Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

BODY FLUID PROTEIN

Facility

$61.00

Service Code	CPT 84157
Hospital Charge Code	4022830
Hospital Revenue Code	309
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

BODY FLUID PROTEIN

Facility

$61.00

Service Code	CPT 84157
Hospital Charge Code	4022830
Hospital Revenue Code	309
Min. Negotiated Rate	$27.45
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	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
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	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

BONE BIOPSY EXCISIONAL

Facility

$1,696.00

Service Code	CPT 20240
Hospital Charge Code	7983040
Hospital Revenue Code	450
Min. Negotiated Rate	$763.20
Max. Negotiated Rate	$4,029.18
Rate for Payer: Aetna of IA Commercial	$1,526.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,526.40
Rate for Payer: Aetna of IA Medicare	$966.72
Rate for Payer: Amerigroup Medicaid	$978.25
Rate for Payer: Amerigroup Medicare	$770.83
Rate for Payer: Cash Price	$1,356.80
Rate for Payer: Cash Price	$1,356.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,272.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$763.20
Rate for Payer: Iowa Total Care Managed Medicaid	$968.76
Rate for Payer: Medical Associates Commercial	$1,272.00
Rate for Payer: Medical Associates Managed Medicare	$763.20
Rate for Payer: Midlands Choice Commercial	$1,187.20
Rate for Payer: Molina Healthcare Managed Medicaid	$983.00
Rate for Payer: Partners Health Alliance Commercial	$877.68
Rate for Payer: United Healthcare Commercial	$1,526.40
Rate for Payer: United Healthcare Managed Medicare	$1,000.64
Rate for Payer: Wellmark IA HMO WHPI	$3,657.73
Rate for Payer: Wellmark IA PPO	$4,029.18

BONE BIOPSY EXCISIONAL

Facility

$1,696.00

Service Code	CPT 20240
Hospital Charge Code	7983040
Hospital Revenue Code	450
Min. Negotiated Rate	$1,187.20
Max. Negotiated Rate	$1,526.40
Rate for Payer: Aetna of IA Commercial	$1,526.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,526.40
Rate for Payer: Cash Price	$1,356.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,272.00
Rate for Payer: Medical Associates Commercial	$1,272.00
Rate for Payer: Midlands Choice Commercial	$1,187.20
Rate for Payer: United Healthcare Commercial	$1,526.40

BONE DISEASES AND ARTHROPATHIES WITH MCC

Facility

$13,365.35

Service Code	MSDRG 553
Min. Negotiated Rate	$13,171.64
Max. Negotiated Rate	$13,365.35
Rate for Payer: Amerigroup Medicaid	$13,300.77
Rate for Payer: Iowa Total Care Managed Medicaid	$13,171.64
Rate for Payer: Molina Healthcare Managed Medicaid	$13,365.35

BONE DISEASES AND ARTHROPATHIES WITHOUT MCC

Facility

$7,467.48

Service Code	MSDRG 554
Min. Negotiated Rate	$7,359.25
Max. Negotiated Rate	$7,467.48
Rate for Payer: Amerigroup Medicaid	$7,431.40
Rate for Payer: Iowa Total Care Managed Medicaid	$7,359.25
Rate for Payer: Molina Healthcare Managed Medicaid	$7,467.48

Bone Fixation

Facility

$495.00

Service Code	HCPCS C1713
Hospital Charge Code	8942329
Hospital Revenue Code	278
Min. Negotiated Rate	$222.75
Max. Negotiated Rate	$445.50
Rate for Payer: Aetna of IA Commercial	$445.50
Rate for Payer: Aetna of IA Medical Rental Products	$445.50
Rate for Payer: Aetna of IA Medicare	$282.15
Rate for Payer: Amerigroup Medicaid	$285.52
Rate for Payer: Amerigroup Medicare	$224.98
Rate for Payer: Cash Price	$396.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$371.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$222.75
Rate for Payer: Iowa Total Care Managed Medicaid	$282.74
Rate for Payer: Medical Associates Commercial	$371.25
Rate for Payer: Medical Associates Managed Medicare	$222.75
Rate for Payer: Midlands Choice Commercial	$346.50
Rate for Payer: Molina Healthcare Managed Medicaid	$286.90
Rate for Payer: Partners Health Alliance Commercial	$256.16
Rate for Payer: United Healthcare Commercial	$445.50
Rate for Payer: United Healthcare Managed Medicare	$292.05

Bone Fixation

Facility

$2,500.00

Service Code	HCPCS C1713
Hospital Charge Code	8942321
Hospital Revenue Code	278
Min. Negotiated Rate	$1,750.00
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna of IA Commercial	$2,250.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,250.00
Rate for Payer: Cash Price	$2,000.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,875.00
Rate for Payer: Medical Associates Commercial	$1,875.00
Rate for Payer: Midlands Choice Commercial	$1,750.00
Rate for Payer: United Healthcare Commercial	$2,250.00

Bone Fixation

Facility

$2,500.00

Service Code	HCPCS C1713
Hospital Charge Code	8942321
Hospital Revenue Code	278
Min. Negotiated Rate	$1,125.00
Max. Negotiated Rate	$2,250.00
Rate for Payer: Aetna of IA Commercial	$2,250.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,250.00
Rate for Payer: Aetna of IA Medicare	$1,425.00
Rate for Payer: Amerigroup Medicaid	$1,442.00
Rate for Payer: Amerigroup Medicare	$1,136.25
Rate for Payer: Cash Price	$2,000.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,875.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,125.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,428.00
Rate for Payer: Medical Associates Commercial	$1,875.00
Rate for Payer: Medical Associates Managed Medicare	$1,125.00
Rate for Payer: Midlands Choice Commercial	$1,750.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,449.00
Rate for Payer: Partners Health Alliance Commercial	$1,293.75
Rate for Payer: United Healthcare Commercial	$2,250.00
Rate for Payer: United Healthcare Managed Medicare	$1,475.00

Bone Fixation

Facility

$495.00

Service Code	HCPCS C1713
Hospital Charge Code	8942329
Hospital Revenue Code	278
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$445.50
Rate for Payer: Aetna of IA Commercial	$445.50
Rate for Payer: Aetna of IA Medical Rental Products	$445.50
Rate for Payer: Cash Price	$396.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$371.25
Rate for Payer: Medical Associates Commercial	$371.25
Rate for Payer: Midlands Choice Commercial	$346.50
Rate for Payer: United Healthcare Commercial	$445.50

Bone Fixation System

Facility

$350.00

Service Code	HCPCS C1713
Hospital Charge Code	8942319
Hospital Revenue Code	278
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna of IA Commercial	$315.00
Rate for Payer: Aetna of IA Medical Rental Products	$315.00
Rate for Payer: Aetna of IA Medicare	$199.50
Rate for Payer: Amerigroup Medicaid	$201.88
Rate for Payer: Amerigroup Medicare	$159.08
Rate for Payer: Cash Price	$280.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$262.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$157.50
Rate for Payer: Iowa Total Care Managed Medicaid	$199.92
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Medical Associates Managed Medicare	$157.50
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: Molina Healthcare Managed Medicaid	$202.86
Rate for Payer: Partners Health Alliance Commercial	$181.12
Rate for Payer: United Healthcare Commercial	$315.00
Rate for Payer: United Healthcare Managed Medicare	$206.50

Bone Fixation System

Facility

$350.00

Service Code	HCPCS C1713
Hospital Charge Code	8942319
Hospital Revenue Code	278
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna of IA Commercial	$315.00
Rate for Payer: Aetna of IA Medical Rental Products	$315.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$262.50
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: United Healthcare Commercial	$315.00

BONE FIXATION SYSTEM

Facility

$2,880.00

Service Code	HCPCS C1713
Hospital Charge Code	8883880
Hospital Revenue Code	278
Min. Negotiated Rate	$1,296.00
Max. Negotiated Rate	$2,592.00
Rate for Payer: Aetna of IA Commercial	$2,592.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,592.00
Rate for Payer: Aetna of IA Medicare	$1,641.60
Rate for Payer: Amerigroup Medicaid	$1,661.18
Rate for Payer: Amerigroup Medicare	$1,308.96
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,160.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,296.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,645.06
Rate for Payer: Medical Associates Commercial	$2,160.00
Rate for Payer: Medical Associates Managed Medicare	$1,296.00
Rate for Payer: Midlands Choice Commercial	$2,016.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,669.25
Rate for Payer: Partners Health Alliance Commercial	$1,490.40
Rate for Payer: United Healthcare Commercial	$2,592.00
Rate for Payer: United Healthcare Managed Medicare	$1,699.20

BONE FIXATION SYSTEM

Facility

$2,880.00

Service Code	HCPCS C1713
Hospital Charge Code	8883880
Hospital Revenue Code	278
Min. Negotiated Rate	$2,016.00
Max. Negotiated Rate	$2,592.00
Rate for Payer: Aetna of IA Commercial	$2,592.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,592.00
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,160.00
Rate for Payer: Medical Associates Commercial	$2,160.00
Rate for Payer: Midlands Choice Commercial	$2,016.00
Rate for Payer: United Healthcare Commercial	$2,592.00

BONE FIXATION SYSTEM 12X12X12 3000-00-121212

Facility

$2,520.00

Service Code	HCPCS C1713
Hospital Charge Code	8964807
Hospital Revenue Code	278
Min. Negotiated Rate	$1,134.00
Max. Negotiated Rate	$2,268.00
Rate for Payer: Aetna of IA Commercial	$2,268.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,268.00
Rate for Payer: Aetna of IA Medicare	$1,436.40
Rate for Payer: Amerigroup Medicaid	$1,453.54
Rate for Payer: Amerigroup Medicare	$1,145.34
Rate for Payer: Cash Price	$2,016.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,890.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,134.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,439.42
Rate for Payer: Medical Associates Commercial	$1,890.00
Rate for Payer: Medical Associates Managed Medicare	$1,134.00
Rate for Payer: Midlands Choice Commercial	$1,764.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,460.59
Rate for Payer: Partners Health Alliance Commercial	$1,304.10
Rate for Payer: United Healthcare Commercial	$2,268.00
Rate for Payer: United Healthcare Managed Medicare	$1,486.80

BONE FIXATION SYSTEM 12X12X12 3000-00-121212

Facility

$2,520.00

Service Code	HCPCS C1713
Hospital Charge Code	8964807
Hospital Revenue Code	278
Min. Negotiated Rate	$1,764.00
Max. Negotiated Rate	$2,268.00
Rate for Payer: Aetna of IA Commercial	$2,268.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,268.00
Rate for Payer: Cash Price	$2,016.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,890.00
Rate for Payer: Medical Associates Commercial	$1,890.00
Rate for Payer: Midlands Choice Commercial	$1,764.00
Rate for Payer: United Healthcare Commercial	$2,268.00

BONE FIXATION SYSTEM 14X14X14 3000-00-141414

Facility

$2,880.00

Service Code	HCPCS C1713
Hospital Charge Code	8956474
Hospital Revenue Code	278
Min. Negotiated Rate	$1,296.00
Max. Negotiated Rate	$2,592.00
Rate for Payer: Aetna of IA Commercial	$2,592.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,592.00
Rate for Payer: Aetna of IA Medicare	$1,641.60
Rate for Payer: Amerigroup Medicaid	$1,661.18
Rate for Payer: Amerigroup Medicare	$1,308.96
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,160.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,296.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,645.06
Rate for Payer: Medical Associates Commercial	$2,160.00
Rate for Payer: Medical Associates Managed Medicare	$1,296.00
Rate for Payer: Midlands Choice Commercial	$2,016.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,669.25
Rate for Payer: Partners Health Alliance Commercial	$1,490.40
Rate for Payer: United Healthcare Commercial	$2,592.00
Rate for Payer: United Healthcare Managed Medicare	$1,699.20

BONE FIXATION SYSTEM 14X14X14 3000-00-141414

Facility

$2,880.00

Service Code	HCPCS C1713
Hospital Charge Code	8956474
Hospital Revenue Code	278
Min. Negotiated Rate	$2,016.00
Max. Negotiated Rate	$2,592.00
Rate for Payer: Aetna of IA Commercial	$2,592.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,592.00
Rate for Payer: Cash Price	$2,304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,160.00
Rate for Payer: Medical Associates Commercial	$2,160.00
Rate for Payer: Midlands Choice Commercial	$2,016.00
Rate for Payer: United Healthcare Commercial	$2,592.00

BONE FIXATION SYSTEM 26X20X20 3000-00-262020

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8964809
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: United Healthcare Commercial	$194.40

BONE FIXATION SYSTEM 26X20X20 3000-00-262020

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8964809
Hospital Revenue Code	278
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Aetna of IA Medicare	$123.12
Rate for Payer: Amerigroup Medicaid	$124.59
Rate for Payer: Amerigroup Medicare	$98.17
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.20
Rate for Payer: Iowa Total Care Managed Medicaid	$123.38
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Medical Associates Managed Medicare	$97.20
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: Molina Healthcare Managed Medicaid	$125.19
Rate for Payer: Partners Health Alliance Commercial	$111.78
Rate for Payer: United Healthcare Commercial	$194.40
Rate for Payer: United Healthcare Managed Medicare	$127.44

BONE FIXATION SYSTEM 30X16X16 3000-06-301616

Facility

$4,608.00

Service Code	HCPCS C1713
Hospital Charge Code	9002590
Hospital Revenue Code	278
Min. Negotiated Rate	$3,225.60
Max. Negotiated Rate	$4,147.20
Rate for Payer: Aetna of IA Commercial	$4,147.20
Rate for Payer: Aetna of IA Medical Rental Products	$4,147.20
Rate for Payer: Cash Price	$3,686.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,456.00
Rate for Payer: Medical Associates Commercial	$3,456.00
Rate for Payer: Midlands Choice Commercial	$3,225.60
Rate for Payer: United Healthcare Commercial	$4,147.20

BONE FIXATION SYSTEM 30X16X16 3000-06-301616

Facility

$4,608.00

Service Code	HCPCS C1713
Hospital Charge Code	9002590
Hospital Revenue Code	278
Min. Negotiated Rate	$2,073.60
Max. Negotiated Rate	$4,147.20
Rate for Payer: Aetna of IA Commercial	$4,147.20
Rate for Payer: Aetna of IA Medical Rental Products	$4,147.20
Rate for Payer: Aetna of IA Medicare	$2,626.56
Rate for Payer: Amerigroup Medicaid	$2,657.89
Rate for Payer: Amerigroup Medicare	$2,094.34
Rate for Payer: Cash Price	$3,686.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,456.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,073.60
Rate for Payer: Iowa Total Care Managed Medicaid	$2,632.09
Rate for Payer: Medical Associates Commercial	$3,456.00
Rate for Payer: Medical Associates Managed Medicare	$2,073.60
Rate for Payer: Midlands Choice Commercial	$3,225.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,670.80
Rate for Payer: Partners Health Alliance Commercial	$2,384.64
Rate for Payer: United Healthcare Commercial	$4,147.20
Rate for Payer: United Healthcare Managed Medicare	$2,718.72

BONE FIXATION SYSTEM PROCEDURE PACK

Facility

$495.00

Service Code	HCPCS C1713
Hospital Charge Code	8883877
Hospital Revenue Code	278
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$445.50
Rate for Payer: Aetna of IA Commercial	$445.50
Rate for Payer: Aetna of IA Medical Rental Products	$445.50
Rate for Payer: Cash Price	$396.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$371.25
Rate for Payer: Medical Associates Commercial	$371.25
Rate for Payer: Midlands Choice Commercial	$346.50
Rate for Payer: United Healthcare Commercial	$445.50

BONE FIXATION SYSTEM PROCEDURE PACK

Facility

$495.00

Service Code	HCPCS C1713
Hospital Charge Code	8883877
Hospital Revenue Code	278
Min. Negotiated Rate	$222.75
Max. Negotiated Rate	$445.50
Rate for Payer: Aetna of IA Commercial	$445.50
Rate for Payer: Aetna of IA Medical Rental Products	$445.50
Rate for Payer: Aetna of IA Medicare	$282.15
Rate for Payer: Amerigroup Medicaid	$285.52
Rate for Payer: Amerigroup Medicare	$224.98
Rate for Payer: Cash Price	$396.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$371.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$222.75
Rate for Payer: Iowa Total Care Managed Medicaid	$282.74
Rate for Payer: Medical Associates Commercial	$371.25
Rate for Payer: Medical Associates Managed Medicare	$222.75
Rate for Payer: Midlands Choice Commercial	$346.50
Rate for Payer: Molina Healthcare Managed Medicaid	$286.90
Rate for Payer: Partners Health Alliance Commercial	$256.16
Rate for Payer: United Healthcare Commercial	$445.50
Rate for Payer: United Healthcare Managed Medicare	$292.05

BONE GRAFT HEMI-FEMORAL SHAFT

Facility

$2,700.00

Service Code	HCPCS L8699
Hospital Charge Code	8046938
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.00
Max. Negotiated Rate	$2,430.00
Rate for Payer: Aetna of IA Commercial	$2,430.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,430.00
Rate for Payer: Aetna of IA Medicare	$1,539.00
Rate for Payer: Amerigroup Medicaid	$1,557.36
Rate for Payer: Amerigroup Medicare	$1,227.15
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,025.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,215.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,542.24
Rate for Payer: Medical Associates Commercial	$2,025.00
Rate for Payer: Medical Associates Managed Medicare	$1,215.00
Rate for Payer: Midlands Choice Commercial	$1,890.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,564.92
Rate for Payer: Partners Health Alliance Commercial	$1,397.25
Rate for Payer: United Healthcare Commercial	$2,430.00
Rate for Payer: United Healthcare Managed Medicare	$1,593.00

Know your out-of-pocket cost for care.

All Charges