Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

clobetasol propionate topical 0.05% Sol 50ml [VDMC]

Facility

$108.00

Service Code	HCPCS DE200
Hospital Charge Code	21028886
Hospital Revenue Code	259
Min. Negotiated Rate	$75.60
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: United Healthcare Commercial	$97.20

clobetasol propionate topical 0.05% Sol 50ml [VDMC]

Facility

$108.00

Service Code	HCPCS DE200
Hospital Charge Code	21028886
Hospital Revenue Code	259
Min. Negotiated Rate	$53.98
Max. Negotiated Rate	$97.20
Rate for Payer: Aetna of IA Commercial	$97.20
Rate for Payer: Aetna of IA Medical Rental Products	$97.20
Rate for Payer: Aetna of IA Medicare	$61.56
Rate for Payer: Amerigroup Medicaid	$54.51
Rate for Payer: Amerigroup Medicare	$54.54
Rate for Payer: Cash Price	$86.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$81.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$54.00
Rate for Payer: Iowa Total Care Managed Medicaid	$53.98
Rate for Payer: Medical Associates Commercial	$81.00
Rate for Payer: Medical Associates Managed Medicare	$54.00
Rate for Payer: Midlands Choice Commercial	$75.60
Rate for Payer: Molina Healthcare Managed Medicaid	$54.81
Rate for Payer: Molina Healthcare Managed Medicare	$54.78
Rate for Payer: Oscar Health of IA Commercial	$81.00
Rate for Payer: Partners Health Alliance Commercial	$81.00
Rate for Payer: United Healthcare Commercial	$97.20
Rate for Payer: United Healthcare Managed Medicare	$63.72

clonazePAM 0.25 mg Dis Tab [VDMC]

Facility

$4.53

Service Code	HCPCS A9270
Hospital Charge Code	10378545
Hospital Revenue Code	259
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$4.08
Rate for Payer: Aetna of IA Commercial	$4.08
Rate for Payer: Aetna of IA Medical Rental Products	$4.08
Rate for Payer: Aetna of IA Medicare	$2.58
Rate for Payer: Amerigroup Medicaid	$2.29
Rate for Payer: Amerigroup Medicare	$2.29
Rate for Payer: Cash Price	$3.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.26
Rate for Payer: Iowa Total Care Managed Medicaid	$2.26
Rate for Payer: Medical Associates Commercial	$3.40
Rate for Payer: Medical Associates Managed Medicare	$2.26
Rate for Payer: Midlands Choice Commercial	$3.17
Rate for Payer: Molina Healthcare Managed Medicaid	$2.30
Rate for Payer: Molina Healthcare Managed Medicare	$2.30
Rate for Payer: Oscar Health of IA Commercial	$3.40
Rate for Payer: Partners Health Alliance Commercial	$3.40
Rate for Payer: United Healthcare Commercial	$4.08
Rate for Payer: United Healthcare Managed Medicare	$2.67

clonazePAM 0.25 mg Dis Tab [VDMC]

Facility

$4.53

Service Code	HCPCS A9270
Hospital Charge Code	10378545
Hospital Revenue Code	259
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$4.08
Rate for Payer: Aetna of IA Commercial	$4.08
Rate for Payer: Aetna of IA Medical Rental Products	$4.08
Rate for Payer: Cash Price	$3.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.40
Rate for Payer: Medical Associates Commercial	$3.40
Rate for Payer: Midlands Choice Commercial	$3.17
Rate for Payer: United Healthcare Commercial	$4.08

clonazePAM 0.5 mg Tab [VDMC]

Facility

$3.11

Service Code	HCPCS A9270
Hospital Charge Code	10378614
Hospital Revenue Code	259
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna of IA Commercial	$2.80
Rate for Payer: Aetna of IA Medical Rental Products	$2.80
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.33
Rate for Payer: Medical Associates Commercial	$2.33
Rate for Payer: Midlands Choice Commercial	$2.18
Rate for Payer: United Healthcare Commercial	$2.80

clonazePAM 0.5 mg Tab [VDMC]

Facility

$3.11

Service Code	HCPCS A9270
Hospital Charge Code	10378614
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna of IA Commercial	$2.80
Rate for Payer: Aetna of IA Medical Rental Products	$2.80
Rate for Payer: Aetna of IA Medicare	$1.77
Rate for Payer: Amerigroup Medicaid	$1.57
Rate for Payer: Amerigroup Medicare	$1.57
Rate for Payer: Cash Price	$2.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.33
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.56
Rate for Payer: Iowa Total Care Managed Medicaid	$1.55
Rate for Payer: Medical Associates Commercial	$2.33
Rate for Payer: Medical Associates Managed Medicare	$1.56
Rate for Payer: Midlands Choice Commercial	$2.18
Rate for Payer: Molina Healthcare Managed Medicaid	$1.58
Rate for Payer: Molina Healthcare Managed Medicare	$1.58
Rate for Payer: Oscar Health of IA Commercial	$2.33
Rate for Payer: Partners Health Alliance Commercial	$2.33
Rate for Payer: United Healthcare Commercial	$2.80
Rate for Payer: United Healthcare Managed Medicare	$1.83

clonazePAM 1 mg Tab [VDMC]

Facility

$3.16

Service Code	HCPCS A9270
Hospital Charge Code	10378683
Hospital Revenue Code	259
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Aetna of IA Medicare	$1.80
Rate for Payer: Amerigroup Medicaid	$1.59
Rate for Payer: Amerigroup Medicare	$1.60
Rate for Payer: Cash Price	$2.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.58
Rate for Payer: Iowa Total Care Managed Medicaid	$1.58
Rate for Payer: Medical Associates Commercial	$2.37
Rate for Payer: Medical Associates Managed Medicare	$1.58
Rate for Payer: Midlands Choice Commercial	$2.21
Rate for Payer: Molina Healthcare Managed Medicaid	$1.60
Rate for Payer: Molina Healthcare Managed Medicare	$1.60
Rate for Payer: Oscar Health of IA Commercial	$2.37
Rate for Payer: Partners Health Alliance Commercial	$2.37
Rate for Payer: United Healthcare Commercial	$2.84
Rate for Payer: United Healthcare Managed Medicare	$1.86

clonazePAM 1 mg Tab [VDMC]

Facility

$3.16

Service Code	HCPCS A9270
Hospital Charge Code	10378683
Hospital Revenue Code	259
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Cash Price	$2.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.37
Rate for Payer: Medical Associates Commercial	$2.37
Rate for Payer: Midlands Choice Commercial	$2.21
Rate for Payer: United Healthcare Commercial	$2.84

cloNIDine 0.1 mg/24 hr Transderm ER Film [VDMC]

Facility

$44.15

Service Code	HCPCS A9270
Hospital Charge Code	10378821
Hospital Revenue Code	259
Min. Negotiated Rate	$22.07
Max. Negotiated Rate	$39.74
Rate for Payer: Aetna of IA Commercial	$39.74
Rate for Payer: Aetna of IA Medical Rental Products	$39.74
Rate for Payer: Aetna of IA Medicare	$25.17
Rate for Payer: Amerigroup Medicaid	$22.28
Rate for Payer: Amerigroup Medicare	$22.30
Rate for Payer: Cash Price	$35.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$22.08
Rate for Payer: Iowa Total Care Managed Medicaid	$22.07
Rate for Payer: Medical Associates Commercial	$33.11
Rate for Payer: Medical Associates Managed Medicare	$22.08
Rate for Payer: Midlands Choice Commercial	$30.90
Rate for Payer: Molina Healthcare Managed Medicaid	$22.41
Rate for Payer: Molina Healthcare Managed Medicare	$22.39
Rate for Payer: Oscar Health of IA Commercial	$33.11
Rate for Payer: Partners Health Alliance Commercial	$33.11
Rate for Payer: United Healthcare Commercial	$39.74
Rate for Payer: United Healthcare Managed Medicare	$26.05

cloNIDine 0.1 mg/24 hr Transderm ER Film [VDMC]

Facility

$44.15

Service Code	HCPCS A9270
Hospital Charge Code	10378821
Hospital Revenue Code	259
Min. Negotiated Rate	$30.90
Max. Negotiated Rate	$39.74
Rate for Payer: Aetna of IA Commercial	$39.74
Rate for Payer: Aetna of IA Medical Rental Products	$39.74
Rate for Payer: Cash Price	$35.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.11
Rate for Payer: Medical Associates Commercial	$33.11
Rate for Payer: Midlands Choice Commercial	$30.90
Rate for Payer: United Healthcare Commercial	$39.74

cloNIDine 0.1 mg Tab [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10378752
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: United Healthcare Commercial	$0.96

cloNIDine 0.1 mg Tab [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10378752
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Aetna of IA Medicare	$0.61
Rate for Payer: Amerigroup Medicaid	$0.54
Rate for Payer: Amerigroup Medicare	$0.54
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.54
Rate for Payer: Iowa Total Care Managed Medicaid	$0.53
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Medical Associates Managed Medicare	$0.54
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: Molina Healthcare Managed Medicaid	$0.54
Rate for Payer: Molina Healthcare Managed Medicare	$0.54
Rate for Payer: Oscar Health of IA Commercial	$0.80
Rate for Payer: Partners Health Alliance Commercial	$0.80
Rate for Payer: United Healthcare Commercial	$0.96
Rate for Payer: United Healthcare Managed Medicare	$0.63

cloNIDine 0.3 mg/24 hr Transderm ER Film [VDMC]

Facility

$78.33

Service Code	HCPCS A9270
Hospital Charge Code	10378886
Hospital Revenue Code	259
Min. Negotiated Rate	$39.15
Max. Negotiated Rate	$70.50
Rate for Payer: Aetna of IA Commercial	$70.50
Rate for Payer: Aetna of IA Medical Rental Products	$70.50
Rate for Payer: Aetna of IA Medicare	$44.65
Rate for Payer: Amerigroup Medicaid	$39.53
Rate for Payer: Amerigroup Medicare	$39.56
Rate for Payer: Cash Price	$62.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$39.16
Rate for Payer: Iowa Total Care Managed Medicaid	$39.15
Rate for Payer: Medical Associates Commercial	$58.75
Rate for Payer: Medical Associates Managed Medicare	$39.16
Rate for Payer: Midlands Choice Commercial	$54.83
Rate for Payer: Molina Healthcare Managed Medicaid	$39.75
Rate for Payer: Molina Healthcare Managed Medicare	$39.73
Rate for Payer: Oscar Health of IA Commercial	$58.75
Rate for Payer: Partners Health Alliance Commercial	$58.75
Rate for Payer: United Healthcare Commercial	$70.50
Rate for Payer: United Healthcare Managed Medicare	$46.21

cloNIDine 0.3 mg/24 hr Transderm ER Film [VDMC]

Facility

$78.33

Service Code	HCPCS A9270
Hospital Charge Code	10378886
Hospital Revenue Code	259
Min. Negotiated Rate	$54.83
Max. Negotiated Rate	$70.50
Rate for Payer: Aetna of IA Commercial	$70.50
Rate for Payer: Aetna of IA Medical Rental Products	$70.50
Rate for Payer: Cash Price	$62.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.75
Rate for Payer: Medical Associates Commercial	$58.75
Rate for Payer: Midlands Choice Commercial	$54.83
Rate for Payer: United Healthcare Commercial	$70.50

clopidogrel 75 mg Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10378951
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
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	$0.85
Rate for Payer: Amerigroup Medicare	$0.85
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	$0.85
Rate for Payer: Iowa Total Care Managed Medicaid	$0.84
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Medical Associates Managed Medicare	$0.85
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: Molina Healthcare Managed Medicaid	$0.86
Rate for Payer: Molina Healthcare Managed Medicare	$0.86
Rate for Payer: Oscar Health of IA Commercial	$1.27
Rate for Payer: Partners Health Alliance Commercial	$1.27
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Managed Medicare	$1.00

clopidogrel 75 mg Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10378951
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

CLOSED REDUCTION

Professional

Both

$1,621.00

Service Code	CPT 25535
Hospital Charge Code	7982868
Hospital Revenue Code	981
Min. Negotiated Rate	$423.81
Max. Negotiated Rate	$1,134.70
Rate for Payer: Aetna of IA Medicare	$423.81
Rate for Payer: Amerigroup Medicaid	$438.22
Rate for Payer: Cash Price	$1,296.80
Rate for Payer: Cash Price	$1,296.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$508.57
Rate for Payer: Iowa Total Care Managed Medicaid	$432.29
Rate for Payer: Medical Associates Commercial	$762.86
Rate for Payer: Medical Associates Managed Medicare	$423.81
Rate for Payer: Midlands Choice Commercial	$1,134.70
Rate for Payer: Oscar Health of IA Commercial	$733.19
Rate for Payer: Partners Health Alliance Commercial	$635.72

CLOSED TREATMENT OF CARPAL BONE FX

Professional

Both

$1,464.00

Service Code	CPT 25635
Hospital Charge Code	8822636
Hospital Revenue Code	981
Min. Negotiated Rate	$392.82
Max. Negotiated Rate	$1,024.80
Rate for Payer: Aetna of IA Medicare	$392.82
Rate for Payer: Amerigroup Medicaid	$406.18
Rate for Payer: Cash Price	$1,171.20
Rate for Payer: Cash Price	$1,171.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.38
Rate for Payer: Iowa Total Care Managed Medicaid	$400.68
Rate for Payer: Medical Associates Commercial	$707.08
Rate for Payer: Medical Associates Managed Medicare	$392.82
Rate for Payer: Midlands Choice Commercial	$1,024.80
Rate for Payer: Oscar Health of IA Commercial	$679.58
Rate for Payer: Partners Health Alliance Commercial	$589.23

Closed treatment of post hip arthroplasty dislocation; without anesthesia

Facility

$3,346.57

Service Code	CPT 27265
Hospital Revenue Code	490
Min. Negotiated Rate	$3,042.34
Max. Negotiated Rate	$3,346.57
Rate for Payer: Wellmark IA HMO	$3,042.34
Rate for Payer: Wellmark IA PPO	$3,346.57

Clostridioides difficile Toxin by EIA DMCL

Facility

$58.00

Service Code	CPT 87324
Hospital Charge Code	8728243
Hospital Revenue Code	306
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

Clostridioides difficile Toxin by EIA DMCL

Facility

$58.00

Service Code	CPT 87324
Hospital Charge Code	8728243
Hospital Revenue Code	306
Min. Negotiated Rate	$28.99
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$29.27
Rate for Payer: Amerigroup Medicare	$29.29
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.00
Rate for Payer: Iowa Total Care Managed Medicaid	$28.99
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$29.00
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$29.44
Rate for Payer: Molina Healthcare Managed Medicare	$29.42
Rate for Payer: Oscar Health of IA Commercial	$43.50
Rate for Payer: Partners Health Alliance Commercial	$43.50
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

CLOSTRIDIUM DIFFICILE

Facility

$152.00

Service Code	CPT 87493
Hospital Charge Code	4022795
Hospital Revenue Code	306
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Aetna of IA Medicare	$86.64
Rate for Payer: Amerigroup Medicaid	$76.71
Rate for Payer: Amerigroup Medicare	$76.76
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.00
Rate for Payer: Iowa Total Care Managed Medicaid	$75.97
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Medical Associates Managed Medicare	$76.00
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: Molina Healthcare Managed Medicaid	$77.14
Rate for Payer: Molina Healthcare Managed Medicare	$77.09
Rate for Payer: Oscar Health of IA Commercial	$114.00
Rate for Payer: Partners Health Alliance Commercial	$114.00
Rate for Payer: United Healthcare Commercial	$136.80
Rate for Payer: United Healthcare Managed Medicare	$89.68
Rate for Payer: Wellmark IA HMO	$68.82
Rate for Payer: Wellmark IA PPO	$75.70

CLOSTRIDIUM DIFFICILE

Facility

$152.00

Service Code	CPT 87493
Hospital Charge Code	4022795
Hospital Revenue Code	306
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: United Healthcare Commercial	$136.80

clotrimazole 10 mg Loz [VDMC]

Facility

$2.10

Service Code	HCPCS A9270
Hospital Charge Code	10379022
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.89
Rate for Payer: Aetna of IA Commercial	$1.89
Rate for Payer: Aetna of IA Medical Rental Products	$1.89
Rate for Payer: Aetna of IA Medicare	$1.20
Rate for Payer: Amerigroup Medicaid	$1.06
Rate for Payer: Amerigroup Medicare	$1.06
Rate for Payer: Cash Price	$1.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.05
Rate for Payer: Iowa Total Care Managed Medicaid	$1.05
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Medical Associates Managed Medicare	$1.05
Rate for Payer: Midlands Choice Commercial	$1.47
Rate for Payer: Molina Healthcare Managed Medicaid	$1.07
Rate for Payer: Molina Healthcare Managed Medicare	$1.07
Rate for Payer: Oscar Health of IA Commercial	$1.58
Rate for Payer: Partners Health Alliance Commercial	$1.58
Rate for Payer: United Healthcare Commercial	$1.89
Rate for Payer: United Healthcare Managed Medicare	$1.24

clotrimazole 10 mg Loz [VDMC]

Facility

$2.10

Service Code	HCPCS A9270
Hospital Charge Code	10379022
Hospital Revenue Code	259
Min. Negotiated Rate	$1.47
Max. Negotiated Rate	$1.89
Rate for Payer: Aetna of IA Commercial	$1.89
Rate for Payer: Aetna of IA Medical Rental Products	$1.89
Rate for Payer: Cash Price	$1.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.58
Rate for Payer: Medical Associates Commercial	$1.58
Rate for Payer: Midlands Choice Commercial	$1.47
Rate for Payer: United Healthcare Commercial	$1.89

Know your out-of-pocket cost for care.

All Charges