Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

levonorgestrel 13.5 mg Dev[VDMC]

Facility

$1,613.74

Service Code	HCPCS J7301
Hospital Charge Code	12484629
Hospital Revenue Code	259
Min. Negotiated Rate	$806.55
Max. Negotiated Rate	$1,452.37
Rate for Payer: Aetna of IA Commercial	$1,452.37
Rate for Payer: Aetna of IA Medical Rental Products	$1,452.37
Rate for Payer: Aetna of IA Medicare	$919.83
Rate for Payer: Amerigroup Medicaid	$814.45
Rate for Payer: Amerigroup Medicare	$814.94
Rate for Payer: Cash Price	$1,290.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,210.30
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$806.87
Rate for Payer: Iowa Total Care Managed Medicaid	$806.55
Rate for Payer: Medical Associates Commercial	$1,210.30
Rate for Payer: Medical Associates Managed Medicare	$806.87
Rate for Payer: Midlands Choice Commercial	$1,129.62
Rate for Payer: Molina Healthcare Managed Medicaid	$818.97
Rate for Payer: Molina Healthcare Managed Medicare	$818.49
Rate for Payer: Oscar Health of IA Commercial	$1,210.30
Rate for Payer: Partners Health Alliance Commercial	$1,210.30
Rate for Payer: United Healthcare Commercial	$1,452.37
Rate for Payer: United Healthcare Managed Medicare	$952.11

levonorgestrel 13.5 mg Dev[VDMC]

Facility

$1,613.74

Service Code	HCPCS J7301
Hospital Charge Code	12484629
Hospital Revenue Code	259
Min. Negotiated Rate	$1,129.62
Max. Negotiated Rate	$1,452.37
Rate for Payer: Aetna of IA Commercial	$1,452.37
Rate for Payer: Aetna of IA Medical Rental Products	$1,452.37
Rate for Payer: Cash Price	$1,290.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,210.30
Rate for Payer: Medical Associates Commercial	$1,210.30
Rate for Payer: Midlands Choice Commercial	$1,129.62
Rate for Payer: United Healthcare Commercial	$1,452.37

levonorgestrel 1.5 mg Tab [VDMC]

Facility

$12.16

Service Code	HCPCS A9270
Hospital Charge Code	10399861
Hospital Revenue Code	259
Min. Negotiated Rate	$8.51
Max. Negotiated Rate	$10.94
Rate for Payer: Aetna of IA Commercial	$10.94
Rate for Payer: Aetna of IA Medical Rental Products	$10.94
Rate for Payer: Cash Price	$9.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.12
Rate for Payer: Medical Associates Commercial	$9.12
Rate for Payer: Midlands Choice Commercial	$8.51
Rate for Payer: United Healthcare Commercial	$10.94

levonorgestrel 1.5 mg Tab [VDMC]

Facility

$12.16

Service Code	HCPCS A9270
Hospital Charge Code	10399861
Hospital Revenue Code	259
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$10.94
Rate for Payer: Aetna of IA Commercial	$10.94
Rate for Payer: Aetna of IA Medical Rental Products	$10.94
Rate for Payer: Aetna of IA Medicare	$6.93
Rate for Payer: Amerigroup Medicaid	$6.14
Rate for Payer: Amerigroup Medicare	$6.14
Rate for Payer: Cash Price	$9.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.08
Rate for Payer: Iowa Total Care Managed Medicaid	$6.08
Rate for Payer: Medical Associates Commercial	$9.12
Rate for Payer: Medical Associates Managed Medicare	$6.08
Rate for Payer: Midlands Choice Commercial	$8.51
Rate for Payer: Molina Healthcare Managed Medicaid	$6.17
Rate for Payer: Molina Healthcare Managed Medicare	$6.17
Rate for Payer: Oscar Health of IA Commercial	$9.12
Rate for Payer: Partners Health Alliance Commercial	$9.12
Rate for Payer: United Healthcare Commercial	$10.94
Rate for Payer: United Healthcare Managed Medicare	$7.17

levonorgestrel 52 mg Dev 3 yrs [VDMC]

Facility

$3,388.40

Service Code	HCPCS J7297
Hospital Charge Code	12564888
Hospital Revenue Code	259
Min. Negotiated Rate	$2,371.88
Max. Negotiated Rate	$3,049.56
Rate for Payer: Aetna of IA Commercial	$3,049.56
Rate for Payer: Aetna of IA Medical Rental Products	$3,049.56
Rate for Payer: Cash Price	$2,710.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,541.30
Rate for Payer: Medical Associates Commercial	$2,541.30
Rate for Payer: Midlands Choice Commercial	$2,371.88
Rate for Payer: United Healthcare Commercial	$3,049.56

levonorgestrel 52 mg Dev 3 yrs [VDMC]

Facility

$3,388.40

Service Code	HCPCS J7297
Hospital Charge Code	12564888
Hospital Revenue Code	259
Min. Negotiated Rate	$1,693.52
Max. Negotiated Rate	$3,049.56
Rate for Payer: Aetna of IA Commercial	$3,049.56
Rate for Payer: Aetna of IA Medical Rental Products	$3,049.56
Rate for Payer: Aetna of IA Medicare	$1,931.39
Rate for Payer: Amerigroup Medicaid	$1,710.13
Rate for Payer: Amerigroup Medicare	$1,711.14
Rate for Payer: Cash Price	$2,710.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,541.30
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,694.20
Rate for Payer: Iowa Total Care Managed Medicaid	$1,693.52
Rate for Payer: Medical Associates Commercial	$2,541.30
Rate for Payer: Medical Associates Managed Medicare	$1,694.20
Rate for Payer: Midlands Choice Commercial	$2,371.88
Rate for Payer: Molina Healthcare Managed Medicaid	$1,719.61
Rate for Payer: Molina Healthcare Managed Medicare	$1,718.60
Rate for Payer: Oscar Health of IA Commercial	$2,541.30
Rate for Payer: Partners Health Alliance Commercial	$2,541.30
Rate for Payer: United Healthcare Commercial	$3,049.56
Rate for Payer: United Healthcare Managed Medicare	$1,999.16

levonorgestrel 52 mg Dev 5 yrs [VDMC]

Facility

$2,171.20

Service Code	HCPCS J7298
Hospital Charge Code	12564524
Hospital Revenue Code	259
Min. Negotiated Rate	$1,519.84
Max. Negotiated Rate	$1,954.08
Rate for Payer: Aetna of IA Commercial	$1,954.08
Rate for Payer: Aetna of IA Medical Rental Products	$1,954.08
Rate for Payer: Cash Price	$1,736.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,628.40
Rate for Payer: Medical Associates Commercial	$1,628.40
Rate for Payer: Midlands Choice Commercial	$1,519.84
Rate for Payer: United Healthcare Commercial	$1,954.08

levonorgestrel 52 mg Dev 5 yrs [VDMC]

Facility

$2,171.20

Service Code	HCPCS J7298
Hospital Charge Code	12564524
Hospital Revenue Code	259
Min. Negotiated Rate	$1,085.17
Max. Negotiated Rate	$1,954.08
Rate for Payer: Aetna of IA Commercial	$1,954.08
Rate for Payer: Aetna of IA Medical Rental Products	$1,954.08
Rate for Payer: Aetna of IA Medicare	$1,237.58
Rate for Payer: Amerigroup Medicaid	$1,095.80
Rate for Payer: Amerigroup Medicare	$1,096.46
Rate for Payer: Cash Price	$1,736.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,628.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,085.60
Rate for Payer: Iowa Total Care Managed Medicaid	$1,085.17
Rate for Payer: Medical Associates Commercial	$1,628.40
Rate for Payer: Medical Associates Managed Medicare	$1,085.60
Rate for Payer: Midlands Choice Commercial	$1,519.84
Rate for Payer: Molina Healthcare Managed Medicaid	$1,101.88
Rate for Payer: Molina Healthcare Managed Medicare	$1,101.23
Rate for Payer: Oscar Health of IA Commercial	$1,628.40
Rate for Payer: Partners Health Alliance Commercial	$1,628.40
Rate for Payer: United Healthcare Commercial	$1,954.08
Rate for Payer: United Healthcare Managed Medicare	$1,281.01

levothyroxine 100 mcg (0.1 mg) SDV Pow [VDMC]

Facility

$266.92

Service Code	NDC 42023-0201-01
Hospital Charge Code	10399995
Hospital Revenue Code	259
Min. Negotiated Rate	$186.84
Max. Negotiated Rate	$240.23
Rate for Payer: Aetna of IA Commercial	$240.23
Rate for Payer: Aetna of IA Medical Rental Products	$240.23
Rate for Payer: Cash Price	$213.54
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$200.19
Rate for Payer: Medical Associates Commercial	$200.19
Rate for Payer: Midlands Choice Commercial	$186.84
Rate for Payer: United Healthcare Commercial	$240.23

levothyroxine 100 mcg (0.1 mg) SDV Pow [VDMC]

Facility

$266.92

Service Code	NDC 42023-0201-01
Hospital Charge Code	10399995
Hospital Revenue Code	259
Min. Negotiated Rate	$133.41
Max. Negotiated Rate	$240.23
Rate for Payer: Aetna of IA Commercial	$240.23
Rate for Payer: Aetna of IA Medical Rental Products	$240.23
Rate for Payer: Aetna of IA Medicare	$152.14
Rate for Payer: Amerigroup Medicaid	$134.71
Rate for Payer: Amerigroup Medicare	$134.79
Rate for Payer: Cash Price	$213.54
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$200.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$133.46
Rate for Payer: Iowa Total Care Managed Medicaid	$133.41
Rate for Payer: Medical Associates Commercial	$200.19
Rate for Payer: Medical Associates Managed Medicare	$133.46
Rate for Payer: Midlands Choice Commercial	$186.84
Rate for Payer: Molina Healthcare Managed Medicaid	$135.46
Rate for Payer: Molina Healthcare Managed Medicare	$135.38
Rate for Payer: Oscar Health of IA Commercial	$200.19
Rate for Payer: Partners Health Alliance Commercial	$200.19
Rate for Payer: United Healthcare Commercial	$240.23
Rate for Payer: United Healthcare Managed Medicare	$157.48

levothyroxine 100 mcg (0.1 mg) Tab [VDMC]

Facility

$3.17

Service Code	HCPCS A9270
Hospital Charge Code	10400058
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna of IA Commercial	$2.85
Rate for Payer: Aetna of IA Medical Rental Products	$2.85
Rate for Payer: Aetna of IA Medicare	$1.81
Rate for Payer: Amerigroup Medicaid	$1.60
Rate for Payer: Amerigroup Medicare	$1.60
Rate for Payer: Cash Price	$2.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.58
Rate for Payer: Iowa Total Care Managed Medicaid	$1.58
Rate for Payer: Medical Associates Commercial	$2.38
Rate for Payer: Medical Associates Managed Medicare	$1.58
Rate for Payer: Midlands Choice Commercial	$2.22
Rate for Payer: Molina Healthcare Managed Medicaid	$1.61
Rate for Payer: Molina Healthcare Managed Medicare	$1.61
Rate for Payer: Oscar Health of IA Commercial	$2.38
Rate for Payer: Partners Health Alliance Commercial	$2.38
Rate for Payer: United Healthcare Commercial	$2.85
Rate for Payer: United Healthcare Managed Medicare	$1.87

levothyroxine 100 mcg (0.1 mg) Tab [VDMC]

Facility

$3.17

Service Code	HCPCS A9270
Hospital Charge Code	10400058
Hospital Revenue Code	259
Min. Negotiated Rate	$2.22
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna of IA Commercial	$2.85
Rate for Payer: Aetna of IA Medical Rental Products	$2.85
Rate for Payer: Cash Price	$2.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.38
Rate for Payer: Medical Associates Commercial	$2.38
Rate for Payer: Midlands Choice Commercial	$2.22
Rate for Payer: United Healthcare Commercial	$2.85

levothyroxine 112 mcg (0.112 mg) Tab [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	10400127
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.92
Rate for Payer: Medical Associates Commercial	$0.92
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.10

levothyroxine 112 mcg (0.112 mg) Tab [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	10400127
Hospital Revenue Code	259
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Aetna of IA Medicare	$0.70
Rate for Payer: Amerigroup Medicaid	$0.62
Rate for Payer: Amerigroup Medicare	$0.62
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.61
Rate for Payer: Iowa Total Care Managed Medicaid	$0.61
Rate for Payer: Medical Associates Commercial	$0.92
Rate for Payer: Medical Associates Managed Medicare	$0.61
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: Molina Healthcare Managed Medicaid	$0.62
Rate for Payer: Molina Healthcare Managed Medicare	$0.62
Rate for Payer: Oscar Health of IA Commercial	$0.92
Rate for Payer: Partners Health Alliance Commercial	$0.92
Rate for Payer: United Healthcare Commercial	$1.10
Rate for Payer: United Healthcare Managed Medicare	$0.72

levothyroxine 125 mcg (0.125 mg) Tab [VDMC]

Facility

$1.75

Service Code	HCPCS A9270
Hospital Charge Code	10400221
Hospital Revenue Code	259
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of IA Commercial	$1.58
Rate for Payer: Aetna of IA Medical Rental Products	$1.58
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.31
Rate for Payer: Medical Associates Commercial	$1.31
Rate for Payer: Midlands Choice Commercial	$1.22
Rate for Payer: United Healthcare Commercial	$1.58

levothyroxine 125 mcg (0.125 mg) Tab [VDMC]

Facility

$1.75

Service Code	HCPCS A9270
Hospital Charge Code	10400221
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of IA Commercial	$1.58
Rate for Payer: Aetna of IA Medical Rental Products	$1.58
Rate for Payer: Aetna of IA Medicare	$1.00
Rate for Payer: Amerigroup Medicaid	$0.88
Rate for Payer: Amerigroup Medicare	$0.88
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.88
Rate for Payer: Iowa Total Care Managed Medicaid	$0.87
Rate for Payer: Medical Associates Commercial	$1.31
Rate for Payer: Medical Associates Managed Medicare	$0.88
Rate for Payer: Midlands Choice Commercial	$1.22
Rate for Payer: Molina Healthcare Managed Medicaid	$0.89
Rate for Payer: Molina Healthcare Managed Medicare	$0.89
Rate for Payer: Oscar Health of IA Commercial	$1.31
Rate for Payer: Partners Health Alliance Commercial	$1.31
Rate for Payer: United Healthcare Commercial	$1.58
Rate for Payer: United Healthcare Managed Medicare	$1.03

levothyroxine 25 mcg (0.025 mg) Tab [VDMC]

Facility

$2.25

Service Code	HCPCS A9270
Hospital Charge Code	10400422
Hospital Revenue Code	259
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of IA Commercial	$2.02
Rate for Payer: Aetna of IA Medical Rental Products	$2.02
Rate for Payer: Aetna of IA Medicare	$1.28
Rate for Payer: Amerigroup Medicaid	$1.14
Rate for Payer: Amerigroup Medicare	$1.14
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.69
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.12
Rate for Payer: Iowa Total Care Managed Medicaid	$1.12
Rate for Payer: Medical Associates Commercial	$1.69
Rate for Payer: Medical Associates Managed Medicare	$1.12
Rate for Payer: Midlands Choice Commercial	$1.58
Rate for Payer: Molina Healthcare Managed Medicaid	$1.14
Rate for Payer: Molina Healthcare Managed Medicare	$1.14
Rate for Payer: Oscar Health of IA Commercial	$1.69
Rate for Payer: Partners Health Alliance Commercial	$1.69
Rate for Payer: United Healthcare Commercial	$2.02
Rate for Payer: United Healthcare Managed Medicare	$1.33

levothyroxine 25 mcg (0.025 mg) Tab [VDMC]

Facility

$2.25

Service Code	HCPCS A9270
Hospital Charge Code	10400422
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of IA Commercial	$2.02
Rate for Payer: Aetna of IA Medical Rental Products	$2.02
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.69
Rate for Payer: Medical Associates Commercial	$1.69
Rate for Payer: Midlands Choice Commercial	$1.58
Rate for Payer: United Healthcare Commercial	$2.02

levothyroxine 50 mcg (0.05 mg) Tab [VDMC]

Facility

$2.85

Service Code	HCPCS A9270
Hospital Charge Code	25354515
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna of IA Commercial	$2.56
Rate for Payer: Aetna of IA Medical Rental Products	$2.56
Rate for Payer: Aetna of IA Medicare	$1.62
Rate for Payer: Amerigroup Medicaid	$1.44
Rate for Payer: Amerigroup Medicare	$1.44
Rate for Payer: Cash Price	$2.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.14
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.42
Rate for Payer: Iowa Total Care Managed Medicaid	$1.42
Rate for Payer: Medical Associates Commercial	$2.14
Rate for Payer: Medical Associates Managed Medicare	$1.42
Rate for Payer: Midlands Choice Commercial	$2.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1.45
Rate for Payer: Molina Healthcare Managed Medicare	$1.45
Rate for Payer: Oscar Health of IA Commercial	$2.14
Rate for Payer: Partners Health Alliance Commercial	$2.14
Rate for Payer: United Healthcare Commercial	$2.56
Rate for Payer: United Healthcare Managed Medicare	$1.68

levothyroxine 50 mcg (0.05 mg) Tab [VDMC]

Facility

$2.85

Service Code	HCPCS A9270
Hospital Charge Code	25354515
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.56
Rate for Payer: Aetna of IA Commercial	$2.56
Rate for Payer: Aetna of IA Medical Rental Products	$2.56
Rate for Payer: Cash Price	$2.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.14
Rate for Payer: Medical Associates Commercial	$2.14
Rate for Payer: Midlands Choice Commercial	$2.00
Rate for Payer: United Healthcare Commercial	$2.56

levothyroxine 75 mcg (0.075 mg) Tab [VDMC]

Facility

$2.28

Service Code	HCPCS A9270
Hospital Charge Code	10400491
Hospital Revenue Code	259
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$2.05
Rate for Payer: Aetna of IA Commercial	$2.05
Rate for Payer: Aetna of IA Medical Rental Products	$2.05
Rate for Payer: Aetna of IA Medicare	$1.30
Rate for Payer: Amerigroup Medicaid	$1.15
Rate for Payer: Amerigroup Medicare	$1.15
Rate for Payer: Cash Price	$1.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.71
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.14
Rate for Payer: Iowa Total Care Managed Medicaid	$1.14
Rate for Payer: Medical Associates Commercial	$1.71
Rate for Payer: Medical Associates Managed Medicare	$1.14
Rate for Payer: Midlands Choice Commercial	$1.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1.16
Rate for Payer: Molina Healthcare Managed Medicare	$1.16
Rate for Payer: Oscar Health of IA Commercial	$1.71
Rate for Payer: Partners Health Alliance Commercial	$1.71
Rate for Payer: United Healthcare Commercial	$2.05
Rate for Payer: United Healthcare Managed Medicare	$1.35

levothyroxine 75 mcg (0.075 mg) Tab [VDMC]

Facility

$2.28

Service Code	HCPCS A9270
Hospital Charge Code	10400491
Hospital Revenue Code	259
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.05
Rate for Payer: Aetna of IA Commercial	$2.05
Rate for Payer: Aetna of IA Medical Rental Products	$2.05
Rate for Payer: Cash Price	$1.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.71
Rate for Payer: Medical Associates Commercial	$1.71
Rate for Payer: Midlands Choice Commercial	$1.60
Rate for Payer: United Healthcare Commercial	$2.05

levothyroxine 88 mcg (0.088 mg) Tab [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	10400603
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.26

levothyroxine 88 mcg (0.088 mg) Tab [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	10400603
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Aetna of IA Medicare	$0.80
Rate for Payer: Amerigroup Medicaid	$0.71
Rate for Payer: Amerigroup Medicare	$0.71
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
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	$0.70
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Molina Healthcare Managed Medicare	$0.71
Rate for Payer: Oscar Health of IA Commercial	$1.05
Rate for Payer: Partners Health Alliance Commercial	$1.05
Rate for Payer: United Healthcare Commercial	$1.26
Rate for Payer: United Healthcare Managed Medicare	$0.83

lidocaine 1% 10 ml MDV [VDMC]

Facility

$28.98

Service Code	HCPCS J2001
Hospital Charge Code	13648301
Hospital Revenue Code	259
Min. Negotiated Rate	$20.29
Max. Negotiated Rate	$26.08
Rate for Payer: Aetna of IA Commercial	$26.08
Rate for Payer: Aetna of IA Medical Rental Products	$26.08
Rate for Payer: Cash Price	$23.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.74
Rate for Payer: Medical Associates Commercial	$21.74
Rate for Payer: Midlands Choice Commercial	$20.29
Rate for Payer: United Healthcare Commercial	$26.08

Know your out-of-pocket cost for care.

All Charges