Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

INFUSION TX EA SEQUENTIAL INF

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	7984743
Hospital Revenue Code	260
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: United Healthcare Commercial	$207.00

INFUSION TX HYDRATION 1ST HR

Facility

$344.00

Service Code	CPT 96360
Hospital Charge Code	7984739
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

INFUSION TX HYDRATION 1ST HR

Facility

$344.00

Service Code	CPT 96360
Hospital Charge Code	7984739
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

INFUSION TX HYDRATION EA AD HR

Facility

$152.00

Service Code	CPT 96361
Hospital Charge Code	7984740
Hospital Revenue Code	260
Min. Negotiated Rate	$68.40
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Aetna of IA Medicare	$86.64
Rate for Payer: Amerigroup Medicaid	$87.67
Rate for Payer: Amerigroup Medicare	$69.08
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$68.40
Rate for Payer: Iowa Total Care Managed Medicaid	$86.82
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Medical Associates Managed Medicare	$68.40
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: Molina Healthcare Managed Medicaid	$88.10
Rate for Payer: Partners Health Alliance Commercial	$78.66
Rate for Payer: United Healthcare Commercial	$136.80
Rate for Payer: United Healthcare Managed Medicare	$89.68

INFUSION TX HYDRATION EA AD HR

Facility

$152.00

Service Code	CPT 96361
Hospital Charge Code	7984740
Hospital Revenue Code	260
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: United Healthcare Commercial	$136.80

INFUSION TX MED ADMIN 1ST HR

Facility

$382.00

Service Code	CPT 96365
Hospital Charge Code	7984741
Hospital Revenue Code	260
Min. Negotiated Rate	$267.40
Max. Negotiated Rate	$343.80
Rate for Payer: Aetna of IA Commercial	$343.80
Rate for Payer: Aetna of IA Medical Rental Products	$343.80
Rate for Payer: Cash Price	$305.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$286.50
Rate for Payer: Medical Associates Commercial	$286.50
Rate for Payer: Midlands Choice Commercial	$267.40
Rate for Payer: United Healthcare Commercial	$343.80

INFUSION TX MED ADMIN 1ST HR

Facility

$382.00

Service Code	CPT 96365
Hospital Charge Code	7984741
Hospital Revenue Code	260
Min. Negotiated Rate	$171.90
Max. Negotiated Rate	$343.80
Rate for Payer: Aetna of IA Commercial	$343.80
Rate for Payer: Aetna of IA Medical Rental Products	$343.80
Rate for Payer: Aetna of IA Medicare	$217.74
Rate for Payer: Amerigroup Medicaid	$220.34
Rate for Payer: Amerigroup Medicare	$173.62
Rate for Payer: Cash Price	$305.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$286.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$171.90
Rate for Payer: Iowa Total Care Managed Medicaid	$218.20
Rate for Payer: Medical Associates Commercial	$286.50
Rate for Payer: Medical Associates Managed Medicare	$171.90
Rate for Payer: Midlands Choice Commercial	$267.40
Rate for Payer: Molina Healthcare Managed Medicaid	$221.41
Rate for Payer: Partners Health Alliance Commercial	$197.69
Rate for Payer: United Healthcare Commercial	$343.80
Rate for Payer: United Healthcare Managed Medicare	$225.38

INFUSION TX MED EA ADDL HOUR

Facility

$161.00

Service Code	CPT 96366
Hospital Charge Code	7984742
Hospital Revenue Code	260
Min. Negotiated Rate	$72.45
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Aetna of IA Medicare	$91.77
Rate for Payer: Amerigroup Medicaid	$92.86
Rate for Payer: Amerigroup Medicare	$73.17
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.45
Rate for Payer: Iowa Total Care Managed Medicaid	$91.96
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Medical Associates Managed Medicare	$72.45
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: Molina Healthcare Managed Medicaid	$93.32
Rate for Payer: Partners Health Alliance Commercial	$83.32
Rate for Payer: United Healthcare Commercial	$144.90
Rate for Payer: United Healthcare Managed Medicare	$94.99

INFUSION TX MED EA ADDL HOUR

Facility

$161.00

Service Code	CPT 96366
Hospital Charge Code	7984742
Hospital Revenue Code	260
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: United Healthcare Commercial	$144.90

INFUSION TX SEQENTIAL

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	4866841
Hospital Revenue Code	260
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Aetna of IA Medicare	$131.10
Rate for Payer: Amerigroup Medicaid	$132.66
Rate for Payer: Amerigroup Medicare	$104.53
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.50
Rate for Payer: Iowa Total Care Managed Medicaid	$131.38
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Medical Associates Managed Medicare	$103.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: Molina Healthcare Managed Medicaid	$133.31
Rate for Payer: Partners Health Alliance Commercial	$119.03
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70

INFUSION TX SEQENTIAL

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	4866841
Hospital Revenue Code	260
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: United Healthcare Commercial	$207.00

INFUSION TX SEQENTIAL

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	6922797
Hospital Revenue Code	260
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Aetna of IA Medicare	$131.10
Rate for Payer: Amerigroup Medicaid	$132.66
Rate for Payer: Amerigroup Medicare	$104.53
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.50
Rate for Payer: Iowa Total Care Managed Medicaid	$131.38
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Medical Associates Managed Medicare	$103.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: Molina Healthcare Managed Medicaid	$133.31
Rate for Payer: Partners Health Alliance Commercial	$119.03
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70

INFUSION TX SEQENTIAL

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	6922797
Hospital Revenue Code	260
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: United Healthcare Commercial	$207.00

Inhalation Pediatric Spacing Device [VDMC]

Facility

$56.64

Service Code	NDC 08373-9823-00
Hospital Charge Code	11676962
Hospital Revenue Code	259
Min. Negotiated Rate	$39.65
Max. Negotiated Rate	$50.98
Rate for Payer: Aetna of IA Commercial	$50.98
Rate for Payer: Aetna of IA Medical Rental Products	$50.98
Rate for Payer: Cash Price	$45.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.48
Rate for Payer: Medical Associates Commercial	$42.48
Rate for Payer: Midlands Choice Commercial	$39.65
Rate for Payer: United Healthcare Commercial	$50.98

Inhalation Pediatric Spacing Device [VDMC]

Facility

$56.64

Service Code	NDC 08373-9823-00
Hospital Charge Code	11676962
Hospital Revenue Code	259
Min. Negotiated Rate	$25.49
Max. Negotiated Rate	$50.98
Rate for Payer: Aetna of IA Commercial	$50.98
Rate for Payer: Aetna of IA Medical Rental Products	$50.98
Rate for Payer: Aetna of IA Medicare	$32.28
Rate for Payer: Amerigroup Medicaid	$32.67
Rate for Payer: Amerigroup Medicare	$25.74
Rate for Payer: Cash Price	$45.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.49
Rate for Payer: Iowa Total Care Managed Medicaid	$32.35
Rate for Payer: Medical Associates Commercial	$42.48
Rate for Payer: Medical Associates Managed Medicare	$25.49
Rate for Payer: Midlands Choice Commercial	$39.65
Rate for Payer: Molina Healthcare Managed Medicaid	$32.83
Rate for Payer: Partners Health Alliance Commercial	$29.31
Rate for Payer: United Healthcare Commercial	$50.98
Rate for Payer: United Healthcare Managed Medicare	$33.42

Inhalation Spacing Device Adult [VDMC]

Facility

$31.44

Service Code	NDC 08373-7478-00
Hospital Charge Code	11676913
Hospital Revenue Code	259
Min. Negotiated Rate	$22.01
Max. Negotiated Rate	$28.30
Rate for Payer: Aetna of IA Commercial	$28.30
Rate for Payer: Aetna of IA Medical Rental Products	$28.30
Rate for Payer: Cash Price	$25.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.58
Rate for Payer: Medical Associates Commercial	$23.58
Rate for Payer: Midlands Choice Commercial	$22.01
Rate for Payer: United Healthcare Commercial	$28.30

Inhalation Spacing Device Adult [VDMC]

Facility

$31.44

Service Code	NDC 08373-7478-00
Hospital Charge Code	11676913
Hospital Revenue Code	259
Min. Negotiated Rate	$14.15
Max. Negotiated Rate	$28.30
Rate for Payer: Aetna of IA Commercial	$28.30
Rate for Payer: Aetna of IA Medical Rental Products	$28.30
Rate for Payer: Aetna of IA Medicare	$17.92
Rate for Payer: Amerigroup Medicaid	$18.13
Rate for Payer: Amerigroup Medicare	$14.29
Rate for Payer: Cash Price	$25.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.15
Rate for Payer: Iowa Total Care Managed Medicaid	$17.96
Rate for Payer: Medical Associates Commercial	$23.58
Rate for Payer: Medical Associates Managed Medicare	$14.15
Rate for Payer: Midlands Choice Commercial	$22.01
Rate for Payer: Molina Healthcare Managed Medicaid	$18.22
Rate for Payer: Partners Health Alliance Commercial	$16.27
Rate for Payer: United Healthcare Commercial	$28.30
Rate for Payer: United Healthcare Managed Medicare	$18.55

INHIBIN A

Facility

$106.00

Service Code	CPT 86336
Hospital Charge Code	8086834
Hospital Revenue Code	302
Min. Negotiated Rate	$47.70
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of IA Commercial	$95.40
Rate for Payer: Aetna of IA Medical Rental Products	$95.40
Rate for Payer: Aetna of IA Medicare	$60.42
Rate for Payer: Amerigroup Medicaid	$61.14
Rate for Payer: Amerigroup Medicare	$48.18
Rate for Payer: Cash Price	$84.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$79.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$47.70
Rate for Payer: Iowa Total Care Managed Medicaid	$60.55
Rate for Payer: Medical Associates Commercial	$79.50
Rate for Payer: Medical Associates Managed Medicare	$47.70
Rate for Payer: Midlands Choice Commercial	$74.20
Rate for Payer: Molina Healthcare Managed Medicaid	$61.44
Rate for Payer: Partners Health Alliance Commercial	$54.85
Rate for Payer: United Healthcare Commercial	$95.40
Rate for Payer: United Healthcare Managed Medicare	$62.54

INHIBIN A

Facility

$106.00

Service Code	CPT 86336
Hospital Charge Code	8086834
Hospital Revenue Code	302
Min. Negotiated Rate	$74.20
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of IA Commercial	$95.40
Rate for Payer: Aetna of IA Medical Rental Products	$95.40
Rate for Payer: Cash Price	$84.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$79.50
Rate for Payer: Medical Associates Commercial	$79.50
Rate for Payer: Midlands Choice Commercial	$74.20
Rate for Payer: United Healthcare Commercial	$95.40

Initial

Facility

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663519
Hospital Revenue Code	943
Min. Negotiated Rate	$64.35
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$82.48
Rate for Payer: Amerigroup Medicare	$64.99
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.35
Rate for Payer: Iowa Total Care Managed Medicaid	$81.68
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$64.35
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$82.88
Rate for Payer: Partners Health Alliance Commercial	$74.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37

Initial

Facility

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663519
Hospital Revenue Code	943
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$128.70

Initial - KX

Facility

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663518
Hospital Revenue Code	943
Min. Negotiated Rate	$64.35
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$82.48
Rate for Payer: Amerigroup Medicare	$64.99
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.35
Rate for Payer: Iowa Total Care Managed Medicaid	$81.68
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$64.35
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$82.88
Rate for Payer: Partners Health Alliance Commercial	$74.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37

Initial - KX

Facility

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663518
Hospital Revenue Code	943
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$128.70

INITIAL OBSERVATION HIGH COMPLEXITY

Professional

Both

$305.00

Service Code	CPT 99220
Hospital Charge Code	5140803
Hospital Revenue Code	983
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$228.75
Rate for Payer: Cash Price	$244.00
Rate for Payer: Medical Associates Commercial	$228.75
Rate for Payer: Midlands Choice Commercial	$213.50
Rate for Payer: Partners Health Alliance Commercial	$228.75

INJECT EPIDURAL PATCH

Facility

$1,120.00

Service Code	CPT 62273
Hospital Charge Code	4866803
Hospital Revenue Code	761
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$1,008.00
Rate for Payer: Aetna of IA Commercial	$1,008.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.00
Rate for Payer: Aetna of IA Medicare	$638.40
Rate for Payer: Amerigroup Medicaid	$646.02
Rate for Payer: Amerigroup Medicare	$509.04
Rate for Payer: Cash Price	$896.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$504.00
Rate for Payer: Iowa Total Care Managed Medicaid	$639.74
Rate for Payer: Medical Associates Commercial	$840.00
Rate for Payer: Medical Associates Managed Medicare	$504.00
Rate for Payer: Midlands Choice Commercial	$784.00
Rate for Payer: Molina Healthcare Managed Medicaid	$649.15
Rate for Payer: Partners Health Alliance Commercial	$579.60
Rate for Payer: United Healthcare Commercial	$1,008.00
Rate for Payer: United Healthcare Managed Medicare	$660.80

Know your out-of-pocket cost for care.

All Charges