Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

XR Upper GI w/ Air Contrast

Facility

$454.00

Service Code	CPT 74246
Hospital Charge Code	1170566
Hospital Revenue Code	320
Min. Negotiated Rate	$204.30
Max. Negotiated Rate	$408.60
Rate for Payer: Aetna of IA Commercial	$408.60
Rate for Payer: Aetna of IA Medical Rental Products	$408.60
Rate for Payer: Aetna of IA Medicare	$258.78
Rate for Payer: Amerigroup Medicaid	$261.87
Rate for Payer: Amerigroup Medicare	$206.34
Rate for Payer: Cash Price	$363.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$340.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$204.30
Rate for Payer: Iowa Total Care Managed Medicaid	$259.32
Rate for Payer: Medical Associates Commercial	$340.50
Rate for Payer: Medical Associates Managed Medicare	$204.30
Rate for Payer: Midlands Choice Commercial	$317.80
Rate for Payer: Molina Healthcare Managed Medicaid	$263.14
Rate for Payer: Partners Health Alliance Commercial	$234.94
Rate for Payer: United Healthcare Commercial	$408.60
Rate for Payer: United Healthcare Managed Medicare	$267.86

XR Upper GI w/ Air w/ Small Bowel

Facility

$668.00

Service Code	CPT 74249
Hospital Charge Code	1170570
Hospital Revenue Code	320
Min. Negotiated Rate	$300.60
Max. Negotiated Rate	$601.20
Rate for Payer: Aetna of IA Commercial	$601.20
Rate for Payer: Aetna of IA Medical Rental Products	$601.20
Rate for Payer: Aetna of IA Medicare	$380.76
Rate for Payer: Amerigroup Medicaid	$385.30
Rate for Payer: Amerigroup Medicare	$303.61
Rate for Payer: Cash Price	$534.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$501.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$300.60
Rate for Payer: Iowa Total Care Managed Medicaid	$381.56
Rate for Payer: Medical Associates Commercial	$501.00
Rate for Payer: Medical Associates Managed Medicare	$300.60
Rate for Payer: Midlands Choice Commercial	$467.60
Rate for Payer: Molina Healthcare Managed Medicaid	$387.17
Rate for Payer: Partners Health Alliance Commercial	$345.69
Rate for Payer: United Healthcare Commercial	$601.20
Rate for Payer: United Healthcare Managed Medicare	$394.12

XR Upper GI w/ Air w/ Small Bowel

Facility

$668.00

Service Code	CPT 74249
Hospital Charge Code	1170570
Hospital Revenue Code	320
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$601.20
Rate for Payer: Aetna of IA Commercial	$601.20
Rate for Payer: Aetna of IA Medical Rental Products	$601.20
Rate for Payer: Cash Price	$534.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$501.00
Rate for Payer: Medical Associates Commercial	$501.00
Rate for Payer: Midlands Choice Commercial	$467.60
Rate for Payer: United Healthcare Commercial	$601.20

XR Upper GI w/ Small Bowel

Facility

$668.00

Service Code	CPT 74245
Hospital Charge Code	1170574
Hospital Revenue Code	320
Min. Negotiated Rate	$300.60
Max. Negotiated Rate	$601.20
Rate for Payer: Aetna of IA Commercial	$601.20
Rate for Payer: Aetna of IA Medical Rental Products	$601.20
Rate for Payer: Aetna of IA Medicare	$380.76
Rate for Payer: Amerigroup Medicaid	$385.30
Rate for Payer: Amerigroup Medicare	$303.61
Rate for Payer: Cash Price	$534.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$501.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$300.60
Rate for Payer: Iowa Total Care Managed Medicaid	$381.56
Rate for Payer: Medical Associates Commercial	$501.00
Rate for Payer: Medical Associates Managed Medicare	$300.60
Rate for Payer: Midlands Choice Commercial	$467.60
Rate for Payer: Molina Healthcare Managed Medicaid	$387.17
Rate for Payer: Partners Health Alliance Commercial	$345.69
Rate for Payer: United Healthcare Commercial	$601.20
Rate for Payer: United Healthcare Managed Medicare	$394.12

XR Upper GI w/ Small Bowel

Facility

$668.00

Service Code	CPT 74245
Hospital Charge Code	1170574
Hospital Revenue Code	320
Min. Negotiated Rate	$467.60
Max. Negotiated Rate	$601.20
Rate for Payer: Aetna of IA Commercial	$601.20
Rate for Payer: Aetna of IA Medical Rental Products	$601.20
Rate for Payer: Cash Price	$534.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$501.00
Rate for Payer: Medical Associates Commercial	$501.00
Rate for Payer: Midlands Choice Commercial	$467.60
Rate for Payer: United Healthcare Commercial	$601.20

XR Urethrocystography Retrograde

Facility

$830.00

Service Code	CPT 74450
Hospital Charge Code	1170578
Hospital Revenue Code	320
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Aetna of IA Medicare	$473.10
Rate for Payer: Amerigroup Medicaid	$478.74
Rate for Payer: Amerigroup Medicare	$377.24
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$373.50
Rate for Payer: Iowa Total Care Managed Medicaid	$474.10
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Medical Associates Managed Medicare	$373.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: Molina Healthcare Managed Medicaid	$481.07
Rate for Payer: Partners Health Alliance Commercial	$429.52
Rate for Payer: United Healthcare Commercial	$747.00
Rate for Payer: United Healthcare Managed Medicare	$489.70

XR Urethrocystography Retrograde

Facility

$830.00

Service Code	CPT 74450
Hospital Charge Code	1170578
Hospital Revenue Code	320
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: United Healthcare Commercial	$747.00

XR Urethrocystography Voiding

Facility

$830.00

Service Code	CPT 74455
Hospital Charge Code	1170580
Hospital Revenue Code	320
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: United Healthcare Commercial	$747.00

XR Urethrocystography Voiding

Facility

$830.00

Service Code	CPT 74455
Hospital Charge Code	1170580
Hospital Revenue Code	320
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Aetna of IA Medicare	$473.10
Rate for Payer: Amerigroup Medicaid	$478.74
Rate for Payer: Amerigroup Medicare	$377.24
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$373.50
Rate for Payer: Iowa Total Care Managed Medicaid	$474.10
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Medical Associates Managed Medicare	$373.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: Molina Healthcare Managed Medicaid	$481.07
Rate for Payer: Partners Health Alliance Commercial	$429.52
Rate for Payer: United Healthcare Commercial	$747.00
Rate for Payer: United Healthcare Managed Medicare	$489.70

XR Venogram Lower Extremity Left

Facility

$830.00

Service Code	CPT 75820 LT
Hospital Charge Code	1170592
Hospital Revenue Code	320
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Aetna of IA Medicare	$473.10
Rate for Payer: Amerigroup Medicaid	$478.74
Rate for Payer: Amerigroup Medicare	$377.24
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$373.50
Rate for Payer: Iowa Total Care Managed Medicaid	$474.10
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Medical Associates Managed Medicare	$373.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: Molina Healthcare Managed Medicaid	$481.07
Rate for Payer: Partners Health Alliance Commercial	$429.52
Rate for Payer: United Healthcare Commercial	$747.00
Rate for Payer: United Healthcare Managed Medicare	$489.70

XR Venogram Lower Extremity Left

Facility

$830.00

Service Code	CPT 75820 LT
Hospital Charge Code	1170592
Hospital Revenue Code	320
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: United Healthcare Commercial	$747.00

XR Venogram Lower Extremity Right

Facility

$830.00

Service Code	CPT 75820 RT
Hospital Charge Code	1170594
Hospital Revenue Code	320
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: United Healthcare Commercial	$747.00

XR Venogram Lower Extremity Right

Facility

$830.00

Service Code	CPT 75820 RT
Hospital Charge Code	1170594
Hospital Revenue Code	320
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Aetna of IA Medicare	$473.10
Rate for Payer: Amerigroup Medicaid	$478.74
Rate for Payer: Amerigroup Medicare	$377.24
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$373.50
Rate for Payer: Iowa Total Care Managed Medicaid	$474.10
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Medical Associates Managed Medicare	$373.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: Molina Healthcare Managed Medicaid	$481.07
Rate for Payer: Partners Health Alliance Commercial	$429.52
Rate for Payer: United Healthcare Commercial	$747.00
Rate for Payer: United Healthcare Managed Medicare	$489.70

XR Venogram Upper Extremity Left

Facility

$830.00

Service Code	CPT 75820 LT
Hospital Charge Code	1170598
Hospital Revenue Code	320
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Aetna of IA Medicare	$473.10
Rate for Payer: Amerigroup Medicaid	$478.74
Rate for Payer: Amerigroup Medicare	$377.24
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$373.50
Rate for Payer: Iowa Total Care Managed Medicaid	$474.10
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Medical Associates Managed Medicare	$373.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: Molina Healthcare Managed Medicaid	$481.07
Rate for Payer: Partners Health Alliance Commercial	$429.52
Rate for Payer: United Healthcare Commercial	$747.00
Rate for Payer: United Healthcare Managed Medicare	$489.70

XR Venogram Upper Extremity Left

Facility

$830.00

Service Code	CPT 75820 LT
Hospital Charge Code	1170598
Hospital Revenue Code	320
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: United Healthcare Commercial	$747.00

XR Venogram Upper Extremity Right

Facility

$830.00

Service Code	CPT 75820 RT
Hospital Charge Code	1170600
Hospital Revenue Code	320
Min. Negotiated Rate	$581.00
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: United Healthcare Commercial	$747.00

XR Venogram Upper Extremity Right

Facility

$830.00

Service Code	CPT 75820 RT
Hospital Charge Code	1170600
Hospital Revenue Code	320
Min. Negotiated Rate	$373.50
Max. Negotiated Rate	$747.00
Rate for Payer: Aetna of IA Commercial	$747.00
Rate for Payer: Aetna of IA Medical Rental Products	$747.00
Rate for Payer: Aetna of IA Medicare	$473.10
Rate for Payer: Amerigroup Medicaid	$478.74
Rate for Payer: Amerigroup Medicare	$377.24
Rate for Payer: Cash Price	$664.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$622.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$373.50
Rate for Payer: Iowa Total Care Managed Medicaid	$474.10
Rate for Payer: Medical Associates Commercial	$622.50
Rate for Payer: Medical Associates Managed Medicare	$373.50
Rate for Payer: Midlands Choice Commercial	$581.00
Rate for Payer: Molina Healthcare Managed Medicaid	$481.07
Rate for Payer: Partners Health Alliance Commercial	$429.52
Rate for Payer: United Healthcare Commercial	$747.00
Rate for Payer: United Healthcare Managed Medicare	$489.70

XR Wrist 2 Views Left

Facility

$127.00

Service Code	CPT 73100 LT
Hospital Charge Code	1170606
Hospital Revenue Code	320
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: United Healthcare Commercial	$114.30

XR Wrist 2 Views Left

Facility

$127.00

Service Code	CPT 73100 LT
Hospital Charge Code	1170606
Hospital Revenue Code	320
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Aetna of IA Medicare	$72.39
Rate for Payer: Amerigroup Medicaid	$73.25
Rate for Payer: Amerigroup Medicare	$57.72
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.15
Rate for Payer: Iowa Total Care Managed Medicaid	$72.54
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Medical Associates Managed Medicare	$57.15
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: Molina Healthcare Managed Medicaid	$73.61
Rate for Payer: Partners Health Alliance Commercial	$65.72
Rate for Payer: United Healthcare Commercial	$114.30
Rate for Payer: United Healthcare Managed Medicare	$74.93

XR Wrist 2 Views Right

Facility

$127.00

Service Code	CPT 73100 RT
Hospital Charge Code	1170608
Hospital Revenue Code	320
Min. Negotiated Rate	$57.15
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Aetna of IA Medicare	$72.39
Rate for Payer: Amerigroup Medicaid	$73.25
Rate for Payer: Amerigroup Medicare	$57.72
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.15
Rate for Payer: Iowa Total Care Managed Medicaid	$72.54
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Medical Associates Managed Medicare	$57.15
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: Molina Healthcare Managed Medicaid	$73.61
Rate for Payer: Partners Health Alliance Commercial	$65.72
Rate for Payer: United Healthcare Commercial	$114.30
Rate for Payer: United Healthcare Managed Medicare	$74.93

XR Wrist 2 Views Right

Facility

$127.00

Service Code	CPT 73100 RT
Hospital Charge Code	1170608
Hospital Revenue Code	320
Min. Negotiated Rate	$88.90
Max. Negotiated Rate	$114.30
Rate for Payer: Aetna of IA Commercial	$114.30
Rate for Payer: Aetna of IA Medical Rental Products	$114.30
Rate for Payer: Cash Price	$101.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$95.25
Rate for Payer: Medical Associates Commercial	$95.25
Rate for Payer: Midlands Choice Commercial	$88.90
Rate for Payer: United Healthcare Commercial	$114.30

XR Wrist Complete Left

Facility

$146.00

Service Code	CPT 73110 LT
Hospital Charge Code	1170612
Hospital Revenue Code	320
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Aetna of IA Medicare	$83.22
Rate for Payer: Amerigroup Medicaid	$84.21
Rate for Payer: Amerigroup Medicare	$66.36
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.70
Rate for Payer: Iowa Total Care Managed Medicaid	$83.40
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Medical Associates Managed Medicare	$65.70
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: Molina Healthcare Managed Medicaid	$84.62
Rate for Payer: Partners Health Alliance Commercial	$75.56
Rate for Payer: United Healthcare Commercial	$131.40
Rate for Payer: United Healthcare Managed Medicare	$86.14

XR Wrist Complete Left

Facility

$146.00

Service Code	CPT 73110 LT
Hospital Charge Code	1170612
Hospital Revenue Code	320
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: United Healthcare Commercial	$131.40

XR Wrist Complete Right

Facility

$146.00

Service Code	CPT 73110 RT
Hospital Charge Code	1170614
Hospital Revenue Code	320
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: United Healthcare Commercial	$131.40

XR Wrist Complete Right

Facility

$146.00

Service Code	CPT 73110 RT
Hospital Charge Code	1170614
Hospital Revenue Code	320
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Aetna of IA Medicare	$83.22
Rate for Payer: Amerigroup Medicaid	$84.21
Rate for Payer: Amerigroup Medicare	$66.36
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.70
Rate for Payer: Iowa Total Care Managed Medicaid	$83.40
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Medical Associates Managed Medicare	$65.70
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: Molina Healthcare Managed Medicaid	$84.62
Rate for Payer: Partners Health Alliance Commercial	$75.56
Rate for Payer: United Healthcare Commercial	$131.40
Rate for Payer: United Healthcare Managed Medicare	$86.14

Know your out-of-pocket cost for care.

All Charges