Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Hepatitis B Core Antibody Total DMCL

Facility

$98.00

Service Code	CPT 86704
Hospital Charge Code	8037861
Hospital Revenue Code	302
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

Hepatitis B Core Antibody Total DMCL

Facility

$98.00

Service Code	CPT 86704
Hospital Charge Code	8037861
Hospital Revenue Code	302
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

Hepatitis Be Antibody DMCL

Facility

$86.00

Service Code	CPT 86707
Hospital Charge Code	8037864
Hospital Revenue Code	302
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Aetna of IA Medicare	$49.02
Rate for Payer: Amerigroup Medicaid	$49.60
Rate for Payer: Amerigroup Medicare	$39.09
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.70
Rate for Payer: Iowa Total Care Managed Medicaid	$49.12
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Medical Associates Managed Medicare	$38.70
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: Molina Healthcare Managed Medicaid	$49.85
Rate for Payer: Partners Health Alliance Commercial	$44.51
Rate for Payer: United Healthcare Commercial	$77.40
Rate for Payer: United Healthcare Managed Medicare	$50.74

Hepatitis Be Antibody DMCL

Facility

$86.00

Service Code	CPT 86707
Hospital Charge Code	8037864
Hospital Revenue Code	302
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: United Healthcare Commercial	$77.40

Hepatitis Be Antigen DMCL

Facility

$86.00

Service Code	CPT 87350
Hospital Charge Code	8037865
Hospital Revenue Code	302
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: United Healthcare Commercial	$77.40

Hepatitis Be Antigen DMCL

Facility

$86.00

Service Code	CPT 87350
Hospital Charge Code	8037865
Hospital Revenue Code	302
Min. Negotiated Rate	$38.70
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Aetna of IA Medicare	$49.02
Rate for Payer: Amerigroup Medicaid	$49.60
Rate for Payer: Amerigroup Medicare	$39.09
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.70
Rate for Payer: Iowa Total Care Managed Medicaid	$49.12
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Medical Associates Managed Medicare	$38.70
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: Molina Healthcare Managed Medicaid	$49.85
Rate for Payer: Partners Health Alliance Commercial	$44.51
Rate for Payer: United Healthcare Commercial	$77.40
Rate for Payer: United Healthcare Managed Medicare	$50.74

hepatitis B immune globulin IM Sol 1 mL [VDMC]

Facility

$298.48

Service Code	HCPCS 90371
Hospital Charge Code	10393420
Hospital Revenue Code	259
Min. Negotiated Rate	$208.94
Max. Negotiated Rate	$268.63
Rate for Payer: Aetna of IA Commercial	$268.63
Rate for Payer: Aetna of IA Medical Rental Products	$268.63
Rate for Payer: Cash Price	$238.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$223.86
Rate for Payer: Medical Associates Commercial	$223.86
Rate for Payer: Midlands Choice Commercial	$208.94
Rate for Payer: United Healthcare Commercial	$268.63

hepatitis B immune globulin IM Sol 1 mL [VDMC]

Facility

$298.48

Service Code	HCPCS 90371
Hospital Charge Code	10393420
Hospital Revenue Code	259
Min. Negotiated Rate	$134.32
Max. Negotiated Rate	$268.63
Rate for Payer: Aetna of IA Commercial	$268.63
Rate for Payer: Aetna of IA Medical Rental Products	$268.63
Rate for Payer: Aetna of IA Medicare	$170.13
Rate for Payer: Amerigroup Medicaid	$172.16
Rate for Payer: Amerigroup Medicare	$135.66
Rate for Payer: Cash Price	$238.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$223.86
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$134.32
Rate for Payer: Iowa Total Care Managed Medicaid	$170.49
Rate for Payer: Medical Associates Commercial	$223.86
Rate for Payer: Medical Associates Managed Medicare	$134.32
Rate for Payer: Midlands Choice Commercial	$208.94
Rate for Payer: Molina Healthcare Managed Medicaid	$173.00
Rate for Payer: Partners Health Alliance Commercial	$154.46
Rate for Payer: United Healthcare Commercial	$268.63
Rate for Payer: United Healthcare Managed Medicare	$176.10

hepatitis B pediatric vaccine 10 mcg/0.5 mL Sus [VDMC]

Facility

$57.72

Service Code	HCPCS 90744
Hospital Charge Code	10393487
Hospital Revenue Code	259
Min. Negotiated Rate	$40.40
Max. Negotiated Rate	$51.95
Rate for Payer: Aetna of IA Commercial	$51.95
Rate for Payer: Aetna of IA Medical Rental Products	$51.95
Rate for Payer: Cash Price	$46.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.29
Rate for Payer: Medical Associates Commercial	$43.29
Rate for Payer: Midlands Choice Commercial	$40.40
Rate for Payer: United Healthcare Commercial	$51.95

hepatitis B pediatric vaccine 10 mcg/0.5 mL Sus [VDMC]

Facility

$57.72

Service Code	HCPCS 90744
Hospital Charge Code	10393487
Hospital Revenue Code	259
Min. Negotiated Rate	$25.97
Max. Negotiated Rate	$51.95
Rate for Payer: Aetna of IA Commercial	$51.95
Rate for Payer: Aetna of IA Medical Rental Products	$51.95
Rate for Payer: Aetna of IA Medicare	$32.90
Rate for Payer: Amerigroup Medicaid	$33.29
Rate for Payer: Amerigroup Medicare	$26.23
Rate for Payer: Cash Price	$46.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.29
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.97
Rate for Payer: Iowa Total Care Managed Medicaid	$32.97
Rate for Payer: Medical Associates Commercial	$43.29
Rate for Payer: Medical Associates Managed Medicare	$25.97
Rate for Payer: Midlands Choice Commercial	$40.40
Rate for Payer: Molina Healthcare Managed Medicaid	$33.45
Rate for Payer: Partners Health Alliance Commercial	$29.87
Rate for Payer: United Healthcare Commercial	$51.95
Rate for Payer: United Healthcare Managed Medicare	$34.05

Hepatitis B Surface Antibody DMCL

Facility

$88.00

Service Code	CPT 86706
Hospital Charge Code	8505640
Hospital Revenue Code	302
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of IA Commercial	$79.20
Rate for Payer: Aetna of IA Medical Rental Products	$79.20
Rate for Payer: Aetna of IA Medicare	$50.16
Rate for Payer: Amerigroup Medicaid	$50.76
Rate for Payer: Amerigroup Medicare	$40.00
Rate for Payer: Cash Price	$70.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$39.60
Rate for Payer: Iowa Total Care Managed Medicaid	$50.27
Rate for Payer: Medical Associates Commercial	$66.00
Rate for Payer: Medical Associates Managed Medicare	$39.60
Rate for Payer: Midlands Choice Commercial	$61.60
Rate for Payer: Molina Healthcare Managed Medicaid	$51.00
Rate for Payer: Partners Health Alliance Commercial	$45.54
Rate for Payer: United Healthcare Commercial	$79.20
Rate for Payer: United Healthcare Managed Medicare	$51.92

Hepatitis B Surface Antibody DMCL

Facility

$88.00

Service Code	CPT 86706
Hospital Charge Code	8505640
Hospital Revenue Code	302
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of IA Commercial	$79.20
Rate for Payer: Aetna of IA Medical Rental Products	$79.20
Rate for Payer: Cash Price	$70.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.00
Rate for Payer: Medical Associates Commercial	$66.00
Rate for Payer: Midlands Choice Commercial	$61.60
Rate for Payer: United Healthcare Commercial	$79.20

Hepatitis B Surface Antigen DMCL

Facility

$92.00

Service Code	CPT 87340
Hospital Charge Code	8037863
Hospital Revenue Code	302
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of IA Commercial	$82.80
Rate for Payer: Aetna of IA Medical Rental Products	$82.80
Rate for Payer: Cash Price	$73.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.00
Rate for Payer: Medical Associates Commercial	$69.00
Rate for Payer: Midlands Choice Commercial	$64.40
Rate for Payer: United Healthcare Commercial	$82.80

Hepatitis B Surface Antigen DMCL

Facility

$92.00

Service Code	CPT 87340
Hospital Charge Code	8037863
Hospital Revenue Code	302
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of IA Commercial	$82.80
Rate for Payer: Aetna of IA Medical Rental Products	$82.80
Rate for Payer: Aetna of IA Medicare	$52.44
Rate for Payer: Amerigroup Medicaid	$53.07
Rate for Payer: Amerigroup Medicare	$41.81
Rate for Payer: Cash Price	$73.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.40
Rate for Payer: Iowa Total Care Managed Medicaid	$52.55
Rate for Payer: Medical Associates Commercial	$69.00
Rate for Payer: Medical Associates Managed Medicare	$41.40
Rate for Payer: Midlands Choice Commercial	$64.40
Rate for Payer: Molina Healthcare Managed Medicaid	$53.32
Rate for Payer: Partners Health Alliance Commercial	$47.61
Rate for Payer: United Healthcare Commercial	$82.80
Rate for Payer: United Healthcare Managed Medicare	$54.28

Hepatitis C Antibody Screen DMCL

Facility

$117.00

Service Code	CPT 86803
Hospital Charge Code	8037866
Hospital Revenue Code	302
Min. Negotiated Rate	$81.90
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna of IA Commercial	$105.30
Rate for Payer: Aetna of IA Medical Rental Products	$105.30
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$87.75
Rate for Payer: Medical Associates Commercial	$87.75
Rate for Payer: Midlands Choice Commercial	$81.90
Rate for Payer: United Healthcare Commercial	$105.30

Hepatitis C Antibody Screen DMCL

Facility

$117.00

Service Code	CPT 86803
Hospital Charge Code	8037866
Hospital Revenue Code	302
Min. Negotiated Rate	$52.65
Max. Negotiated Rate	$105.30
Rate for Payer: Aetna of IA Commercial	$105.30
Rate for Payer: Aetna of IA Medical Rental Products	$105.30
Rate for Payer: Aetna of IA Medicare	$66.69
Rate for Payer: Amerigroup Medicaid	$67.49
Rate for Payer: Amerigroup Medicare	$53.18
Rate for Payer: Cash Price	$93.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$87.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$52.65
Rate for Payer: Iowa Total Care Managed Medicaid	$66.83
Rate for Payer: Medical Associates Commercial	$87.75
Rate for Payer: Medical Associates Managed Medicare	$52.65
Rate for Payer: Midlands Choice Commercial	$81.90
Rate for Payer: Molina Healthcare Managed Medicaid	$67.81
Rate for Payer: Partners Health Alliance Commercial	$60.55
Rate for Payer: United Healthcare Commercial	$105.30
Rate for Payer: United Healthcare Managed Medicare	$69.03

Hepatitis C RNA and Quant (R-PCR) DMCL

Facility

$408.00

Service Code	CPT 87522
Hospital Charge Code	8037867
Hospital Revenue Code	306
Min. Negotiated Rate	$183.60
Max. Negotiated Rate	$367.20
Rate for Payer: Aetna of IA Commercial	$367.20
Rate for Payer: Aetna of IA Medical Rental Products	$367.20
Rate for Payer: Aetna of IA Medicare	$232.56
Rate for Payer: Amerigroup Medicaid	$235.33
Rate for Payer: Amerigroup Medicare	$185.44
Rate for Payer: Cash Price	$326.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$306.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$183.60
Rate for Payer: Iowa Total Care Managed Medicaid	$233.05
Rate for Payer: Medical Associates Commercial	$306.00
Rate for Payer: Medical Associates Managed Medicare	$183.60
Rate for Payer: Midlands Choice Commercial	$285.60
Rate for Payer: Molina Healthcare Managed Medicaid	$236.48
Rate for Payer: Partners Health Alliance Commercial	$211.14
Rate for Payer: United Healthcare Commercial	$367.20
Rate for Payer: United Healthcare Managed Medicare	$240.72

Hepatitis C RNA and Quant (R-PCR) DMCL

Facility

$408.00

Service Code	CPT 87522
Hospital Charge Code	8037867
Hospital Revenue Code	306
Min. Negotiated Rate	$285.60
Max. Negotiated Rate	$367.20
Rate for Payer: Aetna of IA Commercial	$367.20
Rate for Payer: Aetna of IA Medical Rental Products	$367.20
Rate for Payer: Cash Price	$326.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$306.00
Rate for Payer: Medical Associates Commercial	$306.00
Rate for Payer: Midlands Choice Commercial	$285.60
Rate for Payer: United Healthcare Commercial	$367.20

Hepatitis D Virus Delta Antibody DMCL

Facility

$140.00

Service Code	CPT 86692
Hospital Charge Code	8037868
Hospital Revenue Code	302
Min. Negotiated Rate	$98.00
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna of IA Commercial	$126.00
Rate for Payer: Aetna of IA Medical Rental Products	$126.00
Rate for Payer: Cash Price	$112.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.00
Rate for Payer: Medical Associates Commercial	$105.00
Rate for Payer: Midlands Choice Commercial	$98.00
Rate for Payer: United Healthcare Commercial	$126.00

Hepatitis D Virus Delta Antibody DMCL

Facility

$140.00

Service Code	CPT 86692
Hospital Charge Code	8037868
Hospital Revenue Code	302
Min. Negotiated Rate	$63.00
Max. Negotiated Rate	$126.00
Rate for Payer: Aetna of IA Commercial	$126.00
Rate for Payer: Aetna of IA Medical Rental Products	$126.00
Rate for Payer: Aetna of IA Medicare	$79.80
Rate for Payer: Amerigroup Medicaid	$80.75
Rate for Payer: Amerigroup Medicare	$63.63
Rate for Payer: Cash Price	$112.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$63.00
Rate for Payer: Iowa Total Care Managed Medicaid	$79.97
Rate for Payer: Medical Associates Commercial	$105.00
Rate for Payer: Medical Associates Managed Medicare	$63.00
Rate for Payer: Midlands Choice Commercial	$98.00
Rate for Payer: Molina Healthcare Managed Medicaid	$81.14
Rate for Payer: Partners Health Alliance Commercial	$72.45
Rate for Payer: United Healthcare Commercial	$126.00
Rate for Payer: United Healthcare Managed Medicare	$82.60

Hep B Sur Ab Quant DMCL

Facility

$88.00

Service Code	CPT 86706
Hospital Charge Code	8037862
Hospital Revenue Code	302
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of IA Commercial	$79.20
Rate for Payer: Aetna of IA Medical Rental Products	$79.20
Rate for Payer: Aetna of IA Medicare	$50.16
Rate for Payer: Amerigroup Medicaid	$50.76
Rate for Payer: Amerigroup Medicare	$40.00
Rate for Payer: Cash Price	$70.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$39.60
Rate for Payer: Iowa Total Care Managed Medicaid	$50.27
Rate for Payer: Medical Associates Commercial	$66.00
Rate for Payer: Medical Associates Managed Medicare	$39.60
Rate for Payer: Midlands Choice Commercial	$61.60
Rate for Payer: Molina Healthcare Managed Medicaid	$51.00
Rate for Payer: Partners Health Alliance Commercial	$45.54
Rate for Payer: United Healthcare Commercial	$79.20
Rate for Payer: United Healthcare Managed Medicare	$51.92

Hep B Sur Ab Quant DMCL

Facility

$88.00

Service Code	CPT 86706
Hospital Charge Code	8037862
Hospital Revenue Code	302
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of IA Commercial	$79.20
Rate for Payer: Aetna of IA Medical Rental Products	$79.20
Rate for Payer: Cash Price	$70.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.00
Rate for Payer: Medical Associates Commercial	$66.00
Rate for Payer: Midlands Choice Commercial	$61.60
Rate for Payer: United Healthcare Commercial	$79.20

Herpes Simplex PCR Qual DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037869
Hospital Revenue Code	306
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

Herpes Simplex PCR Qual DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037869
Hospital Revenue Code	306
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	$102.47
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

Herpes Simplex PCR Qual Stat DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037870
Hospital Revenue Code	306
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	$102.47
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