Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; EACH ADDITIONAL 15 MINUTES INTRASERVICE TIME (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY SERVICE)

Facility

$57.79

Service Code	CPT 99153
Hospital Revenue Code	360
Min. Negotiated Rate	$52.47
Max. Negotiated Rate	$57.79
Rate for Payer: Wellmark IA HMO WHPI	$52.47
Rate for Payer: Wellmark IA PPO	$57.79

MODERATE SEDATION SERVICES PROVIDED BY THE SAME PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROFESSIONAL PERFORMING THE DIAGNOSTIC OR THERAPEUTIC SERVICE THAT THE SEDATION SUPPORTS, REQUIRING THE PRESENCE OF AN INDEPENDENT TRAINED OBSERVER TO ASSIST IN THE MONITORING OF THE PATIENT'S LEVEL OF CONSCIOUSNESS AND PHYSIOLOGICAL STATUS; INITIAL 15 MINUTES OF INTRASERVICE TIME, PATIENT AGE 5 YEARS OR OLDER

Facility

$57.79

Service Code	CPT 99152
Hospital Revenue Code	360
Min. Negotiated Rate	$52.47
Max. Negotiated Rate	$57.79
Rate for Payer: Wellmark IA HMO WHPI	$52.47
Rate for Payer: Wellmark IA PPO	$57.79

MODIFIED BARIUM SWAL STUDY

Facility

$450.00

Service Code	CPT 92611 GN
Hospital Charge Code	5530783
Hospital Revenue Code	440
Min. Negotiated Rate	$315.00
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna of IA Commercial	$405.00
Rate for Payer: Aetna of IA Medical Rental Products	$405.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$337.50
Rate for Payer: Medical Associates Commercial	$337.50
Rate for Payer: Midlands Choice Commercial	$315.00
Rate for Payer: United Healthcare Commercial	$405.00

MODIFIED BARIUM SWAL STUDY

Facility

$450.00

Service Code	CPT 92611 GN
Hospital Charge Code	5530783
Hospital Revenue Code	440
Min. Negotiated Rate	$202.50
Max. Negotiated Rate	$405.00
Rate for Payer: Aetna of IA Commercial	$405.00
Rate for Payer: Aetna of IA Medical Rental Products	$405.00
Rate for Payer: Aetna of IA Medicare	$256.50
Rate for Payer: Amerigroup Medicaid	$259.56
Rate for Payer: Amerigroup Medicare	$204.52
Rate for Payer: Cash Price	$360.00
Rate for Payer: Cash Price	$360.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$337.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$202.50
Rate for Payer: Iowa Total Care Managed Medicaid	$257.04
Rate for Payer: Medical Associates Commercial	$337.50
Rate for Payer: Medical Associates Managed Medicare	$202.50
Rate for Payer: Midlands Choice Commercial	$315.00
Rate for Payer: Molina Healthcare Managed Medicaid	$260.82
Rate for Payer: Partners Health Alliance Commercial	$232.88
Rate for Payer: United Healthcare Commercial	$405.00
Rate for Payer: United Healthcare Managed Medicare	$265.50
Rate for Payer: Wellmark IA HMO WHPI	$298.49
Rate for Payer: Wellmark IA PPO	$328.80

MOD SEDAT ENDO SERVICE >5YRS

Professional

Both

$192.00

Service Code	HCPCS G0500
Hospital Charge Code	8068958
Hospital Revenue Code	964
Min. Negotiated Rate	$46.49
Max. Negotiated Rate	$144.00
Rate for Payer: Amerigroup Medicaid	$46.95
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cash Price	$153.60
Rate for Payer: Iowa Total Care Managed Medicaid	$46.49
Rate for Payer: Medical Associates Commercial	$144.00
Rate for Payer: Midlands Choice Commercial	$134.40
Rate for Payer: Molina Healthcare Managed Medicaid	$46.72
Rate for Payer: Partners Health Alliance Commercial	$144.00
Rate for Payer: United Healthcare Commercial	$83.78
Rate for Payer: Wellmark IA HMO WHPI	$81.90
Rate for Payer: Wellmark IA PPO	$81.90

MOD SED SAME PHYS/QHP <5 YRS

Professional

Both

$254.00

Service Code	CPT 99151
Hospital Charge Code	8068972
Hospital Revenue Code	975
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$190.50
Rate for Payer: Amerigroup Medicaid	$70.69
Rate for Payer: Cash Price	$203.20
Rate for Payer: Cash Price	$203.20
Rate for Payer: Iowa Total Care Managed Medicaid	$70.00
Rate for Payer: Medical Associates Commercial	$190.50
Rate for Payer: Midlands Choice Commercial	$177.80
Rate for Payer: Molina Healthcare Managed Medicaid	$70.35
Rate for Payer: Partners Health Alliance Commercial	$190.50
Rate for Payer: United Healthcare Commercial	$111.28
Rate for Payer: Wellmark IA HMO WHPI	$73.60
Rate for Payer: Wellmark IA PPO	$86.60

MOD SED SAME PHYS/QHP 5/>YRS

Professional

Both

$169.00

Service Code	CPT 99152
Hospital Charge Code	8068979
Hospital Revenue Code	975
Min. Negotiated Rate	$46.49
Max. Negotiated Rate	$126.75
Rate for Payer: Amerigroup Medicaid	$46.95
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Iowa Total Care Managed Medicaid	$46.49
Rate for Payer: Medical Associates Commercial	$126.75
Rate for Payer: Midlands Choice Commercial	$118.30
Rate for Payer: Molina Healthcare Managed Medicaid	$46.72
Rate for Payer: Partners Health Alliance Commercial	$126.75
Rate for Payer: United Healthcare Commercial	$75.68
Rate for Payer: Wellmark IA HMO WHPI	$61.10
Rate for Payer: Wellmark IA PPO	$71.90

MOD SED SAME PHYS/QHP EA

Professional

Both

$36.00

Service Code	CPT 99153
Hospital Charge Code	8069194
Hospital Revenue Code	981
Min. Negotiated Rate	$9.67
Max. Negotiated Rate	$27.00
Rate for Payer: Amerigroup Medicaid	$9.76
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$9.67
Rate for Payer: Medical Associates Commercial	$27.00
Rate for Payer: Midlands Choice Commercial	$25.20
Rate for Payer: Molina Healthcare Managed Medicaid	$9.72
Rate for Payer: Partners Health Alliance Commercial	$27.00
Rate for Payer: United Healthcare Commercial	$15.44
Rate for Payer: Wellmark IA HMO WHPI	$14.20
Rate for Payer: Wellmark IA PPO	$16.70

MODULAR HIP SYSTEM 155MM X 16MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026267
Hospital Revenue Code	278
Min. Negotiated Rate	$3,673.35
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Aetna of IA Medicare	$4,652.91
Rate for Payer: Amerigroup Medicaid	$4,708.42
Rate for Payer: Amerigroup Medicare	$3,710.08
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,673.35
Rate for Payer: Iowa Total Care Managed Medicaid	$4,662.71
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Medical Associates Managed Medicare	$3,673.35
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: Molina Healthcare Managed Medicaid	$4,731.27
Rate for Payer: Partners Health Alliance Commercial	$4,224.35
Rate for Payer: United Healthcare Commercial	$7,346.70
Rate for Payer: United Healthcare Managed Medicare	$4,816.17

MODULAR HIP SYSTEM 155MM X 16MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026267
Hospital Revenue Code	278
Min. Negotiated Rate	$5,714.10
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: United Healthcare Commercial	$7,346.70

MODULAR HIP SYSTEM 155MM X 18MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026268
Hospital Revenue Code	278
Min. Negotiated Rate	$5,714.10
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: United Healthcare Commercial	$7,346.70

MODULAR HIP SYSTEM 155MM X 18MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026268
Hospital Revenue Code	278
Min. Negotiated Rate	$3,673.35
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Aetna of IA Medicare	$4,652.91
Rate for Payer: Amerigroup Medicaid	$4,708.42
Rate for Payer: Amerigroup Medicare	$3,710.08
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,673.35
Rate for Payer: Iowa Total Care Managed Medicaid	$4,662.71
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Medical Associates Managed Medicare	$3,673.35
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: Molina Healthcare Managed Medicaid	$4,731.27
Rate for Payer: Partners Health Alliance Commercial	$4,224.35
Rate for Payer: United Healthcare Commercial	$7,346.70
Rate for Payer: United Healthcare Managed Medicare	$4,816.17

MODULAR HIP SYSTEM 17MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046936
Hospital Revenue Code	278
Min. Negotiated Rate	$5,817.70
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: United Healthcare Commercial	$7,479.90

MODULAR HIP SYSTEM 17MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046936
Hospital Revenue Code	278
Min. Negotiated Rate	$3,739.95
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Aetna of IA Medicare	$4,737.27
Rate for Payer: Amerigroup Medicaid	$4,793.78
Rate for Payer: Amerigroup Medicare	$3,777.35
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,739.95
Rate for Payer: Iowa Total Care Managed Medicaid	$4,747.24
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Medical Associates Managed Medicare	$3,739.95
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: Molina Healthcare Managed Medicaid	$4,817.06
Rate for Payer: Partners Health Alliance Commercial	$4,300.94
Rate for Payer: United Healthcare Commercial	$7,479.90
Rate for Payer: United Healthcare Managed Medicare	$4,903.49

MODULAR HIP SYSTEM 195MM X 16MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046935
Hospital Revenue Code	278
Min. Negotiated Rate	$3,739.95
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Aetna of IA Medicare	$4,737.27
Rate for Payer: Amerigroup Medicaid	$4,793.78
Rate for Payer: Amerigroup Medicare	$3,777.35
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,739.95
Rate for Payer: Iowa Total Care Managed Medicaid	$4,747.24
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Medical Associates Managed Medicare	$3,739.95
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: Molina Healthcare Managed Medicaid	$4,817.06
Rate for Payer: Partners Health Alliance Commercial	$4,300.94
Rate for Payer: United Healthcare Commercial	$7,479.90
Rate for Payer: United Healthcare Managed Medicare	$4,903.49

MODULAR HIP SYSTEM 195MM X 16MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046935
Hospital Revenue Code	278
Min. Negotiated Rate	$5,817.70
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: United Healthcare Commercial	$7,479.90

MODULAR HIP SYSTEM 195MM X 20MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046937
Hospital Revenue Code	278
Min. Negotiated Rate	$5,817.70
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: United Healthcare Commercial	$7,479.90

MODULAR HIP SYSTEM 195MM X 20MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046937
Hospital Revenue Code	278
Min. Negotiated Rate	$3,739.95
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Aetna of IA Medicare	$4,737.27
Rate for Payer: Amerigroup Medicaid	$4,793.78
Rate for Payer: Amerigroup Medicare	$3,777.35
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,739.95
Rate for Payer: Iowa Total Care Managed Medicaid	$4,747.24
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Medical Associates Managed Medicare	$3,739.95
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: Molina Healthcare Managed Medicaid	$4,817.06
Rate for Payer: Partners Health Alliance Commercial	$4,300.94
Rate for Payer: United Healthcare Commercial	$7,479.90
Rate for Payer: United Healthcare Managed Medicare	$4,903.49

mometasone Nasal 50 mcg/inh Spry [VDMC]

Facility

$111.08

Service Code	HCPCS A9270
Hospital Charge Code	10406687
Hospital Revenue Code	259
Min. Negotiated Rate	$77.76
Max. Negotiated Rate	$99.97
Rate for Payer: Aetna of IA Commercial	$99.97
Rate for Payer: Aetna of IA Medical Rental Products	$99.97
Rate for Payer: Cash Price	$88.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.31
Rate for Payer: Medical Associates Commercial	$83.31
Rate for Payer: Midlands Choice Commercial	$77.76
Rate for Payer: United Healthcare Commercial	$99.97

mometasone Nasal 50 mcg/inh Spry [VDMC]

Facility

$111.08

Service Code	HCPCS A9270
Hospital Charge Code	10406687
Hospital Revenue Code	259
Min. Negotiated Rate	$49.99
Max. Negotiated Rate	$99.97
Rate for Payer: Aetna of IA Commercial	$99.97
Rate for Payer: Aetna of IA Medical Rental Products	$99.97
Rate for Payer: Aetna of IA Medicare	$63.32
Rate for Payer: Amerigroup Medicaid	$64.07
Rate for Payer: Amerigroup Medicare	$50.49
Rate for Payer: Cash Price	$88.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.99
Rate for Payer: Iowa Total Care Managed Medicaid	$63.45
Rate for Payer: Medical Associates Commercial	$83.31
Rate for Payer: Medical Associates Managed Medicare	$49.99
Rate for Payer: Midlands Choice Commercial	$77.76
Rate for Payer: Molina Healthcare Managed Medicaid	$64.38
Rate for Payer: Partners Health Alliance Commercial	$57.48
Rate for Payer: United Healthcare Commercial	$99.97
Rate for Payer: United Healthcare Managed Medicare	$65.54

MONO-SPOT

Facility

$58.00

Service Code	CPT 86308
Hospital Charge Code	4022812
Hospital Revenue Code	302
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$33.45
Rate for Payer: Amerigroup Medicare	$26.36
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.10
Rate for Payer: Iowa Total Care Managed Medicaid	$33.13
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$26.10
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$33.62
Rate for Payer: Partners Health Alliance Commercial	$30.02
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

MONO-SPOT

Facility

$58.00

Service Code	CPT 86308
Hospital Charge Code	4022812
Hospital Revenue Code	302
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

montelukast 10 mg Tab [VDMC]

Facility

$2.09

Service Code	HCPCS A9270
Hospital Charge Code	10406752
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of IA Commercial	$1.88
Rate for Payer: Aetna of IA Medical Rental Products	$1.88
Rate for Payer: Aetna of IA Medicare	$1.19
Rate for Payer: Amerigroup Medicaid	$1.20
Rate for Payer: Amerigroup Medicare	$0.95
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.56
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.94
Rate for Payer: Iowa Total Care Managed Medicaid	$1.19
Rate for Payer: Medical Associates Commercial	$1.56
Rate for Payer: Medical Associates Managed Medicare	$0.94
Rate for Payer: Midlands Choice Commercial	$1.46
Rate for Payer: Molina Healthcare Managed Medicaid	$1.21
Rate for Payer: Partners Health Alliance Commercial	$1.08
Rate for Payer: United Healthcare Commercial	$1.88
Rate for Payer: United Healthcare Managed Medicare	$1.23

montelukast 10 mg Tab [VDMC]

Facility

$2.09

Service Code	HCPCS A9270
Hospital Charge Code	10406752
Hospital Revenue Code	259
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of IA Commercial	$1.88
Rate for Payer: Aetna of IA Medical Rental Products	$1.88
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.56
Rate for Payer: Medical Associates Commercial	$1.56
Rate for Payer: Midlands Choice Commercial	$1.46
Rate for Payer: United Healthcare Commercial	$1.88

montelukast 4 mg Chew Tab [VDMC]

Facility

$1.43

Service Code	HCPCS A9270
Hospital Charge Code	10406821
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Aetna of IA Medicare	$0.82
Rate for Payer: Amerigroup Medicaid	$0.83
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.82
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Managed Medicare	$0.85

Know your out-of-pocket cost for care.

All Charges