Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

THP Clindamycin 150mg 6 capsules [VDMC]

Facility

$13.12

Service Code	HCPCS A9270
Hospital Charge Code	10738150
Hospital Revenue Code	259
Min. Negotiated Rate	$9.18
Max. Negotiated Rate	$11.81
Rate for Payer: Aetna of IA Commercial	$11.81
Rate for Payer: Aetna of IA Medical Rental Products	$11.81
Rate for Payer: Cash Price	$10.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.84
Rate for Payer: Medical Associates Commercial	$9.84
Rate for Payer: Midlands Choice Commercial	$9.18
Rate for Payer: United Healthcare Commercial	$11.81

THP Clindamycin 150mg 6 capsules [VDMC]

Facility

$13.12

Service Code	HCPCS A9270
Hospital Charge Code	10738150
Hospital Revenue Code	259
Min. Negotiated Rate	$5.90
Max. Negotiated Rate	$11.81
Rate for Payer: Aetna of IA Commercial	$11.81
Rate for Payer: Aetna of IA Medical Rental Products	$11.81
Rate for Payer: Aetna of IA Medicare	$7.48
Rate for Payer: Amerigroup Medicaid	$7.57
Rate for Payer: Amerigroup Medicare	$5.96
Rate for Payer: Cash Price	$10.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.84
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.90
Rate for Payer: Iowa Total Care Managed Medicaid	$7.49
Rate for Payer: Medical Associates Commercial	$9.84
Rate for Payer: Medical Associates Managed Medicare	$5.90
Rate for Payer: Midlands Choice Commercial	$9.18
Rate for Payer: Molina Healthcare Managed Medicaid	$7.60
Rate for Payer: Partners Health Alliance Commercial	$6.79
Rate for Payer: United Healthcare Commercial	$11.81
Rate for Payer: United Healthcare Managed Medicare	$7.74

THP Cyclobenzaprine 10mg 4 tablets [VDMC]

Facility

$10.88

Service Code	HCPCS A9270
Hospital Charge Code	10738246
Hospital Revenue Code	259
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$9.80
Rate for Payer: Aetna of IA Commercial	$9.80
Rate for Payer: Aetna of IA Medical Rental Products	$9.80
Rate for Payer: Aetna of IA Medicare	$6.20
Rate for Payer: Amerigroup Medicaid	$6.28
Rate for Payer: Amerigroup Medicare	$4.95
Rate for Payer: Cash Price	$8.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.90
Rate for Payer: Iowa Total Care Managed Medicaid	$6.22
Rate for Payer: Medical Associates Commercial	$8.16
Rate for Payer: Medical Associates Managed Medicare	$4.90
Rate for Payer: Midlands Choice Commercial	$7.62
Rate for Payer: Molina Healthcare Managed Medicaid	$6.31
Rate for Payer: Partners Health Alliance Commercial	$5.63
Rate for Payer: United Healthcare Commercial	$9.80
Rate for Payer: United Healthcare Managed Medicare	$6.42

THP Cyclobenzaprine 10mg 4 tablets [VDMC]

Facility

$10.88

Service Code	HCPCS A9270
Hospital Charge Code	10738246
Hospital Revenue Code	259
Min. Negotiated Rate	$7.62
Max. Negotiated Rate	$9.80
Rate for Payer: Aetna of IA Commercial	$9.80
Rate for Payer: Aetna of IA Medical Rental Products	$9.80
Rate for Payer: Cash Price	$8.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.16
Rate for Payer: Medical Associates Commercial	$8.16
Rate for Payer: Midlands Choice Commercial	$7.62
Rate for Payer: United Healthcare Commercial	$9.80

THP Diazepam 5mg tab [VDMC]

Facility

$10.45

Service Code	HCPCS A9270
Hospital Charge Code	10738410
Hospital Revenue Code	259
Min. Negotiated Rate	$4.70
Max. Negotiated Rate	$9.40
Rate for Payer: Aetna of IA Commercial	$9.40
Rate for Payer: Aetna of IA Medical Rental Products	$9.40
Rate for Payer: Aetna of IA Medicare	$5.95
Rate for Payer: Amerigroup Medicaid	$6.03
Rate for Payer: Amerigroup Medicare	$4.75
Rate for Payer: Cash Price	$8.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.70
Rate for Payer: Iowa Total Care Managed Medicaid	$5.97
Rate for Payer: Medical Associates Commercial	$7.83
Rate for Payer: Medical Associates Managed Medicare	$4.70
Rate for Payer: Midlands Choice Commercial	$7.31
Rate for Payer: Molina Healthcare Managed Medicaid	$6.05
Rate for Payer: Partners Health Alliance Commercial	$5.41
Rate for Payer: United Healthcare Commercial	$9.40
Rate for Payer: United Healthcare Managed Medicare	$6.16

THP Diazepam 5mg tab [VDMC]

Facility

$10.45

Service Code	HCPCS A9270
Hospital Charge Code	10738410
Hospital Revenue Code	259
Min. Negotiated Rate	$7.31
Max. Negotiated Rate	$9.40
Rate for Payer: Aetna of IA Commercial	$9.40
Rate for Payer: Aetna of IA Medical Rental Products	$9.40
Rate for Payer: Cash Price	$8.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.83
Rate for Payer: Medical Associates Commercial	$7.83
Rate for Payer: Midlands Choice Commercial	$7.31
Rate for Payer: United Healthcare Commercial	$9.40

THP Hydrocodone/APAP 5mg/325mg tab [VDMC]

Facility

$11.14

Service Code	HCPCS A9270
Hospital Charge Code	10740164
Hospital Revenue Code	259
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$10.03
Rate for Payer: Aetna of IA Commercial	$10.03
Rate for Payer: Aetna of IA Medical Rental Products	$10.03
Rate for Payer: Cash Price	$8.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.36
Rate for Payer: Medical Associates Commercial	$8.36
Rate for Payer: Midlands Choice Commercial	$7.80
Rate for Payer: United Healthcare Commercial	$10.03

THP Hydrocodone/APAP 5mg/325mg tab [VDMC]

Facility

$11.14

Service Code	HCPCS A9270
Hospital Charge Code	10740164
Hospital Revenue Code	259
Min. Negotiated Rate	$5.01
Max. Negotiated Rate	$10.03
Rate for Payer: Aetna of IA Commercial	$10.03
Rate for Payer: Aetna of IA Medical Rental Products	$10.03
Rate for Payer: Aetna of IA Medicare	$6.35
Rate for Payer: Amerigroup Medicaid	$6.43
Rate for Payer: Amerigroup Medicare	$5.06
Rate for Payer: Cash Price	$8.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.01
Rate for Payer: Iowa Total Care Managed Medicaid	$6.36
Rate for Payer: Medical Associates Commercial	$8.36
Rate for Payer: Medical Associates Managed Medicare	$5.01
Rate for Payer: Midlands Choice Commercial	$7.80
Rate for Payer: Molina Healthcare Managed Medicaid	$6.46
Rate for Payer: Partners Health Alliance Commercial	$5.77
Rate for Payer: United Healthcare Commercial	$10.03
Rate for Payer: United Healthcare Managed Medicare	$6.57

THP Hydroxyzine 25mg tab [VDMC]

Facility

$11.94

Service Code	HCPCS A9270
Hospital Charge Code	10739255
Hospital Revenue Code	259
Min. Negotiated Rate	$5.37
Max. Negotiated Rate	$10.74
Rate for Payer: Aetna of IA Commercial	$10.74
Rate for Payer: Aetna of IA Medical Rental Products	$10.74
Rate for Payer: Aetna of IA Medicare	$6.80
Rate for Payer: Amerigroup Medicaid	$6.89
Rate for Payer: Amerigroup Medicare	$5.43
Rate for Payer: Cash Price	$9.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.37
Rate for Payer: Iowa Total Care Managed Medicaid	$6.82
Rate for Payer: Medical Associates Commercial	$8.95
Rate for Payer: Medical Associates Managed Medicare	$5.37
Rate for Payer: Midlands Choice Commercial	$8.36
Rate for Payer: Molina Healthcare Managed Medicaid	$6.92
Rate for Payer: Partners Health Alliance Commercial	$6.18
Rate for Payer: United Healthcare Commercial	$10.74
Rate for Payer: United Healthcare Managed Medicare	$7.04

THP Hydroxyzine 25mg tab [VDMC]

Facility

$11.94

Service Code	HCPCS A9270
Hospital Charge Code	10739255
Hospital Revenue Code	259
Min. Negotiated Rate	$8.36
Max. Negotiated Rate	$10.74
Rate for Payer: Aetna of IA Commercial	$10.74
Rate for Payer: Aetna of IA Medical Rental Products	$10.74
Rate for Payer: Cash Price	$9.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.95
Rate for Payer: Medical Associates Commercial	$8.95
Rate for Payer: Midlands Choice Commercial	$8.36
Rate for Payer: United Healthcare Commercial	$10.74

THP levofloxacin 500 mg tab [VDMC]

Facility

$14.56

Service Code	HCPCS A9270
Hospital Charge Code	10729129
Hospital Revenue Code	259
Min. Negotiated Rate	$6.55
Max. Negotiated Rate	$13.10
Rate for Payer: Aetna of IA Commercial	$13.10
Rate for Payer: Aetna of IA Medical Rental Products	$13.10
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	$7.53
Rate for Payer: United Healthcare Commercial	$13.10
Rate for Payer: United Healthcare Managed Medicare	$8.59

THP levofloxacin 500 mg tab [VDMC]

Facility

$14.56

Service Code	HCPCS A9270
Hospital Charge Code	10729129
Hospital Revenue Code	259
Min. Negotiated Rate	$10.19
Max. Negotiated Rate	$13.10
Rate for Payer: Aetna of IA Commercial	$13.10
Rate for Payer: Aetna of IA Medical Rental Products	$13.10
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	$13.10

THP methylPREDNISolone 4 mg Tab[VDMC]

Facility

$76.28

Service Code	HCPCS J7509
Hospital Charge Code	11698580
Hospital Revenue Code	259
Min. Negotiated Rate	$53.40
Max. Negotiated Rate	$68.65
Rate for Payer: Aetna of IA Commercial	$68.65
Rate for Payer: Aetna of IA Medical Rental Products	$68.65
Rate for Payer: Cash Price	$61.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.21
Rate for Payer: Medical Associates Commercial	$57.21
Rate for Payer: Midlands Choice Commercial	$53.40
Rate for Payer: United Healthcare Commercial	$68.65

THP methylPREDNISolone 4 mg Tab[VDMC]

Facility

$76.28

Service Code	HCPCS J7509
Hospital Charge Code	11698580
Hospital Revenue Code	259
Min. Negotiated Rate	$34.33
Max. Negotiated Rate	$68.65
Rate for Payer: Aetna of IA Commercial	$68.65
Rate for Payer: Aetna of IA Medical Rental Products	$68.65
Rate for Payer: Aetna of IA Medicare	$43.48
Rate for Payer: Amerigroup Medicaid	$44.00
Rate for Payer: Amerigroup Medicare	$34.67
Rate for Payer: Cash Price	$61.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.21
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$34.33
Rate for Payer: Iowa Total Care Managed Medicaid	$43.57
Rate for Payer: Medical Associates Commercial	$57.21
Rate for Payer: Medical Associates Managed Medicare	$34.33
Rate for Payer: Midlands Choice Commercial	$53.40
Rate for Payer: Molina Healthcare Managed Medicaid	$44.21
Rate for Payer: Partners Health Alliance Commercial	$39.48
Rate for Payer: United Healthcare Commercial	$68.65
Rate for Payer: United Healthcare Managed Medicare	$45.01

THP nitrofurantoin 50 mg cap [VDMC]

Facility

$22.96

Service Code	HCPCS A9270
Hospital Charge Code	10729893
Hospital Revenue Code	259
Min. Negotiated Rate	$16.07
Max. Negotiated Rate	$20.66
Rate for Payer: Aetna of IA Commercial	$20.66
Rate for Payer: Aetna of IA Medical Rental Products	$20.66
Rate for Payer: Cash Price	$18.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.22
Rate for Payer: Medical Associates Commercial	$17.22
Rate for Payer: Midlands Choice Commercial	$16.07
Rate for Payer: United Healthcare Commercial	$20.66

THP nitrofurantoin 50 mg cap [VDMC]

Facility

$22.96

Service Code	HCPCS A9270
Hospital Charge Code	10729893
Hospital Revenue Code	259
Min. Negotiated Rate	$10.33
Max. Negotiated Rate	$20.66
Rate for Payer: Aetna of IA Commercial	$20.66
Rate for Payer: Aetna of IA Medical Rental Products	$20.66
Rate for Payer: Aetna of IA Medicare	$13.09
Rate for Payer: Amerigroup Medicaid	$13.24
Rate for Payer: Amerigroup Medicare	$10.44
Rate for Payer: Cash Price	$18.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.22
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.33
Rate for Payer: Iowa Total Care Managed Medicaid	$13.11
Rate for Payer: Medical Associates Commercial	$17.22
Rate for Payer: Medical Associates Managed Medicare	$10.33
Rate for Payer: Midlands Choice Commercial	$16.07
Rate for Payer: Molina Healthcare Managed Medicaid	$13.31
Rate for Payer: Partners Health Alliance Commercial	$11.88
Rate for Payer: United Healthcare Commercial	$20.66
Rate for Payer: United Healthcare Managed Medicare	$13.55

THP ondansetron 4 mg tab-DIS 5 Tablets [VDMC]

Facility

$13.80

Service Code	HCPCS A9270
Hospital Charge Code	10730029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.66
Max. Negotiated Rate	$12.42
Rate for Payer: Aetna of IA Commercial	$12.42
Rate for Payer: Aetna of IA Medical Rental Products	$12.42
Rate for Payer: Cash Price	$11.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.35
Rate for Payer: Medical Associates Commercial	$10.35
Rate for Payer: Midlands Choice Commercial	$9.66
Rate for Payer: United Healthcare Commercial	$12.42

THP ondansetron 4 mg tab-DIS 5 Tablets [VDMC]

Facility

$13.80

Service Code	HCPCS A9270
Hospital Charge Code	10730029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.21
Max. Negotiated Rate	$12.42
Rate for Payer: Aetna of IA Commercial	$12.42
Rate for Payer: Aetna of IA Medical Rental Products	$12.42
Rate for Payer: Aetna of IA Medicare	$7.87
Rate for Payer: Amerigroup Medicaid	$7.96
Rate for Payer: Amerigroup Medicare	$6.27
Rate for Payer: Cash Price	$11.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.35
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.21
Rate for Payer: Iowa Total Care Managed Medicaid	$7.88
Rate for Payer: Medical Associates Commercial	$10.35
Rate for Payer: Medical Associates Managed Medicare	$6.21
Rate for Payer: Midlands Choice Commercial	$9.66
Rate for Payer: Molina Healthcare Managed Medicaid	$8.00
Rate for Payer: Partners Health Alliance Commercial	$7.14
Rate for Payer: United Healthcare Commercial	$12.42
Rate for Payer: United Healthcare Managed Medicare	$8.14

THP oxycodone/APAP 5 mg/325 mg 5 tablets [VDMC]

Facility

$14.75

Service Code	HCPCS A9270
Hospital Charge Code	10730096
Hospital Revenue Code	259
Min. Negotiated Rate	$6.64
Max. Negotiated Rate	$13.27
Rate for Payer: Aetna of IA Commercial	$13.27
Rate for Payer: Aetna of IA Medical Rental Products	$13.27
Rate for Payer: Aetna of IA Medicare	$8.41
Rate for Payer: Amerigroup Medicaid	$8.51
Rate for Payer: Amerigroup Medicare	$6.70
Rate for Payer: Cash Price	$11.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.06
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.64
Rate for Payer: Iowa Total Care Managed Medicaid	$8.42
Rate for Payer: Medical Associates Commercial	$11.06
Rate for Payer: Medical Associates Managed Medicare	$6.64
Rate for Payer: Midlands Choice Commercial	$10.32
Rate for Payer: Molina Healthcare Managed Medicaid	$8.55
Rate for Payer: Partners Health Alliance Commercial	$7.63
Rate for Payer: United Healthcare Commercial	$13.27
Rate for Payer: United Healthcare Managed Medicare	$8.70

THP oxycodone/APAP 5 mg/325 mg 5 tablets [VDMC]

Facility

$14.75

Service Code	HCPCS A9270
Hospital Charge Code	10730096
Hospital Revenue Code	259
Min. Negotiated Rate	$10.32
Max. Negotiated Rate	$13.27
Rate for Payer: Aetna of IA Commercial	$13.27
Rate for Payer: Aetna of IA Medical Rental Products	$13.27
Rate for Payer: Cash Price	$11.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.06
Rate for Payer: Medical Associates Commercial	$11.06
Rate for Payer: Midlands Choice Commercial	$10.32
Rate for Payer: United Healthcare Commercial	$13.27

THP phenazopyridine 200 mg 6 tabs [VDMC]

Facility

$18.40

Service Code	HCPCS A9270
Hospital Charge Code	10730193
Hospital Revenue Code	259
Min. Negotiated Rate	$8.28
Max. Negotiated Rate	$16.56
Rate for Payer: Aetna of IA Commercial	$16.56
Rate for Payer: Aetna of IA Medical Rental Products	$16.56
Rate for Payer: Aetna of IA Medicare	$10.49
Rate for Payer: Amerigroup Medicaid	$10.61
Rate for Payer: Amerigroup Medicare	$8.36
Rate for Payer: Cash Price	$14.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.28
Rate for Payer: Iowa Total Care Managed Medicaid	$10.51
Rate for Payer: Medical Associates Commercial	$13.80
Rate for Payer: Medical Associates Managed Medicare	$8.28
Rate for Payer: Midlands Choice Commercial	$12.88
Rate for Payer: Molina Healthcare Managed Medicaid	$10.66
Rate for Payer: Partners Health Alliance Commercial	$9.52
Rate for Payer: United Healthcare Commercial	$16.56
Rate for Payer: United Healthcare Managed Medicare	$10.86

THP phenazopyridine 200 mg 6 tabs [VDMC]

Facility

$18.40

Service Code	HCPCS A9270
Hospital Charge Code	10730193
Hospital Revenue Code	259
Min. Negotiated Rate	$12.88
Max. Negotiated Rate	$16.56
Rate for Payer: Aetna of IA Commercial	$16.56
Rate for Payer: Aetna of IA Medical Rental Products	$16.56
Rate for Payer: Cash Price	$14.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.80
Rate for Payer: Medical Associates Commercial	$13.80
Rate for Payer: Midlands Choice Commercial	$12.88
Rate for Payer: United Healthcare Commercial	$16.56

THP promethazine 25mg tabs [VDMC]

Facility

$14.71

Service Code	NDC 99998-1830-01
Hospital Charge Code	10733780
Hospital Revenue Code	259
Min. Negotiated Rate	$6.62
Max. Negotiated Rate	$13.24
Rate for Payer: Aetna of IA Commercial	$13.24
Rate for Payer: Aetna of IA Medical Rental Products	$13.24
Rate for Payer: Aetna of IA Medicare	$8.39
Rate for Payer: Amerigroup Medicaid	$8.49
Rate for Payer: Amerigroup Medicare	$6.69
Rate for Payer: Cash Price	$11.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.62
Rate for Payer: Iowa Total Care Managed Medicaid	$8.40
Rate for Payer: Medical Associates Commercial	$11.04
Rate for Payer: Medical Associates Managed Medicare	$6.62
Rate for Payer: Midlands Choice Commercial	$10.30
Rate for Payer: Molina Healthcare Managed Medicaid	$8.53
Rate for Payer: Partners Health Alliance Commercial	$7.61
Rate for Payer: United Healthcare Commercial	$13.24
Rate for Payer: United Healthcare Managed Medicare	$8.68

THP promethazine 25mg tabs [VDMC]

Facility

$14.71

Service Code	NDC 99998-1830-01
Hospital Charge Code	10733780
Hospital Revenue Code	259
Min. Negotiated Rate	$10.30
Max. Negotiated Rate	$13.24
Rate for Payer: Aetna of IA Commercial	$13.24
Rate for Payer: Aetna of IA Medical Rental Products	$13.24
Rate for Payer: Cash Price	$11.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.04
Rate for Payer: Medical Associates Commercial	$11.04
Rate for Payer: Midlands Choice Commercial	$10.30
Rate for Payer: United Healthcare Commercial	$13.24

THP promethazine/codeine 6.25/10mg/5mL syrup [VDMC]

Facility

$11.17

Service Code	HCPCS A9270
Hospital Charge Code	10734004
Hospital Revenue Code	259
Min. Negotiated Rate	$5.03
Max. Negotiated Rate	$10.05
Rate for Payer: Aetna of IA Commercial	$10.05
Rate for Payer: Aetna of IA Medical Rental Products	$10.05
Rate for Payer: Aetna of IA Medicare	$6.37
Rate for Payer: Amerigroup Medicaid	$6.44
Rate for Payer: Amerigroup Medicare	$5.08
Rate for Payer: Cash Price	$8.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.03
Rate for Payer: Iowa Total Care Managed Medicaid	$6.38
Rate for Payer: Medical Associates Commercial	$8.38
Rate for Payer: Medical Associates Managed Medicare	$5.03
Rate for Payer: Midlands Choice Commercial	$7.82
Rate for Payer: Molina Healthcare Managed Medicaid	$6.47
Rate for Payer: Partners Health Alliance Commercial	$5.78
Rate for Payer: United Healthcare Commercial	$10.05
Rate for Payer: United Healthcare Managed Medicare	$6.59

Know your out-of-pocket cost for care.

All Charges