Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

clotrimazole Top 1% Crm 30gm [VDMC]

Facility

$16.20

Service Code	HCPCS A9270
Hospital Charge Code	10434063
Hospital Revenue Code	259
Min. Negotiated Rate	$11.34
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna of IA Commercial	$14.58
Rate for Payer: Aetna of IA Medical Rental Products	$14.58
Rate for Payer: Cash Price	$12.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.15
Rate for Payer: Medical Associates Commercial	$12.15
Rate for Payer: Midlands Choice Commercial	$11.34
Rate for Payer: United Healthcare Commercial	$14.58

clotrimazole Top 1% Crm 30gm [VDMC]

Facility

$16.20

Service Code	HCPCS A9270
Hospital Charge Code	10434063
Hospital Revenue Code	259
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$14.58
Rate for Payer: Aetna of IA Commercial	$14.58
Rate for Payer: Aetna of IA Medical Rental Products	$14.58
Rate for Payer: Aetna of IA Medicare	$9.23
Rate for Payer: Amerigroup Medicaid	$9.34
Rate for Payer: Amerigroup Medicare	$7.36
Rate for Payer: Cash Price	$12.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.29
Rate for Payer: Iowa Total Care Managed Medicaid	$9.25
Rate for Payer: Medical Associates Commercial	$12.15
Rate for Payer: Medical Associates Managed Medicare	$7.29
Rate for Payer: Midlands Choice Commercial	$11.34
Rate for Payer: Molina Healthcare Managed Medicaid	$9.39
Rate for Payer: Partners Health Alliance Commercial	$8.38
Rate for Payer: United Healthcare Commercial	$14.58
Rate for Payer: United Healthcare Managed Medicare	$9.56

CMPLX RPR E/N/E/L 1.1-2.5 CM

Professional

Both

$1,400.00

Service Code	CPT 13151
Hospital Charge Code	7982819
Hospital Revenue Code	981
Min. Negotiated Rate	$644.37
Max. Negotiated Rate	$1,050.00
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Medical Associates Commercial	$1,050.00
Rate for Payer: Midlands Choice Commercial	$980.00
Rate for Payer: Partners Health Alliance Commercial	$1,050.00
Rate for Payer: United Healthcare Commercial	$644.37

CMPLX RPR E/N/E/L 1.1-2.5 CM

Facility

$579.00

Service Code	CPT 13151
Hospital Charge Code	4863434
Hospital Revenue Code	450
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: United Healthcare Commercial	$521.10

CMPLX RPR E/N/E/L 1.1-2.5 CM

Facility

$579.00

Service Code	CPT 13151
Hospital Charge Code	4863434
Hospital Revenue Code	450
Min. Negotiated Rate	$260.55
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Aetna of IA Medicare	$330.03
Rate for Payer: Amerigroup Medicaid	$333.97
Rate for Payer: Amerigroup Medicare	$263.16
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$260.55
Rate for Payer: Iowa Total Care Managed Medicaid	$330.72
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Medical Associates Managed Medicare	$260.55
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: Molina Healthcare Managed Medicaid	$335.59
Rate for Payer: Partners Health Alliance Commercial	$299.63
Rate for Payer: United Healthcare Commercial	$521.10
Rate for Payer: United Healthcare Managed Medicare	$341.61

CMPLX RPR E/N/E/L 2.6-7.5 CM

Facility

$1,056.00

Service Code	CPT 13152
Hospital Charge Code	4863435
Hospital Revenue Code	450
Min. Negotiated Rate	$739.20
Max. Negotiated Rate	$950.40
Rate for Payer: Aetna of IA Commercial	$950.40
Rate for Payer: Aetna of IA Medical Rental Products	$950.40
Rate for Payer: Cash Price	$844.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$792.00
Rate for Payer: Medical Associates Commercial	$792.00
Rate for Payer: Midlands Choice Commercial	$739.20
Rate for Payer: United Healthcare Commercial	$950.40

CMPLX RPR E/N/E/L 2.6-7.5 CM

Facility

$1,056.00

Service Code	CPT 13152
Hospital Charge Code	4863435
Hospital Revenue Code	450
Min. Negotiated Rate	$475.20
Max. Negotiated Rate	$950.40
Rate for Payer: Aetna of IA Commercial	$950.40
Rate for Payer: Aetna of IA Medical Rental Products	$950.40
Rate for Payer: Aetna of IA Medicare	$601.92
Rate for Payer: Amerigroup Medicaid	$609.10
Rate for Payer: Amerigroup Medicare	$479.95
Rate for Payer: Cash Price	$844.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$792.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$475.20
Rate for Payer: Iowa Total Care Managed Medicaid	$603.19
Rate for Payer: Medical Associates Commercial	$792.00
Rate for Payer: Medical Associates Managed Medicare	$475.20
Rate for Payer: Midlands Choice Commercial	$739.20
Rate for Payer: Molina Healthcare Managed Medicaid	$612.06
Rate for Payer: Partners Health Alliance Commercial	$546.48
Rate for Payer: United Healthcare Commercial	$950.40
Rate for Payer: United Healthcare Managed Medicare	$623.04

CMPLX RPR F/C/C/M/N/AX/G/H/F

Facility

$579.00

Service Code	CPT 13133
Hospital Charge Code	4863431
Hospital Revenue Code	450
Min. Negotiated Rate	$260.55
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Aetna of IA Medicare	$330.03
Rate for Payer: Amerigroup Medicaid	$333.97
Rate for Payer: Amerigroup Medicare	$263.16
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$260.55
Rate for Payer: Iowa Total Care Managed Medicaid	$330.72
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Medical Associates Managed Medicare	$260.55
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: Molina Healthcare Managed Medicaid	$335.59
Rate for Payer: Partners Health Alliance Commercial	$299.63
Rate for Payer: United Healthcare Commercial	$521.10
Rate for Payer: United Healthcare Managed Medicare	$341.61

CMPLX RPR F/C/C/M/N/AX/G/H/F

Facility

$579.00

Service Code	CPT 13133
Hospital Charge Code	4863431
Hospital Revenue Code	450
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: United Healthcare Commercial	$521.10

CMPLX RPR F/C/C/M/N/AX/G/H/F

Facility

$380.00

Service Code	CPT 13132
Hospital Charge Code	4863430
Hospital Revenue Code	450
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna of IA Commercial	$342.00
Rate for Payer: Aetna of IA Medical Rental Products	$342.00
Rate for Payer: Cash Price	$304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$285.00
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: United Healthcare Commercial	$342.00

CMPLX RPR F/C/C/M/N/AX/G/H/F

Facility

$380.00

Service Code	CPT 13132
Hospital Charge Code	4863430
Hospital Revenue Code	450
Min. Negotiated Rate	$171.00
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna of IA Commercial	$342.00
Rate for Payer: Aetna of IA Medical Rental Products	$342.00
Rate for Payer: Aetna of IA Medicare	$216.60
Rate for Payer: Amerigroup Medicaid	$219.18
Rate for Payer: Amerigroup Medicare	$172.71
Rate for Payer: Cash Price	$304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$285.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$171.00
Rate for Payer: Iowa Total Care Managed Medicaid	$217.06
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Medical Associates Managed Medicare	$171.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: Molina Healthcare Managed Medicaid	$220.25
Rate for Payer: Partners Health Alliance Commercial	$196.65
Rate for Payer: United Healthcare Commercial	$342.00
Rate for Payer: United Healthcare Managed Medicare	$224.20

CMPLX RPR F/C/C/M/N/AX/G/H/F

Facility

$304.00

Service Code	CPT 13131
Hospital Charge Code	4863428
Hospital Revenue Code	450
Min. Negotiated Rate	$136.80
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: 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: 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

CMPLX RPR F/C/C/M/N/AX/G/H/F

Facility

$304.00

Service Code	CPT 13131
Hospital Charge Code	4863428
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

CMPLX RPR F/C/C/M/N/AX/G/H/F

Professional

Both

$1,277.00

Service Code	CPT 13132
Hospital Charge Code	7982820
Hospital Revenue Code	981
Min. Negotiated Rate	$723.20
Max. Negotiated Rate	$957.75
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Cash Price	$1,021.60
Rate for Payer: Medical Associates Commercial	$957.75
Rate for Payer: Midlands Choice Commercial	$893.90
Rate for Payer: Partners Health Alliance Commercial	$957.75
Rate for Payer: United Healthcare Commercial	$723.20

CMPLX RPR S/A/L 2.6-7.5 CM

Facility

$525.00

Service Code	CPT 13121
Hospital Charge Code	4863424
Hospital Revenue Code	450
Min. Negotiated Rate	$236.25
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of IA Commercial	$472.50
Rate for Payer: Aetna of IA Medical Rental Products	$472.50
Rate for Payer: Aetna of IA Medicare	$299.25
Rate for Payer: Amerigroup Medicaid	$302.82
Rate for Payer: Amerigroup Medicare	$238.61
Rate for Payer: Cash Price	$420.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$393.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$236.25
Rate for Payer: Iowa Total Care Managed Medicaid	$299.88
Rate for Payer: Medical Associates Commercial	$393.75
Rate for Payer: Medical Associates Managed Medicare	$236.25
Rate for Payer: Midlands Choice Commercial	$367.50
Rate for Payer: Molina Healthcare Managed Medicaid	$304.29
Rate for Payer: Partners Health Alliance Commercial	$271.69
Rate for Payer: United Healthcare Commercial	$472.50
Rate for Payer: United Healthcare Managed Medicare	$309.75

CMPLX RPR S/A/L 2.6-7.5 CM

Professional

Both

$1,415.00

Service Code	CPT 13121
Hospital Charge Code	7982821
Hospital Revenue Code	981
Min. Negotiated Rate	$650.54
Max. Negotiated Rate	$1,061.25
Rate for Payer: Cash Price	$1,132.00
Rate for Payer: Cash Price	$1,132.00
Rate for Payer: Medical Associates Commercial	$1,061.25
Rate for Payer: Midlands Choice Commercial	$990.50
Rate for Payer: Partners Health Alliance Commercial	$1,061.25
Rate for Payer: United Healthcare Commercial	$650.54

CMPLX RPR S/A/L 2.6-7.5 CM

Facility

$525.00

Service Code	CPT 13121
Hospital Charge Code	4863424
Hospital Revenue Code	450
Min. Negotiated Rate	$367.50
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of IA Commercial	$472.50
Rate for Payer: Aetna of IA Medical Rental Products	$472.50
Rate for Payer: Cash Price	$420.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$393.75
Rate for Payer: Medical Associates Commercial	$393.75
Rate for Payer: Midlands Choice Commercial	$367.50
Rate for Payer: United Healthcare Commercial	$472.50

CMPLX RPR S/A/L ADDL 5 CM/>

Facility

$243.00

Service Code	CPT 13122
Hospital Charge Code	4863426
Hospital Revenue Code	450
Min. Negotiated Rate	$109.35
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of IA Commercial	$218.70
Rate for Payer: Aetna of IA Medical Rental Products	$218.70
Rate for Payer: Aetna of IA Medicare	$138.51
Rate for Payer: Amerigroup Medicaid	$140.16
Rate for Payer: Amerigroup Medicare	$110.44
Rate for Payer: Cash Price	$194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$182.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$109.35
Rate for Payer: Iowa Total Care Managed Medicaid	$138.80
Rate for Payer: Medical Associates Commercial	$182.25
Rate for Payer: Medical Associates Managed Medicare	$109.35
Rate for Payer: Midlands Choice Commercial	$170.10
Rate for Payer: Molina Healthcare Managed Medicaid	$140.84
Rate for Payer: Partners Health Alliance Commercial	$125.75
Rate for Payer: United Healthcare Commercial	$218.70
Rate for Payer: United Healthcare Managed Medicare	$143.37

CMPLX RPR S/A/L ADDL 5 CM/>

Facility

$243.00

Service Code	CPT 13122
Hospital Charge Code	4863426
Hospital Revenue Code	450
Min. Negotiated Rate	$170.10
Max. Negotiated Rate	$218.70
Rate for Payer: Aetna of IA Commercial	$218.70
Rate for Payer: Aetna of IA Medical Rental Products	$218.70
Rate for Payer: Cash Price	$194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$182.25
Rate for Payer: Medical Associates Commercial	$182.25
Rate for Payer: Midlands Choice Commercial	$170.10
Rate for Payer: United Healthcare Commercial	$218.70

CMPLX RPR TRUNK 2.6-7.5 CM

Facility

$579.00

Service Code	CPT 13101
Hospital Charge Code	4863412
Hospital Revenue Code	450
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: United Healthcare Commercial	$521.10

CMPLX RPR TRUNK 2.6-7.5 CM

Facility

$579.00

Service Code	CPT 13101
Hospital Charge Code	4863412
Hospital Revenue Code	450
Min. Negotiated Rate	$260.55
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Aetna of IA Medicare	$330.03
Rate for Payer: Amerigroup Medicaid	$333.97
Rate for Payer: Amerigroup Medicare	$263.16
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$260.55
Rate for Payer: Iowa Total Care Managed Medicaid	$330.72
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Medical Associates Managed Medicare	$260.55
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: Molina Healthcare Managed Medicaid	$335.59
Rate for Payer: Partners Health Alliance Commercial	$299.63
Rate for Payer: United Healthcare Commercial	$521.10
Rate for Payer: United Healthcare Managed Medicare	$341.61

CNBT EACH ADDITIONAL HOUR

Facility

$260.00

Service Code	CPT 94645
Hospital Charge Code	6345015
Hospital Revenue Code	410
Min. Negotiated Rate	$117.00
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: Aetna of IA Medicare	$148.20
Rate for Payer: Amerigroup Medicaid	$149.97
Rate for Payer: Amerigroup Medicare	$118.17
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	$117.00
Rate for Payer: Iowa Total Care Managed Medicaid	$148.51
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$117.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$150.70
Rate for Payer: Partners Health Alliance Commercial	$134.55
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40

CNBT EACH ADDITIONAL HOUR

Facility

$260.00

Service Code	CPT 94645
Hospital Charge Code	6345015
Hospital Revenue Code	410
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

CNBT INITIAL 1ST HOUR

Facility

$260.00

Service Code	CPT 94644
Hospital Charge Code	6594783
Hospital Revenue Code	410
Min. Negotiated Rate	$117.00
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: Aetna of IA Medicare	$148.20
Rate for Payer: Amerigroup Medicaid	$149.97
Rate for Payer: Amerigroup Medicare	$118.17
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	$117.00
Rate for Payer: Iowa Total Care Managed Medicaid	$148.51
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$117.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$150.70
Rate for Payer: Partners Health Alliance Commercial	$134.55
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40

CNBT INITIAL 1ST HOUR

Facility

$260.00

Service Code	CPT 94644
Hospital Charge Code	6594783
Hospital Revenue Code	410
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

Know your out-of-pocket cost for care.

All Charges