Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

senna 8.6 mg Tab [VDMC]

Facility

$1.12

Service Code	HCPCS A9270
Hospital Charge Code	10420307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Aetna of IA Medicare	$0.64
Rate for Payer: Amerigroup Medicaid	$0.64
Rate for Payer: Amerigroup Medicare	$0.51
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.84
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.50
Rate for Payer: Iowa Total Care Managed Medicaid	$0.64
Rate for Payer: Medical Associates Commercial	$0.84
Rate for Payer: Medical Associates Managed Medicare	$0.50
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: Molina Healthcare Managed Medicaid	$0.65
Rate for Payer: Partners Health Alliance Commercial	$0.58
Rate for Payer: United Healthcare Commercial	$1.00
Rate for Payer: United Healthcare Managed Medicare	$0.66

senna-docusate-8.6 mg-50 mg Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10384311
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

senna-docusate-8.6 mg-50 mg Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10384311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
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	$1.11
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	$0.62
Rate for Payer: Iowa Total Care Managed Medicaid	$0.79
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Medical Associates Managed Medicare	$0.62
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: Molina Healthcare Managed Medicaid	$0.80
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

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	294946
Hospital Revenue Code	306
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	294946
Hospital Revenue Code	306
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	4210782
Hospital Revenue Code	306
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	4210782
Hospital Revenue Code	306
Min. Negotiated Rate	$31.95
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89

SENSORY INTEGRATION/15 MIN

Facility

$153.00

Service Code	CPT 97533 GO
Hospital Charge Code	1373568
Hospital Revenue Code	430
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Aetna of IA Medicare	$87.21
Rate for Payer: Amerigroup Medicaid	$88.25
Rate for Payer: Amerigroup Medicare	$69.54
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$68.85
Rate for Payer: Iowa Total Care Managed Medicaid	$87.39
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Medical Associates Managed Medicare	$68.85
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: Molina Healthcare Managed Medicaid	$88.68
Rate for Payer: Partners Health Alliance Commercial	$79.18
Rate for Payer: United Healthcare Commercial	$137.70
Rate for Payer: United Healthcare Managed Medicare	$90.27

SENSORY INTEGRATION/15 MIN

Facility

$153.00

Service Code	CPT 97533 GO
Hospital Charge Code	1373568
Hospital Revenue Code	430
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: United Healthcare Commercial	$137.70

SENSORY INTEGRATIVE 15 MIN

Facility

$153.00

Service Code	CPT 97533 GN
Hospital Charge Code	1373955
Hospital Revenue Code	440
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: United Healthcare Commercial	$137.70

SENSORY INTEGRATIVE 15 MIN

Facility

$153.00

Service Code	CPT 97533 GN
Hospital Charge Code	1373955
Hospital Revenue Code	440
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Aetna of IA Medicare	$87.21
Rate for Payer: Amerigroup Medicaid	$88.25
Rate for Payer: Amerigroup Medicare	$69.54
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$68.85
Rate for Payer: Iowa Total Care Managed Medicaid	$87.39
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Medical Associates Managed Medicare	$68.85
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: Molina Healthcare Managed Medicaid	$88.68
Rate for Payer: Partners Health Alliance Commercial	$79.18
Rate for Payer: United Healthcare Commercial	$137.70
Rate for Payer: United Healthcare Managed Medicare	$90.27

sertraline 50 mg Tab [VDMC]

Facility

$1.90

Service Code	HCPCS A9270
Hospital Charge Code	10420378
Hospital Revenue Code	259
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.71
Rate for Payer: Aetna of IA Commercial	$1.71
Rate for Payer: Aetna of IA Medical Rental Products	$1.71
Rate for Payer: Cash Price	$1.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.43
Rate for Payer: Medical Associates Commercial	$1.43
Rate for Payer: Midlands Choice Commercial	$1.33
Rate for Payer: United Healthcare Commercial	$1.71

sertraline 50 mg Tab [VDMC]

Facility

$1.90

Service Code	HCPCS A9270
Hospital Charge Code	10420378
Hospital Revenue Code	259
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.71
Rate for Payer: Aetna of IA Commercial	$1.71
Rate for Payer: Aetna of IA Medical Rental Products	$1.71
Rate for Payer: Aetna of IA Medicare	$1.08
Rate for Payer: Amerigroup Medicaid	$1.10
Rate for Payer: Amerigroup Medicare	$0.87
Rate for Payer: Cash Price	$1.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.43
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.86
Rate for Payer: Iowa Total Care Managed Medicaid	$1.09
Rate for Payer: Medical Associates Commercial	$1.43
Rate for Payer: Medical Associates Managed Medicare	$0.86
Rate for Payer: Midlands Choice Commercial	$1.33
Rate for Payer: Molina Healthcare Managed Medicaid	$1.10
Rate for Payer: Partners Health Alliance Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.71
Rate for Payer: United Healthcare Managed Medicare	$1.12

SESAMOIDECTOMY FIRST TOE CHARGE .

Professional

Both

$1,671.00

Service Code	CPT 28315
Hospital Charge Code	8825536
Hospital Revenue Code	975
Min. Negotiated Rate	$740.61
Max. Negotiated Rate	$1,253.25
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Medical Associates Commercial	$1,253.25
Rate for Payer: Midlands Choice Commercial	$1,169.70
Rate for Payer: Partners Health Alliance Commercial	$1,253.25
Rate for Payer: United Healthcare Commercial	$740.61

sevelamer carbonate 800 mg Tab [VDMC]

Facility

$1.78

Service Code	HCPCS A9270
Hospital Charge Code	10420449
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of IA Commercial	$1.61
Rate for Payer: Aetna of IA Medical Rental Products	$1.61
Rate for Payer: Cash Price	$1.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: United Healthcare Commercial	$1.61

sevelamer carbonate 800 mg Tab [VDMC]

Facility

$1.78

Service Code	HCPCS A9270
Hospital Charge Code	10420449
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of IA Commercial	$1.61
Rate for Payer: Aetna of IA Medical Rental Products	$1.61
Rate for Payer: Aetna of IA Medicare	$1.02
Rate for Payer: Amerigroup Medicaid	$1.03
Rate for Payer: Amerigroup Medicare	$0.81
Rate for Payer: Cash Price	$1.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.80
Rate for Payer: Iowa Total Care Managed Medicaid	$1.02
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Medical Associates Managed Medicare	$0.80
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: Molina Healthcare Managed Medicaid	$1.03
Rate for Payer: Partners Health Alliance Commercial	$0.92
Rate for Payer: United Healthcare Commercial	$1.61
Rate for Payer: United Healthcare Managed Medicare	$1.05

SHAVE SKIN LESION 0.5 CM/<

Facility

$220.00

Service Code	CPT 11310
Hospital Charge Code	7982917
Hospital Revenue Code	450
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna of IA Commercial	$198.00
Rate for Payer: Aetna of IA Medical Rental Products	$198.00
Rate for Payer: Aetna of IA Medicare	$125.40
Rate for Payer: Amerigroup Medicaid	$126.90
Rate for Payer: Amerigroup Medicare	$99.99
Rate for Payer: Cash Price	$176.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.00
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	$125.66
Rate for Payer: Medical Associates Commercial	$165.00
Rate for Payer: Medical Associates Managed Medicare	$99.00
Rate for Payer: Midlands Choice Commercial	$154.00
Rate for Payer: Molina Healthcare Managed Medicaid	$127.51
Rate for Payer: Partners Health Alliance Commercial	$113.85
Rate for Payer: United Healthcare Commercial	$198.00
Rate for Payer: United Healthcare Managed Medicare	$129.80

SHAVE SKIN LESION 0.5 CM/<

Facility

$220.00

Service Code	CPT 11310
Hospital Charge Code	7982917
Hospital Revenue Code	450
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna of IA Commercial	$198.00
Rate for Payer: Aetna of IA Medical Rental Products	$198.00
Rate for Payer: Cash Price	$176.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.00
Rate for Payer: Medical Associates Commercial	$165.00
Rate for Payer: Midlands Choice Commercial	$154.00
Rate for Payer: United Healthcare Commercial	$198.00

SHAVING SKIN LESION 1 F/E/E/N/L/M DIAM >2.0 CM

Professional

Both

$309.00

Service Code	CPT 11313
Hospital Charge Code	8799080
Hospital Revenue Code	975
Min. Negotiated Rate	$216.30
Max. Negotiated Rate	$280.02
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Medical Associates Commercial	$231.75
Rate for Payer: Midlands Choice Commercial	$216.30
Rate for Payer: Partners Health Alliance Commercial	$231.75
Rate for Payer: United Healthcare Commercial	$280.02

SHIGA TOXINS

Facility

$98.00

Service Code	CPT 87427
Hospital Charge Code	7780541
Hospital Revenue Code	306
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

SHIGA TOXINS

Facility

$98.00

Service Code	CPT 87427
Hospital Charge Code	7780541
Hospital Revenue Code	306
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$56.53
Rate for Payer: Amerigroup Medicare	$44.54
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.10
Rate for Payer: Iowa Total Care Managed Medicaid	$55.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$44.10
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$56.80
Rate for Payer: Partners Health Alliance Commercial	$50.72
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82

SHORT 5TH MET HOOK PLATE LEFT

Facility

$2,574.00

Service Code	HCPCS C1713
Hospital Charge Code	8967552
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.30
Max. Negotiated Rate	$2,316.60
Rate for Payer: Aetna of IA Commercial	$2,316.60
Rate for Payer: Aetna of IA Medical Rental Products	$2,316.60
Rate for Payer: Aetna of IA Medicare	$1,467.18
Rate for Payer: Amerigroup Medicaid	$1,484.68
Rate for Payer: Amerigroup Medicare	$1,169.88
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,930.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,158.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1,470.27
Rate for Payer: Medical Associates Commercial	$1,930.50
Rate for Payer: Medical Associates Managed Medicare	$1,158.30
Rate for Payer: Midlands Choice Commercial	$1,801.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,491.89
Rate for Payer: Partners Health Alliance Commercial	$1,332.05
Rate for Payer: United Healthcare Commercial	$2,316.60
Rate for Payer: United Healthcare Managed Medicare	$1,518.66

SHORT 5TH MET HOOK PLATE LEFT

Facility

$2,574.00

Service Code	HCPCS C1713
Hospital Charge Code	8967552
Hospital Revenue Code	278
Min. Negotiated Rate	$1,801.80
Max. Negotiated Rate	$2,316.60
Rate for Payer: Aetna of IA Commercial	$2,316.60
Rate for Payer: Aetna of IA Medical Rental Products	$2,316.60
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,930.50
Rate for Payer: Medical Associates Commercial	$1,930.50
Rate for Payer: Midlands Choice Commercial	$1,801.80
Rate for Payer: United Healthcare Commercial	$2,316.60

SHORT CONDYLAR PLATE

Facility

$171.00

Service Code	HCPCS C1713
Hospital Charge Code	8814828
Hospital Revenue Code	278
Min. Negotiated Rate	$76.95
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of IA Commercial	$153.90
Rate for Payer: Aetna of IA Medical Rental Products	$153.90
Rate for Payer: Aetna of IA Medicare	$97.47
Rate for Payer: Amerigroup Medicaid	$98.63
Rate for Payer: Amerigroup Medicare	$77.72
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$128.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.95
Rate for Payer: Iowa Total Care Managed Medicaid	$97.68
Rate for Payer: Medical Associates Commercial	$128.25
Rate for Payer: Medical Associates Managed Medicare	$76.95
Rate for Payer: Midlands Choice Commercial	$119.70
Rate for Payer: Molina Healthcare Managed Medicaid	$99.11
Rate for Payer: Partners Health Alliance Commercial	$88.49
Rate for Payer: United Healthcare Commercial	$153.90
Rate for Payer: United Healthcare Managed Medicare	$100.89

SHORT CONDYLAR PLATE

Facility

$171.00

Service Code	HCPCS C1713
Hospital Charge Code	8814828
Hospital Revenue Code	278
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of IA Commercial	$153.90
Rate for Payer: Aetna of IA Medical Rental Products	$153.90
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$128.25
Rate for Payer: Medical Associates Commercial	$128.25
Rate for Payer: Midlands Choice Commercial	$119.70
Rate for Payer: United Healthcare Commercial	$153.90

Know your out-of-pocket cost for care.

All Charges