Van Diest Medical Center

All Charges

Charge

Type

Price

zolpidem 5 mg Tab

Facility OP

$3.21

Service Code	CPT A9270
Hospital Charge Code	43755133
Hospital Revenue Code	637
Min. Negotiated Rate	$1.60
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of IA Commercial	$2.89
Rate for Payer: Aetna of IA Medical Rental Products	$2.89
Rate for Payer: Aetna of IA Medicare	$1.83
Rate for Payer: Amerigroup Medicaid	$1.62
Rate for Payer: Amerigroup Medicare	$1.62
Rate for Payer: Cash Price	$2.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.41
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.60
Rate for Payer: Iowa Total Care Managed Medicaid	$1.60
Rate for Payer: Medical Associates Commercial	$2.41
Rate for Payer: Medical Associates Managed Medicare	$1.60
Rate for Payer: Midlands Choice Commercial	$2.25
Rate for Payer: Molina Healthcare Managed Medicaid	$1.63
Rate for Payer: Partners Health Alliance Commercial	$2.41
Rate for Payer: United Healthcare Commercial	$2.89
Rate for Payer: United Healthcare Managed Medicare	$1.89

zolpidem 5 mg Tab

Facility IP

$3.21

Service Code	CPT A9270
Hospital Charge Code	43755133
Hospital Revenue Code	637
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$2.89
Rate for Payer: Aetna of IA Commercial	$2.89
Rate for Payer: Aetna of IA Medical Rental Products	$2.89
Rate for Payer: Cash Price	$2.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.41
Rate for Payer: Medical Associates Commercial	$2.41
Rate for Payer: Midlands Choice Commercial	$2.25
Rate for Payer: United Healthcare Commercial	$2.89

zonisamide 100 mg Cap

Facility IP

$2.54

Service Code	CPT A9270
Hospital Charge Code	43700532
Hospital Revenue Code	637
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of IA Commercial	$2.29
Rate for Payer: Aetna of IA Medical Rental Products	$2.29
Rate for Payer: Cash Price	$2.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.90
Rate for Payer: Medical Associates Commercial	$1.90
Rate for Payer: Midlands Choice Commercial	$1.78
Rate for Payer: United Healthcare Commercial	$2.29

zonisamide 100 mg Cap

Facility OP

$2.54

Service Code	CPT A9270
Hospital Charge Code	43700532
Hospital Revenue Code	637
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of IA Commercial	$2.29
Rate for Payer: Aetna of IA Medical Rental Products	$2.29
Rate for Payer: Aetna of IA Medicare	$1.45
Rate for Payer: Amerigroup Medicaid	$1.28
Rate for Payer: Amerigroup Medicare	$1.28
Rate for Payer: Cash Price	$2.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.27
Rate for Payer: Iowa Total Care Managed Medicaid	$1.27
Rate for Payer: Medical Associates Commercial	$1.90
Rate for Payer: Medical Associates Managed Medicare	$1.27
Rate for Payer: Midlands Choice Commercial	$1.78
Rate for Payer: Molina Healthcare Managed Medicaid	$1.29
Rate for Payer: Partners Health Alliance Commercial	$1.90
Rate for Payer: United Healthcare Commercial	$2.29
Rate for Payer: United Healthcare Managed Medicare	$1.50

zonisamide 50 mg Cap

Facility OP

$1.45

Service Code	CPT 90750
Hospital Charge Code	43700140
Hospital Revenue Code	636
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$228.47
Rate for Payer: Aetna of IA Commercial	$1.30
Rate for Payer: Aetna of IA Medical Rental Products	$1.30
Rate for Payer: Aetna of IA Medicare	$0.83
Rate for Payer: Amerigroup Medicaid	$0.73
Rate for Payer: Amerigroup Medicare	$0.73
Rate for Payer: Cash Price	$1.16
Rate for Payer: Cash Price	$1.16
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.09
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.73
Rate for Payer: Iowa Total Care Managed Medicaid	$0.72
Rate for Payer: Medical Associates Commercial	$1.09
Rate for Payer: Medical Associates Managed Medicare	$0.73
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: Molina Healthcare Managed Medicaid	$0.74
Rate for Payer: Partners Health Alliance Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.30
Rate for Payer: United Healthcare Managed Medicare	$0.86
Rate for Payer: Wellmark IA HMO	$207.70
Rate for Payer: Wellmark IA PPO	$228.47

zonisamide 50 mg Cap

Facility IP

$1.45

Service Code	CPT 90750
Hospital Charge Code	43700140
Hospital Revenue Code	636
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.30
Rate for Payer: Aetna of IA Commercial	$1.30
Rate for Payer: Aetna of IA Medical Rental Products	$1.30
Rate for Payer: Cash Price	$1.16
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.09
Rate for Payer: Medical Associates Commercial	$1.09
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: United Healthcare Commercial	$1.30

zoster vaccine recombinant IM Injection kit 50 and older

Facility OP

$365.85

Service Code	NDC 58160-0823-11
Hospital Charge Code	43700140
Hospital Revenue Code	636
Min. Negotiated Rate	$182.85
Max. Negotiated Rate	$329.26
Rate for Payer: Aetna of IA Commercial	$329.26
Rate for Payer: Aetna of IA Medical Rental Products	$329.26
Rate for Payer: Aetna of IA Medicare	$208.53
Rate for Payer: Amerigroup Medicaid	$184.64
Rate for Payer: Amerigroup Medicare	$184.75
Rate for Payer: Cash Price	$292.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$274.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$182.92
Rate for Payer: Iowa Total Care Managed Medicaid	$182.85
Rate for Payer: Medical Associates Commercial	$274.39
Rate for Payer: Medical Associates Managed Medicare	$182.92
Rate for Payer: Midlands Choice Commercial	$256.10
Rate for Payer: Molina Healthcare Managed Medicaid	$185.67
Rate for Payer: Partners Health Alliance Commercial	$274.39
Rate for Payer: United Healthcare Commercial	$329.26
Rate for Payer: United Healthcare Managed Medicare	$215.85

zoster vaccine recombinant IM Injection kit 50 and older

Facility IP

$365.85

Service Code	NDC 58160-0823-11
Hospital Charge Code	43700140
Hospital Revenue Code	636
Min. Negotiated Rate	$256.10
Max. Negotiated Rate	$329.26
Rate for Payer: Aetna of IA Commercial	$329.26
Rate for Payer: Aetna of IA Medical Rental Products	$329.26
Rate for Payer: Cash Price	$292.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$274.39
Rate for Payer: Medical Associates Commercial	$274.39
Rate for Payer: Midlands Choice Commercial	$256.10
Rate for Payer: United Healthcare Commercial	$329.26

Price Transparency.