Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

pegfilgrastim 6 mg/0.6 mL SubQ SDV Inj [VDMC]

Facility

$8,399.00

Service Code	HCPCS J2506
Hospital Charge Code	10412131
Hospital Revenue Code	259
Min. Negotiated Rate	$5,879.30
Max. Negotiated Rate	$7,559.10
Rate for Payer: Aetna of IA Commercial	$7,559.10
Rate for Payer: Aetna of IA Medical Rental Products	$7,559.10
Rate for Payer: Cash Price	$6,719.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,299.25
Rate for Payer: Medical Associates Commercial	$6,299.25
Rate for Payer: Midlands Choice Commercial	$5,879.30
Rate for Payer: United Healthcare Commercial	$7,559.10

pegfilgrastim-apgf 6 mg/0.6 mL SubQ PFS Inj [VDMC]

Facility

$7,675.26

Service Code	HCPCS Q5122
Hospital Charge Code	27690722
Hospital Revenue Code	259
Min. Negotiated Rate	$3,453.87
Max. Negotiated Rate	$6,907.73
Rate for Payer: Aetna of IA Commercial	$6,907.73
Rate for Payer: Aetna of IA Medical Rental Products	$6,907.73
Rate for Payer: Aetna of IA Medicare	$4,374.90
Rate for Payer: Amerigroup Medicaid	$4,427.09
Rate for Payer: Amerigroup Medicare	$3,488.41
Rate for Payer: Cash Price	$6,140.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,756.44
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,453.87
Rate for Payer: Iowa Total Care Managed Medicaid	$4,384.11
Rate for Payer: Medical Associates Commercial	$5,756.44
Rate for Payer: Medical Associates Managed Medicare	$3,453.87
Rate for Payer: Midlands Choice Commercial	$5,372.68
Rate for Payer: Molina Healthcare Managed Medicaid	$4,448.58
Rate for Payer: Partners Health Alliance Commercial	$3,971.95
Rate for Payer: United Healthcare Commercial	$6,907.73
Rate for Payer: United Healthcare Managed Medicare	$4,528.40

pegfilgrastim-apgf 6 mg/0.6 mL SubQ PFS Inj [VDMC]

Facility

$7,675.26

Service Code	HCPCS Q5122
Hospital Charge Code	27690722
Hospital Revenue Code	259
Min. Negotiated Rate	$5,372.68
Max. Negotiated Rate	$6,907.73
Rate for Payer: Aetna of IA Commercial	$6,907.73
Rate for Payer: Aetna of IA Medical Rental Products	$6,907.73
Rate for Payer: Cash Price	$6,140.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,756.44
Rate for Payer: Medical Associates Commercial	$5,756.44
Rate for Payer: Midlands Choice Commercial	$5,372.68
Rate for Payer: United Healthcare Commercial	$6,907.73

pegfilgrastim-jmdb 6 mg/0.6 mL SubQ PFS Inj[VDMC]

Facility

$3,458.20

Service Code	HCPCS Q5108
Hospital Charge Code	28403492
Hospital Revenue Code	259
Min. Negotiated Rate	$1,556.19
Max. Negotiated Rate	$3,112.38
Rate for Payer: Aetna of IA Commercial	$3,112.38
Rate for Payer: Aetna of IA Medical Rental Products	$3,112.38
Rate for Payer: Aetna of IA Medicare	$1,971.17
Rate for Payer: Amerigroup Medicaid	$1,994.69
Rate for Payer: Amerigroup Medicare	$1,571.75
Rate for Payer: Cash Price	$2,766.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,593.65
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,556.19
Rate for Payer: Iowa Total Care Managed Medicaid	$1,975.32
Rate for Payer: Medical Associates Commercial	$2,593.65
Rate for Payer: Medical Associates Managed Medicare	$1,556.19
Rate for Payer: Midlands Choice Commercial	$2,420.74
Rate for Payer: Molina Healthcare Managed Medicaid	$2,004.37
Rate for Payer: Partners Health Alliance Commercial	$1,789.62
Rate for Payer: United Healthcare Commercial	$3,112.38
Rate for Payer: United Healthcare Managed Medicare	$2,040.34

pegfilgrastim-jmdb 6 mg/0.6 mL SubQ PFS Inj[VDMC]

Facility

$3,458.20

Service Code	HCPCS Q5108
Hospital Charge Code	28403492
Hospital Revenue Code	259
Min. Negotiated Rate	$2,420.74
Max. Negotiated Rate	$3,112.38
Rate for Payer: Aetna of IA Commercial	$3,112.38
Rate for Payer: Aetna of IA Medical Rental Products	$3,112.38
Rate for Payer: Cash Price	$2,766.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,593.65
Rate for Payer: Medical Associates Commercial	$2,593.65
Rate for Payer: Midlands Choice Commercial	$2,420.74
Rate for Payer: United Healthcare Commercial	$3,112.38

PEGGED GLENOID POLY W/PEG LARGE

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047277
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.75
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Aetna of IA Medicare	$1,615.95
Rate for Payer: Amerigroup Medicaid	$1,635.23
Rate for Payer: Amerigroup Medicare	$1,288.51
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,275.75
Rate for Payer: Iowa Total Care Managed Medicaid	$1,619.35
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Medical Associates Managed Medicare	$1,275.75
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,643.17
Rate for Payer: Partners Health Alliance Commercial	$1,467.11
Rate for Payer: United Healthcare Commercial	$2,551.50
Rate for Payer: United Healthcare Managed Medicare	$1,672.65

PEGGED GLENOID POLY W/PEG LARGE

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047277
Hospital Revenue Code	278
Min. Negotiated Rate	$1,984.50
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: United Healthcare Commercial	$2,551.50

PEGGED GLENOID POLY W/PEG MEDIUM

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047276
Hospital Revenue Code	278
Min. Negotiated Rate	$1,984.50
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: United Healthcare Commercial	$2,551.50

PEGGED GLENOID POLY W/PEG MEDIUM

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047276
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.75
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Aetna of IA Medicare	$1,615.95
Rate for Payer: Amerigroup Medicaid	$1,635.23
Rate for Payer: Amerigroup Medicare	$1,288.51
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,275.75
Rate for Payer: Iowa Total Care Managed Medicaid	$1,619.35
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Medical Associates Managed Medicare	$1,275.75
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,643.17
Rate for Payer: Partners Health Alliance Commercial	$1,467.11
Rate for Payer: United Healthcare Commercial	$2,551.50
Rate for Payer: United Healthcare Managed Medicare	$1,672.65

PEGGED GLENOID POLY W/PEG SMALL

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047275
Hospital Revenue Code	278
Min. Negotiated Rate	$1,984.50
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: United Healthcare Commercial	$2,551.50

PEGGED GLENOID POLY W/PEG SMALL

Facility

$2,835.00

Service Code	HCPCS C1776
Hospital Charge Code	8047275
Hospital Revenue Code	278
Min. Negotiated Rate	$1,275.75
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Aetna of IA Medicare	$1,615.95
Rate for Payer: Amerigroup Medicaid	$1,635.23
Rate for Payer: Amerigroup Medicare	$1,288.51
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,275.75
Rate for Payer: Iowa Total Care Managed Medicaid	$1,619.35
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Medical Associates Managed Medicare	$1,275.75
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,643.17
Rate for Payer: Partners Health Alliance Commercial	$1,467.11
Rate for Payer: United Healthcare Commercial	$2,551.50
Rate for Payer: United Healthcare Managed Medicare	$1,672.65

penicillin G benzathine 1,200,000 units/2 mL SDS Sus [VDMC]

Facility

$1,073.50

Service Code	HCPCS J0561
Hospital Charge Code	10432035
Hospital Revenue Code	259
Min. Negotiated Rate	$751.45
Max. Negotiated Rate	$966.15
Rate for Payer: Aetna of IA Commercial	$966.15
Rate for Payer: Aetna of IA Medical Rental Products	$966.15
Rate for Payer: Cash Price	$858.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$805.13
Rate for Payer: Medical Associates Commercial	$805.13
Rate for Payer: Midlands Choice Commercial	$751.45
Rate for Payer: United Healthcare Commercial	$966.15

penicillin G benzathine 1,200,000 units/2 mL SDS Sus [VDMC]

Facility

$1,073.50

Service Code	HCPCS J0561
Hospital Charge Code	10432035
Hospital Revenue Code	259
Min. Negotiated Rate	$483.08
Max. Negotiated Rate	$966.15
Rate for Payer: Aetna of IA Commercial	$966.15
Rate for Payer: Aetna of IA Medical Rental Products	$966.15
Rate for Payer: Aetna of IA Medicare	$611.90
Rate for Payer: Amerigroup Medicaid	$619.20
Rate for Payer: Amerigroup Medicare	$487.91
Rate for Payer: Cash Price	$858.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$805.13
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$483.08
Rate for Payer: Iowa Total Care Managed Medicaid	$613.19
Rate for Payer: Medical Associates Commercial	$805.13
Rate for Payer: Medical Associates Managed Medicare	$483.08
Rate for Payer: Midlands Choice Commercial	$751.45
Rate for Payer: Molina Healthcare Managed Medicaid	$622.20
Rate for Payer: Partners Health Alliance Commercial	$555.54
Rate for Payer: United Healthcare Commercial	$966.15
Rate for Payer: United Healthcare Managed Medicare	$633.37

Penicillin V Potassium 250mg Tab [VDMC]

Facility

$1.27

Service Code	HCPCS A9270
Hospital Charge Code	24496674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.15
Rate for Payer: Aetna of IA Commercial	$1.15
Rate for Payer: Aetna of IA Medical Rental Products	$1.15
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Midlands Choice Commercial	$0.89
Rate for Payer: United Healthcare Commercial	$1.15

Penicillin V Potassium 250mg Tab [VDMC]

Facility

$1.27

Service Code	HCPCS A9270
Hospital Charge Code	24496674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.15
Rate for Payer: Aetna of IA Commercial	$1.15
Rate for Payer: Aetna of IA Medical Rental Products	$1.15
Rate for Payer: Aetna of IA Medicare	$0.73
Rate for Payer: Amerigroup Medicaid	$0.73
Rate for Payer: Amerigroup Medicare	$0.58
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.57
Rate for Payer: Iowa Total Care Managed Medicaid	$0.73
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Medical Associates Managed Medicare	$0.57
Rate for Payer: Midlands Choice Commercial	$0.89
Rate for Payer: Molina Healthcare Managed Medicaid	$0.74
Rate for Payer: Partners Health Alliance Commercial	$0.66
Rate for Payer: United Healthcare Commercial	$1.15
Rate for Payer: United Healthcare Managed Medicare	$0.75

pentoxifylline 400 mg ER Tab [VDMC]

Facility

$1.61

Service Code	HCPCS A9270
Hospital Charge Code	10412466
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of IA Commercial	$1.45
Rate for Payer: Aetna of IA Medical Rental Products	$1.45
Rate for Payer: Cash Price	$1.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.21
Rate for Payer: Medical Associates Commercial	$1.21
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: United Healthcare Commercial	$1.45

pentoxifylline 400 mg ER Tab [VDMC]

Facility

$1.61

Service Code	HCPCS A9270
Hospital Charge Code	10412466
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of IA Commercial	$1.45
Rate for Payer: Aetna of IA Medical Rental Products	$1.45
Rate for Payer: Aetna of IA Medicare	$0.92
Rate for Payer: Amerigroup Medicaid	$0.93
Rate for Payer: Amerigroup Medicare	$0.73
Rate for Payer: Cash Price	$1.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.21
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.72
Rate for Payer: Iowa Total Care Managed Medicaid	$0.92
Rate for Payer: Medical Associates Commercial	$1.21
Rate for Payer: Medical Associates Managed Medicare	$0.72
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: Molina Healthcare Managed Medicaid	$0.93
Rate for Payer: Partners Health Alliance Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.45
Rate for Payer: United Healthcare Managed Medicare	$0.95

PERC IMPL NS ELECTRODE ARRAY EPIDURAL

Professional

Both

$4,343.00

Service Code	CPT 63650
Hospital Charge Code	8015898
Hospital Revenue Code	975
Min. Negotiated Rate	$2,854.50
Max. Negotiated Rate	$3,257.25
Rate for Payer: Cash Price	$3,474.40
Rate for Payer: Cash Price	$3,474.40
Rate for Payer: Medical Associates Commercial	$3,257.25
Rate for Payer: Midlands Choice Commercial	$3,040.10
Rate for Payer: Partners Health Alliance Commercial	$3,257.25
Rate for Payer: United Healthcare Commercial	$2,854.50

permethrin Top 1% lotion 59ml [VDMC]

Facility

$47.16

Service Code	NDC 63736-0120-02
Hospital Charge Code	10436709
Hospital Revenue Code	259
Min. Negotiated Rate	$21.22
Max. Negotiated Rate	$42.44
Rate for Payer: Aetna of IA Commercial	$42.44
Rate for Payer: Aetna of IA Medical Rental Products	$42.44
Rate for Payer: Aetna of IA Medicare	$26.88
Rate for Payer: Amerigroup Medicaid	$27.20
Rate for Payer: Amerigroup Medicare	$21.43
Rate for Payer: Cash Price	$37.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.22
Rate for Payer: Iowa Total Care Managed Medicaid	$26.94
Rate for Payer: Medical Associates Commercial	$35.37
Rate for Payer: Medical Associates Managed Medicare	$21.22
Rate for Payer: Midlands Choice Commercial	$33.01
Rate for Payer: Molina Healthcare Managed Medicaid	$27.33
Rate for Payer: Partners Health Alliance Commercial	$24.41
Rate for Payer: United Healthcare Commercial	$42.44
Rate for Payer: United Healthcare Managed Medicare	$27.82

permethrin Top 1% lotion 59ml [VDMC]

Facility

$47.16

Service Code	NDC 63736-0120-02
Hospital Charge Code	10436709
Hospital Revenue Code	259
Min. Negotiated Rate	$33.01
Max. Negotiated Rate	$42.44
Rate for Payer: Aetna of IA Commercial	$42.44
Rate for Payer: Aetna of IA Medical Rental Products	$42.44
Rate for Payer: Cash Price	$37.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.37
Rate for Payer: Medical Associates Commercial	$35.37
Rate for Payer: Midlands Choice Commercial	$33.01
Rate for Payer: United Healthcare Commercial	$42.44

PETITE MPJ PLATE, RIGHT

Facility

$297.00

Service Code	HCPCS C1713
Hospital Charge Code	8812766
Hospital Revenue Code	278
Min. Negotiated Rate	$133.65
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Aetna of IA Medicare	$169.29
Rate for Payer: Amerigroup Medicaid	$171.31
Rate for Payer: Amerigroup Medicare	$134.99
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$133.65
Rate for Payer: Iowa Total Care Managed Medicaid	$169.65
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Medical Associates Managed Medicare	$133.65
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: Molina Healthcare Managed Medicaid	$172.14
Rate for Payer: Partners Health Alliance Commercial	$153.70
Rate for Payer: United Healthcare Commercial	$267.30
Rate for Payer: United Healthcare Managed Medicare	$175.23

PETITE MPJ PLATE, RIGHT

Facility

$297.00

Service Code	HCPCS C1713
Hospital Charge Code	8812766
Hospital Revenue Code	278
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: United Healthcare Commercial	$267.30

PETITE STEPPED MPG VLC GRIDLOCK PLATE RT

Facility

$2,070.00

Service Code	HCPCS C1713
Hospital Charge Code	8757684
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.00
Max. Negotiated Rate	$1,863.00
Rate for Payer: Aetna of IA Commercial	$1,863.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,863.00
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,552.50
Rate for Payer: Medical Associates Commercial	$1,552.50
Rate for Payer: Midlands Choice Commercial	$1,449.00
Rate for Payer: United Healthcare Commercial	$1,863.00

PETITE STEPPED MPG VLC GRIDLOCK PLATE RT

Facility

$2,070.00

Service Code	HCPCS C1713
Hospital Charge Code	8757684
Hospital Revenue Code	278
Min. Negotiated Rate	$931.50
Max. Negotiated Rate	$1,863.00
Rate for Payer: Aetna of IA Commercial	$1,863.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,863.00
Rate for Payer: Aetna of IA Medicare	$1,179.90
Rate for Payer: Amerigroup Medicaid	$1,193.98
Rate for Payer: Amerigroup Medicare	$940.82
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,552.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$931.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,182.38
Rate for Payer: Medical Associates Commercial	$1,552.50
Rate for Payer: Medical Associates Managed Medicare	$931.50
Rate for Payer: Midlands Choice Commercial	$1,449.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,199.77
Rate for Payer: Partners Health Alliance Commercial	$1,071.22
Rate for Payer: United Healthcare Commercial	$1,863.00
Rate for Payer: United Healthcare Managed Medicare	$1,221.30

petrolatum topical Ointment 396 gram Jar [VDMC]

Facility

$73.10

Service Code	HCPCS A9270
Hospital Charge Code	23020335
Hospital Revenue Code	259
Min. Negotiated Rate	$51.17
Max. Negotiated Rate	$65.79
Rate for Payer: Aetna of IA Commercial	$65.79
Rate for Payer: Aetna of IA Medical Rental Products	$65.79
Rate for Payer: Cash Price	$58.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.83
Rate for Payer: Medical Associates Commercial	$54.83
Rate for Payer: Midlands Choice Commercial	$51.17
Rate for Payer: United Healthcare Commercial	$65.79

Know your out-of-pocket cost for care.

All Charges