Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

US LE Venous Duplex Right

Facility

$582.00

Service Code	CPT 93971 RT\|TC
Hospital Charge Code	1169773
Hospital Revenue Code	921
Min. Negotiated Rate	$407.40
Max. Negotiated Rate	$523.80
Rate for Payer: Aetna of IA Commercial	$523.80
Rate for Payer: Aetna of IA Medical Rental Products	$523.80
Rate for Payer: Cash Price	$465.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$436.50
Rate for Payer: Medical Associates Commercial	$436.50
Rate for Payer: Midlands Choice Commercial	$407.40
Rate for Payer: United Healthcare Commercial	$523.80

US LE Venouse Duplex Left

Facility

$582.00

Service Code	CPT 93971 LT\|TC
Hospital Charge Code	8654295
Hospital Revenue Code	921
Min. Negotiated Rate	$407.40
Max. Negotiated Rate	$523.80
Rate for Payer: Aetna of IA Commercial	$523.80
Rate for Payer: Aetna of IA Medical Rental Products	$523.80
Rate for Payer: Cash Price	$465.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$436.50
Rate for Payer: Medical Associates Commercial	$436.50
Rate for Payer: Midlands Choice Commercial	$407.40
Rate for Payer: United Healthcare Commercial	$523.80

US LE Venouse Duplex Left

Facility

$582.00

Service Code	CPT 93971 LT\|TC
Hospital Charge Code	8654295
Hospital Revenue Code	921
Min. Negotiated Rate	$241.06
Max. Negotiated Rate	$523.80
Rate for Payer: Aetna of IA Commercial	$523.80
Rate for Payer: Aetna of IA Medical Rental Products	$523.80
Rate for Payer: Aetna of IA Medicare	$331.74
Rate for Payer: Amerigroup Medicaid	$335.70
Rate for Payer: Amerigroup Medicare	$264.52
Rate for Payer: Cash Price	$465.60
Rate for Payer: Cash Price	$465.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$436.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$261.90
Rate for Payer: Iowa Total Care Managed Medicaid	$332.44
Rate for Payer: Medical Associates Commercial	$436.50
Rate for Payer: Medical Associates Managed Medicare	$261.90
Rate for Payer: Midlands Choice Commercial	$407.40
Rate for Payer: Molina Healthcare Managed Medicaid	$337.33
Rate for Payer: Partners Health Alliance Commercial	$301.18
Rate for Payer: United Healthcare Commercial	$523.80
Rate for Payer: United Healthcare Managed Medicare	$343.38
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Lower Extremity Non Vascular Left

Facility

$394.00

Service Code	CPT 76881 LT
Hospital Charge Code	1169784
Hospital Revenue Code	402
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Aetna of IA Medicare	$224.58
Rate for Payer: Amerigroup Medicaid	$227.26
Rate for Payer: Amerigroup Medicare	$179.07
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$177.30
Rate for Payer: Iowa Total Care Managed Medicaid	$225.05
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Medical Associates Managed Medicare	$177.30
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: Molina Healthcare Managed Medicaid	$228.36
Rate for Payer: Partners Health Alliance Commercial	$203.90
Rate for Payer: United Healthcare Commercial	$354.60
Rate for Payer: United Healthcare Managed Medicare	$232.46
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Lower Extremity Non Vascular Left

Facility

$394.00

Service Code	CPT 76881 LT
Hospital Charge Code	1169784
Hospital Revenue Code	402
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: United Healthcare Commercial	$354.60

US Lower Extremity Non Vascular Right

Facility

$394.00

Service Code	CPT 76881 RT
Hospital Charge Code	1169787
Hospital Revenue Code	402
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: United Healthcare Commercial	$354.60

US Lower Extremity Non Vascular Right

Facility

$394.00

Service Code	CPT 76881 RT
Hospital Charge Code	1169787
Hospital Revenue Code	402
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Aetna of IA Medicare	$224.58
Rate for Payer: Amerigroup Medicaid	$227.26
Rate for Payer: Amerigroup Medicare	$179.07
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$177.30
Rate for Payer: Iowa Total Care Managed Medicaid	$225.05
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Medical Associates Managed Medicare	$177.30
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: Molina Healthcare Managed Medicaid	$228.36
Rate for Payer: Partners Health Alliance Commercial	$203.90
Rate for Payer: United Healthcare Commercial	$354.60
Rate for Payer: United Healthcare Managed Medicare	$232.46
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Pelvis Non OB Complete

Facility

$459.00

Service Code	CPT 76856 TC
Hospital Charge Code	1169844
Hospital Revenue Code	402
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: United Healthcare Commercial	$413.10

US Pelvis Non OB Complete

Facility

$459.00

Service Code	CPT 76856 TC
Hospital Charge Code	1169844
Hospital Revenue Code	402
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$413.15
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Aetna of IA Medicare	$261.63
Rate for Payer: Amerigroup Medicaid	$264.75
Rate for Payer: Amerigroup Medicare	$208.62
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$206.55
Rate for Payer: Iowa Total Care Managed Medicaid	$262.18
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Medical Associates Managed Medicare	$206.55
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: Molina Healthcare Managed Medicaid	$266.04
Rate for Payer: Partners Health Alliance Commercial	$237.53
Rate for Payer: United Healthcare Commercial	$413.10
Rate for Payer: United Healthcare Managed Medicare	$270.81
Rate for Payer: Wellmark IA HMO WHPI	$375.06
Rate for Payer: Wellmark IA PPO	$413.15

US Pelvis Non OB Complete +Transvaginal

Facility

$459.00

Service Code	CPT 76856 TC
Hospital Charge Code	7840664
Hospital Revenue Code	402
Min. Negotiated Rate	$206.55
Max. Negotiated Rate	$413.15
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Aetna of IA Medicare	$261.63
Rate for Payer: Amerigroup Medicaid	$264.75
Rate for Payer: Amerigroup Medicare	$208.62
Rate for Payer: Cash Price	$367.20
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$206.55
Rate for Payer: Iowa Total Care Managed Medicaid	$262.18
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Medical Associates Managed Medicare	$206.55
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: Molina Healthcare Managed Medicaid	$266.04
Rate for Payer: Partners Health Alliance Commercial	$237.53
Rate for Payer: United Healthcare Commercial	$413.10
Rate for Payer: United Healthcare Managed Medicare	$270.81
Rate for Payer: Wellmark IA HMO WHPI	$375.06
Rate for Payer: Wellmark IA PPO	$413.15

US Pelvis Non OB Complete +Transvaginal

Facility

$459.00

Service Code	CPT 76856 TC
Hospital Charge Code	7840664
Hospital Revenue Code	402
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: United Healthcare Commercial	$413.10

US Pelvis Non OB Limited

Facility

$297.00

Service Code	CPT 76857 TC
Hospital Charge Code	1169846
Hospital Revenue Code	402
Min. Negotiated Rate	$133.65
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Aetna of IA Medicare	$169.29
Rate for Payer: Amerigroup Medicaid	$171.31
Rate for Payer: Amerigroup Medicare	$134.99
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$133.65
Rate for Payer: Iowa Total Care Managed Medicaid	$169.65
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Medical Associates Managed Medicare	$133.65
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: Molina Healthcare Managed Medicaid	$172.14
Rate for Payer: Partners Health Alliance Commercial	$153.70
Rate for Payer: United Healthcare Commercial	$267.30
Rate for Payer: United Healthcare Managed Medicare	$175.23
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Pelvis Non OB Limited

Facility

$297.00

Service Code	CPT 76857 TC
Hospital Charge Code	1169846
Hospital Revenue Code	402
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: United Healthcare Commercial	$267.30

US Pelvis Non OB Transvaginal

Facility

$349.00

Service Code	CPT 76830 TC
Hospital Charge Code	7960823
Hospital Revenue Code	402
Min. Negotiated Rate	$244.30
Max. Negotiated Rate	$314.10
Rate for Payer: Aetna of IA Commercial	$314.10
Rate for Payer: Aetna of IA Medical Rental Products	$314.10
Rate for Payer: Cash Price	$279.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$261.75
Rate for Payer: Medical Associates Commercial	$261.75
Rate for Payer: Midlands Choice Commercial	$244.30
Rate for Payer: United Healthcare Commercial	$314.10

US Pelvis Non OB Transvaginal

Facility

$349.00

Service Code	CPT 76830 TC
Hospital Charge Code	7960823
Hospital Revenue Code	402
Min. Negotiated Rate	$157.05
Max. Negotiated Rate	$314.10
Rate for Payer: Aetna of IA Commercial	$314.10
Rate for Payer: Aetna of IA Medical Rental Products	$314.10
Rate for Payer: Aetna of IA Medicare	$198.93
Rate for Payer: Amerigroup Medicaid	$201.30
Rate for Payer: Amerigroup Medicare	$158.62
Rate for Payer: Cash Price	$279.20
Rate for Payer: Cash Price	$279.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$261.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$157.05
Rate for Payer: Iowa Total Care Managed Medicaid	$199.35
Rate for Payer: Medical Associates Commercial	$261.75
Rate for Payer: Medical Associates Managed Medicare	$157.05
Rate for Payer: Midlands Choice Commercial	$244.30
Rate for Payer: Molina Healthcare Managed Medicaid	$202.28
Rate for Payer: Partners Health Alliance Commercial	$180.61
Rate for Payer: United Healthcare Commercial	$314.10
Rate for Payer: United Healthcare Managed Medicare	$205.91
Rate for Payer: Wellmark IA HMO WHPI	$241.06
Rate for Payer: Wellmark IA PPO	$265.54

US Pregnancy Follow Up

Facility

$296.00

Service Code	CPT 76816 TC
Hospital Charge Code	1169854
Hospital Revenue Code	402
Min. Negotiated Rate	$133.20
Max. Negotiated Rate	$274.13
Rate for Payer: Aetna of IA Commercial	$266.40
Rate for Payer: Aetna of IA Medical Rental Products	$266.40
Rate for Payer: Aetna of IA Medicare	$168.72
Rate for Payer: Amerigroup Medicaid	$170.73
Rate for Payer: Amerigroup Medicare	$134.53
Rate for Payer: Cash Price	$236.80
Rate for Payer: Cash Price	$236.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$133.20
Rate for Payer: Iowa Total Care Managed Medicaid	$169.08
Rate for Payer: Medical Associates Commercial	$222.00
Rate for Payer: Medical Associates Managed Medicare	$133.20
Rate for Payer: Midlands Choice Commercial	$207.20
Rate for Payer: Molina Healthcare Managed Medicaid	$171.56
Rate for Payer: Partners Health Alliance Commercial	$153.18
Rate for Payer: United Healthcare Commercial	$266.40
Rate for Payer: United Healthcare Managed Medicare	$174.64
Rate for Payer: Wellmark IA HMO WHPI	$248.86
Rate for Payer: Wellmark IA PPO	$274.13

US Pregnancy Follow Up

Facility

$296.00

Service Code	CPT 76816 TC
Hospital Charge Code	1169854
Hospital Revenue Code	402
Min. Negotiated Rate	$207.20
Max. Negotiated Rate	$266.40
Rate for Payer: Aetna of IA Commercial	$266.40
Rate for Payer: Aetna of IA Medical Rental Products	$266.40
Rate for Payer: Cash Price	$236.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.00
Rate for Payer: Medical Associates Commercial	$222.00
Rate for Payer: Midlands Choice Commercial	$207.20
Rate for Payer: United Healthcare Commercial	$266.40

US Pregnancy Limited

Facility

$394.00

Service Code	CPT 76815 TC
Hospital Charge Code	1169856
Hospital Revenue Code	402
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Aetna of IA Medicare	$224.58
Rate for Payer: Amerigroup Medicaid	$227.26
Rate for Payer: Amerigroup Medicare	$179.07
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$177.30
Rate for Payer: Iowa Total Care Managed Medicaid	$225.05
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Medical Associates Managed Medicare	$177.30
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: Molina Healthcare Managed Medicaid	$228.36
Rate for Payer: Partners Health Alliance Commercial	$203.90
Rate for Payer: United Healthcare Commercial	$354.60
Rate for Payer: United Healthcare Managed Medicare	$232.46
Rate for Payer: Wellmark IA HMO WHPI	$248.86
Rate for Payer: Wellmark IA PPO	$274.13

US Pregnancy Limited

Facility

$394.00

Service Code	CPT 76815 TC
Hospital Charge Code	1169856
Hospital Revenue Code	402
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: United Healthcare Commercial	$354.60

US Pregnancy Transvaginal

Facility

$394.00

Service Code	CPT 76817 TC
Hospital Charge Code	1169861
Hospital Revenue Code	402
Min. Negotiated Rate	$275.80
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: United Healthcare Commercial	$354.60

US Pregnancy Transvaginal

Facility

$394.00

Service Code	CPT 76817 TC
Hospital Charge Code	1169861
Hospital Revenue Code	402
Min. Negotiated Rate	$177.30
Max. Negotiated Rate	$354.60
Rate for Payer: Aetna of IA Commercial	$354.60
Rate for Payer: Aetna of IA Medical Rental Products	$354.60
Rate for Payer: Aetna of IA Medicare	$224.58
Rate for Payer: Amerigroup Medicaid	$227.26
Rate for Payer: Amerigroup Medicare	$179.07
Rate for Payer: Cash Price	$315.20
Rate for Payer: Cash Price	$315.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$177.30
Rate for Payer: Iowa Total Care Managed Medicaid	$225.05
Rate for Payer: Medical Associates Commercial	$295.50
Rate for Payer: Medical Associates Managed Medicare	$177.30
Rate for Payer: Midlands Choice Commercial	$275.80
Rate for Payer: Molina Healthcare Managed Medicaid	$228.36
Rate for Payer: Partners Health Alliance Commercial	$203.90
Rate for Payer: United Healthcare Commercial	$354.60
Rate for Payer: United Healthcare Managed Medicare	$232.46
Rate for Payer: Wellmark IA HMO WHPI	$248.86
Rate for Payer: Wellmark IA PPO	$274.13

US Pregnant < 14 Weeks

Facility

$524.00

Service Code	CPT 76801 TC
Hospital Charge Code	7960826
Hospital Revenue Code	402
Min. Negotiated Rate	$235.80
Max. Negotiated Rate	$471.60
Rate for Payer: Aetna of IA Commercial	$471.60
Rate for Payer: Aetna of IA Medical Rental Products	$471.60
Rate for Payer: Aetna of IA Medicare	$298.68
Rate for Payer: Amerigroup Medicaid	$302.24
Rate for Payer: Amerigroup Medicare	$238.16
Rate for Payer: Cash Price	$419.20
Rate for Payer: Cash Price	$419.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$393.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$235.80
Rate for Payer: Iowa Total Care Managed Medicaid	$299.31
Rate for Payer: Medical Associates Commercial	$393.00
Rate for Payer: Medical Associates Managed Medicare	$235.80
Rate for Payer: Midlands Choice Commercial	$366.80
Rate for Payer: Molina Healthcare Managed Medicaid	$303.71
Rate for Payer: Partners Health Alliance Commercial	$271.17
Rate for Payer: United Healthcare Commercial	$471.60
Rate for Payer: United Healthcare Managed Medicare	$309.16
Rate for Payer: Wellmark IA HMO WHPI	$248.86
Rate for Payer: Wellmark IA PPO	$274.13

US Pregnant < 14 Weeks

Facility

$524.00

Service Code	CPT 76801 TC
Hospital Charge Code	7960826
Hospital Revenue Code	402
Min. Negotiated Rate	$366.80
Max. Negotiated Rate	$471.60
Rate for Payer: Aetna of IA Commercial	$471.60
Rate for Payer: Aetna of IA Medical Rental Products	$471.60
Rate for Payer: Cash Price	$419.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$393.00
Rate for Payer: Medical Associates Commercial	$393.00
Rate for Payer: Midlands Choice Commercial	$366.80
Rate for Payer: United Healthcare Commercial	$471.60

US Pregnant > 14 Weeks

Facility

$379.00

Service Code	CPT 76805 TC
Hospital Charge Code	7960832
Hospital Revenue Code	402
Min. Negotiated Rate	$170.55
Max. Negotiated Rate	$341.10
Rate for Payer: Aetna of IA Commercial	$341.10
Rate for Payer: Aetna of IA Medical Rental Products	$341.10
Rate for Payer: Aetna of IA Medicare	$216.03
Rate for Payer: Amerigroup Medicaid	$218.61
Rate for Payer: Amerigroup Medicare	$172.26
Rate for Payer: Cash Price	$303.20
Rate for Payer: Cash Price	$303.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$284.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$170.55
Rate for Payer: Iowa Total Care Managed Medicaid	$216.48
Rate for Payer: Medical Associates Commercial	$284.25
Rate for Payer: Medical Associates Managed Medicare	$170.55
Rate for Payer: Midlands Choice Commercial	$265.30
Rate for Payer: Molina Healthcare Managed Medicaid	$219.67
Rate for Payer: Partners Health Alliance Commercial	$196.13
Rate for Payer: United Healthcare Commercial	$341.10
Rate for Payer: United Healthcare Managed Medicare	$223.61
Rate for Payer: Wellmark IA HMO WHPI	$248.86
Rate for Payer: Wellmark IA PPO	$274.13

US Pregnant > 14 Weeks

Facility

$379.00

Service Code	CPT 76805 TC
Hospital Charge Code	7960832
Hospital Revenue Code	402
Min. Negotiated Rate	$265.30
Max. Negotiated Rate	$341.10
Rate for Payer: Aetna of IA Commercial	$341.10
Rate for Payer: Aetna of IA Medical Rental Products	$341.10
Rate for Payer: Cash Price	$303.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$284.25
Rate for Payer: Medical Associates Commercial	$284.25
Rate for Payer: Midlands Choice Commercial	$265.30
Rate for Payer: United Healthcare Commercial	$341.10

Know your out-of-pocket cost for care.

All Charges