Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Sodium Chloride 0.9% IV Sol 250 mL [VDMC]

Facility

$65.26

Service Code	HCPCS J7050
Hospital Charge Code	10441438
Hospital Revenue Code	259
Min. Negotiated Rate	$45.68
Max. Negotiated Rate	$58.73
Rate for Payer: Aetna of IA Commercial	$58.73
Rate for Payer: Aetna of IA Medical Rental Products	$58.73
Rate for Payer: Cash Price	$52.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.94
Rate for Payer: Medical Associates Commercial	$48.94
Rate for Payer: Midlands Choice Commercial	$45.68
Rate for Payer: United Healthcare Commercial	$58.73

Sodium Chloride 0.9% IV Sol 250 mL [VDMC]

Facility

$65.26

Service Code	HCPCS J7050
Hospital Charge Code	10441438
Hospital Revenue Code	259
Min. Negotiated Rate	$32.62
Max. Negotiated Rate	$58.73
Rate for Payer: Aetna of IA Commercial	$58.73
Rate for Payer: Aetna of IA Medical Rental Products	$58.73
Rate for Payer: Aetna of IA Medicare	$37.20
Rate for Payer: Amerigroup Medicaid	$32.94
Rate for Payer: Amerigroup Medicare	$32.96
Rate for Payer: Cash Price	$52.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.63
Rate for Payer: Iowa Total Care Managed Medicaid	$32.62
Rate for Payer: Medical Associates Commercial	$48.94
Rate for Payer: Medical Associates Managed Medicare	$32.63
Rate for Payer: Midlands Choice Commercial	$45.68
Rate for Payer: Molina Healthcare Managed Medicaid	$33.12
Rate for Payer: Molina Healthcare Managed Medicare	$33.10
Rate for Payer: Oscar Health of IA Commercial	$48.94
Rate for Payer: Partners Health Alliance Commercial	$48.94
Rate for Payer: United Healthcare Commercial	$58.73
Rate for Payer: United Healthcare Managed Medicare	$38.50

Sodium Chloride 0.9% IV Sol 50 mL [VDMC]

Facility

$66.80

Service Code	HCPCS J7050
Hospital Charge Code	10441505
Hospital Revenue Code	259
Min. Negotiated Rate	$46.76
Max. Negotiated Rate	$60.12
Rate for Payer: Aetna of IA Commercial	$60.12
Rate for Payer: Aetna of IA Medical Rental Products	$60.12
Rate for Payer: Cash Price	$53.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.10
Rate for Payer: Medical Associates Commercial	$50.10
Rate for Payer: Midlands Choice Commercial	$46.76
Rate for Payer: United Healthcare Commercial	$60.12

Sodium Chloride 0.9% IV Sol 50 mL [VDMC]

Facility

$66.80

Service Code	HCPCS J7050
Hospital Charge Code	10441505
Hospital Revenue Code	259
Min. Negotiated Rate	$33.39
Max. Negotiated Rate	$60.12
Rate for Payer: Aetna of IA Commercial	$60.12
Rate for Payer: Aetna of IA Medical Rental Products	$60.12
Rate for Payer: Aetna of IA Medicare	$38.08
Rate for Payer: Amerigroup Medicaid	$33.71
Rate for Payer: Amerigroup Medicare	$33.73
Rate for Payer: Cash Price	$53.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.40
Rate for Payer: Iowa Total Care Managed Medicaid	$33.39
Rate for Payer: Medical Associates Commercial	$50.10
Rate for Payer: Medical Associates Managed Medicare	$33.40
Rate for Payer: Midlands Choice Commercial	$46.76
Rate for Payer: Molina Healthcare Managed Medicaid	$33.90
Rate for Payer: Molina Healthcare Managed Medicare	$33.88
Rate for Payer: Oscar Health of IA Commercial	$50.10
Rate for Payer: Partners Health Alliance Commercial	$50.10
Rate for Payer: United Healthcare Commercial	$60.12
Rate for Payer: United Healthcare Managed Medicare	$39.41

sodium chloride 1 g Tab [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10421562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of IA Commercial	$1.13
Rate for Payer: Aetna of IA Medical Rental Products	$1.13
Rate for Payer: Aetna of IA Medicare	$0.72
Rate for Payer: Amerigroup Medicaid	$0.64
Rate for Payer: Amerigroup Medicare	$0.64
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.63
Rate for Payer: Iowa Total Care Managed Medicaid	$0.63
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Medical Associates Managed Medicare	$0.63
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: Molina Healthcare Managed Medicaid	$0.64
Rate for Payer: Molina Healthcare Managed Medicare	$0.64
Rate for Payer: Oscar Health of IA Commercial	$0.95
Rate for Payer: Partners Health Alliance Commercial	$0.95
Rate for Payer: United Healthcare Commercial	$1.13
Rate for Payer: United Healthcare Managed Medicare	$0.74

sodium chloride 1 g Tab [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10421562
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of IA Commercial	$1.13
Rate for Payer: Aetna of IA Medical Rental Products	$1.13
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.13

sodium chloride 23.4% IV Sol 30 mL [VDMC]

Facility

$36.56

Service Code	NDC 63323-0187-30
Hospital Charge Code	10438606
Hospital Revenue Code	259
Min. Negotiated Rate	$18.27
Max. Negotiated Rate	$32.90
Rate for Payer: Aetna of IA Commercial	$32.90
Rate for Payer: Aetna of IA Medical Rental Products	$32.90
Rate for Payer: Aetna of IA Medicare	$20.84
Rate for Payer: Amerigroup Medicaid	$18.45
Rate for Payer: Amerigroup Medicare	$18.46
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.28
Rate for Payer: Iowa Total Care Managed Medicaid	$18.27
Rate for Payer: Medical Associates Commercial	$27.42
Rate for Payer: Medical Associates Managed Medicare	$18.28
Rate for Payer: Midlands Choice Commercial	$25.59
Rate for Payer: Molina Healthcare Managed Medicaid	$18.55
Rate for Payer: Molina Healthcare Managed Medicare	$18.54
Rate for Payer: Oscar Health of IA Commercial	$27.42
Rate for Payer: Partners Health Alliance Commercial	$27.42
Rate for Payer: United Healthcare Commercial	$32.90
Rate for Payer: United Healthcare Managed Medicare	$21.57

sodium chloride 23.4% IV Sol 30 mL [VDMC]

Facility

$36.56

Service Code	NDC 63323-0187-30
Hospital Charge Code	10438606
Hospital Revenue Code	259
Min. Negotiated Rate	$25.59
Max. Negotiated Rate	$32.90
Rate for Payer: Aetna of IA Commercial	$32.90
Rate for Payer: Aetna of IA Medical Rental Products	$32.90
Rate for Payer: Cash Price	$29.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.42
Rate for Payer: Medical Associates Commercial	$27.42
Rate for Payer: Midlands Choice Commercial	$25.59
Rate for Payer: United Healthcare Commercial	$32.90

sodium chloride 3% neb Sol 4 ml SDV [VDMC]

Facility

$5.13

Service Code	NDC 00487-9003-60
Hospital Charge Code	12710834
Hospital Revenue Code	259
Min. Negotiated Rate	$2.56
Max. Negotiated Rate	$4.62
Rate for Payer: Aetna of IA Commercial	$4.62
Rate for Payer: Aetna of IA Medical Rental Products	$4.62
Rate for Payer: Aetna of IA Medicare	$2.92
Rate for Payer: Amerigroup Medicaid	$2.59
Rate for Payer: Amerigroup Medicare	$2.59
Rate for Payer: Cash Price	$4.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.85
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.56
Rate for Payer: Iowa Total Care Managed Medicaid	$2.56
Rate for Payer: Medical Associates Commercial	$3.85
Rate for Payer: Medical Associates Managed Medicare	$2.56
Rate for Payer: Midlands Choice Commercial	$3.59
Rate for Payer: Molina Healthcare Managed Medicaid	$2.60
Rate for Payer: Molina Healthcare Managed Medicare	$2.60
Rate for Payer: Oscar Health of IA Commercial	$3.85
Rate for Payer: Partners Health Alliance Commercial	$3.85
Rate for Payer: United Healthcare Commercial	$4.62
Rate for Payer: United Healthcare Managed Medicare	$3.03

sodium chloride 3% neb Sol 4 ml SDV [VDMC]

Facility

$5.13

Service Code	NDC 00487-9003-60
Hospital Charge Code	12710834
Hospital Revenue Code	259
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$4.62
Rate for Payer: Aetna of IA Commercial	$4.62
Rate for Payer: Aetna of IA Medical Rental Products	$4.62
Rate for Payer: Cash Price	$4.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.85
Rate for Payer: Medical Associates Commercial	$3.85
Rate for Payer: Midlands Choice Commercial	$3.59
Rate for Payer: United Healthcare Commercial	$4.62

sodium chloride 7% UD neb sol 4ml SDV [VDMC]

Facility

$6.33

Service Code	HCPCS A4216
Hospital Charge Code	17985180
Hospital Revenue Code	259
Min. Negotiated Rate	$4.43
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna of IA Commercial	$5.70
Rate for Payer: Aetna of IA Medical Rental Products	$5.70
Rate for Payer: Cash Price	$5.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.75
Rate for Payer: Medical Associates Commercial	$4.75
Rate for Payer: Midlands Choice Commercial	$4.43
Rate for Payer: United Healthcare Commercial	$5.70

sodium chloride 7% UD neb sol 4ml SDV [VDMC]

Facility

$6.33

Service Code	HCPCS A4216
Hospital Charge Code	17985180
Hospital Revenue Code	259
Min. Negotiated Rate	$3.16
Max. Negotiated Rate	$5.70
Rate for Payer: Aetna of IA Commercial	$5.70
Rate for Payer: Aetna of IA Medical Rental Products	$5.70
Rate for Payer: Aetna of IA Medicare	$3.61
Rate for Payer: Amerigroup Medicaid	$3.19
Rate for Payer: Amerigroup Medicare	$3.20
Rate for Payer: Cash Price	$5.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.16
Rate for Payer: Iowa Total Care Managed Medicaid	$3.16
Rate for Payer: Medical Associates Commercial	$4.75
Rate for Payer: Medical Associates Managed Medicare	$3.16
Rate for Payer: Midlands Choice Commercial	$4.43
Rate for Payer: Molina Healthcare Managed Medicaid	$3.21
Rate for Payer: Molina Healthcare Managed Medicare	$3.21
Rate for Payer: Oscar Health of IA Commercial	$4.75
Rate for Payer: Partners Health Alliance Commercial	$4.75
Rate for Payer: United Healthcare Commercial	$5.70
Rate for Payer: United Healthcare Managed Medicare	$3.73

Sodium Chloride HYPERTONIC 3% IV Sol 500 mL [VDMC]

Facility

$67.18

Service Code	HCPCS J7131
Hospital Charge Code	10441689
Hospital Revenue Code	259
Min. Negotiated Rate	$47.03
Max. Negotiated Rate	$60.46
Rate for Payer: Aetna of IA Commercial	$60.46
Rate for Payer: Aetna of IA Medical Rental Products	$60.46
Rate for Payer: Cash Price	$53.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.38
Rate for Payer: Medical Associates Commercial	$50.38
Rate for Payer: Midlands Choice Commercial	$47.03
Rate for Payer: United Healthcare Commercial	$60.46

Sodium Chloride HYPERTONIC 3% IV Sol 500 mL [VDMC]

Facility

$67.18

Service Code	HCPCS J7131
Hospital Charge Code	10441689
Hospital Revenue Code	259
Min. Negotiated Rate	$33.58
Max. Negotiated Rate	$60.46
Rate for Payer: Aetna of IA Commercial	$60.46
Rate for Payer: Aetna of IA Medical Rental Products	$60.46
Rate for Payer: Aetna of IA Medicare	$38.29
Rate for Payer: Amerigroup Medicaid	$33.91
Rate for Payer: Amerigroup Medicare	$33.93
Rate for Payer: Cash Price	$53.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.59
Rate for Payer: Iowa Total Care Managed Medicaid	$33.58
Rate for Payer: Medical Associates Commercial	$50.38
Rate for Payer: Medical Associates Managed Medicare	$33.59
Rate for Payer: Midlands Choice Commercial	$47.03
Rate for Payer: Molina Healthcare Managed Medicaid	$34.09
Rate for Payer: Molina Healthcare Managed Medicare	$34.07
Rate for Payer: Oscar Health of IA Commercial	$50.38
Rate for Payer: Partners Health Alliance Commercial	$50.38
Rate for Payer: United Healthcare Commercial	$60.46
Rate for Payer: United Healthcare Managed Medicare	$39.64

sodium chloride, hypertonic, Ophth 5% Sol [VDMC]

Facility

$49.80

Service Code	HCPCS A9270
Hospital Charge Code	10439002
Hospital Revenue Code	259
Min. Negotiated Rate	$24.89
Max. Negotiated Rate	$44.82
Rate for Payer: Aetna of IA Commercial	$44.82
Rate for Payer: Aetna of IA Medical Rental Products	$44.82
Rate for Payer: Aetna of IA Medicare	$28.39
Rate for Payer: Amerigroup Medicaid	$25.13
Rate for Payer: Amerigroup Medicare	$25.15
Rate for Payer: Cash Price	$39.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$37.35
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$24.90
Rate for Payer: Iowa Total Care Managed Medicaid	$24.89
Rate for Payer: Medical Associates Commercial	$37.35
Rate for Payer: Medical Associates Managed Medicare	$24.90
Rate for Payer: Midlands Choice Commercial	$34.86
Rate for Payer: Molina Healthcare Managed Medicaid	$25.27
Rate for Payer: Molina Healthcare Managed Medicare	$25.26
Rate for Payer: Oscar Health of IA Commercial	$37.35
Rate for Payer: Partners Health Alliance Commercial	$37.35
Rate for Payer: United Healthcare Commercial	$44.82
Rate for Payer: United Healthcare Managed Medicare	$29.38

sodium chloride, hypertonic, Ophth 5% Sol [VDMC]

Facility

$49.80

Service Code	HCPCS A9270
Hospital Charge Code	10439002
Hospital Revenue Code	259
Min. Negotiated Rate	$34.86
Max. Negotiated Rate	$44.82
Rate for Payer: Aetna of IA Commercial	$44.82
Rate for Payer: Aetna of IA Medical Rental Products	$44.82
Rate for Payer: Cash Price	$39.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$37.35
Rate for Payer: Medical Associates Commercial	$37.35
Rate for Payer: Midlands Choice Commercial	$34.86
Rate for Payer: United Healthcare Commercial	$44.82

sodium chloride nasal 0.65% Gel [VDMC]

Facility

$26.68

Service Code	HCPCS A9270
Hospital Charge Code	10438811
Hospital Revenue Code	259
Min. Negotiated Rate	$13.33
Max. Negotiated Rate	$24.01
Rate for Payer: Aetna of IA Commercial	$24.01
Rate for Payer: Aetna of IA Medical Rental Products	$24.01
Rate for Payer: Aetna of IA Medicare	$15.21
Rate for Payer: Amerigroup Medicaid	$13.47
Rate for Payer: Amerigroup Medicare	$13.47
Rate for Payer: Cash Price	$21.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.01
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.34
Rate for Payer: Iowa Total Care Managed Medicaid	$13.33
Rate for Payer: Medical Associates Commercial	$20.01
Rate for Payer: Medical Associates Managed Medicare	$13.34
Rate for Payer: Midlands Choice Commercial	$18.68
Rate for Payer: Molina Healthcare Managed Medicaid	$13.54
Rate for Payer: Molina Healthcare Managed Medicare	$13.53
Rate for Payer: Oscar Health of IA Commercial	$20.01
Rate for Payer: Partners Health Alliance Commercial	$20.01
Rate for Payer: United Healthcare Commercial	$24.01
Rate for Payer: United Healthcare Managed Medicare	$15.74

sodium chloride nasal 0.65% Gel [VDMC]

Facility

$26.68

Service Code	HCPCS A9270
Hospital Charge Code	10438811
Hospital Revenue Code	259
Min. Negotiated Rate	$18.68
Max. Negotiated Rate	$24.01
Rate for Payer: Aetna of IA Commercial	$24.01
Rate for Payer: Aetna of IA Medical Rental Products	$24.01
Rate for Payer: Cash Price	$21.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.01
Rate for Payer: Medical Associates Commercial	$20.01
Rate for Payer: Midlands Choice Commercial	$18.68
Rate for Payer: United Healthcare Commercial	$24.01

sodium chloride Nasal 0.65% Spry [VDMC]

Facility

$17.36

Service Code	HCPCS A9270
Hospital Charge Code	10438876
Hospital Revenue Code	259
Min. Negotiated Rate	$8.68
Max. Negotiated Rate	$15.62
Rate for Payer: Aetna of IA Commercial	$15.62
Rate for Payer: Aetna of IA Medical Rental Products	$15.62
Rate for Payer: Aetna of IA Medicare	$9.90
Rate for Payer: Amerigroup Medicaid	$8.76
Rate for Payer: Amerigroup Medicare	$8.77
Rate for Payer: Cash Price	$13.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.02
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.68
Rate for Payer: Iowa Total Care Managed Medicaid	$8.68
Rate for Payer: Medical Associates Commercial	$13.02
Rate for Payer: Medical Associates Managed Medicare	$8.68
Rate for Payer: Midlands Choice Commercial	$12.15
Rate for Payer: Molina Healthcare Managed Medicaid	$8.81
Rate for Payer: Molina Healthcare Managed Medicare	$8.80
Rate for Payer: Oscar Health of IA Commercial	$13.02
Rate for Payer: Partners Health Alliance Commercial	$13.02
Rate for Payer: United Healthcare Commercial	$15.62
Rate for Payer: United Healthcare Managed Medicare	$10.24

sodium chloride Nasal 0.65% Spry [VDMC]

Facility

$17.36

Service Code	HCPCS A9270
Hospital Charge Code	10438876
Hospital Revenue Code	259
Min. Negotiated Rate	$12.15
Max. Negotiated Rate	$15.62
Rate for Payer: Aetna of IA Commercial	$15.62
Rate for Payer: Aetna of IA Medical Rental Products	$15.62
Rate for Payer: Cash Price	$13.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.02
Rate for Payer: Medical Associates Commercial	$13.02
Rate for Payer: Midlands Choice Commercial	$12.15
Rate for Payer: United Healthcare Commercial	$15.62

Sodium Chloride with Phenol [VDMC]

Facility

$39.67

Service Code	NDC 54575-0001-01
Hospital Charge Code	11675675
Hospital Revenue Code	259
Min. Negotiated Rate	$19.83
Max. Negotiated Rate	$35.70
Rate for Payer: Aetna of IA Commercial	$35.70
Rate for Payer: Aetna of IA Medical Rental Products	$35.70
Rate for Payer: Aetna of IA Medicare	$22.61
Rate for Payer: Amerigroup Medicaid	$20.02
Rate for Payer: Amerigroup Medicare	$20.03
Rate for Payer: Cash Price	$31.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$29.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$19.84
Rate for Payer: Iowa Total Care Managed Medicaid	$19.83
Rate for Payer: Medical Associates Commercial	$29.75
Rate for Payer: Medical Associates Managed Medicare	$19.84
Rate for Payer: Midlands Choice Commercial	$27.77
Rate for Payer: Molina Healthcare Managed Medicaid	$20.13
Rate for Payer: Molina Healthcare Managed Medicare	$20.12
Rate for Payer: Oscar Health of IA Commercial	$29.75
Rate for Payer: Partners Health Alliance Commercial	$29.75
Rate for Payer: United Healthcare Commercial	$35.70
Rate for Payer: United Healthcare Managed Medicare	$23.41

Sodium Chloride with Phenol [VDMC]

Facility

$39.67

Service Code	NDC 54575-0001-01
Hospital Charge Code	11675675
Hospital Revenue Code	259
Min. Negotiated Rate	$27.77
Max. Negotiated Rate	$35.70
Rate for Payer: Aetna of IA Commercial	$35.70
Rate for Payer: Aetna of IA Medical Rental Products	$35.70
Rate for Payer: Cash Price	$31.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$29.75
Rate for Payer: Medical Associates Commercial	$29.75
Rate for Payer: Midlands Choice Commercial	$27.77
Rate for Payer: United Healthcare Commercial	$35.70

sodium ferric gluconate complex 12.5 mg/mL 5ml SDV [VDMC]

Facility

$52.94

Service Code	HCPCS J2916
Hospital Charge Code	21999465
Hospital Revenue Code	259
Min. Negotiated Rate	$26.46
Max. Negotiated Rate	$47.65
Rate for Payer: Aetna of IA Commercial	$47.65
Rate for Payer: Aetna of IA Medical Rental Products	$47.65
Rate for Payer: Aetna of IA Medicare	$30.18
Rate for Payer: Amerigroup Medicaid	$26.72
Rate for Payer: Amerigroup Medicare	$26.73
Rate for Payer: Cash Price	$42.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.70
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.47
Rate for Payer: Iowa Total Care Managed Medicaid	$26.46
Rate for Payer: Medical Associates Commercial	$39.70
Rate for Payer: Medical Associates Managed Medicare	$26.47
Rate for Payer: Midlands Choice Commercial	$37.06
Rate for Payer: Molina Healthcare Managed Medicaid	$26.87
Rate for Payer: Molina Healthcare Managed Medicare	$26.85
Rate for Payer: Oscar Health of IA Commercial	$39.70
Rate for Payer: Partners Health Alliance Commercial	$39.70
Rate for Payer: United Healthcare Commercial	$47.65
Rate for Payer: United Healthcare Managed Medicare	$31.23

sodium ferric gluconate complex 12.5 mg/mL 5ml SDV [VDMC]

Facility

$52.94

Service Code	HCPCS J2916
Hospital Charge Code	21999465
Hospital Revenue Code	259
Min. Negotiated Rate	$37.06
Max. Negotiated Rate	$47.65
Rate for Payer: Aetna of IA Commercial	$47.65
Rate for Payer: Aetna of IA Medical Rental Products	$47.65
Rate for Payer: Cash Price	$42.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.70
Rate for Payer: Medical Associates Commercial	$39.70
Rate for Payer: Midlands Choice Commercial	$37.06
Rate for Payer: United Healthcare Commercial	$47.65

sodium hypochlorite 0.125% topical soln [VDMC]

Facility

$64.41

Service Code	NDC 00436-0672-16
Hospital Charge Code	10439067
Hospital Revenue Code	259
Min. Negotiated Rate	$45.09
Max. Negotiated Rate	$57.97
Rate for Payer: Aetna of IA Commercial	$57.97
Rate for Payer: Aetna of IA Medical Rental Products	$57.97
Rate for Payer: Cash Price	$51.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.31
Rate for Payer: Medical Associates Commercial	$48.31
Rate for Payer: Midlands Choice Commercial	$45.09
Rate for Payer: United Healthcare Commercial	$57.97

Know your out-of-pocket cost for care.

All Charges