Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

HUMERAL STEM 11MM X 151MM

Facility

$6,615.00

Service Code	HCPCS C1776
Hospital Charge Code	8047270
Hospital Revenue Code	278
Min. Negotiated Rate	$2,976.75
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	$3,815.53
Rate for Payer: Amerigroup Medicare	$3,006.52
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	$2,976.75
Rate for Payer: Iowa Total Care Managed Medicaid	$3,778.49
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$2,976.75
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,834.05
Rate for Payer: Partners Health Alliance Commercial	$3,423.26
Rate for Payer: United Healthcare Commercial	$5,953.50
Rate for Payer: United Healthcare Managed Medicare	$3,902.85

HUMERAL STEM 11MM X 151MM

Facility

$6,615.00

Service Code	HCPCS C1776
Hospital Charge Code	8047270
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 12MM X 151MM

Facility

$6,615.00

Service Code	HCPCS C1776
Hospital Charge Code	8047271
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 12MM X 151MM

Facility

$6,615.00

Service Code	HCPCS C1776
Hospital Charge Code	8047271
Hospital Revenue Code	278
Min. Negotiated Rate	$2,976.75
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	$3,815.53
Rate for Payer: Amerigroup Medicare	$3,006.52
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	$2,976.75
Rate for Payer: Iowa Total Care Managed Medicaid	$3,778.49
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$2,976.75
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,834.05
Rate for Payer: Partners Health Alliance Commercial	$3,423.26
Rate for Payer: United Healthcare Commercial	$5,953.50
Rate for Payer: United Healthcare Managed Medicare	$3,902.85

HUMERAL STEM 6MM X 115MM

Facility

$6,615.00

Service Code	HCPCS 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 6MM X 115MM

Facility

$6,615.00

Service Code	HCPCS C1776
Hospital Charge Code	8047265
Hospital Revenue Code	278
Min. Negotiated Rate	$2,976.75
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	$3,815.53
Rate for Payer: Amerigroup Medicare	$3,006.52
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	$2,976.75
Rate for Payer: Iowa Total Care Managed Medicaid	$3,778.49
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$2,976.75
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,834.05
Rate for Payer: Partners Health Alliance Commercial	$3,423.26
Rate for Payer: United Healthcare Commercial	$5,953.50
Rate for Payer: United Healthcare Managed Medicare	$3,902.85

HUMERAL STEM 7MM X 140MM

Facility

$6,615.00

Service Code	HCPCS C1776
Hospital Charge Code	8047266
Hospital Revenue Code	278
Min. Negotiated Rate	$2,976.75
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	$3,815.53
Rate for Payer: Amerigroup Medicare	$3,006.52
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	$2,976.75
Rate for Payer: Iowa Total Care Managed Medicaid	$3,778.49
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$2,976.75
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,834.05
Rate for Payer: Partners Health Alliance Commercial	$3,423.26
Rate for Payer: United Healthcare Commercial	$5,953.50
Rate for Payer: United Healthcare Managed Medicare	$3,902.85

HUMERAL STEM 7MM X 140MM

Facility

$6,615.00

Service Code	HCPCS 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 8MM X 143MM

Facility

$6,615.00

Service Code	HCPCS 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	HCPCS C1776
Hospital Charge Code	8047267
Hospital Revenue Code	278
Min. Negotiated Rate	$2,976.75
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	$3,815.53
Rate for Payer: Amerigroup Medicare	$3,006.52
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	$2,976.75
Rate for Payer: Iowa Total Care Managed Medicaid	$3,778.49
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$2,976.75
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,834.05
Rate for Payer: Partners Health Alliance Commercial	$3,423.26
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	HCPCS 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	HCPCS C1776
Hospital Charge Code	8047268
Hospital Revenue Code	278
Min. Negotiated Rate	$2,976.75
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	$3,815.53
Rate for Payer: Amerigroup Medicare	$3,006.52
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	$2,976.75
Rate for Payer: Iowa Total Care Managed Medicaid	$3,778.49
Rate for Payer: Medical Associates Commercial	$4,961.25
Rate for Payer: Medical Associates Managed Medicare	$2,976.75
Rate for Payer: Midlands Choice Commercial	$4,630.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,834.05
Rate for Payer: Partners Health Alliance Commercial	$3,423.26
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	HCPCS 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	HCPCS C1776
Hospital Charge Code	8047293
Hospital Revenue Code	278
Min. Negotiated Rate	$2,316.60
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: Aetna of IA Medicare	$2,934.36
Rate for Payer: Amerigroup Medicaid	$2,969.37
Rate for Payer: Amerigroup Medicare	$2,339.77
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	$2,316.60
Rate for Payer: Iowa Total Care Managed Medicaid	$2,940.54
Rate for Payer: Medical Associates Commercial	$3,861.00
Rate for Payer: Medical Associates Managed Medicare	$2,316.60
Rate for Payer: Midlands Choice Commercial	$3,603.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,983.78
Rate for Payer: Partners Health Alliance Commercial	$2,664.09
Rate for Payer: United Healthcare Commercial	$4,633.20
Rate for Payer: United Healthcare Managed Medicare	$3,037.32

hydrALAZINE 10 mg Tab [VDMC]

Facility

$1.41

Service Code	HCPCS A9270
Hospital Charge Code	10393696
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
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	$0.81
Rate for Payer: Amerigroup Medicaid	$0.82
Rate for Payer: Amerigroup Medicare	$0.64
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	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.81
Rate for Payer: Medical Associates Commercial	$1.06
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$0.99
Rate for Payer: Molina Healthcare Managed Medicaid	$0.82
Rate for Payer: Partners Health Alliance Commercial	$0.73
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

$27.21

Service Code	HCPCS J0360
Hospital Charge Code	10393767
Hospital Revenue Code	259
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$24.49
Rate for Payer: Aetna of IA Commercial	$24.49
Rate for Payer: Aetna of IA Medical Rental Products	$24.49
Rate for Payer: Aetna of IA Medicare	$15.51
Rate for Payer: Amerigroup Medicaid	$15.70
Rate for Payer: Amerigroup Medicare	$12.37
Rate for Payer: Cash Price	$21.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.41
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.25
Rate for Payer: Iowa Total Care Managed Medicaid	$15.54
Rate for Payer: Medical Associates Commercial	$20.41
Rate for Payer: Medical Associates Managed Medicare	$12.25
Rate for Payer: Midlands Choice Commercial	$19.05
Rate for Payer: Molina Healthcare Managed Medicaid	$15.77
Rate for Payer: Partners Health Alliance Commercial	$14.08
Rate for Payer: United Healthcare Commercial	$24.49
Rate for Payer: United Healthcare Managed Medicare	$16.05

hydrALAZINE 20 mg/mL SDV Inj Sol [VDMC]

Facility

$27.21

Service Code	HCPCS J0360
Hospital Charge Code	10393767
Hospital Revenue Code	259
Min. Negotiated Rate	$19.05
Max. Negotiated Rate	$24.49
Rate for Payer: Aetna of IA Commercial	$24.49
Rate for Payer: Aetna of IA Medical Rental Products	$24.49
Rate for Payer: Cash Price	$21.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.41
Rate for Payer: Medical Associates Commercial	$20.41
Rate for Payer: Midlands Choice Commercial	$19.05
Rate for Payer: United Healthcare Commercial	$24.49

hydrALAZINE 25 mg Tab [VDMC]

Facility

$1.42

Service Code	HCPCS A9270
Hospital Charge Code	10393836
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.28
Rate for Payer: Aetna of IA Commercial	$1.28
Rate for Payer: Aetna of IA Medical Rental Products	$1.28
Rate for Payer: Cash Price	$1.14
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	$1.28

hydrALAZINE 25 mg Tab [VDMC]

Facility

$1.42

Service Code	HCPCS A9270
Hospital Charge Code	10393836
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$1.28
Rate for Payer: Aetna of IA Commercial	$1.28
Rate for Payer: Aetna of IA Medical Rental Products	$1.28
Rate for Payer: Aetna of IA Medicare	$0.81
Rate for Payer: Amerigroup Medicaid	$0.82
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.14
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	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.81
Rate for Payer: Medical Associates Commercial	$1.06
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$0.99
Rate for Payer: Molina Healthcare Managed Medicaid	$0.82
Rate for Payer: Partners Health Alliance Commercial	$0.73
Rate for Payer: United Healthcare Commercial	$1.28
Rate for Payer: United Healthcare Managed Medicare	$0.84

hydrochlorothiazide 25 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10393974
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Aetna of IA Medicare	$0.89
Rate for Payer: Amerigroup Medicaid	$0.90
Rate for Payer: Amerigroup Medicare	$0.71
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.70
Rate for Payer: Iowa Total Care Managed Medicaid	$0.89
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: Molina Healthcare Managed Medicaid	$0.90
Rate for Payer: Partners Health Alliance Commercial	$0.81
Rate for Payer: United Healthcare Commercial	$1.40
Rate for Payer: United Healthcare Managed Medicare	$0.92

hydrochlorothiazide 25 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10393974
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.40

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

Facility

$4.16

Service Code	HCPCS A9270
Hospital Charge Code	10363251
Hospital Revenue Code	259
Min. Negotiated Rate	$2.91
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of IA Commercial	$3.75
Rate for Payer: Aetna of IA Medical Rental Products	$3.75
Rate for Payer: Cash Price	$3.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.12
Rate for Payer: Medical Associates Commercial	$3.12
Rate for Payer: Midlands Choice Commercial	$2.91
Rate for Payer: United Healthcare Commercial	$3.75

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

Facility

$4.16

Service Code	HCPCS A9270
Hospital Charge Code	10363251
Hospital Revenue Code	259
Min. Negotiated Rate	$1.87
Max. Negotiated Rate	$3.75
Rate for Payer: Aetna of IA Commercial	$3.75
Rate for Payer: Aetna of IA Medical Rental Products	$3.75
Rate for Payer: Aetna of IA Medicare	$2.37
Rate for Payer: Amerigroup Medicaid	$2.40
Rate for Payer: Amerigroup Medicare	$1.89
Rate for Payer: Cash Price	$3.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.87
Rate for Payer: Iowa Total Care Managed Medicaid	$2.38
Rate for Payer: Medical Associates Commercial	$3.12
Rate for Payer: Medical Associates Managed Medicare	$1.87
Rate for Payer: Midlands Choice Commercial	$2.91
Rate for Payer: Molina Healthcare Managed Medicaid	$2.41
Rate for Payer: Partners Health Alliance Commercial	$2.15
Rate for Payer: United Healthcare Commercial	$3.75
Rate for Payer: United Healthcare Managed Medicare	$2.46

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

Know your out-of-pocket cost for care.

All Charges