Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

chlorthalidone 25 mg Tab [VDMC]

Facility

$3.21

Service Code	HCPCS A9270
Hospital Charge Code	10377640
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of IA Commercial	$2.89
Rate for Payer: Aetna of IA Medical Rental Products	$2.89
Rate for Payer: Aetna of IA Medicare	$1.83
Rate for Payer: Amerigroup Medicaid	$1.85
Rate for Payer: Amerigroup Medicare	$1.46
Rate for Payer: Cash Price	$2.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.44
Rate for Payer: Iowa Total Care Managed Medicaid	$1.83
Rate for Payer: Medical Associates Commercial	$2.40
Rate for Payer: Medical Associates Managed Medicare	$1.44
Rate for Payer: Midlands Choice Commercial	$2.24
Rate for Payer: Molina Healthcare Managed Medicaid	$1.86
Rate for Payer: Partners Health Alliance Commercial	$1.66
Rate for Payer: United Healthcare Commercial	$2.89
Rate for Payer: United Healthcare Managed Medicare	$1.89

cholecalciferol 125 mcg (5000 intl units) Cap [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10431573
Hospital Revenue Code	259
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	$0.85
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

cholecalciferol 125 mcg (5000 intl units) Cap [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10431573
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
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	$0.62
Rate for Payer: Amerigroup Medicare	$0.48
Rate for Payer: Cash Price	$0.85
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	$0.48
Rate for Payer: Iowa Total Care Managed Medicaid	$0.61
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Medical Associates Managed Medicare	$0.48
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: Molina Healthcare Managed Medicaid	$0.62
Rate for Payer: Partners Health Alliance Commercial	$0.55
Rate for Payer: United Healthcare Commercial	$0.96
Rate for Payer: United Healthcare Managed Medicare	$0.63

cholecalciferol 25mcg (1000 intl units) tablet [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10431441
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
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	$0.62
Rate for Payer: Amerigroup Medicare	$0.49
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	$0.48
Rate for Payer: Iowa Total Care Managed Medicaid	$0.61
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Medical Associates Managed Medicare	$0.48
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: Molina Healthcare Managed Medicaid	$0.62
Rate for Payer: Partners Health Alliance Commercial	$0.55
Rate for Payer: United Healthcare Commercial	$0.96
Rate for Payer: United Healthcare Managed Medicare	$0.63

cholecalciferol 25mcg (1000 intl units) tablet [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10431441
Hospital Revenue Code	259
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

cholecalciferol 50 mcg (2000 intl units) Cap [VDMC]

Facility

$2.19

Service Code	HCPCS A9270
Hospital Charge Code	10431508
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of IA Commercial	$1.97
Rate for Payer: Aetna of IA Medical Rental Products	$1.97
Rate for Payer: Aetna of IA Medicare	$1.25
Rate for Payer: Amerigroup Medicaid	$1.27
Rate for Payer: Amerigroup Medicare	$1.00
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.65
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.99
Rate for Payer: Iowa Total Care Managed Medicaid	$1.25
Rate for Payer: Medical Associates Commercial	$1.65
Rate for Payer: Medical Associates Managed Medicare	$0.99
Rate for Payer: Midlands Choice Commercial	$1.54
Rate for Payer: Molina Healthcare Managed Medicaid	$1.27
Rate for Payer: Partners Health Alliance Commercial	$1.14
Rate for Payer: United Healthcare Commercial	$1.97
Rate for Payer: United Healthcare Managed Medicare	$1.29

cholecalciferol 50 mcg (2000 intl units) Cap [VDMC]

Facility

$2.19

Service Code	HCPCS A9270
Hospital Charge Code	10431508
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of IA Commercial	$1.97
Rate for Payer: Aetna of IA Medical Rental Products	$1.97
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.65
Rate for Payer: Medical Associates Commercial	$1.65
Rate for Payer: Midlands Choice Commercial	$1.54
Rate for Payer: United Healthcare Commercial	$1.97

CHOLESTEROL-TOTAL

Facility

$45.00

Service Code	CPT 82465
Hospital Charge Code	633705
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of IA Commercial	$40.50
Rate for Payer: Aetna of IA Medical Rental Products	$40.50
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.75
Rate for Payer: Medical Associates Commercial	$33.75
Rate for Payer: Midlands Choice Commercial	$31.50
Rate for Payer: United Healthcare Commercial	$40.50

CHOLESTEROL-TOTAL

Facility

$45.00

Service Code	CPT 82465
Hospital Charge Code	633705
Hospital Revenue Code	301
Min. Negotiated Rate	$20.25
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of IA Commercial	$40.50
Rate for Payer: Aetna of IA Medical Rental Products	$40.50
Rate for Payer: Aetna of IA Medicare	$25.65
Rate for Payer: Amerigroup Medicaid	$25.96
Rate for Payer: Amerigroup Medicare	$20.45
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.25
Rate for Payer: Iowa Total Care Managed Medicaid	$25.70
Rate for Payer: Medical Associates Commercial	$33.75
Rate for Payer: Medical Associates Managed Medicare	$20.25
Rate for Payer: Midlands Choice Commercial	$31.50
Rate for Payer: Molina Healthcare Managed Medicaid	$26.08
Rate for Payer: Partners Health Alliance Commercial	$23.29
Rate for Payer: United Healthcare Commercial	$40.50
Rate for Payer: United Healthcare Managed Medicare	$26.55

cholestyramine 4 g/5.5 g Pow UD [VDMC]

Facility

$7.05

Service Code	HCPCS A9270
Hospital Charge Code	10377709
Hospital Revenue Code	259
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$6.34
Rate for Payer: Aetna of IA Commercial	$6.34
Rate for Payer: Aetna of IA Medical Rental Products	$6.34
Rate for Payer: Cash Price	$5.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.29
Rate for Payer: Medical Associates Commercial	$5.29
Rate for Payer: Midlands Choice Commercial	$4.93
Rate for Payer: United Healthcare Commercial	$6.34

cholestyramine 4 g/5.5 g Pow UD [VDMC]

Facility

$7.05

Service Code	HCPCS A9270
Hospital Charge Code	10377709
Hospital Revenue Code	259
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$6.34
Rate for Payer: Aetna of IA Commercial	$6.34
Rate for Payer: Aetna of IA Medical Rental Products	$6.34
Rate for Payer: Aetna of IA Medicare	$4.02
Rate for Payer: Amerigroup Medicaid	$4.06
Rate for Payer: Amerigroup Medicare	$3.20
Rate for Payer: Cash Price	$5.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.29
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.17
Rate for Payer: Iowa Total Care Managed Medicaid	$4.03
Rate for Payer: Medical Associates Commercial	$5.29
Rate for Payer: Medical Associates Managed Medicare	$3.17
Rate for Payer: Midlands Choice Commercial	$4.93
Rate for Payer: Molina Healthcare Managed Medicaid	$4.08
Rate for Payer: Partners Health Alliance Commercial	$3.65
Rate for Payer: United Healthcare Commercial	$6.34
Rate for Payer: United Healthcare Managed Medicare	$4.16

chondroitin sulf-sod hyaluron syrg 40 mg-30 mg/mL Ophth Sol 0 mL [VDMC]

Facility

$144.24

Service Code	NDC 08065-1839-05
Hospital Charge Code	10421631
Hospital Revenue Code	259
Min. Negotiated Rate	$100.97
Max. Negotiated Rate	$129.82
Rate for Payer: Aetna of IA Commercial	$129.82
Rate for Payer: Aetna of IA Medical Rental Products	$129.82
Rate for Payer: Cash Price	$115.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.18
Rate for Payer: Medical Associates Commercial	$108.18
Rate for Payer: Midlands Choice Commercial	$100.97
Rate for Payer: United Healthcare Commercial	$129.82

chondroitin sulf-sod hyaluron syrg 40 mg-30 mg/mL Ophth Sol 0 mL [VDMC]

Facility

$144.24

Service Code	NDC 08065-1839-05
Hospital Charge Code	10421631
Hospital Revenue Code	259
Min. Negotiated Rate	$64.91
Max. Negotiated Rate	$129.82
Rate for Payer: Aetna of IA Commercial	$129.82
Rate for Payer: Aetna of IA Medical Rental Products	$129.82
Rate for Payer: Aetna of IA Medicare	$82.22
Rate for Payer: Amerigroup Medicaid	$83.20
Rate for Payer: Amerigroup Medicare	$65.56
Rate for Payer: Cash Price	$115.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.91
Rate for Payer: Iowa Total Care Managed Medicaid	$82.39
Rate for Payer: Medical Associates Commercial	$108.18
Rate for Payer: Medical Associates Managed Medicare	$64.91
Rate for Payer: Midlands Choice Commercial	$100.97
Rate for Payer: Molina Healthcare Managed Medicaid	$83.60
Rate for Payer: Partners Health Alliance Commercial	$74.64
Rate for Payer: United Healthcare Commercial	$129.82
Rate for Payer: United Healthcare Managed Medicare	$85.10

cilostazol 100 mg Tab [VDMC]

Facility

$3.79

Service Code	HCPCS A9270
Hospital Charge Code	10377847
Hospital Revenue Code	259
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$3.41
Rate for Payer: Aetna of IA Commercial	$3.41
Rate for Payer: Aetna of IA Medical Rental Products	$3.41
Rate for Payer: Cash Price	$3.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.85
Rate for Payer: Medical Associates Commercial	$2.85
Rate for Payer: Midlands Choice Commercial	$2.66
Rate for Payer: United Healthcare Commercial	$3.41

cilostazol 100 mg Tab [VDMC]

Facility

$3.79

Service Code	HCPCS A9270
Hospital Charge Code	10377847
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$3.41
Rate for Payer: Aetna of IA Commercial	$3.41
Rate for Payer: Aetna of IA Medical Rental Products	$3.41
Rate for Payer: Aetna of IA Medicare	$2.16
Rate for Payer: Amerigroup Medicaid	$2.19
Rate for Payer: Amerigroup Medicare	$1.72
Rate for Payer: Cash Price	$3.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.85
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.71
Rate for Payer: Iowa Total Care Managed Medicaid	$2.17
Rate for Payer: Medical Associates Commercial	$2.85
Rate for Payer: Medical Associates Managed Medicare	$1.71
Rate for Payer: Midlands Choice Commercial	$2.66
Rate for Payer: Molina Healthcare Managed Medicaid	$2.20
Rate for Payer: Partners Health Alliance Commercial	$1.96
Rate for Payer: United Healthcare Commercial	$3.41
Rate for Payer: United Healthcare Managed Medicare	$2.24

ciprofloxacin 500 mg Tab [VDMC]

Facility

$1.64

Service Code	HCPCS A9270
Hospital Charge Code	10378054
Hospital Revenue Code	259
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of IA Commercial	$1.47
Rate for Payer: Aetna of IA Medical Rental Products	$1.47
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.23
Rate for Payer: Medical Associates Commercial	$1.23
Rate for Payer: Midlands Choice Commercial	$1.15
Rate for Payer: United Healthcare Commercial	$1.47

ciprofloxacin 500 mg Tab [VDMC]

Facility

$1.64

Service Code	HCPCS A9270
Hospital Charge Code	10378054
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of IA Commercial	$1.47
Rate for Payer: Aetna of IA Medical Rental Products	$1.47
Rate for Payer: Aetna of IA Medicare	$0.93
Rate for Payer: Amerigroup Medicaid	$0.94
Rate for Payer: Amerigroup Medicare	$0.74
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.74
Rate for Payer: Iowa Total Care Managed Medicaid	$0.94
Rate for Payer: Medical Associates Commercial	$1.23
Rate for Payer: Medical Associates Managed Medicare	$0.74
Rate for Payer: Midlands Choice Commercial	$1.15
Rate for Payer: Molina Healthcare Managed Medicaid	$0.95
Rate for Payer: Partners Health Alliance Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.47
Rate for Payer: United Healthcare Managed Medicare	$0.97

ciprofloxacin-d5w pgbk 400mg/200ml SDV [VDMC]

Facility

$60.64

Service Code	HCPCS J0744
Hospital Charge Code	10429169
Hospital Revenue Code	259
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$54.58
Rate for Payer: Aetna of IA Commercial	$54.58
Rate for Payer: Aetna of IA Medical Rental Products	$54.58
Rate for Payer: Aetna of IA Medicare	$34.56
Rate for Payer: Amerigroup Medicaid	$34.98
Rate for Payer: Amerigroup Medicare	$27.56
Rate for Payer: Cash Price	$48.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.29
Rate for Payer: Iowa Total Care Managed Medicaid	$34.64
Rate for Payer: Medical Associates Commercial	$45.48
Rate for Payer: Medical Associates Managed Medicare	$27.29
Rate for Payer: Midlands Choice Commercial	$42.45
Rate for Payer: Molina Healthcare Managed Medicaid	$35.15
Rate for Payer: Partners Health Alliance Commercial	$31.38
Rate for Payer: United Healthcare Commercial	$54.58
Rate for Payer: United Healthcare Managed Medicare	$35.78

ciprofloxacin-d5w pgbk 400mg/200ml SDV [VDMC]

Facility

$60.64

Service Code	HCPCS J0744
Hospital Charge Code	10429169
Hospital Revenue Code	259
Min. Negotiated Rate	$42.45
Max. Negotiated Rate	$54.58
Rate for Payer: Aetna of IA Commercial	$54.58
Rate for Payer: Aetna of IA Medical Rental Products	$54.58
Rate for Payer: Cash Price	$48.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.48
Rate for Payer: Medical Associates Commercial	$45.48
Rate for Payer: Midlands Choice Commercial	$42.45
Rate for Payer: United Healthcare Commercial	$54.58

ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus 7.5 ml [VDMC]

Facility

$332.52

Service Code	HCPCS A9270
Hospital Charge Code	14025350
Hospital Revenue Code	259
Min. Negotiated Rate	$149.63
Max. Negotiated Rate	$299.27
Rate for Payer: Aetna of IA Commercial	$299.27
Rate for Payer: Aetna of IA Medical Rental Products	$299.27
Rate for Payer: Aetna of IA Medicare	$189.54
Rate for Payer: Amerigroup Medicaid	$191.80
Rate for Payer: Amerigroup Medicare	$151.13
Rate for Payer: Cash Price	$266.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$149.63
Rate for Payer: Iowa Total Care Managed Medicaid	$189.94
Rate for Payer: Medical Associates Commercial	$249.39
Rate for Payer: Medical Associates Managed Medicare	$149.63
Rate for Payer: Midlands Choice Commercial	$232.76
Rate for Payer: Molina Healthcare Managed Medicaid	$192.73
Rate for Payer: Partners Health Alliance Commercial	$172.08
Rate for Payer: United Healthcare Commercial	$299.27
Rate for Payer: United Healthcare Managed Medicare	$196.19

ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus 7.5 ml [VDMC]

Facility

$332.52

Service Code	HCPCS A9270
Hospital Charge Code	14025350
Hospital Revenue Code	259
Min. Negotiated Rate	$232.76
Max. Negotiated Rate	$299.27
Rate for Payer: Aetna of IA Commercial	$299.27
Rate for Payer: Aetna of IA Medical Rental Products	$299.27
Rate for Payer: Cash Price	$266.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.39
Rate for Payer: Medical Associates Commercial	$249.39
Rate for Payer: Midlands Choice Commercial	$232.76
Rate for Payer: United Healthcare Commercial	$299.27

CIRCUM 28 DAYS OR OLDER

Facility

$1,493.00

Service Code	CPT 54161
Hospital Charge Code	7983036
Hospital Revenue Code	450
Min. Negotiated Rate	$671.85
Max. Negotiated Rate	$1,343.70
Rate for Payer: Aetna of IA Commercial	$1,343.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,343.70
Rate for Payer: Aetna of IA Medicare	$851.01
Rate for Payer: Amerigroup Medicaid	$861.16
Rate for Payer: Amerigroup Medicare	$678.57
Rate for Payer: Cash Price	$1,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,119.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$671.85
Rate for Payer: Iowa Total Care Managed Medicaid	$852.80
Rate for Payer: Medical Associates Commercial	$1,119.75
Rate for Payer: Medical Associates Managed Medicare	$671.85
Rate for Payer: Midlands Choice Commercial	$1,045.10
Rate for Payer: Molina Healthcare Managed Medicaid	$865.34
Rate for Payer: Partners Health Alliance Commercial	$772.63
Rate for Payer: United Healthcare Commercial	$1,343.70
Rate for Payer: United Healthcare Managed Medicare	$880.87

CIRCUM 28 DAYS OR OLDER

Facility

$1,493.00

Service Code	CPT 54161
Hospital Charge Code	7983036
Hospital Revenue Code	450
Min. Negotiated Rate	$1,045.10
Max. Negotiated Rate	$1,343.70
Rate for Payer: Aetna of IA Commercial	$1,343.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,343.70
Rate for Payer: Cash Price	$1,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,119.75
Rate for Payer: Medical Associates Commercial	$1,119.75
Rate for Payer: Midlands Choice Commercial	$1,045.10
Rate for Payer: United Healthcare Commercial	$1,343.70

CIRCUMCISION

Facility

$179.00

Service Code	CPT 54150
Hospital Charge Code	7578787
Hospital Revenue Code	723
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: United Healthcare Commercial	$161.10

CIRCUMCISION

Facility

$179.00

Service Code	CPT 54150
Hospital Charge Code	7578787
Hospital Revenue Code	723
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Aetna of IA Medicare	$102.03
Rate for Payer: Amerigroup Medicaid	$103.25
Rate for Payer: Amerigroup Medicare	$81.36
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$80.55
Rate for Payer: Iowa Total Care Managed Medicaid	$102.24
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Medical Associates Managed Medicare	$80.55
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: Molina Healthcare Managed Medicaid	$103.75
Rate for Payer: Partners Health Alliance Commercial	$92.63
Rate for Payer: United Healthcare Commercial	$161.10
Rate for Payer: United Healthcare Managed Medicare	$105.61

Know your out-of-pocket cost for care.

All Charges