Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ziprasidone 20 mg Cap [VDMC]

Facility

$2.46

Service Code	HCPCS A9270
Hospital Charge Code	10608440
Hospital Revenue Code	259
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$2.21
Rate for Payer: Aetna of IA Commercial	$2.21
Rate for Payer: Aetna of IA Medical Rental Products	$2.21
Rate for Payer: Cash Price	$1.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.84
Rate for Payer: Medical Associates Commercial	$1.84
Rate for Payer: Midlands Choice Commercial	$1.72
Rate for Payer: United Healthcare Commercial	$2.21

ziprasidone 20 mg Cap [VDMC]

Facility

$2.46

Service Code	HCPCS A9270
Hospital Charge Code	10608440
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.21
Rate for Payer: Aetna of IA Commercial	$2.21
Rate for Payer: Aetna of IA Medical Rental Products	$2.21
Rate for Payer: Aetna of IA Medicare	$1.40
Rate for Payer: Amerigroup Medicaid	$1.24
Rate for Payer: Amerigroup Medicare	$1.24
Rate for Payer: Cash Price	$1.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.84
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.23
Rate for Payer: Iowa Total Care Managed Medicaid	$1.23
Rate for Payer: Medical Associates Commercial	$1.84
Rate for Payer: Medical Associates Managed Medicare	$1.23
Rate for Payer: Midlands Choice Commercial	$1.72
Rate for Payer: Molina Healthcare Managed Medicaid	$1.25
Rate for Payer: Molina Healthcare Managed Medicare	$1.25
Rate for Payer: Oscar Health of IA Commercial	$1.84
Rate for Payer: Partners Health Alliance Commercial	$1.84
Rate for Payer: United Healthcare Commercial	$2.21
Rate for Payer: United Healthcare Managed Medicare	$1.45

ziprasidone 20 mg/ml IM SDV Inj [VDMC]

Facility

$147.62

Service Code	HCPCS J3486
Hospital Charge Code	10428897
Hospital Revenue Code	259
Min. Negotiated Rate	$103.33
Max. Negotiated Rate	$132.86
Rate for Payer: Aetna of IA Commercial	$132.86
Rate for Payer: Aetna of IA Medical Rental Products	$132.86
Rate for Payer: Cash Price	$118.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.72
Rate for Payer: Medical Associates Commercial	$110.72
Rate for Payer: Midlands Choice Commercial	$103.33
Rate for Payer: United Healthcare Commercial	$132.86

ziprasidone 20 mg/ml IM SDV Inj [VDMC]

Facility

$147.62

Service Code	HCPCS J3486
Hospital Charge Code	10428897
Hospital Revenue Code	259
Min. Negotiated Rate	$73.78
Max. Negotiated Rate	$132.86
Rate for Payer: Aetna of IA Commercial	$132.86
Rate for Payer: Aetna of IA Medical Rental Products	$132.86
Rate for Payer: Aetna of IA Medicare	$84.14
Rate for Payer: Amerigroup Medicaid	$74.50
Rate for Payer: Amerigroup Medicare	$74.55
Rate for Payer: Cash Price	$118.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$110.72
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$73.81
Rate for Payer: Iowa Total Care Managed Medicaid	$73.78
Rate for Payer: Medical Associates Commercial	$110.72
Rate for Payer: Medical Associates Managed Medicare	$73.81
Rate for Payer: Midlands Choice Commercial	$103.33
Rate for Payer: Molina Healthcare Managed Medicaid	$74.92
Rate for Payer: Molina Healthcare Managed Medicare	$74.87
Rate for Payer: Oscar Health of IA Commercial	$110.72
Rate for Payer: Partners Health Alliance Commercial	$110.72
Rate for Payer: United Healthcare Commercial	$132.86
Rate for Payer: United Healthcare Managed Medicare	$87.10

zoledronic acid 4mg/5ml SDV 5 ml [VDMC]

Facility

$184.32

Service Code	HCPCS J3489
Hospital Charge Code	10428966
Hospital Revenue Code	259
Min. Negotiated Rate	$92.12
Max. Negotiated Rate	$165.89
Rate for Payer: Aetna of IA Commercial	$165.89
Rate for Payer: Aetna of IA Medical Rental Products	$165.89
Rate for Payer: Aetna of IA Medicare	$105.06
Rate for Payer: Amerigroup Medicaid	$93.03
Rate for Payer: Amerigroup Medicare	$93.08
Rate for Payer: Cash Price	$147.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$138.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$92.16
Rate for Payer: Iowa Total Care Managed Medicaid	$92.12
Rate for Payer: Medical Associates Commercial	$138.24
Rate for Payer: Medical Associates Managed Medicare	$92.16
Rate for Payer: Midlands Choice Commercial	$129.02
Rate for Payer: Molina Healthcare Managed Medicaid	$93.54
Rate for Payer: Molina Healthcare Managed Medicare	$93.49
Rate for Payer: Oscar Health of IA Commercial	$138.24
Rate for Payer: Partners Health Alliance Commercial	$138.24
Rate for Payer: United Healthcare Commercial	$165.89
Rate for Payer: United Healthcare Managed Medicare	$108.75

zoledronic acid 4mg/5ml SDV 5 ml [VDMC]

Facility

$184.32

Service Code	HCPCS J3489
Hospital Charge Code	10428966
Hospital Revenue Code	259
Min. Negotiated Rate	$129.02
Max. Negotiated Rate	$165.89
Rate for Payer: Aetna of IA Commercial	$165.89
Rate for Payer: Aetna of IA Medical Rental Products	$165.89
Rate for Payer: Cash Price	$147.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$138.24
Rate for Payer: Medical Associates Commercial	$138.24
Rate for Payer: Midlands Choice Commercial	$129.02
Rate for Payer: United Healthcare Commercial	$165.89

zoledronic acid 5 mg/100 mL SD PREMIX [VDMC]

Facility

$290.92

Service Code	HCPCS J3489
Hospital Charge Code	11224002
Hospital Revenue Code	259
Min. Negotiated Rate	$145.40
Max. Negotiated Rate	$261.83
Rate for Payer: Aetna of IA Commercial	$261.83
Rate for Payer: Aetna of IA Medical Rental Products	$261.83
Rate for Payer: Aetna of IA Medicare	$165.82
Rate for Payer: Amerigroup Medicaid	$146.83
Rate for Payer: Amerigroup Medicare	$146.91
Rate for Payer: Cash Price	$232.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$218.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$145.46
Rate for Payer: Iowa Total Care Managed Medicaid	$145.40
Rate for Payer: Medical Associates Commercial	$218.19
Rate for Payer: Medical Associates Managed Medicare	$145.46
Rate for Payer: Midlands Choice Commercial	$203.64
Rate for Payer: Molina Healthcare Managed Medicaid	$147.64
Rate for Payer: Molina Healthcare Managed Medicare	$147.55
Rate for Payer: Oscar Health of IA Commercial	$218.19
Rate for Payer: Partners Health Alliance Commercial	$218.19
Rate for Payer: United Healthcare Commercial	$261.83
Rate for Payer: United Healthcare Managed Medicare	$171.64

zoledronic acid 5 mg/100 mL SD PREMIX [VDMC]

Facility

$290.92

Service Code	HCPCS J3489
Hospital Charge Code	11224002
Hospital Revenue Code	259
Min. Negotiated Rate	$203.64
Max. Negotiated Rate	$261.83
Rate for Payer: Aetna of IA Commercial	$261.83
Rate for Payer: Aetna of IA Medical Rental Products	$261.83
Rate for Payer: Cash Price	$232.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$218.19
Rate for Payer: Medical Associates Commercial	$218.19
Rate for Payer: Midlands Choice Commercial	$203.64
Rate for Payer: United Healthcare Commercial	$261.83

zolpidem 5 mg Tab [VDMC]

Facility

$3.21

Service Code	HCPCS A9270
Hospital Charge Code	10429031
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$1.63
Rate for Payer: Oscar Health of IA Commercial	$2.41
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 [VDMC]

Facility

$3.21

Service Code	HCPCS A9270
Hospital Charge Code	10429031
Hospital Revenue Code	259
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 [VDMC]

Facility

$2.54

Service Code	HCPCS A9270
Hospital Charge Code	10429098
Hospital Revenue Code	259
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 [VDMC]

Facility

$2.54

Service Code	HCPCS A9270
Hospital Charge Code	10429098
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$1.29
Rate for Payer: Oscar Health of IA Commercial	$1.90
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 [VDMC]

Facility

$1.45

Service Code	HCPCS A9270
Hospital Charge Code	22327744
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
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: 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: 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: Molina Healthcare Managed Medicare	$0.74
Rate for Payer: Oscar Health of IA Commercial	$1.09
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

zonisamide 50 mg Cap [VDMC]

Facility

$1.45

Service Code	HCPCS A9270
Hospital Charge Code	22327744
Hospital Revenue Code	259
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 [VDMC]

Facility

$365.85

Service Code	HCPCS 90750
Hospital Charge Code	14503470
Hospital Revenue Code	259
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: 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: Molina Healthcare Managed Medicare	$185.56
Rate for Payer: Oscar Health of IA Commercial	$274.39
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
Rate for Payer: Wellmark IA HMO	$207.70
Rate for Payer: Wellmark IA PPO	$228.47

zoster vaccine recombinant IM Injection kit 50 and older [VDMC]

Facility

$365.85

Service Code	HCPCS 90750
Hospital Charge Code	14503470
Hospital Revenue Code	259
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

Know your out-of-pocket cost for care.

All Charges