Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

IVP MED ADMIN EA ADDL SEQUENTL

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	7984747
Hospital Revenue Code	260
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

IVP MEDICATION ADMIN

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	7984746
Hospital Revenue Code	260
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: United Healthcare Commercial	$97.20

IVP MEDICATION ADMIN

Facility

$108.00

Service Code	CPT 96374
Hospital Charge Code	7984746
Hospital Revenue Code	260
Min. Negotiated Rate	$53.98
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Aetna of IA Medicare	$61.56
Rate for Payer: Amerigroup Medicaid	$54.51
Rate for Payer: Amerigroup Medicare	$54.54
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$54.00
Rate for Payer: Iowa Total Care Managed Medicaid	$53.98
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Medical Associates Managed Medicare	$54.00
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: Molina Healthcare Managed Medicaid	$54.81
Rate for Payer: Molina Healthcare Managed Medicare	$54.78
Rate for Payer: Oscar Health of IA Commercial	$81.00
Rate for Payer: Partners Health Alliance Commercial	$81.00
Rate for Payer: United Healthcare Commercial	$97.20
Rate for Payer: United Healthcare Managed Medicare	$63.72

JAK2 V617F Mutation Detection DMCL

Facility

$625.00

Service Code	CPT 81270
Hospital Charge Code	8505649
Hospital Revenue Code	301
Min. Negotiated Rate	$143.22
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna of IA Commercial	$562.50
Rate for Payer: Aetna of IA Medical Rental Products	$562.50
Rate for Payer: Aetna of IA Medicare	$356.25
Rate for Payer: Amerigroup Medicaid	$315.44
Rate for Payer: Amerigroup Medicare	$315.62
Rate for Payer: Cash Price	$500.00
Rate for Payer: Cash Price	$500.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$312.50
Rate for Payer: Iowa Total Care Managed Medicaid	$312.38
Rate for Payer: Medical Associates Commercial	$468.75
Rate for Payer: Medical Associates Managed Medicare	$312.50
Rate for Payer: Midlands Choice Commercial	$437.50
Rate for Payer: Molina Healthcare Managed Medicaid	$317.19
Rate for Payer: Molina Healthcare Managed Medicare	$317.00
Rate for Payer: Oscar Health of IA Commercial	$468.75
Rate for Payer: Partners Health Alliance Commercial	$468.75
Rate for Payer: United Healthcare Commercial	$562.50
Rate for Payer: United Healthcare Managed Medicare	$368.75
Rate for Payer: Wellmark IA HMO	$143.22
Rate for Payer: Wellmark IA PPO	$157.54

JAK2 V617F Mutation Detection DMCL

Facility

$625.00

Service Code	CPT 81270
Hospital Charge Code	8505649
Hospital Revenue Code	301
Min. Negotiated Rate	$437.50
Max. Negotiated Rate	$562.50
Rate for Payer: Aetna of IA Commercial	$562.50
Rate for Payer: Aetna of IA Medical Rental Products	$562.50
Rate for Payer: Cash Price	$500.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.75
Rate for Payer: Medical Associates Commercial	$468.75
Rate for Payer: Midlands Choice Commercial	$437.50
Rate for Payer: United Healthcare Commercial	$562.50

KCl 20 mEq/L with Sodium Chloride 0.9% IV Sol 1000 mL [VDMC]

Facility

$58.40

Service Code	HCPCS J3480
Hospital Charge Code	11220285
Hospital Revenue Code	259
Min. Negotiated Rate	$40.88
Max. Negotiated Rate	$52.56
Rate for Payer: Aetna of IA Commercial	$52.56
Rate for Payer: Aetna of IA Medical Rental Products	$52.56
Rate for Payer: Cash Price	$46.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.80
Rate for Payer: Medical Associates Commercial	$43.80
Rate for Payer: Midlands Choice Commercial	$40.88
Rate for Payer: United Healthcare Commercial	$52.56

KCl 20 mEq/L with Sodium Chloride 0.9% IV Sol 1000 mL [VDMC]

Facility

$58.40

Service Code	HCPCS J3480
Hospital Charge Code	11220285
Hospital Revenue Code	259
Min. Negotiated Rate	$29.19
Max. Negotiated Rate	$52.56
Rate for Payer: Aetna of IA Commercial	$52.56
Rate for Payer: Aetna of IA Medical Rental Products	$52.56
Rate for Payer: Aetna of IA Medicare	$33.29
Rate for Payer: Amerigroup Medicaid	$29.47
Rate for Payer: Amerigroup Medicare	$29.49
Rate for Payer: Cash Price	$46.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.20
Rate for Payer: Iowa Total Care Managed Medicaid	$29.19
Rate for Payer: Medical Associates Commercial	$43.80
Rate for Payer: Medical Associates Managed Medicare	$29.20
Rate for Payer: Midlands Choice Commercial	$40.88
Rate for Payer: Molina Healthcare Managed Medicaid	$29.64
Rate for Payer: Molina Healthcare Managed Medicare	$29.62
Rate for Payer: Oscar Health of IA Commercial	$43.80
Rate for Payer: Partners Health Alliance Commercial	$43.80
Rate for Payer: United Healthcare Commercial	$52.56
Rate for Payer: United Healthcare Managed Medicare	$34.46

KCl 40 mEq/L with Sodium Chloride 0.9% IV Sol 1000 mL [VDMC]

Facility

$62.40

Service Code	HCPCS J3480
Hospital Charge Code	10441622
Hospital Revenue Code	259
Min. Negotiated Rate	$43.68
Max. Negotiated Rate	$56.16
Rate for Payer: Aetna of IA Commercial	$56.16
Rate for Payer: Aetna of IA Medical Rental Products	$56.16
Rate for Payer: Cash Price	$49.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$46.80
Rate for Payer: Medical Associates Commercial	$46.80
Rate for Payer: Midlands Choice Commercial	$43.68
Rate for Payer: United Healthcare Commercial	$56.16

KCl 40 mEq/L with Sodium Chloride 0.9% IV Sol 1000 mL [VDMC]

Facility

$62.40

Service Code	HCPCS J3480
Hospital Charge Code	10441622
Hospital Revenue Code	259
Min. Negotiated Rate	$31.19
Max. Negotiated Rate	$56.16
Rate for Payer: Aetna of IA Commercial	$56.16
Rate for Payer: Aetna of IA Medical Rental Products	$56.16
Rate for Payer: Aetna of IA Medicare	$35.57
Rate for Payer: Amerigroup Medicaid	$31.49
Rate for Payer: Amerigroup Medicare	$31.51
Rate for Payer: Cash Price	$49.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$46.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.20
Rate for Payer: Iowa Total Care Managed Medicaid	$31.19
Rate for Payer: Medical Associates Commercial	$46.80
Rate for Payer: Medical Associates Managed Medicare	$31.20
Rate for Payer: Midlands Choice Commercial	$43.68
Rate for Payer: Molina Healthcare Managed Medicaid	$31.67
Rate for Payer: Molina Healthcare Managed Medicare	$31.65
Rate for Payer: Oscar Health of IA Commercial	$46.80
Rate for Payer: Partners Health Alliance Commercial	$46.80
Rate for Payer: United Healthcare Commercial	$56.16
Rate for Payer: United Healthcare Managed Medicare	$36.82

KENOLOG 10MG CHARGE

Professional

Both

$25.00

Service Code	CPT J3301
Hospital Charge Code	8068950
Hospital Revenue Code	636
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$36,918.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Medical Associates Commercial	$18.75
Rate for Payer: Midlands Choice Commercial	$36,918.00
Rate for Payer: Wellmark IA HMO	$1.16
Rate for Payer: Wellmark IA PPO	$1.16

Keppra Level DMCL

Facility

$148.00

Service Code	CPT 80177
Hospital Charge Code	8037721
Hospital Revenue Code	301
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of IA Commercial	$133.20
Rate for Payer: Aetna of IA Medical Rental Products	$133.20
Rate for Payer: Cash Price	$118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.00
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: United Healthcare Commercial	$133.20

Keppra Level DMCL

Facility

$148.00

Service Code	CPT 80177
Hospital Charge Code	8037721
Hospital Revenue Code	301
Min. Negotiated Rate	$49.60
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of IA Commercial	$133.20
Rate for Payer: Aetna of IA Medical Rental Products	$133.20
Rate for Payer: Aetna of IA Medicare	$84.36
Rate for Payer: Amerigroup Medicaid	$74.70
Rate for Payer: Amerigroup Medicare	$74.74
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cash Price	$118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$74.00
Rate for Payer: Iowa Total Care Managed Medicaid	$73.97
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Medical Associates Managed Medicare	$74.00
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: Molina Healthcare Managed Medicaid	$75.11
Rate for Payer: Molina Healthcare Managed Medicare	$75.07
Rate for Payer: Oscar Health of IA Commercial	$111.00
Rate for Payer: Partners Health Alliance Commercial	$111.00
Rate for Payer: United Healthcare Commercial	$133.20
Rate for Payer: United Healthcare Managed Medicare	$87.32
Rate for Payer: Wellmark IA HMO	$49.60
Rate for Payer: Wellmark IA PPO	$54.56

ketamine 100 mg/mL 10 ml MDV Inj Sol [VDMC]

Facility

$62.91

Service Code	HCPCS J3490
Hospital Charge Code	26412384
Hospital Revenue Code	259
Min. Negotiated Rate	$44.04
Max. Negotiated Rate	$56.62
Rate for Payer: Aetna of IA Commercial	$56.62
Rate for Payer: Aetna of IA Medical Rental Products	$56.62
Rate for Payer: Cash Price	$50.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.18
Rate for Payer: Medical Associates Commercial	$47.18
Rate for Payer: Midlands Choice Commercial	$44.04
Rate for Payer: United Healthcare Commercial	$56.62

ketamine 100 mg/mL 10 ml MDV Inj Sol [VDMC]

Facility

$62.91

Service Code	HCPCS J3490
Hospital Charge Code	26412384
Hospital Revenue Code	259
Min. Negotiated Rate	$31.44
Max. Negotiated Rate	$56.62
Rate for Payer: Aetna of IA Commercial	$56.62
Rate for Payer: Aetna of IA Medical Rental Products	$56.62
Rate for Payer: Aetna of IA Medicare	$35.86
Rate for Payer: Amerigroup Medicaid	$31.75
Rate for Payer: Amerigroup Medicare	$31.77
Rate for Payer: Cash Price	$50.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.46
Rate for Payer: Iowa Total Care Managed Medicaid	$31.44
Rate for Payer: Medical Associates Commercial	$47.18
Rate for Payer: Medical Associates Managed Medicare	$31.46
Rate for Payer: Midlands Choice Commercial	$44.04
Rate for Payer: Molina Healthcare Managed Medicaid	$31.93
Rate for Payer: Molina Healthcare Managed Medicare	$31.91
Rate for Payer: Oscar Health of IA Commercial	$47.18
Rate for Payer: Partners Health Alliance Commercial	$47.18
Rate for Payer: United Healthcare Commercial	$56.62
Rate for Payer: United Healthcare Managed Medicare	$37.12

ketamine 100 mg/mL 5 ml inj Sol [VDMC]

Facility

$86.88

Service Code	HCPCS J3490
Hospital Charge Code	14651303
Hospital Revenue Code	259
Min. Negotiated Rate	$60.82
Max. Negotiated Rate	$78.19
Rate for Payer: Aetna of IA Commercial	$78.19
Rate for Payer: Aetna of IA Medical Rental Products	$78.19
Rate for Payer: Cash Price	$69.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$65.16
Rate for Payer: Medical Associates Commercial	$65.16
Rate for Payer: Midlands Choice Commercial	$60.82
Rate for Payer: United Healthcare Commercial	$78.19

ketamine 100 mg/mL 5 ml inj Sol [VDMC]

Facility

$86.88

Service Code	HCPCS J3490
Hospital Charge Code	14651303
Hospital Revenue Code	259
Min. Negotiated Rate	$43.42
Max. Negotiated Rate	$78.19
Rate for Payer: Aetna of IA Commercial	$78.19
Rate for Payer: Aetna of IA Medical Rental Products	$78.19
Rate for Payer: Aetna of IA Medicare	$49.52
Rate for Payer: Amerigroup Medicaid	$43.85
Rate for Payer: Amerigroup Medicare	$43.87
Rate for Payer: Cash Price	$69.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$65.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$43.44
Rate for Payer: Iowa Total Care Managed Medicaid	$43.42
Rate for Payer: Medical Associates Commercial	$65.16
Rate for Payer: Medical Associates Managed Medicare	$43.44
Rate for Payer: Midlands Choice Commercial	$60.82
Rate for Payer: Molina Healthcare Managed Medicaid	$44.09
Rate for Payer: Molina Healthcare Managed Medicare	$44.07
Rate for Payer: Oscar Health of IA Commercial	$65.16
Rate for Payer: Partners Health Alliance Commercial	$65.16
Rate for Payer: United Healthcare Commercial	$78.19
Rate for Payer: United Healthcare Managed Medicare	$51.26

ketamine 10 mg/mL 20 ml MDV Inj Sol [VDMC]

Facility

$111.02

Service Code	HCPCS J3490
Hospital Charge Code	26431860
Hospital Revenue Code	259
Min. Negotiated Rate	$77.71
Max. Negotiated Rate	$99.92
Rate for Payer: Aetna of IA Commercial	$99.92
Rate for Payer: Aetna of IA Medical Rental Products	$99.92
Rate for Payer: Cash Price	$88.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.26
Rate for Payer: Medical Associates Commercial	$83.26
Rate for Payer: Midlands Choice Commercial	$77.71
Rate for Payer: United Healthcare Commercial	$99.92

ketamine 10 mg/mL 20 ml MDV Inj Sol [VDMC]

Facility

$111.02

Service Code	HCPCS J3490
Hospital Charge Code	26431860
Hospital Revenue Code	259
Min. Negotiated Rate	$55.49
Max. Negotiated Rate	$99.92
Rate for Payer: Aetna of IA Commercial	$99.92
Rate for Payer: Aetna of IA Medical Rental Products	$99.92
Rate for Payer: Aetna of IA Medicare	$63.28
Rate for Payer: Amerigroup Medicaid	$56.03
Rate for Payer: Amerigroup Medicare	$56.07
Rate for Payer: Cash Price	$88.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.51
Rate for Payer: Iowa Total Care Managed Medicaid	$55.49
Rate for Payer: Medical Associates Commercial	$83.26
Rate for Payer: Medical Associates Managed Medicare	$55.51
Rate for Payer: Midlands Choice Commercial	$77.71
Rate for Payer: Molina Healthcare Managed Medicaid	$56.34
Rate for Payer: Molina Healthcare Managed Medicare	$56.31
Rate for Payer: Oscar Health of IA Commercial	$83.26
Rate for Payer: Partners Health Alliance Commercial	$83.26
Rate for Payer: United Healthcare Commercial	$99.92
Rate for Payer: United Healthcare Managed Medicare	$65.50

ketamine 50 mg/mL 10 ml MDV Inj Sol [VDMC]

Facility

$48.12

Service Code	HCPCS J3490
Hospital Charge Code	10398197
Hospital Revenue Code	259
Min. Negotiated Rate	$33.68
Max. Negotiated Rate	$43.31
Rate for Payer: Aetna of IA Commercial	$43.31
Rate for Payer: Aetna of IA Medical Rental Products	$43.31
Rate for Payer: Cash Price	$38.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.09
Rate for Payer: Medical Associates Commercial	$36.09
Rate for Payer: Midlands Choice Commercial	$33.68
Rate for Payer: United Healthcare Commercial	$43.31

ketamine 50 mg/mL 10 ml MDV Inj Sol [VDMC]

Facility

$48.12

Service Code	HCPCS J3490
Hospital Charge Code	10398197
Hospital Revenue Code	259
Min. Negotiated Rate	$24.05
Max. Negotiated Rate	$43.31
Rate for Payer: Aetna of IA Commercial	$43.31
Rate for Payer: Aetna of IA Medical Rental Products	$43.31
Rate for Payer: Aetna of IA Medicare	$27.43
Rate for Payer: Amerigroup Medicaid	$24.29
Rate for Payer: Amerigroup Medicare	$24.30
Rate for Payer: Cash Price	$38.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.09
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$24.06
Rate for Payer: Iowa Total Care Managed Medicaid	$24.05
Rate for Payer: Medical Associates Commercial	$36.09
Rate for Payer: Medical Associates Managed Medicare	$24.06
Rate for Payer: Midlands Choice Commercial	$33.68
Rate for Payer: Molina Healthcare Managed Medicaid	$24.42
Rate for Payer: Molina Healthcare Managed Medicare	$24.41
Rate for Payer: Oscar Health of IA Commercial	$36.09
Rate for Payer: Partners Health Alliance Commercial	$36.09
Rate for Payer: United Healthcare Commercial	$43.31
Rate for Payer: United Healthcare Managed Medicare	$28.39

ketoconazole 200 mg Tab [VDMC]

Facility

$4.00

Service Code	HCPCS A9270
Hospital Charge Code	10398264
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of IA Commercial	$3.60
Rate for Payer: Aetna of IA Medical Rental Products	$3.60
Rate for Payer: Aetna of IA Medicare	$2.28
Rate for Payer: Amerigroup Medicaid	$2.02
Rate for Payer: Amerigroup Medicare	$2.02
Rate for Payer: Cash Price	$3.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2.00
Rate for Payer: Medical Associates Commercial	$3.00
Rate for Payer: Medical Associates Managed Medicare	$2.00
Rate for Payer: Midlands Choice Commercial	$2.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2.03
Rate for Payer: Molina Healthcare Managed Medicare	$2.03
Rate for Payer: Oscar Health of IA Commercial	$3.00
Rate for Payer: Partners Health Alliance Commercial	$3.00
Rate for Payer: United Healthcare Commercial	$3.60
Rate for Payer: United Healthcare Managed Medicare	$2.36

ketoconazole 200 mg Tab [VDMC]

Facility

$4.00

Service Code	HCPCS A9270
Hospital Charge Code	10398264
Hospital Revenue Code	259
Min. Negotiated Rate	$2.80
Max. Negotiated Rate	$3.60
Rate for Payer: Aetna of IA Commercial	$3.60
Rate for Payer: Aetna of IA Medical Rental Products	$3.60
Rate for Payer: Cash Price	$3.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.00
Rate for Payer: Medical Associates Commercial	$3.00
Rate for Payer: Midlands Choice Commercial	$2.80
Rate for Payer: United Healthcare Commercial	$3.60

ketoconazole Top 2% Crm 15gm [VDMC]

Facility

$57.32

Service Code	HCPCS A9270
Hospital Charge Code	10435249
Hospital Revenue Code	259
Min. Negotiated Rate	$40.12
Max. Negotiated Rate	$51.59
Rate for Payer: Aetna of IA Commercial	$51.59
Rate for Payer: Aetna of IA Medical Rental Products	$51.59
Rate for Payer: Cash Price	$45.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.99
Rate for Payer: Medical Associates Commercial	$42.99
Rate for Payer: Midlands Choice Commercial	$40.12
Rate for Payer: United Healthcare Commercial	$51.59

ketoconazole Top 2% Crm 15gm [VDMC]

Facility

$57.32

Service Code	HCPCS A9270
Hospital Charge Code	10435249
Hospital Revenue Code	259
Min. Negotiated Rate	$28.65
Max. Negotiated Rate	$51.59
Rate for Payer: Aetna of IA Commercial	$51.59
Rate for Payer: Aetna of IA Medical Rental Products	$51.59
Rate for Payer: Aetna of IA Medicare	$32.67
Rate for Payer: Amerigroup Medicaid	$28.93
Rate for Payer: Amerigroup Medicare	$28.95
Rate for Payer: Cash Price	$45.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.99
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	$28.65
Rate for Payer: Medical Associates Commercial	$42.99
Rate for Payer: Medical Associates Managed Medicare	$28.66
Rate for Payer: Midlands Choice Commercial	$40.12
Rate for Payer: Molina Healthcare Managed Medicaid	$29.09
Rate for Payer: Molina Healthcare Managed Medicare	$29.07
Rate for Payer: Oscar Health of IA Commercial	$42.99
Rate for Payer: Partners Health Alliance Commercial	$42.99
Rate for Payer: United Healthcare Commercial	$51.59
Rate for Payer: United Healthcare Managed Medicare	$33.82

ketoconazole topical 2% Shampoo 120 ml[VDMC]

Facility

$62.76

Service Code	HCPCS A9270
Hospital Charge Code	21026900
Hospital Revenue Code	259
Min. Negotiated Rate	$43.93
Max. Negotiated Rate	$56.48
Rate for Payer: Aetna of IA Commercial	$56.48
Rate for Payer: Aetna of IA Medical Rental Products	$56.48
Rate for Payer: Cash Price	$50.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.07
Rate for Payer: Medical Associates Commercial	$47.07
Rate for Payer: Midlands Choice Commercial	$43.93
Rate for Payer: United Healthcare Commercial	$56.48

Know your out-of-pocket cost for care.

All Charges