Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

INF TX MED 1ST HR

Facility

$382.00

Service Code	CPT 96365
Hospital Charge Code	4866843
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

INF TX MED 1ST HR

Facility

$382.00

Service Code	CPT 96365
Hospital Charge Code	6922795
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

INF TX MED EA ADDL HOUR

Facility

$161.00

Service Code	CPT 96366
Hospital Charge Code	4866842
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

INF TX MED EA ADDL HOUR

Facility

$161.00

Service Code	CPT 96366
Hospital Charge Code	4866842
Hospital Revenue Code	260
Min. Negotiated Rate	$72.45
Max. Negotiated Rate	$690.40
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$626.76
Rate for Payer: Wellmark IA PPO	$690.40

INF TX MED EA ADDL HOUR

Facility

$161.00

Service Code	CPT 96366
Hospital Charge Code	6922796
Hospital Revenue Code	260
Min. Negotiated Rate	$72.45
Max. Negotiated Rate	$690.40
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$626.76
Rate for Payer: Wellmark IA PPO	$690.40

INF TX MED EA ADDL HOUR

Facility

$161.00

Service Code	CPT 96366
Hospital Charge Code	6922796
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

INF TX MED SCHED 1ST HR

Facility

$382.00

Service Code	CPT 96365
Hospital Charge Code	8012937
Hospital Revenue Code	260
Min. Negotiated Rate	$171.90
Max. Negotiated Rate	$598.25
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: 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	$197.68
Rate for Payer: United Healthcare Commercial	$343.80
Rate for Payer: United Healthcare Managed Medicare	$225.38
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

INF TX MED SCHED 1ST HR

Facility

$382.00

Service Code	CPT 96365
Hospital Charge Code	8012937
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

INFUSAPORT DRAW FOR LAB

Facility

$26.00

Service Code	CPT 36591
Hospital Charge Code	7796499
Hospital Revenue Code	761
Min. Negotiated Rate	$11.70
Max. Negotiated Rate	$459.23
Rate for Payer: Aetna of IA Commercial	$23.40
Rate for Payer: Aetna of IA Medical Rental Products	$23.40
Rate for Payer: Aetna of IA Medicare	$14.82
Rate for Payer: Amerigroup Medicaid	$15.00
Rate for Payer: Amerigroup Medicare	$11.82
Rate for Payer: Cash Price	$20.80
Rate for Payer: Cash Price	$20.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.70
Rate for Payer: Iowa Total Care Managed Medicaid	$14.85
Rate for Payer: Medical Associates Commercial	$19.50
Rate for Payer: Medical Associates Managed Medicare	$11.70
Rate for Payer: Midlands Choice Commercial	$18.20
Rate for Payer: Molina Healthcare Managed Medicaid	$15.07
Rate for Payer: Partners Health Alliance Commercial	$13.46
Rate for Payer: United Healthcare Commercial	$23.40
Rate for Payer: United Healthcare Managed Medicare	$15.34
Rate for Payer: Wellmark IA HMO WHPI	$416.89
Rate for Payer: Wellmark IA PPO	$459.23

INFUSAPORT DRAW FOR LAB

Facility

$26.00

Service Code	CPT 36591
Hospital Charge Code	7796499
Hospital Revenue Code	761
Min. Negotiated Rate	$18.20
Max. Negotiated Rate	$23.40
Rate for Payer: Aetna of IA Commercial	$23.40
Rate for Payer: Aetna of IA Medical Rental Products	$23.40
Rate for Payer: Cash Price	$20.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.50
Rate for Payer: Medical Associates Commercial	$19.50
Rate for Payer: Midlands Choice Commercial	$18.20
Rate for Payer: United Healthcare Commercial	$23.40

INFUSAPORT REMOVAL ER CHARGE

Professional

Both

$465.00

Hospital Charge Code	8068985
Hospital Revenue Code	981
Min. Negotiated Rate	$325.50
Max. Negotiated Rate	$348.75
Rate for Payer: Cash Price	$372.00
Rate for Payer: Medical Associates Commercial	$348.75
Rate for Payer: Midlands Choice Commercial	$325.50
Rate for Payer: Partners Health Alliance Commercial	$348.75

INFUSION TX CONCURRENT

Facility

$57.00

Service Code	CPT 96368
Hospital Charge Code	7984744
Hospital Revenue Code	260
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$51.30
Rate for Payer: Aetna of IA Commercial	$51.30
Rate for Payer: Aetna of IA Medical Rental Products	$51.30
Rate for Payer: Cash Price	$45.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.75
Rate for Payer: Medical Associates Commercial	$42.75
Rate for Payer: Midlands Choice Commercial	$39.90
Rate for Payer: United Healthcare Commercial	$51.30

INFUSION TX CONCURRENT

Facility

$57.00

Service Code	CPT 96368
Hospital Charge Code	7984744
Hospital Revenue Code	260
Min. Negotiated Rate	$25.65
Max. Negotiated Rate	$598.25
Rate for Payer: Aetna of IA Commercial	$51.30
Rate for Payer: Aetna of IA Medical Rental Products	$51.30
Rate for Payer: Aetna of IA Medicare	$32.49
Rate for Payer: Amerigroup Medicaid	$32.88
Rate for Payer: Amerigroup Medicare	$25.91
Rate for Payer: Cash Price	$45.60
Rate for Payer: Cash Price	$45.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.65
Rate for Payer: Iowa Total Care Managed Medicaid	$32.56
Rate for Payer: Medical Associates Commercial	$42.75
Rate for Payer: Medical Associates Managed Medicare	$25.65
Rate for Payer: Midlands Choice Commercial	$39.90
Rate for Payer: Molina Healthcare Managed Medicaid	$33.04
Rate for Payer: Partners Health Alliance Commercial	$29.50
Rate for Payer: United Healthcare Commercial	$51.30
Rate for Payer: United Healthcare Managed Medicare	$33.63
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

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 EA SEQUENTIAL INF

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	7984743
Hospital Revenue Code	260
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$598.25
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	$104.54
Rate for Payer: Cash Price	$184.00
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	$119.02
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

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	$598.25
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

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 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 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	$690.40
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$626.76
Rate for Payer: Wellmark IA PPO	$690.40

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	$598.25
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: 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	$197.68
Rate for Payer: United Healthcare Commercial	$343.80
Rate for Payer: United Healthcare Managed Medicare	$225.38
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

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 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 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	$690.40
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$626.76
Rate for Payer: Wellmark IA PPO	$690.40

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	$598.25
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	$104.54
Rate for Payer: Cash Price	$184.00
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	$119.02
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

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

Know your out-of-pocket cost for care.

All Charges