Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ALT (SGPT)

Facility

$51.00

Service Code	CPT 84460
Hospital Charge Code	633632
Hospital Revenue Code	301
Min. Negotiated Rate	$22.95
Max. Negotiated Rate	$45.90
Rate for Payer: Aetna of IA Commercial	$45.90
Rate for Payer: Aetna of IA Medical Rental Products	$45.90
Rate for Payer: Aetna of IA Medicare	$29.07
Rate for Payer: Amerigroup Medicaid	$29.42
Rate for Payer: Amerigroup Medicare	$23.18
Rate for Payer: Cash Price	$40.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$38.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$22.95
Rate for Payer: Iowa Total Care Managed Medicaid	$29.13
Rate for Payer: Medical Associates Commercial	$38.25
Rate for Payer: Medical Associates Managed Medicare	$22.95
Rate for Payer: Midlands Choice Commercial	$35.70
Rate for Payer: Molina Healthcare Managed Medicaid	$29.56
Rate for Payer: Partners Health Alliance Commercial	$26.39
Rate for Payer: United Healthcare Commercial	$45.90
Rate for Payer: United Healthcare Managed Medicare	$30.09

amantadine 100 mg Cap [VDMC]

Facility

$1.33

Service Code	HCPCS A9270
Hospital Charge Code	10365416
Hospital Revenue Code	259
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Cash Price	$1.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: United Healthcare Commercial	$1.20

amantadine 100 mg Cap [VDMC]

Facility

$1.33

Service Code	HCPCS A9270
Hospital Charge Code	10365416
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Aetna of IA Medicare	$0.76
Rate for Payer: Amerigroup Medicaid	$0.77
Rate for Payer: Amerigroup Medicare	$0.60
Rate for Payer: Cash Price	$1.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.60
Rate for Payer: Iowa Total Care Managed Medicaid	$0.76
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Medical Associates Managed Medicare	$0.60
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: Molina Healthcare Managed Medicaid	$0.77
Rate for Payer: Partners Health Alliance Commercial	$0.69
Rate for Payer: United Healthcare Commercial	$1.20
Rate for Payer: United Healthcare Managed Medicare	$0.78

amantadine 50 mg/5 mL Syr [VDMC]

Facility

$7.86

Service Code	HCPCS A9270
Hospital Charge Code	11221210
Hospital Revenue Code	259
Min. Negotiated Rate	$3.54
Max. Negotiated Rate	$7.08
Rate for Payer: Aetna of IA Commercial	$7.08
Rate for Payer: Aetna of IA Medical Rental Products	$7.08
Rate for Payer: Aetna of IA Medicare	$4.48
Rate for Payer: Amerigroup Medicaid	$4.53
Rate for Payer: Amerigroup Medicare	$3.57
Rate for Payer: Cash Price	$6.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.54
Rate for Payer: Iowa Total Care Managed Medicaid	$4.49
Rate for Payer: Medical Associates Commercial	$5.90
Rate for Payer: Medical Associates Managed Medicare	$3.54
Rate for Payer: Midlands Choice Commercial	$5.50
Rate for Payer: Molina Healthcare Managed Medicaid	$4.56
Rate for Payer: Partners Health Alliance Commercial	$4.07
Rate for Payer: United Healthcare Commercial	$7.08
Rate for Payer: United Healthcare Managed Medicare	$4.64

amantadine 50 mg/5 mL Syr [VDMC]

Facility

$7.86

Service Code	HCPCS A9270
Hospital Charge Code	11221210
Hospital Revenue Code	259
Min. Negotiated Rate	$5.50
Max. Negotiated Rate	$7.08
Rate for Payer: Aetna of IA Commercial	$7.08
Rate for Payer: Aetna of IA Medical Rental Products	$7.08
Rate for Payer: Cash Price	$6.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.90
Rate for Payer: Medical Associates Commercial	$5.90
Rate for Payer: Midlands Choice Commercial	$5.50
Rate for Payer: United Healthcare Commercial	$7.08

AMB RESPOND TREAT/NO TRANSPORT

Facility

$118.00

Service Code	HCPCS A0998 QN
Hospital Charge Code	7932767
Hospital Revenue Code	540
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna of IA Commercial	$106.20
Rate for Payer: Aetna of IA Medical Rental Products	$106.20
Rate for Payer: Cash Price	$94.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$88.50
Rate for Payer: Medical Associates Commercial	$88.50
Rate for Payer: Midlands Choice Commercial	$82.60
Rate for Payer: United Healthcare Commercial	$106.20

AMB RESPOND TREAT/NO TRANSPORT

Facility

$118.00

Service Code	HCPCS A0998 QN
Hospital Charge Code	7932767
Hospital Revenue Code	540
Min. Negotiated Rate	$53.10
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna of IA Commercial	$106.20
Rate for Payer: Aetna of IA Medical Rental Products	$106.20
Rate for Payer: Aetna of IA Medicare	$67.26
Rate for Payer: Amerigroup Medicaid	$68.06
Rate for Payer: Amerigroup Medicare	$53.63
Rate for Payer: Cash Price	$94.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$88.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$53.10
Rate for Payer: Iowa Total Care Managed Medicaid	$67.40
Rate for Payer: Medical Associates Commercial	$88.50
Rate for Payer: Medical Associates Managed Medicare	$53.10
Rate for Payer: Midlands Choice Commercial	$82.60
Rate for Payer: Molina Healthcare Managed Medicaid	$68.39
Rate for Payer: Partners Health Alliance Commercial	$61.06
Rate for Payer: United Healthcare Commercial	$106.20
Rate for Payer: United Healthcare Managed Medicare	$100.30

Amikacin Level Trough DMCL

Facility

$62.00

Service Code	CPT 80150
Hospital Charge Code	8037492
Hospital Revenue Code	301
Min. Negotiated Rate	$43.40
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of IA Commercial	$55.80
Rate for Payer: Aetna of IA Medical Rental Products	$55.80
Rate for Payer: Cash Price	$49.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$46.50
Rate for Payer: Medical Associates Commercial	$46.50
Rate for Payer: Midlands Choice Commercial	$43.40
Rate for Payer: United Healthcare Commercial	$55.80

Amikacin Level Trough DMCL

Facility

$62.00

Service Code	CPT 80150
Hospital Charge Code	8037492
Hospital Revenue Code	301
Min. Negotiated Rate	$27.90
Max. Negotiated Rate	$55.80
Rate for Payer: Aetna of IA Commercial	$55.80
Rate for Payer: Aetna of IA Medical Rental Products	$55.80
Rate for Payer: Aetna of IA Medicare	$35.34
Rate for Payer: Amerigroup Medicaid	$35.76
Rate for Payer: Amerigroup Medicare	$28.18
Rate for Payer: Cash Price	$49.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$46.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.90
Rate for Payer: Iowa Total Care Managed Medicaid	$35.41
Rate for Payer: Medical Associates Commercial	$46.50
Rate for Payer: Medical Associates Managed Medicare	$27.90
Rate for Payer: Midlands Choice Commercial	$43.40
Rate for Payer: Molina Healthcare Managed Medicaid	$35.94
Rate for Payer: Partners Health Alliance Commercial	$32.09
Rate for Payer: United Healthcare Commercial	$55.80
Rate for Payer: United Healthcare Managed Medicare	$36.58

aMILoride 5 mg Tab [VDMC]

Facility

$1.73

Service Code	HCPCS A9270
Hospital Charge Code	10365556
Hospital Revenue Code	637
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of IA Commercial	$1.56
Rate for Payer: Aetna of IA Medical Rental Products	$1.56
Rate for Payer: Cash Price	$1.39
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	$1.56

aMILoride 5 mg Tab [VDMC]

Facility

$1.73

Service Code	HCPCS A9270
Hospital Charge Code	10365556
Hospital Revenue Code	637
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of IA Commercial	$1.56
Rate for Payer: Aetna of IA Medical Rental Products	$1.56
Rate for Payer: Aetna of IA Medicare	$0.99
Rate for Payer: Amerigroup Medicaid	$1.00
Rate for Payer: Amerigroup Medicare	$0.79
Rate for Payer: Cash Price	$1.39
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	$0.90
Rate for Payer: United Healthcare Commercial	$1.56
Rate for Payer: United Healthcare Managed Medicare	$1.02

Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) intravenous solution Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) Sol

Facility

$363.20

Service Code	NDC 00338-7032-04
Hospital Charge Code	29229689
Hospital Revenue Code	250
Min. Negotiated Rate	$254.24
Max. Negotiated Rate	$326.88
Rate for Payer: Aetna of IA Commercial	$326.88
Rate for Payer: Aetna of IA Medical Rental Products	$326.88
Rate for Payer: Cash Price	$290.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$272.40
Rate for Payer: Medical Associates Commercial	$272.40
Rate for Payer: Midlands Choice Commercial	$254.24
Rate for Payer: United Healthcare Commercial	$326.88

Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) intravenous solution Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) Sol

Facility

$363.20

Service Code	NDC 00338-7032-04
Hospital Charge Code	29229689
Hospital Revenue Code	250
Min. Negotiated Rate	$163.44
Max. Negotiated Rate	$326.88
Rate for Payer: Aetna of IA Commercial	$326.88
Rate for Payer: Aetna of IA Medical Rental Products	$326.88
Rate for Payer: Aetna of IA Medicare	$207.02
Rate for Payer: Amerigroup Medicaid	$209.49
Rate for Payer: Amerigroup Medicare	$165.07
Rate for Payer: Cash Price	$290.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$272.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$163.44
Rate for Payer: Iowa Total Care Managed Medicaid	$207.46
Rate for Payer: Medical Associates Commercial	$272.40
Rate for Payer: Medical Associates Managed Medicare	$163.44
Rate for Payer: Midlands Choice Commercial	$254.24
Rate for Payer: Molina Healthcare Managed Medicaid	$210.51
Rate for Payer: Partners Health Alliance Commercial	$187.96
Rate for Payer: United Healthcare Commercial	$326.88
Rate for Payer: United Healthcare Managed Medicare	$214.29

Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) Sol

Facility

$245.40

Service Code	NDC 00338-1138-03
Hospital Charge Code	26547466
Hospital Revenue Code	259
Min. Negotiated Rate	$110.43
Max. Negotiated Rate	$220.86
Rate for Payer: Aetna of IA Commercial	$220.86
Rate for Payer: Aetna of IA Medical Rental Products	$220.86
Rate for Payer: Aetna of IA Medicare	$139.88
Rate for Payer: Amerigroup Medicaid	$141.55
Rate for Payer: Amerigroup Medicare	$111.53
Rate for Payer: Cash Price	$196.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$184.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$110.43
Rate for Payer: Iowa Total Care Managed Medicaid	$140.17
Rate for Payer: Medical Associates Commercial	$184.05
Rate for Payer: Medical Associates Managed Medicare	$110.43
Rate for Payer: Midlands Choice Commercial	$171.78
Rate for Payer: Molina Healthcare Managed Medicaid	$142.23
Rate for Payer: Partners Health Alliance Commercial	$126.99
Rate for Payer: United Healthcare Commercial	$220.86
Rate for Payer: United Healthcare Managed Medicare	$144.79

Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 5% with 20% Dextrose (Clinimix Sulfite-Free) Sol

Facility

$245.40

Service Code	NDC 00338-1138-03
Hospital Charge Code	26547466
Hospital Revenue Code	259
Min. Negotiated Rate	$171.78
Max. Negotiated Rate	$220.86
Rate for Payer: Aetna of IA Commercial	$220.86
Rate for Payer: Aetna of IA Medical Rental Products	$220.86
Rate for Payer: Cash Price	$196.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$184.05
Rate for Payer: Medical Associates Commercial	$184.05
Rate for Payer: Midlands Choice Commercial	$171.78
Rate for Payer: United Healthcare Commercial	$220.86

aminophylline 25 mg/mL 10 ml IV Sol SDV [VDMC]

Facility

$63.84

Service Code	HCPCS J0280
Hospital Charge Code	10365617
Hospital Revenue Code	259
Min. Negotiated Rate	$28.73
Max. Negotiated Rate	$57.45
Rate for Payer: Aetna of IA Commercial	$57.45
Rate for Payer: Aetna of IA Medical Rental Products	$57.45
Rate for Payer: Aetna of IA Medicare	$36.39
Rate for Payer: Amerigroup Medicaid	$36.82
Rate for Payer: Amerigroup Medicare	$29.01
Rate for Payer: Cash Price	$51.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.73
Rate for Payer: Iowa Total Care Managed Medicaid	$36.46
Rate for Payer: Medical Associates Commercial	$47.88
Rate for Payer: Medical Associates Managed Medicare	$28.73
Rate for Payer: Midlands Choice Commercial	$44.69
Rate for Payer: Molina Healthcare Managed Medicaid	$37.00
Rate for Payer: Partners Health Alliance Commercial	$33.04
Rate for Payer: United Healthcare Commercial	$57.45
Rate for Payer: United Healthcare Managed Medicare	$37.66

aminophylline 25 mg/mL 10 ml IV Sol SDV [VDMC]

Facility

$63.84

Service Code	HCPCS J0280
Hospital Charge Code	10365617
Hospital Revenue Code	259
Min. Negotiated Rate	$44.69
Max. Negotiated Rate	$57.45
Rate for Payer: Aetna of IA Commercial	$57.45
Rate for Payer: Aetna of IA Medical Rental Products	$57.45
Rate for Payer: Cash Price	$51.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.88
Rate for Payer: Medical Associates Commercial	$47.88
Rate for Payer: Midlands Choice Commercial	$44.69
Rate for Payer: United Healthcare Commercial	$57.45

amiodarone 200 mg Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10365688
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of IA Commercial	$1.52
Rate for Payer: Aetna of IA Medical Rental Products	$1.52
Rate for Payer: Aetna of IA Medicare	$0.96
Rate for Payer: Amerigroup Medicaid	$0.98
Rate for Payer: Amerigroup Medicare	$0.77
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.76
Rate for Payer: Iowa Total Care Managed Medicaid	$0.97
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Medical Associates Managed Medicare	$0.76
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: Molina Healthcare Managed Medicaid	$0.98
Rate for Payer: Partners Health Alliance Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Managed Medicare	$1.00

amiodarone 200 mg Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10365688
Hospital Revenue Code	259
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of IA Commercial	$1.52
Rate for Payer: Aetna of IA Medical Rental Products	$1.52
Rate for Payer: Cash Price	$1.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.27
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: United Healthcare Commercial	$1.52

amiodarone 400 mg Tab [VDMC]

Facility

$3.82

Service Code	HCPCS A9270
Hospital Charge Code	10365757
Hospital Revenue Code	259
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$3.44
Rate for Payer: Aetna of IA Commercial	$3.44
Rate for Payer: Aetna of IA Medical Rental Products	$3.44
Rate for Payer: Aetna of IA Medicare	$2.18
Rate for Payer: Amerigroup Medicaid	$2.20
Rate for Payer: Amerigroup Medicare	$1.74
Rate for Payer: Cash Price	$3.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.86
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.72
Rate for Payer: Iowa Total Care Managed Medicaid	$2.18
Rate for Payer: Medical Associates Commercial	$2.86
Rate for Payer: Medical Associates Managed Medicare	$1.72
Rate for Payer: Midlands Choice Commercial	$2.67
Rate for Payer: Molina Healthcare Managed Medicaid	$2.21
Rate for Payer: Partners Health Alliance Commercial	$1.98
Rate for Payer: United Healthcare Commercial	$3.44
Rate for Payer: United Healthcare Managed Medicare	$2.25

amiodarone 400 mg Tab [VDMC]

Facility

$3.82

Service Code	HCPCS A9270
Hospital Charge Code	10365757
Hospital Revenue Code	259
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$3.44
Rate for Payer: Aetna of IA Commercial	$3.44
Rate for Payer: Aetna of IA Medical Rental Products	$3.44
Rate for Payer: Cash Price	$3.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.86
Rate for Payer: Medical Associates Commercial	$2.86
Rate for Payer: Midlands Choice Commercial	$2.67
Rate for Payer: United Healthcare Commercial	$3.44

amiodarone 50 mg/mL 3 ml IV Sol SDV [VDMC]

Facility

$23.02

Service Code	HCPCS J0282
Hospital Charge Code	10431244
Hospital Revenue Code	259
Min. Negotiated Rate	$16.11
Max. Negotiated Rate	$20.72
Rate for Payer: Aetna of IA Commercial	$20.72
Rate for Payer: Aetna of IA Medical Rental Products	$20.72
Rate for Payer: Cash Price	$18.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.26
Rate for Payer: Medical Associates Commercial	$17.26
Rate for Payer: Midlands Choice Commercial	$16.11
Rate for Payer: United Healthcare Commercial	$20.72

amiodarone 50 mg/mL 3 ml IV Sol SDV [VDMC]

Facility

$23.02

Service Code	HCPCS J0282
Hospital Charge Code	10431244
Hospital Revenue Code	259
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$20.72
Rate for Payer: Aetna of IA Commercial	$20.72
Rate for Payer: Aetna of IA Medical Rental Products	$20.72
Rate for Payer: Aetna of IA Medicare	$13.12
Rate for Payer: Amerigroup Medicaid	$13.28
Rate for Payer: Amerigroup Medicare	$10.46
Rate for Payer: Cash Price	$18.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.36
Rate for Payer: Iowa Total Care Managed Medicaid	$13.15
Rate for Payer: Medical Associates Commercial	$17.26
Rate for Payer: Medical Associates Managed Medicare	$10.36
Rate for Payer: Midlands Choice Commercial	$16.11
Rate for Payer: Molina Healthcare Managed Medicaid	$13.34
Rate for Payer: Partners Health Alliance Commercial	$11.91
Rate for Payer: United Healthcare Commercial	$20.72
Rate for Payer: United Healthcare Managed Medicare	$13.58

amitriptyline 10 mg Tab [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10365826
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
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	$0.72
Rate for Payer: Amerigroup Medicare	$0.57
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.57
Rate for Payer: Iowa Total Care Managed Medicaid	$0.72
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Medical Associates Managed Medicare	$0.57
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: Molina Healthcare Managed Medicaid	$0.73
Rate for Payer: Partners Health Alliance Commercial	$0.65
Rate for Payer: United Healthcare Commercial	$1.13
Rate for Payer: United Healthcare Managed Medicare	$0.74

amitriptyline 10 mg Tab [VDMC]

Facility

$1.26

Service Code	HCPCS A9270
Hospital Charge Code	10365826
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	$0.94
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.13

Know your out-of-pocket cost for care.

All Charges