Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

HUMERAL STEM 6MM X 115MM

Facility

$6,615.00

Service Code	CPT C1776
Hospital Charge Code	8047265
Hospital Revenue Code	278
Min. Negotiated Rate	$4,630.50
Max. Negotiated Rate	$5,953.50
Rate for Payer: Aetna of IA Commercial	$5,953.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,953.50
Rate for Payer: Cash Price	$5,292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,961.25
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: United Healthcare Commercial	$5,953.50

HUMERAL STEM 7MM X 140MM

Facility

$6,615.00

Service Code	CPT C1776
Hospital Charge Code	8047266
Hospital Revenue Code	278
Min. Negotiated Rate	$4,630.50
Max. Negotiated Rate	$5,953.50
Rate for Payer: Aetna of IA Commercial	$5,953.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,953.50
Rate for Payer: Cash Price	$5,292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,961.25
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: United Healthcare Commercial	$5,953.50

HUMERAL STEM 7MM X 140MM

Facility

$6,615.00

Service Code	CPT C1776
Hospital Charge Code	8047266
Hospital Revenue Code	278
Min. Negotiated Rate	$3,306.18
Max. Negotiated Rate	$5,953.50
Rate for Payer: Aetna of IA Commercial	$5,953.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,953.50
Rate for Payer: Aetna of IA Medicare	$3,770.55
Rate for Payer: Amerigroup Medicaid	$3,338.59
Rate for Payer: Amerigroup Medicare	$3,340.58
Rate for Payer: Cash Price	$5,292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,961.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,307.50
Rate for Payer: Iowa Total Care Managed Medicaid	$3,306.18
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$3,307.50
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,357.11
Rate for Payer: Molina Healthcare Managed Medicare	$3,355.13
Rate for Payer: Oscar Health of IA Commercial	$4,961.25
Rate for Payer: Partners Health Alliance Commercial	$4,961.25
Rate for Payer: United Healthcare Commercial	$5,953.50
Rate for Payer: United Healthcare Managed Medicare	$3,902.85

HUMERAL STEM 8MM X 143MM

Facility

$6,615.00

Service Code	CPT C1776
Hospital Charge Code	8047267
Hospital Revenue Code	278
Min. Negotiated Rate	$4,630.50
Max. Negotiated Rate	$5,953.50
Rate for Payer: Aetna of IA Commercial	$5,953.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,953.50
Rate for Payer: Cash Price	$5,292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,961.25
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: United Healthcare Commercial	$5,953.50

HUMERAL STEM 8MM X 143MM

Facility

$6,615.00

Service Code	CPT C1776
Hospital Charge Code	8047267
Hospital Revenue Code	278
Min. Negotiated Rate	$3,306.18
Max. Negotiated Rate	$5,953.50
Rate for Payer: Aetna of IA Commercial	$5,953.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,953.50
Rate for Payer: Aetna of IA Medicare	$3,770.55
Rate for Payer: Amerigroup Medicaid	$3,338.59
Rate for Payer: Amerigroup Medicare	$3,340.58
Rate for Payer: Cash Price	$5,292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,961.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,307.50
Rate for Payer: Iowa Total Care Managed Medicaid	$3,306.18
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$3,307.50
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,357.11
Rate for Payer: Molina Healthcare Managed Medicare	$3,355.13
Rate for Payer: Oscar Health of IA Commercial	$4,961.25
Rate for Payer: Partners Health Alliance Commercial	$4,961.25
Rate for Payer: United Healthcare Commercial	$5,953.50
Rate for Payer: United Healthcare Managed Medicare	$3,902.85

HUMERAL STEM 9MM X 146MM

Facility

$6,615.00

Service Code	CPT C1776
Hospital Charge Code	8047268
Hospital Revenue Code	278
Min. Negotiated Rate	$4,630.50
Max. Negotiated Rate	$5,953.50
Rate for Payer: Aetna of IA Commercial	$5,953.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,953.50
Rate for Payer: Cash Price	$5,292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,961.25
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: United Healthcare Commercial	$5,953.50

HUMERAL STEM 9MM X 146MM

Facility

$6,615.00

Service Code	CPT C1776
Hospital Charge Code	8047268
Hospital Revenue Code	278
Min. Negotiated Rate	$3,306.18
Max. Negotiated Rate	$5,953.50
Rate for Payer: Aetna of IA Commercial	$5,953.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,953.50
Rate for Payer: Aetna of IA Medicare	$3,770.55
Rate for Payer: Amerigroup Medicaid	$3,338.59
Rate for Payer: Amerigroup Medicare	$3,340.58
Rate for Payer: Cash Price	$5,292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,961.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,307.50
Rate for Payer: Iowa Total Care Managed Medicaid	$3,306.18
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$3,307.50
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,357.11
Rate for Payer: Molina Healthcare Managed Medicare	$3,355.13
Rate for Payer: Oscar Health of IA Commercial	$4,961.25
Rate for Payer: Partners Health Alliance Commercial	$4,961.25
Rate for Payer: United Healthcare Commercial	$5,953.50
Rate for Payer: United Healthcare Managed Medicare	$3,902.85

HUMERAL STEM CEMENTED

Facility

$5,148.00

Service Code	CPT C1776
Hospital Charge Code	8047293
Hospital Revenue Code	278
Min. Negotiated Rate	$3,603.60
Max. Negotiated Rate	$4,633.20
Rate for Payer: Aetna of IA Commercial	$4,633.20
Rate for Payer: Aetna of IA Medical Rental Products	$4,633.20
Rate for Payer: Cash Price	$4,118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,861.00
Rate for Payer: Medical Associates Commercial	$3,861.00
Rate for Payer: Midlands Choice Commercial	$3,603.60
Rate for Payer: United Healthcare Commercial	$4,633.20

HUMERAL STEM CEMENTED

Facility

$5,148.00

Service Code	CPT C1776
Hospital Charge Code	8047293
Hospital Revenue Code	278
Min. Negotiated Rate	$2,572.97
Max. Negotiated Rate	$4,633.20
Rate for Payer: Aetna of IA Commercial	$4,633.20
Rate for Payer: Aetna of IA Medical Rental Products	$4,633.20
Rate for Payer: Aetna of IA Medicare	$2,934.36
Rate for Payer: Amerigroup Medicaid	$2,598.20
Rate for Payer: Amerigroup Medicare	$2,599.74
Rate for Payer: Cash Price	$4,118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,861.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,574.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2,572.97
Rate for Payer: Medical Associates Commercial	$3,861.00
Rate for Payer: Medical Associates Managed Medicare	$2,574.00
Rate for Payer: Midlands Choice Commercial	$3,603.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,612.61
Rate for Payer: Molina Healthcare Managed Medicare	$2,611.07
Rate for Payer: Oscar Health of IA Commercial	$3,861.00
Rate for Payer: Partners Health Alliance Commercial	$3,861.00
Rate for Payer: United Healthcare Commercial	$4,633.20
Rate for Payer: United Healthcare Managed Medicare	$3,037.32

hyaluronidase 150 units/mL 1ml inj [VDMC]

Facility

$209.53

Service Code	HCPCS J3473
Hospital Charge Code	17240857
Hospital Revenue Code	259
Min. Negotiated Rate	$146.67
Max. Negotiated Rate	$188.58
Rate for Payer: Aetna of IA Commercial	$188.58
Rate for Payer: Aetna of IA Medical Rental Products	$188.58
Rate for Payer: Cash Price	$167.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.15
Rate for Payer: Medical Associates Commercial	$157.15
Rate for Payer: Midlands Choice Commercial	$146.67
Rate for Payer: United Healthcare Commercial	$188.58

hyaluronidase 150 units/mL 1ml inj [VDMC]

Facility

$209.53

Service Code	HCPCS J3473
Hospital Charge Code	17240857
Hospital Revenue Code	259
Min. Negotiated Rate	$104.72
Max. Negotiated Rate	$188.58
Rate for Payer: Aetna of IA Commercial	$188.58
Rate for Payer: Aetna of IA Medical Rental Products	$188.58
Rate for Payer: Aetna of IA Medicare	$119.43
Rate for Payer: Amerigroup Medicaid	$105.75
Rate for Payer: Amerigroup Medicare	$105.81
Rate for Payer: Cash Price	$167.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$104.76
Rate for Payer: Iowa Total Care Managed Medicaid	$104.72
Rate for Payer: Medical Associates Commercial	$157.15
Rate for Payer: Medical Associates Managed Medicare	$104.76
Rate for Payer: Midlands Choice Commercial	$146.67
Rate for Payer: Molina Healthcare Managed Medicaid	$106.34
Rate for Payer: Molina Healthcare Managed Medicare	$106.27
Rate for Payer: Oscar Health of IA Commercial	$157.15
Rate for Payer: Partners Health Alliance Commercial	$157.15
Rate for Payer: United Healthcare Commercial	$188.58
Rate for Payer: United Healthcare Managed Medicare	$123.62

hydrALAZINE 10 mg Tab [VDMC]

Facility

$1.41

Service Code	HCPCS A9270
Hospital Charge Code	10393696
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.27
Rate for Payer: Aetna of IA Commercial	$1.27
Rate for Payer: Aetna of IA Medical Rental Products	$1.27
Rate for Payer: Aetna of IA Medicare	$0.80
Rate for Payer: Amerigroup Medicaid	$0.71
Rate for Payer: Amerigroup Medicare	$0.71
Rate for Payer: Cash Price	$1.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.06
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.71
Rate for Payer: Iowa Total Care Managed Medicaid	$0.70
Rate for Payer: Medical Associates Commercial	$1.06
Rate for Payer: Medical Associates Managed Medicare	$0.71
Rate for Payer: Midlands Choice Commercial	$0.99
Rate for Payer: Molina Healthcare Managed Medicaid	$0.72
Rate for Payer: Molina Healthcare Managed Medicare	$0.72
Rate for Payer: Oscar Health of IA Commercial	$1.06
Rate for Payer: Partners Health Alliance Commercial	$1.06
Rate for Payer: United Healthcare Commercial	$1.27
Rate for Payer: United Healthcare Managed Medicare	$0.83

hydrALAZINE 10 mg Tab [VDMC]

Facility

$1.41

Service Code	HCPCS A9270
Hospital Charge Code	10393696
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.27
Rate for Payer: Aetna of IA Commercial	$1.27
Rate for Payer: Aetna of IA Medical Rental Products	$1.27
Rate for Payer: Cash Price	$1.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.06
Rate for Payer: Medical Associates Commercial	$1.06
Rate for Payer: Midlands Choice Commercial	$0.99
Rate for Payer: United Healthcare Commercial	$1.27

hydrALAZINE 20 mg/mL SDV Inj Sol [VDMC]

Facility

$27.22

Service Code	HCPCS J0360
Hospital Charge Code	10393767
Hospital Revenue Code	259
Min. Negotiated Rate	$19.05
Max. Negotiated Rate	$24.50
Rate for Payer: Aetna of IA Commercial	$24.50
Rate for Payer: Aetna of IA Medical Rental Products	$24.50
Rate for Payer: Cash Price	$21.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.42
Rate for Payer: Medical Associates Commercial	$20.42
Rate for Payer: Midlands Choice Commercial	$19.05
Rate for Payer: United Healthcare Commercial	$24.50

hydrALAZINE 20 mg/mL SDV Inj Sol [VDMC]

Facility

$27.22

Service Code	HCPCS J0360
Hospital Charge Code	10393767
Hospital Revenue Code	259
Min. Negotiated Rate	$13.60
Max. Negotiated Rate	$24.50
Rate for Payer: Aetna of IA Commercial	$24.50
Rate for Payer: Aetna of IA Medical Rental Products	$24.50
Rate for Payer: Aetna of IA Medicare	$15.52
Rate for Payer: Amerigroup Medicaid	$13.74
Rate for Payer: Amerigroup Medicare	$13.75
Rate for Payer: Cash Price	$21.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.61
Rate for Payer: Iowa Total Care Managed Medicaid	$13.60
Rate for Payer: Medical Associates Commercial	$20.42
Rate for Payer: Medical Associates Managed Medicare	$13.61
Rate for Payer: Midlands Choice Commercial	$19.05
Rate for Payer: Molina Healthcare Managed Medicaid	$13.81
Rate for Payer: Molina Healthcare Managed Medicare	$13.81
Rate for Payer: Oscar Health of IA Commercial	$20.42
Rate for Payer: Partners Health Alliance Commercial	$20.42
Rate for Payer: United Healthcare Commercial	$24.50
Rate for Payer: United Healthcare Managed Medicare	$16.06

hydrALAZINE 25 mg Tab [VDMC]

Facility

$1.34

Service Code	HCPCS A9270
Hospital Charge Code	10393836
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.21
Rate for Payer: Aetna of IA Commercial	$1.21
Rate for Payer: Aetna of IA Medical Rental Products	$1.21
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Midlands Choice Commercial	$0.94
Rate for Payer: United Healthcare Commercial	$1.21

hydrALAZINE 25 mg Tab [VDMC]

Facility

$1.34

Service Code	HCPCS A9270
Hospital Charge Code	10393836
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.21
Rate for Payer: Aetna of IA Commercial	$1.21
Rate for Payer: Aetna of IA Medical Rental Products	$1.21
Rate for Payer: Aetna of IA Medicare	$0.76
Rate for Payer: Amerigroup Medicaid	$0.68
Rate for Payer: Amerigroup Medicare	$0.68
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.67
Rate for Payer: Iowa Total Care Managed Medicaid	$0.67
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Medical Associates Managed Medicare	$0.67
Rate for Payer: Midlands Choice Commercial	$0.94
Rate for Payer: Molina Healthcare Managed Medicaid	$0.68
Rate for Payer: Molina Healthcare Managed Medicare	$0.68
Rate for Payer: Oscar Health of IA Commercial	$1.00
Rate for Payer: Partners Health Alliance Commercial	$1.00
Rate for Payer: United Healthcare Commercial	$1.21
Rate for Payer: United Healthcare Managed Medicare	$0.79

hydrochlorothiazide 25 mg Tab [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10393974
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Aetna of IA Medicare	$0.61
Rate for Payer: Amerigroup Medicaid	$0.54
Rate for Payer: Amerigroup Medicare	$0.54
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.54
Rate for Payer: Iowa Total Care Managed Medicaid	$0.53
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Medical Associates Managed Medicare	$0.54
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: Molina Healthcare Managed Medicaid	$0.54
Rate for Payer: Molina Healthcare Managed Medicare	$0.54
Rate for Payer: Oscar Health of IA Commercial	$0.80
Rate for Payer: Partners Health Alliance Commercial	$0.80
Rate for Payer: United Healthcare Commercial	$0.96
Rate for Payer: United Healthcare Managed Medicare	$0.63

hydrochlorothiazide 25 mg Tab [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10393974
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: United Healthcare Commercial	$0.96

HYDROcodone - acetaminophen 5 mg-325 mg Tab [VDMC]

Facility

$4.25

Service Code	HCPCS A9270
Hospital Charge Code	10363251
Hospital Revenue Code	259
Min. Negotiated Rate	$2.12
Max. Negotiated Rate	$3.82
Rate for Payer: Aetna of IA Commercial	$3.82
Rate for Payer: Aetna of IA Medical Rental Products	$3.82
Rate for Payer: Aetna of IA Medicare	$2.42
Rate for Payer: Amerigroup Medicaid	$2.14
Rate for Payer: Amerigroup Medicare	$2.15
Rate for Payer: Cash Price	$3.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.12
Rate for Payer: Iowa Total Care Managed Medicaid	$2.12
Rate for Payer: Medical Associates Commercial	$3.19
Rate for Payer: Medical Associates Managed Medicare	$2.12
Rate for Payer: Midlands Choice Commercial	$2.98
Rate for Payer: Molina Healthcare Managed Medicaid	$2.16
Rate for Payer: Molina Healthcare Managed Medicare	$2.16
Rate for Payer: Oscar Health of IA Commercial	$3.19
Rate for Payer: Partners Health Alliance Commercial	$3.19
Rate for Payer: United Healthcare Commercial	$3.82
Rate for Payer: United Healthcare Managed Medicare	$2.51

HYDROcodone - acetaminophen 5 mg-325 mg Tab [VDMC]

Facility

$4.25

Service Code	HCPCS A9270
Hospital Charge Code	10363251
Hospital Revenue Code	259
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$3.82
Rate for Payer: Aetna of IA Commercial	$3.82
Rate for Payer: Aetna of IA Medical Rental Products	$3.82
Rate for Payer: Cash Price	$3.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.19
Rate for Payer: Medical Associates Commercial	$3.19
Rate for Payer: Midlands Choice Commercial	$2.98
Rate for Payer: United Healthcare Commercial	$3.82

hydrocodone/apap 7.5-325mg tab [VDMC]

Facility

$4.11

Service Code	HCPCS A9270
Hospital Charge Code	10432773
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$3.70
Rate for Payer: Aetna of IA Commercial	$3.70
Rate for Payer: Aetna of IA Medical Rental Products	$3.70
Rate for Payer: Aetna of IA Medicare	$2.34
Rate for Payer: Amerigroup Medicaid	$2.07
Rate for Payer: Amerigroup Medicare	$2.08
Rate for Payer: Cash Price	$3.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.08
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.06
Rate for Payer: Iowa Total Care Managed Medicaid	$2.05
Rate for Payer: Medical Associates Commercial	$3.08
Rate for Payer: Medical Associates Managed Medicare	$2.06
Rate for Payer: Midlands Choice Commercial	$2.88
Rate for Payer: Molina Healthcare Managed Medicaid	$2.09
Rate for Payer: Molina Healthcare Managed Medicare	$2.08
Rate for Payer: Oscar Health of IA Commercial	$3.08
Rate for Payer: Partners Health Alliance Commercial	$3.08
Rate for Payer: United Healthcare Commercial	$3.70
Rate for Payer: United Healthcare Managed Medicare	$2.42

hydrocodone/apap 7.5-325mg tab [VDMC]

Facility

$4.11

Service Code	HCPCS A9270
Hospital Charge Code	10432773
Hospital Revenue Code	259
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$3.70
Rate for Payer: Aetna of IA Commercial	$3.70
Rate for Payer: Aetna of IA Medical Rental Products	$3.70
Rate for Payer: Cash Price	$3.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.08
Rate for Payer: Medical Associates Commercial	$3.08
Rate for Payer: Midlands Choice Commercial	$2.88
Rate for Payer: United Healthcare Commercial	$3.70

hydrocortisone 100 mg/60 mL Rectal Susp [VDMC]

Facility

$93.96

Service Code	NDC 62559-0111-11
Hospital Charge Code	10394390
Hospital Revenue Code	259
Min. Negotiated Rate	$46.96
Max. Negotiated Rate	$84.56
Rate for Payer: Aetna of IA Commercial	$84.56
Rate for Payer: Aetna of IA Medical Rental Products	$84.56
Rate for Payer: Aetna of IA Medicare	$53.56
Rate for Payer: Amerigroup Medicaid	$47.42
Rate for Payer: Amerigroup Medicare	$47.45
Rate for Payer: Cash Price	$75.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.47
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$46.98
Rate for Payer: Iowa Total Care Managed Medicaid	$46.96
Rate for Payer: Medical Associates Commercial	$70.47
Rate for Payer: Medical Associates Managed Medicare	$46.98
Rate for Payer: Midlands Choice Commercial	$65.77
Rate for Payer: Molina Healthcare Managed Medicaid	$47.68
Rate for Payer: Molina Healthcare Managed Medicare	$47.66
Rate for Payer: Oscar Health of IA Commercial	$70.47
Rate for Payer: Partners Health Alliance Commercial	$70.47
Rate for Payer: United Healthcare Commercial	$84.56
Rate for Payer: United Healthcare Managed Medicare	$55.44

hydrocortisone 100 mg/60 mL Rectal Susp [VDMC]

Facility

$93.96

Service Code	NDC 62559-0111-11
Hospital Charge Code	10394390
Hospital Revenue Code	259
Min. Negotiated Rate	$65.77
Max. Negotiated Rate	$84.56
Rate for Payer: Aetna of IA Commercial	$84.56
Rate for Payer: Aetna of IA Medical Rental Products	$84.56
Rate for Payer: Cash Price	$75.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.47
Rate for Payer: Medical Associates Commercial	$70.47
Rate for Payer: Midlands Choice Commercial	$65.77
Rate for Payer: United Healthcare Commercial	$84.56

Know your out-of-pocket cost for care.

All Charges