
Rate for Payer: Aetna of IA Medical Rental Products	$296.10
Rate for Payer: Aetna of IA Medicare	$187.53
Rate for Payer: Amerigroup Medicaid	$189.77
Rate for Payer: Amerigroup Medicare	$149.53
Rate for Payer: Cash Price	$263.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$246.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$148.05
Rate for Payer: Iowa Total Care Managed Medicaid	$187.92
Rate for Payer: Medical Associates Commercial	$246.75
Rate for Payer: Medical Associates Managed Medicare	$148.05
Rate for Payer: Midlands Choice Commercial	$230.30
Rate for Payer: Molina Healthcare Managed Medicaid	$190.69
Rate for Payer: Partners Health Alliance Commercial	$170.26
Rate for Payer: United Healthcare Commercial	$296.10
Rate for Payer: United Healthcare Managed Medicare	$194.11

Pulm Rehab w Continuos Oximetry

Facility

$329.00

Service Code	CPT 94626
Hospital Charge Code	8873992
Hospital Revenue Code	948
Min. Negotiated Rate	$230.30
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna of IA Commercial	$296.10
Rate for Payer: Aetna of IA Medical Rental Products	$296.10
Rate for Payer: Cash Price	$263.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$246.75
Rate for Payer: Medical Associates Commercial	$246.75
Rate for Payer: Midlands Choice Commercial	$230.30
Rate for Payer: United Healthcare Commercial	$296.10

PUNCH FOR 3.5MM PUNCHLOCK

Facility

$358.00

Service Code	HCPCS C1713
Hospital Charge Code	8026412
Hospital Revenue Code	278
Min. Negotiated Rate	$250.60
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of IA Commercial	$322.20
Rate for Payer: Aetna of IA Medical Rental Products	$322.20
Rate for Payer: Cash Price	$286.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$268.50
Rate for Payer: Medical Associates Commercial	$268.50
Rate for Payer: Midlands Choice Commercial	$250.60
Rate for Payer: United Healthcare Commercial	$322.20

PUNCH FOR 3.5MM PUNCHLOCK

Facility

$358.00

Service Code	HCPCS C1713
Hospital Charge Code	8026412
Hospital Revenue Code	278
Min. Negotiated Rate	$161.10
Max. Negotiated Rate	$322.20
Rate for Payer: Aetna of IA Commercial	$322.20
Rate for Payer: Aetna of IA Medical Rental Products	$322.20
Rate for Payer: Aetna of IA Medicare	$204.06
Rate for Payer: Amerigroup Medicaid	$206.49
Rate for Payer: Amerigroup Medicare	$162.71
Rate for Payer: Cash Price	$286.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$161.10
Rate for Payer: Iowa Total Care Managed Medicaid	$204.49
Rate for Payer: Medical Associates Commercial	$268.50
Rate for Payer: Medical Associates Managed Medicare	$161.10
Rate for Payer: Midlands Choice Commercial	$250.60
Rate for Payer: Molina Healthcare Managed Medicaid	$207.50
Rate for Payer: Partners Health Alliance Commercial	$185.26
Rate for Payer: United Healthcare Commercial	$322.20
Rate for Payer: United Healthcare Managed Medicare	$211.22

PUNCTURE DRAINAGE OF LESION

Professional

Both

$294.00

Service Code	CPT 10160
Hospital Charge Code	7982854
Hospital Revenue Code	981
Min. Negotiated Rate	$196.83
Max. Negotiated Rate	$220.50
Rate for Payer: Cash Price	$235.20
Rate for Payer: Cash Price	$235.20
Rate for Payer: Medical Associates Commercial	$220.50
Rate for Payer: Midlands Choice Commercial	$205.80
Rate for Payer: Partners Health Alliance Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$196.83

PUNCTURE DRAINAGE OF LESION

Facility

$594.00

Service Code	CPT 10160
Hospital Charge Code	4862801
Hospital Revenue Code	450
Min. Negotiated Rate	$415.80
Max. Negotiated Rate	$534.60
Rate for Payer: Aetna of IA Commercial	$534.60
Rate for Payer: Aetna of IA Medical Rental Products	$534.60
Rate for Payer: Cash Price	$475.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$445.50
Rate for Payer: Medical Associates Commercial	$445.50
Rate for Payer: Midlands Choice Commercial	$415.80
Rate for Payer: United Healthcare Commercial	$534.60

PUNCTURE DRAINAGE OF LESION

Facility

$594.00

Service Code	CPT 10160
Hospital Charge Code	4862801
Hospital Revenue Code	450
Min. Negotiated Rate	$267.30
Max. Negotiated Rate	$534.60
Rate for Payer: Aetna of IA Commercial	$534.60
Rate for Payer: Aetna of IA Medical Rental Products	$534.60
Rate for Payer: Aetna of IA Medicare	$338.58
Rate for Payer: Amerigroup Medicaid	$342.62
Rate for Payer: Amerigroup Medicare	$269.97
Rate for Payer: Cash Price	$475.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$445.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$267.30
Rate for Payer: Iowa Total Care Managed Medicaid	$339.29
Rate for Payer: Medical Associates Commercial	$445.50
Rate for Payer: Medical Associates Managed Medicare	$267.30
Rate for Payer: Midlands Choice Commercial	$415.80
Rate for Payer: Molina Healthcare Managed Medicaid	$344.28
Rate for Payer: Partners Health Alliance Commercial	$307.39
Rate for Payer: United Healthcare Commercial	$534.60
Rate for Payer: United Healthcare Managed Medicare	$350.46

PUSHLOCK DISPOSABLE KIT FOR HIP

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8047063
Hospital Revenue Code	278
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Aetna of IA Medicare	$179.55
Rate for Payer: Amerigroup Medicaid	$181.69
Rate for Payer: Amerigroup Medicare	$143.17
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$141.75
Rate for Payer: Iowa Total Care Managed Medicaid	$179.93
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Medical Associates Managed Medicare	$141.75
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: Molina Healthcare Managed Medicaid	$182.57
Rate for Payer: Partners Health Alliance Commercial	$163.01
Rate for Payer: United Healthcare Commercial	$283.50
Rate for Payer: United Healthcare Managed Medicare	$185.85

PUSHLOCK DISPOSABLE KIT FOR HIP

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8047063
Hospital Revenue Code	278
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$283.50

PUSHLOCK KIT

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8026411
Hospital Revenue Code	278
Min. Negotiated Rate	$220.50
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: United Healthcare Commercial	$283.50

PUSHLOCK KIT

Facility

$315.00

Service Code	HCPCS C1713
Hospital Charge Code	8026411
Hospital Revenue Code	278
Min. Negotiated Rate	$141.75
Max. Negotiated Rate	$283.50
Rate for Payer: Aetna of IA Commercial	$283.50
Rate for Payer: Aetna of IA Medical Rental Products	$283.50
Rate for Payer: Aetna of IA Medicare	$179.55
Rate for Payer: Amerigroup Medicaid	$181.69
Rate for Payer: Amerigroup Medicare	$143.17
Rate for Payer: Cash Price	$252.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$236.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$141.75
Rate for Payer: Iowa Total Care Managed Medicaid	$179.93
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Medical Associates Managed Medicare	$141.75
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: Molina Healthcare Managed Medicaid	$182.57
Rate for Payer: Partners Health Alliance Commercial	$163.01
Rate for Payer: United Healthcare Commercial	$283.50
Rate for Payer: United Healthcare Managed Medicare	$185.85

pyridostiGMine 5 mg/mL Inj Sol [VDMC]

Facility

$140.62

Service Code	HCPCS J3490
Hospital Charge Code	10417699
Hospital Revenue Code	259
Min. Negotiated Rate	$63.28
Max. Negotiated Rate	$126.56
Rate for Payer: Aetna of IA Commercial	$126.56
Rate for Payer: Aetna of IA Medical Rental Products	$126.56
Rate for Payer: Aetna of IA Medicare	$80.15
Rate for Payer: Amerigroup Medicaid	$81.11
Rate for Payer: Amerigroup Medicare	$63.91
Rate for Payer: Cash Price	$112.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.47
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$63.28
Rate for Payer: Iowa Total Care Managed Medicaid	$80.32
Rate for Payer: Medical Associates Commercial	$105.47
Rate for Payer: Medical Associates Managed Medicare	$63.28
Rate for Payer: Midlands Choice Commercial	$98.43
Rate for Payer: Molina Healthcare Managed Medicaid	$81.50
Rate for Payer: Partners Health Alliance Commercial	$72.77
Rate for Payer: United Healthcare Commercial	$126.56
Rate for Payer: United Healthcare Managed Medicare	$82.97

pyridostiGMine 5 mg/mL Inj Sol [VDMC]

Facility

$140.62

Service Code	HCPCS J3490
Hospital Charge Code	10417699
Hospital Revenue Code	259
Min. Negotiated Rate	$98.43
Max. Negotiated Rate	$126.56
Rate for Payer: Aetna of IA Commercial	$126.56
Rate for Payer: Aetna of IA Medical Rental Products	$126.56
Rate for Payer: Cash Price	$112.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.47
Rate for Payer: Medical Associates Commercial	$105.47
Rate for Payer: Midlands Choice Commercial	$98.43
Rate for Payer: United Healthcare Commercial	$126.56

pyridostiGMine 60 mg Tab [VDMC]

Facility

$2.11

Service Code	HCPCS A9270
Hospital Charge Code	10417770
Hospital Revenue Code	259
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.89
Rate for Payer: Aetna of IA Commercial	$1.89
Rate for Payer: Aetna of IA Medical Rental Products	$1.89
Rate for Payer: Cash Price	$1.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Midlands Choice Commercial	$1.47
Rate for Payer: United Healthcare Commercial	$1.89

pyridostiGMine 60 mg Tab [VDMC]

Facility

$2.11

Service Code	HCPCS A9270
Hospital Charge Code	10417770
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.89
Rate for Payer: Aetna of IA Commercial	$1.89
Rate for Payer: Aetna of IA Medical Rental Products	$1.89
Rate for Payer: Aetna of IA Medicare	$1.20
Rate for Payer: Amerigroup Medicaid	$1.21
Rate for Payer: Amerigroup Medicare	$0.96
Rate for Payer: Cash Price	$1.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.95
Rate for Payer: Iowa Total Care Managed Medicaid	$1.20
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Medical Associates Managed Medicare	$0.95
Rate for Payer: Midlands Choice Commercial	$1.47
Rate for Payer: Molina Healthcare Managed Medicaid	$1.22
Rate for Payer: Partners Health Alliance Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.89
Rate for Payer: United Healthcare Managed Medicare	$1.24

pyridoxine 100 mg/mL 1ml MDV Inj [VDMC]

Facility

$51.24

Service Code	HCPCS J3415
Hospital Charge Code	10417841
Hospital Revenue Code	259
Min. Negotiated Rate	$23.06
Max. Negotiated Rate	$46.11
Rate for Payer: Aetna of IA Commercial	$46.11
Rate for Payer: Aetna of IA Medical Rental Products	$46.11
Rate for Payer: Aetna of IA Medicare	$29.20
Rate for Payer: Amerigroup Medicaid	$29.55
Rate for Payer: Amerigroup Medicare	$23.29
Rate for Payer: Cash Price	$40.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$38.43
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.06
Rate for Payer: Iowa Total Care Managed Medicaid	$29.27
Rate for Payer: Medical Associates Commercial	$38.43
Rate for Payer: Medical Associates Managed Medicare	$23.06
Rate for Payer: Midlands Choice Commercial	$35.87
Rate for Payer: Molina Healthcare Managed Medicaid	$29.70
Rate for Payer: Partners Health Alliance Commercial	$26.52
Rate for Payer: United Healthcare Commercial	$46.11
Rate for Payer: United Healthcare Managed Medicare	$30.23

pyridoxine 100 mg/mL 1ml MDV Inj [VDMC]

Facility

$51.24

Service Code	HCPCS J3415
Hospital Charge Code	10417841
Hospital Revenue Code	259
Min. Negotiated Rate	$35.87
Max. Negotiated Rate	$46.11
Rate for Payer: Aetna of IA Commercial	$46.11
Rate for Payer: Aetna of IA Medical Rental Products	$46.11
Rate for Payer: Cash Price	$40.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$38.43
Rate for Payer: Medical Associates Commercial	$38.43
Rate for Payer: Midlands Choice Commercial	$35.87
Rate for Payer: United Healthcare Commercial	$46.11

Know your out-of-pocket cost for care.

All Charges