Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MRI Wrist w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73221 RT
Hospital Charge Code	1169142
Hospital Revenue Code	610
Min. Negotiated Rate	$714.70
Max. Negotiated Rate	$918.90
Rate for Payer: Aetna of IA Commercial	$918.90
Rate for Payer: Aetna of IA Medical Rental Products	$918.90
Rate for Payer: Cash Price	$816.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$765.75
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: United Healthcare Commercial	$918.90

MRI Wrist w/o Contrast Right

Facility

$1,021.00

Service Code	CPT 73221 RT
Hospital Charge Code	1169142
Hospital Revenue Code	610
Min. Negotiated Rate	$459.45
Max. Negotiated Rate	$918.90
Rate for Payer: Aetna of IA Commercial	$918.90
Rate for Payer: Aetna of IA Medical Rental Products	$918.90
Rate for Payer: Aetna of IA Medicare	$581.97
Rate for Payer: Amerigroup Medicaid	$588.91
Rate for Payer: Amerigroup Medicare	$464.04
Rate for Payer: Cash Price	$816.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$765.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$459.45
Rate for Payer: Iowa Total Care Managed Medicaid	$583.20
Rate for Payer: Medical Associates Commercial	$765.75
Rate for Payer: Medical Associates Managed Medicare	$459.45
Rate for Payer: Midlands Choice Commercial	$714.70
Rate for Payer: Molina Healthcare Managed Medicaid	$591.77
Rate for Payer: Partners Health Alliance Commercial	$528.37
Rate for Payer: United Healthcare Commercial	$918.90
Rate for Payer: United Healthcare Managed Medicare	$602.39

MRI Wrist w/ + w/o Contrast Left

Facility

$1,025.00

Service Code	CPT 73223 LT
Hospital Charge Code	1169128
Hospital Revenue Code	610
Min. Negotiated Rate	$717.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: United Healthcare Commercial	$922.50

MRI Wrist w/ + w/o Contrast Left

Facility

$1,025.00

Service Code	CPT 73223 LT
Hospital Charge Code	1169128
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Aetna of IA Medicare	$584.25
Rate for Payer: Amerigroup Medicaid	$591.22
Rate for Payer: Amerigroup Medicare	$465.86
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$461.25
Rate for Payer: Iowa Total Care Managed Medicaid	$585.48
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Medical Associates Managed Medicare	$461.25
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Molina Healthcare Managed Medicaid	$594.09
Rate for Payer: Partners Health Alliance Commercial	$530.44
Rate for Payer: United Healthcare Commercial	$922.50
Rate for Payer: United Healthcare Managed Medicare	$604.75

MRI Wrist w/ + w/o Contrast Right

Facility

$1,025.00

Service Code	CPT 73223 RT
Hospital Charge Code	1169130
Hospital Revenue Code	610
Min. Negotiated Rate	$461.25
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Aetna of IA Medicare	$584.25
Rate for Payer: Amerigroup Medicaid	$591.22
Rate for Payer: Amerigroup Medicare	$465.86
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$461.25
Rate for Payer: Iowa Total Care Managed Medicaid	$585.48
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Medical Associates Managed Medicare	$461.25
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Molina Healthcare Managed Medicaid	$594.09
Rate for Payer: Partners Health Alliance Commercial	$530.44
Rate for Payer: United Healthcare Commercial	$922.50
Rate for Payer: United Healthcare Managed Medicare	$604.75

MRI Wrist w/ + w/o Contrast Right

Facility

$1,025.00

Service Code	CPT 73223 RT
Hospital Charge Code	1169130
Hospital Revenue Code	610
Min. Negotiated Rate	$717.50
Max. Negotiated Rate	$922.50
Rate for Payer: Aetna of IA Commercial	$922.50
Rate for Payer: Aetna of IA Medical Rental Products	$922.50
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$768.75
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: United Healthcare Commercial	$922.50

MRSA SCREENING

Facility

$56.00

Service Code	CPT 87081
Hospital Charge Code	4022875
Hospital Revenue Code	306
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of IA Commercial	$50.40
Rate for Payer: Aetna of IA Medical Rental Products	$50.40
Rate for Payer: Cash Price	$44.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.00
Rate for Payer: Medical Associates Commercial	$42.00
Rate for Payer: Midlands Choice Commercial	$39.20
Rate for Payer: United Healthcare Commercial	$50.40

MRSA SCREENING

Facility

$56.00

Service Code	CPT 87081
Hospital Charge Code	4022875
Hospital Revenue Code	306
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$50.40
Rate for Payer: Aetna of IA Commercial	$50.40
Rate for Payer: Aetna of IA Medical Rental Products	$50.40
Rate for Payer: Aetna of IA Medicare	$31.92
Rate for Payer: Amerigroup Medicaid	$32.30
Rate for Payer: Amerigroup Medicare	$25.45
Rate for Payer: Cash Price	$44.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.20
Rate for Payer: Iowa Total Care Managed Medicaid	$31.99
Rate for Payer: Medical Associates Commercial	$42.00
Rate for Payer: Medical Associates Managed Medicare	$25.20
Rate for Payer: Midlands Choice Commercial	$39.20
Rate for Payer: Molina Healthcare Managed Medicaid	$32.46
Rate for Payer: Partners Health Alliance Commercial	$28.98
Rate for Payer: United Healthcare Commercial	$50.40
Rate for Payer: United Healthcare Managed Medicare	$33.04

MULTIPLE PATIENT TRANSPORT

Facility

$310.00

Service Code	HCPCS A0999 QN
Hospital Charge Code	7932765
Hospital Revenue Code	540
Min. Negotiated Rate	$139.50
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of IA Commercial	$279.00
Rate for Payer: Aetna of IA Medical Rental Products	$279.00
Rate for Payer: Aetna of IA Medicare	$176.70
Rate for Payer: Amerigroup Medicaid	$178.81
Rate for Payer: Amerigroup Medicare	$140.90
Rate for Payer: Cash Price	$248.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$232.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$139.50
Rate for Payer: Iowa Total Care Managed Medicaid	$177.07
Rate for Payer: Medical Associates Commercial	$232.50
Rate for Payer: Medical Associates Managed Medicare	$139.50
Rate for Payer: Midlands Choice Commercial	$217.00
Rate for Payer: Molina Healthcare Managed Medicaid	$179.68
Rate for Payer: Partners Health Alliance Commercial	$160.43
Rate for Payer: United Healthcare Commercial	$279.00
Rate for Payer: United Healthcare Managed Medicare	$263.50

MULTIPLE PATIENT TRANSPORT

Facility

$310.00

Service Code	HCPCS A0999 QN
Hospital Charge Code	7932765
Hospital Revenue Code	540
Min. Negotiated Rate	$217.00
Max. Negotiated Rate	$279.00
Rate for Payer: Aetna of IA Commercial	$279.00
Rate for Payer: Aetna of IA Medical Rental Products	$279.00
Rate for Payer: Cash Price	$248.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$232.50
Rate for Payer: Medical Associates Commercial	$232.50
Rate for Payer: Midlands Choice Commercial	$217.00
Rate for Payer: United Healthcare Commercial	$279.00

Multiple Vitamins IV Sol 10 mL[VDMC]

Facility

$76.60

Service Code	NDC 54643-5649-01
Hospital Charge Code	10407586
Hospital Revenue Code	259
Min. Negotiated Rate	$34.47
Max. Negotiated Rate	$68.94
Rate for Payer: Aetna of IA Commercial	$68.94
Rate for Payer: Aetna of IA Medical Rental Products	$68.94
Rate for Payer: Aetna of IA Medicare	$43.66
Rate for Payer: Amerigroup Medicaid	$44.18
Rate for Payer: Amerigroup Medicare	$34.81
Rate for Payer: Cash Price	$61.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.45
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$34.47
Rate for Payer: Iowa Total Care Managed Medicaid	$43.75
Rate for Payer: Medical Associates Commercial	$57.45
Rate for Payer: Medical Associates Managed Medicare	$34.47
Rate for Payer: Midlands Choice Commercial	$53.62
Rate for Payer: Molina Healthcare Managed Medicaid	$44.40
Rate for Payer: Partners Health Alliance Commercial	$39.64
Rate for Payer: United Healthcare Commercial	$68.94
Rate for Payer: United Healthcare Managed Medicare	$45.19

Multiple Vitamins IV Sol 10 mL[VDMC]

Facility

$76.60

Service Code	NDC 54643-5649-01
Hospital Charge Code	10407586
Hospital Revenue Code	259
Min. Negotiated Rate	$53.62
Max. Negotiated Rate	$68.94
Rate for Payer: Aetna of IA Commercial	$68.94
Rate for Payer: Aetna of IA Medical Rental Products	$68.94
Rate for Payer: Cash Price	$61.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.45
Rate for Payer: Medical Associates Commercial	$57.45
Rate for Payer: Midlands Choice Commercial	$53.62
Rate for Payer: United Healthcare Commercial	$68.94

Multiple Vitamins with Minerals Oral Liq 236 mL [VDMC]

Facility

$24.80

Service Code	HCPCS A9270
Hospital Charge Code	10407653
Hospital Revenue Code	259
Min. Negotiated Rate	$17.36
Max. Negotiated Rate	$22.32
Rate for Payer: Aetna of IA Commercial	$22.32
Rate for Payer: Aetna of IA Medical Rental Products	$22.32
Rate for Payer: Cash Price	$19.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.60
Rate for Payer: Medical Associates Commercial	$18.60
Rate for Payer: Midlands Choice Commercial	$17.36
Rate for Payer: United Healthcare Commercial	$22.32

Multiple Vitamins with Minerals Oral Liq 236 mL [VDMC]

Facility

$24.80

Service Code	HCPCS A9270
Hospital Charge Code	10407653
Hospital Revenue Code	259
Min. Negotiated Rate	$11.16
Max. Negotiated Rate	$22.32
Rate for Payer: Aetna of IA Commercial	$22.32
Rate for Payer: Aetna of IA Medical Rental Products	$22.32
Rate for Payer: Aetna of IA Medicare	$14.13
Rate for Payer: Amerigroup Medicaid	$14.30
Rate for Payer: Amerigroup Medicare	$11.27
Rate for Payer: Cash Price	$19.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.60
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.16
Rate for Payer: Iowa Total Care Managed Medicaid	$14.16
Rate for Payer: Medical Associates Commercial	$18.60
Rate for Payer: Medical Associates Managed Medicare	$11.16
Rate for Payer: Midlands Choice Commercial	$17.36
Rate for Payer: Molina Healthcare Managed Medicaid	$14.37
Rate for Payer: Partners Health Alliance Commercial	$12.83
Rate for Payer: United Healthcare Commercial	$22.32
Rate for Payer: United Healthcare Managed Medicare	$14.63

multivitamin Vitamin B Complex with C and Folic Acid Tab[VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	28562975
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.09
Rate for Payer: Medical Associates Commercial	$1.09
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: United Healthcare Commercial	$1.31

multivitamin Vitamin B Complex with C and Folic Acid Tab[VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	28562975
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Aetna of IA Medicare	$0.83
Rate for Payer: Amerigroup Medicaid	$0.84
Rate for Payer: Amerigroup Medicare	$0.66
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.09
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.66
Rate for Payer: Iowa Total Care Managed Medicaid	$0.83
Rate for Payer: Medical Associates Commercial	$1.09
Rate for Payer: Medical Associates Managed Medicare	$0.66
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: Molina Healthcare Managed Medicaid	$0.85
Rate for Payer: Partners Health Alliance Commercial	$0.76
Rate for Payer: United Healthcare Commercial	$1.31
Rate for Payer: United Healthcare Managed Medicare	$0.86

multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab[VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	11361372
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Aetna of IA Medicare	$0.63
Rate for Payer: Amerigroup Medicaid	$0.64
Rate for Payer: Amerigroup Medicare	$0.51
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.50
Rate for Payer: Iowa Total Care Managed Medicaid	$0.64
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Medical Associates Managed Medicare	$0.50
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: Molina Healthcare Managed Medicaid	$0.64
Rate for Payer: Partners Health Alliance Commercial	$0.58
Rate for Payer: United Healthcare Commercial	$1.00
Rate for Payer: United Healthcare Managed Medicare	$0.66

multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab[VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	11361372
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: United Healthcare Commercial	$1.00

Mumps Virus IgG Antibody DMCL

Facility

$124.00

Service Code	CPT 86735
Hospital Charge Code	8037744
Hospital Revenue Code	302
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of IA Commercial	$111.60
Rate for Payer: Aetna of IA Medical Rental Products	$111.60
Rate for Payer: Cash Price	$99.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.00
Rate for Payer: Medical Associates Commercial	$93.00
Rate for Payer: Midlands Choice Commercial	$86.80
Rate for Payer: United Healthcare Commercial	$111.60

Mumps Virus IgG Antibody DMCL

Facility

$124.00

Service Code	CPT 86735
Hospital Charge Code	8037744
Hospital Revenue Code	302
Min. Negotiated Rate	$55.80
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of IA Commercial	$111.60
Rate for Payer: Aetna of IA Medical Rental Products	$111.60
Rate for Payer: Aetna of IA Medicare	$70.68
Rate for Payer: Amerigroup Medicaid	$71.52
Rate for Payer: Amerigroup Medicare	$56.36
Rate for Payer: Cash Price	$99.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.80
Rate for Payer: Iowa Total Care Managed Medicaid	$70.83
Rate for Payer: Medical Associates Commercial	$93.00
Rate for Payer: Medical Associates Managed Medicare	$55.80
Rate for Payer: Midlands Choice Commercial	$86.80
Rate for Payer: Molina Healthcare Managed Medicaid	$71.87
Rate for Payer: Partners Health Alliance Commercial	$64.17
Rate for Payer: United Healthcare Commercial	$111.60
Rate for Payer: United Healthcare Managed Medicare	$73.16

MUPIROCIN 2% OINTMENT

Facility

$41.00

Hospital Charge Code	8013713
Hospital Revenue Code	637
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of IA Commercial	$36.90
Rate for Payer: Aetna of IA Medical Rental Products	$36.90
Rate for Payer: Cash Price	$32.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.75
Rate for Payer: Medical Associates Commercial	$30.75
Rate for Payer: Midlands Choice Commercial	$28.70
Rate for Payer: United Healthcare Commercial	$36.90

MUPIROCIN 2% OINTMENT

Facility

$41.00

Hospital Charge Code	8013713
Hospital Revenue Code	637
Min. Negotiated Rate	$18.45
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of IA Commercial	$36.90
Rate for Payer: Aetna of IA Medical Rental Products	$36.90
Rate for Payer: Aetna of IA Medicare	$23.37
Rate for Payer: Amerigroup Medicaid	$23.65
Rate for Payer: Amerigroup Medicare	$18.63
Rate for Payer: Cash Price	$32.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.45
Rate for Payer: Iowa Total Care Managed Medicaid	$23.42
Rate for Payer: Medical Associates Commercial	$30.75
Rate for Payer: Medical Associates Managed Medicare	$18.45
Rate for Payer: Midlands Choice Commercial	$28.70
Rate for Payer: Molina Healthcare Managed Medicaid	$23.76
Rate for Payer: Partners Health Alliance Commercial	$21.22
Rate for Payer: United Healthcare Commercial	$36.90
Rate for Payer: United Healthcare Managed Medicare	$24.19

mupirocin Top 2% Oint [VDMC]

Facility

$31.96

Service Code	HCPCS A9270
Hospital Charge Code	10436449
Hospital Revenue Code	259
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$28.76
Rate for Payer: Aetna of IA Commercial	$28.76
Rate for Payer: Aetna of IA Medical Rental Products	$28.76
Rate for Payer: Cash Price	$25.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.97
Rate for Payer: Medical Associates Commercial	$23.97
Rate for Payer: Midlands Choice Commercial	$22.37
Rate for Payer: United Healthcare Commercial	$28.76

mupirocin Top 2% Oint [VDMC]

Facility

$31.96

Service Code	HCPCS A9270
Hospital Charge Code	10436449
Hospital Revenue Code	259
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$28.76
Rate for Payer: Aetna of IA Commercial	$28.76
Rate for Payer: Aetna of IA Medical Rental Products	$28.76
Rate for Payer: Aetna of IA Medicare	$18.22
Rate for Payer: Amerigroup Medicaid	$18.43
Rate for Payer: Amerigroup Medicare	$14.53
Rate for Payer: Cash Price	$25.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.97
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.38
Rate for Payer: Iowa Total Care Managed Medicaid	$18.26
Rate for Payer: Medical Associates Commercial	$23.97
Rate for Payer: Medical Associates Managed Medicare	$14.38
Rate for Payer: Midlands Choice Commercial	$22.37
Rate for Payer: Molina Healthcare Managed Medicaid	$18.52
Rate for Payer: Partners Health Alliance Commercial	$16.54
Rate for Payer: United Healthcare Commercial	$28.76
Rate for Payer: United Healthcare Managed Medicare	$18.86

mycophenolate mofetil 250 mg Cap [VDMC]

Facility

$2.45

Service Code	HCPCS A9270
Hospital Charge Code	10407718
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$2.20
Rate for Payer: Aetna of IA Commercial	$2.20
Rate for Payer: Aetna of IA Medical Rental Products	$2.20
Rate for Payer: Cash Price	$1.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.84
Rate for Payer: Medical Associates Commercial	$1.84
Rate for Payer: Midlands Choice Commercial	$1.71
Rate for Payer: United Healthcare Commercial	$2.20

Know your out-of-pocket cost for care.

All Charges