Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Skull Complete

Facility

$268.00

Service Code	CPT 70260
Hospital Charge Code	1170438
Hospital Revenue Code	320
Min. Negotiated Rate	$187.60
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of IA Commercial	$241.20
Rate for Payer: Aetna of IA Medical Rental Products	$241.20
Rate for Payer: Cash Price	$214.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$201.00
Rate for Payer: Medical Associates Commercial	$201.00
Rate for Payer: Midlands Choice Commercial	$187.60
Rate for Payer: United Healthcare Commercial	$241.20

XR Skull Complete

Facility

$268.00

Service Code	CPT 70260
Hospital Charge Code	1170438
Hospital Revenue Code	320
Min. Negotiated Rate	$120.60
Max. Negotiated Rate	$241.20
Rate for Payer: Aetna of IA Commercial	$241.20
Rate for Payer: Aetna of IA Medical Rental Products	$241.20
Rate for Payer: Aetna of IA Medicare	$152.76
Rate for Payer: Amerigroup Medicaid	$154.58
Rate for Payer: Amerigroup Medicare	$121.81
Rate for Payer: Cash Price	$214.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$201.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$120.60
Rate for Payer: Iowa Total Care Managed Medicaid	$153.08
Rate for Payer: Medical Associates Commercial	$201.00
Rate for Payer: Medical Associates Managed Medicare	$120.60
Rate for Payer: Midlands Choice Commercial	$187.60
Rate for Payer: Molina Healthcare Managed Medicaid	$155.33
Rate for Payer: Partners Health Alliance Commercial	$138.69
Rate for Payer: United Healthcare Commercial	$241.20
Rate for Payer: United Healthcare Managed Medicare	$158.12

XR Small Bowel w/ Serial Films

Facility

$437.00

Service Code	CPT 74250
Hospital Charge Code	1170442
Hospital Revenue Code	320
Min. Negotiated Rate	$305.90
Max. Negotiated Rate	$393.30
Rate for Payer: Aetna of IA Commercial	$393.30
Rate for Payer: Aetna of IA Medical Rental Products	$393.30
Rate for Payer: Cash Price	$349.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$327.75
Rate for Payer: Medical Associates Commercial	$327.75
Rate for Payer: Midlands Choice Commercial	$305.90
Rate for Payer: United Healthcare Commercial	$393.30

XR Small Bowel w/ Serial Films

Facility

$437.00

Service Code	CPT 74250
Hospital Charge Code	1170442
Hospital Revenue Code	320
Min. Negotiated Rate	$196.65
Max. Negotiated Rate	$393.30
Rate for Payer: Aetna of IA Commercial	$393.30
Rate for Payer: Aetna of IA Medical Rental Products	$393.30
Rate for Payer: Aetna of IA Medicare	$249.09
Rate for Payer: Amerigroup Medicaid	$252.06
Rate for Payer: Amerigroup Medicare	$198.62
Rate for Payer: Cash Price	$349.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$327.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$196.65
Rate for Payer: Iowa Total Care Managed Medicaid	$249.61
Rate for Payer: Medical Associates Commercial	$327.75
Rate for Payer: Medical Associates Managed Medicare	$196.65
Rate for Payer: Midlands Choice Commercial	$305.90
Rate for Payer: Molina Healthcare Managed Medicaid	$253.29
Rate for Payer: Partners Health Alliance Commercial	$226.15
Rate for Payer: United Healthcare Commercial	$393.30
Rate for Payer: United Healthcare Managed Medicare	$257.83

XR Speech Evaluation Dyname Pharyngeal

Facility

$389.00

Service Code	CPT 74230
Hospital Charge Code	1170444
Hospital Revenue Code	320
Min. Negotiated Rate	$272.30
Max. Negotiated Rate	$350.10
Rate for Payer: Aetna of IA Commercial	$350.10
Rate for Payer: Aetna of IA Medical Rental Products	$350.10
Rate for Payer: Cash Price	$311.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$291.75
Rate for Payer: Medical Associates Commercial	$291.75
Rate for Payer: Midlands Choice Commercial	$272.30
Rate for Payer: United Healthcare Commercial	$350.10

XR Speech Evaluation Dyname Pharyngeal

Facility

$389.00

Service Code	CPT 74230
Hospital Charge Code	1170444
Hospital Revenue Code	320
Min. Negotiated Rate	$175.05
Max. Negotiated Rate	$350.10
Rate for Payer: Aetna of IA Commercial	$350.10
Rate for Payer: Aetna of IA Medical Rental Products	$350.10
Rate for Payer: Aetna of IA Medicare	$221.73
Rate for Payer: Amerigroup Medicaid	$224.38
Rate for Payer: Amerigroup Medicare	$176.80
Rate for Payer: Cash Price	$311.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$291.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$175.05
Rate for Payer: Iowa Total Care Managed Medicaid	$222.20
Rate for Payer: Medical Associates Commercial	$291.75
Rate for Payer: Medical Associates Managed Medicare	$175.05
Rate for Payer: Midlands Choice Commercial	$272.30
Rate for Payer: Molina Healthcare Managed Medicaid	$225.46
Rate for Payer: Partners Health Alliance Commercial	$201.31
Rate for Payer: United Healthcare Commercial	$350.10
Rate for Payer: United Healthcare Managed Medicare	$229.51

XR Spine 1 View Cervical

Facility

$201.00

Service Code	CPT 72020
Hospital Charge Code	1170446
Hospital Revenue Code	320
Min. Negotiated Rate	$90.45
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Aetna of IA Medicare	$114.57
Rate for Payer: Amerigroup Medicaid	$115.94
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.45
Rate for Payer: Iowa Total Care Managed Medicaid	$114.81
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Medical Associates Managed Medicare	$90.45
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$116.50
Rate for Payer: Partners Health Alliance Commercial	$104.02
Rate for Payer: United Healthcare Commercial	$180.90
Rate for Payer: United Healthcare Managed Medicare	$118.59

XR Spine 1 View Cervical

Facility

$201.00

Service Code	CPT 72020
Hospital Charge Code	1170446
Hospital Revenue Code	320
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: United Healthcare Commercial	$180.90

XR Spine 1 View Lumbar

Facility

$201.00

Service Code	CPT 72020
Hospital Charge Code	1170448
Hospital Revenue Code	320
Min. Negotiated Rate	$90.45
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Aetna of IA Medicare	$114.57
Rate for Payer: Amerigroup Medicaid	$115.94
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.45
Rate for Payer: Iowa Total Care Managed Medicaid	$114.81
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Medical Associates Managed Medicare	$90.45
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$116.50
Rate for Payer: Partners Health Alliance Commercial	$104.02
Rate for Payer: United Healthcare Commercial	$180.90
Rate for Payer: United Healthcare Managed Medicare	$118.59

XR Spine 1 View Lumbar

Facility

$201.00

Service Code	CPT 72020
Hospital Charge Code	1170448
Hospital Revenue Code	320
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: United Healthcare Commercial	$180.90

XR Spine 1 View Thoracic

Facility

$201.00

Service Code	CPT 72020
Hospital Charge Code	1170450
Hospital Revenue Code	320
Min. Negotiated Rate	$90.45
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Aetna of IA Medicare	$114.57
Rate for Payer: Amerigroup Medicaid	$115.94
Rate for Payer: Amerigroup Medicare	$91.35
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.45
Rate for Payer: Iowa Total Care Managed Medicaid	$114.81
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Medical Associates Managed Medicare	$90.45
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$116.50
Rate for Payer: Partners Health Alliance Commercial	$104.02
Rate for Payer: United Healthcare Commercial	$180.90
Rate for Payer: United Healthcare Managed Medicare	$118.59

XR Spine 1 View Thoracic

Facility

$201.00

Service Code	CPT 72020
Hospital Charge Code	1170450
Hospital Revenue Code	320
Min. Negotiated Rate	$140.70
Max. Negotiated Rate	$180.90
Rate for Payer: Aetna of IA Commercial	$180.90
Rate for Payer: Aetna of IA Medical Rental Products	$180.90
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.75
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: United Healthcare Commercial	$180.90

XR Spine Cervical 2 or 3 Views

Facility

$155.00

Service Code	CPT 72040
Hospital Charge Code	1170452
Hospital Revenue Code	320
Min. Negotiated Rate	$108.50
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of IA Commercial	$139.50
Rate for Payer: Aetna of IA Medical Rental Products	$139.50
Rate for Payer: Cash Price	$124.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$116.25
Rate for Payer: Medical Associates Commercial	$116.25
Rate for Payer: Midlands Choice Commercial	$108.50
Rate for Payer: United Healthcare Commercial	$139.50

XR Spine Cervical 2 or 3 Views

Facility

$155.00

Service Code	CPT 72040
Hospital Charge Code	1170452
Hospital Revenue Code	320
Min. Negotiated Rate	$69.75
Max. Negotiated Rate	$139.50
Rate for Payer: Aetna of IA Commercial	$139.50
Rate for Payer: Aetna of IA Medical Rental Products	$139.50
Rate for Payer: Aetna of IA Medicare	$88.35
Rate for Payer: Amerigroup Medicaid	$89.40
Rate for Payer: Amerigroup Medicare	$70.45
Rate for Payer: Cash Price	$124.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$116.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.75
Rate for Payer: Iowa Total Care Managed Medicaid	$88.54
Rate for Payer: Medical Associates Commercial	$116.25
Rate for Payer: Medical Associates Managed Medicare	$69.75
Rate for Payer: Midlands Choice Commercial	$108.50
Rate for Payer: Molina Healthcare Managed Medicaid	$89.84
Rate for Payer: Partners Health Alliance Commercial	$80.21
Rate for Payer: United Healthcare Commercial	$139.50
Rate for Payer: United Healthcare Managed Medicare	$91.45

XR Spine Cervical Comp w/ Obliques

Facility

$217.00

Service Code	CPT 72050
Hospital Charge Code	1170454
Hospital Revenue Code	320
Min. Negotiated Rate	$97.65
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of IA Commercial	$195.30
Rate for Payer: Aetna of IA Medical Rental Products	$195.30
Rate for Payer: Aetna of IA Medicare	$123.69
Rate for Payer: Amerigroup Medicaid	$125.17
Rate for Payer: Amerigroup Medicare	$98.63
Rate for Payer: Cash Price	$173.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.65
Rate for Payer: Iowa Total Care Managed Medicaid	$123.95
Rate for Payer: Medical Associates Commercial	$162.75
Rate for Payer: Medical Associates Managed Medicare	$97.65
Rate for Payer: Midlands Choice Commercial	$151.90
Rate for Payer: Molina Healthcare Managed Medicaid	$125.77
Rate for Payer: Partners Health Alliance Commercial	$112.30
Rate for Payer: United Healthcare Commercial	$195.30
Rate for Payer: United Healthcare Managed Medicare	$128.03

XR Spine Cervical Comp w/ Obliques

Facility

$217.00

Service Code	CPT 72050
Hospital Charge Code	1170454
Hospital Revenue Code	320
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of IA Commercial	$195.30
Rate for Payer: Aetna of IA Medical Rental Products	$195.30
Rate for Payer: Cash Price	$173.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.75
Rate for Payer: Medical Associates Commercial	$162.75
Rate for Payer: Midlands Choice Commercial	$151.90
Rate for Payer: United Healthcare Commercial	$195.30

XR Spine Cervical Minimum 4 Views

Facility

$217.00

Service Code	CPT 72050
Hospital Charge Code	1170461
Hospital Revenue Code	320
Min. Negotiated Rate	$151.90
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of IA Commercial	$195.30
Rate for Payer: Aetna of IA Medical Rental Products	$195.30
Rate for Payer: Cash Price	$173.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.75
Rate for Payer: Medical Associates Commercial	$162.75
Rate for Payer: Midlands Choice Commercial	$151.90
Rate for Payer: United Healthcare Commercial	$195.30

XR Spine Cervical Minimum 4 Views

Facility

$217.00

Service Code	CPT 72050
Hospital Charge Code	1170461
Hospital Revenue Code	320
Min. Negotiated Rate	$97.65
Max. Negotiated Rate	$195.30
Rate for Payer: Aetna of IA Commercial	$195.30
Rate for Payer: Aetna of IA Medical Rental Products	$195.30
Rate for Payer: Aetna of IA Medicare	$123.69
Rate for Payer: Amerigroup Medicaid	$125.17
Rate for Payer: Amerigroup Medicare	$98.63
Rate for Payer: Cash Price	$173.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.65
Rate for Payer: Iowa Total Care Managed Medicaid	$123.95
Rate for Payer: Medical Associates Commercial	$162.75
Rate for Payer: Medical Associates Managed Medicare	$97.65
Rate for Payer: Midlands Choice Commercial	$151.90
Rate for Payer: Molina Healthcare Managed Medicaid	$125.77
Rate for Payer: Partners Health Alliance Commercial	$112.30
Rate for Payer: United Healthcare Commercial	$195.30
Rate for Payer: United Healthcare Managed Medicare	$128.03

XR Spine Cervical w/ Flext and/or Ext

Facility

$297.00

Service Code	CPT 72052
Hospital Charge Code	1170463
Hospital Revenue Code	320
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: United Healthcare Commercial	$267.30

XR Spine Cervical w/ Flext and/or Ext

Facility

$297.00

Service Code	CPT 72052
Hospital Charge Code	1170463
Hospital Revenue Code	320
Min. Negotiated Rate	$133.65
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Aetna of IA Medicare	$169.29
Rate for Payer: Amerigroup Medicaid	$171.31
Rate for Payer: Amerigroup Medicare	$134.99
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$133.65
Rate for Payer: Iowa Total Care Managed Medicaid	$169.65
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Medical Associates Managed Medicare	$133.65
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: Molina Healthcare Managed Medicaid	$172.14
Rate for Payer: Partners Health Alliance Commercial	$153.70
Rate for Payer: United Healthcare Commercial	$267.30
Rate for Payer: United Healthcare Managed Medicare	$175.23

XR Spine Lumbar Flexion + Extension

Facility

$287.00

Service Code	CPT 72114
Hospital Charge Code	1170467
Hospital Revenue Code	320
Min. Negotiated Rate	$129.15
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Aetna of IA Medicare	$163.59
Rate for Payer: Amerigroup Medicaid	$165.54
Rate for Payer: Amerigroup Medicare	$130.44
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$129.15
Rate for Payer: Iowa Total Care Managed Medicaid	$163.93
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Medical Associates Managed Medicare	$129.15
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: Molina Healthcare Managed Medicaid	$166.35
Rate for Payer: Partners Health Alliance Commercial	$148.52
Rate for Payer: United Healthcare Commercial	$258.30
Rate for Payer: United Healthcare Managed Medicare	$169.33

XR Spine Lumbar Flexion + Extension

Facility

$287.00

Service Code	CPT 72114
Hospital Charge Code	1170467
Hospital Revenue Code	320
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: United Healthcare Commercial	$258.30

XR Spine Lumbosacral 2 or 3 Views

Facility

$176.00

Service Code	CPT 72100
Hospital Charge Code	1170470
Hospital Revenue Code	320
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84

XR Spine Lumbosacral 2 or 3 Views

Facility

$176.00

Service Code	CPT 72100
Hospital Charge Code	1170470
Hospital Revenue Code	320
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

XR Spine Lumbosacral Minimum 4 Views

Facility

$237.00

Service Code	CPT 72110
Hospital Charge Code	1170476
Hospital Revenue Code	320
Min. Negotiated Rate	$106.65
Max. Negotiated Rate	$213.30
Rate for Payer: Aetna of IA Commercial	$213.30
Rate for Payer: Aetna of IA Medical Rental Products	$213.30
Rate for Payer: Aetna of IA Medicare	$135.09
Rate for Payer: Amerigroup Medicaid	$136.70
Rate for Payer: Amerigroup Medicare	$107.72
Rate for Payer: Cash Price	$189.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$177.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$106.65
Rate for Payer: Iowa Total Care Managed Medicaid	$135.37
Rate for Payer: Medical Associates Commercial	$177.75
Rate for Payer: Medical Associates Managed Medicare	$106.65
Rate for Payer: Midlands Choice Commercial	$165.90
Rate for Payer: Molina Healthcare Managed Medicaid	$137.37
Rate for Payer: Partners Health Alliance Commercial	$122.65
Rate for Payer: United Healthcare Commercial	$213.30
Rate for Payer: United Healthcare Managed Medicare	$139.83

Know your out-of-pocket cost for care.

All Charges