Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$32.90
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: Aetna of IA Medicare	$41.67
Rate for Payer: Amerigroup Medicaid	$42.17
Rate for Payer: Amerigroup Medicare	$33.23
Rate for Payer: Cash Price	$58.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.90
Rate for Payer: Iowa Total Care Managed Medicaid	$41.76
Rate for Payer: Medical Associates Commercial	$54.83
Rate for Payer: Medical Associates Managed Medicare	$32.90
Rate for Payer: Midlands Choice Commercial	$51.17
Rate for Payer: Molina Healthcare Managed Medicaid	$42.37
Rate for Payer: Partners Health Alliance Commercial	$37.83
Rate for Payer: United Healthcare Commercial	$65.79
Rate for Payer: United Healthcare Managed Medicare	$43.13

PET w/ CT Scan Brain

Facility

$4,611.00

Service Code	CPT 78608
Hospital Charge Code	7960817
Hospital Revenue Code	404
Min. Negotiated Rate	$2,074.95
Max. Negotiated Rate	$4,149.90
Rate for Payer: Aetna of IA Commercial	$4,149.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,149.90
Rate for Payer: Aetna of IA Medicare	$2,628.27
Rate for Payer: Amerigroup Medicaid	$2,659.62
Rate for Payer: Amerigroup Medicare	$2,095.70
Rate for Payer: Cash Price	$3,688.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,458.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,074.95
Rate for Payer: Iowa Total Care Managed Medicaid	$2,633.80
Rate for Payer: Medical Associates Commercial	$3,458.25
Rate for Payer: Medical Associates Managed Medicare	$2,074.95
Rate for Payer: Midlands Choice Commercial	$3,227.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,672.54
Rate for Payer: Partners Health Alliance Commercial	$2,386.19
Rate for Payer: United Healthcare Commercial	$4,149.90
Rate for Payer: United Healthcare Managed Medicare	$2,720.49

PET w/ CT Scan Brain

Facility

$4,611.00

Service Code	CPT 78608
Hospital Charge Code	7960817
Hospital Revenue Code	404
Min. Negotiated Rate	$3,227.70
Max. Negotiated Rate	$4,149.90
Rate for Payer: Aetna of IA Commercial	$4,149.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,149.90
Rate for Payer: Cash Price	$3,688.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,458.25
Rate for Payer: Medical Associates Commercial	$3,458.25
Rate for Payer: Midlands Choice Commercial	$3,227.70
Rate for Payer: United Healthcare Commercial	$4,149.90

PET w/ CT Scan Skull Base to Midthigh

Facility

$4,611.00

Service Code	CPT 78815
Hospital Charge Code	1169558
Hospital Revenue Code	404
Min. Negotiated Rate	$2,074.95
Max. Negotiated Rate	$4,149.90
Rate for Payer: Aetna of IA Commercial	$4,149.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,149.90
Rate for Payer: Aetna of IA Medicare	$2,628.27
Rate for Payer: Amerigroup Medicaid	$2,659.62
Rate for Payer: Amerigroup Medicare	$2,095.70
Rate for Payer: Cash Price	$3,688.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,458.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,074.95
Rate for Payer: Iowa Total Care Managed Medicaid	$2,633.80
Rate for Payer: Medical Associates Commercial	$3,458.25
Rate for Payer: Medical Associates Managed Medicare	$2,074.95
Rate for Payer: Midlands Choice Commercial	$3,227.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,672.54
Rate for Payer: Partners Health Alliance Commercial	$2,386.19
Rate for Payer: United Healthcare Commercial	$4,149.90
Rate for Payer: United Healthcare Managed Medicare	$2,720.49

PET w/ CT Scan Skull Base to Midthigh

Facility

$4,611.00

Service Code	CPT 78815
Hospital Charge Code	1169558
Hospital Revenue Code	404
Min. Negotiated Rate	$3,227.70
Max. Negotiated Rate	$4,149.90
Rate for Payer: Aetna of IA Commercial	$4,149.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,149.90
Rate for Payer: Cash Price	$3,688.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,458.25
Rate for Payer: Medical Associates Commercial	$3,458.25
Rate for Payer: Midlands Choice Commercial	$3,227.70
Rate for Payer: United Healthcare Commercial	$4,149.90

PET w/ CT Scan Whole Body

Facility

$4,611.00

Service Code	CPT 78816
Hospital Charge Code	1169560
Hospital Revenue Code	404
Min. Negotiated Rate	$3,227.70
Max. Negotiated Rate	$4,149.90
Rate for Payer: Aetna of IA Commercial	$4,149.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,149.90
Rate for Payer: Cash Price	$3,688.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,458.25
Rate for Payer: Medical Associates Commercial	$3,458.25
Rate for Payer: Midlands Choice Commercial	$3,227.70
Rate for Payer: United Healthcare Commercial	$4,149.90

PET w/ CT Scan Whole Body

Facility

$4,611.00

Service Code	CPT 78816
Hospital Charge Code	1169560
Hospital Revenue Code	404
Min. Negotiated Rate	$2,074.95
Max. Negotiated Rate	$4,149.90
Rate for Payer: Aetna of IA Commercial	$4,149.90
Rate for Payer: Aetna of IA Medical Rental Products	$4,149.90
Rate for Payer: Aetna of IA Medicare	$2,628.27
Rate for Payer: Amerigroup Medicaid	$2,659.62
Rate for Payer: Amerigroup Medicare	$2,095.70
Rate for Payer: Cash Price	$3,688.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,458.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,074.95
Rate for Payer: Iowa Total Care Managed Medicaid	$2,633.80
Rate for Payer: Medical Associates Commercial	$3,458.25
Rate for Payer: Medical Associates Managed Medicare	$2,074.95
Rate for Payer: Midlands Choice Commercial	$3,227.70
Rate for Payer: Molina Healthcare Managed Medicaid	$2,672.54
Rate for Payer: Partners Health Alliance Commercial	$2,386.19
Rate for Payer: United Healthcare Commercial	$4,149.90
Rate for Payer: United Healthcare Managed Medicare	$2,720.49

Facility

$61.00

Service Code	CPT 83986
Hospital Charge Code	4022833
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

Facility

$61.00

Service Code	CPT 83986
Hospital Charge Code	4022833
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99

phenazopyridine 200 mg Tab [VDMC]

Facility

$1.73

Service Code	HCPCS A9270
Hospital Charge Code	10412604
Hospital Revenue Code	259
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.55
Rate for Payer: Aetna of IA Commercial	$1.55
Rate for Payer: Aetna of IA Medical Rental Products	$1.55
Rate for Payer: Cash Price	$1.38
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.30
Rate for Payer: Medical Associates Commercial	$1.30
Rate for Payer: Midlands Choice Commercial	$1.21
Rate for Payer: United Healthcare Commercial	$1.55

phenazopyridine 200 mg Tab [VDMC]

Facility

$1.73

Service Code	HCPCS A9270
Hospital Charge Code	10412604
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.55
Rate for Payer: Aetna of IA Commercial	$1.55
Rate for Payer: Aetna of IA Medical Rental Products	$1.55
Rate for Payer: Aetna of IA Medicare	$0.98
Rate for Payer: Amerigroup Medicaid	$1.00
Rate for Payer: Amerigroup Medicare	$0.79
Rate for Payer: Cash Price	$1.38
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.30
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.78
Rate for Payer: Iowa Total Care Managed Medicaid	$0.99
Rate for Payer: Medical Associates Commercial	$1.30
Rate for Payer: Medical Associates Managed Medicare	$0.78
Rate for Payer: Midlands Choice Commercial	$1.21
Rate for Payer: Molina Healthcare Managed Medicaid	$1.00
Rate for Payer: Partners Health Alliance Commercial	$0.89
Rate for Payer: United Healthcare Commercial	$1.55
Rate for Payer: United Healthcare Managed Medicare	$1.02

PHENobarbital 20 mg/5 mL Oral Elix [VDMC]

Facility

$3.78

Service Code	HCPCS A9270
Hospital Charge Code	10412820
Hospital Revenue Code	259
Min. Negotiated Rate	$2.64
Max. Negotiated Rate	$3.40
Rate for Payer: Aetna of IA Commercial	$3.40
Rate for Payer: Aetna of IA Medical Rental Products	$3.40
Rate for Payer: Cash Price	$3.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.83
Rate for Payer: Medical Associates Commercial	$2.83
Rate for Payer: Midlands Choice Commercial	$2.64
Rate for Payer: United Healthcare Commercial	$3.40

PHENobarbital 20 mg/5 mL Oral Elix [VDMC]

Facility

$3.78

Service Code	HCPCS A9270
Hospital Charge Code	10412820
Hospital Revenue Code	259
Min. Negotiated Rate	$1.70
Max. Negotiated Rate	$3.40
Rate for Payer: Aetna of IA Commercial	$3.40
Rate for Payer: Aetna of IA Medical Rental Products	$3.40
Rate for Payer: Aetna of IA Medicare	$2.15
Rate for Payer: Amerigroup Medicaid	$2.18
Rate for Payer: Amerigroup Medicare	$1.72
Rate for Payer: Cash Price	$3.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.70
Rate for Payer: Iowa Total Care Managed Medicaid	$2.16
Rate for Payer: Medical Associates Commercial	$2.83
Rate for Payer: Medical Associates Managed Medicare	$1.70
Rate for Payer: Midlands Choice Commercial	$2.64
Rate for Payer: Molina Healthcare Managed Medicaid	$2.19
Rate for Payer: Partners Health Alliance Commercial	$1.96
Rate for Payer: United Healthcare Commercial	$3.40
Rate for Payer: United Healthcare Managed Medicare	$2.23

PHENobarbital 32.4 mg Tab [VDMC]

Facility

$3.54

Service Code	HCPCS A9270
Hospital Charge Code	10609410
Hospital Revenue Code	259
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of IA Commercial	$3.18
Rate for Payer: Aetna of IA Medical Rental Products	$3.18
Rate for Payer: Cash Price	$2.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.65
Rate for Payer: Medical Associates Commercial	$2.65
Rate for Payer: Midlands Choice Commercial	$2.48
Rate for Payer: United Healthcare Commercial	$3.18

PHENobarbital 32.4 mg Tab [VDMC]

Facility

$3.54

Service Code	HCPCS A9270
Hospital Charge Code	10609410
Hospital Revenue Code	259
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$3.18
Rate for Payer: Aetna of IA Commercial	$3.18
Rate for Payer: Aetna of IA Medical Rental Products	$3.18
Rate for Payer: Aetna of IA Medicare	$2.02
Rate for Payer: Amerigroup Medicaid	$2.04
Rate for Payer: Amerigroup Medicare	$1.61
Rate for Payer: Cash Price	$2.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.65
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.59
Rate for Payer: Iowa Total Care Managed Medicaid	$2.02
Rate for Payer: Medical Associates Commercial	$2.65
Rate for Payer: Medical Associates Managed Medicare	$1.59
Rate for Payer: Midlands Choice Commercial	$2.48
Rate for Payer: Molina Healthcare Managed Medicaid	$2.05
Rate for Payer: Partners Health Alliance Commercial	$1.83
Rate for Payer: United Healthcare Commercial	$3.18
Rate for Payer: United Healthcare Managed Medicare	$2.09

PHENobarbital 65 mg/ml 1ml MDV Inj [VDMC]

Facility

$115.08

Service Code	HCPCS J2560
Hospital Charge Code	10412958
Hospital Revenue Code	259
Min. Negotiated Rate	$51.79
Max. Negotiated Rate	$103.57
Rate for Payer: Aetna of IA Commercial	$103.57
Rate for Payer: Aetna of IA Medical Rental Products	$103.57
Rate for Payer: Aetna of IA Medicare	$65.60
Rate for Payer: Amerigroup Medicaid	$66.38
Rate for Payer: Amerigroup Medicare	$52.30
Rate for Payer: Cash Price	$92.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.79
Rate for Payer: Iowa Total Care Managed Medicaid	$65.73
Rate for Payer: Medical Associates Commercial	$86.31
Rate for Payer: Medical Associates Managed Medicare	$51.79
Rate for Payer: Midlands Choice Commercial	$80.56
Rate for Payer: Molina Healthcare Managed Medicaid	$66.70
Rate for Payer: Partners Health Alliance Commercial	$59.55
Rate for Payer: United Healthcare Commercial	$103.57
Rate for Payer: United Healthcare Managed Medicare	$67.90

PHENobarbital 65 mg/ml 1ml MDV Inj [VDMC]

Facility

$115.08

Service Code	HCPCS J2560
Hospital Charge Code	10412958
Hospital Revenue Code	259
Min. Negotiated Rate	$80.56
Max. Negotiated Rate	$103.57
Rate for Payer: Aetna of IA Commercial	$103.57
Rate for Payer: Aetna of IA Medical Rental Products	$103.57
Rate for Payer: Cash Price	$92.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.31
Rate for Payer: Medical Associates Commercial	$86.31
Rate for Payer: Midlands Choice Commercial	$80.56
Rate for Payer: United Healthcare Commercial	$103.57

Phenobarbital Level DMCL

Facility

$94.00

Service Code	CPT 80184
Hospital Charge Code	8037752
Hospital Revenue Code	301
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of IA Commercial	$84.60
Rate for Payer: Aetna of IA Medical Rental Products	$84.60
Rate for Payer: Aetna of IA Medicare	$53.58
Rate for Payer: Amerigroup Medicaid	$54.22
Rate for Payer: Amerigroup Medicare	$42.72
Rate for Payer: Cash Price	$75.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$42.30
Rate for Payer: Iowa Total Care Managed Medicaid	$53.69
Rate for Payer: Medical Associates Commercial	$70.50
Rate for Payer: Medical Associates Managed Medicare	$42.30
Rate for Payer: Midlands Choice Commercial	$65.80
Rate for Payer: Molina Healthcare Managed Medicaid	$54.48
Rate for Payer: Partners Health Alliance Commercial	$48.65
Rate for Payer: United Healthcare Commercial	$84.60
Rate for Payer: United Healthcare Managed Medicare	$55.46

Phenobarbital Level DMCL

Facility

$94.00

Service Code	CPT 80184
Hospital Charge Code	8037752
Hospital Revenue Code	301
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of IA Commercial	$84.60
Rate for Payer: Aetna of IA Medical Rental Products	$84.60
Rate for Payer: Cash Price	$75.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.50
Rate for Payer: Medical Associates Commercial	$70.50
Rate for Payer: Midlands Choice Commercial	$65.80
Rate for Payer: United Healthcare Commercial	$84.60

phenol topical 1.4% Spray 177ml [VDMC]

Facility

$11.44

Service Code	HCPCS A9270
Hospital Charge Code	11222199
Hospital Revenue Code	259
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$10.30
Rate for Payer: Aetna of IA Commercial	$10.30
Rate for Payer: Aetna of IA Medical Rental Products	$10.30
Rate for Payer: Aetna of IA Medicare	$6.52
Rate for Payer: Amerigroup Medicaid	$6.60
Rate for Payer: Amerigroup Medicare	$5.20
Rate for Payer: Cash Price	$9.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.15
Rate for Payer: Iowa Total Care Managed Medicaid	$6.54
Rate for Payer: Medical Associates Commercial	$8.58
Rate for Payer: Medical Associates Managed Medicare	$5.15
Rate for Payer: Midlands Choice Commercial	$8.01
Rate for Payer: Molina Healthcare Managed Medicaid	$6.63
Rate for Payer: Partners Health Alliance Commercial	$5.92
Rate for Payer: United Healthcare Commercial	$10.30
Rate for Payer: United Healthcare Managed Medicare	$6.75

phenol topical 1.4% Spray 177ml [VDMC]

Facility

$11.44

Service Code	HCPCS A9270
Hospital Charge Code	11222199
Hospital Revenue Code	259
Min. Negotiated Rate	$8.01
Max. Negotiated Rate	$10.30
Rate for Payer: Aetna of IA Commercial	$10.30
Rate for Payer: Aetna of IA Medical Rental Products	$10.30
Rate for Payer: Cash Price	$9.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.58
Rate for Payer: Medical Associates Commercial	$8.58
Rate for Payer: Midlands Choice Commercial	$8.01
Rate for Payer: United Healthcare Commercial	$10.30

phenol topical 89% Swab[VDMC]

Facility

$28.01

Service Code	NDC 00884-6297-30
Hospital Charge Code	12535014
Hospital Revenue Code	259
Min. Negotiated Rate	$19.61
Max. Negotiated Rate	$25.21
Rate for Payer: Aetna of IA Commercial	$25.21
Rate for Payer: Aetna of IA Medical Rental Products	$25.21
Rate for Payer: Cash Price	$22.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.01
Rate for Payer: Medical Associates Commercial	$21.01
Rate for Payer: Midlands Choice Commercial	$19.61
Rate for Payer: United Healthcare Commercial	$25.21

phenol topical 89% Swab[VDMC]

Facility

$28.01

Service Code	NDC 00884-6297-30
Hospital Charge Code	12535014
Hospital Revenue Code	259
Min. Negotiated Rate	$12.61
Max. Negotiated Rate	$25.21
Rate for Payer: Aetna of IA Commercial	$25.21
Rate for Payer: Aetna of IA Medical Rental Products	$25.21
Rate for Payer: Aetna of IA Medicare	$15.97
Rate for Payer: Amerigroup Medicaid	$16.16
Rate for Payer: Amerigroup Medicare	$12.73
Rate for Payer: Cash Price	$22.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.01
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.61
Rate for Payer: Iowa Total Care Managed Medicaid	$16.00
Rate for Payer: Medical Associates Commercial	$21.01
Rate for Payer: Medical Associates Managed Medicare	$12.61
Rate for Payer: Midlands Choice Commercial	$19.61
Rate for Payer: Molina Healthcare Managed Medicaid	$16.24
Rate for Payer: Partners Health Alliance Commercial	$14.50
Rate for Payer: United Healthcare Commercial	$25.21
Rate for Payer: United Healthcare Managed Medicare	$16.53

phentermine 37.5 mg Cap [VDMC]

Facility

$3.37

Service Code	HCPCS A9270
Hospital Charge Code	22327406
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna of IA Commercial	$3.03
Rate for Payer: Aetna of IA Medical Rental Products	$3.03
Rate for Payer: Aetna of IA Medicare	$1.92
Rate for Payer: Amerigroup Medicaid	$1.94
Rate for Payer: Amerigroup Medicare	$1.53
Rate for Payer: Cash Price	$2.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.53
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.52
Rate for Payer: Iowa Total Care Managed Medicaid	$1.92
Rate for Payer: Medical Associates Commercial	$2.53
Rate for Payer: Medical Associates Managed Medicare	$1.52
Rate for Payer: Midlands Choice Commercial	$2.36
Rate for Payer: Molina Healthcare Managed Medicaid	$1.95
Rate for Payer: Partners Health Alliance Commercial	$1.74
Rate for Payer: United Healthcare Commercial	$3.03
Rate for Payer: United Healthcare Managed Medicare	$1.99

phentermine 37.5 mg Cap [VDMC]

Facility

$3.37

Service Code	HCPCS A9270
Hospital Charge Code	22327406
Hospital Revenue Code	259
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna of IA Commercial	$3.03
Rate for Payer: Aetna of IA Medical Rental Products	$3.03
Rate for Payer: Cash Price	$2.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.53
Rate for Payer: Medical Associates Commercial	$2.53
Rate for Payer: Midlands Choice Commercial	$2.36
Rate for Payer: United Healthcare Commercial	$3.03

Know your out-of-pocket cost for care.

All Charges