Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

3.5MM X 20MM LOCKING SCREW

Facility

$333.00

Service Code	CPT C1713
Hospital Charge Code	8812778
Hospital Revenue Code	278
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: United Healthcare Commercial	$299.70

3.5MM X 20MM LOCKING SCREW

Facility

$333.00

Service Code	CPT C1713
Hospital Charge Code	8812778
Hospital Revenue Code	278
Min. Negotiated Rate	$166.43
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Aetna of IA Medicare	$189.81
Rate for Payer: Amerigroup Medicaid	$168.07
Rate for Payer: Amerigroup Medicare	$168.16
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$166.50
Rate for Payer: Iowa Total Care Managed Medicaid	$166.43
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Medical Associates Managed Medicare	$166.50
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: Molina Healthcare Managed Medicaid	$169.00
Rate for Payer: Molina Healthcare Managed Medicare	$168.90
Rate for Payer: Oscar Health of IA Commercial	$249.75
Rate for Payer: Partners Health Alliance Commercial	$249.75
Rate for Payer: United Healthcare Commercial	$299.70
Rate for Payer: United Healthcare Managed Medicare	$196.47

3.5 MM X 22MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8812770
Hospital Revenue Code	278
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$99.93
Rate for Payer: Amerigroup Medicare	$99.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.00
Rate for Payer: Iowa Total Care Managed Medicaid	$98.96
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$99.00
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$100.48
Rate for Payer: Molina Healthcare Managed Medicare	$100.43
Rate for Payer: Oscar Health of IA Commercial	$148.50
Rate for Payer: Partners Health Alliance Commercial	$148.50
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

3.5 MM X 22MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8812770
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

3.5MM X 2.2MM ARSENAL LOCKING SCREW

Facility

$405.00

Service Code	CPT C1713
Hospital Charge Code	8955189
Hospital Revenue Code	276
Min. Negotiated Rate	$202.42
Max. Negotiated Rate	$364.50
Rate for Payer: Aetna of IA Commercial	$364.50
Rate for Payer: Aetna of IA Medical Rental Products	$364.50
Rate for Payer: Aetna of IA Medicare	$230.85
Rate for Payer: Amerigroup Medicaid	$204.40
Rate for Payer: Amerigroup Medicare	$204.52
Rate for Payer: Cash Price	$324.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$303.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$202.50
Rate for Payer: Iowa Total Care Managed Medicaid	$202.42
Rate for Payer: Medical Associates Commercial	$303.75
Rate for Payer: Medical Associates Managed Medicare	$202.50
Rate for Payer: Midlands Choice Commercial	$283.50
Rate for Payer: Molina Healthcare Managed Medicaid	$205.54
Rate for Payer: Molina Healthcare Managed Medicare	$205.42
Rate for Payer: Oscar Health of IA Commercial	$303.75
Rate for Payer: Partners Health Alliance Commercial	$303.75
Rate for Payer: United Healthcare Commercial	$364.50
Rate for Payer: United Healthcare Managed Medicare	$238.95

3.5MM X 2.2MM ARSENAL LOCKING SCREW

Facility

$405.00

Service Code	CPT C1713
Hospital Charge Code	8955189
Hospital Revenue Code	276
Min. Negotiated Rate	$283.50
Max. Negotiated Rate	$364.50
Rate for Payer: Aetna of IA Commercial	$364.50
Rate for Payer: Aetna of IA Medical Rental Products	$364.50
Rate for Payer: Cash Price	$324.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$303.75
Rate for Payer: Medical Associates Commercial	$303.75
Rate for Payer: Midlands Choice Commercial	$283.50
Rate for Payer: United Healthcare Commercial	$364.50

3.5MMX22MM GL ANKLE LOCKING SCREW

Facility

$324.00

Service Code	CPT C1713
Hospital Charge Code	8760637
Hospital Revenue Code	278
Min. Negotiated Rate	$161.94
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Aetna of IA Medicare	$184.68
Rate for Payer: Amerigroup Medicaid	$163.52
Rate for Payer: Amerigroup Medicare	$163.62
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$162.00
Rate for Payer: Iowa Total Care Managed Medicaid	$161.94
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Medical Associates Managed Medicare	$162.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: Molina Healthcare Managed Medicaid	$164.43
Rate for Payer: Molina Healthcare Managed Medicare	$164.33
Rate for Payer: Oscar Health of IA Commercial	$243.00
Rate for Payer: Partners Health Alliance Commercial	$243.00
Rate for Payer: United Healthcare Commercial	$291.60
Rate for Payer: United Healthcare Managed Medicare	$191.16

3.5MMX22MM GL ANKLE LOCKING SCREW

Facility

$324.00

Service Code	CPT C1713
Hospital Charge Code	8760637
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: United Healthcare Commercial	$291.60

3.5MMX24MM GL ANKLE LOCKING SCREW

Facility

$324.00

Service Code	CPT C1713
Hospital Charge Code	8760639
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: United Healthcare Commercial	$291.60

3.5MMX24MM GL ANKLE LOCKING SCREW

Facility

$324.00

Service Code	CPT C1713
Hospital Charge Code	8760639
Hospital Revenue Code	278
Min. Negotiated Rate	$161.94
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Aetna of IA Medicare	$184.68
Rate for Payer: Amerigroup Medicaid	$163.52
Rate for Payer: Amerigroup Medicare	$163.62
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$162.00
Rate for Payer: Iowa Total Care Managed Medicaid	$161.94
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Medical Associates Managed Medicare	$162.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: Molina Healthcare Managed Medicaid	$164.43
Rate for Payer: Molina Healthcare Managed Medicare	$164.33
Rate for Payer: Oscar Health of IA Commercial	$243.00
Rate for Payer: Partners Health Alliance Commercial	$243.00
Rate for Payer: United Healthcare Commercial	$291.60
Rate for Payer: United Healthcare Managed Medicare	$191.16

36556 INS NON-TUNNEL CV CATH 5 YRS/>

Professional

Both

$774.00

Service Code	CPT 36556
Hospital Charge Code	8069072
Hospital Revenue Code	975
Min. Negotiated Rate	$75.99
Max. Negotiated Rate	$176.48
Rate for Payer: Aetna of IA Medicare	$75.99
Rate for Payer: Amerigroup Medicaid	$78.57
Rate for Payer: Cash Price	$619.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$91.19
Rate for Payer: Iowa Total Care Managed Medicaid	$77.51
Rate for Payer: Medical Associates Commercial	$144.38
Rate for Payer: Medical Associates Managed Medicare	$75.99
Rate for Payer: Midlands Choice Commercial	$176.48
Rate for Payer: Oscar Health of IA Commercial	$131.46
Rate for Payer: Partners Health Alliance Commercial	$113.98

36561 INS TUNNELED CVAD W PORT AGE 5 YRS/>

Professional

Both

$3,608.00

Service Code	CPT 36561
Hospital Charge Code	8069173
Hospital Revenue Code	975
Min. Negotiated Rate	$295.43
Max. Negotiated Rate	$698.10
Rate for Payer: Aetna of IA Medicare	$295.43
Rate for Payer: Amerigroup Medicaid	$305.47
Rate for Payer: Cash Price	$2,886.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$354.52
Rate for Payer: Iowa Total Care Managed Medicaid	$301.34
Rate for Payer: Medical Associates Commercial	$561.32
Rate for Payer: Medical Associates Managed Medicare	$295.43
Rate for Payer: Midlands Choice Commercial	$698.10
Rate for Payer: Oscar Health of IA Commercial	$511.09
Rate for Payer: Partners Health Alliance Commercial	$443.14

36573 Insertion of PICC w/o port including imaging- age 5+

Professional

Both

$651.00

Service Code	CPT 36573
Hospital Charge Code	8799169
Hospital Revenue Code	975
Min. Negotiated Rate	$75.25
Max. Negotiated Rate	$455.70
Rate for Payer: Aetna of IA Medicare	$75.25
Rate for Payer: Amerigroup Medicaid	$77.81
Rate for Payer: Cash Price	$520.80
Rate for Payer: Cash Price	$520.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$90.30
Rate for Payer: Iowa Total Care Managed Medicaid	$76.76
Rate for Payer: Medical Associates Commercial	$142.98
Rate for Payer: Medical Associates Managed Medicare	$75.25
Rate for Payer: Midlands Choice Commercial	$455.70
Rate for Payer: Oscar Health of IA Commercial	$130.18
Rate for Payer: Partners Health Alliance Commercial	$112.88

36589 Removal tunneled central venous catheter

Professional

Both

$465.00

Service Code	CPT 36589
Hospital Charge Code	8799170
Hospital Revenue Code	975
Min. Negotiated Rate	$121.90
Max. Negotiated Rate	$325.50
Rate for Payer: Aetna of IA Medicare	$121.90
Rate for Payer: Amerigroup Medicaid	$126.04
Rate for Payer: Cash Price	$372.00
Rate for Payer: Cash Price	$372.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$146.28
Rate for Payer: Iowa Total Care Managed Medicaid	$124.34
Rate for Payer: Medical Associates Commercial	$231.61
Rate for Payer: Medical Associates Managed Medicare	$121.90
Rate for Payer: Midlands Choice Commercial	$325.50
Rate for Payer: Oscar Health of IA Commercial	$210.89
Rate for Payer: Partners Health Alliance Commercial	$182.85

36590 Removal tunneled VAD w/sub q port/pump central/peripheral

Professional

Both

$741.00

Service Code	CPT 36590
Hospital Charge Code	8799171
Hospital Revenue Code	975
Min. Negotiated Rate	$168.78
Max. Negotiated Rate	$518.70
Rate for Payer: Aetna of IA Medicare	$168.78
Rate for Payer: Amerigroup Medicaid	$174.52
Rate for Payer: Cash Price	$592.80
Rate for Payer: Cash Price	$592.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.54
Rate for Payer: Iowa Total Care Managed Medicaid	$172.16
Rate for Payer: Medical Associates Commercial	$320.68
Rate for Payer: Medical Associates Managed Medicare	$168.78
Rate for Payer: Midlands Choice Commercial	$518.70
Rate for Payer: Oscar Health of IA Commercial	$291.99
Rate for Payer: Partners Health Alliance Commercial	$253.17

36590 REMOVE TUNNELED CVAD W PORT/PUMP

Professional

Both

$741.00

Service Code	CPT 36590
Hospital Charge Code	8069119
Hospital Revenue Code	975
Min. Negotiated Rate	$168.78
Max. Negotiated Rate	$518.70
Rate for Payer: Aetna of IA Medicare	$168.78
Rate for Payer: Amerigroup Medicaid	$174.52
Rate for Payer: Cash Price	$592.80
Rate for Payer: Cash Price	$592.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.54
Rate for Payer: Iowa Total Care Managed Medicaid	$172.16
Rate for Payer: Medical Associates Commercial	$320.68
Rate for Payer: Medical Associates Managed Medicare	$168.78
Rate for Payer: Midlands Choice Commercial	$518.70
Rate for Payer: Oscar Health of IA Commercial	$291.99
Rate for Payer: Partners Health Alliance Commercial	$253.17

37785 LIGATE/DIVIDE/EXCISE VEIN 1 LEG

Professional

Both

$1,190.00

Service Code	CPT 37785
Hospital Charge Code	8069149
Hospital Revenue Code	975
Min. Negotiated Rate	$223.32
Max. Negotiated Rate	$833.00
Rate for Payer: Aetna of IA Medicare	$223.32
Rate for Payer: Amerigroup Medicaid	$230.91
Rate for Payer: Cash Price	$952.00
Rate for Payer: Cash Price	$952.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$267.98
Rate for Payer: Iowa Total Care Managed Medicaid	$227.79
Rate for Payer: Medical Associates Commercial	$424.31
Rate for Payer: Medical Associates Managed Medicare	$223.32
Rate for Payer: Midlands Choice Commercial	$833.00
Rate for Payer: Oscar Health of IA Commercial	$386.34
Rate for Payer: Partners Health Alliance Commercial	$334.98

38220 Bone marrow; aspiration only

Professional

Both

$556.00

Service Code	CPT 38220
Hospital Charge Code	8799172
Hospital Revenue Code	975
Min. Negotiated Rate	$61.42
Max. Negotiated Rate	$389.20
Rate for Payer: Aetna of IA Medicare	$61.42
Rate for Payer: Amerigroup Medicaid	$63.51
Rate for Payer: Cash Price	$444.80
Rate for Payer: Cash Price	$444.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.70
Rate for Payer: Iowa Total Care Managed Medicaid	$62.65
Rate for Payer: Medical Associates Commercial	$116.70
Rate for Payer: Medical Associates Managed Medicare	$61.42
Rate for Payer: Midlands Choice Commercial	$389.20
Rate for Payer: Oscar Health of IA Commercial	$106.26
Rate for Payer: Partners Health Alliance Commercial	$92.13

38221 Bone marrow; biopsy needle or trocar- PROFEE

Professional

Both

$556.00

Service Code	CPT 38221
Hospital Charge Code	8799173
Hospital Revenue Code	975
Min. Negotiated Rate	$64.34
Max. Negotiated Rate	$389.20
Rate for Payer: Aetna of IA Medicare	$64.34
Rate for Payer: Amerigroup Medicaid	$66.53
Rate for Payer: Cash Price	$444.80
Rate for Payer: Cash Price	$444.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$77.21
Rate for Payer: Iowa Total Care Managed Medicaid	$65.63
Rate for Payer: Medical Associates Commercial	$122.25
Rate for Payer: Medical Associates Managed Medicare	$64.34
Rate for Payer: Midlands Choice Commercial	$389.20
Rate for Payer: Oscar Health of IA Commercial	$111.31
Rate for Payer: Partners Health Alliance Commercial	$96.51

38500 LYMPH NODE BIOSPY/REMOVAL

Professional

Both

$1,107.00

Service Code	CPT 38500
Hospital Charge Code	8069132
Hospital Revenue Code	975
Min. Negotiated Rate	$227.55
Max. Negotiated Rate	$774.90
Rate for Payer: Aetna of IA Medicare	$227.55
Rate for Payer: Amerigroup Medicaid	$235.29
Rate for Payer: Cash Price	$885.60
Rate for Payer: Cash Price	$885.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$273.06
Rate for Payer: Iowa Total Care Managed Medicaid	$232.10
Rate for Payer: Medical Associates Commercial	$432.34
Rate for Payer: Medical Associates Managed Medicare	$227.55
Rate for Payer: Midlands Choice Commercial	$774.90
Rate for Payer: Oscar Health of IA Commercial	$393.66
Rate for Payer: Partners Health Alliance Commercial	$341.32

38792 INJ SENTINEL NODE BIOPSY

Professional

Both

$276.00

Service Code	CPT 38792
Hospital Charge Code	8069131
Hospital Revenue Code	975
Min. Negotiated Rate	$29.06
Max. Negotiated Rate	$193.20
Rate for Payer: Aetna of IA Medicare	$29.06
Rate for Payer: Amerigroup Medicaid	$30.05
Rate for Payer: Cash Price	$220.80
Rate for Payer: Cash Price	$220.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.87
Rate for Payer: Iowa Total Care Managed Medicaid	$29.64
Rate for Payer: Medical Associates Commercial	$55.21
Rate for Payer: Medical Associates Managed Medicare	$29.06
Rate for Payer: Midlands Choice Commercial	$193.20
Rate for Payer: Oscar Health of IA Commercial	$50.27
Rate for Payer: Partners Health Alliance Commercial	$43.59

3D MAX LIGHT-LEFT LARGE

Facility

$364.00

Service Code	CPT C1781
Hospital Charge Code	8417552
Hospital Revenue Code	278
Min. Negotiated Rate	$181.93
Max. Negotiated Rate	$327.60
Rate for Payer: Aetna of IA Commercial	$327.60
Rate for Payer: Aetna of IA Medical Rental Products	$327.60
Rate for Payer: Aetna of IA Medicare	$207.48
Rate for Payer: Amerigroup Medicaid	$183.71
Rate for Payer: Amerigroup Medicare	$183.82
Rate for Payer: Cash Price	$291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$273.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$182.00
Rate for Payer: Iowa Total Care Managed Medicaid	$181.93
Rate for Payer: Medical Associates Commercial	$273.00
Rate for Payer: Medical Associates Managed Medicare	$182.00
Rate for Payer: Midlands Choice Commercial	$254.80
Rate for Payer: Molina Healthcare Managed Medicaid	$184.73
Rate for Payer: Molina Healthcare Managed Medicare	$184.62
Rate for Payer: Oscar Health of IA Commercial	$273.00
Rate for Payer: Partners Health Alliance Commercial	$273.00
Rate for Payer: United Healthcare Commercial	$327.60
Rate for Payer: United Healthcare Managed Medicare	$214.76

3D MAX LIGHT-LEFT LARGE

Facility

$364.00

Service Code	CPT C1781
Hospital Charge Code	8417552
Hospital Revenue Code	278
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$327.60
Rate for Payer: Aetna of IA Commercial	$327.60
Rate for Payer: Aetna of IA Medical Rental Products	$327.60
Rate for Payer: Cash Price	$291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$273.00
Rate for Payer: Medical Associates Commercial	$273.00
Rate for Payer: Midlands Choice Commercial	$254.80
Rate for Payer: United Healthcare Commercial	$327.60

3D MAX LIGHT RT LRG

Facility

$364.00

Service Code	CPT C1781
Hospital Charge Code	8417554
Hospital Revenue Code	278
Min. Negotiated Rate	$181.93
Max. Negotiated Rate	$327.60
Rate for Payer: Iowa Total Care Managed Medicaid	$181.93
Rate for Payer: Aetna of IA Commercial	$327.60
Rate for Payer: Aetna of IA Medical Rental Products	$327.60
Rate for Payer: Aetna of IA Medicare	$207.48
Rate for Payer: Amerigroup Medicaid	$183.71
Rate for Payer: Amerigroup Medicare	$183.82
Rate for Payer: Cash Price	$291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$273.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$182.00
Rate for Payer: Medical Associates Commercial	$273.00
Rate for Payer: Medical Associates Managed Medicare	$182.00
Rate for Payer: Midlands Choice Commercial	$254.80
Rate for Payer: Molina Healthcare Managed Medicaid	$184.73
Rate for Payer: Molina Healthcare Managed Medicare	$184.62
Rate for Payer: Oscar Health of IA Commercial	$273.00
Rate for Payer: Partners Health Alliance Commercial	$273.00
Rate for Payer: United Healthcare Commercial	$327.60
Rate for Payer: United Healthcare Managed Medicare	$214.76

3D MAX LIGHT RT LRG

Facility

$364.00

Service Code	CPT C1781
Hospital Charge Code	8417554
Hospital Revenue Code	278
Min. Negotiated Rate	$254.80
Max. Negotiated Rate	$327.60
Rate for Payer: Aetna of IA Commercial	$327.60
Rate for Payer: Aetna of IA Medical Rental Products	$327.60
Rate for Payer: Cash Price	$291.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$273.00
Rate for Payer: Medical Associates Commercial	$273.00
Rate for Payer: Midlands Choice Commercial	$254.80
Rate for Payer: United Healthcare Commercial	$327.60

Know your out-of-pocket cost for care.

All Charges