Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

EXC TR-EXT B9+MARG 2.1-3CM/<

Facility

$750.00

Service Code	CPT 11403
Hospital Charge Code	7982982
Hospital Revenue Code	510
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna of IA Commercial	$675.00
Rate for Payer: Aetna of IA Medical Rental Products	$675.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$562.50
Rate for Payer: Medical Associates Commercial	$562.50
Rate for Payer: Midlands Choice Commercial	$525.00
Rate for Payer: United Healthcare Commercial	$675.00

EXC TR-EXT B9+MARG 3.1-4 CM

Facility

$652.00

Service Code	CPT 11404
Hospital Charge Code	7982981
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$2,975.61
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$2,701.29
Rate for Payer: Wellmark IA PPO	$2,975.61

EXC TR-EXT B9+MARG 3.1-4 CM

Facility

$652.00

Service Code	CPT 11404
Hospital Charge Code	7982981
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 B9+MARG >4.0 CM

Facility

$2,120.00

Service Code	CPT 11406
Hospital Charge Code	7982980
Hospital Revenue Code	450
Min. Negotiated Rate	$954.00
Max. Negotiated Rate	$5,511.52
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

EXC TR-EXT B9+MARG >4.0 CM

Facility

$2,120.00

Service Code	CPT 11406
Hospital Charge Code	7982980
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

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 0.5 CM/<

Facility

$652.00

Service Code	CPT 11600
Hospital Charge Code	7982959
Hospital Revenue Code	450
Min. Negotiated Rate	$293.40
Max. Negotiated Rate	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

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	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

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 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	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

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	$903.62
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$820.31
Rate for Payer: Wellmark IA PPO	$903.62

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	$2,975.61
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$2,701.29
Rate for Payer: Wellmark IA PPO	$2,975.61

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	$242.46
Max. Negotiated Rate	$1,120.50
Rate for Payer: Amerigroup Medicaid	$244.84
Rate for Payer: Cash Price	$1,195.20
Rate for Payer: Cash Price	$1,195.20
Rate for Payer: Iowa Total Care Managed Medicaid	$242.46
Rate for Payer: Medical Associates Commercial	$1,120.50
Rate for Payer: Midlands Choice Commercial	$1,045.80
Rate for Payer: Molina Healthcare Managed Medicaid	$243.65
Rate for Payer: Partners Health Alliance Commercial	$1,120.50
Rate for Payer: United Healthcare Commercial	$675.82
Rate for Payer: Wellmark IA HMO WHPI	$819.90
Rate for Payer: Wellmark IA PPO	$964.50

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	$5,511.52
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$5,003.41
Rate for Payer: Wellmark IA PPO	$5,511.52

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	$7,382.01
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: 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	$1,584.58
Rate for Payer: United Healthcare Commercial	$2,755.80
Rate for Payer: United Healthcare Managed Medicare	$1,806.58
Rate for Payer: Wellmark IA HMO WHPI	$6,701.47
Rate for Payer: Wellmark IA PPO	$7,382.01

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT

Facility

$25,426.81

Service Code	MSDRG 933
Min. Negotiated Rate	$25,058.30
Max. Negotiated Rate	$25,426.81
Rate for Payer: Amerigroup Medicaid	$25,303.97
Rate for Payer: Iowa Total Care Managed Medicaid	$25,058.30
Rate for Payer: Molina Healthcare Managed Medicaid	$25,426.81

EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT

Facility

$236,863.90

Service Code	MSDRG 927
Min. Negotiated Rate	$233,430.99
Max. Negotiated Rate	$236,863.90
Rate for Payer: Amerigroup Medicaid	$235,719.52
Rate for Payer: Iowa Total Care Managed Medicaid	$233,430.99
Rate for Payer: Molina Healthcare Managed Medicaid	$236,863.90

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC

Facility

$17,941.32

Service Code	MSDRG 982
Min. Negotiated Rate	$17,681.29
Max. Negotiated Rate	$17,941.32
Rate for Payer: Amerigroup Medicaid	$17,854.64
Rate for Payer: Iowa Total Care Managed Medicaid	$17,681.29
Rate for Payer: Molina Healthcare Managed Medicaid	$17,941.32

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$46,697.64

Service Code	MSDRG 981
Min. Negotiated Rate	$46,020.85
Max. Negotiated Rate	$46,697.64
Rate for Payer: Amerigroup Medicaid	$46,472.03
Rate for Payer: Iowa Total Care Managed Medicaid	$46,020.85
Rate for Payer: Molina Healthcare Managed Medicaid	$46,697.64

EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$13,611.94

Service Code	MSDRG 983
Min. Negotiated Rate	$13,414.66
Max. Negotiated Rate	$13,611.94
Rate for Payer: Amerigroup Medicaid	$13,546.17
Rate for Payer: Iowa Total Care Managed Medicaid	$13,414.66
Rate for Payer: Molina Healthcare Managed Medicaid	$13,611.94

Know your out-of-pocket cost for care.

All Charges