Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

patiromer 16.8 g Pow [VDMC]

Facility

$113.69

Service Code	HCPCS A9270
Hospital Charge Code	18292192
Hospital Revenue Code	259
Min. Negotiated Rate	$79.59
Max. Negotiated Rate	$102.33
Rate for Payer: Aetna of IA Commercial	$102.33
Rate for Payer: Aetna of IA Medical Rental Products	$102.33
Rate for Payer: Cash Price	$90.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.27
Rate for Payer: Medical Associates Commercial	$85.27
Rate for Payer: Midlands Choice Commercial	$79.59
Rate for Payer: United Healthcare Commercial	$102.33

patiromer 16.8 g Pow [VDMC]

Facility

$113.69

Service Code	HCPCS A9270
Hospital Charge Code	18292192
Hospital Revenue Code	259
Min. Negotiated Rate	$51.16
Max. Negotiated Rate	$102.33
Rate for Payer: Aetna of IA Commercial	$102.33
Rate for Payer: Aetna of IA Medical Rental Products	$102.33
Rate for Payer: Aetna of IA Medicare	$64.81
Rate for Payer: Amerigroup Medicaid	$65.58
Rate for Payer: Amerigroup Medicare	$51.67
Rate for Payer: Cash Price	$90.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.16
Rate for Payer: Iowa Total Care Managed Medicaid	$64.94
Rate for Payer: Medical Associates Commercial	$85.27
Rate for Payer: Medical Associates Managed Medicare	$51.16
Rate for Payer: Midlands Choice Commercial	$79.59
Rate for Payer: Molina Healthcare Managed Medicaid	$65.90
Rate for Payer: Partners Health Alliance Commercial	$58.84
Rate for Payer: United Healthcare Commercial	$102.33
Rate for Payer: United Healthcare Managed Medicare	$67.08

patiromer 8.4 g Pow [VDMC]

Facility

$78.57

Service Code	HCPCS A9270
Hospital Charge Code	27933279
Hospital Revenue Code	259
Min. Negotiated Rate	$35.36
Max. Negotiated Rate	$70.71
Rate for Payer: Aetna of IA Commercial	$70.71
Rate for Payer: Aetna of IA Medical Rental Products	$70.71
Rate for Payer: Aetna of IA Medicare	$44.78
Rate for Payer: Amerigroup Medicaid	$45.32
Rate for Payer: Amerigroup Medicare	$35.71
Rate for Payer: Cash Price	$62.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.93
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.36
Rate for Payer: Iowa Total Care Managed Medicaid	$44.88
Rate for Payer: Medical Associates Commercial	$58.93
Rate for Payer: Medical Associates Managed Medicare	$35.36
Rate for Payer: Midlands Choice Commercial	$55.00
Rate for Payer: Molina Healthcare Managed Medicaid	$45.54
Rate for Payer: Partners Health Alliance Commercial	$40.66
Rate for Payer: United Healthcare Commercial	$70.71
Rate for Payer: United Healthcare Managed Medicare	$46.36

patiromer 8.4 g Pow [VDMC]

Facility

$78.57

Service Code	HCPCS A9270
Hospital Charge Code	27933279
Hospital Revenue Code	259
Min. Negotiated Rate	$55.00
Max. Negotiated Rate	$70.71
Rate for Payer: Aetna of IA Commercial	$70.71
Rate for Payer: Aetna of IA Medical Rental Products	$70.71
Rate for Payer: Cash Price	$62.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.93
Rate for Payer: Medical Associates Commercial	$58.93
Rate for Payer: Midlands Choice Commercial	$55.00
Rate for Payer: United Healthcare Commercial	$70.71

Peds Med Surg

Facility

$1,300.00

Hospital Charge Code	8002759
Hospital Revenue Code	113
Min. Negotiated Rate	$910.00
Max. Negotiated Rate	$2,580.60
Rate for Payer: Aetna of IA Commercial	$1,170.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,170.00
Rate for Payer: Aetna of IA Medicare	$2,258.00
Rate for Payer: Amerigroup Medicare	$2,266.44
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Cash Price	$1,040.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$975.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,244.00
Rate for Payer: Medical Associates Commercial	$975.00
Rate for Payer: Medical Associates Managed Medicare	$2,244.00
Rate for Payer: Midlands Choice Commercial	$910.00
Rate for Payer: Partners Health Alliance Commercial	$2,580.60
Rate for Payer: United Healthcare Commercial	$1,170.00
Rate for Payer: United Healthcare Managed Medicare	$1,306.00

peg 3350 electrolytes100-7.5-2.691gm Oral Pwdr for Sol [VDMC]

Facility

$214.24

Service Code	HCPCS A9270
Hospital Charge Code	10412200
Hospital Revenue Code	259
Min. Negotiated Rate	$149.97
Max. Negotiated Rate	$192.82
Rate for Payer: Aetna of IA Commercial	$192.82
Rate for Payer: Aetna of IA Medical Rental Products	$192.82
Rate for Payer: Cash Price	$171.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$160.68
Rate for Payer: Medical Associates Commercial	$160.68
Rate for Payer: Midlands Choice Commercial	$149.97
Rate for Payer: United Healthcare Commercial	$192.82

peg 3350 electrolytes100-7.5-2.691gm Oral Pwdr for Sol [VDMC]

Facility

$214.24

Service Code	HCPCS A9270
Hospital Charge Code	10412200
Hospital Revenue Code	259
Min. Negotiated Rate	$96.41
Max. Negotiated Rate	$192.82
Rate for Payer: Aetna of IA Commercial	$192.82
Rate for Payer: Aetna of IA Medical Rental Products	$192.82
Rate for Payer: Aetna of IA Medicare	$122.12
Rate for Payer: Amerigroup Medicaid	$123.57
Rate for Payer: Amerigroup Medicare	$97.37
Rate for Payer: Cash Price	$171.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$160.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$96.41
Rate for Payer: Iowa Total Care Managed Medicaid	$122.37
Rate for Payer: Medical Associates Commercial	$160.68
Rate for Payer: Medical Associates Managed Medicare	$96.41
Rate for Payer: Midlands Choice Commercial	$149.97
Rate for Payer: Molina Healthcare Managed Medicaid	$124.17
Rate for Payer: Partners Health Alliance Commercial	$110.87
Rate for Payer: United Healthcare Commercial	$192.82
Rate for Payer: United Healthcare Managed Medicare	$126.40

PEG 3350 electrolytes Oral Pwdr for Sol 4000 mL [VDMC]

Facility

$98.68

Service Code	HCPCS A9270
Hospital Charge Code	10414263
Hospital Revenue Code	259
Min. Negotiated Rate	$44.41
Max. Negotiated Rate	$88.81
Rate for Payer: Aetna of IA Commercial	$88.81
Rate for Payer: Aetna of IA Medical Rental Products	$88.81
Rate for Payer: Aetna of IA Medicare	$56.25
Rate for Payer: Amerigroup Medicaid	$56.92
Rate for Payer: Amerigroup Medicare	$44.85
Rate for Payer: Cash Price	$78.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.01
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.41
Rate for Payer: Iowa Total Care Managed Medicaid	$56.37
Rate for Payer: Medical Associates Commercial	$74.01
Rate for Payer: Medical Associates Managed Medicare	$44.41
Rate for Payer: Midlands Choice Commercial	$69.08
Rate for Payer: Molina Healthcare Managed Medicaid	$57.19
Rate for Payer: Partners Health Alliance Commercial	$51.07
Rate for Payer: United Healthcare Commercial	$88.81
Rate for Payer: United Healthcare Managed Medicare	$58.22

PEG 3350 electrolytes Oral Pwdr for Sol 4000 mL [VDMC]

Facility

$98.68

Service Code	HCPCS A9270
Hospital Charge Code	10414263
Hospital Revenue Code	259
Min. Negotiated Rate	$69.08
Max. Negotiated Rate	$88.81
Rate for Payer: Aetna of IA Commercial	$88.81
Rate for Payer: Aetna of IA Medical Rental Products	$88.81
Rate for Payer: Cash Price	$78.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.01
Rate for Payer: Medical Associates Commercial	$74.01
Rate for Payer: Midlands Choice Commercial	$69.08
Rate for Payer: United Healthcare Commercial	$88.81

peg 400-propylene glycol drops [VDMC]

Facility

$56.44

Service Code	HCPCS A9270
Hospital Charge Code	10409939
Hospital Revenue Code	259
Min. Negotiated Rate	$39.51
Max. Negotiated Rate	$50.80
Rate for Payer: Aetna of IA Commercial	$50.80
Rate for Payer: Aetna of IA Medical Rental Products	$50.80
Rate for Payer: Cash Price	$45.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.33
Rate for Payer: Medical Associates Commercial	$42.33
Rate for Payer: Midlands Choice Commercial	$39.51
Rate for Payer: United Healthcare Commercial	$50.80

peg 400-propylene glycol drops [VDMC]

Facility

$56.44

Service Code	HCPCS A9270
Hospital Charge Code	10409939
Hospital Revenue Code	259
Min. Negotiated Rate	$25.40
Max. Negotiated Rate	$50.80
Rate for Payer: Aetna of IA Commercial	$50.80
Rate for Payer: Aetna of IA Medical Rental Products	$50.80
Rate for Payer: Aetna of IA Medicare	$32.17
Rate for Payer: Amerigroup Medicaid	$32.55
Rate for Payer: Amerigroup Medicare	$25.65
Rate for Payer: Cash Price	$45.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.33
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.40
Rate for Payer: Iowa Total Care Managed Medicaid	$32.24
Rate for Payer: Medical Associates Commercial	$42.33
Rate for Payer: Medical Associates Managed Medicare	$25.40
Rate for Payer: Midlands Choice Commercial	$39.51
Rate for Payer: Molina Healthcare Managed Medicaid	$32.71
Rate for Payer: Partners Health Alliance Commercial	$29.21
Rate for Payer: United Healthcare Commercial	$50.80
Rate for Payer: United Healthcare Managed Medicare	$33.30

pegfilgrastim 6 mg/0.6 mL SubQ SDV Inj [VDMC]

Facility

$8,399.00

Service Code	HCPCS J2506
Hospital Charge Code	10412131
Hospital Revenue Code	259
Min. Negotiated Rate	$5,879.30
Max. Negotiated Rate	$7,559.10
Rate for Payer: Aetna of IA Commercial	$7,559.10
Rate for Payer: Aetna of IA Medical Rental Products	$7,559.10
Rate for Payer: Cash Price	$6,719.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,299.25
Rate for Payer: Medical Associates Commercial	$6,299.25
Rate for Payer: Midlands Choice Commercial	$5,879.30
Rate for Payer: United Healthcare Commercial	$7,559.10

pegfilgrastim 6 mg/0.6 mL SubQ SDV Inj [VDMC]

Facility

$8,399.00

Service Code	HCPCS J2506
Hospital Charge Code	10412131
Hospital Revenue Code	259
Min. Negotiated Rate	$3,779.55
Max. Negotiated Rate	$7,559.10
Rate for Payer: Aetna of IA Commercial	$7,559.10
Rate for Payer: Aetna of IA Medical Rental Products	$7,559.10
Rate for Payer: Aetna of IA Medicare	$4,787.43
Rate for Payer: Amerigroup Medicaid	$4,844.54
Rate for Payer: Amerigroup Medicare	$3,817.35
Rate for Payer: Cash Price	$6,719.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,299.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,779.55
Rate for Payer: Iowa Total Care Managed Medicaid	$4,797.51
Rate for Payer: Medical Associates Commercial	$6,299.25
Rate for Payer: Medical Associates Managed Medicare	$3,779.55
Rate for Payer: Midlands Choice Commercial	$5,879.30
Rate for Payer: Molina Healthcare Managed Medicaid	$4,868.06
Rate for Payer: Partners Health Alliance Commercial	$4,346.48
Rate for Payer: United Healthcare Commercial	$7,559.10
Rate for Payer: United Healthcare Managed Medicare	$4,955.41

pegfilgrastim-apgf 6 mg/0.6 mL SubQ PFS Inj [VDMC]

Facility

$7,675.26

Service Code	HCPCS Q5122
Hospital Charge Code	27690722
Hospital Revenue Code	259
Min. Negotiated Rate	$3,453.87
Max. Negotiated Rate	$6,907.73
Rate for Payer: Aetna of IA Commercial	$6,907.73
Rate for Payer: Aetna of IA Medical Rental Products	$6,907.73
Rate for Payer: Aetna of IA Medicare	$4,374.90
Rate for Payer: Amerigroup Medicaid	$4,427.09
Rate for Payer: Amerigroup Medicare	$3,488.41
Rate for Payer: Cash Price	$6,140.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,756.44
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,453.87
Rate for Payer: Iowa Total Care Managed Medicaid	$4,384.11
Rate for Payer: Medical Associates Commercial	$5,756.44
Rate for Payer: Medical Associates Managed Medicare	$3,453.87
Rate for Payer: Midlands Choice Commercial	$5,372.68
Rate for Payer: Molina Healthcare Managed Medicaid	$4,448.58
Rate for Payer: Partners Health Alliance Commercial	$3,971.95
Rate for Payer: United Healthcare Commercial	$6,907.73
Rate for Payer: United Healthcare Managed Medicare	$4,528.40

pegfilgrastim-apgf 6 mg/0.6 mL SubQ PFS Inj [VDMC]

Facility

$7,675.26

Service Code	HCPCS Q5122
Hospital Charge Code	27690722
Hospital Revenue Code	259
Min. Negotiated Rate	$5,372.68
Max. Negotiated Rate	$6,907.73
Rate for Payer: Aetna of IA Commercial	$6,907.73
Rate for Payer: Aetna of IA Medical Rental Products	$6,907.73
Rate for Payer: Cash Price	$6,140.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,756.44
Rate for Payer: Medical Associates Commercial	$5,756.44
Rate for Payer: Midlands Choice Commercial	$5,372.68
Rate for Payer: United Healthcare Commercial	$6,907.73

pegfilgrastim-jmdb 6 mg/0.6 mL SubQ PFS Inj[VDMC]

Facility

$3,458.20

Service Code	HCPCS Q5108
Hospital Charge Code	28403492
Hospital Revenue Code	259
Min. Negotiated Rate	$2,420.74
Max. Negotiated Rate	$3,112.38
Rate for Payer: Aetna of IA Commercial	$3,112.38
Rate for Payer: Aetna of IA Medical Rental Products	$3,112.38
Rate for Payer: Cash Price	$2,766.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,593.65
Rate for Payer: Medical Associates Commercial	$2,593.65
Rate for Payer: Midlands Choice Commercial	$2,420.74
Rate for Payer: United Healthcare Commercial	$3,112.38

pegfilgrastim-jmdb 6 mg/0.6 mL SubQ PFS Inj[VDMC]

Facility

$3,458.20

Service Code	HCPCS Q5108
Hospital Charge Code	28403492
Hospital Revenue Code	259
Min. Negotiated Rate	$1,556.19
Max. Negotiated Rate	$3,112.38
Rate for Payer: Aetna of IA Commercial	$3,112.38
Rate for Payer: Aetna of IA Medical Rental Products	$3,112.38
Rate for Payer: Aetna of IA Medicare	$1,971.17
Rate for Payer: Amerigroup Medicaid	$1,994.69
Rate for Payer: Amerigroup Medicare	$1,571.75
Rate for Payer: Cash Price	$2,766.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,593.65
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,556.19
Rate for Payer: Iowa Total Care Managed Medicaid	$1,975.32
Rate for Payer: Medical Associates Commercial	$2,593.65
Rate for Payer: Medical Associates Managed Medicare	$1,556.19
Rate for Payer: Midlands Choice Commercial	$2,420.74
Rate for Payer: Molina Healthcare Managed Medicaid	$2,004.37
Rate for Payer: Partners Health Alliance Commercial	$1,789.62
Rate for Payer: United Healthcare Commercial	$3,112.38
Rate for Payer: United Healthcare Managed Medicare	$2,040.34

PEGGED GLENOID POLY W/PEG LARGE

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047277
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.75
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Aetna of IA Medicare	$1,615.95
Rate for Payer: Amerigroup Medicaid	$1,635.23
Rate for Payer: Amerigroup Medicare	$1,288.51
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,275.75
Rate for Payer: Iowa Total Care Managed Medicaid	$1,619.35
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Medical Associates Managed Medicare	$1,275.75
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,643.17
Rate for Payer: Partners Health Alliance Commercial	$1,467.11
Rate for Payer: United Healthcare Commercial	$2,551.50
Rate for Payer: United Healthcare Managed Medicare	$1,672.65

PEGGED GLENOID POLY W/PEG LARGE

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047277
Hospital Revenue Code	278
Min. Negotiated Rate	$1,984.50
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: United Healthcare Commercial	$2,551.50

PEGGED GLENOID POLY W/PEG MEDIUM

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047276
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.75
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Aetna of IA Medicare	$1,615.95
Rate for Payer: Amerigroup Medicaid	$1,635.23
Rate for Payer: Amerigroup Medicare	$1,288.51
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,275.75
Rate for Payer: Iowa Total Care Managed Medicaid	$1,619.35
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Medical Associates Managed Medicare	$1,275.75
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,643.17
Rate for Payer: Partners Health Alliance Commercial	$1,467.11
Rate for Payer: United Healthcare Commercial	$2,551.50
Rate for Payer: United Healthcare Managed Medicare	$1,672.65

PEGGED GLENOID POLY W/PEG MEDIUM

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047276
Hospital Revenue Code	278
Min. Negotiated Rate	$1,984.50
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: United Healthcare Commercial	$2,551.50

PEGGED GLENOID POLY W/PEG SMALL

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047275
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.75
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Aetna of IA Medicare	$1,615.95
Rate for Payer: Amerigroup Medicaid	$1,635.23
Rate for Payer: Amerigroup Medicare	$1,288.51
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,275.75
Rate for Payer: Iowa Total Care Managed Medicaid	$1,619.35
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Medical Associates Managed Medicare	$1,275.75
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,643.17
Rate for Payer: Partners Health Alliance Commercial	$1,467.11
Rate for Payer: United Healthcare Commercial	$2,551.50
Rate for Payer: United Healthcare Managed Medicare	$1,672.65

PEGGED GLENOID POLY W/PEG SMALL

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047275
Hospital Revenue Code	278
Min. Negotiated Rate	$1,984.50
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: United Healthcare Commercial	$2,551.50

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC

Facility

$19,258.71

Service Code	MSDRG 734
Min. Negotiated Rate	$18,979.59
Max. Negotiated Rate	$19,258.71
Rate for Payer: Amerigroup Medicaid	$19,165.66
Rate for Payer: Iowa Total Care Managed Medicaid	$18,979.59
Rate for Payer: Molina Healthcare Managed Medicaid	$19,258.71

PELVIC EVISCERATION, RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC

Facility

$18,640.55

Service Code	MSDRG 735
Min. Negotiated Rate	$18,370.39
Max. Negotiated Rate	$18,640.55
Rate for Payer: Amerigroup Medicaid	$18,550.49
Rate for Payer: Iowa Total Care Managed Medicaid	$18,370.39
Rate for Payer: Molina Healthcare Managed Medicaid	$18,640.55

Know your out-of-pocket cost for care.

All Charges