Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

albuterol 0.083% 2.5mg neb Sol 3 mL SDV [VDMC]

Facility

$4.73

Service Code	HCPCS A9270
Hospital Charge Code	10364375
Hospital Revenue Code	259
Min. Negotiated Rate	$3.31
Max. Negotiated Rate	$4.26
Rate for Payer: Aetna of IA Commercial	$4.26
Rate for Payer: Aetna of IA Medical Rental Products	$4.26
Rate for Payer: Cash Price	$3.79
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.55
Rate for Payer: Medical Associates Commercial	$3.55
Rate for Payer: Midlands Choice Commercial	$3.31
Rate for Payer: United Healthcare Commercial	$4.26

albuterol 0.5% 5mg/ml 20ml Inh Sol [VDMC]

Facility

$180.64

Service Code	HCPCS A9270
Hospital Charge Code	10364446
Hospital Revenue Code	259
Min. Negotiated Rate	$90.28
Max. Negotiated Rate	$162.58
Rate for Payer: Aetna of IA Commercial	$162.58
Rate for Payer: Aetna of IA Medical Rental Products	$162.58
Rate for Payer: Aetna of IA Medicare	$102.96
Rate for Payer: Amerigroup Medicaid	$91.17
Rate for Payer: Amerigroup Medicare	$91.22
Rate for Payer: Cash Price	$144.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.32
Rate for Payer: Iowa Total Care Managed Medicaid	$90.28
Rate for Payer: Medical Associates Commercial	$135.48
Rate for Payer: Medical Associates Managed Medicare	$90.32
Rate for Payer: Midlands Choice Commercial	$126.45
Rate for Payer: Molina Healthcare Managed Medicaid	$91.67
Rate for Payer: Molina Healthcare Managed Medicare	$91.62
Rate for Payer: Oscar Health of IA Commercial	$135.48
Rate for Payer: Partners Health Alliance Commercial	$135.48
Rate for Payer: United Healthcare Commercial	$162.58
Rate for Payer: United Healthcare Managed Medicare	$106.58

albuterol 0.5% 5mg/ml 20ml Inh Sol [VDMC]

Facility

$180.64

Service Code	HCPCS A9270
Hospital Charge Code	10364446
Hospital Revenue Code	259
Min. Negotiated Rate	$126.45
Max. Negotiated Rate	$162.58
Rate for Payer: Aetna of IA Commercial	$162.58
Rate for Payer: Aetna of IA Medical Rental Products	$162.58
Rate for Payer: Cash Price	$144.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.48
Rate for Payer: Medical Associates Commercial	$135.48
Rate for Payer: Midlands Choice Commercial	$126.45
Rate for Payer: United Healthcare Commercial	$162.58

albuterol 1.25mg Inh Sol 3 mL [VDMC]

Facility

$6.03

Service Code	HCPCS A9270
Hospital Charge Code	10364304
Hospital Revenue Code	259
Min. Negotiated Rate	$3.01
Max. Negotiated Rate	$5.43
Rate for Payer: Aetna of IA Commercial	$5.43
Rate for Payer: Aetna of IA Medical Rental Products	$5.43
Rate for Payer: Aetna of IA Medicare	$3.44
Rate for Payer: Amerigroup Medicaid	$3.04
Rate for Payer: Amerigroup Medicare	$3.05
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	$3.02
Rate for Payer: Iowa Total Care Managed Medicaid	$3.01
Rate for Payer: Medical Associates Commercial	$4.52
Rate for Payer: Medical Associates Managed Medicare	$3.02
Rate for Payer: Midlands Choice Commercial	$4.22
Rate for Payer: Molina Healthcare Managed Medicaid	$3.06
Rate for Payer: Molina Healthcare Managed Medicare	$3.06
Rate for Payer: Oscar Health of IA Commercial	$4.52
Rate for Payer: Partners Health Alliance Commercial	$4.52
Rate for Payer: United Healthcare Commercial	$5.43
Rate for Payer: United Healthcare Managed Medicare	$3.56

albuterol 1.25mg Inh Sol 3 mL [VDMC]

Facility

$6.03

Service Code	HCPCS A9270
Hospital Charge Code	10364304
Hospital Revenue Code	259
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$5.43
Rate for Payer: Aetna of IA Commercial	$5.43
Rate for Payer: Aetna of IA Medical Rental Products	$5.43
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	$4.22
Rate for Payer: United Healthcare Commercial	$5.43

albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [VDMC]

Facility

$72.85

Service Code	HCPCS A9270
Hospital Charge Code	10364515
Hospital Revenue Code	259
Min. Negotiated Rate	$36.41
Max. Negotiated Rate	$65.56
Rate for Payer: Aetna of IA Commercial	$65.56
Rate for Payer: Aetna of IA Medical Rental Products	$65.56
Rate for Payer: Aetna of IA Medicare	$41.52
Rate for Payer: Amerigroup Medicaid	$36.77
Rate for Payer: Amerigroup Medicare	$36.79
Rate for Payer: Cash Price	$58.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.42
Rate for Payer: Iowa Total Care Managed Medicaid	$36.41
Rate for Payer: Medical Associates Commercial	$54.64
Rate for Payer: Medical Associates Managed Medicare	$36.42
Rate for Payer: Midlands Choice Commercial	$51.00
Rate for Payer: Molina Healthcare Managed Medicaid	$36.97
Rate for Payer: Molina Healthcare Managed Medicare	$36.95
Rate for Payer: Oscar Health of IA Commercial	$54.64
Rate for Payer: Partners Health Alliance Commercial	$54.64
Rate for Payer: United Healthcare Commercial	$65.56
Rate for Payer: United Healthcare Managed Medicare	$42.98

albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [VDMC]

Facility

$72.85

Service Code	HCPCS A9270
Hospital Charge Code	10364515
Hospital Revenue Code	259
Min. Negotiated Rate	$51.00
Max. Negotiated Rate	$65.56
Rate for Payer: Aetna of IA Medical Rental Products	$65.56
Rate for Payer: Cash Price	$58.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.64
Rate for Payer: Medical Associates Commercial	$54.64
Rate for Payer: Midlands Choice Commercial	$51.00
Rate for Payer: United Healthcare Commercial	$65.56

albuterol-ipratropium 0.5mg/3mg neb Sol 3 mL SDV [VDMC]

Facility

$4.97

Service Code	HCPCS A9270
Hospital Charge Code	10364653
Hospital Revenue Code	259
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$4.47
Rate for Payer: Aetna of IA Commercial	$4.47
Rate for Payer: Aetna of IA Medical Rental Products	$4.47
Rate for Payer: Cash Price	$3.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.73
Rate for Payer: Medical Associates Commercial	$3.73
Rate for Payer: Midlands Choice Commercial	$3.48
Rate for Payer: United Healthcare Commercial	$4.47

albuterol-ipratropium 0.5mg/3mg neb Sol 3 mL SDV [VDMC]

Facility

$4.97

Service Code	HCPCS A9270
Hospital Charge Code	10364653
Hospital Revenue Code	259
Min. Negotiated Rate	$2.48
Max. Negotiated Rate	$4.47
Rate for Payer: Aetna of IA Commercial	$4.47
Rate for Payer: Aetna of IA Medical Rental Products	$4.47
Rate for Payer: Aetna of IA Medicare	$2.83
Rate for Payer: Amerigroup Medicaid	$2.51
Rate for Payer: Amerigroup Medicare	$2.51
Rate for Payer: Cash Price	$3.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.48
Rate for Payer: Iowa Total Care Managed Medicaid	$2.48
Rate for Payer: Medical Associates Commercial	$3.73
Rate for Payer: Medical Associates Managed Medicare	$2.48
Rate for Payer: Midlands Choice Commercial	$3.48
Rate for Payer: Molina Healthcare Managed Medicaid	$2.52
Rate for Payer: Molina Healthcare Managed Medicare	$2.52
Rate for Payer: Oscar Health of IA Commercial	$3.73
Rate for Payer: Partners Health Alliance Commercial	$3.73
Rate for Payer: United Healthcare Commercial	$4.47
Rate for Payer: United Healthcare Managed Medicare	$2.93

albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aer[VDMC]

Facility

$1,540.36

Service Code	HCPCS A9270
Hospital Charge Code	11449831
Hospital Revenue Code	259
Min. Negotiated Rate	$1,078.25
Max. Negotiated Rate	$1,386.32
Rate for Payer: Aetna of IA Commercial	$1,386.32
Rate for Payer: Aetna of IA Medical Rental Products	$1,386.32
Rate for Payer: Cash Price	$1,232.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,155.27
Rate for Payer: Medical Associates Commercial	$1,155.27
Rate for Payer: Midlands Choice Commercial	$1,078.25
Rate for Payer: United Healthcare Commercial	$1,386.32

albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aer[VDMC]

Facility

$1,540.36

Service Code	HCPCS A9270
Hospital Charge Code	11449831
Hospital Revenue Code	259
Min. Negotiated Rate	$769.87
Max. Negotiated Rate	$1,386.32
Rate for Payer: Aetna of IA Commercial	$1,386.32
Rate for Payer: Aetna of IA Medical Rental Products	$1,386.32
Rate for Payer: Aetna of IA Medicare	$878.01
Rate for Payer: Amerigroup Medicaid	$777.42
Rate for Payer: Amerigroup Medicare	$777.88
Rate for Payer: Cash Price	$1,232.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,155.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$770.18
Rate for Payer: Iowa Total Care Managed Medicaid	$769.87
Rate for Payer: Medical Associates Commercial	$1,155.27
Rate for Payer: Medical Associates Managed Medicare	$770.18
Rate for Payer: Midlands Choice Commercial	$1,078.25
Rate for Payer: Molina Healthcare Managed Medicaid	$781.73
Rate for Payer: Molina Healthcare Managed Medicare	$781.27
Rate for Payer: Oscar Health of IA Commercial	$1,155.27
Rate for Payer: Partners Health Alliance Commercial	$1,155.27
Rate for Payer: United Healthcare Commercial	$1,386.32
Rate for Payer: United Healthcare Managed Medicare	$908.81

ALCOHOL

Facility

$139.00

Service Code	CPT G0480
Hospital Charge Code	1503765
Hospital Revenue Code	301
Min. Negotiated Rate	$69.47
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Molina Healthcare Managed Medicare	$70.50
Rate for Payer: Oscar Health of IA Commercial	$104.25
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$102.92
Rate for Payer: Wellmark IA PPO	$113.21

ALCOHOL

Facility

$139.00

Service Code	CPT G0480
Hospital Charge Code	1503765
Hospital Revenue Code	301
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

Alcohol, Drug Abuse or Dependence, Left AMA

Facility

$4,499.95

Service Code	MS-DRG 894
Hospital Charge Code	618
Min. Negotiated Rate	$4,434.74
Max. Negotiated Rate	$4,499.95
Rate for Payer: Amerigroup Medicaid	$4,478.21
Rate for Payer: Iowa Total Care Managed Medicaid	$4,434.74
Rate for Payer: Molina Healthcare Managed Medicaid	$4,499.95

Alcohol, Drug Abuse or Dependence Without Rehabilitation Therapy With MCC

Facility

$12,018.58

Service Code	MS-DRG 896
Hospital Charge Code	620
Min. Negotiated Rate	$11,844.39
Max. Negotiated Rate	$12,018.58
Rate for Payer: Amerigroup Medicaid	$11,960.51
Rate for Payer: Iowa Total Care Managed Medicaid	$11,844.39
Rate for Payer: Molina Healthcare Managed Medicaid	$12,018.58

Alcohol, Drug Abuse or Dependence Without Rehabilitation Therapy Without MCC

Facility

$6,877.88

Service Code	MS-DRG 897
Hospital Charge Code	621
Min. Negotiated Rate	$6,778.20
Max. Negotiated Rate	$6,877.88
Rate for Payer: Amerigroup Medicaid	$6,844.65
Rate for Payer: Iowa Total Care Managed Medicaid	$6,778.20
Rate for Payer: Molina Healthcare Managed Medicaid	$6,877.88

Alcohol, Drug Abuse or Dependence With Rehabilitation Therapy

Facility

$9,940.84

Service Code	MS-DRG 895
Hospital Charge Code	619
Min. Negotiated Rate	$9,796.77
Max. Negotiated Rate	$9,940.84
Rate for Payer: Amerigroup Medicaid	$9,892.82
Rate for Payer: Iowa Total Care Managed Medicaid	$9,796.77
Rate for Payer: Molina Healthcare Managed Medicaid	$9,940.84

ALDL

Facility

$73.00

Service Code	CPT 83721
Hospital Charge Code	6310783
Hospital Revenue Code	301
Min. Negotiated Rate	$36.49
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Aetna of IA Medicare	$41.61
Rate for Payer: Amerigroup Medicaid	$36.84
Rate for Payer: Amerigroup Medicare	$36.86
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.50
Rate for Payer: Iowa Total Care Managed Medicaid	$36.49
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Medical Associates Managed Medicare	$36.50
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: Molina Healthcare Managed Medicaid	$37.05
Rate for Payer: Molina Healthcare Managed Medicare	$37.03
Rate for Payer: Oscar Health of IA Commercial	$54.75
Rate for Payer: Partners Health Alliance Commercial	$54.75
Rate for Payer: United Healthcare Commercial	$65.70
Rate for Payer: United Healthcare Managed Medicare	$43.07
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

ALDL

Facility

$73.00

Service Code	CPT 83721
Hospital Charge Code	6310783
Hospital Revenue Code	301
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: United Healthcare Commercial	$65.70

ALDOLASE

Facility

$66.00

Service Code	CPT 82085
Hospital Charge Code	8037487
Hospital Revenue Code	301
Min. Negotiated Rate	$32.99
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Aetna of IA Medicare	$37.62
Rate for Payer: Amerigroup Medicaid	$33.31
Rate for Payer: Amerigroup Medicare	$33.33
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.00
Rate for Payer: Iowa Total Care Managed Medicaid	$32.99
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Medical Associates Managed Medicare	$33.00
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: Molina Healthcare Managed Medicaid	$33.50
Rate for Payer: Molina Healthcare Managed Medicare	$33.48
Rate for Payer: Oscar Health of IA Commercial	$49.50
Rate for Payer: Partners Health Alliance Commercial	$49.50
Rate for Payer: United Healthcare Commercial	$59.40
Rate for Payer: United Healthcare Managed Medicare	$38.94
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

ALDOLASE

Facility

$66.00

Service Code	CPT 82085
Hospital Charge Code	8037487
Hospital Revenue Code	301
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: United Healthcare Commercial	$59.40

ALDOSTERONE

Facility

$277.00

Service Code	CPT 82088
Hospital Charge Code	8037488
Hospital Revenue Code	301
Min. Negotiated Rate	$85.56
Max. Negotiated Rate	$249.30
Rate for Payer: Aetna of IA Commercial	$249.30
Rate for Payer: Aetna of IA Medical Rental Products	$249.30
Rate for Payer: Aetna of IA Medicare	$157.89
Rate for Payer: Amerigroup Medicaid	$139.80
Rate for Payer: Amerigroup Medicare	$139.88
Rate for Payer: Cash Price	$221.60
Rate for Payer: Cash Price	$221.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$207.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$138.50
Rate for Payer: Iowa Total Care Managed Medicaid	$138.44
Rate for Payer: Medical Associates Commercial	$207.75
Rate for Payer: Medical Associates Managed Medicare	$138.50
Rate for Payer: Midlands Choice Commercial	$193.90
Rate for Payer: Molina Healthcare Managed Medicaid	$140.58
Rate for Payer: Molina Healthcare Managed Medicare	$140.49
Rate for Payer: Oscar Health of IA Commercial	$207.75
Rate for Payer: Partners Health Alliance Commercial	$207.75
Rate for Payer: United Healthcare Commercial	$249.30
Rate for Payer: United Healthcare Managed Medicare	$163.43
Rate for Payer: Wellmark IA HMO	$85.56
Rate for Payer: Wellmark IA PPO	$94.12

ALDOSTERONE

Facility

$277.00

Service Code	CPT 82088
Hospital Charge Code	8037488
Hospital Revenue Code	301
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$249.30
Rate for Payer: Aetna of IA Commercial	$249.30
Rate for Payer: Aetna of IA Medical Rental Products	$249.30
Rate for Payer: Cash Price	$221.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$207.75
Rate for Payer: Medical Associates Commercial	$207.75
Rate for Payer: Midlands Choice Commercial	$193.90
Rate for Payer: United Healthcare Commercial	$249.30

al hydroxide/mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL [VDMC]

Facility

$12.36

Service Code	HCPCS A9270
Hospital Charge Code	10364164
Hospital Revenue Code	259
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$11.12
Rate for Payer: Aetna of IA Commercial	$11.12
Rate for Payer: Aetna of IA Medical Rental Products	$11.12
Rate for Payer: Aetna of IA Medicare	$7.05
Rate for Payer: Amerigroup Medicaid	$6.24
Rate for Payer: Amerigroup Medicare	$6.24
Rate for Payer: Cash Price	$9.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.18
Rate for Payer: Iowa Total Care Managed Medicaid	$6.18
Rate for Payer: Medical Associates Commercial	$9.27
Rate for Payer: Medical Associates Managed Medicare	$6.18
Rate for Payer: Midlands Choice Commercial	$8.65
Rate for Payer: Molina Healthcare Managed Medicaid	$6.27
Rate for Payer: Molina Healthcare Managed Medicare	$6.27
Rate for Payer: Oscar Health of IA Commercial	$9.27
Rate for Payer: Partners Health Alliance Commercial	$9.27
Rate for Payer: United Healthcare Commercial	$11.12
Rate for Payer: United Healthcare Managed Medicare	$7.29

al hydroxide/mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL [VDMC]

Facility

$12.36

Service Code	HCPCS A9270
Hospital Charge Code	10364164
Hospital Revenue Code	259
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$11.12
Rate for Payer: Aetna of IA Commercial	$11.12
Rate for Payer: Aetna of IA Medical Rental Products	$11.12
Rate for Payer: Cash Price	$9.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.27
Rate for Payer: Medical Associates Commercial	$9.27
Rate for Payer: Midlands Choice Commercial	$8.65
Rate for Payer: United Healthcare Commercial	$11.12

Know your out-of-pocket cost for care.

All Charges