Van Diest Medical Center

All Charges

Charge

Type

Price

clonazePAM 0.5 mg Tab

Facility OP

$3.11

Service Code	CPT A9270
Hospital Charge Code	43701046
Hospital Revenue Code	637
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna of IA Commercial	$2.80
Rate for Payer: Aetna of IA Medical Rental Products	$2.80
Rate for Payer: Aetna of IA Medicare	$1.77
Rate for Payer: Amerigroup Medicaid	$1.57
Rate for Payer: Amerigroup Medicare	$1.57
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.33
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.56
Rate for Payer: Iowa Total Care Managed Medicaid	$1.55
Rate for Payer: Medical Associates Commercial	$2.33
Rate for Payer: Medical Associates Managed Medicare	$1.56
Rate for Payer: Midlands Choice Commercial	$2.18
Rate for Payer: Molina Healthcare Managed Medicaid	$1.58
Rate for Payer: Partners Health Alliance Commercial	$2.33
Rate for Payer: United Healthcare Commercial	$2.80
Rate for Payer: United Healthcare Managed Medicare	$1.83

clonazePAM 1 mg Tab

Facility OP

$3.16

Service Code	CPT A9270
Hospital Charge Code	43770218
Hospital Revenue Code	637
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Aetna of IA Medicare	$1.80
Rate for Payer: Amerigroup Medicaid	$1.59
Rate for Payer: Amerigroup Medicare	$1.60
Rate for Payer: Cash Price	$2.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.58
Rate for Payer: Iowa Total Care Managed Medicaid	$1.58
Rate for Payer: Medical Associates Commercial	$2.37
Rate for Payer: Medical Associates Managed Medicare	$1.58
Rate for Payer: Midlands Choice Commercial	$2.21
Rate for Payer: Molina Healthcare Managed Medicaid	$1.60
Rate for Payer: Partners Health Alliance Commercial	$2.37
Rate for Payer: United Healthcare Commercial	$2.84
Rate for Payer: United Healthcare Managed Medicare	$1.86

clonazePAM 1 mg Tab

Facility IP

$3.16

Service Code	CPT A9270
Hospital Charge Code	43770218
Hospital Revenue Code	637
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Cash Price	$2.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.37
Rate for Payer: Medical Associates Commercial	$2.37
Rate for Payer: Midlands Choice Commercial	$2.21
Rate for Payer: United Healthcare Commercial	$2.84

cloNIDine 0.1 mg/24 hr Transderm ER Film

Facility IP

$44.15

Service Code	CPT A9270
Hospital Charge Code	43702256
Hospital Revenue Code	637
Min. Negotiated Rate	$30.90
Max. Negotiated Rate	$39.74
Rate for Payer: Aetna of IA Commercial	$39.74
Rate for Payer: Aetna of IA Medical Rental Products	$39.74
Rate for Payer: Cash Price	$35.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.11
Rate for Payer: Medical Associates Commercial	$33.11
Rate for Payer: Midlands Choice Commercial	$30.90
Rate for Payer: United Healthcare Commercial	$39.74

cloNIDine 0.1 mg/24 hr Transderm ER Film

Facility OP

$44.15

Service Code	CPT A9270
Hospital Charge Code	43702256
Hospital Revenue Code	637
Min. Negotiated Rate	$22.07
Max. Negotiated Rate	$39.74
Rate for Payer: Aetna of IA Commercial	$39.74
Rate for Payer: Aetna of IA Medical Rental Products	$39.74
Rate for Payer: Aetna of IA Medicare	$25.17
Rate for Payer: Amerigroup Medicaid	$22.28
Rate for Payer: Amerigroup Medicare	$22.30
Rate for Payer: Cash Price	$35.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$22.08
Rate for Payer: Iowa Total Care Managed Medicaid	$22.07
Rate for Payer: Medical Associates Commercial	$33.11
Rate for Payer: Medical Associates Managed Medicare	$22.08
Rate for Payer: Midlands Choice Commercial	$30.90
Rate for Payer: Molina Healthcare Managed Medicaid	$22.41
Rate for Payer: Partners Health Alliance Commercial	$33.11
Rate for Payer: United Healthcare Commercial	$39.74
Rate for Payer: United Healthcare Managed Medicare	$26.05

cloNIDine 0.1 mg Tab

Facility IP

$1.07

Service Code	CPT A9270
Hospital Charge Code	43702536
Hospital Revenue Code	637
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: United Healthcare Commercial	$0.96

cloNIDine 0.1 mg Tab

Facility OP

$1.07

Service Code	CPT A9270
Hospital Charge Code	43702536
Hospital Revenue Code	637
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Aetna of IA Medicare	$0.61
Rate for Payer: Amerigroup Medicaid	$0.54
Rate for Payer: Amerigroup Medicare	$0.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.54
Rate for Payer: Iowa Total Care Managed Medicaid	$0.53
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Medical Associates Managed Medicare	$0.54
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: Molina Healthcare Managed Medicaid	$0.54
Rate for Payer: Partners Health Alliance Commercial	$0.80
Rate for Payer: United Healthcare Commercial	$0.96
Rate for Payer: United Healthcare Managed Medicare	$0.63

cloNIDine 0.3 mg/24 hr Transderm ER Film

Facility OP

$78.33

Service Code	CPT A9270
Hospital Charge Code	43702258
Hospital Revenue Code	637
Min. Negotiated Rate	$39.15
Max. Negotiated Rate	$70.50
Rate for Payer: Aetna of IA Commercial	$70.50
Rate for Payer: Aetna of IA Medical Rental Products	$70.50
Rate for Payer: Aetna of IA Medicare	$44.65
Rate for Payer: Amerigroup Medicaid	$39.53
Rate for Payer: Amerigroup Medicare	$39.56
Rate for Payer: Cash Price	$62.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$39.16
Rate for Payer: Iowa Total Care Managed Medicaid	$39.15
Rate for Payer: Medical Associates Commercial	$58.75
Rate for Payer: Medical Associates Managed Medicare	$39.16
Rate for Payer: Midlands Choice Commercial	$54.83
Rate for Payer: Molina Healthcare Managed Medicaid	$39.75
Rate for Payer: Partners Health Alliance Commercial	$58.75
Rate for Payer: United Healthcare Commercial	$70.50
Rate for Payer: United Healthcare Managed Medicare	$46.21

cloNIDine 0.3 mg/24 hr Transderm ER Film

Facility IP

$78.33

Service Code	CPT A9270
Hospital Charge Code	43702258
Hospital Revenue Code	637
Min. Negotiated Rate	$54.83
Max. Negotiated Rate	$70.50
Rate for Payer: Aetna of IA Commercial	$70.50
Rate for Payer: Aetna of IA Medical Rental Products	$70.50
Rate for Payer: Cash Price	$62.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.75
Rate for Payer: Medical Associates Commercial	$58.75
Rate for Payer: Midlands Choice Commercial	$54.83
Rate for Payer: United Healthcare Commercial	$70.50

clopidogrel 75 mg Tab

Facility IP

$1.69

Service Code	CPT A9270
Hospital Charge Code	43701005
Hospital Revenue Code	637
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of IA Commercial	$1.52
Rate for Payer: Aetna of IA Medical Rental Products	$1.52
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.27
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: United Healthcare Commercial	$1.52

clopidogrel 75 mg Tab

Facility OP

$1.69

Service Code	CPT A9270
Hospital Charge Code	43701005
Hospital Revenue Code	637
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of IA Commercial	$1.52
Rate for Payer: Aetna of IA Medical Rental Products	$1.52
Rate for Payer: Aetna of IA Medicare	$0.96
Rate for Payer: Amerigroup Medicaid	$0.85
Rate for Payer: Amerigroup Medicare	$0.85
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.85
Rate for Payer: Iowa Total Care Managed Medicaid	$0.84
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Medical Associates Managed Medicare	$0.85
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: Molina Healthcare Managed Medicaid	$0.86
Rate for Payer: Partners Health Alliance Commercial	$1.27
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Managed Medicare	$1.00

CLOSED REDUCTION

Professional

$1,621.00

Service Code	CPT 25535
Hospital Charge Code	7982868
Hospital Revenue Code	981
Min. Negotiated Rate	$423.81
Max. Negotiated Rate	$1,134.70
Rate for Payer: Aetna of IA Medicare	$423.81
Rate for Payer: Amerigroup Medicaid	$438.22
Rate for Payer: Cash Price	$1,296.80
Rate for Payer: Cash Price	$1,296.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$508.57
Rate for Payer: Iowa Total Care Managed Medicaid	$432.29
Rate for Payer: Medical Associates Commercial	$805.24
Rate for Payer: Medical Associates Managed Medicare	$423.81
Rate for Payer: Midlands Choice Commercial	$1,134.70
Rate for Payer: Partners Health Alliance Commercial	$635.72
Rate for Payer: Wellmark IA HMO	$891.00
Rate for Payer: Wellmark IA PPO	$1,046.00

CLOSED TREATMENT OF CARPAL BONE FX

Professional

$1,464.00

Service Code	CPT 25635
Hospital Charge Code	8822636
Hospital Revenue Code	981
Min. Negotiated Rate	$392.82
Max. Negotiated Rate	$1,024.80
Rate for Payer: Aetna of IA Medicare	$392.82
Rate for Payer: Amerigroup Medicaid	$406.18
Rate for Payer: Cash Price	$1,171.20
Rate for Payer: Cash Price	$1,171.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.38
Rate for Payer: Iowa Total Care Managed Medicaid	$400.68
Rate for Payer: Medical Associates Commercial	$746.36
Rate for Payer: Medical Associates Managed Medicare	$392.82
Rate for Payer: Midlands Choice Commercial	$1,024.80
Rate for Payer: Partners Health Alliance Commercial	$589.23
Rate for Payer: Wellmark IA HMO	$825.00
Rate for Payer: Wellmark IA PPO	$968.00

Closed treatment of post hip arthroplasty dislocation; without anesthesia

Facility OP

$3,346.57

Service Code	CPT 27265
Hospital Revenue Code	490
Min. Negotiated Rate	$3,042.34
Max. Negotiated Rate	$3,346.57
Rate for Payer: Wellmark IA HMO	$3,042.34
Rate for Payer: Wellmark IA PPO	$3,346.57

Clostridioides difficile Toxin by EIA DMCL

Facility IP

$58.00

Service Code	CPT 87324
Hospital Charge Code	8728243
Hospital Revenue Code	306
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

Clostridioides difficile Toxin by EIA DMCL

Facility OP

$58.00

Service Code	CPT 87324
Hospital Charge Code	8728243
Hospital Revenue Code	306
Min. Negotiated Rate	$28.99
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$29.27
Rate for Payer: Amerigroup Medicare	$29.29
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.00
Rate for Payer: Iowa Total Care Managed Medicaid	$28.99
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$29.00
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$29.44
Rate for Payer: Partners Health Alliance Commercial	$43.50
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

CLOSTRIDIUM DIFFICILE

Facility IP

$152.00

Service Code	CPT 87493
Hospital Charge Code	4022795
Hospital Revenue Code	306
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: United Healthcare Commercial	$136.80

CLOSTRIDIUM DIFFICILE

Facility OP

$152.00

Service Code	CPT 87493
Hospital Charge Code	4022795
Hospital Revenue Code	306
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Aetna of IA Medicare	$86.64
Rate for Payer: Amerigroup Medicaid	$76.71
Rate for Payer: Amerigroup Medicare	$76.76
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.00
Rate for Payer: Iowa Total Care Managed Medicaid	$75.97
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Medical Associates Managed Medicare	$76.00
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: Molina Healthcare Managed Medicaid	$77.14
Rate for Payer: Partners Health Alliance Commercial	$114.00
Rate for Payer: United Healthcare Commercial	$136.80
Rate for Payer: United Healthcare Managed Medicare	$89.68
Rate for Payer: Wellmark IA HMO	$68.82
Rate for Payer: Wellmark IA PPO	$75.70

clotrimazole 10 mg Loz

Facility IP

$2.10

Service Code	CPT A9270
Hospital Charge Code	43701260
Hospital Revenue Code	637
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.89
Rate for Payer: Aetna of IA Commercial	$1.89
Rate for Payer: Aetna of IA Medical Rental Products	$1.89
Rate for Payer: Cash Price	$1.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Midlands Choice Commercial	$1.47
Rate for Payer: United Healthcare Commercial	$1.89

clotrimazole 10 mg Loz

Facility OP

$2.10

Service Code	CPT A9270
Hospital Charge Code	43701260
Hospital Revenue Code	637
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.89
Rate for Payer: Aetna of IA Commercial	$1.89
Rate for Payer: Aetna of IA Medical Rental Products	$1.89
Rate for Payer: Aetna of IA Medicare	$1.20
Rate for Payer: Amerigroup Medicaid	$1.06
Rate for Payer: Amerigroup Medicare	$1.06
Rate for Payer: Cash Price	$1.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.05
Rate for Payer: Iowa Total Care Managed Medicaid	$1.05
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Medical Associates Managed Medicare	$1.05
Rate for Payer: Midlands Choice Commercial	$1.47
Rate for Payer: Molina Healthcare Managed Medicaid	$1.07
Rate for Payer: Partners Health Alliance Commercial	$1.58
Rate for Payer: United Healthcare Commercial	$1.89
Rate for Payer: United Healthcare Managed Medicare	$1.24

clotrimazole Top 1% Crm 30gm

Facility OP

$16.20

Service Code	CPT A9270
Hospital Charge Code	43701930
Hospital Revenue Code	637
Min. Negotiated Rate	$8.10
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna of IA Commercial	$14.58
Rate for Payer: Aetna of IA Medical Rental Products	$14.58
Rate for Payer: Aetna of IA Medicare	$9.23
Rate for Payer: Amerigroup Medicaid	$8.18
Rate for Payer: Amerigroup Medicare	$8.18
Rate for Payer: Cash Price	$12.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.10
Rate for Payer: Iowa Total Care Managed Medicaid	$8.10
Rate for Payer: Medical Associates Commercial	$12.15
Rate for Payer: Medical Associates Managed Medicare	$8.10
Rate for Payer: Midlands Choice Commercial	$11.34
Rate for Payer: Molina Healthcare Managed Medicaid	$8.22
Rate for Payer: Partners Health Alliance Commercial	$12.15
Rate for Payer: United Healthcare Commercial	$14.58
Rate for Payer: United Healthcare Managed Medicare	$9.56

clotrimazole Top 1% Crm 30gm

Facility IP

$16.20

Service Code	CPT A9270
Hospital Charge Code	43701930
Hospital Revenue Code	637
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna of IA Commercial	$14.58
Rate for Payer: Aetna of IA Medical Rental Products	$14.58
Rate for Payer: Cash Price	$12.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.15
Rate for Payer: Medical Associates Commercial	$12.15
Rate for Payer: Midlands Choice Commercial	$11.34
Rate for Payer: United Healthcare Commercial	$14.58

CMPLX RPR E/N/E/L 1.1-2.5 CM

Professional

$1,400.00

Service Code	CPT 13151
Hospital Charge Code	7982819
Hospital Revenue Code	981
Min. Negotiated Rate	$251.83
Max. Negotiated Rate	$980.00
Rate for Payer: Aetna of IA Medicare	$251.83
Rate for Payer: Amerigroup Medicaid	$260.39
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$302.20
Rate for Payer: Iowa Total Care Managed Medicaid	$256.87
Rate for Payer: Medical Associates Commercial	$478.48
Rate for Payer: Medical Associates Managed Medicare	$251.83
Rate for Payer: Midlands Choice Commercial	$980.00
Rate for Payer: Partners Health Alliance Commercial	$377.74
Rate for Payer: Wellmark IA HMO	$526.00
Rate for Payer: Wellmark IA PPO	$617.00

CMPLX RPR F/C/C/M/N/AX/G/H/F

Professional

$1,277.00

Service Code	CPT 13132
Hospital Charge Code	7982820
Hospital Revenue Code	981
Min. Negotiated Rate	$274.46
Max. Negotiated Rate	$893.90
Rate for Payer: Aetna of IA Medicare	$274.46
Rate for Payer: Amerigroup Medicaid	$283.79
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$329.35
Rate for Payer: Iowa Total Care Managed Medicaid	$279.95
Rate for Payer: Medical Associates Commercial	$521.47
Rate for Payer: Medical Associates Managed Medicare	$274.46
Rate for Payer: Midlands Choice Commercial	$893.90
Rate for Payer: Partners Health Alliance Commercial	$411.69
Rate for Payer: Wellmark IA HMO	$571.00
Rate for Payer: Wellmark IA PPO	$671.00

CMPLX RPR S/A/L 2.6-7.5 CM

Professional

$1,415.00

Service Code	CPT 13121
Hospital Charge Code	7982821
Hospital Revenue Code	981
Min. Negotiated Rate	$233.97
Max. Negotiated Rate	$990.50
Rate for Payer: Aetna of IA Medicare	$233.97
Rate for Payer: Amerigroup Medicaid	$241.92
Rate for Payer: Cash Price	$1,132.00
Rate for Payer: Cash Price	$1,132.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$280.76
Rate for Payer: Iowa Total Care Managed Medicaid	$238.65
Rate for Payer: Medical Associates Commercial	$444.54
Rate for Payer: Medical Associates Managed Medicare	$233.97
Rate for Payer: Midlands Choice Commercial	$990.50
Rate for Payer: Partners Health Alliance Commercial	$350.96
Rate for Payer: Wellmark IA HMO	$485.00
Rate for Payer: Wellmark IA PPO	$570.00

Price Transparency.

All Charges