Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

isosorbide mononitrate 20 mg Tab [VDMC]

Facility

$1.53

Service Code	HCPCS A9270
Hospital Charge Code	10397848
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.38
Rate for Payer: Aetna of IA Commercial	$1.38
Rate for Payer: Aetna of IA Medical Rental Products	$1.38
Rate for Payer: Cash Price	$1.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.15
Rate for Payer: Medical Associates Commercial	$1.15
Rate for Payer: Midlands Choice Commercial	$1.07
Rate for Payer: United Healthcare Commercial	$1.38

isosorbide mononitrate 30 mg ER Tab [VDMC]

Facility

$1.92

Service Code	HCPCS A9270
Hospital Charge Code	10397917
Hospital Revenue Code	259
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.73
Rate for Payer: Aetna of IA Commercial	$1.73
Rate for Payer: Aetna of IA Medical Rental Products	$1.73
Rate for Payer: Cash Price	$1.54
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.44
Rate for Payer: Medical Associates Commercial	$1.44
Rate for Payer: Midlands Choice Commercial	$1.35
Rate for Payer: United Healthcare Commercial	$1.73

isosorbide mononitrate 30 mg ER Tab [VDMC]

Facility

$1.92

Service Code	HCPCS A9270
Hospital Charge Code	10397917
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.73
Rate for Payer: Aetna of IA Commercial	$1.73
Rate for Payer: Aetna of IA Medical Rental Products	$1.73
Rate for Payer: Aetna of IA Medicare	$1.10
Rate for Payer: Amerigroup Medicaid	$1.11
Rate for Payer: Amerigroup Medicare	$0.87
Rate for Payer: Cash Price	$1.54
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.44
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.87
Rate for Payer: Iowa Total Care Managed Medicaid	$1.10
Rate for Payer: Medical Associates Commercial	$1.44
Rate for Payer: Medical Associates Managed Medicare	$0.87
Rate for Payer: Midlands Choice Commercial	$1.35
Rate for Payer: Molina Healthcare Managed Medicaid	$1.12
Rate for Payer: Partners Health Alliance Commercial	$1.00
Rate for Payer: United Healthcare Commercial	$1.73
Rate for Payer: United Healthcare Managed Medicare	$1.14

ITM

Facility

$531.00

Service Code	CPT 62322
Hospital Charge Code	7984738
Hospital Revenue Code	720
Min. Negotiated Rate	$238.95
Max. Negotiated Rate	$1,679.15
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Aetna of IA Medicare	$302.67
Rate for Payer: Amerigroup Medicaid	$306.28
Rate for Payer: Amerigroup Medicare	$241.34
Rate for Payer: Cash Price	$424.80
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$238.95
Rate for Payer: Iowa Total Care Managed Medicaid	$303.31
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Medical Associates Managed Medicare	$238.95
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: Molina Healthcare Managed Medicaid	$307.77
Rate for Payer: Partners Health Alliance Commercial	$274.79
Rate for Payer: United Healthcare Commercial	$477.90
Rate for Payer: United Healthcare Managed Medicare	$313.29
Rate for Payer: Wellmark IA HMO WHPI	$1,524.35
Rate for Payer: Wellmark IA PPO	$1,679.15

ITM

Facility

$531.00

Service Code	CPT 62322
Hospital Charge Code	7984738
Hospital Revenue Code	720
Min. Negotiated Rate	$371.70
Max. Negotiated Rate	$477.90
Rate for Payer: Aetna of IA Commercial	$477.90
Rate for Payer: Aetna of IA Medical Rental Products	$477.90
Rate for Payer: Cash Price	$424.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$398.25
Rate for Payer: Medical Associates Commercial	$398.25
Rate for Payer: Midlands Choice Commercial	$371.70
Rate for Payer: United Healthcare Commercial	$477.90

itraconazole 100 mg Cap [VDMC]

Facility

$5.34

Service Code	HCPCS A9270
Hospital Charge Code	10398128
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of IA Commercial	$4.80
Rate for Payer: Aetna of IA Medical Rental Products	$4.80
Rate for Payer: Aetna of IA Medicare	$3.04
Rate for Payer: Amerigroup Medicaid	$3.08
Rate for Payer: Amerigroup Medicare	$2.43
Rate for Payer: Cash Price	$4.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.40
Rate for Payer: Iowa Total Care Managed Medicaid	$3.05
Rate for Payer: Medical Associates Commercial	$4.00
Rate for Payer: Medical Associates Managed Medicare	$2.40
Rate for Payer: Midlands Choice Commercial	$3.74
Rate for Payer: Molina Healthcare Managed Medicaid	$3.09
Rate for Payer: Partners Health Alliance Commercial	$2.76
Rate for Payer: United Healthcare Commercial	$4.80
Rate for Payer: United Healthcare Managed Medicare	$3.15

itraconazole 100 mg Cap [VDMC]

Facility

$5.34

Service Code	HCPCS A9270
Hospital Charge Code	10398128
Hospital Revenue Code	259
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of IA Commercial	$4.80
Rate for Payer: Aetna of IA Medical Rental Products	$4.80
Rate for Payer: Cash Price	$4.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.00
Rate for Payer: Medical Associates Commercial	$4.00
Rate for Payer: Midlands Choice Commercial	$3.74
Rate for Payer: United Healthcare Commercial	$4.80

IUD REMOVAL CHARGE

Professional

Both

$315.00

Service Code	CPT 58301
Hospital Charge Code	8068939
Hospital Revenue Code	975
Min. Negotiated Rate	$78.94
Max. Negotiated Rate	$246.40
Rate for Payer: Amerigroup Medicaid	$79.71
Rate for Payer: Cash Price	$252.00
Rate for Payer: Cash Price	$252.00
Rate for Payer: Iowa Total Care Managed Medicaid	$78.94
Rate for Payer: Medical Associates Commercial	$236.25
Rate for Payer: Midlands Choice Commercial	$220.50
Rate for Payer: Molina Healthcare Managed Medicaid	$79.32
Rate for Payer: Partners Health Alliance Commercial	$236.25
Rate for Payer: United Healthcare Commercial	$153.92
Rate for Payer: Wellmark IA HMO WHPI	$209.50
Rate for Payer: Wellmark IA PPO	$246.40

IV CONSCIOUS SEDATION CHARGE

Professional

Both

$258.00

Hospital Charge Code	8084811
Hospital Revenue Code	964
Min. Negotiated Rate	$180.60
Max. Negotiated Rate	$193.50
Rate for Payer: Cash Price	$206.40
Rate for Payer: Medical Associates Commercial	$193.50
Rate for Payer: Midlands Choice Commercial	$180.60
Rate for Payer: Partners Health Alliance Commercial	$193.50

IVP MED ADMIN EA ADDL SEQUENTL

Facility

$64.00

Service Code	CPT 96375
Hospital Charge Code	7984747
Hospital Revenue Code	260
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

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	$37.58
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	$62.29
Rate for Payer: Amerigroup Medicare	$49.09
Rate for Payer: Cash Price	$86.40
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	$48.60
Rate for Payer: Iowa Total Care Managed Medicaid	$61.69
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Medical Associates Managed Medicare	$48.60
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: Molina Healthcare Managed Medicaid	$62.60
Rate for Payer: Partners Health Alliance Commercial	$55.89
Rate for Payer: United Healthcare Commercial	$97.20
Rate for Payer: United Healthcare Managed Medicare	$63.72
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

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

JAK2 V617F Mutation Detection DMCL

Facility

$625.00

Service Code	CPT 81270
Hospital Charge Code	8505649
Hospital Revenue Code	301
Min. Negotiated Rate	$100.68
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	$360.50
Rate for Payer: Amerigroup Medicare	$284.06
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	$281.25
Rate for Payer: Iowa Total Care Managed Medicaid	$357.00
Rate for Payer: Medical Associates Commercial	$468.75
Rate for Payer: Medical Associates Managed Medicare	$281.25
Rate for Payer: Midlands Choice Commercial	$437.50
Rate for Payer: Molina Healthcare Managed Medicaid	$362.25
Rate for Payer: Partners Health Alliance Commercial	$323.44
Rate for Payer: United Healthcare Commercial	$562.50
Rate for Payer: United Healthcare Managed Medicare	$368.75
Rate for Payer: Wellmark IA HMO WHPI	$100.68
Rate for Payer: Wellmark IA PPO	$110.90

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

JOINT REPLACEMENT

Facility

$6,840.00

Service Code	HCPCS C1776
Hospital Charge Code	9000008
Hospital Revenue Code	278
Min. Negotiated Rate	$4,788.00
Max. Negotiated Rate	$6,156.00
Rate for Payer: Aetna of IA Commercial	$6,156.00
Rate for Payer: Aetna of IA Medical Rental Products	$6,156.00
Rate for Payer: Cash Price	$5,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,130.00
Rate for Payer: Medical Associates Commercial	$5,130.00
Rate for Payer: Midlands Choice Commercial	$4,788.00
Rate for Payer: United Healthcare Commercial	$6,156.00

JOINT REPLACEMENT

Facility

$6,840.00

Service Code	HCPCS C1776
Hospital Charge Code	9000008
Hospital Revenue Code	278
Min. Negotiated Rate	$3,078.00
Max. Negotiated Rate	$6,156.00
Rate for Payer: Aetna of IA Commercial	$6,156.00
Rate for Payer: Aetna of IA Medical Rental Products	$6,156.00
Rate for Payer: Aetna of IA Medicare	$3,898.80
Rate for Payer: Amerigroup Medicaid	$3,945.31
Rate for Payer: Amerigroup Medicare	$3,108.78
Rate for Payer: Cash Price	$5,472.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,130.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,078.00
Rate for Payer: Iowa Total Care Managed Medicaid	$3,907.01
Rate for Payer: Medical Associates Commercial	$5,130.00
Rate for Payer: Medical Associates Managed Medicare	$3,078.00
Rate for Payer: Midlands Choice Commercial	$4,788.00
Rate for Payer: Molina Healthcare Managed Medicaid	$3,964.46
Rate for Payer: Partners Health Alliance Commercial	$3,539.70
Rate for Payer: United Healthcare Commercial	$6,156.00
Rate for Payer: United Healthcare Managed Medicare	$4,035.60

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	$26.28
Max. Negotiated Rate	$221.80
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	$33.69
Rate for Payer: Amerigroup Medicare	$26.54
Rate for Payer: Cash Price	$46.72
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	$26.28
Rate for Payer: Iowa Total Care Managed Medicaid	$33.36
Rate for Payer: Medical Associates Commercial	$43.80
Rate for Payer: Medical Associates Managed Medicare	$26.28
Rate for Payer: Midlands Choice Commercial	$40.88
Rate for Payer: Molina Healthcare Managed Medicaid	$33.85
Rate for Payer: Partners Health Alliance Commercial	$30.22
Rate for Payer: United Healthcare Commercial	$52.56
Rate for Payer: United Healthcare Managed Medicare	$34.46
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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 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	$28.08
Max. Negotiated Rate	$221.80
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	$35.99
Rate for Payer: Amerigroup Medicare	$28.36
Rate for Payer: Cash Price	$49.92
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	$28.08
Rate for Payer: Iowa Total Care Managed Medicaid	$35.64
Rate for Payer: Medical Associates Commercial	$46.80
Rate for Payer: Medical Associates Managed Medicare	$28.08
Rate for Payer: Midlands Choice Commercial	$43.68
Rate for Payer: Molina Healthcare Managed Medicaid	$36.17
Rate for Payer: Partners Health Alliance Commercial	$32.29
Rate for Payer: United Healthcare Commercial	$56.16
Rate for Payer: United Healthcare Managed Medicare	$36.82
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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

KENOLOG 10MG CHARGE

Professional

Both

$25.00

Service Code	CPT J3301
Hospital Charge Code	8068950
Hospital Revenue Code	636
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$18.75
Rate for Payer: Amerigroup Medicaid	$2.52
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2.50
Rate for Payer: Medical Associates Commercial	$18.75
Rate for Payer: Midlands Choice Commercial	$17.50
Rate for Payer: Molina Healthcare Managed Medicaid	$2.51
Rate for Payer: Partners Health Alliance Commercial	$18.75
Rate for Payer: United Healthcare Commercial	$0.90
Rate for Payer: Wellmark IA HMO WHPI	$1.08
Rate for Payer: Wellmark IA PPO	$1.08

Keppra Level DMCL

Facility

$148.00

Service Code	CPT 80177
Hospital Charge Code	8037721
Hospital Revenue Code	301
Min. Negotiated Rate	$65.23
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	$85.37
Rate for Payer: Amerigroup Medicare	$67.27
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	$66.60
Rate for Payer: Iowa Total Care Managed Medicaid	$84.54
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Medical Associates Managed Medicare	$66.60
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: Molina Healthcare Managed Medicaid	$85.78
Rate for Payer: Partners Health Alliance Commercial	$76.59
Rate for Payer: United Healthcare Commercial	$133.20
Rate for Payer: United Healthcare Managed Medicare	$87.32
Rate for Payer: Wellmark IA HMO WHPI	$65.23
Rate for Payer: Wellmark IA PPO	$71.85

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

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

Know your out-of-pocket cost for care.

All Charges