Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

zolpidem 5 mg Tab [VDMC]

Facility

$3.21

Service Code	HCPCS A9270
Hospital Charge Code	10429031
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
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	$1.85
Rate for Payer: Amerigroup Medicare	$1.46
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	$1.44
Rate for Payer: Iowa Total Care Managed Medicaid	$1.83
Rate for Payer: Medical Associates Commercial	$2.41
Rate for Payer: Medical Associates Managed Medicare	$1.44
Rate for Payer: Midlands Choice Commercial	$2.25
Rate for Payer: Molina Healthcare Managed Medicaid	$1.86
Rate for Payer: Partners Health Alliance Commercial	$1.66
Rate for Payer: United Healthcare Commercial	$2.89
Rate for Payer: United Healthcare Managed Medicare	$1.89

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	$1.14
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	$1.47
Rate for Payer: Amerigroup Medicare	$1.15
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	$1.14
Rate for Payer: Iowa Total Care Managed Medicaid	$1.45
Rate for Payer: Medical Associates Commercial	$1.90
Rate for Payer: Medical Associates Managed Medicare	$1.14
Rate for Payer: Midlands Choice Commercial	$1.78
Rate for Payer: Molina Healthcare Managed Medicaid	$1.47
Rate for Payer: Partners Health Alliance Commercial	$1.31
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	$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

zonisamide 50 mg Cap [VDMC]

Facility

$1.45

Service Code	HCPCS A9270
Hospital Charge Code	22327744
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
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	$0.84
Rate for Payer: Amerigroup Medicare	$0.66
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	$0.65
Rate for Payer: Iowa Total Care Managed Medicaid	$0.83
Rate for Payer: Medical Associates Commercial	$1.09
Rate for Payer: Medical Associates Managed Medicare	$0.65
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: Molina Healthcare Managed Medicaid	$0.84
Rate for Payer: Partners Health Alliance Commercial	$0.75
Rate for Payer: United Healthcare Commercial	$1.30
Rate for Payer: United Healthcare Managed Medicare	$0.86

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

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	$164.63
Max. Negotiated Rate	$400.65
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	$211.02
Rate for Payer: Amerigroup Medicare	$166.28
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	$164.63
Rate for Payer: Iowa Total Care Managed Medicaid	$208.97
Rate for Payer: Medical Associates Commercial	$274.39
Rate for Payer: Medical Associates Managed Medicare	$164.63
Rate for Payer: Midlands Choice Commercial	$256.10
Rate for Payer: Molina Healthcare Managed Medicaid	$212.05
Rate for Payer: Partners Health Alliance Commercial	$189.33
Rate for Payer: United Healthcare Commercial	$329.26
Rate for Payer: United Healthcare Managed Medicare	$215.85
Rate for Payer: Wellmark IA HMO WHPI	$363.72
Rate for Payer: Wellmark IA PPO	$400.65

Know your out-of-pocket cost for care.