Van Diest Medical Center

All Charges

Charge

Type

Price

rivaroxaban 15 mg Tab

Facility OP

$67.64

Service Code	CPT A9270
Hospital Charge Code	43701049
Hospital Revenue Code	637
Min. Negotiated Rate	$33.81
Max. Negotiated Rate	$60.88
Rate for Payer: Aetna of IA Commercial	$60.88
Rate for Payer: Aetna of IA Medical Rental Products	$60.88
Rate for Payer: Aetna of IA Medicare	$38.55
Rate for Payer: Amerigroup Medicaid	$34.14
Rate for Payer: Amerigroup Medicare	$34.16
Rate for Payer: Cash Price	$54.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.82
Rate for Payer: Iowa Total Care Managed Medicaid	$33.81
Rate for Payer: Medical Associates Commercial	$50.73
Rate for Payer: Medical Associates Managed Medicare	$33.82
Rate for Payer: Midlands Choice Commercial	$47.35
Rate for Payer: Molina Healthcare Managed Medicaid	$34.33
Rate for Payer: Partners Health Alliance Commercial	$50.73
Rate for Payer: United Healthcare Commercial	$60.88
Rate for Payer: United Healthcare Managed Medicare	$39.91

rivaroxaban 15 mg Tab

Facility IP

$67.64

Service Code	CPT A9270
Hospital Charge Code	43701049
Hospital Revenue Code	637
Min. Negotiated Rate	$47.35
Max. Negotiated Rate	$60.88
Rate for Payer: Aetna of IA Commercial	$60.88
Rate for Payer: Aetna of IA Medical Rental Products	$60.88
Rate for Payer: Cash Price	$54.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.73
Rate for Payer: Medical Associates Commercial	$50.73
Rate for Payer: Midlands Choice Commercial	$47.35
Rate for Payer: United Healthcare Commercial	$60.88

rivastiGMine 1.5 mg Cap

Facility IP

$2.73

Service Code	CPT A9270
Hospital Charge Code	43799271
Hospital Revenue Code	637
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.46
Rate for Payer: Aetna of IA Commercial	$2.46
Rate for Payer: Aetna of IA Medical Rental Products	$2.46
Rate for Payer: Cash Price	$2.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.05
Rate for Payer: Medical Associates Commercial	$2.05
Rate for Payer: Midlands Choice Commercial	$1.91
Rate for Payer: United Healthcare Commercial	$2.46

rivastiGMine 1.5 mg Cap

Facility OP

$2.73

Service Code	CPT A9270
Hospital Charge Code	43799271
Hospital Revenue Code	637
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$2.46
Rate for Payer: Aetna of IA Commercial	$2.46
Rate for Payer: Aetna of IA Medical Rental Products	$2.46
Rate for Payer: Aetna of IA Medicare	$1.56
Rate for Payer: Amerigroup Medicaid	$1.38
Rate for Payer: Amerigroup Medicare	$1.38
Rate for Payer: Cash Price	$2.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.36
Rate for Payer: Iowa Total Care Managed Medicaid	$1.36
Rate for Payer: Medical Associates Commercial	$2.05
Rate for Payer: Medical Associates Managed Medicare	$1.36
Rate for Payer: Midlands Choice Commercial	$1.91
Rate for Payer: Molina Healthcare Managed Medicaid	$1.39
Rate for Payer: Partners Health Alliance Commercial	$2.05
Rate for Payer: United Healthcare Commercial	$2.46
Rate for Payer: United Healthcare Managed Medicare	$1.61

rocuronium 10 mg/mL 5 ml MDV IV

Facility IP

$47.69

Service Code	CPT J3490
Hospital Charge Code	43700081
Hospital Revenue Code	636
Min. Negotiated Rate	$33.38
Max. Negotiated Rate	$42.92
Rate for Payer: Aetna of IA Commercial	$42.92
Rate for Payer: Aetna of IA Medical Rental Products	$42.92
Rate for Payer: Cash Price	$38.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.77
Rate for Payer: Medical Associates Commercial	$35.77
Rate for Payer: Midlands Choice Commercial	$33.38
Rate for Payer: United Healthcare Commercial	$42.92

rocuronium 10 mg/mL 5 ml MDV IV

Facility OP

$47.69

Service Code	CPT J3490
Hospital Charge Code	43700081
Hospital Revenue Code	636
Min. Negotiated Rate	$23.84
Max. Negotiated Rate	$42.92
Rate for Payer: Aetna of IA Commercial	$42.92
Rate for Payer: Aetna of IA Medical Rental Products	$42.92
Rate for Payer: Aetna of IA Medicare	$27.18
Rate for Payer: Amerigroup Medicaid	$24.07
Rate for Payer: Amerigroup Medicare	$24.08
Rate for Payer: Cash Price	$38.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.77
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.84
Rate for Payer: Iowa Total Care Managed Medicaid	$23.84
Rate for Payer: Medical Associates Commercial	$35.77
Rate for Payer: Medical Associates Managed Medicare	$23.84
Rate for Payer: Midlands Choice Commercial	$33.38
Rate for Payer: Molina Healthcare Managed Medicaid	$24.20
Rate for Payer: Partners Health Alliance Commercial	$35.77
Rate for Payer: United Healthcare Commercial	$42.92
Rate for Payer: United Healthcare Managed Medicare	$28.14

ROOM/BED: Respite

Facility IP

$400.00

Hospital Charge Code	8002762
Hospital Revenue Code	115
Min. Negotiated Rate	$280.00
Max. Negotiated Rate	$2,339.10
Rate for Payer: Aetna of IA Commercial	$360.00
Rate for Payer: Aetna of IA Medical Rental Products	$360.00
Rate for Payer: Aetna of IA Medicare	$2,258.00
Rate for Payer: Amerigroup Medicare	$2,054.34
Rate for Payer: Cash Price	$320.00
Rate for Payer: Cash Price	$320.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$300.00
Rate for Payer: Medical Associates Commercial	$300.00
Rate for Payer: Medical Associates Managed Medicare	$2,034.00
Rate for Payer: Midlands Choice Commercial	$280.00
Rate for Payer: Partners Health Alliance Commercial	$2,339.10
Rate for Payer: United Healthcare Commercial	$360.00

rOPINIRole 0.5 mg Tab

Facility OP

$2.17

Service Code	CPT A9270
Hospital Charge Code	43721458
Hospital Revenue Code	637
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of IA Commercial	$1.95
Rate for Payer: Aetna of IA Medical Rental Products	$1.95
Rate for Payer: Aetna of IA Medicare	$1.24
Rate for Payer: Amerigroup Medicaid	$1.10
Rate for Payer: Amerigroup Medicare	$1.10
Rate for Payer: Cash Price	$1.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.63
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.08
Rate for Payer: Iowa Total Care Managed Medicaid	$1.08
Rate for Payer: Medical Associates Commercial	$1.63
Rate for Payer: Medical Associates Managed Medicare	$1.08
Rate for Payer: Midlands Choice Commercial	$1.52
Rate for Payer: Molina Healthcare Managed Medicaid	$1.10
Rate for Payer: Partners Health Alliance Commercial	$1.63
Rate for Payer: United Healthcare Commercial	$1.95
Rate for Payer: United Healthcare Managed Medicare	$1.28

rOPINIRole 0.5 mg Tab

Facility IP

$2.17

Service Code	CPT A9270
Hospital Charge Code	43721458
Hospital Revenue Code	637
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of IA Commercial	$1.95
Rate for Payer: Aetna of IA Medical Rental Products	$1.95
Rate for Payer: Cash Price	$1.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.63
Rate for Payer: Medical Associates Commercial	$1.63
Rate for Payer: Midlands Choice Commercial	$1.52
Rate for Payer: United Healthcare Commercial	$1.95

rOPINIRole 1 mg Tab

Facility OP

$1.99

Service Code	CPT A9270
Hospital Charge Code	43706230
Hospital Revenue Code	637
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna of IA Commercial	$1.79
Rate for Payer: Aetna of IA Medical Rental Products	$1.79
Rate for Payer: Aetna of IA Medicare	$1.13
Rate for Payer: Amerigroup Medicaid	$1.00
Rate for Payer: Amerigroup Medicare	$1.00
Rate for Payer: Cash Price	$1.59
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.49
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.00
Rate for Payer: Iowa Total Care Managed Medicaid	$0.99
Rate for Payer: Medical Associates Commercial	$1.49
Rate for Payer: Medical Associates Managed Medicare	$1.00
Rate for Payer: Midlands Choice Commercial	$1.39
Rate for Payer: Molina Healthcare Managed Medicaid	$1.01
Rate for Payer: Partners Health Alliance Commercial	$1.49
Rate for Payer: United Healthcare Commercial	$1.79
Rate for Payer: United Healthcare Managed Medicare	$1.17

rOPINIRole 1 mg Tab

Facility IP

$1.99

Service Code	CPT A9270
Hospital Charge Code	43706230
Hospital Revenue Code	637
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna of IA Commercial	$1.79
Rate for Payer: Aetna of IA Medical Rental Products	$1.79
Rate for Payer: Cash Price	$1.59
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.49
Rate for Payer: Medical Associates Commercial	$1.49
Rate for Payer: Midlands Choice Commercial	$1.39
Rate for Payer: United Healthcare Commercial	$1.79

ropivacaine 0.5% 30 mL SDV

Facility OP

$38.39

Service Code	CPT J2795
Hospital Charge Code	43700291
Hospital Revenue Code	636
Min. Negotiated Rate	$19.19
Max. Negotiated Rate	$34.55
Rate for Payer: Aetna of IA Commercial	$34.55
Rate for Payer: Aetna of IA Medical Rental Products	$34.55
Rate for Payer: Aetna of IA Medicare	$21.88
Rate for Payer: Amerigroup Medicaid	$19.38
Rate for Payer: Amerigroup Medicare	$19.39
Rate for Payer: Cash Price	$30.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$28.79
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$19.20
Rate for Payer: Iowa Total Care Managed Medicaid	$19.19
Rate for Payer: Medical Associates Commercial	$28.79
Rate for Payer: Medical Associates Managed Medicare	$19.20
Rate for Payer: Midlands Choice Commercial	$26.87
Rate for Payer: Molina Healthcare Managed Medicaid	$19.48
Rate for Payer: Partners Health Alliance Commercial	$28.79
Rate for Payer: United Healthcare Commercial	$34.55
Rate for Payer: United Healthcare Managed Medicare	$22.65

ropivacaine 0.5% 30 mL SDV

Facility IP

$38.39

Service Code	CPT J2795
Hospital Charge Code	43700291
Hospital Revenue Code	636
Min. Negotiated Rate	$26.87
Max. Negotiated Rate	$34.55
Rate for Payer: Aetna of IA Commercial	$34.55
Rate for Payer: Aetna of IA Medical Rental Products	$34.55
Rate for Payer: Cash Price	$30.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$28.79
Rate for Payer: Medical Associates Commercial	$28.79
Rate for Payer: Midlands Choice Commercial	$26.87
Rate for Payer: United Healthcare Commercial	$34.55

rosuvastatin 10 mg Tab

Facility IP

$1.62

Service Code	CPT A9270
Hospital Charge Code	43700107
Hospital Revenue Code	637
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of IA Commercial	$1.46
Rate for Payer: Aetna of IA Medical Rental Products	$1.46
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.22
Rate for Payer: Medical Associates Commercial	$1.22
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: United Healthcare Commercial	$1.46

rosuvastatin 10 mg Tab

Facility OP

$1.62

Service Code	CPT A9270
Hospital Charge Code	43700107
Hospital Revenue Code	637
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of IA Commercial	$1.46
Rate for Payer: Aetna of IA Medical Rental Products	$1.46
Rate for Payer: Aetna of IA Medicare	$0.92
Rate for Payer: Amerigroup Medicaid	$0.82
Rate for Payer: Amerigroup Medicare	$0.82
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.22
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.81
Rate for Payer: Iowa Total Care Managed Medicaid	$0.81
Rate for Payer: Medical Associates Commercial	$1.22
Rate for Payer: Medical Associates Managed Medicare	$0.81
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: Molina Healthcare Managed Medicaid	$0.82
Rate for Payer: Partners Health Alliance Commercial	$1.22
Rate for Payer: United Healthcare Commercial	$1.46
Rate for Payer: United Healthcare Managed Medicare	$0.96

ROTAVIRUS ANTIGEN DETECTION

Facility IP

$98.00

Service Code	CPT 87425
Hospital Charge Code	4024784
Hospital Revenue Code	306
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

ROTAVIRUS ANTIGEN DETECTION

Facility OP

$98.00

Service Code	CPT 87425
Hospital Charge Code	4024784
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$49.46
Rate for Payer: Amerigroup Medicare	$49.49
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.00
Rate for Payer: Iowa Total Care Managed Medicaid	$48.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$49.00
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$49.74
Rate for Payer: Partners Health Alliance Commercial	$73.50
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

rotavirus vaccine pentavalent Sus UD

Facility IP

$177.82

Service Code	CPT 90680
Hospital Charge Code	43700441
Hospital Revenue Code	636
Min. Negotiated Rate	$124.47
Max. Negotiated Rate	$160.04
Rate for Payer: Aetna of IA Commercial	$160.04
Rate for Payer: Aetna of IA Medical Rental Products	$160.04
Rate for Payer: Cash Price	$142.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$133.36
Rate for Payer: Medical Associates Commercial	$133.36
Rate for Payer: Midlands Choice Commercial	$124.47
Rate for Payer: United Healthcare Commercial	$160.04

rotavirus vaccine pentavalent Sus UD

Facility OP

$177.82

Service Code	CPT 90680
Hospital Charge Code	43700441
Hospital Revenue Code	636
Min. Negotiated Rate	$88.87
Max. Negotiated Rate	$228.47
Rate for Payer: Aetna of IA Commercial	$160.04
Rate for Payer: Aetna of IA Medical Rental Products	$160.04
Rate for Payer: Aetna of IA Medicare	$101.36
Rate for Payer: Amerigroup Medicaid	$89.75
Rate for Payer: Amerigroup Medicare	$89.80
Rate for Payer: Cash Price	$142.25
Rate for Payer: Cash Price	$142.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$133.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$88.91
Rate for Payer: Iowa Total Care Managed Medicaid	$88.87
Rate for Payer: Medical Associates Commercial	$133.36
Rate for Payer: Medical Associates Managed Medicare	$88.91
Rate for Payer: Midlands Choice Commercial	$124.47
Rate for Payer: Molina Healthcare Managed Medicaid	$90.24
Rate for Payer: Partners Health Alliance Commercial	$133.36
Rate for Payer: United Healthcare Commercial	$160.04
Rate for Payer: United Healthcare Managed Medicare	$104.91
Rate for Payer: Wellmark IA HMO	$207.70
Rate for Payer: Wellmark IA PPO	$228.47

RPR FE/E/EN/L/M 12.6-20.0 CM

Professional

$675.00

Service Code	CPT 12016
Hospital Charge Code	7982835
Hospital Revenue Code	981
Min. Negotiated Rate	$113.47
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of IA Medicare	$113.47
Rate for Payer: Amerigroup Medicaid	$117.33
Rate for Payer: Cash Price	$540.00
Rate for Payer: Cash Price	$540.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$136.16
Rate for Payer: Iowa Total Care Managed Medicaid	$115.74
Rate for Payer: Medical Associates Commercial	$215.59
Rate for Payer: Medical Associates Managed Medicare	$113.47
Rate for Payer: Midlands Choice Commercial	$472.50
Rate for Payer: Partners Health Alliance Commercial	$170.20
Rate for Payer: Wellmark IA HMO	$242.00
Rate for Payer: Wellmark IA PPO	$284.00

RPR F/E/E/N/L/M 2.5 CM/<

Professional

$280.00

Service Code	CPT 12011
Hospital Charge Code	7982839
Hospital Revenue Code	981
Min. Negotiated Rate	$49.54
Max. Negotiated Rate	$196.00
Rate for Payer: Aetna of IA Medicare	$49.54
Rate for Payer: Amerigroup Medicaid	$51.22
Rate for Payer: Cash Price	$224.00
Rate for Payer: Cash Price	$224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$59.45
Rate for Payer: Iowa Total Care Managed Medicaid	$50.53
Rate for Payer: Medical Associates Commercial	$94.13
Rate for Payer: Medical Associates Managed Medicare	$49.54
Rate for Payer: Midlands Choice Commercial	$196.00
Rate for Payer: Partners Health Alliance Commercial	$74.31
Rate for Payer: Wellmark IA HMO	$104.00
Rate for Payer: Wellmark IA PPO	$123.00

RPR F/E/E/N/L/M 2.6-5.0 CM

Professional

$275.00

Service Code	CPT 12013
Hospital Charge Code	7982838
Hospital Revenue Code	981
Min. Negotiated Rate	$51.61
Max. Negotiated Rate	$192.50
Rate for Payer: Aetna of IA Medicare	$51.61
Rate for Payer: Amerigroup Medicaid	$53.36
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.93
Rate for Payer: Iowa Total Care Managed Medicaid	$52.64
Rate for Payer: Medical Associates Commercial	$98.06
Rate for Payer: Medical Associates Managed Medicare	$51.61
Rate for Payer: Midlands Choice Commercial	$192.50
Rate for Payer: Partners Health Alliance Commercial	$77.42
Rate for Payer: Wellmark IA HMO	$111.00
Rate for Payer: Wellmark IA PPO	$130.00

RPR F/E/E/N/L/M 5.1-7.5 CM

Professional

$441.00

Service Code	CPT 12014
Hospital Charge Code	7982837
Hospital Revenue Code	981
Min. Negotiated Rate	$66.66
Max. Negotiated Rate	$308.70
Rate for Payer: Aetna of IA Medicare	$66.66
Rate for Payer: Amerigroup Medicaid	$68.93
Rate for Payer: Cash Price	$352.80
Rate for Payer: Cash Price	$352.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$79.99
Rate for Payer: Iowa Total Care Managed Medicaid	$67.99
Rate for Payer: Medical Associates Commercial	$126.65
Rate for Payer: Medical Associates Managed Medicare	$66.66
Rate for Payer: Midlands Choice Commercial	$308.70
Rate for Payer: Partners Health Alliance Commercial	$99.99
Rate for Payer: Wellmark IA HMO	$141.00
Rate for Payer: Wellmark IA PPO	$166.00

RPR F/E/E/N/L/M 7.6-12.5 CM

Professional

$450.00

Service Code	CPT 12015
Hospital Charge Code	7982836
Hospital Revenue Code	981
Min. Negotiated Rate	$83.67
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna of IA Medicare	$83.67
Rate for Payer: Amerigroup Medicaid	$86.51
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.40
Rate for Payer: Iowa Total Care Managed Medicaid	$85.34
Rate for Payer: Medical Associates Commercial	$158.97
Rate for Payer: Medical Associates Managed Medicare	$83.67
Rate for Payer: Midlands Choice Commercial	$315.00
Rate for Payer: Partners Health Alliance Commercial	$125.50
Rate for Payer: Wellmark IA HMO	$178.00
Rate for Payer: Wellmark IA PPO	$209.00

RPR S/N/A/GEN/TRK12.6-20.0CM

Professional

$390.00

Service Code	CPT 12005
Hospital Charge Code	7982841
Hospital Revenue Code	981
Min. Negotiated Rate	$84.24
Max. Negotiated Rate	$273.00
Rate for Payer: Aetna of IA Medicare	$84.24
Rate for Payer: Amerigroup Medicaid	$87.10
Rate for Payer: Cash Price	$312.00
Rate for Payer: Cash Price	$312.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$101.09
Rate for Payer: Iowa Total Care Managed Medicaid	$85.92
Rate for Payer: Medical Associates Commercial	$160.06
Rate for Payer: Medical Associates Managed Medicare	$84.24
Rate for Payer: Midlands Choice Commercial	$273.00
Rate for Payer: Partners Health Alliance Commercial	$126.36
Rate for Payer: Wellmark IA HMO	$179.00
Rate for Payer: Wellmark IA PPO	$210.00

Price Transparency.

All Charges