Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

VIRAL CULTURE

Facility

$139.00

Service Code	CPT 87252
Hospital Charge Code	8519125
Hospital Revenue Code	306
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

Viral Illness With MCC

Facility

$8,902.47

Service Code	MS-DRG 865
Hospital Charge Code	601
Min. Negotiated Rate	$8,773.45
Max. Negotiated Rate	$8,902.47
Rate for Payer: Amerigroup Medicaid	$8,859.46
Rate for Payer: Iowa Total Care Managed Medicaid	$8,773.45
Rate for Payer: Molina Healthcare Managed Medicaid	$8,902.47

Viral Illness Without MCC

Facility

$5,221.40

Service Code	MS-DRG 866
Hospital Charge Code	602
Min. Negotiated Rate	$5,145.73
Max. Negotiated Rate	$5,221.40
Rate for Payer: Amerigroup Medicaid	$5,196.17
Rate for Payer: Iowa Total Care Managed Medicaid	$5,145.73
Rate for Payer: Molina Healthcare Managed Medicaid	$5,221.40

Viral Meningitis With CC/MCC

Facility

$8,718.42

Service Code	MS-DRG 075
Hospital Charge Code	755
Min. Negotiated Rate	$8,592.06
Max. Negotiated Rate	$8,718.42
Rate for Payer: Amerigroup Medicaid	$8,676.30
Rate for Payer: Iowa Total Care Managed Medicaid	$8,592.06
Rate for Payer: Molina Healthcare Managed Medicaid	$8,718.42

Viral Meningitis Without CC/MCC

Facility

$5,572.77

Service Code	MS-DRG 076
Hospital Charge Code	756
Min. Negotiated Rate	$5,492.01
Max. Negotiated Rate	$5,572.77
Rate for Payer: Amerigroup Medicaid	$5,545.85
Rate for Payer: Iowa Total Care Managed Medicaid	$5,492.01
Rate for Payer: Molina Healthcare Managed Medicaid	$5,572.77

Viscosity DMCL

Facility

$100.00

Service Code	CPT 85810
Hospital Charge Code	8519256
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: United Healthcare Commercial	$90.00

Viscosity DMCL

Facility

$100.00

Service Code	CPT 85810
Hospital Charge Code	8519256
Hospital Revenue Code	301
Min. Negotiated Rate	$49.98
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Aetna of IA Medicare	$57.00
Rate for Payer: Amerigroup Medicaid	$50.47
Rate for Payer: Amerigroup Medicare	$50.50
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$50.00
Rate for Payer: Iowa Total Care Managed Medicaid	$49.98
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Medical Associates Managed Medicare	$50.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: Molina Healthcare Managed Medicaid	$50.75
Rate for Payer: Molina Healthcare Managed Medicare	$50.72
Rate for Payer: Oscar Health of IA Commercial	$75.00
Rate for Payer: Partners Health Alliance Commercial	$75.00
Rate for Payer: United Healthcare Commercial	$90.00
Rate for Payer: United Healthcare Managed Medicare	$59.00
Rate for Payer: Wellmark IA HMO	$68.82
Rate for Payer: Wellmark IA PPO	$75.70

VITAL CAPACITY, TOTAL

Facility

$260.00

Service Code	CPT 94150
Hospital Charge Code	7980861
Hospital Revenue Code	460
Min. Negotiated Rate	$129.95
Max. Negotiated Rate	$282.35
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Aetna of IA Medicare	$148.20
Rate for Payer: Amerigroup Medicaid	$131.22
Rate for Payer: Amerigroup Medicare	$131.30
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$130.00
Rate for Payer: Iowa Total Care Managed Medicaid	$129.95
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$130.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$131.95
Rate for Payer: Molina Healthcare Managed Medicare	$131.87
Rate for Payer: Oscar Health of IA Commercial	$195.00
Rate for Payer: Partners Health Alliance Commercial	$195.00
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40
Rate for Payer: Wellmark IA HMO	$256.68
Rate for Payer: Wellmark IA PPO	$282.35

VITAL CAPACITY, TOTAL

Facility

$260.00

Service Code	CPT 94150
Hospital Charge Code	7980861
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

VITAL CAPACITY, TOTAL

Facility

$260.00

Service Code	CPT 94150
Hospital Charge Code	5338941
Hospital Revenue Code	460
Min. Negotiated Rate	$129.95
Max. Negotiated Rate	$282.35
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Aetna of IA Medicare	$148.20
Rate for Payer: Amerigroup Medicaid	$131.22
Rate for Payer: Amerigroup Medicare	$131.30
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$130.00
Rate for Payer: Iowa Total Care Managed Medicaid	$129.95
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$130.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$131.95
Rate for Payer: Molina Healthcare Managed Medicare	$131.87
Rate for Payer: Oscar Health of IA Commercial	$195.00
Rate for Payer: Partners Health Alliance Commercial	$195.00
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40
Rate for Payer: Wellmark IA HMO	$256.68
Rate for Payer: Wellmark IA PPO	$282.35

VITAL CAPACITY, TOTAL

Facility

$260.00

Service Code	CPT 94150
Hospital Charge Code	5338941
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

Vitamin A DMCL

Facility

$139.00

Service Code	CPT 84590
Hospital Charge Code	8037824
Hospital Revenue Code	301
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

Vitamin A DMCL

Facility

$139.00

Service Code	CPT 84590
Hospital Charge Code	8037824
Hospital Revenue Code	301
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Molina Healthcare Managed Medicare	$70.50
Rate for Payer: Oscar Health of IA Commercial	$104.25
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

vitamin A & D Top Oint [VDMC]

Facility

$26.71

Service Code	HCPCS A9270
Hospital Charge Code	10428349
Hospital Revenue Code	259
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$24.04
Rate for Payer: Aetna of IA Commercial	$24.04
Rate for Payer: Aetna of IA Medical Rental Products	$24.04
Rate for Payer: Aetna of IA Medicare	$15.22
Rate for Payer: Amerigroup Medicaid	$13.48
Rate for Payer: Amerigroup Medicare	$13.49
Rate for Payer: Cash Price	$21.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.36
Rate for Payer: Iowa Total Care Managed Medicaid	$13.35
Rate for Payer: Medical Associates Commercial	$20.03
Rate for Payer: Medical Associates Managed Medicare	$13.36
Rate for Payer: Midlands Choice Commercial	$18.70
Rate for Payer: Molina Healthcare Managed Medicaid	$13.56
Rate for Payer: Molina Healthcare Managed Medicare	$13.55
Rate for Payer: Oscar Health of IA Commercial	$20.03
Rate for Payer: Partners Health Alliance Commercial	$20.03
Rate for Payer: United Healthcare Commercial	$24.04
Rate for Payer: United Healthcare Managed Medicare	$15.76

vitamin A & D Top Oint [VDMC]

Facility

$26.71

Service Code	HCPCS A9270
Hospital Charge Code	10428349
Hospital Revenue Code	259
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$24.04
Rate for Payer: Aetna of IA Commercial	$24.04
Rate for Payer: Aetna of IA Medical Rental Products	$24.04
Rate for Payer: Cash Price	$21.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.03
Rate for Payer: Medical Associates Commercial	$20.03
Rate for Payer: Midlands Choice Commercial	$18.70
Rate for Payer: United Healthcare Commercial	$24.04

Vitamin B-12

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	8146790
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
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	$51.98
Rate for Payer: Amerigroup Medicare	$52.02
Rate for Payer: Cash Price	$82.40
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	$51.50
Rate for Payer: Iowa Total Care Managed Medicaid	$51.48
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Medical Associates Managed Medicare	$51.50
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: Molina Healthcare Managed Medicaid	$52.27
Rate for Payer: Molina Healthcare Managed Medicare	$52.24
Rate for Payer: Oscar Health of IA Commercial	$77.25
Rate for Payer: Partners Health Alliance Commercial	$77.25
Rate for Payer: United Healthcare Commercial	$92.70
Rate for Payer: United Healthcare Managed Medicare	$60.77
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Vitamin B-12

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	8146790
Hospital Revenue Code	301
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

Vitamin B12 and Folate DMCL

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	8037826
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
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	$51.98
Rate for Payer: Amerigroup Medicare	$52.02
Rate for Payer: Cash Price	$82.40
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	$51.50
Rate for Payer: Iowa Total Care Managed Medicaid	$51.48
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Medical Associates Managed Medicare	$51.50
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: Molina Healthcare Managed Medicaid	$52.27
Rate for Payer: Molina Healthcare Managed Medicare	$52.24
Rate for Payer: Oscar Health of IA Commercial	$77.25
Rate for Payer: Partners Health Alliance Commercial	$77.25
Rate for Payer: United Healthcare Commercial	$92.70
Rate for Payer: United Healthcare Managed Medicare	$60.77
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Vitamin B12 and Folate DMCL

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	8037826
Hospital Revenue Code	301
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

Vitamin B12 Level DMCL

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	8037827
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
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	$51.98
Rate for Payer: Amerigroup Medicare	$52.02
Rate for Payer: Cash Price	$82.40
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	$51.50
Rate for Payer: Iowa Total Care Managed Medicaid	$51.48
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Medical Associates Managed Medicare	$51.50
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: Molina Healthcare Managed Medicaid	$52.27
Rate for Payer: Molina Healthcare Managed Medicare	$52.24
Rate for Payer: Oscar Health of IA Commercial	$77.25
Rate for Payer: Partners Health Alliance Commercial	$77.25
Rate for Payer: United Healthcare Commercial	$92.70
Rate for Payer: United Healthcare Managed Medicare	$60.77
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Vitamin B12 Level DMCL

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	8037827
Hospital Revenue Code	301
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

Vitamin B12 Lvl TMCL

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	4008786
Hospital Revenue Code	301
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

Vitamin B12 Lvl TMCL

Facility

$103.00

Service Code	CPT 82607
Hospital Charge Code	4008786
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
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	$51.98
Rate for Payer: Amerigroup Medicare	$52.02
Rate for Payer: Cash Price	$82.40
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	$51.50
Rate for Payer: Iowa Total Care Managed Medicaid	$51.48
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Medical Associates Managed Medicare	$51.50
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: Molina Healthcare Managed Medicaid	$52.27
Rate for Payer: Molina Healthcare Managed Medicare	$52.24
Rate for Payer: Oscar Health of IA Commercial	$77.25
Rate for Payer: Partners Health Alliance Commercial	$77.25
Rate for Payer: United Healthcare Commercial	$92.70
Rate for Payer: United Healthcare Managed Medicare	$60.77
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Vitamin B1 Level DMCL

Facility

$173.00

Service Code	CPT 84425
Hospital Charge Code	8037825
Hospital Revenue Code	301
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of IA Commercial	$155.70
Rate for Payer: Aetna of IA Medical Rental Products	$155.70
Rate for Payer: Aetna of IA Medicare	$98.61
Rate for Payer: Amerigroup Medicaid	$87.31
Rate for Payer: Amerigroup Medicare	$87.36
Rate for Payer: Cash Price	$138.40
Rate for Payer: Cash Price	$138.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$86.50
Rate for Payer: Iowa Total Care Managed Medicaid	$86.47
Rate for Payer: Medical Associates Commercial	$129.75
Rate for Payer: Medical Associates Managed Medicare	$86.50
Rate for Payer: Midlands Choice Commercial	$121.10
Rate for Payer: Molina Healthcare Managed Medicaid	$87.80
Rate for Payer: Molina Healthcare Managed Medicare	$87.75
Rate for Payer: Oscar Health of IA Commercial	$129.75
Rate for Payer: Partners Health Alliance Commercial	$129.75
Rate for Payer: United Healthcare Commercial	$155.70
Rate for Payer: United Healthcare Managed Medicare	$102.07
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

Vitamin B1 Level DMCL

Facility

$173.00

Service Code	CPT 84425
Hospital Charge Code	8037825
Hospital Revenue Code	301
Min. Negotiated Rate	$121.10
Max. Negotiated Rate	$155.70
Rate for Payer: Aetna of IA Commercial	$155.70
Rate for Payer: Aetna of IA Medical Rental Products	$155.70
Rate for Payer: Cash Price	$138.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.75
Rate for Payer: Medical Associates Commercial	$129.75
Rate for Payer: Midlands Choice Commercial	$121.10
Rate for Payer: United Healthcare Commercial	$155.70

Know your out-of-pocket cost for care.

All Charges