Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

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

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	$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

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

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

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

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: 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
Rate for Payer: Wellmark IA HMO WHPI	$3,625.12
Rate for Payer: Wellmark IA PPO	$3,993.25

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	$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: 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
Rate for Payer: Wellmark IA HMO WHPI	$3,625.12
Rate for Payer: Wellmark IA PPO	$3,993.25

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: 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
Rate for Payer: Wellmark IA HMO WHPI	$3,625.12
Rate for Payer: Wellmark IA PPO	$3,993.25

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

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: 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
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

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

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

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 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 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 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 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	$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

Know your out-of-pocket cost for care.

All Charges