Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SALICYLATE

Facility

$139.00

Service Code	HCPCS G0480
Hospital Charge Code	1503768
Hospital Revenue Code	301
Min. Negotiated Rate	$62.55
Max. Negotiated Rate	$129.65
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$80.18
Rate for Payer: Amerigroup Medicare	$63.18
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.55
Rate for Payer: Iowa Total Care Managed Medicaid	$79.40
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$62.55
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$80.56
Rate for Payer: Partners Health Alliance Commercial	$71.93
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO WHPI	$117.69
Rate for Payer: Wellmark IA PPO	$129.65

SALICYLATE

Facility

$139.00

Service Code	HCPCS G0480
Hospital Charge Code	1503768
Hospital Revenue Code	301
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

SALIVARY GLAND PROCEDURES

Facility

$11,544.64

Service Code	MSDRG 139
Min. Negotiated Rate	$11,377.32
Max. Negotiated Rate	$11,544.64
Rate for Payer: Amerigroup Medicaid	$11,488.87
Rate for Payer: Iowa Total Care Managed Medicaid	$11,377.32
Rate for Payer: Molina Healthcare Managed Medicaid	$11,544.64

saliva substitutes - Spr[VDMC]

Facility

$39.76

Service Code	HCPCS A9155
Hospital Charge Code	12862338
Hospital Revenue Code	259
Min. Negotiated Rate	$17.89
Max. Negotiated Rate	$35.78
Rate for Payer: Aetna of IA Commercial	$35.78
Rate for Payer: Aetna of IA Medical Rental Products	$35.78
Rate for Payer: Aetna of IA Medicare	$22.66
Rate for Payer: Amerigroup Medicaid	$22.93
Rate for Payer: Amerigroup Medicare	$18.07
Rate for Payer: Cash Price	$31.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$29.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$17.89
Rate for Payer: Iowa Total Care Managed Medicaid	$22.71
Rate for Payer: Medical Associates Commercial	$29.82
Rate for Payer: Medical Associates Managed Medicare	$17.89
Rate for Payer: Midlands Choice Commercial	$27.83
Rate for Payer: Molina Healthcare Managed Medicaid	$23.05
Rate for Payer: Partners Health Alliance Commercial	$20.58
Rate for Payer: United Healthcare Commercial	$35.78
Rate for Payer: United Healthcare Managed Medicare	$23.46

saliva substitutes - Spr[VDMC]

Facility

$39.76

Service Code	HCPCS A9155
Hospital Charge Code	12862338
Hospital Revenue Code	259
Min. Negotiated Rate	$27.83
Max. Negotiated Rate	$35.78
Rate for Payer: Aetna of IA Commercial	$35.78
Rate for Payer: Aetna of IA Medical Rental Products	$35.78
Rate for Payer: Cash Price	$31.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$29.82
Rate for Payer: Medical Associates Commercial	$29.82
Rate for Payer: Midlands Choice Commercial	$27.83
Rate for Payer: United Healthcare Commercial	$35.78

salsalate 500 mg Tab [VDMC]

Facility

$2.11

Service Code	HCPCS A9270
Hospital Charge Code	10420104
Hospital Revenue Code	259
Min. Negotiated Rate	$1.48
Max. Negotiated Rate	$1.90
Rate for Payer: Aetna of IA Commercial	$1.90
Rate for Payer: Aetna of IA Medical Rental Products	$1.90
Rate for Payer: Cash Price	$1.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Midlands Choice Commercial	$1.48
Rate for Payer: United Healthcare Commercial	$1.90

salsalate 500 mg Tab [VDMC]

Facility

$2.11

Service Code	HCPCS A9270
Hospital Charge Code	10420104
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.90
Rate for Payer: Aetna of IA Commercial	$1.90
Rate for Payer: Aetna of IA Medical Rental Products	$1.90
Rate for Payer: Aetna of IA Medicare	$1.20
Rate for Payer: Amerigroup Medicaid	$1.22
Rate for Payer: Amerigroup Medicare	$0.96
Rate for Payer: Cash Price	$1.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.95
Rate for Payer: Iowa Total Care Managed Medicaid	$1.21
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Medical Associates Managed Medicare	$0.95
Rate for Payer: Midlands Choice Commercial	$1.48
Rate for Payer: Molina Healthcare Managed Medicaid	$1.22
Rate for Payer: Partners Health Alliance Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.90
Rate for Payer: United Healthcare Managed Medicare	$1.24

SARS-CoV-2 (COVID-19) 12YR+ mRNA-LNP vaccine (cvx 312) preservative-free 50 mcg/0.5 mL Sus

Facility

$273.82

Service Code	HCPCS 91322
Hospital Charge Code	26766683
Hospital Revenue Code	259
Min. Negotiated Rate	$80.12
Max. Negotiated Rate	$246.44
Rate for Payer: Aetna of IA Commercial	$246.44
Rate for Payer: Aetna of IA Medical Rental Products	$246.44
Rate for Payer: Aetna of IA Medicare	$156.08
Rate for Payer: Amerigroup Medicaid	$157.94
Rate for Payer: Amerigroup Medicare	$124.45
Rate for Payer: Cash Price	$219.06
Rate for Payer: Cash Price	$219.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$205.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$123.22
Rate for Payer: Iowa Total Care Managed Medicaid	$156.41
Rate for Payer: Medical Associates Commercial	$205.36
Rate for Payer: Medical Associates Managed Medicare	$123.22
Rate for Payer: Midlands Choice Commercial	$191.67
Rate for Payer: Molina Healthcare Managed Medicaid	$158.71
Rate for Payer: Partners Health Alliance Commercial	$141.70
Rate for Payer: United Healthcare Commercial	$246.44
Rate for Payer: United Healthcare Managed Medicare	$161.55
Rate for Payer: Wellmark IA HMO WHPI	$80.12
Rate for Payer: Wellmark IA PPO	$88.25

SARS-CoV-2 (COVID-19) 12YR+ mRNA-LNP vaccine (cvx 312) preservative-free 50 mcg/0.5 mL Sus

Facility

$273.82

Service Code	HCPCS 91322
Hospital Charge Code	26766683
Hospital Revenue Code	259
Min. Negotiated Rate	$191.67
Max. Negotiated Rate	$246.44
Rate for Payer: Aetna of IA Commercial	$246.44
Rate for Payer: Aetna of IA Medical Rental Products	$246.44
Rate for Payer: Cash Price	$219.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$205.36
Rate for Payer: Medical Associates Commercial	$205.36
Rate for Payer: Midlands Choice Commercial	$191.67
Rate for Payer: United Healthcare Commercial	$246.44

SARS-CoV-2 (COVID-19) 6M-11YR mRNA-LNP vaccine (cvx 311) preservative-free 25 mcg/0.25 mL Sus

Facility

$250.92

Service Code	HCPCS 91321
Hospital Charge Code	26766930
Hospital Revenue Code	259
Min. Negotiated Rate	$175.64
Max. Negotiated Rate	$225.83
Rate for Payer: Aetna of IA Commercial	$225.83
Rate for Payer: Aetna of IA Medical Rental Products	$225.83
Rate for Payer: Cash Price	$200.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.19
Rate for Payer: Medical Associates Commercial	$188.19
Rate for Payer: Midlands Choice Commercial	$175.64
Rate for Payer: United Healthcare Commercial	$225.83

SARS-CoV-2 (COVID-19) 6M-11YR mRNA-LNP vaccine (cvx 311) preservative-free 25 mcg/0.25 mL Sus

Facility

$250.92

Service Code	HCPCS 91321
Hospital Charge Code	26766930
Hospital Revenue Code	259
Min. Negotiated Rate	$80.12
Max. Negotiated Rate	$225.83
Rate for Payer: Aetna of IA Commercial	$225.83
Rate for Payer: Aetna of IA Medical Rental Products	$225.83
Rate for Payer: Aetna of IA Medicare	$143.02
Rate for Payer: Amerigroup Medicaid	$144.73
Rate for Payer: Amerigroup Medicare	$114.04
Rate for Payer: Cash Price	$200.74
Rate for Payer: Cash Price	$200.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$188.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$112.91
Rate for Payer: Iowa Total Care Managed Medicaid	$143.33
Rate for Payer: Medical Associates Commercial	$188.19
Rate for Payer: Medical Associates Managed Medicare	$112.91
Rate for Payer: Midlands Choice Commercial	$175.64
Rate for Payer: Molina Healthcare Managed Medicaid	$145.43
Rate for Payer: Partners Health Alliance Commercial	$129.85
Rate for Payer: United Healthcare Commercial	$225.83
Rate for Payer: United Healthcare Managed Medicare	$148.04
Rate for Payer: Wellmark IA HMO WHPI	$80.12
Rate for Payer: Wellmark IA PPO	$88.25

SARS-CoV-2 (COVID-19) BioFire

Facility

$338.00

Service Code	HCPCS U0004
Hospital Charge Code	8789912
Hospital Revenue Code	306
Min. Negotiated Rate	$152.10
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Aetna of IA Medicare	$192.66
Rate for Payer: Amerigroup Medicaid	$194.96
Rate for Payer: Amerigroup Medicare	$153.62
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$152.10
Rate for Payer: Iowa Total Care Managed Medicaid	$193.07
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Medical Associates Managed Medicare	$152.10
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: Molina Healthcare Managed Medicaid	$195.90
Rate for Payer: Partners Health Alliance Commercial	$174.92
Rate for Payer: United Healthcare Commercial	$304.20
Rate for Payer: United Healthcare Managed Medicare	$199.42

SARS-CoV-2 (COVID-19) BioFire

Facility

$338.00

Service Code	HCPCS U0004
Hospital Charge Code	8789912
Hospital Revenue Code	306
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: United Healthcare Commercial	$304.20

saxagliptin 5 mg Tab [VDMC]

Facility

$52.72

Service Code	HCPCS A9270
Hospital Charge Code	10420173
Hospital Revenue Code	259
Min. Negotiated Rate	$36.91
Max. Negotiated Rate	$47.45
Rate for Payer: Aetna of IA Commercial	$47.45
Rate for Payer: Aetna of IA Medical Rental Products	$47.45
Rate for Payer: Cash Price	$42.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.54
Rate for Payer: Medical Associates Commercial	$39.54
Rate for Payer: Midlands Choice Commercial	$36.91
Rate for Payer: United Healthcare Commercial	$47.45

saxagliptin 5 mg Tab [VDMC]

Facility

$52.72

Service Code	HCPCS A9270
Hospital Charge Code	10420173
Hospital Revenue Code	259
Min. Negotiated Rate	$23.73
Max. Negotiated Rate	$47.45
Rate for Payer: Aetna of IA Commercial	$47.45
Rate for Payer: Aetna of IA Medical Rental Products	$47.45
Rate for Payer: Aetna of IA Medicare	$30.05
Rate for Payer: Amerigroup Medicaid	$30.41
Rate for Payer: Amerigroup Medicare	$23.96
Rate for Payer: Cash Price	$42.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.73
Rate for Payer: Iowa Total Care Managed Medicaid	$30.12
Rate for Payer: Medical Associates Commercial	$39.54
Rate for Payer: Medical Associates Managed Medicare	$23.73
Rate for Payer: Midlands Choice Commercial	$36.91
Rate for Payer: Molina Healthcare Managed Medicaid	$30.56
Rate for Payer: Partners Health Alliance Commercial	$27.28
Rate for Payer: United Healthcare Commercial	$47.45
Rate for Payer: United Healthcare Managed Medicare	$31.11

SCIATIC NERVE BLOCK CHARGE

Professional

Both

$342.00

Service Code	CPT 64445
Hospital Charge Code	8059065
Hospital Revenue Code	975
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$350.80
Rate for Payer: Amerigroup Medicaid	$113.80
Rate for Payer: Cash Price	$273.60
Rate for Payer: Cash Price	$273.60
Rate for Payer: Iowa Total Care Managed Medicaid	$112.70
Rate for Payer: Medical Associates Commercial	$256.50
Rate for Payer: Midlands Choice Commercial	$239.40
Rate for Payer: Molina Healthcare Managed Medicaid	$113.25
Rate for Payer: Partners Health Alliance Commercial	$256.50
Rate for Payer: United Healthcare Commercial	$189.84
Rate for Payer: Wellmark IA HMO WHPI	$298.20
Rate for Payer: Wellmark IA PPO	$350.80

scopolamine 1.5 mg Transderm ER Film [VDMC]

Facility

$77.91

Service Code	NDC 10019-0553-04
Hospital Charge Code	10420242
Hospital Revenue Code	259
Min. Negotiated Rate	$35.06
Max. Negotiated Rate	$70.12
Rate for Payer: Aetna of IA Commercial	$70.12
Rate for Payer: Aetna of IA Medical Rental Products	$70.12
Rate for Payer: Aetna of IA Medicare	$44.41
Rate for Payer: Amerigroup Medicaid	$44.94
Rate for Payer: Amerigroup Medicare	$35.41
Rate for Payer: Cash Price	$62.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.43
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.06
Rate for Payer: Iowa Total Care Managed Medicaid	$44.50
Rate for Payer: Medical Associates Commercial	$58.43
Rate for Payer: Medical Associates Managed Medicare	$35.06
Rate for Payer: Midlands Choice Commercial	$54.54
Rate for Payer: Molina Healthcare Managed Medicaid	$45.16
Rate for Payer: Partners Health Alliance Commercial	$40.32
Rate for Payer: United Healthcare Commercial	$70.12
Rate for Payer: United Healthcare Managed Medicare	$45.97

scopolamine 1.5 mg Transderm ER Film [VDMC]

Facility

$77.91

Service Code	NDC 10019-0553-04
Hospital Charge Code	10420242
Hospital Revenue Code	259
Min. Negotiated Rate	$54.54
Max. Negotiated Rate	$70.12
Rate for Payer: Aetna of IA Commercial	$70.12
Rate for Payer: Aetna of IA Medical Rental Products	$70.12
Rate for Payer: Cash Price	$62.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.43
Rate for Payer: Medical Associates Commercial	$58.43
Rate for Payer: Midlands Choice Commercial	$54.54
Rate for Payer: United Healthcare Commercial	$70.12

SCREW 2.2MMX16MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8814832
Hospital Revenue Code	278
Min. Negotiated Rate	$89.10
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	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
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	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

SCREW 2.2MMX16MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8814832
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

SCREW 2.2MMX20MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8814834
Hospital Revenue Code	278
Min. Negotiated Rate	$89.10
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	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
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	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

SCREW 2.2MMX20MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8814834
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

SCREW 2.2X14MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8814830
Hospital Revenue Code	278
Min. Negotiated Rate	$89.10
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	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
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	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

SCREW 2.2X14MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8814830
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

SCREW 2.2X18MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8815108
Hospital Revenue Code	278
Min. Negotiated Rate	$89.10
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	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
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	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

Know your out-of-pocket cost for care.

All Charges