Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ACETABULAR SHELL SYSTEM-52E

Facility

$4,358.00

Service Code	CPT L8699
Hospital Charge Code	8046816
Hospital Revenue Code	278
Min. Negotiated Rate	$3,050.60
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: United Healthcare Commercial	$3,922.20

ACETABULAR SHELL SYSTEM-52E

Facility

$4,358.00

Service Code	CPT L8699
Hospital Charge Code	8046816
Hospital Revenue Code	278
Min. Negotiated Rate	$2,178.13
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Aetna of IA Medicare	$2,484.06
Rate for Payer: Amerigroup Medicaid	$2,199.48
Rate for Payer: Amerigroup Medicare	$2,200.79
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,179.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2,178.13
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Medical Associates Managed Medicare	$2,179.00
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,211.68
Rate for Payer: Molina Healthcare Managed Medicare	$2,210.38
Rate for Payer: Oscar Health of IA Commercial	$3,268.50
Rate for Payer: Partners Health Alliance Commercial	$3,268.50
Rate for Payer: United Healthcare Commercial	$3,922.20
Rate for Payer: United Healthcare Managed Medicare	$2,571.22

ACETABULAR SHELL SYSTEM-56F

Facility

$4,358.00

Service Code	CPT L8699
Hospital Charge Code	8046818
Hospital Revenue Code	278
Min. Negotiated Rate	$2,178.13
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Aetna of IA Medicare	$2,484.06
Rate for Payer: Amerigroup Medicaid	$2,199.48
Rate for Payer: Amerigroup Medicare	$2,200.79
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,179.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2,178.13
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Medical Associates Managed Medicare	$2,179.00
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,211.68
Rate for Payer: Molina Healthcare Managed Medicare	$2,210.38
Rate for Payer: Oscar Health of IA Commercial	$3,268.50
Rate for Payer: Partners Health Alliance Commercial	$3,268.50
Rate for Payer: United Healthcare Commercial	$3,922.20
Rate for Payer: United Healthcare Managed Medicare	$2,571.22

ACETABULAR SHELL SYSTEM-56F

Facility

$4,358.00

Service Code	CPT L8699
Hospital Charge Code	8046818
Hospital Revenue Code	278
Min. Negotiated Rate	$3,050.60
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: United Healthcare Commercial	$3,922.20

ACETAMINOPHEN

Facility

$147.00

Service Code	CPT G0480
Hospital Charge Code	1503764
Hospital Revenue Code	301
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: United Healthcare Commercial	$132.30

ACETAMINOPHEN

Facility

$147.00

Service Code	CPT G0480
Hospital Charge Code	1503764
Hospital Revenue Code	301
Min. Negotiated Rate	$73.47
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Aetna of IA Medicare	$83.79
Rate for Payer: Amerigroup Medicaid	$74.19
Rate for Payer: Amerigroup Medicare	$74.24
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.50
Rate for Payer: Iowa Total Care Managed Medicaid	$73.47
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Medical Associates Managed Medicare	$73.50
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: Molina Healthcare Managed Medicaid	$74.60
Rate for Payer: Molina Healthcare Managed Medicare	$74.56
Rate for Payer: Oscar Health of IA Commercial	$110.25
Rate for Payer: Partners Health Alliance Commercial	$110.25
Rate for Payer: United Healthcare Commercial	$132.30
Rate for Payer: United Healthcare Managed Medicare	$86.73
Rate for Payer: Wellmark IA HMO	$102.92
Rate for Payer: Wellmark IA PPO	$113.21

acetaminophen 10 mg/mL 100 ml vial SDV [VDMC]

Facility

$34.78

Service Code	HCPCS J0131
Hospital Charge Code	10362412
Hospital Revenue Code	259
Min. Negotiated Rate	$24.35
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna of IA Commercial	$31.30
Rate for Payer: Aetna of IA Medical Rental Products	$31.30
Rate for Payer: Cash Price	$27.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.08
Rate for Payer: Medical Associates Commercial	$26.08
Rate for Payer: Midlands Choice Commercial	$24.35
Rate for Payer: United Healthcare Commercial	$31.30

acetaminophen 10 mg/mL 100 ml vial SDV [VDMC]

Facility

$34.78

Service Code	HCPCS J0131
Hospital Charge Code	10362412
Hospital Revenue Code	259
Min. Negotiated Rate	$17.38
Max. Negotiated Rate	$31.30
Rate for Payer: Aetna of IA Commercial	$31.30
Rate for Payer: Aetna of IA Medical Rental Products	$31.30
Rate for Payer: Aetna of IA Medicare	$19.82
Rate for Payer: Amerigroup Medicaid	$17.55
Rate for Payer: Amerigroup Medicare	$17.56
Rate for Payer: Cash Price	$27.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.08
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$17.39
Rate for Payer: Iowa Total Care Managed Medicaid	$17.38
Rate for Payer: Medical Associates Commercial	$26.08
Rate for Payer: Medical Associates Managed Medicare	$17.39
Rate for Payer: Midlands Choice Commercial	$24.35
Rate for Payer: Molina Healthcare Managed Medicaid	$17.65
Rate for Payer: Molina Healthcare Managed Medicare	$17.64
Rate for Payer: Oscar Health of IA Commercial	$26.08
Rate for Payer: Partners Health Alliance Commercial	$26.08
Rate for Payer: United Healthcare Commercial	$31.30
Rate for Payer: United Healthcare Managed Medicare	$20.52

acetaminophen 120 mg Ped Supp [VDMC]

Facility

$4.21

Service Code	NDC 45802-0732-30
Hospital Charge Code	11223780
Hospital Revenue Code	259
Min. Negotiated Rate	$2.95
Max. Negotiated Rate	$3.79
Rate for Payer: Aetna of IA Commercial	$3.79
Rate for Payer: Aetna of IA Medical Rental Products	$3.79
Rate for Payer: Cash Price	$3.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.16
Rate for Payer: Medical Associates Commercial	$3.16
Rate for Payer: Midlands Choice Commercial	$2.95
Rate for Payer: United Healthcare Commercial	$3.79

acetaminophen 120 mg Ped Supp [VDMC]

Facility

$4.21

Service Code	NDC 45802-0732-30
Hospital Charge Code	11223780
Hospital Revenue Code	259
Min. Negotiated Rate	$2.10
Max. Negotiated Rate	$3.79
Rate for Payer: Aetna of IA Commercial	$3.79
Rate for Payer: Aetna of IA Medical Rental Products	$3.79
Rate for Payer: Aetna of IA Medicare	$2.40
Rate for Payer: Amerigroup Medicaid	$2.12
Rate for Payer: Amerigroup Medicare	$2.13
Rate for Payer: Cash Price	$3.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.10
Rate for Payer: Iowa Total Care Managed Medicaid	$2.10
Rate for Payer: Medical Associates Commercial	$3.16
Rate for Payer: Medical Associates Managed Medicare	$2.10
Rate for Payer: Midlands Choice Commercial	$2.95
Rate for Payer: Molina Healthcare Managed Medicaid	$2.14
Rate for Payer: Molina Healthcare Managed Medicare	$2.14
Rate for Payer: Oscar Health of IA Commercial	$3.16
Rate for Payer: Partners Health Alliance Commercial	$3.16
Rate for Payer: United Healthcare Commercial	$3.79
Rate for Payer: United Healthcare Managed Medicare	$2.48

acetaminophen 160 mg/5 mL 118ml Sus[VDMC]

Facility

$14.56

Service Code	NDC 45802-0201-26
Hospital Charge Code	13997492
Hospital Revenue Code	259
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$13.10
Rate for Payer: Aetna of IA Commercial	$13.10
Rate for Payer: Aetna of IA Medical Rental Products	$13.10
Rate for Payer: Cash Price	$11.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.92
Rate for Payer: Medical Associates Commercial	$10.92
Rate for Payer: Midlands Choice Commercial	$10.19
Rate for Payer: United Healthcare Commercial	$13.10

acetaminophen 160 mg/5 mL 118ml Sus[VDMC]

Facility

$14.56

Service Code	NDC 45802-0201-26
Hospital Charge Code	13997492
Hospital Revenue Code	259
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$13.10
Rate for Payer: Aetna of IA Commercial	$13.10
Rate for Payer: Aetna of IA Medical Rental Products	$13.10
Rate for Payer: Aetna of IA Medicare	$8.30
Rate for Payer: Amerigroup Medicaid	$7.35
Rate for Payer: Amerigroup Medicare	$7.35
Rate for Payer: Cash Price	$11.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.28
Rate for Payer: Iowa Total Care Managed Medicaid	$7.28
Rate for Payer: Medical Associates Commercial	$10.92
Rate for Payer: Medical Associates Managed Medicare	$7.28
Rate for Payer: Midlands Choice Commercial	$10.19
Rate for Payer: Molina Healthcare Managed Medicaid	$7.39
Rate for Payer: Molina Healthcare Managed Medicare	$7.38
Rate for Payer: Oscar Health of IA Commercial	$10.92
Rate for Payer: Partners Health Alliance Commercial	$10.92
Rate for Payer: United Healthcare Commercial	$13.10
Rate for Payer: United Healthcare Managed Medicare	$8.59

acetaminophen 160 mg/5 mL 5ml cup Sus UD [VDMC]

Facility

$3.59

Service Code	HCPCS A9270
Hospital Charge Code	14931415
Hospital Revenue Code	259
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$3.23
Rate for Payer: Aetna of IA Commercial	$3.23
Rate for Payer: Aetna of IA Medical Rental Products	$3.23
Rate for Payer: Aetna of IA Medicare	$2.05
Rate for Payer: Amerigroup Medicaid	$1.81
Rate for Payer: Amerigroup Medicare	$1.81
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.69
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.80
Rate for Payer: Iowa Total Care Managed Medicaid	$1.79
Rate for Payer: Medical Associates Commercial	$2.69
Rate for Payer: Medical Associates Managed Medicare	$1.80
Rate for Payer: Midlands Choice Commercial	$2.51
Rate for Payer: Molina Healthcare Managed Medicaid	$1.82
Rate for Payer: Molina Healthcare Managed Medicare	$1.82
Rate for Payer: Oscar Health of IA Commercial	$2.69
Rate for Payer: Partners Health Alliance Commercial	$2.69
Rate for Payer: United Healthcare Commercial	$3.23
Rate for Payer: United Healthcare Managed Medicare	$2.12

acetaminophen 160 mg/5 mL 5ml cup Sus UD [VDMC]

Facility

$3.59

Service Code	HCPCS A9270
Hospital Charge Code	14931415
Hospital Revenue Code	259
Min. Negotiated Rate	$2.51
Max. Negotiated Rate	$3.23
Rate for Payer: Aetna of IA Commercial	$3.23
Rate for Payer: Aetna of IA Medical Rental Products	$3.23
Rate for Payer: Cash Price	$2.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.69
Rate for Payer: Medical Associates Commercial	$2.69
Rate for Payer: Midlands Choice Commercial	$2.51
Rate for Payer: United Healthcare Commercial	$3.23

acetaminophen 325 mg Supp [VDMC]

Facility

$5.30

Service Code	HCPCS A9270
Hospital Charge Code	11223821
Hospital Revenue Code	259
Min. Negotiated Rate	$2.65
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of IA Commercial	$4.77
Rate for Payer: Aetna of IA Medical Rental Products	$4.77
Rate for Payer: Aetna of IA Medicare	$3.02
Rate for Payer: Amerigroup Medicaid	$2.67
Rate for Payer: Amerigroup Medicare	$2.68
Rate for Payer: Cash Price	$4.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.65
Rate for Payer: Iowa Total Care Managed Medicaid	$2.65
Rate for Payer: Medical Associates Commercial	$3.98
Rate for Payer: Medical Associates Managed Medicare	$2.65
Rate for Payer: Midlands Choice Commercial	$3.71
Rate for Payer: Molina Healthcare Managed Medicaid	$2.69
Rate for Payer: Molina Healthcare Managed Medicare	$2.69
Rate for Payer: Oscar Health of IA Commercial	$3.98
Rate for Payer: Partners Health Alliance Commercial	$3.98
Rate for Payer: United Healthcare Commercial	$4.77
Rate for Payer: United Healthcare Managed Medicare	$3.13

acetaminophen 325 mg Supp [VDMC]

Facility

$5.30

Service Code	HCPCS A9270
Hospital Charge Code	11223821
Hospital Revenue Code	259
Min. Negotiated Rate	$3.71
Max. Negotiated Rate	$4.77
Rate for Payer: Aetna of IA Commercial	$4.77
Rate for Payer: Aetna of IA Medical Rental Products	$4.77
Rate for Payer: Cash Price	$4.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.98
Rate for Payer: Medical Associates Commercial	$3.98
Rate for Payer: Midlands Choice Commercial	$3.71
Rate for Payer: United Healthcare Commercial	$4.77

acetaminophen 650 mg Sup [VDMC]

Facility

$4.11

Service Code	HCPCS A9270
Hospital Charge Code	11223865
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

acetaminophen 650 mg Sup [VDMC]

Facility

$4.11

Service Code	HCPCS A9270
Hospital Charge Code	11223865
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
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	$2.07
Rate for Payer: Amerigroup Medicare	$2.08
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	$2.06
Rate for Payer: Iowa Total Care Managed Medicaid	$2.05
Rate for Payer: Medical Associates Commercial	$3.08
Rate for Payer: Medical Associates Managed Medicare	$2.06
Rate for Payer: Midlands Choice Commercial	$2.88
Rate for Payer: Molina Healthcare Managed Medicaid	$2.09
Rate for Payer: Molina Healthcare Managed Medicare	$2.08
Rate for Payer: Oscar Health of IA Commercial	$3.08
Rate for Payer: Partners Health Alliance Commercial	$3.08
Rate for Payer: United Healthcare Commercial	$3.70
Rate for Payer: United Healthcare Managed Medicare	$2.42

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 5 mL [VDMC]

Facility

$3.22

Service Code	HCPCS A9270
Hospital Charge Code	10362903
Hospital Revenue Code	259
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$2.90
Rate for Payer: Aetna of IA Commercial	$2.90
Rate for Payer: Aetna of IA Medical Rental Products	$2.90
Rate for Payer: Aetna of IA Medicare	$1.84
Rate for Payer: Amerigroup Medicaid	$1.63
Rate for Payer: Amerigroup Medicare	$1.63
Rate for Payer: Cash Price	$2.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.61
Rate for Payer: Iowa Total Care Managed Medicaid	$1.61
Rate for Payer: Medical Associates Commercial	$2.42
Rate for Payer: Medical Associates Managed Medicare	$1.61
Rate for Payer: Midlands Choice Commercial	$2.25
Rate for Payer: Molina Healthcare Managed Medicaid	$1.63
Rate for Payer: Molina Healthcare Managed Medicare	$1.63
Rate for Payer: Oscar Health of IA Commercial	$2.42
Rate for Payer: Partners Health Alliance Commercial	$2.42
Rate for Payer: United Healthcare Commercial	$2.90
Rate for Payer: United Healthcare Managed Medicare	$1.90

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 5 mL [VDMC]

Facility

$3.22

Service Code	HCPCS A9270
Hospital Charge Code	10362903
Hospital Revenue Code	259
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.90
Rate for Payer: Aetna of IA Commercial	$2.90
Rate for Payer: Aetna of IA Medical Rental Products	$2.90
Rate for Payer: Cash Price	$2.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.42
Rate for Payer: Medical Associates Commercial	$2.42
Rate for Payer: Midlands Choice Commercial	$2.25
Rate for Payer: United Healthcare Commercial	$2.90

acetaminophen-codeine 300 mg-30 mg Tab UD[VDMC]

Facility

$3.90

Service Code	HCPCS A9270
Hospital Charge Code	11225033
Hospital Revenue Code	259
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of IA Commercial	$3.51
Rate for Payer: Aetna of IA Medical Rental Products	$3.51
Rate for Payer: Aetna of IA Medicare	$2.22
Rate for Payer: Amerigroup Medicaid	$1.97
Rate for Payer: Amerigroup Medicare	$1.97
Rate for Payer: Cash Price	$3.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.95
Rate for Payer: Iowa Total Care Managed Medicaid	$1.95
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Medical Associates Managed Medicare	$1.95
Rate for Payer: Midlands Choice Commercial	$2.73
Rate for Payer: Molina Healthcare Managed Medicaid	$1.98
Rate for Payer: Molina Healthcare Managed Medicare	$1.98
Rate for Payer: Oscar Health of IA Commercial	$2.92
Rate for Payer: Partners Health Alliance Commercial	$2.92
Rate for Payer: United Healthcare Commercial	$3.51
Rate for Payer: United Healthcare Managed Medicare	$2.30

acetaminophen-codeine 300 mg-30 mg Tab UD[VDMC]

Facility

$3.90

Service Code	HCPCS A9270
Hospital Charge Code	11225033
Hospital Revenue Code	259
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of IA Commercial	$3.51
Rate for Payer: Aetna of IA Medical Rental Products	$3.51
Rate for Payer: Cash Price	$3.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.92
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Midlands Choice Commercial	$2.73
Rate for Payer: United Healthcare Commercial	$3.51

acetaminophen-HYDROcodone 325 mg-10 mg Tab [VDMC]

Facility

$4.41

Service Code	HCPCS A9270
Hospital Charge Code	10363180
Hospital Revenue Code	259
Min. Negotiated Rate	$2.20
Max. Negotiated Rate	$3.97
Rate for Payer: Aetna of IA Commercial	$3.97
Rate for Payer: Aetna of IA Medical Rental Products	$3.97
Rate for Payer: Aetna of IA Medicare	$2.51
Rate for Payer: Amerigroup Medicaid	$2.23
Rate for Payer: Amerigroup Medicare	$2.23
Rate for Payer: Cash Price	$3.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.20
Rate for Payer: Iowa Total Care Managed Medicaid	$2.20
Rate for Payer: Medical Associates Commercial	$3.31
Rate for Payer: Medical Associates Managed Medicare	$2.20
Rate for Payer: Midlands Choice Commercial	$3.09
Rate for Payer: Molina Healthcare Managed Medicaid	$2.24
Rate for Payer: Molina Healthcare Managed Medicare	$2.24
Rate for Payer: Oscar Health of IA Commercial	$3.31
Rate for Payer: Partners Health Alliance Commercial	$3.31
Rate for Payer: United Healthcare Commercial	$3.97
Rate for Payer: United Healthcare Managed Medicare	$2.60

acetaminophen-HYDROcodone 325 mg-10 mg Tab [VDMC]

Facility

$4.41

Service Code	HCPCS A9270
Hospital Charge Code	10363180
Hospital Revenue Code	259
Min. Negotiated Rate	$3.09
Max. Negotiated Rate	$3.97
Rate for Payer: Aetna of IA Commercial	$3.97
Rate for Payer: Aetna of IA Medical Rental Products	$3.97
Rate for Payer: Cash Price	$3.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.31
Rate for Payer: Medical Associates Commercial	$3.31
Rate for Payer: Midlands Choice Commercial	$3.09
Rate for Payer: United Healthcare Commercial	$3.97

acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Sol 15 mL [VDMC]

Facility

$6.76

Service Code	HCPCS A9270
Hospital Charge Code	10363320
Hospital Revenue Code	259
Min. Negotiated Rate	$3.38
Max. Negotiated Rate	$6.08
Rate for Payer: Aetna of IA Commercial	$6.08
Rate for Payer: Aetna of IA Medical Rental Products	$6.08
Rate for Payer: Aetna of IA Medicare	$3.85
Rate for Payer: Amerigroup Medicaid	$3.41
Rate for Payer: Amerigroup Medicare	$3.41
Rate for Payer: Cash Price	$5.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.38
Rate for Payer: Iowa Total Care Managed Medicaid	$3.38
Rate for Payer: Medical Associates Commercial	$5.07
Rate for Payer: Medical Associates Managed Medicare	$3.38
Rate for Payer: Midlands Choice Commercial	$4.73
Rate for Payer: Molina Healthcare Managed Medicaid	$3.43
Rate for Payer: Molina Healthcare Managed Medicare	$3.43
Rate for Payer: Oscar Health of IA Commercial	$5.07
Rate for Payer: Partners Health Alliance Commercial	$5.07
Rate for Payer: United Healthcare Commercial	$6.08
Rate for Payer: United Healthcare Managed Medicare	$3.99

Know your out-of-pocket cost for care.

All Charges