Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$9.79
Rate for Payer: Aetna of IA Commercial	$9.79
Rate for Payer: Aetna of IA Medical Rental Products	$9.79
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	$9.79

THP Diazepam 5mg tab [VDMC]

Facility

$10.45

Service Code	HCPCS A9270
Hospital Charge Code	10738410
Hospital Revenue Code	259
Min. Negotiated Rate	$7.32
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	$7.84
Rate for Payer: Medical Associates Commercial	$7.84
Rate for Payer: Midlands Choice Commercial	$7.32
Rate for Payer: United Healthcare Commercial	$9.40

THP Diazepam 5mg tab [VDMC]

Facility

$10.45

Service Code	HCPCS A9270
Hospital Charge Code	10738410
Hospital Revenue Code	259
Min. Negotiated Rate	$5.22
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	$5.96
Rate for Payer: Amerigroup Medicaid	$5.27
Rate for Payer: Amerigroup Medicare	$5.28
Rate for Payer: Cash Price	$8.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.84
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.22
Rate for Payer: Iowa Total Care Managed Medicaid	$5.22
Rate for Payer: Medical Associates Commercial	$7.84
Rate for Payer: Medical Associates Managed Medicare	$5.22
Rate for Payer: Midlands Choice Commercial	$7.32
Rate for Payer: Molina Healthcare Managed Medicaid	$5.30
Rate for Payer: Molina Healthcare Managed Medicare	$5.30
Rate for Payer: Oscar Health of IA Commercial	$7.84
Rate for Payer: Partners Health Alliance Commercial	$7.84
Rate for Payer: United Healthcare Commercial	$9.40
Rate for Payer: United Healthcare Managed Medicare	$6.17

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	$5.57
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	$5.62
Rate for Payer: Amerigroup Medicare	$5.63
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	$5.57
Rate for Payer: Iowa Total Care Managed Medicaid	$5.57
Rate for Payer: Medical Associates Commercial	$8.36
Rate for Payer: Medical Associates Managed Medicare	$5.57
Rate for Payer: Midlands Choice Commercial	$7.80
Rate for Payer: Molina Healthcare Managed Medicaid	$5.65
Rate for Payer: Molina Healthcare Managed Medicare	$5.65
Rate for Payer: Oscar Health of IA Commercial	$8.36
Rate for Payer: Partners Health Alliance Commercial	$8.36
Rate for Payer: United Healthcare Commercial	$10.03
Rate for Payer: United Healthcare Managed Medicare	$6.57

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 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	$10.75
Rate for Payer: Aetna of IA Commercial	$10.75
Rate for Payer: Aetna of IA Medical Rental Products	$10.75
Rate for Payer: Cash Price	$9.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.96
Rate for Payer: Medical Associates Commercial	$8.96
Rate for Payer: Midlands Choice Commercial	$8.36
Rate for Payer: United Healthcare Commercial	$10.75

THP Hydroxyzine 25mg tab [VDMC]

Facility

$11.94

Service Code	HCPCS A9270
Hospital Charge Code	10739255
Hospital Revenue Code	259
Min. Negotiated Rate	$5.97
Max. Negotiated Rate	$10.75
Rate for Payer: Aetna of IA Commercial	$10.75
Rate for Payer: Aetna of IA Medical Rental Products	$10.75
Rate for Payer: Aetna of IA Medicare	$6.81
Rate for Payer: Amerigroup Medicaid	$6.03
Rate for Payer: Amerigroup Medicare	$6.03
Rate for Payer: Cash Price	$9.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.96
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.97
Rate for Payer: Iowa Total Care Managed Medicaid	$5.97
Rate for Payer: Medical Associates Commercial	$8.96
Rate for Payer: Medical Associates Managed Medicare	$5.97
Rate for Payer: Midlands Choice Commercial	$8.36
Rate for Payer: Molina Healthcare Managed Medicaid	$6.06
Rate for Payer: Molina Healthcare Managed Medicare	$6.06
Rate for Payer: Oscar Health of IA Commercial	$8.96
Rate for Payer: Partners Health Alliance Commercial	$8.96
Rate for Payer: United Healthcare Commercial	$10.75
Rate for Payer: United Healthcare Managed Medicare	$7.04

THP levofloxacin 500 mg tab [VDMC]

Facility

$14.56

Service Code	HCPCS A9270
Hospital Charge Code	10729129
Hospital Revenue Code	259
Min. Negotiated Rate	$7.28
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	$7.35
Rate for Payer: Amerigroup Medicare	$7.35
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	$7.28
Rate for Payer: Iowa Total Care Managed Medicaid	$7.28
Rate for Payer: Medical Associates Commercial	$10.92
Rate for Payer: Medical Associates Managed Medicare	$7.28
Rate for Payer: Midlands Choice Commercial	$10.19
Rate for Payer: Molina Healthcare Managed Medicaid	$7.39
Rate for Payer: Molina Healthcare Managed Medicare	$7.38
Rate for Payer: Oscar Health of IA Commercial	$10.92
Rate for Payer: Partners Health Alliance Commercial	$10.92
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	$38.12
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	$38.50
Rate for Payer: Amerigroup Medicare	$38.52
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	$38.14
Rate for Payer: Iowa Total Care Managed Medicaid	$38.12
Rate for Payer: Medical Associates Commercial	$57.21
Rate for Payer: Medical Associates Managed Medicare	$38.14
Rate for Payer: Midlands Choice Commercial	$53.40
Rate for Payer: Molina Healthcare Managed Medicaid	$38.71
Rate for Payer: Molina Healthcare Managed Medicare	$38.69
Rate for Payer: Oscar Health of IA Commercial	$57.21
Rate for Payer: Partners Health Alliance Commercial	$57.21
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	$11.48
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	$11.59
Rate for Payer: Amerigroup Medicare	$11.59
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	$11.48
Rate for Payer: Iowa Total Care Managed Medicaid	$11.48
Rate for Payer: Medical Associates Commercial	$17.22
Rate for Payer: Medical Associates Managed Medicare	$11.48
Rate for Payer: Midlands Choice Commercial	$16.07
Rate for Payer: Molina Healthcare Managed Medicaid	$11.65
Rate for Payer: Molina Healthcare Managed Medicare	$11.65
Rate for Payer: Oscar Health of IA Commercial	$17.22
Rate for Payer: Partners Health Alliance Commercial	$17.22
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	$6.90
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	$6.96
Rate for Payer: Amerigroup Medicare	$6.97
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	$6.90
Rate for Payer: Iowa Total Care Managed Medicaid	$6.90
Rate for Payer: Medical Associates Commercial	$10.35
Rate for Payer: Medical Associates Managed Medicare	$6.90
Rate for Payer: Midlands Choice Commercial	$9.66
Rate for Payer: Molina Healthcare Managed Medicaid	$7.00
Rate for Payer: Molina Healthcare Managed Medicare	$7.00
Rate for Payer: Oscar Health of IA Commercial	$10.35
Rate for Payer: Partners Health Alliance Commercial	$10.35
Rate for Payer: United Healthcare Commercial	$12.42
Rate for Payer: United Healthcare Managed Medicare	$8.14

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 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	$13.28
Rate for Payer: Aetna of IA Commercial	$13.28
Rate for Payer: Aetna of IA Medical Rental Products	$13.28
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	$13.28

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	$7.37
Max. Negotiated Rate	$13.28
Rate for Payer: Aetna of IA Commercial	$13.28
Rate for Payer: Aetna of IA Medical Rental Products	$13.28
Rate for Payer: Aetna of IA Medicare	$8.41
Rate for Payer: Amerigroup Medicaid	$7.44
Rate for Payer: Amerigroup Medicare	$7.45
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	$7.38
Rate for Payer: Iowa Total Care Managed Medicaid	$7.37
Rate for Payer: Medical Associates Commercial	$11.06
Rate for Payer: Medical Associates Managed Medicare	$7.38
Rate for Payer: Midlands Choice Commercial	$10.32
Rate for Payer: Molina Healthcare Managed Medicaid	$7.49
Rate for Payer: Molina Healthcare Managed Medicare	$7.48
Rate for Payer: Oscar Health of IA Commercial	$11.06
Rate for Payer: Partners Health Alliance Commercial	$11.06
Rate for Payer: United Healthcare Commercial	$13.28
Rate for Payer: United Healthcare Managed Medicare	$8.70

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 phenazopyridine 200 mg 6 tabs [VDMC]

Facility

$18.40

Service Code	HCPCS A9270
Hospital Charge Code	10730193
Hospital Revenue Code	259
Min. Negotiated Rate	$9.20
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	$9.29
Rate for Payer: Amerigroup Medicare	$9.29
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	$9.20
Rate for Payer: Iowa Total Care Managed Medicaid	$9.20
Rate for Payer: Medical Associates Commercial	$13.80
Rate for Payer: Medical Associates Managed Medicare	$9.20
Rate for Payer: Midlands Choice Commercial	$12.88
Rate for Payer: Molina Healthcare Managed Medicaid	$9.34
Rate for Payer: Molina Healthcare Managed Medicare	$9.33
Rate for Payer: Oscar Health of IA Commercial	$13.80
Rate for Payer: Partners Health Alliance Commercial	$13.80
Rate for Payer: United Healthcare Commercial	$16.56
Rate for Payer: United Healthcare Managed Medicare	$10.86

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	$5.58
Max. Negotiated Rate	$10.05
Rate for Payer: United Healthcare Commercial	$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	$5.64
Rate for Payer: Amerigroup Medicare	$5.64
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	$5.58
Rate for Payer: Iowa Total Care Managed Medicaid	$5.58
Rate for Payer: Medical Associates Commercial	$8.38
Rate for Payer: Medical Associates Managed Medicare	$5.58
Rate for Payer: Midlands Choice Commercial	$7.82
Rate for Payer: Molina Healthcare Managed Medicaid	$5.67
Rate for Payer: Molina Healthcare Managed Medicare	$5.67
Rate for Payer: Oscar Health of IA Commercial	$8.38
Rate for Payer: Partners Health Alliance Commercial	$8.38
Rate for Payer: United Healthcare Managed Medicare	$6.59

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	$7.82
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: Cash Price	$8.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.38
Rate for Payer: Medical Associates Commercial	$8.38
Rate for Payer: Midlands Choice Commercial	$7.82
Rate for Payer: United Healthcare Commercial	$10.05

THP sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Sus 30 mL [VDMC]

Facility

$32.73

Service Code	HCPCS A9270
Hospital Charge Code	11422706
Hospital Revenue Code	259
Min. Negotiated Rate	$22.91
Max. Negotiated Rate	$29.46
Rate for Payer: Aetna of IA Commercial	$29.46
Rate for Payer: Aetna of IA Medical Rental Products	$29.46
Rate for Payer: Cash Price	$26.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.55
Rate for Payer: Medical Associates Commercial	$24.55
Rate for Payer: Midlands Choice Commercial	$22.91
Rate for Payer: United Healthcare Commercial	$29.46

THP sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Sus 30 mL [VDMC]

Facility

$32.73

Service Code	HCPCS A9270
Hospital Charge Code	11422706
Hospital Revenue Code	259
Min. Negotiated Rate	$16.36
Max. Negotiated Rate	$29.46
Rate for Payer: Aetna of IA Commercial	$29.46
Rate for Payer: Aetna of IA Medical Rental Products	$29.46
Rate for Payer: Aetna of IA Medicare	$18.66
Rate for Payer: Amerigroup Medicaid	$16.52
Rate for Payer: Amerigroup Medicare	$16.53
Rate for Payer: Cash Price	$26.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.55
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$16.36
Rate for Payer: Iowa Total Care Managed Medicaid	$16.36
Rate for Payer: Medical Associates Commercial	$24.55
Rate for Payer: Medical Associates Managed Medicare	$16.36
Rate for Payer: Midlands Choice Commercial	$22.91
Rate for Payer: Molina Healthcare Managed Medicaid	$16.61
Rate for Payer: Molina Healthcare Managed Medicare	$16.60
Rate for Payer: Oscar Health of IA Commercial	$24.55
Rate for Payer: Partners Health Alliance Commercial	$24.55
Rate for Payer: United Healthcare Commercial	$29.46
Rate for Payer: United Healthcare Managed Medicare	$19.31

THP sulfamethoxazole-trimethoprim DS 800 mg/160 mg 6 Tablet[VDMC]

Facility

$13.60

Service Code	HCPCS A9270
Hospital Charge Code	10735326
Hospital Revenue Code	259
Min. Negotiated Rate	$6.80
Max. Negotiated Rate	$12.24
Rate for Payer: Aetna of IA Commercial	$12.24
Rate for Payer: Aetna of IA Medical Rental Products	$12.24
Rate for Payer: Aetna of IA Medicare	$7.75
Rate for Payer: Amerigroup Medicaid	$6.86
Rate for Payer: Amerigroup Medicare	$6.87
Rate for Payer: Cash Price	$10.88
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.80
Rate for Payer: Iowa Total Care Managed Medicaid	$6.80
Rate for Payer: Medical Associates Commercial	$10.20
Rate for Payer: Medical Associates Managed Medicare	$6.80
Rate for Payer: Midlands Choice Commercial	$9.52
Rate for Payer: Molina Healthcare Managed Medicaid	$6.90
Rate for Payer: Molina Healthcare Managed Medicare	$6.90
Rate for Payer: Oscar Health of IA Commercial	$10.20
Rate for Payer: Partners Health Alliance Commercial	$10.20
Rate for Payer: United Healthcare Commercial	$12.24
Rate for Payer: United Healthcare Managed Medicare	$8.02

THP sulfamethoxazole-trimethoprim DS 800 mg/160 mg 6 Tablet[VDMC]

Facility

$13.60

Service Code	HCPCS A9270
Hospital Charge Code	10735326
Hospital Revenue Code	259
Min. Negotiated Rate	$9.52
Max. Negotiated Rate	$12.24
Rate for Payer: Aetna of IA Commercial	$12.24
Rate for Payer: Aetna of IA Medical Rental Products	$12.24
Rate for Payer: Cash Price	$10.88
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.20
Rate for Payer: Medical Associates Commercial	$10.20
Rate for Payer: Midlands Choice Commercial	$9.52
Rate for Payer: United Healthcare Commercial	$12.24

Know your out-of-pocket cost for care.

All Charges