Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

dextrose 40% Oral gel [VDMC]

Facility

$13.31

Service Code	HCPCS A9270
Hospital Charge Code	10392316
Hospital Revenue Code	259
Min. Negotiated Rate	$9.31
Max. Negotiated Rate	$11.98
Rate for Payer: Aetna of IA Commercial	$11.98
Rate for Payer: Aetna of IA Medical Rental Products	$11.98
Rate for Payer: Cash Price	$10.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.98
Rate for Payer: Medical Associates Commercial	$9.98
Rate for Payer: Midlands Choice Commercial	$9.31
Rate for Payer: United Healthcare Commercial	$11.98

dextrose 40% Oral gel [VDMC]

Facility

$13.31

Service Code	HCPCS A9270
Hospital Charge Code	10392316
Hospital Revenue Code	259
Min. Negotiated Rate	$5.99
Max. Negotiated Rate	$11.98
Rate for Payer: Aetna of IA Commercial	$11.98
Rate for Payer: Aetna of IA Medical Rental Products	$11.98
Rate for Payer: Aetna of IA Medicare	$7.58
Rate for Payer: Amerigroup Medicaid	$7.68
Rate for Payer: Amerigroup Medicare	$6.05
Rate for Payer: Cash Price	$10.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.99
Rate for Payer: Iowa Total Care Managed Medicaid	$7.60
Rate for Payer: Medical Associates Commercial	$9.98
Rate for Payer: Medical Associates Managed Medicare	$5.99
Rate for Payer: Midlands Choice Commercial	$9.31
Rate for Payer: Molina Healthcare Managed Medicaid	$7.71
Rate for Payer: Partners Health Alliance Commercial	$6.89
Rate for Payer: United Healthcare Commercial	$11.98
Rate for Payer: United Healthcare Managed Medicare	$7.85

Dextrose 5% in Lactated Ringers 1000ml IV [VDMC]

Facility

$68.20

Service Code	HCPCS J7121
Hospital Charge Code	10440304
Hospital Revenue Code	259
Min. Negotiated Rate	$30.69
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$61.38
Rate for Payer: Aetna of IA Medical Rental Products	$61.38
Rate for Payer: Aetna of IA Medicare	$38.87
Rate for Payer: Amerigroup Medicaid	$39.34
Rate for Payer: Amerigroup Medicare	$31.00
Rate for Payer: Cash Price	$54.56
Rate for Payer: Cash Price	$54.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$51.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.69
Rate for Payer: Iowa Total Care Managed Medicaid	$38.96
Rate for Payer: Medical Associates Commercial	$51.15
Rate for Payer: Medical Associates Managed Medicare	$30.69
Rate for Payer: Midlands Choice Commercial	$47.74
Rate for Payer: Molina Healthcare Managed Medicaid	$39.53
Rate for Payer: Partners Health Alliance Commercial	$35.29
Rate for Payer: United Healthcare Commercial	$61.38
Rate for Payer: United Healthcare Managed Medicare	$40.24
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% in Lactated Ringers 1000ml IV [VDMC]

Facility

$68.20

Service Code	HCPCS J7121
Hospital Charge Code	10440304
Hospital Revenue Code	259
Min. Negotiated Rate	$47.74
Max. Negotiated Rate	$61.38
Rate for Payer: Aetna of IA Commercial	$61.38
Rate for Payer: Aetna of IA Medical Rental Products	$61.38
Rate for Payer: Cash Price	$54.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$51.15
Rate for Payer: Medical Associates Commercial	$51.15
Rate for Payer: Midlands Choice Commercial	$47.74
Rate for Payer: United Healthcare Commercial	$61.38

Dextrose 5% in Water IV 500ml Sol PVC FREE [VDMC]

Facility

$71.36

Service Code	HCPCS J7060
Hospital Charge Code	13773598
Hospital Revenue Code	259
Min. Negotiated Rate	$32.11
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$64.22
Rate for Payer: Aetna of IA Medical Rental Products	$64.22
Rate for Payer: Aetna of IA Medicare	$40.68
Rate for Payer: Amerigroup Medicaid	$41.16
Rate for Payer: Amerigroup Medicare	$32.43
Rate for Payer: Cash Price	$57.09
Rate for Payer: Cash Price	$57.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.52
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.11
Rate for Payer: Iowa Total Care Managed Medicaid	$40.76
Rate for Payer: Medical Associates Commercial	$53.52
Rate for Payer: Medical Associates Managed Medicare	$32.11
Rate for Payer: Midlands Choice Commercial	$49.95
Rate for Payer: Molina Healthcare Managed Medicaid	$41.36
Rate for Payer: Partners Health Alliance Commercial	$36.93
Rate for Payer: United Healthcare Commercial	$64.22
Rate for Payer: United Healthcare Managed Medicare	$42.10
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% in Water IV 500ml Sol PVC FREE [VDMC]

Facility

$71.36

Service Code	HCPCS J7060
Hospital Charge Code	13773598
Hospital Revenue Code	259
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$64.22
Rate for Payer: Aetna of IA Commercial	$64.22
Rate for Payer: Aetna of IA Medical Rental Products	$64.22
Rate for Payer: Cash Price	$57.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.52
Rate for Payer: Medical Associates Commercial	$53.52
Rate for Payer: Midlands Choice Commercial	$49.95
Rate for Payer: United Healthcare Commercial	$64.22

Dextrose 5% in Water IV Sol 1000 mL [VDMC]

Facility

$74.40

Service Code	HCPCS J7060
Hospital Charge Code	10440505
Hospital Revenue Code	259
Min. Negotiated Rate	$33.48
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$66.96
Rate for Payer: Aetna of IA Medical Rental Products	$66.96
Rate for Payer: Aetna of IA Medicare	$42.41
Rate for Payer: Amerigroup Medicaid	$42.91
Rate for Payer: Amerigroup Medicare	$33.81
Rate for Payer: Cash Price	$59.52
Rate for Payer: Cash Price	$59.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.48
Rate for Payer: Iowa Total Care Managed Medicaid	$42.50
Rate for Payer: Medical Associates Commercial	$55.80
Rate for Payer: Medical Associates Managed Medicare	$33.48
Rate for Payer: Midlands Choice Commercial	$52.08
Rate for Payer: Molina Healthcare Managed Medicaid	$43.12
Rate for Payer: Partners Health Alliance Commercial	$38.50
Rate for Payer: United Healthcare Commercial	$66.96
Rate for Payer: United Healthcare Managed Medicare	$43.90
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% in Water IV Sol 1000 mL [VDMC]

Facility

$74.40

Service Code	HCPCS J7060
Hospital Charge Code	10440505
Hospital Revenue Code	259
Min. Negotiated Rate	$52.08
Max. Negotiated Rate	$66.96
Rate for Payer: Aetna of IA Commercial	$66.96
Rate for Payer: Aetna of IA Medical Rental Products	$66.96
Rate for Payer: Cash Price	$59.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.80
Rate for Payer: Medical Associates Commercial	$55.80
Rate for Payer: Midlands Choice Commercial	$52.08
Rate for Payer: United Healthcare Commercial	$66.96

Dextrose 5% in Water IV Sol 100 mL [VDMC]

Facility

$65.52

Service Code	HCPCS J7060
Hospital Charge Code	10440438
Hospital Revenue Code	259
Min. Negotiated Rate	$45.86
Max. Negotiated Rate	$58.97
Rate for Payer: Aetna of IA Commercial	$58.97
Rate for Payer: Aetna of IA Medical Rental Products	$58.97
Rate for Payer: Cash Price	$52.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.14
Rate for Payer: Medical Associates Commercial	$49.14
Rate for Payer: Midlands Choice Commercial	$45.86
Rate for Payer: United Healthcare Commercial	$58.97

Dextrose 5% in Water IV Sol 100 mL [VDMC]

Facility

$65.52

Service Code	HCPCS J7060
Hospital Charge Code	10440438
Hospital Revenue Code	259
Min. Negotiated Rate	$29.48
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$58.97
Rate for Payer: Aetna of IA Medical Rental Products	$58.97
Rate for Payer: Aetna of IA Medicare	$37.35
Rate for Payer: Amerigroup Medicaid	$37.79
Rate for Payer: Amerigroup Medicare	$29.78
Rate for Payer: Cash Price	$52.42
Rate for Payer: Cash Price	$52.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.14
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.48
Rate for Payer: Iowa Total Care Managed Medicaid	$37.43
Rate for Payer: Medical Associates Commercial	$49.14
Rate for Payer: Medical Associates Managed Medicare	$29.48
Rate for Payer: Midlands Choice Commercial	$45.86
Rate for Payer: Molina Healthcare Managed Medicaid	$37.98
Rate for Payer: Partners Health Alliance Commercial	$33.91
Rate for Payer: United Healthcare Commercial	$58.97
Rate for Payer: United Healthcare Managed Medicare	$38.66
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% in Water IV Sol 250 mL PVC FREE [VDMC]

Facility

$73.61

Service Code	HCPCS J7070
Hospital Charge Code	10440572
Hospital Revenue Code	259
Min. Negotiated Rate	$33.12
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$66.25
Rate for Payer: Aetna of IA Medical Rental Products	$66.25
Rate for Payer: Aetna of IA Medicare	$41.96
Rate for Payer: Amerigroup Medicaid	$42.46
Rate for Payer: Amerigroup Medicare	$33.46
Rate for Payer: Cash Price	$58.89
Rate for Payer: Cash Price	$58.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.21
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.12
Rate for Payer: Iowa Total Care Managed Medicaid	$42.05
Rate for Payer: Medical Associates Commercial	$55.21
Rate for Payer: Medical Associates Managed Medicare	$33.12
Rate for Payer: Midlands Choice Commercial	$51.53
Rate for Payer: Molina Healthcare Managed Medicaid	$42.66
Rate for Payer: Partners Health Alliance Commercial	$38.09
Rate for Payer: United Healthcare Commercial	$66.25
Rate for Payer: United Healthcare Managed Medicare	$43.43
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% in Water IV Sol 250 mL PVC FREE [VDMC]

Facility

$73.61

Service Code	HCPCS J7070
Hospital Charge Code	10440572
Hospital Revenue Code	259
Min. Negotiated Rate	$51.53
Max. Negotiated Rate	$66.25
Rate for Payer: Aetna of IA Commercial	$66.25
Rate for Payer: Aetna of IA Medical Rental Products	$66.25
Rate for Payer: Cash Price	$58.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.21
Rate for Payer: Medical Associates Commercial	$55.21
Rate for Payer: Midlands Choice Commercial	$51.53
Rate for Payer: United Healthcare Commercial	$66.25

Dextrose 5% in Water IV Sol 500 mL [VDMC]

Facility

$63.70

Service Code	HCPCS J7070
Hospital Charge Code	10440639
Hospital Revenue Code	259
Min. Negotiated Rate	$28.66
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$57.33
Rate for Payer: Aetna of IA Medical Rental Products	$57.33
Rate for Payer: Aetna of IA Medicare	$36.31
Rate for Payer: Amerigroup Medicaid	$36.74
Rate for Payer: Amerigroup Medicare	$28.95
Rate for Payer: Cash Price	$50.96
Rate for Payer: Cash Price	$50.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.78
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.66
Rate for Payer: Iowa Total Care Managed Medicaid	$36.39
Rate for Payer: Medical Associates Commercial	$47.78
Rate for Payer: Medical Associates Managed Medicare	$28.66
Rate for Payer: Midlands Choice Commercial	$44.59
Rate for Payer: Molina Healthcare Managed Medicaid	$36.92
Rate for Payer: Partners Health Alliance Commercial	$32.96
Rate for Payer: United Healthcare Commercial	$57.33
Rate for Payer: United Healthcare Managed Medicare	$37.58
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% in Water IV Sol 500 mL [VDMC]

Facility

$63.70

Service Code	HCPCS J7070
Hospital Charge Code	10440639
Hospital Revenue Code	259
Min. Negotiated Rate	$44.59
Max. Negotiated Rate	$57.33
Rate for Payer: Aetna of IA Commercial	$57.33
Rate for Payer: Aetna of IA Medical Rental Products	$57.33
Rate for Payer: Cash Price	$50.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.78
Rate for Payer: Medical Associates Commercial	$47.78
Rate for Payer: Midlands Choice Commercial	$44.59
Rate for Payer: United Healthcare Commercial	$57.33

Dextrose 5% with 0.2% NaCl IV Sol 1000 mL [VDMC]

Facility

$87.32

Service Code	HCPCS J7042
Hospital Charge Code	22746066
Hospital Revenue Code	259
Min. Negotiated Rate	$39.29
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$78.59
Rate for Payer: Aetna of IA Medical Rental Products	$78.59
Rate for Payer: Aetna of IA Medicare	$49.77
Rate for Payer: Amerigroup Medicaid	$50.37
Rate for Payer: Amerigroup Medicare	$39.69
Rate for Payer: Cash Price	$69.86
Rate for Payer: Cash Price	$69.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$65.49
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$39.29
Rate for Payer: Iowa Total Care Managed Medicaid	$49.88
Rate for Payer: Medical Associates Commercial	$65.49
Rate for Payer: Medical Associates Managed Medicare	$39.29
Rate for Payer: Midlands Choice Commercial	$61.12
Rate for Payer: Molina Healthcare Managed Medicaid	$50.61
Rate for Payer: Partners Health Alliance Commercial	$45.19
Rate for Payer: United Healthcare Commercial	$78.59
Rate for Payer: United Healthcare Managed Medicare	$51.52
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% with 0.2% NaCl IV Sol 1000 mL [VDMC]

Facility

$87.32

Service Code	HCPCS J7042
Hospital Charge Code	22746066
Hospital Revenue Code	259
Min. Negotiated Rate	$61.12
Max. Negotiated Rate	$78.59
Rate for Payer: Aetna of IA Commercial	$78.59
Rate for Payer: Aetna of IA Medical Rental Products	$78.59
Rate for Payer: Cash Price	$69.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$65.49
Rate for Payer: Medical Associates Commercial	$65.49
Rate for Payer: Midlands Choice Commercial	$61.12
Rate for Payer: United Healthcare Commercial	$78.59

Dextrose 5% with 0.45% NaCl and KCl 20 mEq/l IV Sol 1000 mL [VDMC]

Facility

$57.64

Service Code	HCPCS J3480
Hospital Charge Code	10440773
Hospital Revenue Code	259
Min. Negotiated Rate	$25.94
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$51.88
Rate for Payer: Aetna of IA Medical Rental Products	$51.88
Rate for Payer: Aetna of IA Medicare	$32.85
Rate for Payer: Amerigroup Medicaid	$33.25
Rate for Payer: Amerigroup Medicare	$26.20
Rate for Payer: Cash Price	$46.11
Rate for Payer: Cash Price	$46.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.94
Rate for Payer: Iowa Total Care Managed Medicaid	$32.92
Rate for Payer: Medical Associates Commercial	$43.23
Rate for Payer: Medical Associates Managed Medicare	$25.94
Rate for Payer: Midlands Choice Commercial	$40.35
Rate for Payer: Molina Healthcare Managed Medicaid	$33.41
Rate for Payer: Partners Health Alliance Commercial	$29.83
Rate for Payer: United Healthcare Commercial	$51.88
Rate for Payer: United Healthcare Managed Medicare	$34.01
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% with 0.45% NaCl and KCl 20 mEq/l IV Sol 1000 mL [VDMC]

Facility

$57.64

Service Code	HCPCS J3480
Hospital Charge Code	10440773
Hospital Revenue Code	259
Min. Negotiated Rate	$40.35
Max. Negotiated Rate	$51.88
Rate for Payer: Aetna of IA Commercial	$51.88
Rate for Payer: Aetna of IA Medical Rental Products	$51.88
Rate for Payer: Cash Price	$46.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.23
Rate for Payer: Medical Associates Commercial	$43.23
Rate for Payer: Midlands Choice Commercial	$40.35
Rate for Payer: United Healthcare Commercial	$51.88

Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [VDMC]

Facility

$59.76

Service Code	HCPCS J3480
Hospital Charge Code	10440840
Hospital Revenue Code	259
Min. Negotiated Rate	$26.89
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$53.78
Rate for Payer: Aetna of IA Medical Rental Products	$53.78
Rate for Payer: Aetna of IA Medicare	$34.06
Rate for Payer: Amerigroup Medicaid	$34.47
Rate for Payer: Amerigroup Medicare	$27.16
Rate for Payer: Cash Price	$47.81
Rate for Payer: Cash Price	$47.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.89
Rate for Payer: Iowa Total Care Managed Medicaid	$34.13
Rate for Payer: Medical Associates Commercial	$44.82
Rate for Payer: Medical Associates Managed Medicare	$26.89
Rate for Payer: Midlands Choice Commercial	$41.83
Rate for Payer: Molina Healthcare Managed Medicaid	$34.64
Rate for Payer: Partners Health Alliance Commercial	$30.93
Rate for Payer: United Healthcare Commercial	$53.78
Rate for Payer: United Healthcare Managed Medicare	$35.26
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [VDMC]

Facility

$59.76

Service Code	HCPCS J3480
Hospital Charge Code	10440840
Hospital Revenue Code	259
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$53.78
Rate for Payer: Aetna of IA Commercial	$53.78
Rate for Payer: Aetna of IA Medical Rental Products	$53.78
Rate for Payer: Cash Price	$47.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.82
Rate for Payer: Medical Associates Commercial	$44.82
Rate for Payer: Midlands Choice Commercial	$41.83
Rate for Payer: United Healthcare Commercial	$53.78

Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [VDMC]

Facility

$74.52

Service Code	HCPCS J7042
Hospital Charge Code	10440907
Hospital Revenue Code	259
Min. Negotiated Rate	$52.16
Max. Negotiated Rate	$67.07
Rate for Payer: Aetna of IA Commercial	$67.07
Rate for Payer: Aetna of IA Medical Rental Products	$67.07
Rate for Payer: Cash Price	$59.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.89
Rate for Payer: Medical Associates Commercial	$55.89
Rate for Payer: Midlands Choice Commercial	$52.16
Rate for Payer: United Healthcare Commercial	$67.07

Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [VDMC]

Facility

$74.52

Service Code	HCPCS J7042
Hospital Charge Code	10440907
Hospital Revenue Code	259
Min. Negotiated Rate	$33.53
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$67.07
Rate for Payer: Aetna of IA Medical Rental Products	$67.07
Rate for Payer: Aetna of IA Medicare	$42.48
Rate for Payer: Amerigroup Medicaid	$42.98
Rate for Payer: Amerigroup Medicare	$33.87
Rate for Payer: Cash Price	$59.62
Rate for Payer: Cash Price	$59.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.89
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.53
Rate for Payer: Iowa Total Care Managed Medicaid	$42.57
Rate for Payer: Medical Associates Commercial	$55.89
Rate for Payer: Medical Associates Managed Medicare	$33.53
Rate for Payer: Midlands Choice Commercial	$52.16
Rate for Payer: Molina Healthcare Managed Medicaid	$43.19
Rate for Payer: Partners Health Alliance Commercial	$38.56
Rate for Payer: United Healthcare Commercial	$67.07
Rate for Payer: United Healthcare Managed Medicare	$43.97
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% with 0.9% NaCl intravenous solution 1000mL [VDMC]

Facility

$74.52

Service Code	HCPCS J7042
Hospital Charge Code	11220542
Hospital Revenue Code	259
Min. Negotiated Rate	$52.16
Max. Negotiated Rate	$67.07
Rate for Payer: Aetna of IA Commercial	$67.07
Rate for Payer: Aetna of IA Medical Rental Products	$67.07
Rate for Payer: Cash Price	$59.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.89
Rate for Payer: Medical Associates Commercial	$55.89
Rate for Payer: Midlands Choice Commercial	$52.16
Rate for Payer: United Healthcare Commercial	$67.07

Dextrose 5% with 0.9% NaCl intravenous solution 1000mL [VDMC]

Facility

$74.52

Service Code	HCPCS J7042
Hospital Charge Code	11220542
Hospital Revenue Code	259
Min. Negotiated Rate	$33.53
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$67.07
Rate for Payer: Aetna of IA Medical Rental Products	$67.07
Rate for Payer: Aetna of IA Medicare	$42.48
Rate for Payer: Amerigroup Medicaid	$42.98
Rate for Payer: Amerigroup Medicare	$33.87
Rate for Payer: Cash Price	$59.62
Rate for Payer: Cash Price	$59.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$55.89
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.53
Rate for Payer: Iowa Total Care Managed Medicaid	$42.57
Rate for Payer: Medical Associates Commercial	$55.89
Rate for Payer: Medical Associates Managed Medicare	$33.53
Rate for Payer: Midlands Choice Commercial	$52.16
Rate for Payer: Molina Healthcare Managed Medicaid	$43.19
Rate for Payer: Partners Health Alliance Commercial	$38.56
Rate for Payer: United Healthcare Commercial	$67.07
Rate for Payer: United Healthcare Managed Medicare	$43.97
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Dextrose 5% with 0.9% NaCl intravenous solution 500 mL [VDMC]

Facility

$65.50

Service Code	HCPCS J7042
Hospital Charge Code	11220493
Hospital Revenue Code	259
Min. Negotiated Rate	$45.85
Max. Negotiated Rate	$58.95
Rate for Payer: Aetna of IA Commercial	$58.95
Rate for Payer: Aetna of IA Medical Rental Products	$58.95
Rate for Payer: Cash Price	$52.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.12
Rate for Payer: Medical Associates Commercial	$49.12
Rate for Payer: Midlands Choice Commercial	$45.85
Rate for Payer: United Healthcare Commercial	$58.95

Know your out-of-pocket cost for care.

All Charges