Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

betamethasone-clotrimazole topical 0.05%-1% Cre 45gm [VDMC]

Facility

$45.64

Service Code	HCPCS A9270
Hospital Charge Code	11222287
Hospital Revenue Code	259
Min. Negotiated Rate	$22.81
Max. Negotiated Rate	$41.08
Rate for Payer: Aetna of IA Commercial	$41.08
Rate for Payer: Aetna of IA Medical Rental Products	$41.08
Rate for Payer: Aetna of IA Medicare	$26.01
Rate for Payer: Amerigroup Medicaid	$23.03
Rate for Payer: Amerigroup Medicare	$23.05
Rate for Payer: Cash Price	$36.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$22.82
Rate for Payer: Iowa Total Care Managed Medicaid	$22.81
Rate for Payer: Medical Associates Commercial	$34.23
Rate for Payer: Medical Associates Managed Medicare	$22.82
Rate for Payer: Midlands Choice Commercial	$31.95
Rate for Payer: Molina Healthcare Managed Medicaid	$23.16
Rate for Payer: Molina Healthcare Managed Medicare	$23.15
Rate for Payer: Oscar Health of IA Commercial	$34.23
Rate for Payer: Partners Health Alliance Commercial	$34.23
Rate for Payer: United Healthcare Commercial	$41.08
Rate for Payer: United Healthcare Managed Medicare	$26.93

bevacizumab 25 mg/mL Sol 16 ml SDV [VDMC]

Facility

$6,475.52

Service Code	HCPCS J9035
Hospital Charge Code	13616474
Hospital Revenue Code	259
Min. Negotiated Rate	$3,236.46
Max. Negotiated Rate	$5,827.97
Rate for Payer: Aetna of IA Commercial	$5,827.97
Rate for Payer: Aetna of IA Medical Rental Products	$5,827.97
Rate for Payer: Aetna of IA Medicare	$3,691.05
Rate for Payer: Amerigroup Medicaid	$3,268.19
Rate for Payer: Amerigroup Medicare	$3,270.14
Rate for Payer: Cash Price	$5,180.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,856.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,237.76
Rate for Payer: Iowa Total Care Managed Medicaid	$3,236.46
Rate for Payer: Medical Associates Commercial	$4,856.64
Rate for Payer: Medical Associates Managed Medicare	$3,237.76
Rate for Payer: Midlands Choice Commercial	$4,532.86
Rate for Payer: Molina Healthcare Managed Medicaid	$3,286.33
Rate for Payer: Molina Healthcare Managed Medicare	$3,284.38
Rate for Payer: Oscar Health of IA Commercial	$4,856.64
Rate for Payer: Partners Health Alliance Commercial	$4,856.64
Rate for Payer: United Healthcare Commercial	$5,827.97
Rate for Payer: United Healthcare Managed Medicare	$3,820.56

bevacizumab 25 mg/mL Sol 16 ml SDV [VDMC]

Facility

$6,475.52

Service Code	HCPCS J9035
Hospital Charge Code	13616474
Hospital Revenue Code	259
Min. Negotiated Rate	$4,532.86
Max. Negotiated Rate	$5,827.97
Rate for Payer: Aetna of IA Commercial	$5,827.97
Rate for Payer: Aetna of IA Medical Rental Products	$5,827.97
Rate for Payer: Cash Price	$5,180.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,856.64
Rate for Payer: Medical Associates Commercial	$4,856.64
Rate for Payer: Midlands Choice Commercial	$4,532.86
Rate for Payer: United Healthcare Commercial	$5,827.97

bevacizumab 25 mg/mL Sol 4 ml SDV [VDMC]

Facility

$1,693.88

Service Code	HCPCS J9035
Hospital Charge Code	14362915
Hospital Revenue Code	259
Min. Negotiated Rate	$1,185.72
Max. Negotiated Rate	$1,524.49
Rate for Payer: Aetna of IA Commercial	$1,524.49
Rate for Payer: Aetna of IA Medical Rental Products	$1,524.49
Rate for Payer: Cash Price	$1,355.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,270.41
Rate for Payer: Medical Associates Commercial	$1,270.41
Rate for Payer: Midlands Choice Commercial	$1,185.72
Rate for Payer: United Healthcare Commercial	$1,524.49

bevacizumab 25 mg/mL Sol 4 ml SDV [VDMC]

Facility

$1,693.88

Service Code	HCPCS J9035
Hospital Charge Code	14362915
Hospital Revenue Code	259
Min. Negotiated Rate	$846.60
Max. Negotiated Rate	$1,524.49
Rate for Payer: Aetna of IA Commercial	$1,524.49
Rate for Payer: Aetna of IA Medical Rental Products	$1,524.49
Rate for Payer: Aetna of IA Medicare	$965.51
Rate for Payer: Amerigroup Medicaid	$854.90
Rate for Payer: Amerigroup Medicare	$855.41
Rate for Payer: Cash Price	$1,355.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,270.41
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$846.94
Rate for Payer: Iowa Total Care Managed Medicaid	$846.60
Rate for Payer: Medical Associates Commercial	$1,270.41
Rate for Payer: Medical Associates Managed Medicare	$846.94
Rate for Payer: Midlands Choice Commercial	$1,185.72
Rate for Payer: Molina Healthcare Managed Medicaid	$859.64
Rate for Payer: Molina Healthcare Managed Medicare	$859.14
Rate for Payer: Oscar Health of IA Commercial	$1,270.41
Rate for Payer: Partners Health Alliance Commercial	$1,270.41
Rate for Payer: United Healthcare Commercial	$1,524.49
Rate for Payer: United Healthcare Managed Medicare	$999.39

bevacizumab bvzr 100 mg/4 mL SDV [VDMC]

Facility

$2,134.96

Service Code	HCPCS Q5118
Hospital Charge Code	21939493
Hospital Revenue Code	259
Min. Negotiated Rate	$1,494.47
Max. Negotiated Rate	$1,921.46
Rate for Payer: Aetna of IA Commercial	$1,921.46
Rate for Payer: Aetna of IA Medical Rental Products	$1,921.46
Rate for Payer: Cash Price	$1,707.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,601.22
Rate for Payer: Medical Associates Commercial	$1,601.22
Rate for Payer: Midlands Choice Commercial	$1,494.47
Rate for Payer: United Healthcare Commercial	$1,921.46

bevacizumab bvzr 100 mg/4 mL SDV [VDMC]

Facility

$2,134.96

Service Code	HCPCS Q5118
Hospital Charge Code	21939493
Hospital Revenue Code	259
Min. Negotiated Rate	$1,067.05
Max. Negotiated Rate	$1,921.46
Rate for Payer: Aetna of IA Commercial	$1,921.46
Rate for Payer: Aetna of IA Medical Rental Products	$1,921.46
Rate for Payer: Aetna of IA Medicare	$1,216.93
Rate for Payer: Amerigroup Medicaid	$1,077.51
Rate for Payer: Amerigroup Medicare	$1,078.15
Rate for Payer: Cash Price	$1,707.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,601.22
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,067.48
Rate for Payer: Iowa Total Care Managed Medicaid	$1,067.05
Rate for Payer: Medical Associates Commercial	$1,601.22
Rate for Payer: Medical Associates Managed Medicare	$1,067.48
Rate for Payer: Midlands Choice Commercial	$1,494.47
Rate for Payer: Molina Healthcare Managed Medicaid	$1,083.49
Rate for Payer: Molina Healthcare Managed Medicare	$1,082.85
Rate for Payer: Oscar Health of IA Commercial	$1,601.22
Rate for Payer: Partners Health Alliance Commercial	$1,601.22
Rate for Payer: United Healthcare Commercial	$1,921.46
Rate for Payer: United Healthcare Managed Medicare	$1,259.63

bevacizumab bvzr 400 mg/16mL SDV [VDMC]

Facility

$8,389.88

Service Code	HCPCS Q5118
Hospital Charge Code	21939436
Hospital Revenue Code	259
Min. Negotiated Rate	$5,872.92
Max. Negotiated Rate	$7,550.89
Rate for Payer: Aetna of IA Commercial	$7,550.89
Rate for Payer: Aetna of IA Medical Rental Products	$7,550.89
Rate for Payer: Cash Price	$6,711.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,292.41
Rate for Payer: Medical Associates Commercial	$6,292.41
Rate for Payer: Midlands Choice Commercial	$5,872.92
Rate for Payer: United Healthcare Commercial	$7,550.89

bevacizumab bvzr 400 mg/16mL SDV [VDMC]

Facility

$8,389.88

Service Code	HCPCS Q5118
Hospital Charge Code	21939436
Hospital Revenue Code	259
Min. Negotiated Rate	$4,193.26
Max. Negotiated Rate	$7,550.89
Rate for Payer: Aetna of IA Commercial	$7,550.89
Rate for Payer: Aetna of IA Medical Rental Products	$7,550.89
Rate for Payer: Aetna of IA Medicare	$4,782.23
Rate for Payer: Amerigroup Medicaid	$4,234.37
Rate for Payer: Amerigroup Medicare	$4,236.89
Rate for Payer: Cash Price	$6,711.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,292.41
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4,194.94
Rate for Payer: Iowa Total Care Managed Medicaid	$4,193.26
Rate for Payer: Medical Associates Commercial	$6,292.41
Rate for Payer: Medical Associates Managed Medicare	$4,194.94
Rate for Payer: Midlands Choice Commercial	$5,872.92
Rate for Payer: Molina Healthcare Managed Medicaid	$4,257.86
Rate for Payer: Molina Healthcare Managed Medicare	$4,255.35
Rate for Payer: Oscar Health of IA Commercial	$6,292.41
Rate for Payer: Partners Health Alliance Commercial	$6,292.41
Rate for Payer: United Healthcare Commercial	$7,550.89
Rate for Payer: United Healthcare Managed Medicare	$4,950.03

bicalutamide 50 mg Tab [VDMC]

Facility

$1.74

Service Code	HCPCS A9270
Hospital Charge Code	10370427
Hospital Revenue Code	259
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.57
Rate for Payer: Aetna of IA Commercial	$1.57
Rate for Payer: Aetna of IA Medical Rental Products	$1.57
Rate for Payer: Cash Price	$1.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.30
Rate for Payer: Medical Associates Commercial	$1.30
Rate for Payer: Midlands Choice Commercial	$1.22
Rate for Payer: United Healthcare Commercial	$1.57

bicalutamide 50 mg Tab [VDMC]

Facility

$1.74

Service Code	HCPCS A9270
Hospital Charge Code	10370427
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.57
Rate for Payer: Aetna of IA Commercial	$1.57
Rate for Payer: Aetna of IA Medical Rental Products	$1.57
Rate for Payer: Aetna of IA Medicare	$0.99
Rate for Payer: Amerigroup Medicaid	$0.88
Rate for Payer: Amerigroup Medicare	$0.88
Rate for Payer: Cash Price	$1.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.30
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.87
Rate for Payer: Iowa Total Care Managed Medicaid	$0.87
Rate for Payer: Medical Associates Commercial	$1.30
Rate for Payer: Medical Associates Managed Medicare	$0.87
Rate for Payer: Midlands Choice Commercial	$1.22
Rate for Payer: Molina Healthcare Managed Medicaid	$0.88
Rate for Payer: Molina Healthcare Managed Medicare	$0.88
Rate for Payer: Oscar Health of IA Commercial	$1.30
Rate for Payer: Partners Health Alliance Commercial	$1.30
Rate for Payer: United Healthcare Commercial	$1.57
Rate for Payer: United Healthcare Managed Medicare	$1.03

BIER BLOCK ANESTHESIA

Facility

$422.00

Hospital Charge Code	8059080
Hospital Revenue Code	370
Min. Negotiated Rate	$210.92
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of IA Commercial	$379.80
Rate for Payer: Aetna of IA Medical Rental Products	$379.80
Rate for Payer: Aetna of IA Medicare	$240.54
Rate for Payer: Amerigroup Medicaid	$212.98
Rate for Payer: Amerigroup Medicare	$213.11
Rate for Payer: Cash Price	$337.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$316.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$211.00
Rate for Payer: Iowa Total Care Managed Medicaid	$210.92
Rate for Payer: Medical Associates Commercial	$316.50
Rate for Payer: Medical Associates Managed Medicare	$211.00
Rate for Payer: Midlands Choice Commercial	$295.40
Rate for Payer: Molina Healthcare Managed Medicaid	$214.16
Rate for Payer: Molina Healthcare Managed Medicare	$214.04
Rate for Payer: Oscar Health of IA Commercial	$316.50
Rate for Payer: Partners Health Alliance Commercial	$316.50
Rate for Payer: United Healthcare Commercial	$379.80
Rate for Payer: United Healthcare Managed Medicare	$248.98

BIER BLOCK ANESTHESIA

Facility

$422.00

Hospital Charge Code	8059080
Hospital Revenue Code	370
Min. Negotiated Rate	$295.40
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of IA Commercial	$379.80
Rate for Payer: Aetna of IA Medical Rental Products	$379.80
Rate for Payer: Cash Price	$337.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$316.50
Rate for Payer: Medical Associates Commercial	$316.50
Rate for Payer: Midlands Choice Commercial	$295.40
Rate for Payer: United Healthcare Commercial	$379.80

Bilateral or Multiple Major Joint Procedures of Lower Extremity With MCC

Facility

$59,804.48

Service Code	MS-DRG 461
Hospital Charge Code	281
Min. Negotiated Rate	$58,937.75
Max. Negotiated Rate	$59,804.48
Rate for Payer: Amerigroup Medicaid	$59,515.57
Rate for Payer: Iowa Total Care Managed Medicaid	$58,937.75
Rate for Payer: Molina Healthcare Managed Medicaid	$59,804.48

Bilateral or Multiple Major Joint Procedures of Lower Extremity Without MCC

Facility

$32,470.12

Service Code	MS-DRG 462
Hospital Charge Code	282
Min. Negotiated Rate	$31,999.54
Max. Negotiated Rate	$32,470.12
Rate for Payer: Amerigroup Medicaid	$32,313.26
Rate for Payer: Iowa Total Care Managed Medicaid	$31,999.54
Rate for Payer: Molina Healthcare Managed Medicaid	$32,470.12

Biliary Tract Procedures Except Only Cholecystectomy With or Without C.D.E. With CC

Facility

$27,863.88

Service Code	MS-DRG 409
Hospital Charge Code	241
Min. Negotiated Rate	$27,460.05
Max. Negotiated Rate	$27,863.88
Rate for Payer: Amerigroup Medicaid	$27,729.27
Rate for Payer: Iowa Total Care Managed Medicaid	$27,460.05
Rate for Payer: Molina Healthcare Managed Medicaid	$27,863.88

Biliary Tract Procedures Except Only Cholecystectomy With or Without C.D.E. With MCC

Facility

$27,863.88

Service Code	MS-DRG 408
Hospital Charge Code	240
Min. Negotiated Rate	$27,460.05
Max. Negotiated Rate	$27,863.88
Rate for Payer: Amerigroup Medicaid	$27,729.27
Rate for Payer: Iowa Total Care Managed Medicaid	$27,460.05
Rate for Payer: Molina Healthcare Managed Medicaid	$27,863.88

Biliary Tract Procedures Except Only Cholecystectomy With or Without C.D.E. Without CC/MCC

Facility

$16,403.37

Service Code	MS-DRG 410
Hospital Charge Code	242
Min. Negotiated Rate	$16,165.64
Max. Negotiated Rate	$16,403.37
Rate for Payer: Amerigroup Medicaid	$16,324.13
Rate for Payer: Iowa Total Care Managed Medicaid	$16,165.64
Rate for Payer: Molina Healthcare Managed Medicaid	$16,403.37

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	6312793
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	6312793
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$30.79
Rate for Payer: Amerigroup Medicare	$30.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.50
Rate for Payer: Iowa Total Care Managed Medicaid	$30.49
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$30.50
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$30.96
Rate for Payer: Molina Healthcare Managed Medicare	$30.94
Rate for Payer: Oscar Health of IA Commercial	$45.75
Rate for Payer: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	633670
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	633670
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$30.79
Rate for Payer: Amerigroup Medicare	$30.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.50
Rate for Payer: Iowa Total Care Managed Medicaid	$30.49
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$30.50
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$30.96
Rate for Payer: Molina Healthcare Managed Medicare	$30.94
Rate for Payer: Oscar Health of IA Commercial	$45.75
Rate for Payer: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

Bilirubin Total

Facility

$61.00

Service Code	CPT 82247
Hospital Charge Code	6312792
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

Bilirubin Total

Facility

$61.00

Service Code	CPT 82247
Hospital Charge Code	6312792
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$30.79
Rate for Payer: Amerigroup Medicare	$30.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.50
Rate for Payer: Iowa Total Care Managed Medicaid	$30.49
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$30.50
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$30.96
Rate for Payer: Molina Healthcare Managed Medicare	$30.94
Rate for Payer: Oscar Health of IA Commercial	$45.75
Rate for Payer: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

BILIRUBIN TOTAL

Facility

$61.00

Service Code	CPT 82247
Hospital Charge Code	633672
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$30.79
Rate for Payer: Amerigroup Medicare	$30.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.50
Rate for Payer: Iowa Total Care Managed Medicaid	$30.49
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$30.50
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$30.96
Rate for Payer: Molina Healthcare Managed Medicare	$30.94
Rate for Payer: Oscar Health of IA Commercial	$45.75
Rate for Payer: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

Know your out-of-pocket cost for care.

All Charges