Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ADM IVP EA ADDL SEQ SAME MED

Facility

$46.00

Service Code	CPT 96376
Hospital Charge Code	4866828
Hospital Revenue Code	761
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Aetna of IA Medicare	$26.22
Rate for Payer: Amerigroup Medicaid	$26.53
Rate for Payer: Amerigroup Medicare	$20.91
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.70
Rate for Payer: Iowa Total Care Managed Medicaid	$26.28
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Medical Associates Managed Medicare	$20.70
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: Molina Healthcare Managed Medicaid	$26.66
Rate for Payer: Partners Health Alliance Commercial	$23.80
Rate for Payer: United Healthcare Commercial	$41.40
Rate for Payer: United Healthcare Managed Medicare	$27.14
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP EA ADDL SEQ SAME MED

Facility

$46.00

Service Code	CPT 96376
Hospital Charge Code	7984748
Hospital Revenue Code	260
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: United Healthcare Commercial	$41.40

ADM IVP EA ADDL SEQ SAME MED

Facility

$46.00

Service Code	CPT 96376
Hospital Charge Code	7984748
Hospital Revenue Code	260
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Aetna of IA Medicare	$26.22
Rate for Payer: Amerigroup Medicaid	$26.53
Rate for Payer: Amerigroup Medicare	$20.91
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.70
Rate for Payer: Iowa Total Care Managed Medicaid	$26.28
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Medical Associates Managed Medicare	$20.70
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: Molina Healthcare Managed Medicaid	$26.66
Rate for Payer: Partners Health Alliance Commercial	$23.80
Rate for Payer: United Healthcare Commercial	$41.40
Rate for Payer: United Healthcare Managed Medicare	$27.14
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP EA ADDL SEQ SAME MED

Facility

$44.00

Service Code	CPT 96376
Hospital Charge Code	6922830
Hospital Revenue Code	260
Min. Negotiated Rate	$19.80
Max. Negotiated Rate	$41.39
Rate for Payer: Aetna of IA Commercial	$39.60
Rate for Payer: Aetna of IA Medical Rental Products	$39.60
Rate for Payer: Aetna of IA Medicare	$25.08
Rate for Payer: Amerigroup Medicaid	$25.38
Rate for Payer: Amerigroup Medicare	$20.00
Rate for Payer: Cash Price	$35.20
Rate for Payer: Cash Price	$35.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$19.80
Rate for Payer: Iowa Total Care Managed Medicaid	$25.13
Rate for Payer: Medical Associates Commercial	$33.00
Rate for Payer: Medical Associates Managed Medicare	$19.80
Rate for Payer: Midlands Choice Commercial	$30.80
Rate for Payer: Molina Healthcare Managed Medicaid	$25.50
Rate for Payer: Partners Health Alliance Commercial	$22.77
Rate for Payer: United Healthcare Commercial	$39.60
Rate for Payer: United Healthcare Managed Medicare	$25.96
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP EA ADDL SEQ SAME MED

Facility

$46.00

Service Code	CPT 96376
Hospital Charge Code	4866828
Hospital Revenue Code	761
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: United Healthcare Commercial	$41.40

ADM IVP EA ADDL SEQ SAME MED

Facility

$44.00

Service Code	CPT 96376
Hospital Charge Code	6922830
Hospital Revenue Code	260
Min. Negotiated Rate	$30.80
Max. Negotiated Rate	$39.60
Rate for Payer: Aetna of IA Commercial	$39.60
Rate for Payer: Aetna of IA Medical Rental Products	$39.60
Rate for Payer: Cash Price	$35.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.00
Rate for Payer: Medical Associates Commercial	$33.00
Rate for Payer: Midlands Choice Commercial	$30.80
Rate for Payer: United Healthcare Commercial	$39.60

ADM IVP EA ADL SEQ SAME MED SC

Facility

$46.00

Service Code	CPT 96376
Hospital Charge Code	8012942
Hospital Revenue Code	761
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Aetna of IA Medicare	$26.22
Rate for Payer: Amerigroup Medicaid	$26.53
Rate for Payer: Amerigroup Medicare	$20.91
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.70
Rate for Payer: Iowa Total Care Managed Medicaid	$26.28
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Medical Associates Managed Medicare	$20.70
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: Molina Healthcare Managed Medicaid	$26.66
Rate for Payer: Partners Health Alliance Commercial	$23.80
Rate for Payer: United Healthcare Commercial	$41.40
Rate for Payer: United Healthcare Managed Medicare	$27.14
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP EA ADL SEQ SAME MED SC

Facility

$46.00

Service Code	CPT 96376
Hospital Charge Code	8012942
Hospital Revenue Code	761
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: United Healthcare Commercial	$41.40

ADM IVP TX

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	4866832
Hospital Revenue Code	260
Min. Negotiated Rate	$37.58
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Aetna of IA Medicare	$61.56
Rate for Payer: Amerigroup Medicaid	$62.29
Rate for Payer: Amerigroup Medicare	$49.09
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$48.60
Rate for Payer: Iowa Total Care Managed Medicaid	$61.69
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Medical Associates Managed Medicare	$48.60
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: Molina Healthcare Managed Medicaid	$62.60
Rate for Payer: Partners Health Alliance Commercial	$55.89
Rate for Payer: United Healthcare Commercial	$97.20
Rate for Payer: United Healthcare Managed Medicare	$63.72
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP TX

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	6922828
Hospital Revenue Code	260
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: United Healthcare Commercial	$97.20

ADM IVP TX

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	4866832
Hospital Revenue Code	260
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: United Healthcare Commercial	$97.20

ADM IVP TX

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	6922828
Hospital Revenue Code	260
Min. Negotiated Rate	$37.58
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Aetna of IA Medicare	$61.56
Rate for Payer: Amerigroup Medicaid	$62.29
Rate for Payer: Amerigroup Medicare	$49.09
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$48.60
Rate for Payer: Iowa Total Care Managed Medicaid	$61.69
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Medical Associates Managed Medicare	$48.60
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: Molina Healthcare Managed Medicaid	$62.60
Rate for Payer: Partners Health Alliance Commercial	$55.89
Rate for Payer: United Healthcare Commercial	$97.20
Rate for Payer: United Healthcare Managed Medicare	$63.72
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP TX EA ADD'L MED

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	6922829
Hospital Revenue Code	260
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP TX EA ADD'L MED

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	4866830
Hospital Revenue Code	260
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP TX EA ADD'L MED

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	4866830
Hospital Revenue Code	260
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

ADM IVP TX EA ADD'L MED

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	6922829
Hospital Revenue Code	260
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

ADM IVP TX, SCHEDULED

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	8012940
Hospital Revenue Code	761
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: United Healthcare Commercial	$97.20

ADM IVP TX, SCHEDULED

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	8012940
Hospital Revenue Code	761
Min. Negotiated Rate	$37.58
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Aetna of IA Medicare	$61.56
Rate for Payer: Amerigroup Medicaid	$62.29
Rate for Payer: Amerigroup Medicare	$49.09
Rate for Payer: Cash Price	$86.40
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$48.60
Rate for Payer: Iowa Total Care Managed Medicaid	$61.69
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Medical Associates Managed Medicare	$48.60
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: Molina Healthcare Managed Medicaid	$62.60
Rate for Payer: Partners Health Alliance Commercial	$55.89
Rate for Payer: United Healthcare Commercial	$97.20
Rate for Payer: United Healthcare Managed Medicare	$63.72
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP TX, SCHEDULED EA ADD'L

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	8012941
Hospital Revenue Code	761
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM IVP TX, SCHEDULED EA ADD'L

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	8012941
Hospital Revenue Code	761
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

ADM IVP TX SCHED W/ OTHER PROC

Facility

$57.00

Service Code	CPT 96374
Hospital Charge Code	8012939
Hospital Revenue Code	761
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

ADM IVP TX SCHED W/ OTHER PROC

Facility

$57.00

Service Code	CPT 96374
Hospital Charge Code	8012939
Hospital Revenue Code	761
Min. Negotiated Rate	$25.65
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: 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	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM VACC 1ST

Facility

$30.00

Service Code	CPT 90471
Hospital Charge Code	4866871
Hospital Revenue Code	771
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of IA Commercial	$27.00
Rate for Payer: Aetna of IA Medical Rental Products	$27.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.50
Rate for Payer: Medical Associates Commercial	$22.50
Rate for Payer: Midlands Choice Commercial	$21.00
Rate for Payer: United Healthcare Commercial	$27.00

ADM VACC 1ST

Facility

$30.00

Service Code	CPT 90471
Hospital Charge Code	4866871
Hospital Revenue Code	771
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$41.39
Rate for Payer: Aetna of IA Commercial	$27.00
Rate for Payer: Aetna of IA Medical Rental Products	$27.00
Rate for Payer: Aetna of IA Medicare	$17.10
Rate for Payer: Amerigroup Medicaid	$17.30
Rate for Payer: Amerigroup Medicare	$13.64
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.50
Rate for Payer: Iowa Total Care Managed Medicaid	$17.14
Rate for Payer: Medical Associates Commercial	$22.50
Rate for Payer: Medical Associates Managed Medicare	$13.50
Rate for Payer: Midlands Choice Commercial	$21.00
Rate for Payer: Molina Healthcare Managed Medicaid	$17.39
Rate for Payer: Partners Health Alliance Commercial	$15.52
Rate for Payer: United Healthcare Commercial	$27.00
Rate for Payer: United Healthcare Managed Medicare	$17.70
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADM VACC EA ADDL VACCINE

Facility

$41.00

Service Code	CPT 90472
Hospital Charge Code	4866874
Hospital Revenue Code	771
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of IA Commercial	$36.90
Rate for Payer: Aetna of IA Medical Rental Products	$36.90
Rate for Payer: Cash Price	$32.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.75
Rate for Payer: Medical Associates Commercial	$30.75
Rate for Payer: Midlands Choice Commercial	$28.70
Rate for Payer: United Healthcare Commercial	$36.90

Know your out-of-pocket cost for care.

All Charges