Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ACETABULAR SHELL SYSTEM-56F

Facility

$4,358.00

Service Code	HCPCS L8699
Hospital Charge Code	8046818
Hospital Revenue Code	278
Min. Negotiated Rate	$3,050.60
Max. Negotiated Rate	$3,922.20
Rate for Payer: Aetna of IA Commercial	$3,922.20
Rate for Payer: Aetna of IA Medical Rental Products	$3,922.20
Rate for Payer: Cash Price	$3,486.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,268.50
Rate for Payer: Medical Associates Commercial	$3,268.50
Rate for Payer: Midlands Choice Commercial	$3,050.60
Rate for Payer: United Healthcare Commercial	$3,922.20

ACETAMINOPHEN

Facility

$147.00

Service Code	HCPCS G0480
Hospital Charge Code	1503764
Hospital Revenue Code	301
Min. Negotiated Rate	$102.90
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: United Healthcare Commercial	$132.30

ACETAMINOPHEN

Facility

$147.00

Service Code	HCPCS G0480
Hospital Charge Code	1503764
Hospital Revenue Code	301
Min. Negotiated Rate	$66.15
Max. Negotiated Rate	$132.30
Rate for Payer: Aetna of IA Commercial	$132.30
Rate for Payer: Aetna of IA Medical Rental Products	$132.30
Rate for Payer: Aetna of IA Medicare	$83.79
Rate for Payer: Amerigroup Medicaid	$84.79
Rate for Payer: Amerigroup Medicare	$66.81
Rate for Payer: Cash Price	$117.60
Rate for Payer: Cash Price	$117.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$66.15
Rate for Payer: Iowa Total Care Managed Medicaid	$83.97
Rate for Payer: Medical Associates Commercial	$110.25
Rate for Payer: Medical Associates Managed Medicare	$66.15
Rate for Payer: Midlands Choice Commercial	$102.90
Rate for Payer: Molina Healthcare Managed Medicaid	$85.20
Rate for Payer: Partners Health Alliance Commercial	$76.07
Rate for Payer: United Healthcare Commercial	$132.30
Rate for Payer: United Healthcare Managed Medicare	$86.73
Rate for Payer: Wellmark IA HMO WHPI	$117.69
Rate for Payer: Wellmark IA PPO	$129.65

acetaminophen 10 mg/mL 100 ml vial SDV [VDMC]

Facility

$34.78

Service Code	HCPCS J0131
Hospital Charge Code	10362412
Hospital Revenue Code	259
Min. Negotiated Rate	$15.65
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$31.31
Rate for Payer: Aetna of IA Medical Rental Products	$31.31
Rate for Payer: Aetna of IA Medicare	$19.83
Rate for Payer: Amerigroup Medicaid	$20.06
Rate for Payer: Amerigroup Medicare	$15.81
Rate for Payer: Cash Price	$27.83
Rate for Payer: Cash Price	$27.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.09
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.65
Rate for Payer: Iowa Total Care Managed Medicaid	$19.87
Rate for Payer: Medical Associates Commercial	$26.09
Rate for Payer: Medical Associates Managed Medicare	$15.65
Rate for Payer: Midlands Choice Commercial	$24.35
Rate for Payer: Molina Healthcare Managed Medicaid	$20.16
Rate for Payer: Partners Health Alliance Commercial	$18.00
Rate for Payer: United Healthcare Commercial	$31.31
Rate for Payer: United Healthcare Managed Medicare	$20.52
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

acetaminophen 10 mg/mL 100 ml vial SDV [VDMC]

Facility

$34.78

Service Code	HCPCS J0131
Hospital Charge Code	10362412
Hospital Revenue Code	259
Min. Negotiated Rate	$24.35
Max. Negotiated Rate	$31.31
Rate for Payer: Aetna of IA Commercial	$31.31
Rate for Payer: Aetna of IA Medical Rental Products	$31.31
Rate for Payer: Cash Price	$27.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.09
Rate for Payer: Medical Associates Commercial	$26.09
Rate for Payer: Midlands Choice Commercial	$24.35
Rate for Payer: United Healthcare Commercial	$31.31

acetaminophen 120 mg Ped Supp [VDMC]

Facility

$3.64

Service Code	NDC 45802-0732-30
Hospital Charge Code	11223780
Hospital Revenue Code	259
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$3.28
Rate for Payer: Aetna of IA Commercial	$3.28
Rate for Payer: Aetna of IA Medical Rental Products	$3.28
Rate for Payer: Cash Price	$2.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.73
Rate for Payer: Medical Associates Commercial	$2.73
Rate for Payer: Midlands Choice Commercial	$2.55
Rate for Payer: United Healthcare Commercial	$3.28

acetaminophen 120 mg Ped Supp [VDMC]

Facility

$3.64

Service Code	NDC 45802-0732-30
Hospital Charge Code	11223780
Hospital Revenue Code	259
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$3.28
Rate for Payer: Aetna of IA Commercial	$3.28
Rate for Payer: Aetna of IA Medical Rental Products	$3.28
Rate for Payer: Aetna of IA Medicare	$2.08
Rate for Payer: Amerigroup Medicaid	$2.10
Rate for Payer: Amerigroup Medicare	$1.66
Rate for Payer: Cash Price	$2.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.64
Rate for Payer: Iowa Total Care Managed Medicaid	$2.08
Rate for Payer: Medical Associates Commercial	$2.73
Rate for Payer: Medical Associates Managed Medicare	$1.64
Rate for Payer: Midlands Choice Commercial	$2.55
Rate for Payer: Molina Healthcare Managed Medicaid	$2.11
Rate for Payer: Partners Health Alliance Commercial	$1.89
Rate for Payer: United Healthcare Commercial	$3.28
Rate for Payer: United Healthcare Managed Medicare	$2.15

acetaminophen 160 mg/5 mL 118ml Sus[VDMC]

Facility

$14.56

Service Code	NDC 45802-0201-26
Hospital Charge Code	13997492
Hospital Revenue Code	259
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$13.11
Rate for Payer: Aetna of IA Commercial	$13.11
Rate for Payer: Aetna of IA Medical Rental Products	$13.11
Rate for Payer: Cash Price	$11.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.92
Rate for Payer: Medical Associates Commercial	$10.92
Rate for Payer: Midlands Choice Commercial	$10.19
Rate for Payer: United Healthcare Commercial	$13.11

acetaminophen 160 mg/5 mL 118ml Sus[VDMC]

Facility

$14.56

Service Code	NDC 45802-0201-26
Hospital Charge Code	13997492
Hospital Revenue Code	259
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$13.11
Rate for Payer: Aetna of IA Commercial	$13.11
Rate for Payer: Aetna of IA Medical Rental Products	$13.11
Rate for Payer: Aetna of IA Medicare	$8.30
Rate for Payer: Amerigroup Medicaid	$8.40
Rate for Payer: Amerigroup Medicare	$6.62
Rate for Payer: Cash Price	$11.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.55
Rate for Payer: Iowa Total Care Managed Medicaid	$8.32
Rate for Payer: Medical Associates Commercial	$10.92
Rate for Payer: Medical Associates Managed Medicare	$6.55
Rate for Payer: Midlands Choice Commercial	$10.19
Rate for Payer: Molina Healthcare Managed Medicaid	$8.44
Rate for Payer: Partners Health Alliance Commercial	$7.54
Rate for Payer: United Healthcare Commercial	$13.11
Rate for Payer: United Healthcare Managed Medicare	$8.59

acetaminophen 160 mg/5 mL 5ml cup Sus UD [VDMC]

Facility

$3.99

Service Code	HCPCS A9270
Hospital Charge Code	14931415
Hospital Revenue Code	259
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$3.59
Rate for Payer: Aetna of IA Commercial	$3.59
Rate for Payer: Aetna of IA Medical Rental Products	$3.59
Rate for Payer: Cash Price	$3.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.99
Rate for Payer: Medical Associates Commercial	$2.99
Rate for Payer: Midlands Choice Commercial	$2.79
Rate for Payer: United Healthcare Commercial	$3.59

acetaminophen 160 mg/5 mL 5ml cup Sus UD [VDMC]

Facility

$3.99

Service Code	HCPCS A9270
Hospital Charge Code	14931415
Hospital Revenue Code	259
Min. Negotiated Rate	$1.80
Max. Negotiated Rate	$3.59
Rate for Payer: Aetna of IA Commercial	$3.59
Rate for Payer: Aetna of IA Medical Rental Products	$3.59
Rate for Payer: Aetna of IA Medicare	$2.27
Rate for Payer: Amerigroup Medicaid	$2.30
Rate for Payer: Amerigroup Medicare	$1.81
Rate for Payer: Cash Price	$3.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.99
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.80
Rate for Payer: Iowa Total Care Managed Medicaid	$2.28
Rate for Payer: Medical Associates Commercial	$2.99
Rate for Payer: Medical Associates Managed Medicare	$1.80
Rate for Payer: Midlands Choice Commercial	$2.79
Rate for Payer: Molina Healthcare Managed Medicaid	$2.31
Rate for Payer: Partners Health Alliance Commercial	$2.07
Rate for Payer: United Healthcare Commercial	$3.59
Rate for Payer: United Healthcare Managed Medicare	$2.35

acetaminophen 325 mg Supp [VDMC]

Facility

$6.02

Service Code	HCPCS A9270
Hospital Charge Code	11223821
Hospital Revenue Code	259
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$5.42
Rate for Payer: Aetna of IA Commercial	$5.42
Rate for Payer: Aetna of IA Medical Rental Products	$5.42
Rate for Payer: Aetna of IA Medicare	$3.43
Rate for Payer: Amerigroup Medicaid	$3.47
Rate for Payer: Amerigroup Medicare	$2.74
Rate for Payer: Cash Price	$4.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.52
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.71
Rate for Payer: Iowa Total Care Managed Medicaid	$3.44
Rate for Payer: Medical Associates Commercial	$4.52
Rate for Payer: Medical Associates Managed Medicare	$2.71
Rate for Payer: Midlands Choice Commercial	$4.21
Rate for Payer: Molina Healthcare Managed Medicaid	$3.49
Rate for Payer: Partners Health Alliance Commercial	$3.12
Rate for Payer: United Healthcare Commercial	$5.42
Rate for Payer: United Healthcare Managed Medicare	$3.55

acetaminophen 325 mg Supp [VDMC]

Facility

$6.02

Service Code	HCPCS A9270
Hospital Charge Code	11223821
Hospital Revenue Code	259
Min. Negotiated Rate	$4.21
Max. Negotiated Rate	$5.42
Rate for Payer: Aetna of IA Commercial	$5.42
Rate for Payer: Aetna of IA Medical Rental Products	$5.42
Rate for Payer: Cash Price	$4.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.52
Rate for Payer: Medical Associates Commercial	$4.52
Rate for Payer: Midlands Choice Commercial	$4.21
Rate for Payer: United Healthcare Commercial	$5.42

acetaminophen 650 mg Sup [VDMC]

Facility

$3.92

Service Code	HCPCS A9270
Hospital Charge Code	11223865
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.52
Rate for Payer: Aetna of IA Commercial	$3.52
Rate for Payer: Aetna of IA Medical Rental Products	$3.52
Rate for Payer: Cash Price	$3.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.94
Rate for Payer: Medical Associates Commercial	$2.94
Rate for Payer: Midlands Choice Commercial	$2.74
Rate for Payer: United Healthcare Commercial	$3.52

acetaminophen 650 mg Sup [VDMC]

Facility

$3.92

Service Code	HCPCS A9270
Hospital Charge Code	11223865
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$3.52
Rate for Payer: Aetna of IA Commercial	$3.52
Rate for Payer: Aetna of IA Medical Rental Products	$3.52
Rate for Payer: Aetna of IA Medicare	$2.23
Rate for Payer: Amerigroup Medicaid	$2.26
Rate for Payer: Amerigroup Medicare	$1.78
Rate for Payer: Cash Price	$3.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.76
Rate for Payer: Iowa Total Care Managed Medicaid	$2.24
Rate for Payer: Medical Associates Commercial	$2.94
Rate for Payer: Medical Associates Managed Medicare	$1.76
Rate for Payer: Midlands Choice Commercial	$2.74
Rate for Payer: Molina Healthcare Managed Medicaid	$2.27
Rate for Payer: Partners Health Alliance Commercial	$2.03
Rate for Payer: United Healthcare Commercial	$3.52
Rate for Payer: United Healthcare Managed Medicare	$2.31

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 5 mL [VDMC]

Facility

$3.43

Service Code	HCPCS A9270
Hospital Charge Code	10362903
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna of IA Commercial	$3.09
Rate for Payer: Aetna of IA Medical Rental Products	$3.09
Rate for Payer: Aetna of IA Medicare	$1.96
Rate for Payer: Amerigroup Medicaid	$1.98
Rate for Payer: Amerigroup Medicare	$1.56
Rate for Payer: Cash Price	$2.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.54
Rate for Payer: Iowa Total Care Managed Medicaid	$1.96
Rate for Payer: Medical Associates Commercial	$2.57
Rate for Payer: Medical Associates Managed Medicare	$1.54
Rate for Payer: Midlands Choice Commercial	$2.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.99
Rate for Payer: Partners Health Alliance Commercial	$1.78
Rate for Payer: United Healthcare Commercial	$3.09
Rate for Payer: United Healthcare Managed Medicare	$2.02

acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 5 mL [VDMC]

Facility

$3.43

Service Code	HCPCS A9270
Hospital Charge Code	10362903
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.09
Rate for Payer: Aetna of IA Commercial	$3.09
Rate for Payer: Aetna of IA Medical Rental Products	$3.09
Rate for Payer: Cash Price	$2.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.57
Rate for Payer: Medical Associates Commercial	$2.57
Rate for Payer: Midlands Choice Commercial	$2.40
Rate for Payer: United Healthcare Commercial	$3.09

acetaminophen-codeine 300 mg-30 mg Tab UD[VDMC]

Facility

$3.90

Service Code	HCPCS A9270
Hospital Charge Code	11225033
Hospital Revenue Code	259
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of IA Commercial	$3.51
Rate for Payer: Aetna of IA Medical Rental Products	$3.51
Rate for Payer: Cash Price	$3.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.92
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Midlands Choice Commercial	$2.73
Rate for Payer: United Healthcare Commercial	$3.51

acetaminophen-codeine 300 mg-30 mg Tab UD[VDMC]

Facility

$3.90

Service Code	HCPCS A9270
Hospital Charge Code	11225033
Hospital Revenue Code	259
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of IA Commercial	$3.51
Rate for Payer: Aetna of IA Medical Rental Products	$3.51
Rate for Payer: Aetna of IA Medicare	$2.22
Rate for Payer: Amerigroup Medicaid	$2.25
Rate for Payer: Amerigroup Medicare	$1.77
Rate for Payer: Cash Price	$3.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.75
Rate for Payer: Iowa Total Care Managed Medicaid	$2.23
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Medical Associates Managed Medicare	$1.75
Rate for Payer: Midlands Choice Commercial	$2.73
Rate for Payer: Molina Healthcare Managed Medicaid	$2.26
Rate for Payer: Partners Health Alliance Commercial	$2.02
Rate for Payer: United Healthcare Commercial	$3.51
Rate for Payer: United Healthcare Managed Medicare	$2.30

acetaminophen-HYDROcodone 325 mg-10 mg Tab [VDMC]

Facility

$4.63

Service Code	HCPCS A9270
Hospital Charge Code	10363180
Hospital Revenue Code	259
Min. Negotiated Rate	$2.08
Max. Negotiated Rate	$4.16
Rate for Payer: Aetna of IA Commercial	$4.16
Rate for Payer: Aetna of IA Medical Rental Products	$4.16
Rate for Payer: Aetna of IA Medicare	$2.64
Rate for Payer: Amerigroup Medicaid	$2.67
Rate for Payer: Amerigroup Medicare	$2.10
Rate for Payer: Cash Price	$3.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.47
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.08
Rate for Payer: Iowa Total Care Managed Medicaid	$2.64
Rate for Payer: Medical Associates Commercial	$3.47
Rate for Payer: Medical Associates Managed Medicare	$2.08
Rate for Payer: Midlands Choice Commercial	$3.24
Rate for Payer: Molina Healthcare Managed Medicaid	$2.68
Rate for Payer: Partners Health Alliance Commercial	$2.39
Rate for Payer: United Healthcare Commercial	$4.16
Rate for Payer: United Healthcare Managed Medicare	$2.73

acetaminophen-HYDROcodone 325 mg-10 mg Tab [VDMC]

Facility

$4.63

Service Code	HCPCS A9270
Hospital Charge Code	10363180
Hospital Revenue Code	259
Min. Negotiated Rate	$3.24
Max. Negotiated Rate	$4.16
Rate for Payer: Aetna of IA Commercial	$4.16
Rate for Payer: Aetna of IA Medical Rental Products	$4.16
Rate for Payer: Cash Price	$3.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.47
Rate for Payer: Medical Associates Commercial	$3.47
Rate for Payer: Midlands Choice Commercial	$3.24
Rate for Payer: United Healthcare Commercial	$4.16

acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Sol 15 mL [VDMC]

Facility

$6.54

Service Code	HCPCS A9270
Hospital Charge Code	10363320
Hospital Revenue Code	259
Min. Negotiated Rate	$2.94
Max. Negotiated Rate	$5.88
Rate for Payer: Molina Healthcare Managed Medicaid	$3.79
Rate for Payer: Partners Health Alliance Commercial	$3.38
Rate for Payer: United Healthcare Commercial	$5.88
Rate for Payer: United Healthcare Managed Medicare	$3.86
Rate for Payer: Aetna of IA Commercial	$5.88
Rate for Payer: Aetna of IA Medical Rental Products	$5.88
Rate for Payer: Aetna of IA Medicare	$3.73
Rate for Payer: Amerigroup Medicaid	$3.77
Rate for Payer: Amerigroup Medicare	$2.97
Rate for Payer: Cash Price	$5.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.94
Rate for Payer: Iowa Total Care Managed Medicaid	$3.73
Rate for Payer: Medical Associates Commercial	$4.90
Rate for Payer: Medical Associates Managed Medicare	$2.94
Rate for Payer: Midlands Choice Commercial	$4.57

acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Sol 15 mL [VDMC]

Facility

$6.54

Service Code	HCPCS A9270
Hospital Charge Code	10363320
Hospital Revenue Code	259
Min. Negotiated Rate	$4.57
Max. Negotiated Rate	$5.88
Rate for Payer: Aetna of IA Commercial	$5.88
Rate for Payer: Aetna of IA Medical Rental Products	$5.88
Rate for Payer: Cash Price	$5.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.90
Rate for Payer: Medical Associates Commercial	$4.90
Rate for Payer: Midlands Choice Commercial	$4.57
Rate for Payer: United Healthcare Commercial	$5.88

acetaminophen-oxyCODONE 325 mg-5 mg Tab [VDMC]

Facility

$3.87

Service Code	HCPCS A9270
Hospital Charge Code	10363391
Hospital Revenue Code	259
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$3.48
Rate for Payer: Aetna of IA Commercial	$3.48
Rate for Payer: Aetna of IA Medical Rental Products	$3.48
Rate for Payer: Cash Price	$3.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.90
Rate for Payer: Medical Associates Commercial	$2.90
Rate for Payer: Midlands Choice Commercial	$2.71
Rate for Payer: United Healthcare Commercial	$3.48

acetaminophen-oxyCODONE 325 mg-5 mg Tab [VDMC]

Facility

$3.87

Service Code	HCPCS A9270
Hospital Charge Code	10363391
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$3.48
Rate for Payer: Aetna of IA Commercial	$3.48
Rate for Payer: Aetna of IA Medical Rental Products	$3.48
Rate for Payer: Aetna of IA Medicare	$2.21
Rate for Payer: Amerigroup Medicaid	$2.23
Rate for Payer: Amerigroup Medicare	$1.76
Rate for Payer: Cash Price	$3.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.74
Rate for Payer: Iowa Total Care Managed Medicaid	$2.21
Rate for Payer: Medical Associates Commercial	$2.90
Rate for Payer: Medical Associates Managed Medicare	$1.74
Rate for Payer: Midlands Choice Commercial	$2.71
Rate for Payer: Molina Healthcare Managed Medicaid	$2.24
Rate for Payer: Partners Health Alliance Commercial	$2.00
Rate for Payer: United Healthcare Commercial	$3.48
Rate for Payer: United Healthcare Managed Medicare	$2.28

Know your out-of-pocket cost for care.

All Charges