Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

NM Liver/Spleen Imaging

Facility

$2,452.00

Service Code	CPT 78215
Hospital Charge Code	1169286
Hospital Revenue Code	341
Min. Negotiated Rate	$1,103.40
Max. Negotiated Rate	$2,206.80
Rate for Payer: Aetna of IA Commercial	$2,206.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,206.80
Rate for Payer: Aetna of IA Medicare	$1,397.64
Rate for Payer: Amerigroup Medicaid	$1,414.31
Rate for Payer: Amerigroup Medicare	$1,114.43
Rate for Payer: Cash Price	$1,961.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,839.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,103.40
Rate for Payer: Iowa Total Care Managed Medicaid	$1,400.58
Rate for Payer: Medical Associates Commercial	$1,839.00
Rate for Payer: Medical Associates Managed Medicare	$1,103.40
Rate for Payer: Midlands Choice Commercial	$1,716.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,421.18
Rate for Payer: Partners Health Alliance Commercial	$1,268.91
Rate for Payer: United Healthcare Commercial	$2,206.80
Rate for Payer: United Healthcare Managed Medicare	$1,446.68

NM Liver/Spleen Imaging

Facility

$2,452.00

Service Code	CPT 78215
Hospital Charge Code	1169286
Hospital Revenue Code	341
Min. Negotiated Rate	$1,716.40
Max. Negotiated Rate	$2,206.80
Rate for Payer: Aetna of IA Commercial	$2,206.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,206.80
Rate for Payer: Cash Price	$1,961.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,839.00
Rate for Payer: Medical Associates Commercial	$1,839.00
Rate for Payer: Midlands Choice Commercial	$1,716.40
Rate for Payer: United Healthcare Commercial	$2,206.80

NM Myocardial Spect Multi Rest/Stress

Facility

$2,500.00

Service Code	CPT 78452
Hospital Charge Code	1169308
Hospital Revenue Code	341
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

NM Myocardial Spect Multi Rest/Stress

Facility

$2,500.00

Service Code	CPT 78452
Hospital Charge Code	1169308
Hospital Revenue Code	341
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

NM Parathyroid Study

Facility

$1,236.00

Service Code	CPT 78071
Hospital Charge Code	1169316
Hospital Revenue Code	341
Min. Negotiated Rate	$556.20
Max. Negotiated Rate	$1,112.40
Rate for Payer: Aetna of IA Commercial	$1,112.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,112.40
Rate for Payer: Aetna of IA Medicare	$704.52
Rate for Payer: Amerigroup Medicaid	$712.92
Rate for Payer: Amerigroup Medicare	$561.76
Rate for Payer: Cash Price	$988.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$927.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$556.20
Rate for Payer: Iowa Total Care Managed Medicaid	$706.00
Rate for Payer: Medical Associates Commercial	$927.00
Rate for Payer: Medical Associates Managed Medicare	$556.20
Rate for Payer: Midlands Choice Commercial	$865.20
Rate for Payer: Molina Healthcare Managed Medicaid	$716.39
Rate for Payer: Partners Health Alliance Commercial	$639.63
Rate for Payer: United Healthcare Commercial	$1,112.40
Rate for Payer: United Healthcare Managed Medicare	$729.24

NM Parathyroid Study

Facility

$1,236.00

Service Code	CPT 78071
Hospital Charge Code	1169316
Hospital Revenue Code	341
Min. Negotiated Rate	$865.20
Max. Negotiated Rate	$1,112.40
Rate for Payer: Aetna of IA Commercial	$1,112.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,112.40
Rate for Payer: Cash Price	$988.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$927.00
Rate for Payer: Medical Associates Commercial	$927.00
Rate for Payer: Midlands Choice Commercial	$865.20
Rate for Payer: United Healthcare Commercial	$1,112.40

NM Pulmonary Perfusion Imaging

Facility

$1,130.00

Service Code	CPT 78580
Hospital Charge Code	1169328
Hospital Revenue Code	341
Min. Negotiated Rate	$791.00
Max. Negotiated Rate	$1,017.00
Rate for Payer: Aetna of IA Commercial	$1,017.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,017.00
Rate for Payer: Cash Price	$904.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$847.50
Rate for Payer: Medical Associates Commercial	$847.50
Rate for Payer: Midlands Choice Commercial	$791.00
Rate for Payer: United Healthcare Commercial	$1,017.00

NM Pulmonary Perfusion Imaging

Facility

$1,130.00

Service Code	CPT 78580
Hospital Charge Code	1169328
Hospital Revenue Code	341
Min. Negotiated Rate	$508.50
Max. Negotiated Rate	$1,017.00
Rate for Payer: Aetna of IA Commercial	$1,017.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,017.00
Rate for Payer: Aetna of IA Medicare	$644.10
Rate for Payer: Amerigroup Medicaid	$651.78
Rate for Payer: Amerigroup Medicare	$513.59
Rate for Payer: Cash Price	$904.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$847.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$508.50
Rate for Payer: Iowa Total Care Managed Medicaid	$645.46
Rate for Payer: Medical Associates Commercial	$847.50
Rate for Payer: Medical Associates Managed Medicare	$508.50
Rate for Payer: Midlands Choice Commercial	$791.00
Rate for Payer: Molina Healthcare Managed Medicaid	$654.95
Rate for Payer: Partners Health Alliance Commercial	$584.77
Rate for Payer: United Healthcare Commercial	$1,017.00
Rate for Payer: United Healthcare Managed Medicare	$666.70

NM Pulmonary Ventilation/Perfusion

Facility

$1,745.00

Service Code	CPT 78582
Hospital Charge Code	1169346
Hospital Revenue Code	341
Min. Negotiated Rate	$785.25
Max. Negotiated Rate	$1,570.50
Rate for Payer: Aetna of IA Commercial	$1,570.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,570.50
Rate for Payer: Aetna of IA Medicare	$994.65
Rate for Payer: Amerigroup Medicaid	$1,006.52
Rate for Payer: Amerigroup Medicare	$793.10
Rate for Payer: Cash Price	$1,396.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,308.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$785.25
Rate for Payer: Iowa Total Care Managed Medicaid	$996.74
Rate for Payer: Medical Associates Commercial	$1,308.75
Rate for Payer: Medical Associates Managed Medicare	$785.25
Rate for Payer: Midlands Choice Commercial	$1,221.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,011.40
Rate for Payer: Partners Health Alliance Commercial	$903.04
Rate for Payer: United Healthcare Commercial	$1,570.50
Rate for Payer: United Healthcare Managed Medicare	$1,029.55

NM Pulmonary Ventilation/Perfusion

Facility

$1,745.00

Service Code	CPT 78582
Hospital Charge Code	1169346
Hospital Revenue Code	341
Min. Negotiated Rate	$1,221.50
Max. Negotiated Rate	$1,570.50
Rate for Payer: Aetna of IA Commercial	$1,570.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,570.50
Rate for Payer: Cash Price	$1,396.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,308.75
Rate for Payer: Medical Associates Commercial	$1,308.75
Rate for Payer: Midlands Choice Commercial	$1,221.50
Rate for Payer: United Healthcare Commercial	$1,570.50

NM Spect- Single Study at Rest or Stress

Facility

$3,100.00

Service Code	CPT 78451
Hospital Charge Code	1169310
Hospital Revenue Code	341
Min. Negotiated Rate	$2,170.00
Max. Negotiated Rate	$2,790.00
Rate for Payer: Aetna of IA Commercial	$2,790.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,790.00
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,325.00
Rate for Payer: Medical Associates Commercial	$2,325.00
Rate for Payer: Midlands Choice Commercial	$2,170.00
Rate for Payer: United Healthcare Commercial	$2,790.00

NM Spect- Single Study at Rest or Stress

Facility

$3,100.00

Service Code	CPT 78451
Hospital Charge Code	1169310
Hospital Revenue Code	341
Min. Negotiated Rate	$1,395.00
Max. Negotiated Rate	$2,790.00
Rate for Payer: Aetna of IA Commercial	$2,790.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,790.00
Rate for Payer: Aetna of IA Medicare	$1,767.00
Rate for Payer: Amerigroup Medicaid	$1,788.08
Rate for Payer: Amerigroup Medicare	$1,408.95
Rate for Payer: Cash Price	$2,480.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,325.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,395.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,770.72
Rate for Payer: Medical Associates Commercial	$2,325.00
Rate for Payer: Medical Associates Managed Medicare	$1,395.00
Rate for Payer: Midlands Choice Commercial	$2,170.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,796.76
Rate for Payer: Partners Health Alliance Commercial	$1,604.25
Rate for Payer: United Healthcare Commercial	$2,790.00
Rate for Payer: United Healthcare Managed Medicare	$1,829.00

NM Thyroid Imaging Only

Facility

$1,190.00

Service Code	CPT 78013
Hospital Charge Code	1169390
Hospital Revenue Code	341
Min. Negotiated Rate	$833.00
Max. Negotiated Rate	$1,071.00
Rate for Payer: Aetna of IA Commercial	$1,071.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,071.00
Rate for Payer: Cash Price	$952.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$892.50
Rate for Payer: Medical Associates Commercial	$892.50
Rate for Payer: Midlands Choice Commercial	$833.00
Rate for Payer: United Healthcare Commercial	$1,071.00

NM Thyroid Imaging Only

Facility

$1,190.00

Service Code	CPT 78013
Hospital Charge Code	1169390
Hospital Revenue Code	341
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,071.00
Rate for Payer: Aetna of IA Commercial	$1,071.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,071.00
Rate for Payer: Aetna of IA Medicare	$678.30
Rate for Payer: Amerigroup Medicaid	$686.39
Rate for Payer: Amerigroup Medicare	$540.86
Rate for Payer: Cash Price	$952.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$892.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$535.50
Rate for Payer: Iowa Total Care Managed Medicaid	$679.73
Rate for Payer: Medical Associates Commercial	$892.50
Rate for Payer: Medical Associates Managed Medicare	$535.50
Rate for Payer: Midlands Choice Commercial	$833.00
Rate for Payer: Molina Healthcare Managed Medicaid	$689.72
Rate for Payer: Partners Health Alliance Commercial	$615.83
Rate for Payer: United Healthcare Commercial	$1,071.00
Rate for Payer: United Healthcare Managed Medicare	$702.10

NM Thyroid Imaging w/ Uptake Single

Facility

$1,439.00

Service Code	CPT 78014
Hospital Charge Code	1169394
Hospital Revenue Code	341
Min. Negotiated Rate	$647.55
Max. Negotiated Rate	$1,295.10
Rate for Payer: Aetna of IA Commercial	$1,295.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,295.10
Rate for Payer: Aetna of IA Medicare	$820.23
Rate for Payer: Amerigroup Medicaid	$830.02
Rate for Payer: Amerigroup Medicare	$654.03
Rate for Payer: Cash Price	$1,151.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,079.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$647.55
Rate for Payer: Iowa Total Care Managed Medicaid	$821.96
Rate for Payer: Medical Associates Commercial	$1,079.25
Rate for Payer: Medical Associates Managed Medicare	$647.55
Rate for Payer: Midlands Choice Commercial	$1,007.30
Rate for Payer: Molina Healthcare Managed Medicaid	$834.04
Rate for Payer: Partners Health Alliance Commercial	$744.68
Rate for Payer: United Healthcare Commercial	$1,295.10
Rate for Payer: United Healthcare Managed Medicare	$849.01

NM Thyroid Imaging w/ Uptake Single

Facility

$1,439.00

Service Code	CPT 78014
Hospital Charge Code	1169394
Hospital Revenue Code	341
Min. Negotiated Rate	$1,007.30
Max. Negotiated Rate	$1,295.10
Rate for Payer: Aetna of IA Commercial	$1,295.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,295.10
Rate for Payer: Cash Price	$1,151.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,079.25
Rate for Payer: Medical Associates Commercial	$1,079.25
Rate for Payer: Midlands Choice Commercial	$1,007.30
Rate for Payer: United Healthcare Commercial	$1,295.10

NM Thyroid Uptake Single Determination

Facility

$1,190.00

Service Code	CPT 78012
Hospital Charge Code	1169400
Hospital Revenue Code	341
Min. Negotiated Rate	$833.00
Max. Negotiated Rate	$1,071.00
Rate for Payer: Aetna of IA Commercial	$1,071.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,071.00
Rate for Payer: Cash Price	$952.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$892.50
Rate for Payer: Medical Associates Commercial	$892.50
Rate for Payer: Midlands Choice Commercial	$833.00
Rate for Payer: United Healthcare Commercial	$1,071.00

NM Thyroid Uptake Single Determination

Facility

$1,190.00

Service Code	CPT 78012
Hospital Charge Code	1169400
Hospital Revenue Code	341
Min. Negotiated Rate	$535.50
Max. Negotiated Rate	$1,071.00
Rate for Payer: Aetna of IA Commercial	$1,071.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,071.00
Rate for Payer: Aetna of IA Medicare	$678.30
Rate for Payer: Amerigroup Medicaid	$686.39
Rate for Payer: Amerigroup Medicare	$540.86
Rate for Payer: Cash Price	$952.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$892.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$535.50
Rate for Payer: Iowa Total Care Managed Medicaid	$679.73
Rate for Payer: Medical Associates Commercial	$892.50
Rate for Payer: Medical Associates Managed Medicare	$535.50
Rate for Payer: Midlands Choice Commercial	$833.00
Rate for Payer: Molina Healthcare Managed Medicaid	$689.72
Rate for Payer: Partners Health Alliance Commercial	$615.83
Rate for Payer: United Healthcare Commercial	$1,071.00
Rate for Payer: United Healthcare Managed Medicare	$702.10

NON COVERED MILEAGE PER 10TH OF A MILE

Facility

$2.00

Service Code	HCPCS A0888
Hospital Charge Code	5966786
Hospital Revenue Code	540
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Aetna of IA Medicare	$1.14
Rate for Payer: Amerigroup Medicaid	$1.15
Rate for Payer: Amerigroup Medicare	$0.91
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1.14
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Medical Associates Managed Medicare	$0.90
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.16
Rate for Payer: Partners Health Alliance Commercial	$1.03
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Managed Medicare	$1.70

NON COVERED MILEAGE PER 10TH OF A MILE

Facility

$2.00

Service Code	HCPCS A0888
Hospital Charge Code	5966786
Hospital Revenue Code	540
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: United Healthcare Commercial	$1.80

NON-DOT Rapid In House Urine Drug Collection

Facility

$50.00

Service Code	CPT 99001
Hospital Charge Code	8098797
Hospital Revenue Code	300
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of IA Commercial	$45.00
Rate for Payer: Aetna of IA Medical Rental Products	$45.00
Rate for Payer: Aetna of IA Medicare	$28.50
Rate for Payer: Amerigroup Medicaid	$28.84
Rate for Payer: Amerigroup Medicare	$22.73
Rate for Payer: Cash Price	$40.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$37.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$22.50
Rate for Payer: Iowa Total Care Managed Medicaid	$28.56
Rate for Payer: Medical Associates Commercial	$37.50
Rate for Payer: Medical Associates Managed Medicare	$22.50
Rate for Payer: Midlands Choice Commercial	$35.00
Rate for Payer: Molina Healthcare Managed Medicaid	$28.98
Rate for Payer: Partners Health Alliance Commercial	$25.88
Rate for Payer: United Healthcare Commercial	$45.00
Rate for Payer: United Healthcare Managed Medicare	$29.50

NON-DOT Rapid In House Urine Drug Collection

Facility

$50.00

Service Code	CPT 99001
Hospital Charge Code	8098797
Hospital Revenue Code	300
Min. Negotiated Rate	$35.00
Max. Negotiated Rate	$45.00
Rate for Payer: Aetna of IA Commercial	$45.00
Rate for Payer: Aetna of IA Medical Rental Products	$45.00
Rate for Payer: Cash Price	$40.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$37.50
Rate for Payer: Medical Associates Commercial	$37.50
Rate for Payer: Midlands Choice Commercial	$35.00
Rate for Payer: United Healthcare Commercial	$45.00

NON-LOCKING SCREW 2.7MMX14MM

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8759894
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

NON-LOCKING SCREW 2.7MMX14MM

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8759894
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

NON-LOCKING SCREW 2.7MMx16MM

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8967554
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

Know your out-of-pocket cost for care.

All Charges