Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

levofloxacin 750 mg/150 mL IV Sol [VDMC]

Facility

$58.23

Service Code	HCPCS J1956
Hospital Charge Code	10399790
Hospital Revenue Code	259
Min. Negotiated Rate	$26.20
Max. Negotiated Rate	$52.40
Rate for Payer: Aetna of IA Commercial	$52.40
Rate for Payer: Aetna of IA Medical Rental Products	$52.40
Rate for Payer: Aetna of IA Medicare	$33.19
Rate for Payer: Amerigroup Medicaid	$33.58
Rate for Payer: Amerigroup Medicare	$26.46
Rate for Payer: Cash Price	$46.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.67
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.20
Rate for Payer: Iowa Total Care Managed Medicaid	$33.26
Rate for Payer: Medical Associates Commercial	$43.67
Rate for Payer: Medical Associates Managed Medicare	$26.20
Rate for Payer: Midlands Choice Commercial	$40.76
Rate for Payer: Molina Healthcare Managed Medicaid	$33.75
Rate for Payer: Partners Health Alliance Commercial	$30.13
Rate for Payer: United Healthcare Commercial	$52.40
Rate for Payer: United Healthcare Managed Medicare	$34.35

levofloxacin 750 mg/150 mL IV Sol [VDMC]

Facility

$58.23

Service Code	HCPCS J1956
Hospital Charge Code	10399790
Hospital Revenue Code	259
Min. Negotiated Rate	$40.76
Max. Negotiated Rate	$52.40
Rate for Payer: Aetna of IA Commercial	$52.40
Rate for Payer: Aetna of IA Medical Rental Products	$52.40
Rate for Payer: Cash Price	$46.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.67
Rate for Payer: Medical Associates Commercial	$43.67
Rate for Payer: Midlands Choice Commercial	$40.76
Rate for Payer: United Healthcare Commercial	$52.40

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	$1,210.31
Rate for Payer: Medical Associates Commercial	$1,210.31
Rate for Payer: Midlands Choice Commercial	$1,129.62
Rate for Payer: United Healthcare Commercial	$1,452.37

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	$726.18
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	$930.81
Rate for Payer: Amerigroup Medicare	$733.44
Rate for Payer: Cash Price	$1,290.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,210.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$726.18
Rate for Payer: Iowa Total Care Managed Medicaid	$921.77
Rate for Payer: Medical Associates Commercial	$1,210.31
Rate for Payer: Medical Associates Managed Medicare	$726.18
Rate for Payer: Midlands Choice Commercial	$1,129.62
Rate for Payer: Molina Healthcare Managed Medicaid	$935.32
Rate for Payer: Partners Health Alliance Commercial	$835.11
Rate for Payer: United Healthcare Commercial	$1,452.37
Rate for Payer: United Healthcare Managed Medicare	$952.11

levonorgestrel 1.5 mg Tab [VDMC]

Facility

$12.16

Service Code	HCPCS A9270
Hospital Charge Code	10399861
Hospital Revenue Code	259
Min. Negotiated Rate	$5.47
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	$7.01
Rate for Payer: Amerigroup Medicare	$5.53
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	$5.47
Rate for Payer: Iowa Total Care Managed Medicaid	$6.95
Rate for Payer: Medical Associates Commercial	$9.12
Rate for Payer: Medical Associates Managed Medicare	$5.47
Rate for Payer: Midlands Choice Commercial	$8.51
Rate for Payer: Molina Healthcare Managed Medicaid	$7.05
Rate for Payer: Partners Health Alliance Commercial	$6.29
Rate for Payer: United Healthcare Commercial	$10.94
Rate for Payer: United Healthcare Managed Medicare	$7.17

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 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	$1,524.78
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	$1,954.43
Rate for Payer: Amerigroup Medicare	$1,540.03
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	$1,524.78
Rate for Payer: Iowa Total Care Managed Medicaid	$1,935.45
Rate for Payer: Medical Associates Commercial	$2,541.30
Rate for Payer: Medical Associates Managed Medicare	$1,524.78
Rate for Payer: Midlands Choice Commercial	$2,371.88
Rate for Payer: Molina Healthcare Managed Medicaid	$1,963.92
Rate for Payer: Partners Health Alliance Commercial	$1,753.50
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

$2,274.76

Service Code	HCPCS J7298
Hospital Charge Code	12564524
Hospital Revenue Code	259
Min. Negotiated Rate	$1,592.33
Max. Negotiated Rate	$2,047.28
Rate for Payer: Aetna of IA Commercial	$2,047.28
Rate for Payer: Aetna of IA Medical Rental Products	$2,047.28
Rate for Payer: Cash Price	$1,819.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,706.07
Rate for Payer: Medical Associates Commercial	$1,706.07
Rate for Payer: Midlands Choice Commercial	$1,592.33
Rate for Payer: United Healthcare Commercial	$2,047.28

levonorgestrel 52 mg Dev 5 yrs [VDMC]

Facility

$2,274.76

Service Code	HCPCS J7298
Hospital Charge Code	12564524
Hospital Revenue Code	259
Min. Negotiated Rate	$1,023.64
Max. Negotiated Rate	$2,047.28
Rate for Payer: Aetna of IA Commercial	$2,047.28
Rate for Payer: Aetna of IA Medical Rental Products	$2,047.28
Rate for Payer: Aetna of IA Medicare	$1,296.61
Rate for Payer: Amerigroup Medicaid	$1,312.08
Rate for Payer: Amerigroup Medicare	$1,033.88
Rate for Payer: Cash Price	$1,819.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,706.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,023.64
Rate for Payer: Iowa Total Care Managed Medicaid	$1,299.34
Rate for Payer: Medical Associates Commercial	$1,706.07
Rate for Payer: Medical Associates Managed Medicare	$1,023.64
Rate for Payer: Midlands Choice Commercial	$1,592.33
Rate for Payer: Molina Healthcare Managed Medicaid	$1,318.45
Rate for Payer: Partners Health Alliance Commercial	$1,177.19
Rate for Payer: United Healthcare Commercial	$2,047.28
Rate for Payer: United Healthcare Managed Medicare	$1,342.11

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

Facility

$266.52

Service Code	HCPCS J0650
Hospital Charge Code	10399995
Hospital Revenue Code	259
Min. Negotiated Rate	$186.56
Max. Negotiated Rate	$239.87
Rate for Payer: Aetna of IA Commercial	$239.87
Rate for Payer: Aetna of IA Medical Rental Products	$239.87
Rate for Payer: Cash Price	$213.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$199.89
Rate for Payer: Medical Associates Commercial	$199.89
Rate for Payer: Midlands Choice Commercial	$186.56
Rate for Payer: United Healthcare Commercial	$239.87

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

Facility

$266.52

Service Code	HCPCS J0650
Hospital Charge Code	10399995
Hospital Revenue Code	259
Min. Negotiated Rate	$119.93
Max. Negotiated Rate	$239.87
Rate for Payer: Aetna of IA Commercial	$239.87
Rate for Payer: Aetna of IA Medical Rental Products	$239.87
Rate for Payer: Aetna of IA Medicare	$151.92
Rate for Payer: Amerigroup Medicaid	$153.73
Rate for Payer: Amerigroup Medicare	$121.13
Rate for Payer: Cash Price	$213.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$199.89
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$119.93
Rate for Payer: Iowa Total Care Managed Medicaid	$152.24
Rate for Payer: Medical Associates Commercial	$199.89
Rate for Payer: Medical Associates Managed Medicare	$119.93
Rate for Payer: Midlands Choice Commercial	$186.56
Rate for Payer: Molina Healthcare Managed Medicaid	$154.47
Rate for Payer: Partners Health Alliance Commercial	$137.92
Rate for Payer: United Healthcare Commercial	$239.87
Rate for Payer: United Healthcare Managed Medicare	$157.25

levothyroxine 100 mcg (0.1 mg) Tab [VDMC]

Facility

$2.86

Service Code	HCPCS A9270
Hospital Charge Code	10400058
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$2.57
Rate for Payer: Aetna of IA Commercial	$2.57
Rate for Payer: Aetna of IA Medical Rental Products	$2.57
Rate for Payer: Aetna of IA Medicare	$1.63
Rate for Payer: Amerigroup Medicaid	$1.65
Rate for Payer: Amerigroup Medicare	$1.30
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	$1.29
Rate for Payer: Iowa Total Care Managed Medicaid	$1.63
Rate for Payer: Medical Associates Commercial	$2.14
Rate for Payer: Medical Associates Managed Medicare	$1.29
Rate for Payer: Midlands Choice Commercial	$2.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1.66
Rate for Payer: Partners Health Alliance Commercial	$1.48
Rate for Payer: United Healthcare Commercial	$2.57
Rate for Payer: United Healthcare Managed Medicare	$1.68

levothyroxine 100 mcg (0.1 mg) Tab [VDMC]

Facility

$2.86

Service Code	HCPCS A9270
Hospital Charge Code	10400058
Hospital Revenue Code	259
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.57
Rate for Payer: Aetna of IA Commercial	$2.57
Rate for Payer: Aetna of IA Medical Rental Products	$2.57
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	$2.57

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	$0.55
Max. Negotiated Rate	$1.09
Rate for Payer: Aetna of IA Commercial	$1.09
Rate for Payer: Aetna of IA Medical Rental Products	$1.09
Rate for Payer: Aetna of IA Medicare	$0.69
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.55
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.55
Rate for Payer: Iowa Total Care Managed Medicaid	$0.69
Rate for Payer: Medical Associates Commercial	$0.91
Rate for Payer: Medical Associates Managed Medicare	$0.55
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: Molina Healthcare Managed Medicaid	$0.70
Rate for Payer: Partners Health Alliance Commercial	$0.63
Rate for Payer: United Healthcare Commercial	$1.09
Rate for Payer: United Healthcare Managed Medicare	$0.72

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	$1.09
Rate for Payer: Aetna of IA Commercial	$1.09
Rate for Payer: Aetna of IA Medical Rental Products	$1.09
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.91
Rate for Payer: Medical Associates Commercial	$0.91
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.09

levothyroxine 125 mcg (0.125 mg) Tab [VDMC]

Facility

$2.55

Service Code	HCPCS A9270
Hospital Charge Code	10400221
Hospital Revenue Code	259
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of IA Commercial	$2.29
Rate for Payer: Aetna of IA Medical Rental Products	$2.29
Rate for Payer: Cash Price	$2.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.91
Rate for Payer: Medical Associates Commercial	$1.91
Rate for Payer: Midlands Choice Commercial	$1.78
Rate for Payer: United Healthcare Commercial	$2.29

levothyroxine 125 mcg (0.125 mg) Tab [VDMC]

Facility

$2.55

Service Code	HCPCS A9270
Hospital Charge Code	10400221
Hospital Revenue Code	259
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of IA Commercial	$2.29
Rate for Payer: Aetna of IA Medical Rental Products	$2.29
Rate for Payer: Aetna of IA Medicare	$1.45
Rate for Payer: Amerigroup Medicaid	$1.47
Rate for Payer: Amerigroup Medicare	$1.16
Rate for Payer: Cash Price	$2.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1.46
Rate for Payer: Medical Associates Commercial	$1.91
Rate for Payer: Medical Associates Managed Medicare	$1.15
Rate for Payer: Midlands Choice Commercial	$1.78
Rate for Payer: Molina Healthcare Managed Medicaid	$1.48
Rate for Payer: Partners Health Alliance Commercial	$1.32
Rate for Payer: United Healthcare Commercial	$2.29
Rate for Payer: United Healthcare Managed Medicare	$1.50

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	$1.01
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	$1.30
Rate for Payer: Amerigroup Medicare	$1.02
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	$1.01
Rate for Payer: Iowa Total Care Managed Medicaid	$1.28
Rate for Payer: Medical Associates Commercial	$1.69
Rate for Payer: Medical Associates Managed Medicare	$1.01
Rate for Payer: Midlands Choice Commercial	$1.57
Rate for Payer: Molina Healthcare Managed Medicaid	$1.30
Rate for Payer: Partners Health Alliance Commercial	$1.16
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	$1.57
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	$1.57
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	$1.28
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	$1.64
Rate for Payer: Amerigroup Medicare	$1.29
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	$1.28
Rate for Payer: Iowa Total Care Managed Medicaid	$1.63
Rate for Payer: Medical Associates Commercial	$2.14
Rate for Payer: Medical Associates Managed Medicare	$1.28
Rate for Payer: Midlands Choice Commercial	$1.99
Rate for Payer: Molina Healthcare Managed Medicaid	$1.65
Rate for Payer: Partners Health Alliance Commercial	$1.47
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	$1.99
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	$1.99
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	$1.03
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of IA Commercial	$2.06
Rate for Payer: Aetna of IA Medical Rental Products	$2.06
Rate for Payer: Aetna of IA Medicare	$1.30
Rate for Payer: Amerigroup Medicaid	$1.32
Rate for Payer: Amerigroup Medicare	$1.04
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	$1.03
Rate for Payer: Iowa Total Care Managed Medicaid	$1.31
Rate for Payer: Medical Associates Commercial	$1.71
Rate for Payer: Medical Associates Managed Medicare	$1.03
Rate for Payer: Midlands Choice Commercial	$1.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1.32
Rate for Payer: Partners Health Alliance Commercial	$1.18
Rate for Payer: United Healthcare Commercial	$2.06
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	$2.06
Rate for Payer: Aetna of IA Commercial	$2.06
Rate for Payer: Aetna of IA Medical Rental Products	$2.06
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	$2.06

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	$0.63
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	$0.81
Rate for Payer: Amerigroup Medicare	$0.64
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	$0.63
Rate for Payer: Iowa Total Care Managed Medicaid	$0.80
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Medical Associates Managed Medicare	$0.63
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: Molina Healthcare Managed Medicaid	$0.81
Rate for Payer: Partners Health Alliance Commercial	$0.72
Rate for Payer: United Healthcare Commercial	$1.26
Rate for Payer: United Healthcare Managed Medicare	$0.83

Know your out-of-pocket cost for care.

All Charges