Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

HYDROmorphone 2 mg/mL Sol 20mL [VDMC]

Facility

$108.56

Service Code	HCPCS J1171
Hospital Charge Code	11717471
Hospital Revenue Code	259
Min. Negotiated Rate	$75.99
Max. Negotiated Rate	$97.70
Rate for Payer: Aetna of IA Commercial	$97.70
Rate for Payer: Aetna of IA Medical Rental Products	$97.70
Rate for Payer: Cash Price	$86.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.42
Rate for Payer: Medical Associates Commercial	$81.42
Rate for Payer: Midlands Choice Commercial	$75.99
Rate for Payer: United Healthcare Commercial	$97.70

HYDROmorphone 2 mg/mL Sol 20mL [VDMC]

Facility

$108.56

Service Code	HCPCS J1171
Hospital Charge Code	11717471
Hospital Revenue Code	259
Min. Negotiated Rate	$48.85
Max. Negotiated Rate	$97.70
Rate for Payer: Aetna of IA Commercial	$97.70
Rate for Payer: Aetna of IA Medical Rental Products	$97.70
Rate for Payer: Aetna of IA Medicare	$61.88
Rate for Payer: Amerigroup Medicaid	$62.62
Rate for Payer: Amerigroup Medicare	$49.34
Rate for Payer: Cash Price	$86.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$48.85
Rate for Payer: Iowa Total Care Managed Medicaid	$62.01
Rate for Payer: Medical Associates Commercial	$81.42
Rate for Payer: Medical Associates Managed Medicare	$48.85
Rate for Payer: Midlands Choice Commercial	$75.99
Rate for Payer: Molina Healthcare Managed Medicaid	$62.92
Rate for Payer: Partners Health Alliance Commercial	$56.18
Rate for Payer: United Healthcare Commercial	$97.70
Rate for Payer: United Healthcare Managed Medicare	$64.05

HYDROmorphone 2 mg/mL syringe 1mL [VDMC]

Facility

$48.65

Service Code	HCPCS J1171
Hospital Charge Code	10394794
Hospital Revenue Code	259
Min. Negotiated Rate	$34.05
Max. Negotiated Rate	$43.78
Rate for Payer: Aetna of IA Commercial	$43.78
Rate for Payer: Aetna of IA Medical Rental Products	$43.78
Rate for Payer: Cash Price	$38.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.49
Rate for Payer: Medical Associates Commercial	$36.49
Rate for Payer: Midlands Choice Commercial	$34.05
Rate for Payer: United Healthcare Commercial	$43.78

HYDROmorphone 2 mg/mL syringe 1mL [VDMC]

Facility

$48.65

Service Code	HCPCS J1171
Hospital Charge Code	10394794
Hospital Revenue Code	259
Min. Negotiated Rate	$21.89
Max. Negotiated Rate	$43.78
Rate for Payer: Aetna of IA Commercial	$43.78
Rate for Payer: Aetna of IA Medical Rental Products	$43.78
Rate for Payer: Aetna of IA Medicare	$27.73
Rate for Payer: Amerigroup Medicaid	$28.06
Rate for Payer: Amerigroup Medicare	$22.11
Rate for Payer: Cash Price	$38.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.49
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.89
Rate for Payer: Iowa Total Care Managed Medicaid	$27.79
Rate for Payer: Medical Associates Commercial	$36.49
Rate for Payer: Medical Associates Managed Medicare	$21.89
Rate for Payer: Midlands Choice Commercial	$34.05
Rate for Payer: Molina Healthcare Managed Medicaid	$28.20
Rate for Payer: Partners Health Alliance Commercial	$25.18
Rate for Payer: United Healthcare Commercial	$43.78
Rate for Payer: United Healthcare Managed Medicare	$28.70

HYDROmorphone 2 mg/mL vial [VDMC]

Facility

$45.31

Service Code	HCPCS J1171
Hospital Charge Code	15701801
Hospital Revenue Code	259
Min. Negotiated Rate	$20.39
Max. Negotiated Rate	$40.78
Rate for Payer: Aetna of IA Commercial	$40.78
Rate for Payer: Aetna of IA Medical Rental Products	$40.78
Rate for Payer: Aetna of IA Medicare	$25.82
Rate for Payer: Amerigroup Medicaid	$26.13
Rate for Payer: Amerigroup Medicare	$20.59
Rate for Payer: Cash Price	$36.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.39
Rate for Payer: Iowa Total Care Managed Medicaid	$25.88
Rate for Payer: Medical Associates Commercial	$33.98
Rate for Payer: Medical Associates Managed Medicare	$20.39
Rate for Payer: Midlands Choice Commercial	$31.71
Rate for Payer: Molina Healthcare Managed Medicaid	$26.26
Rate for Payer: Partners Health Alliance Commercial	$23.45
Rate for Payer: United Healthcare Commercial	$40.78
Rate for Payer: United Healthcare Managed Medicare	$26.73

HYDROmorphone 2 mg/mL vial [VDMC]

Facility

$45.31

Service Code	HCPCS J1171
Hospital Charge Code	15701801
Hospital Revenue Code	259
Min. Negotiated Rate	$31.71
Max. Negotiated Rate	$40.78
Rate for Payer: Aetna of IA Commercial	$40.78
Rate for Payer: Aetna of IA Medical Rental Products	$40.78
Rate for Payer: Cash Price	$36.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.98
Rate for Payer: Medical Associates Commercial	$33.98
Rate for Payer: Midlands Choice Commercial	$31.71
Rate for Payer: United Healthcare Commercial	$40.78

HYDROmorphone 2 mg Tab [VDMC]

Facility

$3.48

Service Code	HCPCS A9270
Hospital Charge Code	10394725
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna of IA Commercial	$3.13
Rate for Payer: Aetna of IA Medical Rental Products	$3.13
Rate for Payer: Aetna of IA Medicare	$1.98
Rate for Payer: Amerigroup Medicaid	$2.01
Rate for Payer: Amerigroup Medicare	$1.58
Rate for Payer: Cash Price	$2.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.61
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.57
Rate for Payer: Iowa Total Care Managed Medicaid	$1.99
Rate for Payer: Medical Associates Commercial	$2.61
Rate for Payer: Medical Associates Managed Medicare	$1.57
Rate for Payer: Midlands Choice Commercial	$2.44
Rate for Payer: Molina Healthcare Managed Medicaid	$2.02
Rate for Payer: Partners Health Alliance Commercial	$1.80
Rate for Payer: United Healthcare Commercial	$3.13
Rate for Payer: United Healthcare Managed Medicare	$2.05

HYDROmorphone 2 mg Tab [VDMC]

Facility

$3.48

Service Code	HCPCS A9270
Hospital Charge Code	10394725
Hospital Revenue Code	259
Min. Negotiated Rate	$2.44
Max. Negotiated Rate	$3.13
Rate for Payer: Aetna of IA Commercial	$3.13
Rate for Payer: Aetna of IA Medical Rental Products	$3.13
Rate for Payer: Cash Price	$2.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.61
Rate for Payer: Medical Associates Commercial	$2.61
Rate for Payer: Midlands Choice Commercial	$2.44
Rate for Payer: United Healthcare Commercial	$3.13

HYDROmorphone 4 mg/mL Inj Sol [VDMC]

Facility

$47.19

Service Code	HCPCS J1171
Hospital Charge Code	10394932
Hospital Revenue Code	259
Min. Negotiated Rate	$21.24
Max. Negotiated Rate	$42.47
Rate for Payer: Aetna of IA Commercial	$42.47
Rate for Payer: Aetna of IA Medical Rental Products	$42.47
Rate for Payer: Aetna of IA Medicare	$26.90
Rate for Payer: Amerigroup Medicaid	$27.22
Rate for Payer: Amerigroup Medicare	$21.45
Rate for Payer: Cash Price	$37.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.24
Rate for Payer: Iowa Total Care Managed Medicaid	$26.96
Rate for Payer: Medical Associates Commercial	$35.39
Rate for Payer: Medical Associates Managed Medicare	$21.24
Rate for Payer: Midlands Choice Commercial	$33.03
Rate for Payer: Molina Healthcare Managed Medicaid	$27.35
Rate for Payer: Partners Health Alliance Commercial	$24.42
Rate for Payer: United Healthcare Commercial	$42.47
Rate for Payer: United Healthcare Managed Medicare	$27.84

HYDROmorphone 4 mg/mL Inj Sol [VDMC]

Facility

$47.19

Service Code	HCPCS J1171
Hospital Charge Code	10394932
Hospital Revenue Code	259
Min. Negotiated Rate	$33.03
Max. Negotiated Rate	$42.47
Rate for Payer: Aetna of IA Commercial	$42.47
Rate for Payer: Aetna of IA Medical Rental Products	$42.47
Rate for Payer: Cash Price	$37.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.39
Rate for Payer: Medical Associates Commercial	$35.39
Rate for Payer: Midlands Choice Commercial	$33.03
Rate for Payer: United Healthcare Commercial	$42.47

hydrophilic ointment 454 gm [VDMC]

Facility

$52.00

Service Code	HCPCS A9270
Hospital Charge Code	10432657
Hospital Revenue Code	259
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Aetna of IA Medicare	$29.64
Rate for Payer: Amerigroup Medicaid	$29.99
Rate for Payer: Amerigroup Medicare	$23.63
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.40
Rate for Payer: Iowa Total Care Managed Medicaid	$29.70
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Medical Associates Managed Medicare	$23.40
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: Molina Healthcare Managed Medicaid	$30.14
Rate for Payer: Partners Health Alliance Commercial	$26.91
Rate for Payer: United Healthcare Commercial	$46.80
Rate for Payer: United Healthcare Managed Medicare	$30.68

hydrophilic ointment 454 gm [VDMC]

Facility

$52.00

Service Code	HCPCS A9270
Hospital Charge Code	10432657
Hospital Revenue Code	259
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: United Healthcare Commercial	$46.80

HYDROPHILIC WOUND DRESSING 85 GRAM

Facility

$64.00

Hospital Charge Code	8013714
Hospital Revenue Code	250
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

HYDROPHILIC WOUND DRESSING 85 GRAM

Facility

$64.00

Hospital Charge Code	8013714
Hospital Revenue Code	250
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76

Hydrophilic Wound Dressing oint tube [VDMC]

Facility

$8.44

Service Code	HCPCS A9270
Hospital Charge Code	23071981
Hospital Revenue Code	259
Min. Negotiated Rate	$5.91
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna of IA Commercial	$7.60
Rate for Payer: Aetna of IA Medical Rental Products	$7.60
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6.33
Rate for Payer: Medical Associates Commercial	$6.33
Rate for Payer: Midlands Choice Commercial	$5.91
Rate for Payer: United Healthcare Commercial	$7.60

Hydrophilic Wound Dressing oint tube [VDMC]

Facility

$8.44

Service Code	HCPCS A9270
Hospital Charge Code	23071981
Hospital Revenue Code	259
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$7.60
Rate for Payer: Aetna of IA Commercial	$7.60
Rate for Payer: Aetna of IA Medical Rental Products	$7.60
Rate for Payer: Aetna of IA Medicare	$4.81
Rate for Payer: Amerigroup Medicaid	$4.87
Rate for Payer: Amerigroup Medicare	$3.84
Rate for Payer: Cash Price	$6.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6.33
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.80
Rate for Payer: Iowa Total Care Managed Medicaid	$4.82
Rate for Payer: Medical Associates Commercial	$6.33
Rate for Payer: Medical Associates Managed Medicare	$3.80
Rate for Payer: Midlands Choice Commercial	$5.91
Rate for Payer: Molina Healthcare Managed Medicaid	$4.89
Rate for Payer: Partners Health Alliance Commercial	$4.37
Rate for Payer: United Healthcare Commercial	$7.60
Rate for Payer: United Healthcare Managed Medicare	$4.98

hydroxychloroquine 200 mg Tab [VDMC]

Facility

$1.68

Service Code	HCPCS A9270
Hospital Charge Code	10395001
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of IA Commercial	$1.51
Rate for Payer: Aetna of IA Medical Rental Products	$1.51
Rate for Payer: Aetna of IA Medicare	$0.96
Rate for Payer: Amerigroup Medicaid	$0.97
Rate for Payer: Amerigroup Medicare	$0.76
Rate for Payer: Cash Price	$1.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.76
Rate for Payer: Iowa Total Care Managed Medicaid	$0.96
Rate for Payer: Medical Associates Commercial	$1.26
Rate for Payer: Medical Associates Managed Medicare	$0.76
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: Molina Healthcare Managed Medicaid	$0.97
Rate for Payer: Partners Health Alliance Commercial	$0.87
Rate for Payer: United Healthcare Commercial	$1.51
Rate for Payer: United Healthcare Managed Medicare	$0.99

hydroxychloroquine 200 mg Tab [VDMC]

Facility

$1.68

Service Code	HCPCS A9270
Hospital Charge Code	10395001
Hospital Revenue Code	259
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of IA Commercial	$1.51
Rate for Payer: Aetna of IA Medical Rental Products	$1.51
Rate for Payer: Cash Price	$1.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.26
Rate for Payer: Medical Associates Commercial	$1.26
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: United Healthcare Commercial	$1.51

hydroxyurEA 500 mg Cap [VDMC]

Facility

$2.30

Service Code	HCPCS A9270
Hospital Charge Code	10395072
Hospital Revenue Code	259
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$2.07
Rate for Payer: Aetna of IA Commercial	$2.07
Rate for Payer: Aetna of IA Medical Rental Products	$2.07
Rate for Payer: Cash Price	$1.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.73
Rate for Payer: Medical Associates Commercial	$1.73
Rate for Payer: Midlands Choice Commercial	$1.61
Rate for Payer: United Healthcare Commercial	$2.07

hydroxyurEA 500 mg Cap [VDMC]

Facility

$2.30

Service Code	HCPCS A9270
Hospital Charge Code	10395072
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$2.07
Rate for Payer: Aetna of IA Commercial	$2.07
Rate for Payer: Aetna of IA Medical Rental Products	$2.07
Rate for Payer: Aetna of IA Medicare	$1.31
Rate for Payer: Amerigroup Medicaid	$1.33
Rate for Payer: Amerigroup Medicare	$1.05
Rate for Payer: Cash Price	$1.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.04
Rate for Payer: Iowa Total Care Managed Medicaid	$1.32
Rate for Payer: Medical Associates Commercial	$1.73
Rate for Payer: Medical Associates Managed Medicare	$1.04
Rate for Payer: Midlands Choice Commercial	$1.61
Rate for Payer: Molina Healthcare Managed Medicaid	$1.34
Rate for Payer: Partners Health Alliance Commercial	$1.19
Rate for Payer: United Healthcare Commercial	$2.07
Rate for Payer: United Healthcare Managed Medicare	$1.36

hydrOXYzine hydrochloride 10 mg Tab [VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	10395143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: United Healthcare Commercial	$1.00

hydrOXYzine hydrochloride 10 mg Tab [VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	10395143
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Aetna of IA Medicare	$0.63
Rate for Payer: Amerigroup Medicaid	$0.64
Rate for Payer: Amerigroup Medicare	$0.51
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.50
Rate for Payer: Iowa Total Care Managed Medicaid	$0.64
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Medical Associates Managed Medicare	$0.50
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: Molina Healthcare Managed Medicaid	$0.64
Rate for Payer: Partners Health Alliance Commercial	$0.58
Rate for Payer: United Healthcare Commercial	$1.00
Rate for Payer: United Healthcare Managed Medicare	$0.66

hydrOXYzine hydrochloride 25 mg/mL Sol[VDMC]

Facility

$85.94

Service Code	HCPCS J3410
Hospital Charge Code	11754562
Hospital Revenue Code	259
Min. Negotiated Rate	$38.67
Max. Negotiated Rate	$77.34
Rate for Payer: Aetna of IA Commercial	$77.34
Rate for Payer: Aetna of IA Medical Rental Products	$77.34
Rate for Payer: Aetna of IA Medicare	$48.98
Rate for Payer: Amerigroup Medicaid	$49.57
Rate for Payer: Amerigroup Medicare	$39.06
Rate for Payer: Cash Price	$68.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.45
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.67
Rate for Payer: Iowa Total Care Managed Medicaid	$49.09
Rate for Payer: Medical Associates Commercial	$64.45
Rate for Payer: Medical Associates Managed Medicare	$38.67
Rate for Payer: Midlands Choice Commercial	$60.16
Rate for Payer: Molina Healthcare Managed Medicaid	$49.81
Rate for Payer: Partners Health Alliance Commercial	$44.47
Rate for Payer: United Healthcare Commercial	$77.34
Rate for Payer: United Healthcare Managed Medicare	$50.70

hydrOXYzine hydrochloride 25 mg/mL Sol[VDMC]

Facility

$85.94

Service Code	HCPCS J3410
Hospital Charge Code	11754562
Hospital Revenue Code	259
Min. Negotiated Rate	$60.16
Max. Negotiated Rate	$77.34
Rate for Payer: Aetna of IA Commercial	$77.34
Rate for Payer: Aetna of IA Medical Rental Products	$77.34
Rate for Payer: Cash Price	$68.75
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.45
Rate for Payer: Medical Associates Commercial	$64.45
Rate for Payer: Midlands Choice Commercial	$60.16
Rate for Payer: United Healthcare Commercial	$77.34

hydrOXYzine hydrochloride 25 mg Tab [VDMC]

Facility

$1.59

Service Code	HCPCS A9270
Hospital Charge Code	10395212
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.43
Rate for Payer: Aetna of IA Commercial	$1.43
Rate for Payer: Aetna of IA Medical Rental Products	$1.43
Rate for Payer: Cash Price	$1.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.19
Rate for Payer: Medical Associates Commercial	$1.19
Rate for Payer: Midlands Choice Commercial	$1.11
Rate for Payer: United Healthcare Commercial	$1.43

Know your out-of-pocket cost for care.

All Charges