Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

indomethacin 25 mg Cap [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10396322
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of IA Commercial	$1.13
Rate for Payer: Aetna of IA Medical Rental Products	$1.13
Rate for Payer: Aetna of IA Medicare	$0.71
Rate for Payer: Amerigroup Medicaid	$0.72
Rate for Payer: Amerigroup Medicare	$0.57
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.56
Rate for Payer: Iowa Total Care Managed Medicaid	$0.71
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: Molina Healthcare Managed Medicaid	$0.72
Rate for Payer: Partners Health Alliance Commercial	$0.65
Rate for Payer: United Healthcare Commercial	$1.13
Rate for Payer: United Healthcare Managed Medicare	$0.74

IND. PSYCH 30 ADD ON

Professional

Both

$363.00

Service Code	CPT 90833 AJ\|HO
Hospital Charge Code	5492789
Hospital Revenue Code	914
Min. Negotiated Rate	$112.18
Max. Negotiated Rate	$272.25
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Partners Health Alliance Commercial	$272.25
Rate for Payer: United Healthcare Commercial	$112.18

IND. PSYCH 45 ADD ON

Professional

Both

$363.00

Service Code	CPT 90836 AJ\|HO
Hospital Charge Code	5492790
Hospital Revenue Code	914
Min. Negotiated Rate	$142.05
Max. Negotiated Rate	$272.25
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Partners Health Alliance Commercial	$272.25
Rate for Payer: United Healthcare Commercial	$142.05

IND. PSYCH 60 ADD ON

Professional

Both

$363.00

Service Code	CPT 90838 AJ\|HO
Hospital Charge Code	5492791
Hospital Revenue Code	914
Min. Negotiated Rate	$186.90
Max. Negotiated Rate	$272.25
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Partners Health Alliance Commercial	$272.25
Rate for Payer: United Healthcare Commercial	$186.90

inFLIXimab 100 mg SDV Pow [VDMC]

Facility

$973.38

Service Code	HCPCS J1745
Hospital Charge Code	12420566
Hospital Revenue Code	259
Min. Negotiated Rate	$438.02
Max. Negotiated Rate	$876.04
Rate for Payer: Aetna of IA Commercial	$876.04
Rate for Payer: Aetna of IA Medical Rental Products	$876.04
Rate for Payer: Aetna of IA Medicare	$554.83
Rate for Payer: Amerigroup Medicaid	$561.45
Rate for Payer: Amerigroup Medicare	$442.40
Rate for Payer: Cash Price	$778.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$730.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$438.02
Rate for Payer: Iowa Total Care Managed Medicaid	$555.99
Rate for Payer: Medical Associates Commercial	$730.03
Rate for Payer: Medical Associates Managed Medicare	$438.02
Rate for Payer: Midlands Choice Commercial	$681.37
Rate for Payer: Molina Healthcare Managed Medicaid	$564.17
Rate for Payer: Partners Health Alliance Commercial	$503.72
Rate for Payer: United Healthcare Commercial	$876.04
Rate for Payer: United Healthcare Managed Medicare	$574.29

inFLIXimab 100 mg SDV Pow [VDMC]

Facility

$973.38

Service Code	HCPCS J1745
Hospital Charge Code	12420566
Hospital Revenue Code	259
Min. Negotiated Rate	$681.37
Max. Negotiated Rate	$876.04
Rate for Payer: Aetna of IA Commercial	$876.04
Rate for Payer: Aetna of IA Medical Rental Products	$876.04
Rate for Payer: Cash Price	$778.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$730.03
Rate for Payer: Medical Associates Commercial	$730.03
Rate for Payer: Midlands Choice Commercial	$681.37
Rate for Payer: United Healthcare Commercial	$876.04

inFLIXimab-abda 100 mg SDV Pow [VDMC]

Facility

$1,447.32

Service Code	HCPCS Q5104
Hospital Charge Code	24795850
Hospital Revenue Code	259
Min. Negotiated Rate	$1,013.12
Max. Negotiated Rate	$1,302.59
Rate for Payer: Aetna of IA Commercial	$1,302.59
Rate for Payer: Aetna of IA Medical Rental Products	$1,302.59
Rate for Payer: Cash Price	$1,157.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,085.49
Rate for Payer: Medical Associates Commercial	$1,085.49
Rate for Payer: Midlands Choice Commercial	$1,013.12
Rate for Payer: United Healthcare Commercial	$1,302.59

inFLIXimab-abda 100 mg SDV Pow [VDMC]

Facility

$1,447.32

Service Code	HCPCS Q5104
Hospital Charge Code	24795850
Hospital Revenue Code	259
Min. Negotiated Rate	$651.29
Max. Negotiated Rate	$1,302.59
Rate for Payer: Aetna of IA Commercial	$1,302.59
Rate for Payer: Aetna of IA Medical Rental Products	$1,302.59
Rate for Payer: Aetna of IA Medicare	$824.97
Rate for Payer: Amerigroup Medicaid	$834.81
Rate for Payer: Amerigroup Medicare	$657.81
Rate for Payer: Cash Price	$1,157.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,085.49
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$651.29
Rate for Payer: Iowa Total Care Managed Medicaid	$826.71
Rate for Payer: Medical Associates Commercial	$1,085.49
Rate for Payer: Medical Associates Managed Medicare	$651.29
Rate for Payer: Midlands Choice Commercial	$1,013.12
Rate for Payer: Molina Healthcare Managed Medicaid	$838.87
Rate for Payer: Partners Health Alliance Commercial	$748.99
Rate for Payer: United Healthcare Commercial	$1,302.59
Rate for Payer: United Healthcare Managed Medicare	$853.92

inFLIXimab axxq 100 mg Pow [VDMC]

Facility

$1,045.70

Service Code	HCPCS Q5121
Hospital Charge Code	24236862
Hospital Revenue Code	259
Min. Negotiated Rate	$470.56
Max. Negotiated Rate	$941.13
Rate for Payer: Aetna of IA Commercial	$941.13
Rate for Payer: Aetna of IA Medical Rental Products	$941.13
Rate for Payer: Aetna of IA Medicare	$596.05
Rate for Payer: Amerigroup Medicaid	$603.16
Rate for Payer: Amerigroup Medicare	$475.27
Rate for Payer: Cash Price	$836.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$784.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$470.56
Rate for Payer: Iowa Total Care Managed Medicaid	$597.30
Rate for Payer: Medical Associates Commercial	$784.27
Rate for Payer: Medical Associates Managed Medicare	$470.56
Rate for Payer: Midlands Choice Commercial	$731.99
Rate for Payer: Molina Healthcare Managed Medicaid	$606.09
Rate for Payer: Partners Health Alliance Commercial	$541.15
Rate for Payer: United Healthcare Commercial	$941.13
Rate for Payer: United Healthcare Managed Medicare	$616.96

inFLIXimab axxq 100 mg Pow [VDMC]

Facility

$1,045.70

Service Code	HCPCS Q5121
Hospital Charge Code	24236862
Hospital Revenue Code	259
Min. Negotiated Rate	$731.99
Max. Negotiated Rate	$941.13
Rate for Payer: Aetna of IA Commercial	$941.13
Rate for Payer: Aetna of IA Medical Rental Products	$941.13
Rate for Payer: Cash Price	$836.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$784.27
Rate for Payer: Medical Associates Commercial	$784.27
Rate for Payer: Midlands Choice Commercial	$731.99
Rate for Payer: United Healthcare Commercial	$941.13

inFLIXimab-dyyb 100 mg Pow SDV [VDMC]

Facility

$1,016.76

Service Code	HCPCS Q5103
Hospital Charge Code	20049518
Hospital Revenue Code	259
Min. Negotiated Rate	$457.54
Max. Negotiated Rate	$915.08
Rate for Payer: Aetna of IA Commercial	$915.08
Rate for Payer: Aetna of IA Medical Rental Products	$915.08
Rate for Payer: Aetna of IA Medicare	$579.55
Rate for Payer: Amerigroup Medicaid	$586.47
Rate for Payer: Amerigroup Medicare	$462.12
Rate for Payer: Cash Price	$813.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$762.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$457.54
Rate for Payer: Iowa Total Care Managed Medicaid	$580.77
Rate for Payer: Medical Associates Commercial	$762.57
Rate for Payer: Medical Associates Managed Medicare	$457.54
Rate for Payer: Midlands Choice Commercial	$711.73
Rate for Payer: Molina Healthcare Managed Medicaid	$589.31
Rate for Payer: Partners Health Alliance Commercial	$526.17
Rate for Payer: United Healthcare Commercial	$915.08
Rate for Payer: United Healthcare Managed Medicare	$599.89

inFLIXimab-dyyb 100 mg Pow SDV [VDMC]

Facility

$1,016.76

Service Code	HCPCS Q5103
Hospital Charge Code	20049518
Hospital Revenue Code	259
Min. Negotiated Rate	$711.73
Max. Negotiated Rate	$915.08
Rate for Payer: Aetna of IA Commercial	$915.08
Rate for Payer: Aetna of IA Medical Rental Products	$915.08
Rate for Payer: Cash Price	$813.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$762.57
Rate for Payer: Medical Associates Commercial	$762.57
Rate for Payer: Midlands Choice Commercial	$711.73
Rate for Payer: United Healthcare Commercial	$915.08

INFLUENZA AB

Facility

$82.00

Service Code	CPT 87804
Hospital Charge Code	4110785
Hospital Revenue Code	306
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

INFLUENZA AB

Facility

$82.00

Service Code	CPT 87804
Hospital Charge Code	4110785
Hospital Revenue Code	306
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

influenza HD virus vaccine, inactivated adjuvanted preservative-free trivalent Sus UD[VDMC]

Facility

$121.68

Service Code	HCPCS 90653
Hospital Charge Code	28497053
Hospital Revenue Code	259
Min. Negotiated Rate	$54.76
Max. Negotiated Rate	$109.51
Rate for Payer: Aetna of IA Commercial	$109.51
Rate for Payer: Aetna of IA Medical Rental Products	$109.51
Rate for Payer: Aetna of IA Medicare	$69.36
Rate for Payer: Amerigroup Medicaid	$70.19
Rate for Payer: Amerigroup Medicare	$55.30
Rate for Payer: Cash Price	$97.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$91.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$54.76
Rate for Payer: Iowa Total Care Managed Medicaid	$69.50
Rate for Payer: Medical Associates Commercial	$91.26
Rate for Payer: Medical Associates Managed Medicare	$54.76
Rate for Payer: Midlands Choice Commercial	$85.18
Rate for Payer: Molina Healthcare Managed Medicaid	$70.53
Rate for Payer: Partners Health Alliance Commercial	$62.97
Rate for Payer: United Healthcare Commercial	$109.51
Rate for Payer: United Healthcare Managed Medicare	$71.79

influenza HD virus vaccine, inactivated adjuvanted preservative-free trivalent Sus UD[VDMC]

Facility

$121.68

Service Code	HCPCS 90653
Hospital Charge Code	28497053
Hospital Revenue Code	259
Min. Negotiated Rate	$85.18
Max. Negotiated Rate	$109.51
Rate for Payer: Aetna of IA Commercial	$109.51
Rate for Payer: Aetna of IA Medical Rental Products	$109.51
Rate for Payer: Cash Price	$97.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$91.26
Rate for Payer: Medical Associates Commercial	$91.26
Rate for Payer: Midlands Choice Commercial	$85.18
Rate for Payer: United Healthcare Commercial	$109.51

influenza TRI Syringe virus vaccine, inactivated preservative-free trivalent Sus[VDMC]

Facility

$31.00

Service Code	HCPCS 90656
Hospital Charge Code	28463286
Hospital Revenue Code	259
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna of IA Commercial	$27.90
Rate for Payer: Aetna of IA Medical Rental Products	$27.90
Rate for Payer: Aetna of IA Medicare	$17.67
Rate for Payer: Amerigroup Medicaid	$17.88
Rate for Payer: Amerigroup Medicare	$14.09
Rate for Payer: Cash Price	$24.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.95
Rate for Payer: Iowa Total Care Managed Medicaid	$17.71
Rate for Payer: Medical Associates Commercial	$23.25
Rate for Payer: Medical Associates Managed Medicare	$13.95
Rate for Payer: Midlands Choice Commercial	$21.70
Rate for Payer: Molina Healthcare Managed Medicaid	$17.97
Rate for Payer: Partners Health Alliance Commercial	$16.04
Rate for Payer: United Healthcare Commercial	$27.90
Rate for Payer: United Healthcare Managed Medicare	$18.29

influenza TRI Syringe virus vaccine, inactivated preservative-free trivalent Sus[VDMC]

Facility

$31.00

Service Code	HCPCS 90656
Hospital Charge Code	28463286
Hospital Revenue Code	259
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna of IA Commercial	$27.90
Rate for Payer: Aetna of IA Medical Rental Products	$27.90
Rate for Payer: Cash Price	$24.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.25
Rate for Payer: Medical Associates Commercial	$23.25
Rate for Payer: Midlands Choice Commercial	$21.70
Rate for Payer: United Healthcare Commercial	$27.90

INF TX-CONCURRENT

Facility

$103.00

Service Code	CPT 96368
Hospital Charge Code	4866839
Hospital Revenue Code	260
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of IA Commercial	$92.70
Rate for Payer: Aetna of IA Medical Rental Products	$92.70
Rate for Payer: Cash Price	$82.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$77.25
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: United Healthcare Commercial	$92.70

INF TX-CONCURRENT

Facility

$103.00

Service Code	CPT 96368
Hospital Charge Code	4866839
Hospital Revenue Code	260
Min. Negotiated Rate	$46.35
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of IA Commercial	$92.70
Rate for Payer: Aetna of IA Medical Rental Products	$92.70
Rate for Payer: Aetna of IA Medicare	$58.71
Rate for Payer: Amerigroup Medicaid	$59.41
Rate for Payer: Amerigroup Medicare	$46.81
Rate for Payer: Cash Price	$82.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$77.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$46.35
Rate for Payer: Iowa Total Care Managed Medicaid	$58.83
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Medical Associates Managed Medicare	$46.35
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: Molina Healthcare Managed Medicaid	$59.70
Rate for Payer: Partners Health Alliance Commercial	$53.30
Rate for Payer: United Healthcare Commercial	$92.70
Rate for Payer: United Healthcare Managed Medicare	$60.77

INF TX-CONCURRENT

Facility

$103.00

Service Code	CPT 96368
Hospital Charge Code	6922818
Hospital Revenue Code	260
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of IA Commercial	$92.70
Rate for Payer: Aetna of IA Medical Rental Products	$92.70
Rate for Payer: Cash Price	$82.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$77.25
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: United Healthcare Commercial	$92.70

INF TX-CONCURRENT

Facility

$103.00

Service Code	CPT 96368
Hospital Charge Code	6922818
Hospital Revenue Code	260
Min. Negotiated Rate	$46.35
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of IA Commercial	$92.70
Rate for Payer: Aetna of IA Medical Rental Products	$92.70
Rate for Payer: Aetna of IA Medicare	$58.71
Rate for Payer: Amerigroup Medicaid	$59.41
Rate for Payer: Amerigroup Medicare	$46.81
Rate for Payer: Cash Price	$82.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$77.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$46.35
Rate for Payer: Iowa Total Care Managed Medicaid	$58.83
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Medical Associates Managed Medicare	$46.35
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: Molina Healthcare Managed Medicaid	$59.70
Rate for Payer: Partners Health Alliance Commercial	$53.30
Rate for Payer: United Healthcare Commercial	$92.70
Rate for Payer: United Healthcare Managed Medicare	$60.77

INF TX HYDRATION 1ST HR

Facility

$344.00

Service Code	CPT 96360
Hospital Charge Code	6922793
Hospital Revenue Code	260
Min. Negotiated Rate	$240.80
Max. Negotiated Rate	$309.60
Rate for Payer: Aetna of IA Commercial	$309.60
Rate for Payer: Aetna of IA Medical Rental Products	$309.60
Rate for Payer: Cash Price	$275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$258.00
Rate for Payer: Medical Associates Commercial	$258.00
Rate for Payer: Midlands Choice Commercial	$240.80
Rate for Payer: United Healthcare Commercial	$309.60

INF TX HYDRATION 1ST HR

Facility

$344.00

Service Code	CPT 96360
Hospital Charge Code	4866847
Hospital Revenue Code	260
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$309.60
Rate for Payer: Aetna of IA Commercial	$309.60
Rate for Payer: Aetna of IA Medical Rental Products	$309.60
Rate for Payer: Aetna of IA Medicare	$196.08
Rate for Payer: Amerigroup Medicaid	$198.42
Rate for Payer: Amerigroup Medicare	$156.35
Rate for Payer: Cash Price	$275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$258.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$154.80
Rate for Payer: Iowa Total Care Managed Medicaid	$196.49
Rate for Payer: Medical Associates Commercial	$258.00
Rate for Payer: Medical Associates Managed Medicare	$154.80
Rate for Payer: Midlands Choice Commercial	$240.80
Rate for Payer: Molina Healthcare Managed Medicaid	$199.38
Rate for Payer: Partners Health Alliance Commercial	$178.02
Rate for Payer: United Healthcare Commercial	$309.60
Rate for Payer: United Healthcare Managed Medicare	$202.96

INF TX HYDRATION 1ST HR

Facility

$344.00

Service Code	CPT 96360
Hospital Charge Code	6922793
Hospital Revenue Code	260
Min. Negotiated Rate	$154.80
Max. Negotiated Rate	$309.60
Rate for Payer: Aetna of IA Commercial	$309.60
Rate for Payer: Aetna of IA Medical Rental Products	$309.60
Rate for Payer: Aetna of IA Medicare	$196.08
Rate for Payer: Amerigroup Medicaid	$198.42
Rate for Payer: Amerigroup Medicare	$156.35
Rate for Payer: Cash Price	$275.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$258.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$154.80
Rate for Payer: Iowa Total Care Managed Medicaid	$196.49
Rate for Payer: Medical Associates Commercial	$258.00
Rate for Payer: Medical Associates Managed Medicare	$154.80
Rate for Payer: Midlands Choice Commercial	$240.80
Rate for Payer: Molina Healthcare Managed Medicaid	$199.38
Rate for Payer: Partners Health Alliance Commercial	$178.02
Rate for Payer: United Healthcare Commercial	$309.60
Rate for Payer: United Healthcare Managed Medicare	$202.96

Know your out-of-pocket cost for care.

All Charges