Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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 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 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 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 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 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 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	$221.80
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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	$0.64
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

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

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	$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 - 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/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

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	$1.85
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	$2.37
Rate for Payer: Amerigroup Medicare	$1.87
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	$1.85
Rate for Payer: Iowa Total Care Managed Medicaid	$2.35
Rate for Payer: Medical Associates Commercial	$3.08
Rate for Payer: Medical Associates Managed Medicare	$1.85
Rate for Payer: Midlands Choice Commercial	$2.88
Rate for Payer: Molina Healthcare Managed Medicaid	$2.38
Rate for Payer: Partners Health Alliance Commercial	$2.13
Rate for Payer: United Healthcare Commercial	$3.70
Rate for Payer: United Healthcare Managed Medicare	$2.42

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	$42.28
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	$54.20
Rate for Payer: Amerigroup Medicare	$42.71
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	$42.28
Rate for Payer: Iowa Total Care Managed Medicaid	$53.67
Rate for Payer: Medical Associates Commercial	$70.47
Rate for Payer: Medical Associates Managed Medicare	$42.28
Rate for Payer: Midlands Choice Commercial	$65.77
Rate for Payer: Molina Healthcare Managed Medicaid	$54.46
Rate for Payer: Partners Health Alliance Commercial	$48.62
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

hydrocortisone 100 mg PF Pow SDV inj [VDMC]

Facility

$96.60

Service Code	HCPCS J1720
Hospital Charge Code	10394323
Hospital Revenue Code	259
Min. Negotiated Rate	$43.47
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$86.94
Rate for Payer: Aetna of IA Medical Rental Products	$86.94
Rate for Payer: Aetna of IA Medicare	$55.06
Rate for Payer: Amerigroup Medicaid	$55.72
Rate for Payer: Amerigroup Medicare	$43.90
Rate for Payer: Cash Price	$77.28
Rate for Payer: Cash Price	$77.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$72.45
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$43.47
Rate for Payer: Iowa Total Care Managed Medicaid	$55.18
Rate for Payer: Medical Associates Commercial	$72.45
Rate for Payer: Medical Associates Managed Medicare	$43.47
Rate for Payer: Midlands Choice Commercial	$67.62
Rate for Payer: Molina Healthcare Managed Medicaid	$55.99
Rate for Payer: Partners Health Alliance Commercial	$49.99
Rate for Payer: United Healthcare Commercial	$86.94
Rate for Payer: United Healthcare Managed Medicare	$56.99
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

hydrocortisone 100 mg PF Pow SDV inj [VDMC]

Facility

$96.60

Service Code	HCPCS J1720
Hospital Charge Code	10394323
Hospital Revenue Code	259
Min. Negotiated Rate	$67.62
Max. Negotiated Rate	$86.94
Rate for Payer: Aetna of IA Commercial	$86.94
Rate for Payer: Aetna of IA Medical Rental Products	$86.94
Rate for Payer: Cash Price	$77.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$72.45
Rate for Payer: Medical Associates Commercial	$72.45
Rate for Payer: Midlands Choice Commercial	$67.62
Rate for Payer: United Healthcare Commercial	$86.94

hydrocortisone 10 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10394252
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of IA Commercial	$1.41
Rate for Payer: Aetna of IA Medical Rental Products	$1.41
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	$1.41

Know your out-of-pocket cost for care.

All Charges