Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PARAFFIN BATH APPLICATION

Facility

$73.00

Service Code	CPT 97018 GP
Hospital Charge Code	1373914
Hospital Revenue Code	420
Min. Negotiated Rate	$32.85
Max. Negotiated Rate	$81.22
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Aetna of IA Medicare	$41.61
Rate for Payer: Amerigroup Medicaid	$42.11
Rate for Payer: Amerigroup Medicare	$33.18
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.85
Rate for Payer: Iowa Total Care Managed Medicaid	$41.70
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Medical Associates Managed Medicare	$32.85
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: Molina Healthcare Managed Medicaid	$42.31
Rate for Payer: Partners Health Alliance Commercial	$37.78
Rate for Payer: United Healthcare Commercial	$65.70
Rate for Payer: United Healthcare Managed Medicare	$43.07
Rate for Payer: Wellmark IA HMO WHPI	$73.74
Rate for Payer: Wellmark IA PPO	$81.22

Parathyroid Hormone Intact DMCL

Facility

$281.00

Service Code	CPT 83970
Hospital Charge Code	8037747
Hospital Revenue Code	301
Min. Negotiated Rate	$196.70
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of IA Commercial	$252.90
Rate for Payer: Aetna of IA Medical Rental Products	$252.90
Rate for Payer: Cash Price	$224.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$210.75
Rate for Payer: Medical Associates Commercial	$210.75
Rate for Payer: Midlands Choice Commercial	$196.70
Rate for Payer: United Healthcare Commercial	$252.90

Parathyroid Hormone Intact DMCL

Facility

$281.00

Service Code	CPT 83970
Hospital Charge Code	8037747
Hospital Revenue Code	301
Min. Negotiated Rate	$82.95
Max. Negotiated Rate	$252.90
Rate for Payer: Aetna of IA Commercial	$252.90
Rate for Payer: Aetna of IA Medical Rental Products	$252.90
Rate for Payer: Aetna of IA Medicare	$160.17
Rate for Payer: Amerigroup Medicaid	$162.08
Rate for Payer: Amerigroup Medicare	$127.71
Rate for Payer: Cash Price	$224.80
Rate for Payer: Cash Price	$224.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$210.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$126.45
Rate for Payer: Iowa Total Care Managed Medicaid	$160.51
Rate for Payer: Medical Associates Commercial	$210.75
Rate for Payer: Medical Associates Managed Medicare	$126.45
Rate for Payer: Midlands Choice Commercial	$196.70
Rate for Payer: Molina Healthcare Managed Medicaid	$162.87
Rate for Payer: Partners Health Alliance Commercial	$145.42
Rate for Payer: United Healthcare Commercial	$252.90
Rate for Payer: United Healthcare Managed Medicare	$165.79
Rate for Payer: Wellmark IA HMO WHPI	$82.95
Rate for Payer: Wellmark IA PPO	$91.38

paricalcitol 5 mcg/mL Sol SDV Inj Sol [VDMC]

Facility

$30.10

Service Code	HCPCS J2501
Hospital Charge Code	23689427
Hospital Revenue Code	259
Min. Negotiated Rate	$21.07
Max. Negotiated Rate	$27.09
Rate for Payer: Aetna of IA Commercial	$27.09
Rate for Payer: Aetna of IA Medical Rental Products	$27.09
Rate for Payer: Cash Price	$24.08
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.58
Rate for Payer: Medical Associates Commercial	$22.58
Rate for Payer: Midlands Choice Commercial	$21.07
Rate for Payer: United Healthcare Commercial	$27.09

paricalcitol 5 mcg/mL Sol SDV Inj Sol [VDMC]

Facility

$30.10

Service Code	HCPCS J2501
Hospital Charge Code	23689427
Hospital Revenue Code	259
Min. Negotiated Rate	$13.55
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$27.09
Rate for Payer: Aetna of IA Medical Rental Products	$27.09
Rate for Payer: Aetna of IA Medicare	$17.16
Rate for Payer: Amerigroup Medicaid	$17.36
Rate for Payer: Amerigroup Medicare	$13.68
Rate for Payer: Cash Price	$24.08
Rate for Payer: Cash Price	$24.08
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.55
Rate for Payer: Iowa Total Care Managed Medicaid	$17.20
Rate for Payer: Medical Associates Commercial	$22.58
Rate for Payer: Medical Associates Managed Medicare	$13.55
Rate for Payer: Midlands Choice Commercial	$21.07
Rate for Payer: Molina Healthcare Managed Medicaid	$17.45
Rate for Payer: Partners Health Alliance Commercial	$15.58
Rate for Payer: United Healthcare Commercial	$27.09
Rate for Payer: United Healthcare Managed Medicare	$17.76
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Parietal Cell Antibody DMCL

Facility

$114.00

Service Code	CPT 86256
Hospital Charge Code	8037748
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

Parietal Cell Antibody DMCL

Facility

$114.00

Service Code	CPT 86256
Hospital Charge Code	8037748
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

PARING OF CORN/CALLUS 2-4

Facility

$144.00

Service Code	CPT 11056
Hospital Charge Code	7438806
Hospital Revenue Code	510
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$129.60
Rate for Payer: Aetna of IA Commercial	$129.60
Rate for Payer: Aetna of IA Medical Rental Products	$129.60
Rate for Payer: Cash Price	$115.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.00
Rate for Payer: Medical Associates Commercial	$108.00
Rate for Payer: Midlands Choice Commercial	$100.80
Rate for Payer: United Healthcare Commercial	$129.60

PARING OF CORN/CALLUS 2-4

Facility

$144.00

Service Code	CPT 11056
Hospital Charge Code	7438806
Hospital Revenue Code	510
Min. Negotiated Rate	$64.80
Max. Negotiated Rate	$333.49
Rate for Payer: Aetna of IA Commercial	$129.60
Rate for Payer: Aetna of IA Medical Rental Products	$129.60
Rate for Payer: Aetna of IA Medicare	$82.08
Rate for Payer: Amerigroup Medicaid	$83.06
Rate for Payer: Amerigroup Medicare	$65.45
Rate for Payer: Cash Price	$115.20
Rate for Payer: Cash Price	$115.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.80
Rate for Payer: Iowa Total Care Managed Medicaid	$82.25
Rate for Payer: Medical Associates Commercial	$108.00
Rate for Payer: Medical Associates Managed Medicare	$64.80
Rate for Payer: Midlands Choice Commercial	$100.80
Rate for Payer: Molina Healthcare Managed Medicaid	$83.46
Rate for Payer: Partners Health Alliance Commercial	$74.52
Rate for Payer: United Healthcare Commercial	$129.60
Rate for Payer: United Healthcare Managed Medicare	$84.96
Rate for Payer: Wellmark IA HMO WHPI	$302.74
Rate for Payer: Wellmark IA PPO	$333.49

PARoxetine 12.5 mg ER Tab [VDMC]

Facility

$3.27

Service Code	HCPCS A9270
Hospital Charge Code	10411863
Hospital Revenue Code	259
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$2.95
Rate for Payer: Aetna of IA Commercial	$2.95
Rate for Payer: Aetna of IA Medical Rental Products	$2.95
Rate for Payer: Aetna of IA Medicare	$1.87
Rate for Payer: Amerigroup Medicaid	$1.89
Rate for Payer: Amerigroup Medicare	$1.49
Rate for Payer: Cash Price	$2.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.45
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.47
Rate for Payer: Iowa Total Care Managed Medicaid	$1.87
Rate for Payer: Medical Associates Commercial	$2.45
Rate for Payer: Medical Associates Managed Medicare	$1.47
Rate for Payer: Midlands Choice Commercial	$2.29
Rate for Payer: Molina Healthcare Managed Medicaid	$1.90
Rate for Payer: Partners Health Alliance Commercial	$1.69
Rate for Payer: United Healthcare Commercial	$2.95
Rate for Payer: United Healthcare Managed Medicare	$1.93

PARoxetine 12.5 mg ER Tab [VDMC]

Facility

$3.27

Service Code	HCPCS A9270
Hospital Charge Code	10411863
Hospital Revenue Code	259
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$2.95
Rate for Payer: Aetna of IA Commercial	$2.95
Rate for Payer: Aetna of IA Medical Rental Products	$2.95
Rate for Payer: Cash Price	$2.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.45
Rate for Payer: Medical Associates Commercial	$2.45
Rate for Payer: Midlands Choice Commercial	$2.29
Rate for Payer: United Healthcare Commercial	$2.95

PARoxetine 20 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10411932
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Cash Price	$1.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.40

PARoxetine 20 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10411932
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Aetna of IA Medicare	$0.89
Rate for Payer: Amerigroup Medicaid	$0.90
Rate for Payer: Amerigroup Medicare	$0.71
Rate for Payer: Cash Price	$1.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.70
Rate for Payer: Iowa Total Care Managed Medicaid	$0.89
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: Molina Healthcare Managed Medicaid	$0.90
Rate for Payer: Partners Health Alliance Commercial	$0.80
Rate for Payer: United Healthcare Commercial	$1.40
Rate for Payer: United Healthcare Managed Medicare	$0.92

PARS SUTURE IMPLANT KIT W/SUTURETAPE

Facility

$2,691.00

Service Code	HCPCS C1713
Hospital Charge Code	8783230
Hospital Revenue Code	278
Min. Negotiated Rate	$1,883.70
Max. Negotiated Rate	$2,421.90
Rate for Payer: Aetna of IA Commercial	$2,421.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,421.90
Rate for Payer: Cash Price	$2,152.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,018.25
Rate for Payer: Medical Associates Commercial	$2,018.25
Rate for Payer: Midlands Choice Commercial	$1,883.70
Rate for Payer: United Healthcare Commercial	$2,421.90

PARS SUTURE IMPLANT KIT W/SUTURETAPE

Facility

$2,691.00

Service Code	HCPCS C1713
Hospital Charge Code	8783230
Hospital Revenue Code	278
Min. Negotiated Rate	$1,210.95
Max. Negotiated Rate	$2,421.90
Rate for Payer: Aetna of IA Commercial	$2,421.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,421.90
Rate for Payer: Aetna of IA Medicare	$1,533.87
Rate for Payer: Amerigroup Medicaid	$1,552.17
Rate for Payer: Amerigroup Medicare	$1,223.06
Rate for Payer: Cash Price	$2,152.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,018.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,210.95
Rate for Payer: Iowa Total Care Managed Medicaid	$1,537.10
Rate for Payer: Medical Associates Commercial	$2,018.25
Rate for Payer: Medical Associates Managed Medicare	$1,210.95
Rate for Payer: Midlands Choice Commercial	$1,883.70
Rate for Payer: Molina Healthcare Managed Medicaid	$1,559.70
Rate for Payer: Partners Health Alliance Commercial	$1,392.59
Rate for Payer: United Healthcare Commercial	$2,421.90
Rate for Payer: United Healthcare Managed Medicare	$1,587.69

PARTIAL EXCISION (CRATERIZATION, SAUCERIZATION, OR DIAPHYSECTOMY) BONE (EG, OSTEOMYELITIS); PROXIMAL OR MIDDLE PHALANX OF FINGER

Facility

$6,713.48

Service Code	CPT 26235
Hospital Revenue Code	360
Min. Negotiated Rate	$6,094.56
Max. Negotiated Rate	$6,713.48
Rate for Payer: Wellmark IA HMO WHPI	$6,094.56
Rate for Payer: Wellmark IA PPO	$6,713.48

PARTIAL REMOVAL OF RADIUS

Facility

$3,062.00

Service Code	CPT 25230
Hospital Charge Code	7982924
Hospital Revenue Code	450
Min. Negotiated Rate	$2,143.40
Max. Negotiated Rate	$2,755.80
Rate for Payer: Aetna of IA Commercial	$2,755.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,755.80
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,296.50
Rate for Payer: Medical Associates Commercial	$2,296.50
Rate for Payer: Midlands Choice Commercial	$2,143.40
Rate for Payer: United Healthcare Commercial	$2,755.80

PARTIAL REMOVAL OF RADIUS

Facility

$3,062.00

Service Code	CPT 25230
Hospital Charge Code	7982924
Hospital Revenue Code	450
Min. Negotiated Rate	$1,377.90
Max. Negotiated Rate	$4,391.56
Rate for Payer: Aetna of IA Commercial	$2,755.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,755.80
Rate for Payer: Aetna of IA Medicare	$1,745.34
Rate for Payer: Amerigroup Medicaid	$1,766.16
Rate for Payer: Amerigroup Medicare	$1,391.68
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,296.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,377.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1,749.01
Rate for Payer: Medical Associates Commercial	$2,296.50
Rate for Payer: Medical Associates Managed Medicare	$1,377.90
Rate for Payer: Midlands Choice Commercial	$2,143.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,774.74
Rate for Payer: Partners Health Alliance Commercial	$1,584.58
Rate for Payer: United Healthcare Commercial	$2,755.80
Rate for Payer: United Healthcare Managed Medicare	$1,806.58
Rate for Payer: Wellmark IA HMO WHPI	$3,986.71
Rate for Payer: Wellmark IA PPO	$4,391.56

Partial Thromboplastin Time DMCL

Facility

$64.00

Service Code	CPT 85730
Hospital Charge Code	8037749
Hospital Revenue Code	305
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

Partial Thromboplastin Time DMCL

Facility

$64.00

Service Code	CPT 85730
Hospital Charge Code	8037749
Hospital Revenue Code	305
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC

Facility

$15,095.97

Service Code	MSDRG 543
Min. Negotiated Rate	$14,877.18
Max. Negotiated Rate	$15,095.97
Rate for Payer: Amerigroup Medicaid	$15,023.04
Rate for Payer: Iowa Total Care Managed Medicaid	$14,877.18
Rate for Payer: Molina Healthcare Managed Medicaid	$15,095.97

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC

Facility

$17,271.36

Service Code	MSDRG 542
Min. Negotiated Rate	$17,021.04
Max. Negotiated Rate	$17,271.36
Rate for Payer: Amerigroup Medicaid	$17,187.92
Rate for Payer: Iowa Total Care Managed Medicaid	$17,021.04
Rate for Payer: Molina Healthcare Managed Medicaid	$17,271.36

PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC

Facility

$5,368.66

Service Code	MSDRG 544
Min. Negotiated Rate	$5,290.85
Max. Negotiated Rate	$5,368.66
Rate for Payer: Amerigroup Medicaid	$5,342.72
Rate for Payer: Iowa Total Care Managed Medicaid	$5,290.85
Rate for Payer: Molina Healthcare Managed Medicaid	$5,368.66

Pathology Gyn Request DMCL

Facility

$110.00

Service Code	HCPCS G0123
Hospital Charge Code	8037736
Hospital Revenue Code	309
Min. Negotiated Rate	$49.50
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna of IA Commercial	$99.00
Rate for Payer: Aetna of IA Medical Rental Products	$99.00
Rate for Payer: Aetna of IA Medicare	$62.70
Rate for Payer: Amerigroup Medicaid	$63.45
Rate for Payer: Amerigroup Medicare	$50.00
Rate for Payer: Cash Price	$88.00
Rate for Payer: Cash Price	$88.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$82.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.50
Rate for Payer: Iowa Total Care Managed Medicaid	$62.83
Rate for Payer: Medical Associates Commercial	$82.50
Rate for Payer: Medical Associates Managed Medicare	$49.50
Rate for Payer: Midlands Choice Commercial	$77.00
Rate for Payer: Molina Healthcare Managed Medicaid	$63.76
Rate for Payer: Partners Health Alliance Commercial	$56.92
Rate for Payer: United Healthcare Commercial	$99.00
Rate for Payer: United Healthcare Managed Medicare	$64.90
Rate for Payer: Wellmark IA HMO WHPI	$51.76
Rate for Payer: Wellmark IA PPO	$57.01

Pathology Gyn Request DMCL

Facility

$110.00

Service Code	HCPCS G0123
Hospital Charge Code	8037736
Hospital Revenue Code	309
Min. Negotiated Rate	$77.00
Max. Negotiated Rate	$99.00
Rate for Payer: Aetna of IA Commercial	$99.00
Rate for Payer: Aetna of IA Medical Rental Products	$99.00
Rate for Payer: Cash Price	$88.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$82.50
Rate for Payer: Medical Associates Commercial	$82.50
Rate for Payer: Midlands Choice Commercial	$77.00
Rate for Payer: United Healthcare Commercial	$99.00

Know your out-of-pocket cost for care.

All Charges