Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Facility

$1,487.44

Service Code	CPT 62323
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)

Facility

$705.87

Service Code	CPT 20552
Hospital Revenue Code	360
Min. Negotiated Rate	$641.70
Max. Negotiated Rate	$705.87
Rate for Payer: Wellmark IA HMO	$641.70
Rate for Payer: Wellmark IA PPO	$705.87

INJ FORAMEN EPIDURAL ADD ON

Professional

Both

$289.00

Service Code	CPT 64484
Hospital Charge Code	8015854
Hospital Revenue Code	975
Min. Negotiated Rate	$47.10
Max. Negotiated Rate	$202.30
Rate for Payer: Aetna of IA Medicare	$47.10
Rate for Payer: Amerigroup Medicaid	$48.70
Rate for Payer: Cash Price	$231.20
Rate for Payer: Cash Price	$231.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.52
Rate for Payer: Iowa Total Care Managed Medicaid	$48.04
Rate for Payer: Medical Associates Commercial	$89.49
Rate for Payer: Medical Associates Managed Medicare	$47.10
Rate for Payer: Midlands Choice Commercial	$202.30
Rate for Payer: Oscar Health of IA Commercial	$81.48
Rate for Payer: Partners Health Alliance Commercial	$70.65

INJ FORAMEN EPIDURAL L/S

Professional

Both

$720.00

Service Code	CPT 64483
Hospital Charge Code	8015433
Hospital Revenue Code	975
Min. Negotiated Rate	$101.98
Max. Negotiated Rate	$238.23
Rate for Payer: Aetna of IA Medicare	$101.98
Rate for Payer: Amerigroup Medicaid	$105.45
Rate for Payer: Cash Price	$576.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$122.38
Rate for Payer: Iowa Total Care Managed Medicaid	$104.02
Rate for Payer: Medical Associates Commercial	$193.76
Rate for Payer: Medical Associates Managed Medicare	$101.98
Rate for Payer: Midlands Choice Commercial	$238.23
Rate for Payer: Oscar Health of IA Commercial	$176.43
Rate for Payer: Partners Health Alliance Commercial	$152.97

INJ PARAVERTEBRAL FACET JOINT C/T

Professional

Both

$624.00

Service Code	CPT 64490
Hospital Charge Code	8015855
Hospital Revenue Code	975
Min. Negotiated Rate	$96.37
Max. Negotiated Rate	$436.80
Rate for Payer: Aetna of IA Medicare	$96.37
Rate for Payer: Amerigroup Medicaid	$99.65
Rate for Payer: Cash Price	$499.20
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$115.64
Rate for Payer: Iowa Total Care Managed Medicaid	$98.30
Rate for Payer: Medical Associates Commercial	$183.10
Rate for Payer: Medical Associates Managed Medicare	$96.37
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Oscar Health of IA Commercial	$166.72
Rate for Payer: Partners Health Alliance Commercial	$144.56

INJ PARAVERT F JNT L/S 1 LEV

Professional

Both

$566.00

Service Code	CPT 64493
Hospital Charge Code	8015865
Hospital Revenue Code	975
Min. Negotiated Rate	$82.81
Max. Negotiated Rate	$396.20
Rate for Payer: Aetna of IA Medicare	$82.81
Rate for Payer: Amerigroup Medicaid	$85.63
Rate for Payer: Cash Price	$452.80
Rate for Payer: Cash Price	$452.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.37
Rate for Payer: Iowa Total Care Managed Medicaid	$84.47
Rate for Payer: Medical Associates Commercial	$157.34
Rate for Payer: Medical Associates Managed Medicare	$82.81
Rate for Payer: Midlands Choice Commercial	$396.20
Rate for Payer: Oscar Health of IA Commercial	$143.26
Rate for Payer: Partners Health Alliance Commercial	$124.22

INJ PARAVERT F JNT L/S 2 LEV

Professional

Both

$285.00

Service Code	CPT 64494
Hospital Charge Code	8015866
Hospital Revenue Code	975
Min. Negotiated Rate	$46.50
Max. Negotiated Rate	$199.50
Rate for Payer: Aetna of IA Medicare	$46.50
Rate for Payer: Amerigroup Medicaid	$48.08
Rate for Payer: Cash Price	$228.00
Rate for Payer: Cash Price	$228.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.80
Rate for Payer: Iowa Total Care Managed Medicaid	$47.43
Rate for Payer: Medical Associates Commercial	$88.35
Rate for Payer: Medical Associates Managed Medicare	$46.50
Rate for Payer: Midlands Choice Commercial	$199.50
Rate for Payer: Oscar Health of IA Commercial	$80.44
Rate for Payer: Partners Health Alliance Commercial	$69.75

INJ PARAVERT F JNT L/S 2 LEV

Professional

Both

$286.00

Service Code	CPT 64495
Hospital Charge Code	8015867
Hospital Revenue Code	975
Min. Negotiated Rate	$47.39
Max. Negotiated Rate	$200.20
Rate for Payer: Aetna of IA Medicare	$47.39
Rate for Payer: Amerigroup Medicaid	$49.00
Rate for Payer: Cash Price	$228.80
Rate for Payer: Cash Price	$228.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.87
Rate for Payer: Iowa Total Care Managed Medicaid	$48.34
Rate for Payer: Medical Associates Commercial	$90.04
Rate for Payer: Medical Associates Managed Medicare	$47.39
Rate for Payer: Midlands Choice Commercial	$200.20
Rate for Payer: Oscar Health of IA Commercial	$81.98
Rate for Payer: Partners Health Alliance Commercial	$71.08

INJ PARAVERT F JOINT C/T 2 LEV

Professional

Both

$309.00

Service Code	CPT 64491
Hospital Charge Code	8015859
Hospital Revenue Code	975
Min. Negotiated Rate	$54.13
Max. Negotiated Rate	$216.30
Rate for Payer: Aetna of IA Medicare	$54.13
Rate for Payer: Amerigroup Medicaid	$55.97
Rate for Payer: Cash Price	$247.20
Rate for Payer: Cash Price	$247.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.96
Rate for Payer: Iowa Total Care Managed Medicaid	$55.21
Rate for Payer: Medical Associates Commercial	$102.85
Rate for Payer: Medical Associates Managed Medicare	$54.13
Rate for Payer: Midlands Choice Commercial	$216.30
Rate for Payer: Oscar Health of IA Commercial	$93.64
Rate for Payer: Partners Health Alliance Commercial	$81.20

INJ PARAVERT F JOINT C/T 3 LEV

Professional

Both

$310.00

Service Code	CPT 64492
Hospital Charge Code	8015864
Hospital Revenue Code	975
Min. Negotiated Rate	$55.03
Max. Negotiated Rate	$217.00
Rate for Payer: Aetna of IA Medicare	$55.03
Rate for Payer: Amerigroup Medicaid	$56.90
Rate for Payer: Cash Price	$248.00
Rate for Payer: Cash Price	$248.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.04
Rate for Payer: Iowa Total Care Managed Medicaid	$56.13
Rate for Payer: Medical Associates Commercial	$104.56
Rate for Payer: Medical Associates Managed Medicare	$55.03
Rate for Payer: Midlands Choice Commercial	$217.00
Rate for Payer: Oscar Health of IA Commercial	$95.20
Rate for Payer: Partners Health Alliance Commercial	$82.54

INJ PERFLUTREN LIP MICROS,ML

Facility

$121.00

Service Code	CPT Q9957
Hospital Charge Code	8910875
Hospital Revenue Code	255
Min. Negotiated Rate	$60.48
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of IA Commercial	$108.90
Rate for Payer: Aetna of IA Medical Rental Products	$108.90
Rate for Payer: Aetna of IA Medicare	$68.97
Rate for Payer: Amerigroup Medicaid	$61.07
Rate for Payer: Amerigroup Medicare	$61.10
Rate for Payer: Cash Price	$96.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$90.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$60.50
Rate for Payer: Iowa Total Care Managed Medicaid	$60.48
Rate for Payer: Medical Associates Commercial	$90.75
Rate for Payer: Medical Associates Managed Medicare	$60.50
Rate for Payer: Midlands Choice Commercial	$84.70
Rate for Payer: Molina Healthcare Managed Medicaid	$61.41
Rate for Payer: Molina Healthcare Managed Medicare	$61.37
Rate for Payer: Oscar Health of IA Commercial	$90.75
Rate for Payer: Partners Health Alliance Commercial	$90.75
Rate for Payer: United Healthcare Commercial	$108.90
Rate for Payer: United Healthcare Managed Medicare	$71.39

INJ PERFLUTREN LIP MICROS,ML

Facility

$121.00

Service Code	CPT Q9957
Hospital Charge Code	8910875
Hospital Revenue Code	255
Min. Negotiated Rate	$84.70
Max. Negotiated Rate	$108.90
Rate for Payer: Aetna of IA Commercial	$108.90
Rate for Payer: Aetna of IA Medical Rental Products	$108.90
Rate for Payer: Cash Price	$96.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$90.75
Rate for Payer: Medical Associates Commercial	$90.75
Rate for Payer: Midlands Choice Commercial	$84.70
Rate for Payer: United Healthcare Commercial	$108.90

INJ SGL TENDON SHTH OR LIGAMENT

Professional

Both

$175.00

Service Code	CPT 20550
Hospital Charge Code	8101266
Hospital Revenue Code	975
Min. Negotiated Rate	$35.32
Max. Negotiated Rate	$122.50
Rate for Payer: Aetna of IA Medicare	$35.32
Rate for Payer: Amerigroup Medicaid	$36.52
Rate for Payer: Cash Price	$140.00
Rate for Payer: Cash Price	$140.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.38
Rate for Payer: Iowa Total Care Managed Medicaid	$36.03
Rate for Payer: Medical Associates Commercial	$67.11
Rate for Payer: Medical Associates Managed Medicare	$35.32
Rate for Payer: Midlands Choice Commercial	$122.50
Rate for Payer: Oscar Health of IA Commercial	$61.10
Rate for Payer: Partners Health Alliance Commercial	$52.98

INJ SINGLE/MULT TRIGGER PTS 1/2 MUSCLES

Professional

Both

$183.00

Service Code	CPT 20552
Hospital Charge Code	8037760
Hospital Revenue Code	975
Min. Negotiated Rate	$33.57
Max. Negotiated Rate	$78.29
Rate for Payer: Aetna of IA Medicare	$33.57
Rate for Payer: Amerigroup Medicaid	$34.71
Rate for Payer: Cash Price	$146.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$40.28
Rate for Payer: Iowa Total Care Managed Medicaid	$34.24
Rate for Payer: Medical Associates Commercial	$63.78
Rate for Payer: Medical Associates Managed Medicare	$33.57
Rate for Payer: Midlands Choice Commercial	$78.29
Rate for Payer: Oscar Health of IA Commercial	$58.08
Rate for Payer: Partners Health Alliance Commercial	$50.36

INJ SINGLE/MULT TRIGGER PTS 3 OR MORE MU

Professional

Both

$211.00

Service Code	CPT 20553
Hospital Charge Code	8015253
Hospital Revenue Code	975
Min. Negotiated Rate	$38.16
Max. Negotiated Rate	$89.67
Rate for Payer: Aetna of IA Medicare	$38.16
Rate for Payer: Amerigroup Medicaid	$39.46
Rate for Payer: Cash Price	$168.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.79
Rate for Payer: Iowa Total Care Managed Medicaid	$38.92
Rate for Payer: Medical Associates Commercial	$72.50
Rate for Payer: Medical Associates Managed Medicare	$38.16
Rate for Payer: Midlands Choice Commercial	$89.67
Rate for Payer: Oscar Health of IA Commercial	$66.02
Rate for Payer: Partners Health Alliance Commercial	$57.24

INJ SINGLE TENDON

Professional

Both

$201.00

Service Code	CPT 20551
Hospital Charge Code	8015895
Hospital Revenue Code	975
Min. Negotiated Rate	$35.17
Max. Negotiated Rate	$140.70
Rate for Payer: Aetna of IA Medicare	$35.17
Rate for Payer: Amerigroup Medicaid	$36.37
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.20
Rate for Payer: Iowa Total Care Managed Medicaid	$35.87
Rate for Payer: Medical Associates Commercial	$66.82
Rate for Payer: Medical Associates Managed Medicare	$35.17
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Oscar Health of IA Commercial	$60.84
Rate for Payer: Partners Health Alliance Commercial	$52.76

INJ TRIGGER POINT 1/2 MUSCL

Professional

Both

$151.00

Service Code	CPT 20552
Hospital Charge Code	7982816
Hospital Revenue Code	981
Min. Negotiated Rate	$33.57
Max. Negotiated Rate	$78.29
Rate for Payer: Aetna of IA Medicare	$33.57
Rate for Payer: Amerigroup Medicaid	$34.71
Rate for Payer: Cash Price	$120.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$40.28
Rate for Payer: Iowa Total Care Managed Medicaid	$34.24
Rate for Payer: Medical Associates Commercial	$60.43
Rate for Payer: Medical Associates Managed Medicare	$33.57
Rate for Payer: Midlands Choice Commercial	$78.29
Rate for Payer: Oscar Health of IA Commercial	$58.08
Rate for Payer: Partners Health Alliance Commercial	$50.36

INR PROTIME PROTHROMBIN TIME

Facility

$43.00

Service Code	CPT 85610
Hospital Charge Code	8093940
Hospital Revenue Code	305
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of IA Commercial	$38.70
Rate for Payer: Aetna of IA Medical Rental Products	$38.70
Rate for Payer: Cash Price	$34.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.25
Rate for Payer: Medical Associates Commercial	$32.25
Rate for Payer: Midlands Choice Commercial	$30.10
Rate for Payer: United Healthcare Commercial	$38.70

INR PROTIME PROTHROMBIN TIME

Facility

$43.00

Service Code	CPT 85610
Hospital Charge Code	8093940
Hospital Revenue Code	305
Min. Negotiated Rate	$21.49
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of IA Commercial	$38.70
Rate for Payer: Aetna of IA Medical Rental Products	$38.70
Rate for Payer: Aetna of IA Medicare	$24.51
Rate for Payer: Amerigroup Medicaid	$21.70
Rate for Payer: Amerigroup Medicare	$21.72
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.50
Rate for Payer: Iowa Total Care Managed Medicaid	$21.49
Rate for Payer: Medical Associates Commercial	$32.25
Rate for Payer: Medical Associates Managed Medicare	$21.50
Rate for Payer: Midlands Choice Commercial	$30.10
Rate for Payer: Molina Healthcare Managed Medicaid	$21.82
Rate for Payer: Molina Healthcare Managed Medicare	$21.81
Rate for Payer: Oscar Health of IA Commercial	$32.25
Rate for Payer: Partners Health Alliance Commercial	$32.25
Rate for Payer: United Healthcare Commercial	$38.70
Rate for Payer: United Healthcare Managed Medicare	$25.37
Rate for Payer: Wellmark IA HMO	$24.18
Rate for Payer: Wellmark IA PPO	$26.60

INR PROTIME PROTHROMBIN TIME

Facility

$43.00

Service Code	CPT 85610
Hospital Charge Code	633793
Hospital Revenue Code	305
Min. Negotiated Rate	$21.49
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of IA Commercial	$38.70
Rate for Payer: Aetna of IA Medical Rental Products	$38.70
Rate for Payer: Aetna of IA Medicare	$24.51
Rate for Payer: Amerigroup Medicaid	$21.70
Rate for Payer: Amerigroup Medicare	$21.72
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cash Price	$34.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.50
Rate for Payer: Iowa Total Care Managed Medicaid	$21.49
Rate for Payer: Medical Associates Commercial	$32.25
Rate for Payer: Medical Associates Managed Medicare	$21.50
Rate for Payer: Midlands Choice Commercial	$30.10
Rate for Payer: Molina Healthcare Managed Medicaid	$21.82
Rate for Payer: Molina Healthcare Managed Medicare	$21.81
Rate for Payer: Oscar Health of IA Commercial	$32.25
Rate for Payer: Partners Health Alliance Commercial	$32.25
Rate for Payer: United Healthcare Commercial	$38.70
Rate for Payer: United Healthcare Managed Medicare	$25.37
Rate for Payer: Wellmark IA HMO	$24.18
Rate for Payer: Wellmark IA PPO	$26.60

INR PROTIME PROTHROMBIN TIME

Facility

$43.00

Service Code	CPT 85610
Hospital Charge Code	633793
Hospital Revenue Code	305
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of IA Commercial	$38.70
Rate for Payer: Aetna of IA Medical Rental Products	$38.70
Rate for Payer: Cash Price	$34.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.25
Rate for Payer: Medical Associates Commercial	$32.25
Rate for Payer: Midlands Choice Commercial	$30.10
Rate for Payer: United Healthcare Commercial	$38.70

INSERT BLADDER CATHETER

Facility

$235.00

Service Code	CPT 51701
Hospital Charge Code	4863314
Hospital Revenue Code	450
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of IA Commercial	$211.50
Rate for Payer: Aetna of IA Medical Rental Products	$211.50
Rate for Payer: Cash Price	$188.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$176.25
Rate for Payer: Medical Associates Commercial	$176.25
Rate for Payer: Midlands Choice Commercial	$164.50
Rate for Payer: United Healthcare Commercial	$211.50

INSERT BLADDER CATHETER

Facility

$235.00

Service Code	CPT 51701
Hospital Charge Code	4863314
Hospital Revenue Code	450
Min. Negotiated Rate	$117.45
Max. Negotiated Rate	$403.74
Rate for Payer: Aetna of IA Commercial	$211.50
Rate for Payer: Aetna of IA Medical Rental Products	$211.50
Rate for Payer: Aetna of IA Medicare	$133.95
Rate for Payer: Amerigroup Medicaid	$118.60
Rate for Payer: Amerigroup Medicare	$118.68
Rate for Payer: Cash Price	$188.00
Rate for Payer: Cash Price	$188.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$176.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$117.50
Rate for Payer: Iowa Total Care Managed Medicaid	$117.45
Rate for Payer: Medical Associates Commercial	$176.25
Rate for Payer: Medical Associates Managed Medicare	$117.50
Rate for Payer: Midlands Choice Commercial	$164.50
Rate for Payer: Molina Healthcare Managed Medicaid	$119.26
Rate for Payer: Molina Healthcare Managed Medicare	$119.19
Rate for Payer: Oscar Health of IA Commercial	$176.25
Rate for Payer: Partners Health Alliance Commercial	$176.25
Rate for Payer: United Healthcare Commercial	$211.50
Rate for Payer: United Healthcare Managed Medicare	$138.65
Rate for Payer: Wellmark IA HMO	$367.04
Rate for Payer: Wellmark IA PPO	$403.74

Insert Chest Tube Procedure

Facility

$1,299.00

Service Code	CPT 32551
Hospital Charge Code	8069122
Hospital Revenue Code	761
Min. Negotiated Rate	$909.30
Max. Negotiated Rate	$1,169.10
Rate for Payer: Aetna of IA Commercial	$1,169.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,169.10
Rate for Payer: Cash Price	$1,039.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$974.25
Rate for Payer: Medical Associates Commercial	$974.25
Rate for Payer: Midlands Choice Commercial	$909.30
Rate for Payer: United Healthcare Commercial	$1,169.10

Insert Chest Tube Procedure

Facility

$1,299.00

Service Code	CPT 32551
Hospital Charge Code	8069122
Hospital Revenue Code	761
Min. Negotiated Rate	$649.24
Max. Negotiated Rate	$1,703.64
Rate for Payer: Aetna of IA Commercial	$1,169.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,169.10
Rate for Payer: Aetna of IA Medicare	$740.43
Rate for Payer: Amerigroup Medicaid	$655.61
Rate for Payer: Amerigroup Medicare	$656.00
Rate for Payer: Cash Price	$1,039.20
Rate for Payer: Cash Price	$1,039.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$974.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$649.50
Rate for Payer: Iowa Total Care Managed Medicaid	$649.24
Rate for Payer: Medical Associates Commercial	$974.25
Rate for Payer: Medical Associates Managed Medicare	$649.50
Rate for Payer: Midlands Choice Commercial	$909.30
Rate for Payer: Molina Healthcare Managed Medicaid	$659.24
Rate for Payer: Molina Healthcare Managed Medicare	$658.85
Rate for Payer: Oscar Health of IA Commercial	$974.25
Rate for Payer: Partners Health Alliance Commercial	$974.25
Rate for Payer: United Healthcare Commercial	$1,169.10
Rate for Payer: United Healthcare Managed Medicare	$766.41
Rate for Payer: Wellmark IA HMO	$1,548.76
Rate for Payer: Wellmark IA PPO	$1,703.64

Know your out-of-pocket cost for care.

All Charges