Price Transparency

Know your out-of-pocket cost for care.

search
Charge Type Setting Price  
Service Code CPT 25600
Hospital Charge Code 7982806
Hospital Revenue Code 981
Min. Negotiated Rate $253.10
Max. Negotiated Rate $815.25
Rate for Payer: Amerigroup Medicaid $255.58
Rate for Payer: Cash Price $869.60
Rate for Payer: Cash Price $869.60
Rate for Payer: Iowa Total Care Managed Medicaid $253.10
Rate for Payer: Medical Associates Commercial $815.25
Rate for Payer: Midlands Choice Commercial $760.90
Rate for Payer: Molina Healthcare Managed Medicaid $254.34
Rate for Payer: Partners Health Alliance Commercial $815.25
Rate for Payer: United Healthcare Commercial $498.50
Rate for Payer: Wellmark IA HMO WHPI $669.30
Rate for Payer: Wellmark IA PPO $787.40
Service Code CPT 25605
Hospital Charge Code 7982805
Hospital Revenue Code 981
Min. Negotiated Rate $447.76
Max. Negotiated Rate $1,353.75
Rate for Payer: Amerigroup Medicaid $452.15
Rate for Payer: Cash Price $1,444.00
Rate for Payer: Cash Price $1,444.00
Rate for Payer: Iowa Total Care Managed Medicaid $447.76
Rate for Payer: Medical Associates Commercial $1,353.75
Rate for Payer: Midlands Choice Commercial $1,263.50
Rate for Payer: Molina Healthcare Managed Medicaid $449.95
Rate for Payer: Partners Health Alliance Commercial $1,353.75
Rate for Payer: United Healthcare Commercial $814.96
Rate for Payer: Wellmark IA HMO WHPI $1,054.80
Rate for Payer: Wellmark IA PPO $1,241.00
Service Code CPT 25600
Hospital Charge Code 4864850
Hospital Revenue Code 450
Min. Negotiated Rate $439.60
Max. Negotiated Rate $565.20
Rate for Payer: Aetna of IA Commercial $565.20
Rate for Payer: Aetna of IA Medical Rental Products $565.20
Rate for Payer: Cash Price $502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $471.00
Rate for Payer: Medical Associates Commercial $471.00
Rate for Payer: Midlands Choice Commercial $439.60
Rate for Payer: United Healthcare Commercial $565.20
Service Code CPT 25605
Hospital Charge Code 4864851
Hospital Revenue Code 450
Min. Negotiated Rate $879.20
Max. Negotiated Rate $1,130.40
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: United Healthcare Commercial $1,130.40
Service Code CPT 25605
Hospital Charge Code 4864851
Hospital Revenue Code 450
Min. Negotiated Rate $565.20
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Aetna of IA Medicare $715.92
Rate for Payer: Amerigroup Medicaid $724.46
Rate for Payer: Amerigroup Medicare $570.85
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $565.20
Rate for Payer: Iowa Total Care Managed Medicaid $717.43
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Medical Associates Managed Medicare $565.20
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: Molina Healthcare Managed Medicaid $727.98
Rate for Payer: Partners Health Alliance Commercial $649.98
Rate for Payer: United Healthcare Commercial $1,130.40
Rate for Payer: United Healthcare Managed Medicare $741.04
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 25600
Hospital Charge Code 4864850
Hospital Revenue Code 450
Min. Negotiated Rate $282.60
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $565.20
Rate for Payer: Aetna of IA Medical Rental Products $565.20
Rate for Payer: Aetna of IA Medicare $357.96
Rate for Payer: Amerigroup Medicaid $362.23
Rate for Payer: Amerigroup Medicare $285.43
Rate for Payer: Cash Price $502.40
Rate for Payer: Cash Price $502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $471.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $282.60
Rate for Payer: Iowa Total Care Managed Medicaid $358.71
Rate for Payer: Medical Associates Commercial $471.00
Rate for Payer: Medical Associates Managed Medicare $282.60
Rate for Payer: Midlands Choice Commercial $439.60
Rate for Payer: Molina Healthcare Managed Medicaid $363.99
Rate for Payer: Partners Health Alliance Commercial $324.99
Rate for Payer: United Healthcare Commercial $565.20
Rate for Payer: United Healthcare Managed Medicare $370.52
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 26686
Hospital Charge Code 7982927
Hospital Revenue Code 450
Min. Negotiated Rate $2,457.00
Max. Negotiated Rate $3,159.00
Rate for Payer: Aetna of IA Commercial $3,159.00
Rate for Payer: Aetna of IA Medical Rental Products $3,159.00
Rate for Payer: Cash Price $2,808.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $2,632.50
Rate for Payer: Medical Associates Commercial $2,632.50
Rate for Payer: Midlands Choice Commercial $2,457.00
Rate for Payer: United Healthcare Commercial $3,159.00
Service Code CPT 26686
Hospital Charge Code 7982927
Hospital Revenue Code 450
Min. Negotiated Rate $1,579.50
Max. Negotiated Rate $10,774.68
Rate for Payer: Aetna of IA Commercial $3,159.00
Rate for Payer: Aetna of IA Medical Rental Products $3,159.00
Rate for Payer: Aetna of IA Medicare $2,000.70
Rate for Payer: Amerigroup Medicaid $2,024.57
Rate for Payer: Amerigroup Medicare $1,595.30
Rate for Payer: Cash Price $2,808.00
Rate for Payer: Cash Price $2,808.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $2,632.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $1,579.50
Rate for Payer: Iowa Total Care Managed Medicaid $2,004.91
Rate for Payer: Medical Associates Commercial $2,632.50
Rate for Payer: Medical Associates Managed Medicare $1,579.50
Rate for Payer: Midlands Choice Commercial $2,457.00
Rate for Payer: Molina Healthcare Managed Medicaid $2,034.40
Rate for Payer: Partners Health Alliance Commercial $1,816.42
Rate for Payer: United Healthcare Commercial $3,159.00
Rate for Payer: United Healthcare Managed Medicare $2,070.90
Rate for Payer: Wellmark IA HMO WHPI $9,781.36
Rate for Payer: Wellmark IA PPO $10,774.68
Service Code CPT 26686
Hospital Charge Code 7982867
Hospital Revenue Code 981
Min. Negotiated Rate $545.28
Max. Negotiated Rate $1,563.75
Rate for Payer: Amerigroup Medicaid $550.63
Rate for Payer: Cash Price $1,668.00
Rate for Payer: Cash Price $1,668.00
Rate for Payer: Iowa Total Care Managed Medicaid $545.28
Rate for Payer: Medical Associates Commercial $1,563.75
Rate for Payer: Midlands Choice Commercial $1,459.50
Rate for Payer: Molina Healthcare Managed Medicaid $547.95
Rate for Payer: Partners Health Alliance Commercial $1,563.75
Rate for Payer: United Healthcare Commercial $941.14
Rate for Payer: Wellmark IA HMO WHPI $1,196.40
Rate for Payer: Wellmark IA PPO $1,407.50
Service Code CPT 27265
Hospital Charge Code 4864782
Hospital Revenue Code 450
Min. Negotiated Rate $339.30
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $678.60
Rate for Payer: Aetna of IA Medical Rental Products $678.60
Rate for Payer: Aetna of IA Medicare $429.78
Rate for Payer: Amerigroup Medicaid $434.91
Rate for Payer: Amerigroup Medicare $342.69
Rate for Payer: Cash Price $603.20
Rate for Payer: Cash Price $603.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $565.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $339.30
Rate for Payer: Iowa Total Care Managed Medicaid $430.68
Rate for Payer: Medical Associates Commercial $565.50
Rate for Payer: Medical Associates Managed Medicare $339.30
Rate for Payer: Midlands Choice Commercial $527.80
Rate for Payer: Molina Healthcare Managed Medicaid $437.02
Rate for Payer: Partners Health Alliance Commercial $390.20
Rate for Payer: United Healthcare Commercial $678.60
Rate for Payer: United Healthcare Managed Medicare $444.86
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 27265
Hospital Charge Code 4864782
Hospital Revenue Code 450
Min. Negotiated Rate $527.80
Max. Negotiated Rate $678.60
Rate for Payer: Aetna of IA Commercial $678.60
Rate for Payer: Aetna of IA Medical Rental Products $678.60
Rate for Payer: Cash Price $603.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $565.50
Rate for Payer: Medical Associates Commercial $565.50
Rate for Payer: Midlands Choice Commercial $527.80
Rate for Payer: United Healthcare Commercial $678.60
Service Code CPT 27250
Hospital Charge Code 4863441
Hospital Revenue Code 450
Min. Negotiated Rate $388.80
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $777.60
Rate for Payer: Aetna of IA Medical Rental Products $777.60
Rate for Payer: Aetna of IA Medicare $492.48
Rate for Payer: Amerigroup Medicaid $498.36
Rate for Payer: Amerigroup Medicare $392.69
Rate for Payer: Cash Price $691.20
Rate for Payer: Cash Price $691.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $648.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $388.80
Rate for Payer: Iowa Total Care Managed Medicaid $493.52
Rate for Payer: Medical Associates Commercial $648.00
Rate for Payer: Medical Associates Managed Medicare $388.80
Rate for Payer: Midlands Choice Commercial $604.80
Rate for Payer: Molina Healthcare Managed Medicaid $500.77
Rate for Payer: Partners Health Alliance Commercial $447.12
Rate for Payer: United Healthcare Commercial $777.60
Rate for Payer: United Healthcare Managed Medicare $509.76
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 27266
Hospital Charge Code 4864789
Hospital Revenue Code 450
Min. Negotiated Rate $626.85
Max. Negotiated Rate $2,696.01
Rate for Payer: Aetna of IA Commercial $1,253.70
Rate for Payer: Aetna of IA Medical Rental Products $1,253.70
Rate for Payer: Aetna of IA Medicare $794.01
Rate for Payer: Amerigroup Medicaid $803.48
Rate for Payer: Amerigroup Medicare $633.12
Rate for Payer: Cash Price $1,114.40
Rate for Payer: Cash Price $1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $1,044.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $626.85
Rate for Payer: Iowa Total Care Managed Medicaid $795.68
Rate for Payer: Medical Associates Commercial $1,044.75
Rate for Payer: Medical Associates Managed Medicare $626.85
Rate for Payer: Midlands Choice Commercial $975.10
Rate for Payer: Molina Healthcare Managed Medicaid $807.38
Rate for Payer: Partners Health Alliance Commercial $720.88
Rate for Payer: United Healthcare Commercial $1,253.70
Rate for Payer: United Healthcare Managed Medicare $821.87
Rate for Payer: Wellmark IA HMO WHPI $2,447.47
Rate for Payer: Wellmark IA PPO $2,696.01
Service Code CPT 27250
Hospital Charge Code 4863441
Hospital Revenue Code 450
Min. Negotiated Rate $604.80
Max. Negotiated Rate $777.60
Rate for Payer: Aetna of IA Commercial $777.60
Rate for Payer: Aetna of IA Medical Rental Products $777.60
Rate for Payer: Cash Price $691.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $648.00
Rate for Payer: Medical Associates Commercial $648.00
Rate for Payer: Midlands Choice Commercial $604.80
Rate for Payer: United Healthcare Commercial $777.60
Service Code CPT 27266
Hospital Charge Code 4864789
Hospital Revenue Code 450
Min. Negotiated Rate $975.10
Max. Negotiated Rate $1,253.70
Rate for Payer: Aetna of IA Commercial $1,253.70
Rate for Payer: Aetna of IA Medical Rental Products $1,253.70
Rate for Payer: Cash Price $1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $1,044.75
Rate for Payer: Medical Associates Commercial $1,044.75
Rate for Payer: Midlands Choice Commercial $975.10
Rate for Payer: United Healthcare Commercial $1,253.70
Service Code CPT 23605
Hospital Charge Code 4864815
Hospital Revenue Code 450
Min. Negotiated Rate $565.20
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Aetna of IA Medicare $715.92
Rate for Payer: Amerigroup Medicaid $724.46
Rate for Payer: Amerigroup Medicare $570.85
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $565.20
Rate for Payer: Iowa Total Care Managed Medicaid $717.43
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Medical Associates Managed Medicare $565.20
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: Molina Healthcare Managed Medicaid $727.98
Rate for Payer: Partners Health Alliance Commercial $649.98
Rate for Payer: United Healthcare Commercial $1,130.40
Rate for Payer: United Healthcare Managed Medicare $741.04
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 24505
Hospital Charge Code 4864827
Hospital Revenue Code 450
Min. Negotiated Rate $879.20
Max. Negotiated Rate $1,130.40
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: United Healthcare Commercial $1,130.40
Service Code CPT 23625
Hospital Charge Code 4864817
Hospital Revenue Code 450
Min. Negotiated Rate $565.20
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Aetna of IA Medicare $715.92
Rate for Payer: Amerigroup Medicaid $724.46
Rate for Payer: Amerigroup Medicare $570.85
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $565.20
Rate for Payer: Iowa Total Care Managed Medicaid $717.43
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Medical Associates Managed Medicare $565.20
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: Molina Healthcare Managed Medicaid $727.98
Rate for Payer: Partners Health Alliance Commercial $649.98
Rate for Payer: United Healthcare Commercial $1,130.40
Rate for Payer: United Healthcare Managed Medicare $741.04
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 24505
Hospital Charge Code 7982809
Hospital Revenue Code 981
Min. Negotiated Rate $441.64
Max. Negotiated Rate $1,242.75
Rate for Payer: Amerigroup Medicaid $445.97
Rate for Payer: Cash Price $1,325.60
Rate for Payer: Cash Price $1,325.60
Rate for Payer: Iowa Total Care Managed Medicaid $441.64
Rate for Payer: Medical Associates Commercial $1,242.75
Rate for Payer: Midlands Choice Commercial $1,159.90
Rate for Payer: Molina Healthcare Managed Medicaid $443.80
Rate for Payer: Partners Health Alliance Commercial $1,242.75
Rate for Payer: United Healthcare Commercial $750.69
Rate for Payer: Wellmark IA HMO WHPI $987.50
Rate for Payer: Wellmark IA PPO $1,161.80
Service Code CPT 23605
Hospital Charge Code 4864815
Hospital Revenue Code 450
Min. Negotiated Rate $879.20
Max. Negotiated Rate $1,130.40
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: United Healthcare Commercial $1,130.40
Service Code CPT 24505
Hospital Charge Code 4864827
Hospital Revenue Code 450
Min. Negotiated Rate $565.20
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Aetna of IA Medicare $715.92
Rate for Payer: Amerigroup Medicaid $724.46
Rate for Payer: Amerigroup Medicare $570.85
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $565.20
Rate for Payer: Iowa Total Care Managed Medicaid $717.43
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Medical Associates Managed Medicare $565.20
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: Molina Healthcare Managed Medicaid $727.98
Rate for Payer: Partners Health Alliance Commercial $649.98
Rate for Payer: United Healthcare Commercial $1,130.40
Rate for Payer: United Healthcare Managed Medicare $741.04
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 23625
Hospital Charge Code 4864817
Hospital Revenue Code 450
Min. Negotiated Rate $879.20
Max. Negotiated Rate $1,130.40
Rate for Payer: Aetna of IA Commercial $1,130.40
Rate for Payer: Aetna of IA Medical Rental Products $1,130.40
Rate for Payer: Cash Price $1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $942.00
Rate for Payer: Medical Associates Commercial $942.00
Rate for Payer: Midlands Choice Commercial $879.20
Rate for Payer: United Healthcare Commercial $1,130.40
Service Code CPT 24500
Hospital Charge Code 4864825
Hospital Revenue Code 450
Min. Negotiated Rate $282.60
Max. Negotiated Rate $2,009.51
Rate for Payer: Aetna of IA Commercial $565.20
Rate for Payer: Aetna of IA Medical Rental Products $565.20
Rate for Payer: Aetna of IA Medicare $357.96
Rate for Payer: Amerigroup Medicaid $362.23
Rate for Payer: Amerigroup Medicare $285.43
Rate for Payer: Cash Price $502.40
Rate for Payer: Cash Price $502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $471.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS $282.60
Rate for Payer: Iowa Total Care Managed Medicaid $358.71
Rate for Payer: Medical Associates Commercial $471.00
Rate for Payer: Medical Associates Managed Medicare $282.60
Rate for Payer: Midlands Choice Commercial $439.60
Rate for Payer: Molina Healthcare Managed Medicaid $363.99
Rate for Payer: Partners Health Alliance Commercial $324.99
Rate for Payer: United Healthcare Commercial $565.20
Rate for Payer: United Healthcare Managed Medicare $370.52
Rate for Payer: Wellmark IA HMO WHPI $1,824.26
Rate for Payer: Wellmark IA PPO $2,009.51
Service Code CPT 24500
Hospital Charge Code 4864825
Hospital Revenue Code 450
Min. Negotiated Rate $439.60
Max. Negotiated Rate $565.20
Rate for Payer: Aetna of IA Commercial $565.20
Rate for Payer: Aetna of IA Medical Rental Products $565.20
Rate for Payer: Cash Price $502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial $471.00
Rate for Payer: Medical Associates Commercial $471.00
Rate for Payer: Midlands Choice Commercial $439.60
Rate for Payer: United Healthcare Commercial $565.20
Service Code CPT 23625
Hospital Charge Code 7982812
Hospital Revenue Code 981
Min. Negotiated Rate $322.59
Max. Negotiated Rate $940.50
Rate for Payer: Amerigroup Medicaid $325.75
Rate for Payer: Cash Price $1,003.20
Rate for Payer: Cash Price $1,003.20
Rate for Payer: Iowa Total Care Managed Medicaid $322.59
Rate for Payer: Medical Associates Commercial $940.50
Rate for Payer: Midlands Choice Commercial $877.80
Rate for Payer: Molina Healthcare Managed Medicaid $324.17
Rate for Payer: Partners Health Alliance Commercial $940.50
Rate for Payer: United Healthcare Commercial $572.94
Rate for Payer: Wellmark IA HMO WHPI $757.90
Rate for Payer: Wellmark IA PPO $891.70