Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

buprenorphine 10mcg/hr Transdermal [VDMC]

Facility

$180.88

Service Code	HCPCS A9270
Hospital Charge Code	10372211
Hospital Revenue Code	259
Min. Negotiated Rate	$126.62
Max. Negotiated Rate	$162.79
Rate for Payer: Aetna of IA Commercial	$162.79
Rate for Payer: Aetna of IA Medical Rental Products	$162.79
Rate for Payer: Cash Price	$144.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.66
Rate for Payer: Medical Associates Commercial	$135.66
Rate for Payer: Midlands Choice Commercial	$126.62
Rate for Payer: United Healthcare Commercial	$162.79

buprenorphine 10mcg/hr Transdermal [VDMC]

Facility

$180.88

Service Code	HCPCS A9270
Hospital Charge Code	10372211
Hospital Revenue Code	259
Min. Negotiated Rate	$81.40
Max. Negotiated Rate	$162.79
Rate for Payer: Aetna of IA Commercial	$162.79
Rate for Payer: Aetna of IA Medical Rental Products	$162.79
Rate for Payer: Aetna of IA Medicare	$103.10
Rate for Payer: Amerigroup Medicaid	$104.33
Rate for Payer: Amerigroup Medicare	$82.21
Rate for Payer: Cash Price	$144.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.66
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.40
Rate for Payer: Iowa Total Care Managed Medicaid	$103.32
Rate for Payer: Medical Associates Commercial	$135.66
Rate for Payer: Medical Associates Managed Medicare	$81.40
Rate for Payer: Midlands Choice Commercial	$126.62
Rate for Payer: Molina Healthcare Managed Medicaid	$104.84
Rate for Payer: Partners Health Alliance Commercial	$93.61
Rate for Payer: United Healthcare Commercial	$162.79
Rate for Payer: United Healthcare Managed Medicare	$106.72

buprenorphine 5 mcg/hr Fil [VDMC]

Facility

$131.24

Service Code	NDC 42858-0750-40
Hospital Charge Code	10372146
Hospital Revenue Code	259
Min. Negotiated Rate	$59.06
Max. Negotiated Rate	$118.12
Rate for Payer: Aetna of IA Commercial	$118.12
Rate for Payer: Aetna of IA Medical Rental Products	$118.12
Rate for Payer: Aetna of IA Medicare	$74.81
Rate for Payer: Amerigroup Medicaid	$75.70
Rate for Payer: Amerigroup Medicare	$59.65
Rate for Payer: Cash Price	$104.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.43
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$59.06
Rate for Payer: Iowa Total Care Managed Medicaid	$74.96
Rate for Payer: Medical Associates Commercial	$98.43
Rate for Payer: Medical Associates Managed Medicare	$59.06
Rate for Payer: Midlands Choice Commercial	$91.87
Rate for Payer: Molina Healthcare Managed Medicaid	$76.07
Rate for Payer: Partners Health Alliance Commercial	$67.92
Rate for Payer: United Healthcare Commercial	$118.12
Rate for Payer: United Healthcare Managed Medicare	$77.43

buprenorphine 5 mcg/hr Fil [VDMC]

Facility

$131.24

Service Code	NDC 42858-0750-40
Hospital Charge Code	10372146
Hospital Revenue Code	259
Min. Negotiated Rate	$91.87
Max. Negotiated Rate	$118.12
Rate for Payer: Aetna of IA Commercial	$118.12
Rate for Payer: Aetna of IA Medical Rental Products	$118.12
Rate for Payer: Cash Price	$104.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.43
Rate for Payer: Medical Associates Commercial	$98.43
Rate for Payer: Midlands Choice Commercial	$91.87
Rate for Payer: United Healthcare Commercial	$118.12

buPROPion 100 mg ER Tab/12 HR [VDMC]

Facility

$3.11

Service Code	HCPCS A9270
Hospital Charge Code	10372272
Hospital Revenue Code	259
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna of IA Commercial	$2.80
Rate for Payer: Aetna of IA Medical Rental Products	$2.80
Rate for Payer: Aetna of IA Medicare	$1.77
Rate for Payer: Amerigroup Medicaid	$1.80
Rate for Payer: Amerigroup Medicare	$1.41
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.33
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.40
Rate for Payer: Iowa Total Care Managed Medicaid	$1.78
Rate for Payer: Medical Associates Commercial	$2.33
Rate for Payer: Medical Associates Managed Medicare	$1.40
Rate for Payer: Midlands Choice Commercial	$2.18
Rate for Payer: Molina Healthcare Managed Medicaid	$1.80
Rate for Payer: Partners Health Alliance Commercial	$1.61
Rate for Payer: United Healthcare Commercial	$2.80
Rate for Payer: United Healthcare Managed Medicare	$1.84

buPROPion 100 mg ER Tab/12 HR [VDMC]

Facility

$3.11

Service Code	HCPCS A9270
Hospital Charge Code	10372272
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna of IA Commercial	$2.80
Rate for Payer: Aetna of IA Medical Rental Products	$2.80
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.33
Rate for Payer: Medical Associates Commercial	$2.33
Rate for Payer: Midlands Choice Commercial	$2.18
Rate for Payer: United Healthcare Commercial	$2.80

buPROPion 150 mg/24 hours ER Tab [VDMC]

Facility

$4.43

Service Code	HCPCS A9270
Hospital Charge Code	10372414
Hospital Revenue Code	259
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$3.99
Rate for Payer: Aetna of IA Commercial	$3.99
Rate for Payer: Aetna of IA Medical Rental Products	$3.99
Rate for Payer: Aetna of IA Medicare	$2.53
Rate for Payer: Amerigroup Medicaid	$2.56
Rate for Payer: Amerigroup Medicare	$2.01
Rate for Payer: Cash Price	$3.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.99
Rate for Payer: Iowa Total Care Managed Medicaid	$2.53
Rate for Payer: Medical Associates Commercial	$3.32
Rate for Payer: Medical Associates Managed Medicare	$1.99
Rate for Payer: Midlands Choice Commercial	$3.10
Rate for Payer: Molina Healthcare Managed Medicaid	$2.57
Rate for Payer: Partners Health Alliance Commercial	$2.29
Rate for Payer: United Healthcare Commercial	$3.99
Rate for Payer: United Healthcare Managed Medicare	$2.62

buPROPion 150 mg/24 hours ER Tab [VDMC]

Facility

$4.43

Service Code	HCPCS A9270
Hospital Charge Code	10372414
Hospital Revenue Code	259
Min. Negotiated Rate	$3.10
Max. Negotiated Rate	$3.99
Rate for Payer: Aetna of IA Commercial	$3.99
Rate for Payer: Aetna of IA Medical Rental Products	$3.99
Rate for Payer: Cash Price	$3.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.32
Rate for Payer: Medical Associates Commercial	$3.32
Rate for Payer: Midlands Choice Commercial	$3.10
Rate for Payer: United Healthcare Commercial	$3.99

buPROPion 150 mg ER Tab/12 HR [VDMC]

Facility

$2.26

Service Code	HCPCS A9270
Hospital Charge Code	10372343
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna of IA Commercial	$2.04
Rate for Payer: Aetna of IA Medical Rental Products	$2.04
Rate for Payer: Aetna of IA Medicare	$1.29
Rate for Payer: Amerigroup Medicaid	$1.30
Rate for Payer: Amerigroup Medicare	$1.03
Rate for Payer: Cash Price	$1.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.70
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.02
Rate for Payer: Iowa Total Care Managed Medicaid	$1.29
Rate for Payer: Medical Associates Commercial	$1.70
Rate for Payer: Medical Associates Managed Medicare	$1.02
Rate for Payer: Midlands Choice Commercial	$1.58
Rate for Payer: Molina Healthcare Managed Medicaid	$1.31
Rate for Payer: Partners Health Alliance Commercial	$1.17
Rate for Payer: United Healthcare Commercial	$2.04
Rate for Payer: United Healthcare Managed Medicare	$1.33

buPROPion 150 mg ER Tab/12 HR [VDMC]

Facility

$2.26

Service Code	HCPCS A9270
Hospital Charge Code	10372343
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna of IA Commercial	$2.04
Rate for Payer: Aetna of IA Medical Rental Products	$2.04
Rate for Payer: Cash Price	$1.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.70
Rate for Payer: Medical Associates Commercial	$1.70
Rate for Payer: Midlands Choice Commercial	$1.58
Rate for Payer: United Healthcare Commercial	$2.04

busPIRone 5 mg Tab [VDMC]

Facility

$1.33

Service Code	HCPCS A9270
Hospital Charge Code	10372556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Aetna of IA Medicare	$0.76
Rate for Payer: Amerigroup Medicaid	$0.77
Rate for Payer: Amerigroup Medicare	$0.61
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.60
Rate for Payer: Iowa Total Care Managed Medicaid	$0.76
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Medical Associates Managed Medicare	$0.60
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: Molina Healthcare Managed Medicaid	$0.77
Rate for Payer: Partners Health Alliance Commercial	$0.69
Rate for Payer: United Healthcare Commercial	$1.20
Rate for Payer: United Healthcare Managed Medicare	$0.79

busPIRone 5 mg Tab [VDMC]

Facility

$1.33

Service Code	HCPCS A9270
Hospital Charge Code	10372556
Hospital Revenue Code	259
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: United Healthcare Commercial	$1.20

BX of cervix single/multiple w or w/o fulguration (removal cervical polyp)

Professional

Both

$422.00

Service Code	CPT 57500
Hospital Charge Code	8378890
Hospital Revenue Code	975
Min. Negotiated Rate	$216.40
Max. Negotiated Rate	$316.50
Rate for Payer: Cash Price	$337.60
Rate for Payer: Cash Price	$337.60
Rate for Payer: Medical Associates Commercial	$316.50
Rate for Payer: Midlands Choice Commercial	$295.40
Rate for Payer: Partners Health Alliance Commercial	$316.50
Rate for Payer: United Healthcare Commercial	$216.40

CA 125 DMCL

Facility

$170.00

Service Code	CPT 86304
Hospital Charge Code	8037505
Hospital Revenue Code	302
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of IA Commercial	$153.00
Rate for Payer: Aetna of IA Medical Rental Products	$153.00
Rate for Payer: Aetna of IA Medicare	$96.90
Rate for Payer: Amerigroup Medicaid	$98.06
Rate for Payer: Amerigroup Medicare	$77.27
Rate for Payer: Cash Price	$136.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$127.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.50
Rate for Payer: Iowa Total Care Managed Medicaid	$97.10
Rate for Payer: Medical Associates Commercial	$127.50
Rate for Payer: Medical Associates Managed Medicare	$76.50
Rate for Payer: Midlands Choice Commercial	$119.00
Rate for Payer: Molina Healthcare Managed Medicaid	$98.53
Rate for Payer: Partners Health Alliance Commercial	$87.97
Rate for Payer: United Healthcare Commercial	$153.00
Rate for Payer: United Healthcare Managed Medicare	$100.30

CA 125 DMCL

Facility

$170.00

Service Code	CPT 86304
Hospital Charge Code	8037505
Hospital Revenue Code	302
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of IA Commercial	$153.00
Rate for Payer: Aetna of IA Medical Rental Products	$153.00
Rate for Payer: Cash Price	$136.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$127.50
Rate for Payer: Medical Associates Commercial	$127.50
Rate for Payer: Midlands Choice Commercial	$119.00
Rate for Payer: United Healthcare Commercial	$153.00

CA 15 3 DMCL

Facility

$82.00

Service Code	CPT 86300
Hospital Charge Code	8519168
Hospital Revenue Code	301
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$47.30
Rate for Payer: Amerigroup Medicare	$37.27
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.90
Rate for Payer: Iowa Total Care Managed Medicaid	$46.84
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$36.90
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$47.53
Rate for Payer: Partners Health Alliance Commercial	$42.44
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38

CA 15 3 DMCL

Facility

$82.00

Service Code	CPT 86300
Hospital Charge Code	8519168
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

CA 19 9 DMCL

Facility

$170.00

Service Code	CPT 86301
Hospital Charge Code	8037506
Hospital Revenue Code	302
Min. Negotiated Rate	$119.00
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of IA Commercial	$153.00
Rate for Payer: Aetna of IA Medical Rental Products	$153.00
Rate for Payer: Cash Price	$136.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$127.50
Rate for Payer: Medical Associates Commercial	$127.50
Rate for Payer: Midlands Choice Commercial	$119.00
Rate for Payer: United Healthcare Commercial	$153.00

CA 19 9 DMCL

Facility

$170.00

Service Code	CPT 86301
Hospital Charge Code	8037506
Hospital Revenue Code	302
Min. Negotiated Rate	$76.50
Max. Negotiated Rate	$153.00
Rate for Payer: Aetna of IA Commercial	$153.00
Rate for Payer: Aetna of IA Medical Rental Products	$153.00
Rate for Payer: Aetna of IA Medicare	$96.90
Rate for Payer: Amerigroup Medicaid	$98.06
Rate for Payer: Amerigroup Medicare	$77.27
Rate for Payer: Cash Price	$136.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$127.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.50
Rate for Payer: Iowa Total Care Managed Medicaid	$97.10
Rate for Payer: Medical Associates Commercial	$127.50
Rate for Payer: Medical Associates Managed Medicare	$76.50
Rate for Payer: Midlands Choice Commercial	$119.00
Rate for Payer: Molina Healthcare Managed Medicaid	$98.53
Rate for Payer: Partners Health Alliance Commercial	$87.97
Rate for Payer: United Healthcare Commercial	$153.00
Rate for Payer: United Healthcare Managed Medicare	$100.30

CA 27.29 DMCL

Facility

$82.00

Service Code	CPT 86300
Hospital Charge Code	8519159
Hospital Revenue Code	301
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$47.30
Rate for Payer: Amerigroup Medicare	$37.27
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.90
Rate for Payer: Iowa Total Care Managed Medicaid	$46.84
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$36.90
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$47.53
Rate for Payer: Partners Health Alliance Commercial	$42.44
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38

CA 27.29 DMCL

Facility

$82.00

Service Code	CPT 86300
Hospital Charge Code	8519159
Hospital Revenue Code	301
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

CABLE PLUGS FOR 4.0 MM LOCKING SCREWS

Facility

$57.00

Service Code	HCPCS C1713
Hospital Charge Code	8046631
Hospital Revenue Code	278
Min. Negotiated Rate	$25.65
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of IA Commercial	$51.30
Rate for Payer: Aetna of IA Medical Rental Products	$51.30
Rate for Payer: Aetna of IA Medicare	$32.49
Rate for Payer: Amerigroup Medicaid	$32.88
Rate for Payer: Amerigroup Medicare	$25.91
Rate for Payer: Cash Price	$45.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.65
Rate for Payer: Iowa Total Care Managed Medicaid	$32.56
Rate for Payer: Medical Associates Commercial	$42.75
Rate for Payer: Medical Associates Managed Medicare	$25.65
Rate for Payer: Midlands Choice Commercial	$39.90
Rate for Payer: Molina Healthcare Managed Medicaid	$33.04
Rate for Payer: Partners Health Alliance Commercial	$29.50
Rate for Payer: United Healthcare Commercial	$51.30
Rate for Payer: United Healthcare Managed Medicare	$33.63

CABLE PLUGS FOR 4.0 MM LOCKING SCREWS

Facility

$57.00

Service Code	HCPCS C1713
Hospital Charge Code	8046631
Hospital Revenue Code	278
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of IA Commercial	$51.30
Rate for Payer: Aetna of IA Medical Rental Products	$51.30
Rate for Payer: Cash Price	$45.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.75
Rate for Payer: Medical Associates Commercial	$42.75
Rate for Payer: Midlands Choice Commercial	$39.90
Rate for Payer: United Healthcare Commercial	$51.30

CADEXOMER IODINE GEL 40G 11.4 OZ

Facility

$126.00

Service Code	HCPCS A6261
Hospital Charge Code	8013712
Hospital Revenue Code	272
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna of IA Commercial	$113.40
Rate for Payer: Aetna of IA Medical Rental Products	$113.40
Rate for Payer: Aetna of IA Medicare	$71.82
Rate for Payer: Amerigroup Medicaid	$72.68
Rate for Payer: Amerigroup Medicare	$57.27
Rate for Payer: Cash Price	$100.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$94.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$56.70
Rate for Payer: Iowa Total Care Managed Medicaid	$71.97
Rate for Payer: Medical Associates Commercial	$94.50
Rate for Payer: Medical Associates Managed Medicare	$56.70
Rate for Payer: Midlands Choice Commercial	$88.20
Rate for Payer: Molina Healthcare Managed Medicaid	$73.03
Rate for Payer: Partners Health Alliance Commercial	$65.20
Rate for Payer: United Healthcare Commercial	$113.40
Rate for Payer: United Healthcare Managed Medicare	$74.34

CADEXOMER IODINE GEL 40G 11.4 OZ

Facility

$126.00

Service Code	HCPCS A6261
Hospital Charge Code	8013712
Hospital Revenue Code	272
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$113.40
Rate for Payer: Aetna of IA Commercial	$113.40
Rate for Payer: Aetna of IA Medical Rental Products	$113.40
Rate for Payer: Cash Price	$100.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$94.50
Rate for Payer: Medical Associates Commercial	$94.50
Rate for Payer: Midlands Choice Commercial	$88.20
Rate for Payer: United Healthcare Commercial	$113.40

Know your out-of-pocket cost for care.

All Charges