Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SCREW SOLID LAG, 5.5MM X 45MM

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047223
Hospital Revenue Code	278
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

SCREW SOLID LAG, 5.5MM X 50MM

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047224
Hospital Revenue Code	278
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

SCREW SOLID LAG, 5.5MM X 50MM

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047224
Hospital Revenue Code	278
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

SCREW SOLID LAG, 5.5MM X 55MM

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047225
Hospital Revenue Code	278
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

SCREW SOLID LAG, 5.5MM X 55MM

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047225
Hospital Revenue Code	278
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

SCREW SOLID LAG, 5.5MM X 55MM (X2)

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047228
Hospital Revenue Code	278
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

SCREW SOLID LAG, 5.5MM X 55MM (X2)

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047228
Hospital Revenue Code	278
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

SCREW SOLID LAG, 5.5MM X 55MM (X2)-PT

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047227
Hospital Revenue Code	278
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

SCREW SOLID LAG, 5.5MM X 55MM (X2)-PT

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047227
Hospital Revenue Code	278
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

SCREW SOLID LAG, 5.5MM X 60MM

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047226
Hospital Revenue Code	278
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

SCREW SOLID LAG, 5.5MM X 60MM

Facility

$270.00

Service Code	CPT C1713
Hospital Charge Code	8047226
Hospital Revenue Code	278
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

SCREW TIGER CANNULATED 4.0MMX24MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8713565
Hospital Revenue Code	278
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$99.93
Rate for Payer: Amerigroup Medicare	$99.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.00
Rate for Payer: Iowa Total Care Managed Medicaid	$98.96
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$99.00
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$100.48
Rate for Payer: Molina Healthcare Managed Medicare	$100.43
Rate for Payer: Oscar Health of IA Commercial	$148.50
Rate for Payer: Partners Health Alliance Commercial	$148.50
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

SCREW TIGER CANNULATED 4.0MMX24MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8713565
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

SCREW TIGER CANNULATED 4.0MMX28MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8713567
Hospital Revenue Code	278
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$99.93
Rate for Payer: Amerigroup Medicare	$99.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.00
Rate for Payer: Iowa Total Care Managed Medicaid	$98.96
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$99.00
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$100.48
Rate for Payer: Molina Healthcare Managed Medicare	$100.43
Rate for Payer: Oscar Health of IA Commercial	$148.50
Rate for Payer: Partners Health Alliance Commercial	$148.50
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

SCREW TIGER CANNULATED 4.0MMX28MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8713567
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

SCU

Facility

$2,034.00

Hospital Charge Code	8002748
Hospital Revenue Code	200
Min. Negotiated Rate	$1,306.00
Max. Negotiated Rate	$9,842.42
Rate for Payer: Aetna of IA Commercial	$1,830.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,830.60
Rate for Payer: Aetna of IA Medicare	$2,258.00
Rate for Payer: Amerigroup Medicare	$2,054.34
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Cash Price	$1,627.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,525.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Medical Associates Commercial	$1,525.50
Rate for Payer: Medical Associates Managed Medicare	$2,034.00
Rate for Payer: Midlands Choice Commercial	$1,423.80
Rate for Payer: Molina Healthcare Managed Medicare	$9,842.42
Rate for Payer: Oscar Health of IA Commercial	$3,051.00
Rate for Payer: Partners Health Alliance Commercial	$2,339.10
Rate for Payer: United Healthcare Commercial	$1,830.60
Rate for Payer: United Healthcare Managed Medicare	$1,306.00

SED RATE

Facility

$36.00

Service Code	CPT 85652
Hospital Charge Code	4006783
Hospital Revenue Code	305
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of IA Commercial	$32.40
Rate for Payer: Aetna of IA Medical Rental Products	$32.40
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.00
Rate for Payer: Medical Associates Commercial	$27.00
Rate for Payer: Midlands Choice Commercial	$25.20
Rate for Payer: United Healthcare Commercial	$32.40

SED RATE

Facility

$36.00

Service Code	CPT 85652
Hospital Charge Code	4006783
Hospital Revenue Code	305
Min. Negotiated Rate	$17.99
Max. Negotiated Rate	$36.15
Rate for Payer: Aetna of IA Commercial	$32.40
Rate for Payer: Aetna of IA Medical Rental Products	$32.40
Rate for Payer: Aetna of IA Medicare	$20.52
Rate for Payer: Amerigroup Medicaid	$18.17
Rate for Payer: Amerigroup Medicare	$18.18
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.00
Rate for Payer: Iowa Total Care Managed Medicaid	$17.99
Rate for Payer: Medical Associates Commercial	$27.00
Rate for Payer: Medical Associates Managed Medicare	$18.00
Rate for Payer: Midlands Choice Commercial	$25.20
Rate for Payer: Molina Healthcare Managed Medicaid	$18.27
Rate for Payer: Molina Healthcare Managed Medicare	$18.26
Rate for Payer: Oscar Health of IA Commercial	$27.00
Rate for Payer: Partners Health Alliance Commercial	$27.00
Rate for Payer: United Healthcare Commercial	$32.40
Rate for Payer: United Healthcare Managed Medicare	$21.24
Rate for Payer: Wellmark IA HMO	$32.86
Rate for Payer: Wellmark IA PPO	$36.15

Seizures With MCC

Facility

$10,076.67

Service Code	MS-DRG 100
Hospital Charge Code	1
Min. Negotiated Rate	$9,930.63
Max. Negotiated Rate	$10,076.67
Rate for Payer: Amerigroup Medicaid	$10,027.99
Rate for Payer: Iowa Total Care Managed Medicaid	$9,930.63
Rate for Payer: Molina Healthcare Managed Medicaid	$10,076.67

Seizures Without MCC

Facility

$5,309.00

Service Code	MS-DRG 101
Hospital Charge Code	2
Min. Negotiated Rate	$5,232.06
Max. Negotiated Rate	$5,309.00
Rate for Payer: Amerigroup Medicaid	$5,283.35
Rate for Payer: Iowa Total Care Managed Medicaid	$5,232.06
Rate for Payer: Molina Healthcare Managed Medicaid	$5,309.00

SELECTIVE DEBRIDEMENT EA ADD'L 20 SQ CM

Professional

Both

$207.00

Service Code	CPT 97598
Hospital Charge Code	8068909
Hospital Revenue Code	983
Min. Negotiated Rate	$22.35
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Medicare	$22.35
Rate for Payer: Amerigroup Medicaid	$23.11
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.82
Rate for Payer: Iowa Total Care Managed Medicaid	$22.80
Rate for Payer: Medical Associates Commercial	$40.23
Rate for Payer: Medical Associates Managed Medicare	$22.35
Rate for Payer: Midlands Choice Commercial	$144.90
Rate for Payer: Oscar Health of IA Commercial	$38.67
Rate for Payer: Partners Health Alliance Commercial	$33.52

SELECTIVE DEBRIDEMENT FIRST 20 SQ CM

Facility

$266.00

Service Code	CPT 97597
Hospital Charge Code	7440831
Hospital Revenue Code	510
Min. Negotiated Rate	$186.20
Max. Negotiated Rate	$239.40
Rate for Payer: Aetna of IA Commercial	$239.40
Rate for Payer: Aetna of IA Medical Rental Products	$239.40
Rate for Payer: Cash Price	$212.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$199.50
Rate for Payer: Medical Associates Commercial	$199.50
Rate for Payer: Midlands Choice Commercial	$186.20
Rate for Payer: United Healthcare Commercial	$239.40

SELECTIVE DEBRIDEMENT FIRST 20 SQ CM

Facility

$266.00

Service Code	CPT 97597
Hospital Charge Code	7440831
Hospital Revenue Code	510
Min. Negotiated Rate	$132.95
Max. Negotiated Rate	$598.11
Rate for Payer: Aetna of IA Commercial	$239.40
Rate for Payer: Aetna of IA Medical Rental Products	$239.40
Rate for Payer: Aetna of IA Medicare	$151.62
Rate for Payer: Amerigroup Medicaid	$134.25
Rate for Payer: Amerigroup Medicare	$134.33
Rate for Payer: Cash Price	$212.80
Rate for Payer: Cash Price	$212.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$199.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$133.00
Rate for Payer: Iowa Total Care Managed Medicaid	$132.95
Rate for Payer: Medical Associates Commercial	$199.50
Rate for Payer: Medical Associates Managed Medicare	$133.00
Rate for Payer: Midlands Choice Commercial	$186.20
Rate for Payer: Molina Healthcare Managed Medicaid	$135.00
Rate for Payer: Molina Healthcare Managed Medicare	$134.92
Rate for Payer: Oscar Health of IA Commercial	$199.50
Rate for Payer: Partners Health Alliance Commercial	$199.50
Rate for Payer: United Healthcare Commercial	$239.40
Rate for Payer: United Healthcare Managed Medicare	$156.94
Rate for Payer: Wellmark IA HMO	$543.74
Rate for Payer: Wellmark IA PPO	$598.11

SEMEN VASECTOMY

Facility

$74.00

Service Code	CPT 89321
Hospital Charge Code	3527268
Hospital Revenue Code	309
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$66.60
Rate for Payer: Aetna of IA Commercial	$66.60
Rate for Payer: Aetna of IA Medical Rental Products	$66.60
Rate for Payer: Cash Price	$59.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.50
Rate for Payer: Medical Associates Commercial	$55.50
Rate for Payer: Midlands Choice Commercial	$51.80
Rate for Payer: United Healthcare Commercial	$66.60

SEMEN VASECTOMY

Facility

$74.00

Service Code	CPT 89321
Hospital Charge Code	3527268
Hospital Revenue Code	309
Min. Negotiated Rate	$36.99
Max. Negotiated Rate	$67.52
Rate for Payer: Aetna of IA Commercial	$66.60
Rate for Payer: Aetna of IA Medical Rental Products	$66.60
Rate for Payer: Aetna of IA Medicare	$42.18
Rate for Payer: Amerigroup Medicaid	$37.35
Rate for Payer: Amerigroup Medicare	$37.37
Rate for Payer: Cash Price	$59.20
Rate for Payer: Cash Price	$59.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$37.00
Rate for Payer: Iowa Total Care Managed Medicaid	$36.99
Rate for Payer: Medical Associates Commercial	$55.50
Rate for Payer: Medical Associates Managed Medicare	$37.00
Rate for Payer: Midlands Choice Commercial	$51.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.56
Rate for Payer: Molina Healthcare Managed Medicare	$37.53
Rate for Payer: Oscar Health of IA Commercial	$55.50
Rate for Payer: Partners Health Alliance Commercial	$55.50
Rate for Payer: United Healthcare Commercial	$66.60
Rate for Payer: United Healthcare Managed Medicare	$43.66
Rate for Payer: Wellmark IA HMO	$61.38
Rate for Payer: Wellmark IA PPO	$67.52

Know your out-of-pocket cost for care.

All Charges