Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

phenol topical 1.4% Spray 177ml [VDMC]

Facility

$11.00

Service Code	HCPCS A9270
Hospital Charge Code	11222199
Hospital Revenue Code	259
Min. Negotiated Rate	$7.70
Max. Negotiated Rate	$9.90
Rate for Payer: Aetna of IA Commercial	$9.90
Rate for Payer: Aetna of IA Medical Rental Products	$9.90
Rate for Payer: Cash Price	$8.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.25
Rate for Payer: Medical Associates Commercial	$8.25
Rate for Payer: Midlands Choice Commercial	$7.70
Rate for Payer: United Healthcare Commercial	$9.90

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	$14.00
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	$14.14
Rate for Payer: Amerigroup Medicare	$14.15
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	$14.00
Rate for Payer: Iowa Total Care Managed Medicaid	$14.00
Rate for Payer: Medical Associates Commercial	$21.01
Rate for Payer: Medical Associates Managed Medicare	$14.00
Rate for Payer: Midlands Choice Commercial	$19.61
Rate for Payer: Molina Healthcare Managed Medicaid	$14.22
Rate for Payer: Molina Healthcare Managed Medicare	$14.21
Rate for Payer: Oscar Health of IA Commercial	$21.01
Rate for Payer: Partners Health Alliance Commercial	$21.01
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	$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

phentermine 37.5 mg Cap [VDMC]

Facility

$3.37

Service Code	HCPCS A9270
Hospital Charge Code	22327406
Hospital Revenue Code	259
Min. Negotiated Rate	$1.68
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	$1.70
Rate for Payer: Amerigroup Medicare	$1.70
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	$1.68
Rate for Payer: Iowa Total Care Managed Medicaid	$1.68
Rate for Payer: Medical Associates Commercial	$2.53
Rate for Payer: Medical Associates Managed Medicare	$1.68
Rate for Payer: Midlands Choice Commercial	$2.36
Rate for Payer: Molina Healthcare Managed Medicaid	$1.71
Rate for Payer: Molina Healthcare Managed Medicare	$1.71
Rate for Payer: Oscar Health of IA Commercial	$2.53
Rate for Payer: Partners Health Alliance Commercial	$2.53
Rate for Payer: United Healthcare Commercial	$3.03
Rate for Payer: United Healthcare Managed Medicare	$1.99

phenylephrine 10 mg/mL 1ml SDV Inj [VDMC]

Facility

$27.58

Service Code	HCPCS J2371
Hospital Charge Code	10413096
Hospital Revenue Code	259
Min. Negotiated Rate	$13.78
Max. Negotiated Rate	$24.82
Rate for Payer: Aetna of IA Commercial	$24.82
Rate for Payer: Aetna of IA Medical Rental Products	$24.82
Rate for Payer: Aetna of IA Medicare	$15.72
Rate for Payer: Amerigroup Medicaid	$13.92
Rate for Payer: Amerigroup Medicare	$13.93
Rate for Payer: Cash Price	$22.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.79
Rate for Payer: Iowa Total Care Managed Medicaid	$13.78
Rate for Payer: Medical Associates Commercial	$20.68
Rate for Payer: Medical Associates Managed Medicare	$13.79
Rate for Payer: Midlands Choice Commercial	$19.31
Rate for Payer: Molina Healthcare Managed Medicaid	$14.00
Rate for Payer: Molina Healthcare Managed Medicare	$13.99
Rate for Payer: Oscar Health of IA Commercial	$20.68
Rate for Payer: Partners Health Alliance Commercial	$20.68
Rate for Payer: United Healthcare Commercial	$24.82
Rate for Payer: United Healthcare Managed Medicare	$16.27

phenylephrine 10 mg/mL 1ml SDV Inj [VDMC]

Facility

$27.58

Service Code	HCPCS J2371
Hospital Charge Code	10413096
Hospital Revenue Code	259
Min. Negotiated Rate	$19.31
Max. Negotiated Rate	$24.82
Rate for Payer: Aetna of IA Commercial	$24.82
Rate for Payer: Aetna of IA Medical Rental Products	$24.82
Rate for Payer: Cash Price	$22.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.68
Rate for Payer: Medical Associates Commercial	$20.68
Rate for Payer: Midlands Choice Commercial	$19.31
Rate for Payer: United Healthcare Commercial	$24.82

phenylephrine Nasal 0.5% Spry [VDMC]

Facility

$28.08

Service Code	HCPCS A9270
Hospital Charge Code	10436776
Hospital Revenue Code	259
Min. Negotiated Rate	$19.66
Max. Negotiated Rate	$25.27
Rate for Payer: Aetna of IA Commercial	$25.27
Rate for Payer: Aetna of IA Medical Rental Products	$25.27
Rate for Payer: Cash Price	$22.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.06
Rate for Payer: Medical Associates Commercial	$21.06
Rate for Payer: Midlands Choice Commercial	$19.66
Rate for Payer: United Healthcare Commercial	$25.27

phenylephrine Nasal 0.5% Spry [VDMC]

Facility

$28.08

Service Code	HCPCS A9270
Hospital Charge Code	10436776
Hospital Revenue Code	259
Min. Negotiated Rate	$14.03
Max. Negotiated Rate	$25.27
Rate for Payer: Aetna of IA Commercial	$25.27
Rate for Payer: Aetna of IA Medical Rental Products	$25.27
Rate for Payer: Aetna of IA Medicare	$16.01
Rate for Payer: Amerigroup Medicaid	$14.17
Rate for Payer: Amerigroup Medicare	$14.18
Rate for Payer: Cash Price	$22.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.06
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.04
Rate for Payer: Iowa Total Care Managed Medicaid	$14.03
Rate for Payer: Medical Associates Commercial	$21.06
Rate for Payer: Medical Associates Managed Medicare	$14.04
Rate for Payer: Midlands Choice Commercial	$19.66
Rate for Payer: Molina Healthcare Managed Medicaid	$14.25
Rate for Payer: Molina Healthcare Managed Medicare	$14.24
Rate for Payer: Oscar Health of IA Commercial	$21.06
Rate for Payer: Partners Health Alliance Commercial	$21.06
Rate for Payer: United Healthcare Commercial	$25.27
Rate for Payer: United Healthcare Managed Medicare	$16.57

phenylephrine ophthalmic 2.5% 2 ml SDV [VDMC]

Facility

$134.60

Service Code	NDC 70756-0629-25
Hospital Charge Code	11613338
Hospital Revenue Code	259
Min. Negotiated Rate	$94.22
Max. Negotiated Rate	$121.14
Rate for Payer: Aetna of IA Commercial	$121.14
Rate for Payer: Aetna of IA Medical Rental Products	$121.14
Rate for Payer: Cash Price	$107.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.95
Rate for Payer: Medical Associates Commercial	$100.95
Rate for Payer: Midlands Choice Commercial	$94.22
Rate for Payer: United Healthcare Commercial	$121.14

phenylephrine ophthalmic 2.5% 2 ml SDV [VDMC]

Facility

$134.60

Service Code	NDC 70756-0629-25
Hospital Charge Code	11613338
Hospital Revenue Code	259
Min. Negotiated Rate	$67.27
Max. Negotiated Rate	$121.14
Rate for Payer: Aetna of IA Commercial	$121.14
Rate for Payer: Aetna of IA Medical Rental Products	$121.14
Rate for Payer: Aetna of IA Medicare	$76.72
Rate for Payer: Amerigroup Medicaid	$67.93
Rate for Payer: Amerigroup Medicare	$67.97
Rate for Payer: Cash Price	$107.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.30
Rate for Payer: Iowa Total Care Managed Medicaid	$67.27
Rate for Payer: Medical Associates Commercial	$100.95
Rate for Payer: Medical Associates Managed Medicare	$67.30
Rate for Payer: Midlands Choice Commercial	$94.22
Rate for Payer: Molina Healthcare Managed Medicaid	$68.31
Rate for Payer: Molina Healthcare Managed Medicare	$68.27
Rate for Payer: Oscar Health of IA Commercial	$100.95
Rate for Payer: Partners Health Alliance Commercial	$100.95
Rate for Payer: United Healthcare Commercial	$121.14
Rate for Payer: United Healthcare Managed Medicare	$79.41

phenytoin 100 mg/4 ml Oral Susp [VDMC]

Facility

$14.00

Service Code	HCPCS A9270
Hospital Charge Code	10432102
Hospital Revenue Code	259
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of IA Commercial	$12.60
Rate for Payer: Aetna of IA Medical Rental Products	$12.60
Rate for Payer: Aetna of IA Medicare	$7.98
Rate for Payer: Amerigroup Medicaid	$7.07
Rate for Payer: Amerigroup Medicare	$7.07
Rate for Payer: Cash Price	$11.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7.00
Rate for Payer: Medical Associates Commercial	$10.50
Rate for Payer: Medical Associates Managed Medicare	$7.00
Rate for Payer: Midlands Choice Commercial	$9.80
Rate for Payer: Molina Healthcare Managed Medicaid	$7.10
Rate for Payer: Molina Healthcare Managed Medicare	$7.10
Rate for Payer: Oscar Health of IA Commercial	$10.50
Rate for Payer: Partners Health Alliance Commercial	$10.50
Rate for Payer: United Healthcare Commercial	$12.60
Rate for Payer: United Healthcare Managed Medicare	$8.26

phenytoin 100 mg/4 ml Oral Susp [VDMC]

Facility

$14.00

Service Code	HCPCS A9270
Hospital Charge Code	10432102
Hospital Revenue Code	259
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$12.60
Rate for Payer: Aetna of IA Commercial	$12.60
Rate for Payer: Aetna of IA Medical Rental Products	$12.60
Rate for Payer: Cash Price	$11.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.50
Rate for Payer: Medical Associates Commercial	$10.50
Rate for Payer: Midlands Choice Commercial	$9.80
Rate for Payer: United Healthcare Commercial	$12.60

phenytoin 100 mg ER Cap [VDMC]

Facility

$2.25

Service Code	HCPCS A9270
Hospital Charge Code	10413165
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of IA Commercial	$2.02
Rate for Payer: Aetna of IA Medical Rental Products	$2.02
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.69
Rate for Payer: Medical Associates Commercial	$1.69
Rate for Payer: Midlands Choice Commercial	$1.58
Rate for Payer: United Healthcare Commercial	$2.02

phenytoin 100 mg ER Cap [VDMC]

Facility

$2.25

Service Code	HCPCS A9270
Hospital Charge Code	10413165
Hospital Revenue Code	259
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of IA Commercial	$2.02
Rate for Payer: Aetna of IA Medical Rental Products	$2.02
Rate for Payer: Aetna of IA Medicare	$1.28
Rate for Payer: Amerigroup Medicaid	$1.14
Rate for Payer: Amerigroup Medicare	$1.14
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.69
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.12
Rate for Payer: Iowa Total Care Managed Medicaid	$1.12
Rate for Payer: Medical Associates Commercial	$1.69
Rate for Payer: Medical Associates Managed Medicare	$1.12
Rate for Payer: Midlands Choice Commercial	$1.58
Rate for Payer: Molina Healthcare Managed Medicaid	$1.14
Rate for Payer: Molina Healthcare Managed Medicare	$1.14
Rate for Payer: Oscar Health of IA Commercial	$1.69
Rate for Payer: Partners Health Alliance Commercial	$1.69
Rate for Payer: United Healthcare Commercial	$2.02
Rate for Payer: United Healthcare Managed Medicare	$1.33

phenytoin 125 mg/5 mL Oral Susp [VDMC]

Facility

$110.88

Service Code	HCPCS A9270
Hospital Charge Code	10413236
Hospital Revenue Code	259
Min. Negotiated Rate	$77.62
Max. Negotiated Rate	$99.79
Rate for Payer: Aetna of IA Commercial	$99.79
Rate for Payer: Aetna of IA Medical Rental Products	$99.79
Rate for Payer: Cash Price	$88.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.16
Rate for Payer: Medical Associates Commercial	$83.16
Rate for Payer: Midlands Choice Commercial	$77.62
Rate for Payer: United Healthcare Commercial	$99.79

phenytoin 125 mg/5 mL Oral Susp [VDMC]

Facility

$110.88

Service Code	HCPCS A9270
Hospital Charge Code	10413236
Hospital Revenue Code	259
Min. Negotiated Rate	$55.42
Max. Negotiated Rate	$99.79
Rate for Payer: Aetna of IA Commercial	$99.79
Rate for Payer: Aetna of IA Medical Rental Products	$99.79
Rate for Payer: Aetna of IA Medicare	$63.20
Rate for Payer: Amerigroup Medicaid	$55.96
Rate for Payer: Amerigroup Medicare	$55.99
Rate for Payer: Cash Price	$88.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.44
Rate for Payer: Iowa Total Care Managed Medicaid	$55.42
Rate for Payer: Medical Associates Commercial	$83.16
Rate for Payer: Medical Associates Managed Medicare	$55.44
Rate for Payer: Midlands Choice Commercial	$77.62
Rate for Payer: Molina Healthcare Managed Medicaid	$56.27
Rate for Payer: Molina Healthcare Managed Medicare	$56.24
Rate for Payer: Oscar Health of IA Commercial	$83.16
Rate for Payer: Partners Health Alliance Commercial	$83.16
Rate for Payer: United Healthcare Commercial	$99.79
Rate for Payer: United Healthcare Managed Medicare	$65.42

phenytoin 50 mg/mL 2 ml SDV Inj Sol [VDMC]

Facility

$24.58

Service Code	HCPCS J1165
Hospital Charge Code	24854394
Hospital Revenue Code	259
Min. Negotiated Rate	$17.21
Max. Negotiated Rate	$22.12
Rate for Payer: Aetna of IA Commercial	$22.12
Rate for Payer: Aetna of IA Medical Rental Products	$22.12
Rate for Payer: Cash Price	$19.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.44
Rate for Payer: Medical Associates Commercial	$18.44
Rate for Payer: Midlands Choice Commercial	$17.21
Rate for Payer: United Healthcare Commercial	$22.12

phenytoin 50 mg/mL 2 ml SDV Inj Sol [VDMC]

Facility

$24.58

Service Code	HCPCS J1165
Hospital Charge Code	24854394
Hospital Revenue Code	259
Min. Negotiated Rate	$12.29
Max. Negotiated Rate	$22.12
Rate for Payer: Aetna of IA Commercial	$22.12
Rate for Payer: Aetna of IA Medical Rental Products	$22.12
Rate for Payer: Aetna of IA Medicare	$14.01
Rate for Payer: Amerigroup Medicaid	$12.41
Rate for Payer: Amerigroup Medicare	$12.41
Rate for Payer: Cash Price	$19.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.44
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.29
Rate for Payer: Iowa Total Care Managed Medicaid	$12.29
Rate for Payer: Medical Associates Commercial	$18.44
Rate for Payer: Medical Associates Managed Medicare	$12.29
Rate for Payer: Midlands Choice Commercial	$17.21
Rate for Payer: Molina Healthcare Managed Medicaid	$12.47
Rate for Payer: Molina Healthcare Managed Medicare	$12.47
Rate for Payer: Oscar Health of IA Commercial	$18.44
Rate for Payer: Partners Health Alliance Commercial	$18.44
Rate for Payer: United Healthcare Commercial	$22.12
Rate for Payer: United Healthcare Managed Medicare	$14.50

phenytoin 50 mg/mL 5 ml SDV Inj Sol [VDMC]

Facility

$26.60

Service Code	HCPCS J1165
Hospital Charge Code	10432165
Hospital Revenue Code	259
Min. Negotiated Rate	$13.29
Max. Negotiated Rate	$23.94
Rate for Payer: Aetna of IA Commercial	$23.94
Rate for Payer: Aetna of IA Medical Rental Products	$23.94
Rate for Payer: Aetna of IA Medicare	$15.16
Rate for Payer: Amerigroup Medicaid	$13.43
Rate for Payer: Amerigroup Medicare	$13.43
Rate for Payer: Cash Price	$21.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.30
Rate for Payer: Iowa Total Care Managed Medicaid	$13.29
Rate for Payer: Medical Associates Commercial	$19.95
Rate for Payer: Medical Associates Managed Medicare	$13.30
Rate for Payer: Midlands Choice Commercial	$18.62
Rate for Payer: Molina Healthcare Managed Medicaid	$13.50
Rate for Payer: Molina Healthcare Managed Medicare	$13.49
Rate for Payer: Oscar Health of IA Commercial	$19.95
Rate for Payer: Partners Health Alliance Commercial	$19.95
Rate for Payer: United Healthcare Commercial	$23.94
Rate for Payer: United Healthcare Managed Medicare	$15.69

phenytoin 50 mg/mL 5 ml SDV Inj Sol [VDMC]

Facility

$26.60

Service Code	HCPCS J1165
Hospital Charge Code	10432165
Hospital Revenue Code	259
Min. Negotiated Rate	$18.62
Max. Negotiated Rate	$23.94
Rate for Payer: Aetna of IA Commercial	$23.94
Rate for Payer: Aetna of IA Medical Rental Products	$23.94
Rate for Payer: Cash Price	$21.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.95
Rate for Payer: Medical Associates Commercial	$19.95
Rate for Payer: Midlands Choice Commercial	$18.62
Rate for Payer: United Healthcare Commercial	$23.94

Phenytoin DMCL

Facility

$131.00

Service Code	CPT 80185
Hospital Charge Code	8037753
Hospital Revenue Code	301
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of IA Commercial	$117.90
Rate for Payer: Aetna of IA Medical Rental Products	$117.90
Rate for Payer: Cash Price	$104.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.25
Rate for Payer: Medical Associates Commercial	$98.25
Rate for Payer: Midlands Choice Commercial	$91.70
Rate for Payer: United Healthcare Commercial	$117.90

Phenytoin DMCL

Facility

$131.00

Service Code	CPT 80185
Hospital Charge Code	8037753
Hospital Revenue Code	301
Min. Negotiated Rate	$49.60
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of IA Commercial	$117.90
Rate for Payer: Aetna of IA Medical Rental Products	$117.90
Rate for Payer: Aetna of IA Medicare	$74.67
Rate for Payer: Amerigroup Medicaid	$66.12
Rate for Payer: Amerigroup Medicare	$66.16
Rate for Payer: Cash Price	$104.80
Rate for Payer: Cash Price	$104.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.50
Rate for Payer: Iowa Total Care Managed Medicaid	$65.47
Rate for Payer: Medical Associates Commercial	$98.25
Rate for Payer: Medical Associates Managed Medicare	$65.50
Rate for Payer: Midlands Choice Commercial	$91.70
Rate for Payer: Molina Healthcare Managed Medicaid	$66.48
Rate for Payer: Molina Healthcare Managed Medicare	$66.44
Rate for Payer: Oscar Health of IA Commercial	$98.25
Rate for Payer: Partners Health Alliance Commercial	$98.25
Rate for Payer: United Healthcare Commercial	$117.90
Rate for Payer: United Healthcare Managed Medicare	$77.29
Rate for Payer: Wellmark IA HMO	$49.60
Rate for Payer: Wellmark IA PPO	$54.56

PHLEBOTOMY, SCHEDULED

Facility

$222.00

Service Code	CPT 99195
Hospital Charge Code	8012944
Hospital Revenue Code	949
Min. Negotiated Rate	$155.40
Max. Negotiated Rate	$199.80
Rate for Payer: Aetna of IA Commercial	$199.80
Rate for Payer: Aetna of IA Medical Rental Products	$199.80
Rate for Payer: Cash Price	$177.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$166.50
Rate for Payer: Medical Associates Commercial	$166.50
Rate for Payer: Midlands Choice Commercial	$155.40
Rate for Payer: United Healthcare Commercial	$199.80

PHLEBOTOMY, SCHEDULED

Facility

$222.00

Service Code	CPT 99195
Hospital Charge Code	8012944
Hospital Revenue Code	949
Min. Negotiated Rate	$110.96
Max. Negotiated Rate	$387.38
Rate for Payer: Aetna of IA Commercial	$199.80
Rate for Payer: Aetna of IA Medical Rental Products	$199.80
Rate for Payer: Aetna of IA Medicare	$126.54
Rate for Payer: Amerigroup Medicaid	$112.04
Rate for Payer: Amerigroup Medicare	$112.11
Rate for Payer: Cash Price	$177.60
Rate for Payer: Cash Price	$177.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$166.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$111.00
Rate for Payer: Iowa Total Care Managed Medicaid	$110.96
Rate for Payer: Medical Associates Commercial	$166.50
Rate for Payer: Medical Associates Managed Medicare	$111.00
Rate for Payer: Midlands Choice Commercial	$155.40
Rate for Payer: Molina Healthcare Managed Medicaid	$112.66
Rate for Payer: Molina Healthcare Managed Medicare	$112.60
Rate for Payer: Oscar Health of IA Commercial	$166.50
Rate for Payer: Partners Health Alliance Commercial	$166.50
Rate for Payer: United Healthcare Commercial	$199.80
Rate for Payer: United Healthcare Managed Medicare	$130.98
Rate for Payer: Wellmark IA HMO	$352.16
Rate for Payer: Wellmark IA PPO	$387.38

Know your out-of-pocket cost for care.

All Charges