Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$15,073.45

Service Code	MSDRG 465
Min. Negotiated Rate	$14,854.99
Max. Negotiated Rate	$15,073.45
Rate for Payer: Amerigroup Medicaid	$15,000.63
Rate for Payer: Iowa Total Care Managed Medicaid	$14,854.99
Rate for Payer: Molina Healthcare Managed Medicaid	$15,073.45

WOUND DEBRIDEMENTS FOR INJURIES WITH CC

Facility

$18,908.53

Service Code	MSDRG 902
Min. Negotiated Rate	$18,634.49
Max. Negotiated Rate	$18,908.53
Rate for Payer: Amerigroup Medicaid	$18,817.18
Rate for Payer: Iowa Total Care Managed Medicaid	$18,634.49
Rate for Payer: Molina Healthcare Managed Medicaid	$18,908.53

WOUND DEBRIDEMENTS FOR INJURIES WITH MCC

Facility

$48,003.78

Service Code	MSDRG 901
Min. Negotiated Rate	$47,308.05
Max. Negotiated Rate	$48,003.78
Rate for Payer: Amerigroup Medicaid	$47,771.85
Rate for Payer: Iowa Total Care Managed Medicaid	$47,308.05
Rate for Payer: Molina Healthcare Managed Medicaid	$48,003.78

WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC

Facility

$12,043.45

Service Code	MSDRG 903
Min. Negotiated Rate	$11,868.90
Max. Negotiated Rate	$12,043.45
Rate for Payer: Amerigroup Medicaid	$11,985.26
Rate for Payer: Iowa Total Care Managed Medicaid	$11,868.90
Rate for Payer: Molina Healthcare Managed Medicaid	$12,043.45

WOUND(S) CARE NON-SELECTIVE

Facility

$304.00

Service Code	CPT 97602
Hospital Charge Code	4866825
Hospital Revenue Code	450
Min. Negotiated Rate	$136.80
Max. Negotiated Rate	$1,127.76
Rate for Payer: Aetna of IA Commercial	$273.60
Rate for Payer: Aetna of IA Medical Rental Products	$273.60
Rate for Payer: Aetna of IA Medicare	$173.28
Rate for Payer: Amerigroup Medicaid	$175.35
Rate for Payer: Amerigroup Medicare	$138.17
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cash Price	$243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$228.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$136.80
Rate for Payer: Iowa Total Care Managed Medicaid	$173.64
Rate for Payer: Medical Associates Commercial	$228.00
Rate for Payer: Medical Associates Managed Medicare	$136.80
Rate for Payer: Midlands Choice Commercial	$212.80
Rate for Payer: Molina Healthcare Managed Medicaid	$176.20
Rate for Payer: Partners Health Alliance Commercial	$157.32
Rate for Payer: United Healthcare Commercial	$273.60
Rate for Payer: United Healthcare Managed Medicare	$179.36
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

WOUND(S) CARE NON-SELECTIVE

Facility

$304.00

Service Code	CPT 97602
Hospital Charge Code	4866825
Hospital Revenue Code	450
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna of IA Commercial	$273.60
Rate for Payer: Aetna of IA Medical Rental Products	$273.60
Rate for Payer: Cash Price	$243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$228.00
Rate for Payer: Medical Associates Commercial	$228.00
Rate for Payer: Midlands Choice Commercial	$212.80
Rate for Payer: United Healthcare Commercial	$273.60

XENFORM TISSUE REPAIR 8MMX12MM

Facility

$2,530.00

Hospital Charge Code	8026509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,138.50
Max. Negotiated Rate	$2,277.00
Rate for Payer: Aetna of IA Commercial	$2,277.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,277.00
Rate for Payer: Aetna of IA Medicare	$1,442.10
Rate for Payer: Amerigroup Medicaid	$1,459.30
Rate for Payer: Amerigroup Medicare	$1,149.88
Rate for Payer: Cash Price	$2,024.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,897.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,138.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,445.14
Rate for Payer: Medical Associates Commercial	$1,897.50
Rate for Payer: Medical Associates Managed Medicare	$1,138.50
Rate for Payer: Midlands Choice Commercial	$1,771.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,466.39
Rate for Payer: Partners Health Alliance Commercial	$1,309.28
Rate for Payer: United Healthcare Commercial	$2,277.00
Rate for Payer: United Healthcare Managed Medicare	$1,492.70

XENFORM TISSUE REPAIR 8MMX12MM

Facility

$2,530.00

Hospital Charge Code	8026509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,771.00
Max. Negotiated Rate	$2,277.00
Rate for Payer: Aetna of IA Commercial	$2,277.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,277.00
Rate for Payer: Cash Price	$2,024.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,897.50
Rate for Payer: Medical Associates Commercial	$1,897.50
Rate for Payer: Midlands Choice Commercial	$1,771.00
Rate for Payer: United Healthcare Commercial	$2,277.00

X-LARGE PLUGS

Facility

$324.00

Service Code	HCPCS C1781
Hospital Charge Code	8417556
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: United Healthcare Commercial	$291.60

X-LARGE PLUGS

Facility

$324.00

Service Code	HCPCS C1781
Hospital Charge Code	8417556
Hospital Revenue Code	278
Min. Negotiated Rate	$145.80
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Aetna of IA Medicare	$184.68
Rate for Payer: Amerigroup Medicaid	$186.88
Rate for Payer: Amerigroup Medicare	$147.26
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$145.80
Rate for Payer: Iowa Total Care Managed Medicaid	$185.07
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Medical Associates Managed Medicare	$145.80
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: Molina Healthcare Managed Medicaid	$187.79
Rate for Payer: Partners Health Alliance Commercial	$167.67
Rate for Payer: United Healthcare Commercial	$291.60
Rate for Payer: United Healthcare Managed Medicare	$191.16

XR Abdomen 2 View

Facility

$180.00

Service Code	CPT 74019
Hospital Charge Code	2408784
Hospital Revenue Code	320
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Abdomen 2 View

Facility

$180.00

Service Code	CPT 74019
Hospital Charge Code	2408784
Hospital Revenue Code	320
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

XR ABDOMEN AP

Facility

$150.00

Service Code	CPT 74018
Hospital Charge Code	1169926
Hospital Revenue Code	320
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: United Healthcare Commercial	$135.00

XR ABDOMEN AP

Facility

$150.00

Service Code	CPT 74018
Hospital Charge Code	1169926
Hospital Revenue Code	320
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Aetna of IA Medicare	$85.50
Rate for Payer: Amerigroup Medicaid	$86.52
Rate for Payer: Amerigroup Medicare	$68.18
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.50
Rate for Payer: Iowa Total Care Managed Medicaid	$85.68
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Medical Associates Managed Medicare	$67.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: Molina Healthcare Managed Medicaid	$86.94
Rate for Payer: Partners Health Alliance Commercial	$77.62
Rate for Payer: United Healthcare Commercial	$135.00
Rate for Payer: United Healthcare Managed Medicare	$88.50
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Abdomen AP Obliques Cone Views

Facility

$202.00

Service Code	CPT 74010
Hospital Charge Code	1169928
Hospital Revenue Code	320
Min. Negotiated Rate	$90.90
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of IA Commercial	$181.80
Rate for Payer: Aetna of IA Medical Rental Products	$181.80
Rate for Payer: Aetna of IA Medicare	$115.14
Rate for Payer: Amerigroup Medicaid	$116.51
Rate for Payer: Amerigroup Medicare	$91.81
Rate for Payer: Cash Price	$161.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$151.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.90
Rate for Payer: Iowa Total Care Managed Medicaid	$115.38
Rate for Payer: Medical Associates Commercial	$151.50
Rate for Payer: Medical Associates Managed Medicare	$90.90
Rate for Payer: Midlands Choice Commercial	$141.40
Rate for Payer: Molina Healthcare Managed Medicaid	$117.08
Rate for Payer: Partners Health Alliance Commercial	$104.54
Rate for Payer: United Healthcare Commercial	$181.80
Rate for Payer: United Healthcare Managed Medicare	$119.18

XR Abdomen AP Obliques Cone Views

Facility

$202.00

Service Code	CPT 74010
Hospital Charge Code	1169928
Hospital Revenue Code	320
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of IA Commercial	$181.80
Rate for Payer: Aetna of IA Medical Rental Products	$181.80
Rate for Payer: Cash Price	$161.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$151.50
Rate for Payer: Medical Associates Commercial	$151.50
Rate for Payer: Midlands Choice Commercial	$141.40
Rate for Payer: United Healthcare Commercial	$181.80

XR Abdomen Complete w/ Decub/Erect

Facility

$180.00

Service Code	CPT 74021
Hospital Charge Code	1169930
Hospital Revenue Code	320
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

XR Abdomen Complete w/ Decub/Erect

Facility

$180.00

Service Code	CPT 74021
Hospital Charge Code	1169930
Hospital Revenue Code	320
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Abdomen Series w/ Chest 1 View

Facility

$180.00

Service Code	CPT 74022
Hospital Charge Code	1169932
Hospital Revenue Code	320
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

XR Abdomen Series w/ Chest 1 View

Facility

$180.00

Service Code	CPT 74022
Hospital Charge Code	1169932
Hospital Revenue Code	320
Min. Negotiated Rate	$81.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR AC Joints Bilateral w/ + w/o wts

Facility

$148.00

Service Code	CPT 73050
Hospital Charge Code	1169922
Hospital Revenue Code	320
Min. Negotiated Rate	$66.60
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of IA Commercial	$133.20
Rate for Payer: Aetna of IA Medical Rental Products	$133.20
Rate for Payer: Aetna of IA Medicare	$84.36
Rate for Payer: Amerigroup Medicaid	$85.37
Rate for Payer: Amerigroup Medicare	$67.27
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cash Price	$118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$66.60
Rate for Payer: Iowa Total Care Managed Medicaid	$84.54
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Medical Associates Managed Medicare	$66.60
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: Molina Healthcare Managed Medicaid	$85.78
Rate for Payer: Partners Health Alliance Commercial	$76.59
Rate for Payer: United Healthcare Commercial	$133.20
Rate for Payer: United Healthcare Managed Medicare	$87.32
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR AC Joints Bilateral w/ + w/o wts

Facility

$148.00

Service Code	CPT 73050
Hospital Charge Code	1169922
Hospital Revenue Code	320
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of IA Commercial	$133.20
Rate for Payer: Aetna of IA Medical Rental Products	$133.20
Rate for Payer: Cash Price	$118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.00
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: United Healthcare Commercial	$133.20

XR Ankle 2 Views Left

Facility

$133.00

Service Code	CPT 73600 LT
Hospital Charge Code	1169936
Hospital Revenue Code	320
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: United Healthcare Commercial	$119.70

XR Ankle 2 Views Left

Facility

$133.00

Service Code	CPT 73600 LT
Hospital Charge Code	1169936
Hospital Revenue Code	320
Min. Negotiated Rate	$59.85
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Aetna of IA Medicare	$75.81
Rate for Payer: Amerigroup Medicaid	$76.71
Rate for Payer: Amerigroup Medicare	$60.45
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$59.85
Rate for Payer: Iowa Total Care Managed Medicaid	$75.97
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Medical Associates Managed Medicare	$59.85
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: Molina Healthcare Managed Medicaid	$77.09
Rate for Payer: Partners Health Alliance Commercial	$68.83
Rate for Payer: United Healthcare Commercial	$119.70
Rate for Payer: United Healthcare Managed Medicare	$78.47
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

XR Ankle 2 Views Right

Facility

$133.00

Service Code	CPT 73600 RT
Hospital Charge Code	1169938
Hospital Revenue Code	320
Min. Negotiated Rate	$59.85
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Aetna of IA Medicare	$75.81
Rate for Payer: Amerigroup Medicaid	$76.71
Rate for Payer: Amerigroup Medicare	$60.45
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$59.85
Rate for Payer: Iowa Total Care Managed Medicaid	$75.97
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Medical Associates Managed Medicare	$59.85
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: Molina Healthcare Managed Medicaid	$77.09
Rate for Payer: Partners Health Alliance Commercial	$68.83
Rate for Payer: United Healthcare Commercial	$119.70
Rate for Payer: United Healthcare Managed Medicare	$78.47
Rate for Payer: Wellmark IA HMO WHPI	$103.51
Rate for Payer: Wellmark IA PPO	$114.03

Know your out-of-pocket cost for care.

All Charges