Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

EXC TR-EXT MAL+MARG 0.5 CM/<

Facility

$652.00

Service Code	CPT 11600
Hospital Charge Code	7982959
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: United Healthcare Commercial	$586.80

EXC TR-EXT MAL+MARG 0.6-1 CM

Facility

$652.00

Service Code	CPT 11601
Hospital Charge Code	7982958
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: United Healthcare Commercial	$586.80

EXC TR-EXT MAL+MARG 0.6-1 CM

Facility

$652.00

Service Code	CPT 11601
Hospital Charge Code	7982958
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Aetna of IA Medicare	$371.64
Rate for Payer: Amerigroup Medicaid	$376.07
Rate for Payer: Amerigroup Medicare	$296.33
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$293.40
Rate for Payer: Iowa Total Care Managed Medicaid	$372.42
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Medical Associates Managed Medicare	$293.40
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: Molina Healthcare Managed Medicaid	$377.90
Rate for Payer: Partners Health Alliance Commercial	$337.41
Rate for Payer: United Healthcare Commercial	$586.80
Rate for Payer: United Healthcare Managed Medicare	$384.68

EXC TR-EXT MAL+MARG 1.1-2 CM

Facility

$815.00

Service Code	CPT 11602
Hospital Charge Code	7982957
Hospital Revenue Code	450
Min. Negotiated Rate	$366.75
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Aetna of IA Medicare	$464.55
Rate for Payer: Amerigroup Medicaid	$470.09
Rate for Payer: Amerigroup Medicare	$370.42
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$366.75
Rate for Payer: Iowa Total Care Managed Medicaid	$465.53
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Medical Associates Managed Medicare	$366.75
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: Molina Healthcare Managed Medicaid	$472.37
Rate for Payer: Partners Health Alliance Commercial	$421.76
Rate for Payer: United Healthcare Commercial	$733.50
Rate for Payer: United Healthcare Managed Medicare	$480.85

EXC TR-EXT MAL+MARG 1.1-2 CM

Facility

$815.00

Service Code	CPT 11602
Hospital Charge Code	7982957
Hospital Revenue Code	450
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: United Healthcare Commercial	$733.50

EXC TR-EXT MAL+MARG 2.1-3 CM

Facility

$652.00

Service Code	CPT 11603
Hospital Charge Code	7982956
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Aetna of IA Medicare	$371.64
Rate for Payer: Amerigroup Medicaid	$376.07
Rate for Payer: Amerigroup Medicare	$296.33
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$293.40
Rate for Payer: Iowa Total Care Managed Medicaid	$372.42
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Medical Associates Managed Medicare	$293.40
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: Molina Healthcare Managed Medicaid	$377.90
Rate for Payer: Partners Health Alliance Commercial	$337.41
Rate for Payer: United Healthcare Commercial	$586.80
Rate for Payer: United Healthcare Managed Medicare	$384.68

EXC TR-EXT MAL+MARG 2.1-3 CM

Facility

$652.00

Service Code	CPT 11603
Hospital Charge Code	7982956
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: United Healthcare Commercial	$586.80

EXC TR-EXT MAL+MARG 3.1-4 CM

Facility

$652.00

Service Code	CPT 11604
Hospital Charge Code	7982955
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Aetna of IA Medicare	$371.64
Rate for Payer: Amerigroup Medicaid	$376.07
Rate for Payer: Amerigroup Medicare	$296.33
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$293.40
Rate for Payer: Iowa Total Care Managed Medicaid	$372.42
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Medical Associates Managed Medicare	$293.40
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: Molina Healthcare Managed Medicaid	$377.90
Rate for Payer: Partners Health Alliance Commercial	$337.41
Rate for Payer: United Healthcare Commercial	$586.80
Rate for Payer: United Healthcare Managed Medicare	$384.68

EXC TR-EXT MAL+MARG 3.1-4 CM

Facility

$652.00

Service Code	CPT 11604
Hospital Charge Code	7982955
Hospital Revenue Code	450
Min. Negotiated Rate	$456.40
Max. Negotiated Rate	$586.80
Rate for Payer: Aetna of IA Commercial	$586.80
Rate for Payer: Aetna of IA Medical Rental Products	$586.80
Rate for Payer: Cash Price	$521.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$489.00
Rate for Payer: Medical Associates Commercial	$489.00
Rate for Payer: Midlands Choice Commercial	$456.40
Rate for Payer: United Healthcare Commercial	$586.80

EXC TR-EXT MAL+MARG > 4 CM

Professional

Both

$1,494.00

Service Code	CPT 11606
Hospital Charge Code	8069148
Hospital Revenue Code	975
Min. Negotiated Rate	$675.82
Max. Negotiated Rate	$1,120.50
Rate for Payer: Cash Price	$1,195.20
Rate for Payer: Cash Price	$1,195.20
Rate for Payer: Medical Associates Commercial	$1,120.50
Rate for Payer: Midlands Choice Commercial	$1,045.80
Rate for Payer: Partners Health Alliance Commercial	$1,120.50
Rate for Payer: United Healthcare Commercial	$675.82

EXC TR-EXT MAL+MARG >4 CM

Facility

$2,120.00

Service Code	CPT 11606
Hospital Charge Code	7982954
Hospital Revenue Code	450
Min. Negotiated Rate	$954.00
Max. Negotiated Rate	$1,908.00
Rate for Payer: Aetna of IA Commercial	$1,908.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,908.00
Rate for Payer: Aetna of IA Medicare	$1,208.40
Rate for Payer: Amerigroup Medicaid	$1,222.82
Rate for Payer: Amerigroup Medicare	$963.54
Rate for Payer: Cash Price	$1,696.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,590.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$954.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,210.94
Rate for Payer: Medical Associates Commercial	$1,590.00
Rate for Payer: Medical Associates Managed Medicare	$954.00
Rate for Payer: Midlands Choice Commercial	$1,484.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,228.75
Rate for Payer: Partners Health Alliance Commercial	$1,097.10
Rate for Payer: United Healthcare Commercial	$1,908.00
Rate for Payer: United Healthcare Managed Medicare	$1,250.80

EXC TR-EXT MAL+MARG >4 CM

Facility

$2,120.00

Service Code	CPT 11606
Hospital Charge Code	7982954
Hospital Revenue Code	450
Min. Negotiated Rate	$1,484.00
Max. Negotiated Rate	$1,908.00
Rate for Payer: Aetna of IA Commercial	$1,908.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,908.00
Rate for Payer: Cash Price	$1,696.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,590.00
Rate for Payer: Medical Associates Commercial	$1,590.00
Rate for Payer: Midlands Choice Commercial	$1,484.00
Rate for Payer: United Healthcare Commercial	$1,908.00

EXPLORATION OF KNEE JOINT

Facility

$3,062.00

Service Code	CPT 27310
Hospital Charge Code	7983049
Hospital Revenue Code	450
Min. Negotiated Rate	$2,143.40
Max. Negotiated Rate	$2,755.80
Rate for Payer: Aetna of IA Commercial	$2,755.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,755.80
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,296.50
Rate for Payer: Medical Associates Commercial	$2,296.50
Rate for Payer: Midlands Choice Commercial	$2,143.40
Rate for Payer: United Healthcare Commercial	$2,755.80

EXPLORATION OF KNEE JOINT

Facility

$3,062.00

Service Code	CPT 27310
Hospital Charge Code	7983049
Hospital Revenue Code	450
Min. Negotiated Rate	$1,377.90
Max. Negotiated Rate	$2,755.80
Rate for Payer: Aetna of IA Commercial	$2,755.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,755.80
Rate for Payer: Aetna of IA Medicare	$1,745.34
Rate for Payer: Amerigroup Medicaid	$1,766.16
Rate for Payer: Amerigroup Medicare	$1,391.68
Rate for Payer: Cash Price	$2,449.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,296.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,377.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1,749.01
Rate for Payer: Medical Associates Commercial	$2,296.50
Rate for Payer: Medical Associates Managed Medicare	$1,377.90
Rate for Payer: Midlands Choice Commercial	$2,143.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,774.74
Rate for Payer: Partners Health Alliance Commercial	$1,584.59
Rate for Payer: United Healthcare Commercial	$2,755.80
Rate for Payer: United Healthcare Managed Medicare	$1,806.58

EXTERNAL CEPHALIC VERSION

Facility

$3,594.00

Service Code	CPT 59412
Hospital Charge Code	7984752
Hospital Revenue Code	721
Min. Negotiated Rate	$1,617.30
Max. Negotiated Rate	$3,234.60
Rate for Payer: Aetna of IA Commercial	$3,234.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,234.60
Rate for Payer: Aetna of IA Medicare	$2,048.58
Rate for Payer: Amerigroup Medicaid	$2,073.02
Rate for Payer: Amerigroup Medicare	$1,633.47
Rate for Payer: Cash Price	$2,875.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,695.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,617.30
Rate for Payer: Iowa Total Care Managed Medicaid	$2,052.89
Rate for Payer: Medical Associates Commercial	$2,695.50
Rate for Payer: Medical Associates Managed Medicare	$1,617.30
Rate for Payer: Midlands Choice Commercial	$2,515.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2,083.08
Rate for Payer: Partners Health Alliance Commercial	$1,859.89
Rate for Payer: United Healthcare Commercial	$3,234.60
Rate for Payer: United Healthcare Managed Medicare	$2,120.46

EXTERNAL CEPHALIC VERSION

Facility

$3,594.00

Service Code	CPT 59412
Hospital Charge Code	7984752
Hospital Revenue Code	721
Min. Negotiated Rate	$2,515.80
Max. Negotiated Rate	$3,234.60
Rate for Payer: Aetna of IA Commercial	$3,234.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,234.60
Rate for Payer: Cash Price	$2,875.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,695.50
Rate for Payer: Medical Associates Commercial	$2,695.50
Rate for Payer: Midlands Choice Commercial	$2,515.80
Rate for Payer: United Healthcare Commercial	$3,234.60

EXTRA ATTENDANT- SAFETY REASONS

Facility

$84.00

Service Code	HCPCS A0424 QN
Hospital Charge Code	7932764
Hospital Revenue Code	540
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of IA Commercial	$75.60
Rate for Payer: Aetna of IA Medical Rental Products	$75.60
Rate for Payer: Cash Price	$67.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.00
Rate for Payer: Medical Associates Commercial	$63.00
Rate for Payer: Midlands Choice Commercial	$58.80
Rate for Payer: United Healthcare Commercial	$75.60

EXTRA ATTENDANT- SAFETY REASONS

Facility

$84.00

Service Code	HCPCS A0424 QN
Hospital Charge Code	7932764
Hospital Revenue Code	540
Min. Negotiated Rate	$37.80
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of IA Commercial	$75.60
Rate for Payer: Aetna of IA Medical Rental Products	$75.60
Rate for Payer: Aetna of IA Medicare	$47.88
Rate for Payer: Amerigroup Medicaid	$48.45
Rate for Payer: Amerigroup Medicare	$38.18
Rate for Payer: Cash Price	$67.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$37.80
Rate for Payer: Iowa Total Care Managed Medicaid	$47.98
Rate for Payer: Medical Associates Commercial	$63.00
Rate for Payer: Medical Associates Managed Medicare	$37.80
Rate for Payer: Midlands Choice Commercial	$58.80
Rate for Payer: Molina Healthcare Managed Medicaid	$48.69
Rate for Payer: Partners Health Alliance Commercial	$43.47
Rate for Payer: United Healthcare Commercial	$75.60
Rate for Payer: United Healthcare Managed Medicare	$71.40

Extractable Nuclear Antigen Ab DMCL

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8037843
Hospital Revenue Code	302
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$58.99
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26

Extractable Nuclear Antigen Ab DMCL

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8037843
Hospital Revenue Code	302
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

EXTRACTABLE NUCLEAR ANTIGEN OR ANTIBODY

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8093932
Hospital Revenue Code	302
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

EXTRACTABLE NUCLEAR ANTIGEN OR ANTIBODY

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8093932
Hospital Revenue Code	302
Min. Negotiated Rate	$51.30
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$58.99
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26

ezetimibe 10 mg Tab [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10387879
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Aetna of IA Medicare	$0.85
Rate for Payer: Amerigroup Medicaid	$0.86
Rate for Payer: Amerigroup Medicare	$0.68
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.67
Rate for Payer: Iowa Total Care Managed Medicaid	$0.85
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Medical Associates Managed Medicare	$0.67
Rate for Payer: Midlands Choice Commercial	$1.05
Rate for Payer: Molina Healthcare Managed Medicaid	$0.87
Rate for Payer: Partners Health Alliance Commercial	$0.77
Rate for Payer: United Healthcare Commercial	$1.34
Rate for Payer: United Healthcare Managed Medicare	$0.88

ezetimibe 10 mg Tab [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10387879
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Midlands Choice Commercial	$1.05
Rate for Payer: United Healthcare Commercial	$1.34

Factor V Leiden DMCL

Facility

$220.00

Service Code	CPT 81241
Hospital Charge Code	8037844
Hospital Revenue Code	301
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

Know your out-of-pocket cost for care.

All Charges