Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

diazepam 5 mg/mL 2 ml SDV Inj syringe [VDMC]

Facility

$92.25

Service Code	HCPCS J3360
Hospital Charge Code	10382374
Hospital Revenue Code	259
Min. Negotiated Rate	$41.51
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$83.02
Rate for Payer: Aetna of IA Medical Rental Products	$83.02
Rate for Payer: Aetna of IA Medicare	$52.58
Rate for Payer: Amerigroup Medicaid	$53.21
Rate for Payer: Amerigroup Medicare	$41.93
Rate for Payer: Cash Price	$73.80
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.51
Rate for Payer: Iowa Total Care Managed Medicaid	$52.69
Rate for Payer: Medical Associates Commercial	$69.19
Rate for Payer: Medical Associates Managed Medicare	$41.51
Rate for Payer: Midlands Choice Commercial	$64.57
Rate for Payer: Molina Healthcare Managed Medicaid	$53.47
Rate for Payer: Partners Health Alliance Commercial	$47.74
Rate for Payer: United Healthcare Commercial	$83.02
Rate for Payer: United Healthcare Managed Medicare	$54.43
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

diazepam 5 mg/mL 2 ml SDV Inj syringe [VDMC]

Facility

$92.25

Service Code	HCPCS J3360
Hospital Charge Code	10382374
Hospital Revenue Code	259
Min. Negotiated Rate	$64.57
Max. Negotiated Rate	$83.02
Rate for Payer: Aetna of IA Commercial	$83.02
Rate for Payer: Aetna of IA Medical Rental Products	$83.02
Rate for Payer: Cash Price	$73.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.19
Rate for Payer: Medical Associates Commercial	$69.19
Rate for Payer: Midlands Choice Commercial	$64.57
Rate for Payer: United Healthcare Commercial	$83.02

diazepam 5 mg Tab [VDMC]

Facility

$3.16

Service Code	HCPCS A9270
Hospital Charge Code	10382305
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
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	$1.82
Rate for Payer: Amerigroup Medicare	$1.44
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	$1.42
Rate for Payer: Iowa Total Care Managed Medicaid	$1.81
Rate for Payer: Medical Associates Commercial	$2.37
Rate for Payer: Medical Associates Managed Medicare	$1.42
Rate for Payer: Midlands Choice Commercial	$2.21
Rate for Payer: Molina Healthcare Managed Medicaid	$1.83
Rate for Payer: Partners Health Alliance Commercial	$1.64
Rate for Payer: United Healthcare Commercial	$2.84
Rate for Payer: United Healthcare Managed Medicare	$1.86

diazepam 5 mg Tab [VDMC]

Facility

$3.16

Service Code	HCPCS A9270
Hospital Charge Code	10382305
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

dibucaine topical 1% Oin[VDMC]

Facility

$20.16

Service Code	NDC 00536-1211-95
Hospital Charge Code	13327364
Hospital Revenue Code	259
Min. Negotiated Rate	$9.07
Max. Negotiated Rate	$18.14
Rate for Payer: Aetna of IA Commercial	$18.14
Rate for Payer: Aetna of IA Medical Rental Products	$18.14
Rate for Payer: Aetna of IA Medicare	$11.49
Rate for Payer: Amerigroup Medicaid	$11.63
Rate for Payer: Amerigroup Medicare	$9.16
Rate for Payer: Cash Price	$16.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$15.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$9.07
Rate for Payer: Iowa Total Care Managed Medicaid	$11.52
Rate for Payer: Medical Associates Commercial	$15.12
Rate for Payer: Medical Associates Managed Medicare	$9.07
Rate for Payer: Midlands Choice Commercial	$14.11
Rate for Payer: Molina Healthcare Managed Medicaid	$11.68
Rate for Payer: Partners Health Alliance Commercial	$10.43
Rate for Payer: United Healthcare Commercial	$18.14
Rate for Payer: United Healthcare Managed Medicare	$11.89

dibucaine topical 1% Oin[VDMC]

Facility

$20.16

Service Code	NDC 00536-1211-95
Hospital Charge Code	13327364
Hospital Revenue Code	259
Min. Negotiated Rate	$14.11
Max. Negotiated Rate	$18.14
Rate for Payer: Aetna of IA Commercial	$18.14
Rate for Payer: Aetna of IA Medical Rental Products	$18.14
Rate for Payer: Cash Price	$16.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$15.12
Rate for Payer: Medical Associates Commercial	$15.12
Rate for Payer: Midlands Choice Commercial	$14.11
Rate for Payer: United Healthcare Commercial	$18.14

diclofenac sodium 50 mg Oral EC Tab [VDMC]

Facility

$1.31

Service Code	HCPCS A9270
Hospital Charge Code	10382445
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of IA Commercial	$1.18
Rate for Payer: Aetna of IA Medical Rental Products	$1.18
Rate for Payer: Aetna of IA Medicare	$0.74
Rate for Payer: Amerigroup Medicaid	$0.75
Rate for Payer: Amerigroup Medicare	$0.59
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.59
Rate for Payer: Iowa Total Care Managed Medicaid	$0.75
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Medical Associates Managed Medicare	$0.59
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: Molina Healthcare Managed Medicaid	$0.76
Rate for Payer: Partners Health Alliance Commercial	$0.68
Rate for Payer: United Healthcare Commercial	$1.18
Rate for Payer: United Healthcare Managed Medicare	$0.77

diclofenac sodium 50 mg Oral EC Tab [VDMC]

Facility

$1.31

Service Code	HCPCS A9270
Hospital Charge Code	10382445
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of IA Commercial	$1.18
Rate for Payer: Aetna of IA Medical Rental Products	$1.18
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: United Healthcare Commercial	$1.18

diclofenac sodium 75 mg DR Oral EC Tab [VDMC]

Facility

$1.42

Service Code	HCPCS A9270
Hospital Charge Code	10382516
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.28
Rate for Payer: Aetna of IA Commercial	$1.28
Rate for Payer: Aetna of IA Medical Rental Products	$1.28
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: United Healthcare Commercial	$1.28

diclofenac sodium 75 mg DR Oral EC Tab [VDMC]

Facility

$1.42

Service Code	HCPCS A9270
Hospital Charge Code	10382516
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$1.28
Rate for Payer: Aetna of IA Commercial	$1.28
Rate for Payer: Aetna of IA Medical Rental Products	$1.28
Rate for Payer: Aetna of IA Medicare	$0.81
Rate for Payer: Amerigroup Medicaid	$0.82
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.81
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: Molina Healthcare Managed Medicaid	$0.82
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.28
Rate for Payer: United Healthcare Managed Medicare	$0.84

diclofenac Top 1% gel [VDMC]

Facility

$16.06

Service Code	HCPCS A9270
Hospital Charge Code	10434323
Hospital Revenue Code	259
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$14.45
Rate for Payer: Aetna of IA Commercial	$14.45
Rate for Payer: Aetna of IA Medical Rental Products	$14.45
Rate for Payer: Aetna of IA Medicare	$9.15
Rate for Payer: Amerigroup Medicaid	$9.26
Rate for Payer: Amerigroup Medicare	$7.30
Rate for Payer: Cash Price	$12.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.23
Rate for Payer: Iowa Total Care Managed Medicaid	$9.17
Rate for Payer: Medical Associates Commercial	$12.04
Rate for Payer: Medical Associates Managed Medicare	$7.23
Rate for Payer: Midlands Choice Commercial	$11.24
Rate for Payer: Molina Healthcare Managed Medicaid	$9.31
Rate for Payer: Partners Health Alliance Commercial	$8.31
Rate for Payer: United Healthcare Commercial	$14.45
Rate for Payer: United Healthcare Managed Medicare	$9.47

diclofenac Top 1% gel [VDMC]

Facility

$16.06

Service Code	HCPCS A9270
Hospital Charge Code	10434323
Hospital Revenue Code	259
Min. Negotiated Rate	$11.24
Max. Negotiated Rate	$14.45
Rate for Payer: Aetna of IA Commercial	$14.45
Rate for Payer: Aetna of IA Medical Rental Products	$14.45
Rate for Payer: Cash Price	$12.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.04
Rate for Payer: Medical Associates Commercial	$12.04
Rate for Payer: Midlands Choice Commercial	$11.24
Rate for Payer: United Healthcare Commercial	$14.45

dicyclomine 20 mg Tab [VDMC]

Facility

$1.44

Service Code	HCPCS A9270
Hospital Charge Code	10382646
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Aetna of IA Medicare	$0.82
Rate for Payer: Amerigroup Medicaid	$0.83
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.08
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	$0.82
Rate for Payer: Medical Associates Commercial	$1.08
Rate for Payer: Medical Associates Managed Medicare	$0.65
Rate for Payer: Midlands Choice Commercial	$1.01
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Managed Medicare	$0.85

dicyclomine 20 mg Tab [VDMC]

Facility

$1.44

Service Code	HCPCS A9270
Hospital Charge Code	10382646
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.08
Rate for Payer: Medical Associates Commercial	$1.08
Rate for Payer: Midlands Choice Commercial	$1.01
Rate for Payer: United Healthcare Commercial	$1.29

DIGESTIVE MALIGNANCY WITH CC

Facility

$12,056.96

Service Code	MSDRG 375
Min. Negotiated Rate	$11,882.22
Max. Negotiated Rate	$12,056.96
Rate for Payer: Amerigroup Medicaid	$11,998.71
Rate for Payer: Iowa Total Care Managed Medicaid	$11,882.22
Rate for Payer: Molina Healthcare Managed Medicaid	$12,056.96

DIGESTIVE MALIGNANCY WITH MCC

Facility

$18,169.89

Service Code	MSDRG 374
Min. Negotiated Rate	$17,906.55
Max. Negotiated Rate	$18,169.89
Rate for Payer: Amerigroup Medicaid	$18,082.11
Rate for Payer: Iowa Total Care Managed Medicaid	$17,906.55
Rate for Payer: Molina Healthcare Managed Medicaid	$18,169.89

DIGESTIVE MALIGNANCY WITHOUT CC/MCC

Facility

$8,021.46

Service Code	MSDRG 376
Min. Negotiated Rate	$7,905.20
Max. Negotiated Rate	$8,021.46
Rate for Payer: Amerigroup Medicaid	$7,982.71
Rate for Payer: Iowa Total Care Managed Medicaid	$7,905.20
Rate for Payer: Molina Healthcare Managed Medicaid	$8,021.46

DIGIT AMPUTATION ER CHARGE

Professional

Both

$2,327.00

Hospital Charge Code	8069104
Hospital Revenue Code	981
Min. Negotiated Rate	$1,628.90
Max. Negotiated Rate	$1,745.25
Rate for Payer: Cash Price	$1,861.60
Rate for Payer: Medical Associates Commercial	$1,745.25
Rate for Payer: Midlands Choice Commercial	$1,628.90
Rate for Payer: Partners Health Alliance Commercial	$1,745.25

DIGOXIN

Facility

$111.00

Service Code	CPT 80162
Hospital Charge Code	1628891
Hospital Revenue Code	301
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: United Healthcare Commercial	$99.90

DIGOXIN

Facility

$111.00

Service Code	CPT 80162
Hospital Charge Code	1628891
Hospital Revenue Code	301
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Aetna of IA Medicare	$63.27
Rate for Payer: Amerigroup Medicaid	$64.02
Rate for Payer: Amerigroup Medicare	$50.45
Rate for Payer: Cash Price	$88.80
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.95
Rate for Payer: Iowa Total Care Managed Medicaid	$63.40
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Medical Associates Managed Medicare	$49.95
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: Molina Healthcare Managed Medicaid	$64.34
Rate for Payer: Partners Health Alliance Commercial	$57.44
Rate for Payer: United Healthcare Commercial	$99.90
Rate for Payer: United Healthcare Managed Medicare	$65.49
Rate for Payer: Wellmark IA HMO WHPI	$65.23
Rate for Payer: Wellmark IA PPO	$71.85

digoxin 125 mcg (0.125 mg) Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10382717
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
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	$0.97
Rate for Payer: Amerigroup Medicare	$0.77
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	$0.76
Rate for Payer: Iowa Total Care Managed Medicaid	$0.96
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Medical Associates Managed Medicare	$0.76
Rate for Payer: Midlands Choice Commercial	$1.18
Rate for Payer: Molina Healthcare Managed Medicaid	$0.98
Rate for Payer: Partners Health Alliance Commercial	$0.87
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Managed Medicare	$1.00

digoxin 125 mcg (0.125 mg) Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10382717
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

digoxin 250 mcg (0.25 mg) Tab [VDMC]

Facility

$1.71

Service Code	HCPCS A9270
Hospital Charge Code	10382786
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of IA Commercial	$1.54
Rate for Payer: Aetna of IA Medical Rental Products	$1.54
Rate for Payer: Aetna of IA Medicare	$0.97
Rate for Payer: Amerigroup Medicaid	$0.98
Rate for Payer: Amerigroup Medicare	$0.78
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.77
Rate for Payer: Iowa Total Care Managed Medicaid	$0.98
Rate for Payer: Medical Associates Commercial	$1.28
Rate for Payer: Medical Associates Managed Medicare	$0.77
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: Molina Healthcare Managed Medicaid	$0.99
Rate for Payer: Partners Health Alliance Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.54
Rate for Payer: United Healthcare Managed Medicare	$1.01

digoxin 250 mcg (0.25 mg) Tab [VDMC]

Facility

$1.71

Service Code	HCPCS A9270
Hospital Charge Code	10382786
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of IA Commercial	$1.54
Rate for Payer: Aetna of IA Medical Rental Products	$1.54
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.28
Rate for Payer: Medical Associates Commercial	$1.28
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: United Healthcare Commercial	$1.54

digoxin 250 mcg/mL (0.25 mg/mL) 2 ML SDV Inj Sol [VDMC]

Facility

$40.20

Service Code	HCPCS J1160
Hospital Charge Code	10382857
Hospital Revenue Code	259
Min. Negotiated Rate	$18.09
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$36.18
Rate for Payer: Aetna of IA Medical Rental Products	$36.18
Rate for Payer: Aetna of IA Medicare	$22.91
Rate for Payer: Amerigroup Medicaid	$23.19
Rate for Payer: Amerigroup Medicare	$18.27
Rate for Payer: Cash Price	$32.16
Rate for Payer: Cash Price	$32.16
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.09
Rate for Payer: Iowa Total Care Managed Medicaid	$22.96
Rate for Payer: Medical Associates Commercial	$30.15
Rate for Payer: Medical Associates Managed Medicare	$18.09
Rate for Payer: Midlands Choice Commercial	$28.14
Rate for Payer: Molina Healthcare Managed Medicaid	$23.30
Rate for Payer: Partners Health Alliance Commercial	$20.80
Rate for Payer: United Healthcare Commercial	$36.18
Rate for Payer: United Healthcare Managed Medicare	$23.72
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

Know your out-of-pocket cost for care.

All Charges