Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IMPLANT TITANIUM SET SCREW 8X17.5MM

Facility

$215.00

Service Code	CPT C1713
Hospital Charge Code	8046405
Hospital Revenue Code	278
Min. Negotiated Rate	$150.50
Max. Negotiated Rate	$193.50
Rate for Payer: Aetna of IA Commercial	$193.50
Rate for Payer: Aetna of IA Medical Rental Products	$193.50
Rate for Payer: Cash Price	$172.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$161.25
Rate for Payer: Medical Associates Commercial	$161.25
Rate for Payer: Midlands Choice Commercial	$150.50
Rate for Payer: United Healthcare Commercial	$193.50

IMPLANT TITANIUM TROCHANTERIC 11X180X120

Facility

$1,518.00

Service Code	CPT C1713
Hospital Charge Code	8046425
Hospital Revenue Code	278
Min. Negotiated Rate	$758.70
Max. Negotiated Rate	$1,366.20
Rate for Payer: Aetna of IA Commercial	$1,366.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,366.20
Rate for Payer: Aetna of IA Medicare	$865.26
Rate for Payer: Amerigroup Medicaid	$766.13
Rate for Payer: Amerigroup Medicare	$766.59
Rate for Payer: Cash Price	$1,214.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,138.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$759.00
Rate for Payer: Iowa Total Care Managed Medicaid	$758.70
Rate for Payer: Medical Associates Commercial	$1,138.50
Rate for Payer: Medical Associates Managed Medicare	$759.00
Rate for Payer: Midlands Choice Commercial	$1,062.60
Rate for Payer: Molina Healthcare Managed Medicaid	$770.38
Rate for Payer: Molina Healthcare Managed Medicare	$769.93
Rate for Payer: Oscar Health of IA Commercial	$1,138.50
Rate for Payer: Partners Health Alliance Commercial	$1,138.50
Rate for Payer: United Healthcare Commercial	$1,366.20
Rate for Payer: United Healthcare Managed Medicare	$895.62

IMPLANT TITANIUM TROCHANTERIC 11X180X120

Facility

$1,518.00

Service Code	CPT C1713
Hospital Charge Code	8046425
Hospital Revenue Code	278
Min. Negotiated Rate	$1,062.60
Max. Negotiated Rate	$1,366.20
Rate for Payer: Aetna of IA Commercial	$1,366.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,366.20
Rate for Payer: Cash Price	$1,214.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,138.50
Rate for Payer: Medical Associates Commercial	$1,138.50
Rate for Payer: Midlands Choice Commercial	$1,062.60
Rate for Payer: United Healthcare Commercial	$1,366.20

IMPLANT TITANIUM TROCHANTERIC 11X180X125

Facility

$2,126.00

Service Code	CPT C1713
Hospital Charge Code	8046426
Hospital Revenue Code	278
Min. Negotiated Rate	$1,488.20
Max. Negotiated Rate	$1,913.40
Rate for Payer: Aetna of IA Commercial	$1,913.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,913.40
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,594.50
Rate for Payer: Medical Associates Commercial	$1,594.50
Rate for Payer: Midlands Choice Commercial	$1,488.20
Rate for Payer: United Healthcare Commercial	$1,913.40

IMPLANT TITANIUM TROCHANTERIC 11X180X125

Facility

$2,126.00

Service Code	CPT C1713
Hospital Charge Code	8046426
Hospital Revenue Code	278
Min. Negotiated Rate	$1,062.57
Max. Negotiated Rate	$1,913.40
Rate for Payer: Aetna of IA Commercial	$1,913.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,913.40
Rate for Payer: Aetna of IA Medicare	$1,211.82
Rate for Payer: Amerigroup Medicaid	$1,072.99
Rate for Payer: Amerigroup Medicare	$1,073.63
Rate for Payer: Cash Price	$1,700.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,594.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,063.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,062.57
Rate for Payer: Medical Associates Commercial	$1,594.50
Rate for Payer: Medical Associates Managed Medicare	$1,063.00
Rate for Payer: Midlands Choice Commercial	$1,488.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,078.94
Rate for Payer: Molina Healthcare Managed Medicare	$1,078.31
Rate for Payer: Oscar Health of IA Commercial	$1,594.50
Rate for Payer: Partners Health Alliance Commercial	$1,594.50
Rate for Payer: United Healthcare Commercial	$1,913.40
Rate for Payer: United Healthcare Managed Medicare	$1,254.34

IMPLANT TITANIUM TROCHANTERIC 11X180X130

Facility

$1,518.00

Service Code	CPT C1713
Hospital Charge Code	8046427
Hospital Revenue Code	278
Min. Negotiated Rate	$1,062.60
Max. Negotiated Rate	$1,366.20
Rate for Payer: Aetna of IA Commercial	$1,366.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,366.20
Rate for Payer: Cash Price	$1,214.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,138.50
Rate for Payer: Medical Associates Commercial	$1,138.50
Rate for Payer: Midlands Choice Commercial	$1,062.60
Rate for Payer: United Healthcare Commercial	$1,366.20

IMPLANT TITANIUM TROCHANTERIC 11X180X130

Facility

$1,518.00

Service Code	CPT C1713
Hospital Charge Code	8046427
Hospital Revenue Code	278
Min. Negotiated Rate	$758.70
Max. Negotiated Rate	$1,366.20
Rate for Payer: Aetna of IA Commercial	$1,366.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,366.20
Rate for Payer: Aetna of IA Medicare	$865.26
Rate for Payer: Amerigroup Medicaid	$766.13
Rate for Payer: Amerigroup Medicare	$766.59
Rate for Payer: Cash Price	$1,214.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,138.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$759.00
Rate for Payer: Iowa Total Care Managed Medicaid	$758.70
Rate for Payer: Medical Associates Commercial	$1,138.50
Rate for Payer: Medical Associates Managed Medicare	$759.00
Rate for Payer: Midlands Choice Commercial	$1,062.60
Rate for Payer: Molina Healthcare Managed Medicaid	$770.38
Rate for Payer: Molina Healthcare Managed Medicare	$769.93
Rate for Payer: Oscar Health of IA Commercial	$1,138.50
Rate for Payer: Partners Health Alliance Commercial	$1,138.50
Rate for Payer: United Healthcare Commercial	$1,366.20
Rate for Payer: United Healthcare Managed Medicare	$895.62

IMPLANT TOTAL KNEE CEMENTED STEM 12X100M

Facility

$2,774.00

Service Code	CPT C1776
Hospital Charge Code	8026188
Hospital Revenue Code	278
Min. Negotiated Rate	$1,941.80
Max. Negotiated Rate	$2,496.60
Rate for Payer: Aetna of IA Commercial	$2,496.60
Rate for Payer: Aetna of IA Medical Rental Products	$2,496.60
Rate for Payer: Cash Price	$2,219.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,080.50
Rate for Payer: Medical Associates Commercial	$2,080.50
Rate for Payer: Midlands Choice Commercial	$1,941.80
Rate for Payer: United Healthcare Commercial	$2,496.60

IMPLANT TOTAL KNEE CEMENTED STEM 12X100M

Facility

$2,774.00

Service Code	CPT C1776
Hospital Charge Code	8026188
Hospital Revenue Code	278
Min. Negotiated Rate	$1,386.45
Max. Negotiated Rate	$2,496.60
Rate for Payer: Aetna of IA Commercial	$2,496.60
Rate for Payer: Aetna of IA Medical Rental Products	$2,496.60
Rate for Payer: Aetna of IA Medicare	$1,581.18
Rate for Payer: Amerigroup Medicaid	$1,400.04
Rate for Payer: Amerigroup Medicare	$1,400.87
Rate for Payer: Cash Price	$2,219.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,080.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,387.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,386.45
Rate for Payer: Medical Associates Commercial	$2,080.50
Rate for Payer: Medical Associates Managed Medicare	$1,387.00
Rate for Payer: Midlands Choice Commercial	$1,941.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,407.80
Rate for Payer: Molina Healthcare Managed Medicare	$1,406.97
Rate for Payer: Oscar Health of IA Commercial	$2,080.50
Rate for Payer: Partners Health Alliance Commercial	$2,080.50
Rate for Payer: United Healthcare Commercial	$2,496.60
Rate for Payer: United Healthcare Managed Medicare	$1,636.66

IMPLANT WASHER, 7 MM. SS

Facility

$54.00

Service Code	CPT C1713
Hospital Charge Code	8047139
Hospital Revenue Code	278
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of IA Commercial	$48.60
Rate for Payer: Aetna of IA Medical Rental Products	$48.60
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$40.50
Rate for Payer: Medical Associates Commercial	$40.50
Rate for Payer: Midlands Choice Commercial	$37.80
Rate for Payer: United Healthcare Commercial	$48.60

IMPLANT WASHER, 7 MM. SS

Facility

$54.00

Service Code	CPT C1713
Hospital Charge Code	8047139
Hospital Revenue Code	278
Min. Negotiated Rate	$26.99
Max. Negotiated Rate	$48.60
Rate for Payer: Aetna of IA Commercial	$48.60
Rate for Payer: Aetna of IA Medical Rental Products	$48.60
Rate for Payer: Aetna of IA Medicare	$30.78
Rate for Payer: Amerigroup Medicaid	$27.25
Rate for Payer: Amerigroup Medicare	$27.27
Rate for Payer: Cash Price	$43.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$40.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.00
Rate for Payer: Iowa Total Care Managed Medicaid	$26.99
Rate for Payer: Medical Associates Commercial	$40.50
Rate for Payer: Medical Associates Managed Medicare	$27.00
Rate for Payer: Midlands Choice Commercial	$37.80
Rate for Payer: Molina Healthcare Managed Medicaid	$27.40
Rate for Payer: Molina Healthcare Managed Medicare	$27.39
Rate for Payer: Oscar Health of IA Commercial	$40.50
Rate for Payer: Partners Health Alliance Commercial	$40.50
Rate for Payer: United Healthcare Commercial	$48.60
Rate for Payer: United Healthcare Managed Medicare	$31.86

IMPL SYS, BIO-COMP ACHILLES MID-SUBSTANCE

Facility

$1,755.00

Service Code	CPT C1713
Hospital Charge Code	8784972
Hospital Revenue Code	278
Min. Negotiated Rate	$1,228.50
Max. Negotiated Rate	$1,579.50
Rate for Payer: Aetna of IA Commercial	$1,579.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,579.50
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,316.25
Rate for Payer: Medical Associates Commercial	$1,316.25
Rate for Payer: Midlands Choice Commercial	$1,228.50
Rate for Payer: United Healthcare Commercial	$1,579.50

IMPL SYS, BIO-COMP ACHILLES MID-SUBSTANCE

Facility

$1,755.00

Service Code	CPT C1713
Hospital Charge Code	8784972
Hospital Revenue Code	278
Min. Negotiated Rate	$877.15
Max. Negotiated Rate	$1,579.50
Rate for Payer: Aetna of IA Commercial	$1,579.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,579.50
Rate for Payer: Aetna of IA Medicare	$1,000.35
Rate for Payer: Amerigroup Medicaid	$885.75
Rate for Payer: Amerigroup Medicare	$886.28
Rate for Payer: Cash Price	$1,404.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,316.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$877.50
Rate for Payer: Iowa Total Care Managed Medicaid	$877.15
Rate for Payer: Medical Associates Commercial	$1,316.25
Rate for Payer: Medical Associates Managed Medicare	$877.50
Rate for Payer: Midlands Choice Commercial	$1,228.50
Rate for Payer: Molina Healthcare Managed Medicaid	$890.66
Rate for Payer: Molina Healthcare Managed Medicare	$890.14
Rate for Payer: Oscar Health of IA Commercial	$1,316.25
Rate for Payer: Partners Health Alliance Commercial	$1,316.25
Rate for Payer: United Healthcare Commercial	$1,579.50
Rate for Payer: United Healthcare Managed Medicare	$1,035.45

Inborn and Other Disorders of Metabolism

Facility

$8,401.49

Service Code	MS-DRG 642
Hospital Charge Code	428
Min. Negotiated Rate	$8,279.73
Max. Negotiated Rate	$8,401.49
Rate for Payer: Amerigroup Medicaid	$8,360.90
Rate for Payer: Iowa Total Care Managed Medicaid	$8,279.73
Rate for Payer: Molina Healthcare Managed Medicaid	$8,401.49

INCISE EXTERNAL HEMORRHOID

Professional

Both

$588.00

Service Code	CPT 46083
Hospital Charge Code	7982770
Hospital Revenue Code	981
Min. Negotiated Rate	$99.65
Max. Negotiated Rate	$411.60
Rate for Payer: Aetna of IA Medicare	$99.65
Rate for Payer: Amerigroup Medicaid	$103.04
Rate for Payer: Cash Price	$470.40
Rate for Payer: Cash Price	$470.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$119.58
Rate for Payer: Iowa Total Care Managed Medicaid	$101.64
Rate for Payer: Medical Associates Commercial	$179.37
Rate for Payer: Medical Associates Managed Medicare	$99.65
Rate for Payer: Midlands Choice Commercial	$411.60
Rate for Payer: Oscar Health of IA Commercial	$172.39
Rate for Payer: Partners Health Alliance Commercial	$149.48

INCISION AND DRAINAGE

Professional

Both

$304.00

Service Code	CPT 10060
Hospital Charge Code	7982860
Hospital Revenue Code	981
Min. Negotiated Rate	$97.80
Max. Negotiated Rate	$210.84
Rate for Payer: Aetna of IA Medicare	$97.80
Rate for Payer: Amerigroup Medicaid	$101.13
Rate for Payer: Cash Price	$243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.36
Rate for Payer: Iowa Total Care Managed Medicaid	$99.76
Rate for Payer: Medical Associates Commercial	$176.04
Rate for Payer: Medical Associates Managed Medicare	$97.80
Rate for Payer: Midlands Choice Commercial	$210.84
Rate for Payer: Oscar Health of IA Commercial	$169.19
Rate for Payer: Partners Health Alliance Commercial	$146.70

Incision and drainage of epididymis, testis and/or scrotal space (eg, abscess or hematoma)

Facility

$3,386.81

Service Code	CPT 54700
Hospital Revenue Code	490
Min. Negotiated Rate	$3,078.92
Max. Negotiated Rate	$3,386.81
Rate for Payer: Wellmark IA HMO	$3,078.92
Rate for Payer: Wellmark IA PPO	$3,386.81

INCISION OF RECTAL ABSCESS

Facility

$2,317.00

Service Code	CPT 46040
Hospital Charge Code	4864970
Hospital Revenue Code	761
Min. Negotiated Rate	$1,158.04
Max. Negotiated Rate	$4,960.19
Rate for Payer: Aetna of IA Commercial	$2,085.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,085.30
Rate for Payer: Aetna of IA Medicare	$1,320.69
Rate for Payer: Amerigroup Medicaid	$1,169.39
Rate for Payer: Amerigroup Medicare	$1,170.08
Rate for Payer: Cash Price	$1,853.60
Rate for Payer: Cash Price	$1,853.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,737.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,158.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,158.04
Rate for Payer: Medical Associates Commercial	$1,737.75
Rate for Payer: Medical Associates Managed Medicare	$1,158.50
Rate for Payer: Midlands Choice Commercial	$1,621.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,175.88
Rate for Payer: Molina Healthcare Managed Medicare	$1,175.18
Rate for Payer: Oscar Health of IA Commercial	$1,737.75
Rate for Payer: Partners Health Alliance Commercial	$1,737.75
Rate for Payer: United Healthcare Commercial	$2,085.30
Rate for Payer: United Healthcare Managed Medicare	$1,367.03
Rate for Payer: Wellmark IA HMO	$4,509.26
Rate for Payer: Wellmark IA PPO	$4,960.19

INCISION OF RECTAL ABSCESS

Facility

$2,317.00

Service Code	CPT 46040
Hospital Charge Code	4864970
Hospital Revenue Code	761
Min. Negotiated Rate	$1,621.90
Max. Negotiated Rate	$2,085.30
Rate for Payer: Aetna of IA Commercial	$2,085.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,085.30
Rate for Payer: Cash Price	$1,853.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,737.75
Rate for Payer: Medical Associates Commercial	$1,737.75
Rate for Payer: Midlands Choice Commercial	$1,621.90
Rate for Payer: United Healthcare Commercial	$2,085.30

INCISION OF RECTAL ABSCESS

Professional

Both

$1,788.00

Service Code	CPT 46040
Hospital Charge Code	7982771
Hospital Revenue Code	981
Min. Negotiated Rate	$383.48
Max. Negotiated Rate	$1,251.60
Rate for Payer: Aetna of IA Medicare	$383.48
Rate for Payer: Amerigroup Medicaid	$396.52
Rate for Payer: Cash Price	$1,430.40
Rate for Payer: Cash Price	$1,430.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$460.18
Rate for Payer: Iowa Total Care Managed Medicaid	$391.15
Rate for Payer: Medical Associates Commercial	$690.26
Rate for Payer: Medical Associates Managed Medicare	$383.48
Rate for Payer: Midlands Choice Commercial	$1,251.60
Rate for Payer: Oscar Health of IA Commercial	$663.42
Rate for Payer: Partners Health Alliance Commercial	$575.22

INC/REPL SPINE NSTIM PG/RCVR

Professional

Both

$1,229.00

Service Code	CPT 63685
Hospital Charge Code	8015885
Hospital Revenue Code	975
Min. Negotiated Rate	$305.54
Max. Negotiated Rate	$860.30
Rate for Payer: Aetna of IA Medicare	$305.54
Rate for Payer: Amerigroup Medicaid	$315.93
Rate for Payer: Cash Price	$983.20
Rate for Payer: Cash Price	$983.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$366.65
Rate for Payer: Iowa Total Care Managed Medicaid	$311.65
Rate for Payer: Medical Associates Commercial	$580.53
Rate for Payer: Medical Associates Managed Medicare	$305.54
Rate for Payer: Midlands Choice Commercial	$860.30
Rate for Payer: Oscar Health of IA Commercial	$528.58
Rate for Payer: Partners Health Alliance Commercial	$458.31

indapamide 2.5 mg Tab [VDMC]

Facility

$1.39

Service Code	HCPCS A9270
Hospital Charge Code	10396186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of IA Commercial	$1.25
Rate for Payer: Aetna of IA Medical Rental Products	$1.25
Rate for Payer: Aetna of IA Medicare	$0.79
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.70
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.70
Rate for Payer: Iowa Total Care Managed Medicaid	$0.69
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Molina Healthcare Managed Medicare	$0.71
Rate for Payer: Oscar Health of IA Commercial	$1.04
Rate for Payer: Partners Health Alliance Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.25
Rate for Payer: United Healthcare Managed Medicare	$0.82

indapamide 2.5 mg Tab [VDMC]

Facility

$1.39

Service Code	HCPCS A9270
Hospital Charge Code	10396186
Hospital Revenue Code	259
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$1.25
Rate for Payer: Aetna of IA Commercial	$1.25
Rate for Payer: Aetna of IA Medical Rental Products	$1.25
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: United Healthcare Commercial	$1.25

indocyanine green 25 mg Pow SDV [VDMC]

Facility

$514.76

Service Code	HCPCS C9776
Hospital Charge Code	27084544
Hospital Revenue Code	259
Min. Negotiated Rate	$257.28
Max. Negotiated Rate	$463.28
Rate for Payer: Aetna of IA Commercial	$463.28
Rate for Payer: Aetna of IA Medical Rental Products	$463.28
Rate for Payer: Aetna of IA Medicare	$293.41
Rate for Payer: Amerigroup Medicaid	$259.80
Rate for Payer: Amerigroup Medicare	$259.95
Rate for Payer: Cash Price	$411.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$386.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$257.38
Rate for Payer: Iowa Total Care Managed Medicaid	$257.28
Rate for Payer: Medical Associates Commercial	$386.07
Rate for Payer: Medical Associates Managed Medicare	$257.38
Rate for Payer: Midlands Choice Commercial	$360.33
Rate for Payer: Molina Healthcare Managed Medicaid	$261.24
Rate for Payer: Molina Healthcare Managed Medicare	$261.09
Rate for Payer: Oscar Health of IA Commercial	$386.07
Rate for Payer: Partners Health Alliance Commercial	$386.07
Rate for Payer: United Healthcare Commercial	$463.28
Rate for Payer: United Healthcare Managed Medicare	$303.71

indocyanine green 25 mg Pow SDV [VDMC]

Facility

$514.76

Service Code	HCPCS C9776
Hospital Charge Code	27084544
Hospital Revenue Code	259
Min. Negotiated Rate	$360.33
Max. Negotiated Rate	$463.28
Rate for Payer: Aetna of IA Commercial	$463.28
Rate for Payer: Aetna of IA Medical Rental Products	$463.28
Rate for Payer: Cash Price	$411.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$386.07
Rate for Payer: Medical Associates Commercial	$386.07
Rate for Payer: Midlands Choice Commercial	$360.33
Rate for Payer: United Healthcare Commercial	$463.28

Know your out-of-pocket cost for care.

All Charges