Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

prednisoLONE 45 mg/15 mL Syr [VDMC]

Facility

$38.98

Service Code	HCPCS J7510
Hospital Charge Code	11221578
Hospital Revenue Code	259
Min. Negotiated Rate	$27.29
Max. Negotiated Rate	$35.08
Rate for Payer: Aetna of IA Commercial	$35.08
Rate for Payer: Aetna of IA Medical Rental Products	$35.08
Rate for Payer: Cash Price	$31.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$29.24
Rate for Payer: Medical Associates Commercial	$29.24
Rate for Payer: Midlands Choice Commercial	$27.29
Rate for Payer: United Healthcare Commercial	$35.08

prednisoLONE 45 mg/15 mL Syr [VDMC]

Facility

$38.98

Service Code	HCPCS J7510
Hospital Charge Code	11221578
Hospital Revenue Code	259
Min. Negotiated Rate	$17.54
Max. Negotiated Rate	$35.08
Rate for Payer: Aetna of IA Commercial	$35.08
Rate for Payer: Aetna of IA Medical Rental Products	$35.08
Rate for Payer: Aetna of IA Medicare	$22.22
Rate for Payer: Amerigroup Medicaid	$22.49
Rate for Payer: Amerigroup Medicare	$17.72
Rate for Payer: Cash Price	$31.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$29.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$17.54
Rate for Payer: Iowa Total Care Managed Medicaid	$22.27
Rate for Payer: Medical Associates Commercial	$29.24
Rate for Payer: Medical Associates Managed Medicare	$17.54
Rate for Payer: Midlands Choice Commercial	$27.29
Rate for Payer: Molina Healthcare Managed Medicaid	$22.59
Rate for Payer: Partners Health Alliance Commercial	$20.17
Rate for Payer: United Healthcare Commercial	$35.08
Rate for Payer: United Healthcare Managed Medicare	$23.00

prednisoLONE Ophth acetate 1% Susp 5 ml [VDMC]

Facility

$125.32

Service Code	HCPCS A9270
Hospital Charge Code	10437361
Hospital Revenue Code	259
Min. Negotiated Rate	$56.39
Max. Negotiated Rate	$112.79
Rate for Payer: Aetna of IA Commercial	$112.79
Rate for Payer: Aetna of IA Medical Rental Products	$112.79
Rate for Payer: Aetna of IA Medicare	$71.43
Rate for Payer: Amerigroup Medicaid	$72.28
Rate for Payer: Amerigroup Medicare	$56.96
Rate for Payer: Cash Price	$100.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.99
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$56.39
Rate for Payer: Iowa Total Care Managed Medicaid	$71.58
Rate for Payer: Medical Associates Commercial	$93.99
Rate for Payer: Medical Associates Managed Medicare	$56.39
Rate for Payer: Midlands Choice Commercial	$87.72
Rate for Payer: Molina Healthcare Managed Medicaid	$72.64
Rate for Payer: Partners Health Alliance Commercial	$64.85
Rate for Payer: United Healthcare Commercial	$112.79
Rate for Payer: United Healthcare Managed Medicare	$73.94

prednisoLONE Ophth acetate 1% Susp 5 ml [VDMC]

Facility

$125.32

Service Code	HCPCS A9270
Hospital Charge Code	10437361
Hospital Revenue Code	259
Min. Negotiated Rate	$87.72
Max. Negotiated Rate	$112.79
Rate for Payer: Aetna of IA Commercial	$112.79
Rate for Payer: Aetna of IA Medical Rental Products	$112.79
Rate for Payer: Cash Price	$100.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.99
Rate for Payer: Medical Associates Commercial	$93.99
Rate for Payer: Midlands Choice Commercial	$87.72
Rate for Payer: United Healthcare Commercial	$112.79

prednisoLONE sodium phosphate 5 mg/5 mL Oral Liq [VDMC]

Facility

$10.92

Service Code	HCPCS J7510
Hospital Charge Code	10415499
Hospital Revenue Code	259
Min. Negotiated Rate	$7.64
Max. Negotiated Rate	$9.82
Rate for Payer: Aetna of IA Commercial	$9.82
Rate for Payer: Aetna of IA Medical Rental Products	$9.82
Rate for Payer: Cash Price	$8.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.19
Rate for Payer: Medical Associates Commercial	$8.19
Rate for Payer: Midlands Choice Commercial	$7.64
Rate for Payer: United Healthcare Commercial	$9.82

prednisoLONE sodium phosphate 5 mg/5 mL Oral Liq [VDMC]

Facility

$10.92

Service Code	HCPCS J7510
Hospital Charge Code	10415499
Hospital Revenue Code	259
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$9.82
Rate for Payer: Aetna of IA Commercial	$9.82
Rate for Payer: Aetna of IA Medical Rental Products	$9.82
Rate for Payer: Aetna of IA Medicare	$6.22
Rate for Payer: Amerigroup Medicaid	$6.30
Rate for Payer: Amerigroup Medicare	$4.96
Rate for Payer: Cash Price	$8.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.91
Rate for Payer: Iowa Total Care Managed Medicaid	$6.23
Rate for Payer: Medical Associates Commercial	$8.19
Rate for Payer: Medical Associates Managed Medicare	$4.91
Rate for Payer: Midlands Choice Commercial	$7.64
Rate for Payer: Molina Healthcare Managed Medicaid	$6.33
Rate for Payer: Partners Health Alliance Commercial	$5.65
Rate for Payer: United Healthcare Commercial	$9.82
Rate for Payer: United Healthcare Managed Medicare	$6.44

predniSONE 10 mg Tab [VDMC]

Facility

$1.39

Service Code	HCPCS A9270
Hospital Charge Code	10415637
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
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	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.25

predniSONE 10 mg Tab [VDMC]

Facility

$1.39

Service Code	HCPCS A9270
Hospital Charge Code	10415637
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
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	$0.80
Rate for Payer: Amerigroup Medicare	$0.63
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.63
Rate for Payer: Iowa Total Care Managed Medicaid	$0.80
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Medical Associates Managed Medicare	$0.63
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: Molina Healthcare Managed Medicaid	$0.81
Rate for Payer: Partners Health Alliance Commercial	$0.72
Rate for Payer: United Healthcare Commercial	$1.25
Rate for Payer: United Healthcare Managed Medicare	$0.82

predniSONE 1 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10415568
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of IA Commercial	$1.41
Rate for Payer: Aetna of IA Medical Rental Products	$1.41
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.41

predniSONE 1 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10415568
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of IA Commercial	$1.41
Rate for Payer: Aetna of IA Medical Rental Products	$1.41
Rate for Payer: Aetna of IA Medicare	$0.89
Rate for Payer: Amerigroup Medicaid	$0.90
Rate for Payer: Amerigroup Medicare	$0.71
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
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	$0.89
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: Molina Healthcare Managed Medicaid	$0.91
Rate for Payer: Partners Health Alliance Commercial	$0.81
Rate for Payer: United Healthcare Commercial	$1.41
Rate for Payer: United Healthcare Managed Medicare	$0.92

predniSONE 20 mg Tab [VDMC]

Facility

$1.62

Service Code	HCPCS A9270
Hospital Charge Code	10415706
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of IA Commercial	$1.46
Rate for Payer: Aetna of IA Medical Rental Products	$1.46
Rate for Payer: Aetna of IA Medicare	$0.92
Rate for Payer: Amerigroup Medicaid	$0.93
Rate for Payer: Amerigroup Medicare	$0.74
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.22
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.73
Rate for Payer: Iowa Total Care Managed Medicaid	$0.93
Rate for Payer: Medical Associates Commercial	$1.22
Rate for Payer: Medical Associates Managed Medicare	$0.73
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: Molina Healthcare Managed Medicaid	$0.94
Rate for Payer: Partners Health Alliance Commercial	$0.84
Rate for Payer: United Healthcare Commercial	$1.46
Rate for Payer: United Healthcare Managed Medicare	$0.96

predniSONE 20 mg Tab [VDMC]

Facility

$1.62

Service Code	HCPCS A9270
Hospital Charge Code	10415706
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of IA Commercial	$1.46
Rate for Payer: Aetna of IA Medical Rental Products	$1.46
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.22
Rate for Payer: Medical Associates Commercial	$1.22
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: United Healthcare Commercial	$1.46

predniSONE 5 mg Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10415775
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of IA Commercial	$1.24
Rate for Payer: Aetna of IA Medical Rental Products	$1.24
Rate for Payer: Aetna of IA Medicare	$0.78
Rate for Payer: Amerigroup Medicaid	$0.79
Rate for Payer: Amerigroup Medicare	$0.63
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.62
Rate for Payer: Iowa Total Care Managed Medicaid	$0.79
Rate for Payer: Medical Associates Commercial	$1.03
Rate for Payer: Medical Associates Managed Medicare	$0.62
Rate for Payer: Midlands Choice Commercial	$0.96
Rate for Payer: Molina Healthcare Managed Medicaid	$0.80
Rate for Payer: Partners Health Alliance Commercial	$0.71
Rate for Payer: United Healthcare Commercial	$1.24
Rate for Payer: United Healthcare Managed Medicare	$0.81

predniSONE 5 mg Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10415775
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of IA Commercial	$1.24
Rate for Payer: Aetna of IA Medical Rental Products	$1.24
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.03
Rate for Payer: Medical Associates Commercial	$1.03
Rate for Payer: Midlands Choice Commercial	$0.96
Rate for Payer: United Healthcare Commercial	$1.24

pregabalin 25 mg oral capsule [VDMC]

Facility

$4.35

Service Code	HCPCS A9270
Hospital Charge Code	10415844
Hospital Revenue Code	259
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$3.91
Rate for Payer: Aetna of IA Commercial	$3.91
Rate for Payer: Aetna of IA Medical Rental Products	$3.91
Rate for Payer: Aetna of IA Medicare	$2.48
Rate for Payer: Amerigroup Medicaid	$2.51
Rate for Payer: Amerigroup Medicare	$1.98
Rate for Payer: Cash Price	$3.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.96
Rate for Payer: Iowa Total Care Managed Medicaid	$2.48
Rate for Payer: Medical Associates Commercial	$3.26
Rate for Payer: Medical Associates Managed Medicare	$1.96
Rate for Payer: Midlands Choice Commercial	$3.04
Rate for Payer: Molina Healthcare Managed Medicaid	$2.52
Rate for Payer: Partners Health Alliance Commercial	$2.25
Rate for Payer: United Healthcare Commercial	$3.91
Rate for Payer: United Healthcare Managed Medicare	$2.57

pregabalin 25 mg oral capsule [VDMC]

Facility

$4.35

Service Code	HCPCS A9270
Hospital Charge Code	10415844
Hospital Revenue Code	259
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$3.91
Rate for Payer: Aetna of IA Commercial	$3.91
Rate for Payer: Aetna of IA Medical Rental Products	$3.91
Rate for Payer: Cash Price	$3.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.26
Rate for Payer: Medical Associates Commercial	$3.26
Rate for Payer: Midlands Choice Commercial	$3.04
Rate for Payer: United Healthcare Commercial	$3.91

pregabalin 75 mg oral capsule [VDMC]

Facility

$4.35

Service Code	HCPCS A9270
Hospital Charge Code	10415913
Hospital Revenue Code	259
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$3.91
Rate for Payer: Aetna of IA Commercial	$3.91
Rate for Payer: Aetna of IA Medical Rental Products	$3.91
Rate for Payer: Aetna of IA Medicare	$2.48
Rate for Payer: Amerigroup Medicaid	$2.51
Rate for Payer: Amerigroup Medicare	$1.98
Rate for Payer: Cash Price	$3.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.96
Rate for Payer: Iowa Total Care Managed Medicaid	$2.48
Rate for Payer: Medical Associates Commercial	$3.26
Rate for Payer: Medical Associates Managed Medicare	$1.96
Rate for Payer: Midlands Choice Commercial	$3.04
Rate for Payer: Molina Healthcare Managed Medicaid	$2.52
Rate for Payer: Partners Health Alliance Commercial	$2.25
Rate for Payer: United Healthcare Commercial	$3.91
Rate for Payer: United Healthcare Managed Medicare	$2.57

pregabalin 75 mg oral capsule [VDMC]

Facility

$4.35

Service Code	HCPCS A9270
Hospital Charge Code	10415913
Hospital Revenue Code	259
Min. Negotiated Rate	$3.04
Max. Negotiated Rate	$3.91
Rate for Payer: Aetna of IA Commercial	$3.91
Rate for Payer: Aetna of IA Medical Rental Products	$3.91
Rate for Payer: Cash Price	$3.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.26
Rate for Payer: Medical Associates Commercial	$3.26
Rate for Payer: Midlands Choice Commercial	$3.04
Rate for Payer: United Healthcare Commercial	$3.91

PREGNANCY-SERUM

Facility

$92.00

Service Code	CPT 84703
Hospital Charge Code	4022808
Hospital Revenue Code	301
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of IA Commercial	$82.80
Rate for Payer: Aetna of IA Medical Rental Products	$82.80
Rate for Payer: Aetna of IA Medicare	$52.44
Rate for Payer: Amerigroup Medicaid	$53.07
Rate for Payer: Amerigroup Medicare	$41.81
Rate for Payer: Cash Price	$73.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.40
Rate for Payer: Iowa Total Care Managed Medicaid	$52.55
Rate for Payer: Medical Associates Commercial	$69.00
Rate for Payer: Medical Associates Managed Medicare	$41.40
Rate for Payer: Midlands Choice Commercial	$64.40
Rate for Payer: Molina Healthcare Managed Medicaid	$53.32
Rate for Payer: Partners Health Alliance Commercial	$47.61
Rate for Payer: United Healthcare Commercial	$82.80
Rate for Payer: United Healthcare Managed Medicare	$54.28

PREGNANCY-SERUM

Facility

$92.00

Service Code	CPT 84703
Hospital Charge Code	4022808
Hospital Revenue Code	301
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of IA Commercial	$82.80
Rate for Payer: Aetna of IA Medical Rental Products	$82.80
Rate for Payer: Cash Price	$73.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.00
Rate for Payer: Medical Associates Commercial	$69.00
Rate for Payer: Midlands Choice Commercial	$64.40
Rate for Payer: United Healthcare Commercial	$82.80

PREGNANCY TEST-URINE

Facility

$60.00

Service Code	CPT 81025
Hospital Charge Code	4022807
Hospital Revenue Code	301
Min. Negotiated Rate	$42.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of IA Commercial	$54.00
Rate for Payer: Aetna of IA Medical Rental Products	$54.00
Rate for Payer: Cash Price	$48.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.00
Rate for Payer: Medical Associates Commercial	$45.00
Rate for Payer: Midlands Choice Commercial	$42.00
Rate for Payer: United Healthcare Commercial	$54.00

PREGNANCY TEST-URINE

Facility

$60.00

Service Code	CPT 81025
Hospital Charge Code	4022807
Hospital Revenue Code	301
Min. Negotiated Rate	$27.00
Max. Negotiated Rate	$54.00
Rate for Payer: Aetna of IA Commercial	$54.00
Rate for Payer: Aetna of IA Medical Rental Products	$54.00
Rate for Payer: Aetna of IA Medicare	$34.20
Rate for Payer: Amerigroup Medicaid	$34.61
Rate for Payer: Amerigroup Medicare	$27.27
Rate for Payer: Cash Price	$48.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.00
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	$34.27
Rate for Payer: Medical Associates Commercial	$45.00
Rate for Payer: Medical Associates Managed Medicare	$27.00
Rate for Payer: Midlands Choice Commercial	$42.00
Rate for Payer: Molina Healthcare Managed Medicaid	$34.78
Rate for Payer: Partners Health Alliance Commercial	$31.05
Rate for Payer: United Healthcare Commercial	$54.00
Rate for Payer: United Healthcare Managed Medicare	$35.40

Prenatal Multivitamins [VDMC]

Facility

$1.22

Service Code	HCPCS S0197
Hospital Charge Code	13362152
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Aetna of IA Medicare	$0.70
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.55
Rate for Payer: Cash Price	$0.98
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.55
Rate for Payer: Iowa Total Care Managed Medicaid	$0.70
Rate for Payer: Medical Associates Commercial	$0.92
Rate for Payer: Medical Associates Managed Medicare	$0.55
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Partners Health Alliance Commercial	$0.63
Rate for Payer: United Healthcare Commercial	$1.10
Rate for Payer: United Healthcare Managed Medicare	$0.72

Prenatal Multivitamins [VDMC]

Facility

$1.22

Service Code	HCPCS S0197
Hospital Charge Code	13362152
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Cash Price	$0.98
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.92
Rate for Payer: Medical Associates Commercial	$0.92
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.10

PRESUTURED LAT ANKLE TENDON TISSUE

Facility

$2,200.00

Service Code	HCPCS C1762
Hospital Charge Code	8749000
Hospital Revenue Code	278
Min. Negotiated Rate	$1,540.00
Max. Negotiated Rate	$1,980.00
Rate for Payer: Aetna of IA Commercial	$1,980.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,980.00
Rate for Payer: Cash Price	$1,760.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,650.00
Rate for Payer: Medical Associates Commercial	$1,650.00
Rate for Payer: Midlands Choice Commercial	$1,540.00
Rate for Payer: United Healthcare Commercial	$1,980.00

Know your out-of-pocket cost for care.

All Charges