Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC

Facility

$14,439.53

Service Code	MSDRG 294
Min. Negotiated Rate	$14,230.25
Max. Negotiated Rate	$14,439.53
Rate for Payer: Amerigroup Medicaid	$14,369.77
Rate for Payer: Iowa Total Care Managed Medicaid	$14,230.25
Rate for Payer: Molina Healthcare Managed Medicaid	$14,439.53

DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC

Facility

$11,049.21

Service Code	MSDRG 295
Min. Negotiated Rate	$10,889.07
Max. Negotiated Rate	$11,049.21
Rate for Payer: Amerigroup Medicaid	$10,995.83
Rate for Payer: Iowa Total Care Managed Medicaid	$10,889.07
Rate for Payer: Molina Healthcare Managed Medicaid	$11,049.21

deferoxamine 2 g Pow SDV [VDMC]

Facility

$137.94

Service Code	HCPCS J0895
Hospital Charge Code	11219207
Hospital Revenue Code	259
Min. Negotiated Rate	$96.56
Max. Negotiated Rate	$124.15
Rate for Payer: Aetna of IA Commercial	$124.15
Rate for Payer: Aetna of IA Medical Rental Products	$124.15
Rate for Payer: Cash Price	$110.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.46
Rate for Payer: Medical Associates Commercial	$103.46
Rate for Payer: Midlands Choice Commercial	$96.56
Rate for Payer: United Healthcare Commercial	$124.15

deferoxamine 2 g Pow SDV [VDMC]

Facility

$137.94

Service Code	HCPCS J0895
Hospital Charge Code	11219207
Hospital Revenue Code	259
Min. Negotiated Rate	$62.07
Max. Negotiated Rate	$124.15
Rate for Payer: Aetna of IA Commercial	$124.15
Rate for Payer: Aetna of IA Medical Rental Products	$124.15
Rate for Payer: Aetna of IA Medicare	$78.63
Rate for Payer: Amerigroup Medicaid	$79.56
Rate for Payer: Amerigroup Medicare	$62.69
Rate for Payer: Cash Price	$110.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$103.46
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$62.07
Rate for Payer: Iowa Total Care Managed Medicaid	$78.79
Rate for Payer: Medical Associates Commercial	$103.46
Rate for Payer: Medical Associates Managed Medicare	$62.07
Rate for Payer: Midlands Choice Commercial	$96.56
Rate for Payer: Molina Healthcare Managed Medicaid	$79.95
Rate for Payer: Partners Health Alliance Commercial	$71.38
Rate for Payer: United Healthcare Commercial	$124.15
Rate for Payer: United Healthcare Managed Medicare	$81.38

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC

Facility

$23,489.01

Service Code	MSDRG 056
Min. Negotiated Rate	$23,148.58
Max. Negotiated Rate	$23,489.01
Rate for Payer: Amerigroup Medicaid	$23,375.52
Rate for Payer: Iowa Total Care Managed Medicaid	$23,148.58
Rate for Payer: Molina Healthcare Managed Medicaid	$23,489.01

DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC

Facility

$18,758.78

Service Code	MSDRG 057
Min. Negotiated Rate	$18,486.90
Max. Negotiated Rate	$18,758.78
Rate for Payer: Amerigroup Medicaid	$18,668.15
Rate for Payer: Iowa Total Care Managed Medicaid	$18,486.90
Rate for Payer: Molina Healthcare Managed Medicaid	$18,758.78

Dehydroepiandrosterone Sulfate DMCL

Facility

$135.00

Service Code	CPT 82627
Hospital Charge Code	8037835
Hospital Revenue Code	301
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of IA Commercial	$121.50
Rate for Payer: Aetna of IA Medical Rental Products	$121.50
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$101.25
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: United Healthcare Commercial	$121.50

Dehydroepiandrosterone Sulfate DMCL

Facility

$135.00

Service Code	CPT 82627
Hospital Charge Code	8037835
Hospital Revenue Code	301
Min. Negotiated Rate	$49.63
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of IA Commercial	$121.50
Rate for Payer: Aetna of IA Medical Rental Products	$121.50
Rate for Payer: Aetna of IA Medicare	$76.95
Rate for Payer: Amerigroup Medicaid	$77.87
Rate for Payer: Amerigroup Medicare	$61.36
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$101.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$60.75
Rate for Payer: Iowa Total Care Managed Medicaid	$77.11
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Medical Associates Managed Medicare	$60.75
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: Molina Healthcare Managed Medicaid	$78.25
Rate for Payer: Partners Health Alliance Commercial	$69.86
Rate for Payer: United Healthcare Commercial	$121.50
Rate for Payer: United Healthcare Managed Medicare	$79.65
Rate for Payer: Wellmark IA HMO WHPI	$49.63
Rate for Payer: Wellmark IA PPO	$54.67

DELIVERY ONLY

Professional

Both

$1,371.00

Service Code	CPT 59409
Hospital Charge Code	4662848
Hospital Revenue Code	983
Min. Negotiated Rate	$781.83
Max. Negotiated Rate	$1,146.50
Rate for Payer: Amerigroup Medicaid	$789.50
Rate for Payer: Cash Price	$1,096.80
Rate for Payer: Cash Price	$1,096.80
Rate for Payer: Iowa Total Care Managed Medicaid	$781.83
Rate for Payer: Medical Associates Commercial	$1,028.25
Rate for Payer: Midlands Choice Commercial	$959.70
Rate for Payer: Molina Healthcare Managed Medicaid	$785.66
Rate for Payer: Partners Health Alliance Commercial	$1,028.25
Rate for Payer: United Healthcare Commercial	$869.25
Rate for Payer: Wellmark IA HMO WHPI	$974.50
Rate for Payer: Wellmark IA PPO	$1,146.50

denosumab 120 mg/1.7 mL SDV inj [VDMC]

Facility

$6,440.32

Service Code	HCPCS J0897
Hospital Charge Code	28570546
Hospital Revenue Code	259
Min. Negotiated Rate	$2,898.14
Max. Negotiated Rate	$5,796.29
Rate for Payer: Aetna of IA Commercial	$5,796.29
Rate for Payer: Aetna of IA Medical Rental Products	$5,796.29
Rate for Payer: Aetna of IA Medicare	$3,670.98
Rate for Payer: Amerigroup Medicaid	$3,714.78
Rate for Payer: Amerigroup Medicare	$2,927.13
Rate for Payer: Cash Price	$5,152.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,830.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,898.14
Rate for Payer: Iowa Total Care Managed Medicaid	$3,678.71
Rate for Payer: Medical Associates Commercial	$4,830.24
Rate for Payer: Medical Associates Managed Medicare	$2,898.14
Rate for Payer: Midlands Choice Commercial	$4,508.22
Rate for Payer: Molina Healthcare Managed Medicaid	$3,732.81
Rate for Payer: Partners Health Alliance Commercial	$3,332.87
Rate for Payer: United Healthcare Commercial	$5,796.29
Rate for Payer: United Healthcare Managed Medicare	$3,799.79

denosumab 120 mg/1.7 mL SDV inj [VDMC]

Facility

$6,440.32

Service Code	HCPCS J0897
Hospital Charge Code	28570546
Hospital Revenue Code	259
Min. Negotiated Rate	$4,508.22
Max. Negotiated Rate	$5,796.29
Rate for Payer: Aetna of IA Commercial	$5,796.29
Rate for Payer: Aetna of IA Medical Rental Products	$5,796.29
Rate for Payer: Cash Price	$5,152.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,830.24
Rate for Payer: Medical Associates Commercial	$4,830.24
Rate for Payer: Midlands Choice Commercial	$4,508.22
Rate for Payer: United Healthcare Commercial	$5,796.29

denosumab 60 mg/mL 1 ml SDV inj [VDMC]

Facility

$3,719.58

Service Code	HCPCS J0897
Hospital Charge Code	10381296
Hospital Revenue Code	259
Min. Negotiated Rate	$1,673.81
Max. Negotiated Rate	$3,347.62
Rate for Payer: Aetna of IA Commercial	$3,347.62
Rate for Payer: Aetna of IA Medical Rental Products	$3,347.62
Rate for Payer: Aetna of IA Medicare	$2,120.16
Rate for Payer: Amerigroup Medicaid	$2,145.45
Rate for Payer: Amerigroup Medicare	$1,690.55
Rate for Payer: Cash Price	$2,975.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,789.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,673.81
Rate for Payer: Iowa Total Care Managed Medicaid	$2,124.62
Rate for Payer: Medical Associates Commercial	$2,789.68
Rate for Payer: Medical Associates Managed Medicare	$1,673.81
Rate for Payer: Midlands Choice Commercial	$2,603.71
Rate for Payer: Molina Healthcare Managed Medicaid	$2,155.87
Rate for Payer: Partners Health Alliance Commercial	$1,924.88
Rate for Payer: United Healthcare Commercial	$3,347.62
Rate for Payer: United Healthcare Managed Medicare	$2,194.55

denosumab 60 mg/mL 1 ml SDV inj [VDMC]

Facility

$3,719.58

Service Code	HCPCS J0897
Hospital Charge Code	10381296
Hospital Revenue Code	259
Min. Negotiated Rate	$2,603.71
Max. Negotiated Rate	$3,347.62
Rate for Payer: Aetna of IA Commercial	$3,347.62
Rate for Payer: Aetna of IA Medical Rental Products	$3,347.62
Rate for Payer: Cash Price	$2,975.66
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,789.68
Rate for Payer: Medical Associates Commercial	$2,789.68
Rate for Payer: Midlands Choice Commercial	$2,603.71
Rate for Payer: United Healthcare Commercial	$3,347.62

DENTAL AND ORAL DISEASES WITH CC

Facility

$8,670.02

Service Code	MSDRG 158
Min. Negotiated Rate	$8,544.37
Max. Negotiated Rate	$8,670.02
Rate for Payer: Amerigroup Medicaid	$8,628.13
Rate for Payer: Iowa Total Care Managed Medicaid	$8,544.37
Rate for Payer: Molina Healthcare Managed Medicaid	$8,670.02

DENTAL AND ORAL DISEASES WITH MCC

Facility

$13,520.73

Service Code	MSDRG 157
Min. Negotiated Rate	$13,324.77
Max. Negotiated Rate	$13,520.73
Rate for Payer: Amerigroup Medicaid	$13,455.41
Rate for Payer: Iowa Total Care Managed Medicaid	$13,324.77
Rate for Payer: Molina Healthcare Managed Medicaid	$13,520.73

DENTAL AND ORAL DISEASES WITHOUT CC/MCC

Facility

$7,420.19

Service Code	MSDRG 159
Min. Negotiated Rate	$7,312.65
Max. Negotiated Rate	$7,420.19
Rate for Payer: Amerigroup Medicaid	$7,384.34
Rate for Payer: Iowa Total Care Managed Medicaid	$7,312.65
Rate for Payer: Molina Healthcare Managed Medicaid	$7,420.19

Dentemp [VDMC]

Facility

$18.36

Service Code	HCPCS A9270
Hospital Charge Code	22157052
Hospital Revenue Code	259
Min. Negotiated Rate	$8.26
Max. Negotiated Rate	$16.52
Rate for Payer: Aetna of IA Commercial	$16.52
Rate for Payer: Aetna of IA Medical Rental Products	$16.52
Rate for Payer: Aetna of IA Medicare	$10.47
Rate for Payer: Amerigroup Medicaid	$10.59
Rate for Payer: Amerigroup Medicare	$8.34
Rate for Payer: Cash Price	$14.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.77
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.26
Rate for Payer: Iowa Total Care Managed Medicaid	$10.49
Rate for Payer: Medical Associates Commercial	$13.77
Rate for Payer: Medical Associates Managed Medicare	$8.26
Rate for Payer: Midlands Choice Commercial	$12.85
Rate for Payer: Molina Healthcare Managed Medicaid	$10.64
Rate for Payer: Partners Health Alliance Commercial	$9.50
Rate for Payer: United Healthcare Commercial	$16.52
Rate for Payer: United Healthcare Managed Medicare	$10.83

Dentemp [VDMC]

Facility

$18.36

Service Code	HCPCS A9270
Hospital Charge Code	22157052
Hospital Revenue Code	259
Min. Negotiated Rate	$12.85
Max. Negotiated Rate	$16.52
Rate for Payer: Aetna of IA Commercial	$16.52
Rate for Payer: Aetna of IA Medical Rental Products	$16.52
Rate for Payer: Cash Price	$14.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.77
Rate for Payer: Medical Associates Commercial	$13.77
Rate for Payer: Midlands Choice Commercial	$12.85
Rate for Payer: United Healthcare Commercial	$16.52

DEPRESSIVE NEUROSES

Facility

$6,510.40

Service Code	MSDRG 881
Min. Negotiated Rate	$6,416.04
Max. Negotiated Rate	$6,510.40
Rate for Payer: Amerigroup Medicaid	$6,478.94
Rate for Payer: Iowa Total Care Managed Medicaid	$6,416.04
Rate for Payer: Molina Healthcare Managed Medicaid	$6,510.40

dermagran hydrophilic wound dressing [VDMC]

Facility

$64.04

Service Code	HCPCS A9270
Hospital Charge Code	11342798
Hospital Revenue Code	259
Min. Negotiated Rate	$28.82
Max. Negotiated Rate	$57.63
Rate for Payer: Aetna of IA Commercial	$57.63
Rate for Payer: Aetna of IA Medical Rental Products	$57.63
Rate for Payer: Aetna of IA Medicare	$36.50
Rate for Payer: Amerigroup Medicaid	$36.94
Rate for Payer: Amerigroup Medicare	$29.11
Rate for Payer: Cash Price	$51.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.82
Rate for Payer: Iowa Total Care Managed Medicaid	$36.58
Rate for Payer: Medical Associates Commercial	$48.03
Rate for Payer: Medical Associates Managed Medicare	$28.82
Rate for Payer: Midlands Choice Commercial	$44.83
Rate for Payer: Molina Healthcare Managed Medicaid	$37.12
Rate for Payer: Partners Health Alliance Commercial	$33.14
Rate for Payer: United Healthcare Commercial	$57.63
Rate for Payer: United Healthcare Managed Medicare	$37.78

dermagran hydrophilic wound dressing [VDMC]

Facility

$64.04

Service Code	HCPCS A9270
Hospital Charge Code	11342798
Hospital Revenue Code	259
Min. Negotiated Rate	$44.83
Max. Negotiated Rate	$57.63
Rate for Payer: Aetna of IA Commercial	$57.63
Rate for Payer: Aetna of IA Medical Rental Products	$57.63
Rate for Payer: Cash Price	$51.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.03
Rate for Payer: Medical Associates Commercial	$48.03
Rate for Payer: Midlands Choice Commercial	$44.83
Rate for Payer: United Healthcare Commercial	$57.63

desmopressin 0.2 mg Tab [VDMC]

Facility

$3.92

Service Code	HCPCS A9270
Hospital Charge Code	10381363
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.53
Rate for Payer: Aetna of IA Commercial	$3.53
Rate for Payer: Aetna of IA Medical Rental Products	$3.53
Rate for Payer: Cash Price	$3.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.94
Rate for Payer: Medical Associates Commercial	$2.94
Rate for Payer: Midlands Choice Commercial	$2.74
Rate for Payer: United Healthcare Commercial	$3.53

desmopressin 0.2 mg Tab [VDMC]

Facility

$3.92

Service Code	HCPCS A9270
Hospital Charge Code	10381363
Hospital Revenue Code	259
Min. Negotiated Rate	$1.76
Max. Negotiated Rate	$3.53
Rate for Payer: Aetna of IA Commercial	$3.53
Rate for Payer: Aetna of IA Medical Rental Products	$3.53
Rate for Payer: Aetna of IA Medicare	$2.23
Rate for Payer: Amerigroup Medicaid	$2.26
Rate for Payer: Amerigroup Medicare	$1.78
Rate for Payer: Cash Price	$3.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.76
Rate for Payer: Iowa Total Care Managed Medicaid	$2.24
Rate for Payer: Medical Associates Commercial	$2.94
Rate for Payer: Medical Associates Managed Medicare	$1.76
Rate for Payer: Midlands Choice Commercial	$2.74
Rate for Payer: Molina Healthcare Managed Medicaid	$2.27
Rate for Payer: Partners Health Alliance Commercial	$2.03
Rate for Payer: United Healthcare Commercial	$3.53
Rate for Payer: United Healthcare Managed Medicare	$2.31

DESTRUCT B9 LESION 1-14

Facility

$275.00

Service Code	CPT 17110
Hospital Charge Code	4864787
Hospital Revenue Code	450
Min. Negotiated Rate	$192.50
Max. Negotiated Rate	$247.50
Rate for Payer: Aetna of IA Commercial	$247.50
Rate for Payer: Aetna of IA Medical Rental Products	$247.50
Rate for Payer: Cash Price	$220.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$206.25
Rate for Payer: Medical Associates Commercial	$206.25
Rate for Payer: Midlands Choice Commercial	$192.50
Rate for Payer: United Healthcare Commercial	$247.50

DESTRUCT B9 LESION 1-14

Facility

$275.00

Service Code	CPT 17110
Hospital Charge Code	4864787
Hospital Revenue Code	450
Min. Negotiated Rate	$123.75
Max. Negotiated Rate	$333.49
Rate for Payer: Aetna of IA Commercial	$247.50
Rate for Payer: Aetna of IA Medical Rental Products	$247.50
Rate for Payer: Aetna of IA Medicare	$156.75
Rate for Payer: Amerigroup Medicaid	$158.62
Rate for Payer: Amerigroup Medicare	$124.99
Rate for Payer: Cash Price	$220.00
Rate for Payer: Cash Price	$220.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$206.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$123.75
Rate for Payer: Iowa Total Care Managed Medicaid	$157.08
Rate for Payer: Medical Associates Commercial	$206.25
Rate for Payer: Medical Associates Managed Medicare	$123.75
Rate for Payer: Midlands Choice Commercial	$192.50
Rate for Payer: Molina Healthcare Managed Medicaid	$159.39
Rate for Payer: Partners Health Alliance Commercial	$142.31
Rate for Payer: United Healthcare Commercial	$247.50
Rate for Payer: United Healthcare Managed Medicare	$162.25
Rate for Payer: Wellmark IA HMO WHPI	$302.74
Rate for Payer: Wellmark IA PPO	$333.49

Know your out-of-pocket cost for care.

All Charges