Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ertapenem 1 g Inj SDV [VDMC]

Facility

$81.70

Service Code	HCPCS J1335
Hospital Charge Code	10386917
Hospital Revenue Code	259
Min. Negotiated Rate	$57.19
Max. Negotiated Rate	$73.53
Rate for Payer: Aetna of IA Commercial	$73.53
Rate for Payer: Aetna of IA Medical Rental Products	$73.53
Rate for Payer: Cash Price	$65.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.27
Rate for Payer: Medical Associates Commercial	$61.27
Rate for Payer: Midlands Choice Commercial	$57.19
Rate for Payer: United Healthcare Commercial	$73.53

erythromycin 500 mg DR Tab [VDMC]

Facility

$25.17

Service Code	HCPCS A9270
Hospital Charge Code	28180188
Hospital Revenue Code	259
Min. Negotiated Rate	$17.62
Max. Negotiated Rate	$22.66
Rate for Payer: Aetna of IA Commercial	$22.66
Rate for Payer: Aetna of IA Medical Rental Products	$22.66
Rate for Payer: Cash Price	$20.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.88
Rate for Payer: Medical Associates Commercial	$18.88
Rate for Payer: Midlands Choice Commercial	$17.62
Rate for Payer: United Healthcare Commercial	$22.66

erythromycin 500 mg DR Tab [VDMC]

Facility

$25.17

Service Code	HCPCS A9270
Hospital Charge Code	28180188
Hospital Revenue Code	259
Min. Negotiated Rate	$11.33
Max. Negotiated Rate	$22.66
Rate for Payer: Aetna of IA Commercial	$22.66
Rate for Payer: Aetna of IA Medical Rental Products	$22.66
Rate for Payer: Aetna of IA Medicare	$14.35
Rate for Payer: Amerigroup Medicaid	$14.52
Rate for Payer: Amerigroup Medicare	$11.44
Rate for Payer: Cash Price	$20.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.33
Rate for Payer: Iowa Total Care Managed Medicaid	$14.38
Rate for Payer: Medical Associates Commercial	$18.88
Rate for Payer: Medical Associates Managed Medicare	$11.33
Rate for Payer: Midlands Choice Commercial	$17.62
Rate for Payer: Molina Healthcare Managed Medicaid	$14.59
Rate for Payer: Partners Health Alliance Commercial	$13.03
Rate for Payer: United Healthcare Commercial	$22.66
Rate for Payer: United Healthcare Managed Medicare	$14.85

erythromycin ophthalmic 0.5% Oint. 3.5gm [VDMC]

Facility

$65.00

Service Code	HCPCS A9270
Hospital Charge Code	18197658
Hospital Revenue Code	259
Min. Negotiated Rate	$29.25
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of IA Commercial	$58.50
Rate for Payer: Aetna of IA Medical Rental Products	$58.50
Rate for Payer: Aetna of IA Medicare	$37.05
Rate for Payer: Amerigroup Medicaid	$37.49
Rate for Payer: Amerigroup Medicare	$29.54
Rate for Payer: Cash Price	$52.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.25
Rate for Payer: Iowa Total Care Managed Medicaid	$37.13
Rate for Payer: Medical Associates Commercial	$48.75
Rate for Payer: Medical Associates Managed Medicare	$29.25
Rate for Payer: Midlands Choice Commercial	$45.50
Rate for Payer: Molina Healthcare Managed Medicaid	$37.67
Rate for Payer: Partners Health Alliance Commercial	$33.64
Rate for Payer: United Healthcare Commercial	$58.50
Rate for Payer: United Healthcare Managed Medicare	$38.35

erythromycin ophthalmic 0.5% Oint. 3.5gm [VDMC]

Facility

$65.00

Service Code	HCPCS A9270
Hospital Charge Code	18197658
Hospital Revenue Code	259
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of IA Commercial	$58.50
Rate for Payer: Aetna of IA Medical Rental Products	$58.50
Rate for Payer: Cash Price	$52.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.75
Rate for Payer: Medical Associates Commercial	$48.75
Rate for Payer: Midlands Choice Commercial	$45.50
Rate for Payer: United Healthcare Commercial	$58.50

Erythropoietin Level DMCL

Facility

$179.00

Service Code	CPT 82668
Hospital Charge Code	8037840
Hospital Revenue Code	301
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Aetna of IA Medicare	$102.03
Rate for Payer: Amerigroup Medicaid	$103.25
Rate for Payer: Amerigroup Medicare	$81.36
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$80.55
Rate for Payer: Iowa Total Care Managed Medicaid	$102.24
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Medical Associates Managed Medicare	$80.55
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: Molina Healthcare Managed Medicaid	$103.75
Rate for Payer: Partners Health Alliance Commercial	$92.63
Rate for Payer: United Healthcare Commercial	$161.10
Rate for Payer: United Healthcare Managed Medicare	$105.61

Erythropoietin Level DMCL

Facility

$179.00

Service Code	CPT 82668
Hospital Charge Code	8037840
Hospital Revenue Code	301
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: United Healthcare Commercial	$161.10

escitalopram 10 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10387189
Hospital Revenue Code	259
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of IA Commercial	$1.41
Rate for Payer: Aetna of IA Medical Rental Products	$1.41
Rate for Payer: Aetna of IA Medicare	$0.89
Rate for Payer: Amerigroup Medicaid	$0.90
Rate for Payer: Amerigroup Medicare	$0.71
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.70
Rate for Payer: Iowa Total Care Managed Medicaid	$0.89
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$1.10
Rate for Payer: Molina Healthcare Managed Medicaid	$0.91
Rate for Payer: Partners Health Alliance Commercial	$0.81
Rate for Payer: United Healthcare Commercial	$1.41
Rate for Payer: United Healthcare Managed Medicare	$0.92

escitalopram 10 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10387189
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of IA Commercial	$1.41
Rate for Payer: Aetna of IA Medical Rental Products	$1.41
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Midlands Choice Commercial	$1.10
Rate for Payer: United Healthcare Commercial	$1.41

esketamine 56 mg/2 Nasal Spray [VDMC]

Facility

$3,172.96

Service Code	HCPCS S0013
Hospital Charge Code	18384531
Hospital Revenue Code	259
Min. Negotiated Rate	$1,427.83
Max. Negotiated Rate	$2,855.66
Rate for Payer: Aetna of IA Commercial	$2,855.66
Rate for Payer: Aetna of IA Medical Rental Products	$2,855.66
Rate for Payer: Aetna of IA Medicare	$1,808.59
Rate for Payer: Amerigroup Medicaid	$1,830.16
Rate for Payer: Amerigroup Medicare	$1,442.11
Rate for Payer: Cash Price	$2,538.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,379.72
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,427.83
Rate for Payer: Iowa Total Care Managed Medicaid	$1,812.39
Rate for Payer: Medical Associates Commercial	$2,379.72
Rate for Payer: Medical Associates Managed Medicare	$1,427.83
Rate for Payer: Midlands Choice Commercial	$2,221.07
Rate for Payer: Molina Healthcare Managed Medicaid	$1,839.05
Rate for Payer: Partners Health Alliance Commercial	$1,642.01
Rate for Payer: United Healthcare Commercial	$2,855.66
Rate for Payer: United Healthcare Managed Medicare	$1,872.05

esketamine 56 mg/2 Nasal Spray [VDMC]

Facility

$3,172.96

Service Code	HCPCS S0013
Hospital Charge Code	18384531
Hospital Revenue Code	259
Min. Negotiated Rate	$2,221.07
Max. Negotiated Rate	$2,855.66
Rate for Payer: Aetna of IA Commercial	$2,855.66
Rate for Payer: Aetna of IA Medical Rental Products	$2,855.66
Rate for Payer: Cash Price	$2,538.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,379.72
Rate for Payer: Medical Associates Commercial	$2,379.72
Rate for Payer: Midlands Choice Commercial	$2,221.07
Rate for Payer: United Healthcare Commercial	$2,855.66

esketamine 84 mg/3 nasal spray [VDMC]

Facility

$4,758.00

Service Code	HCPCS S0013
Hospital Charge Code	18384750
Hospital Revenue Code	259
Min. Negotiated Rate	$3,330.60
Max. Negotiated Rate	$4,282.20
Rate for Payer: Aetna of IA Commercial	$4,282.20
Rate for Payer: Aetna of IA Medical Rental Products	$4,282.20
Rate for Payer: Cash Price	$3,806.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,568.50
Rate for Payer: Medical Associates Commercial	$3,568.50
Rate for Payer: Midlands Choice Commercial	$3,330.60
Rate for Payer: United Healthcare Commercial	$4,282.20

esketamine 84 mg/3 nasal spray [VDMC]

Facility

$4,758.00

Service Code	HCPCS S0013
Hospital Charge Code	18384750
Hospital Revenue Code	259
Min. Negotiated Rate	$2,141.10
Max. Negotiated Rate	$4,282.20
Rate for Payer: Aetna of IA Commercial	$4,282.20
Rate for Payer: Aetna of IA Medical Rental Products	$4,282.20
Rate for Payer: Aetna of IA Medicare	$2,712.06
Rate for Payer: Amerigroup Medicaid	$2,744.41
Rate for Payer: Amerigroup Medicare	$2,162.51
Rate for Payer: Cash Price	$3,806.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,568.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,141.10
Rate for Payer: Iowa Total Care Managed Medicaid	$2,717.77
Rate for Payer: Medical Associates Commercial	$3,568.50
Rate for Payer: Medical Associates Managed Medicare	$2,141.10
Rate for Payer: Midlands Choice Commercial	$3,330.60
Rate for Payer: Molina Healthcare Managed Medicaid	$2,757.74
Rate for Payer: Partners Health Alliance Commercial	$2,462.26
Rate for Payer: United Healthcare Commercial	$4,282.20
Rate for Payer: United Healthcare Managed Medicare	$2,807.22

esmolol 10 mg/mL 10 ml SDV Vial [VDMC]

Facility

$27.14

Service Code	HCPCS J1805
Hospital Charge Code	10431703
Hospital Revenue Code	259
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$24.42
Rate for Payer: Aetna of IA Commercial	$24.42
Rate for Payer: Aetna of IA Medical Rental Products	$24.42
Rate for Payer: Aetna of IA Medicare	$15.47
Rate for Payer: Amerigroup Medicaid	$15.65
Rate for Payer: Amerigroup Medicare	$12.33
Rate for Payer: Cash Price	$21.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.35
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.21
Rate for Payer: Iowa Total Care Managed Medicaid	$15.50
Rate for Payer: Medical Associates Commercial	$20.35
Rate for Payer: Medical Associates Managed Medicare	$12.21
Rate for Payer: Midlands Choice Commercial	$19.00
Rate for Payer: Molina Healthcare Managed Medicaid	$15.73
Rate for Payer: Partners Health Alliance Commercial	$14.04
Rate for Payer: United Healthcare Commercial	$24.42
Rate for Payer: United Healthcare Managed Medicare	$16.01

esmolol 10 mg/mL 10 ml SDV Vial [VDMC]

Facility

$27.14

Service Code	HCPCS J1805
Hospital Charge Code	10431703
Hospital Revenue Code	259
Min. Negotiated Rate	$19.00
Max. Negotiated Rate	$24.42
Rate for Payer: Aetna of IA Commercial	$24.42
Rate for Payer: Aetna of IA Medical Rental Products	$24.42
Rate for Payer: Cash Price	$21.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.35
Rate for Payer: Medical Associates Commercial	$20.35
Rate for Payer: Midlands Choice Commercial	$19.00
Rate for Payer: United Healthcare Commercial	$24.42

ESSURE TUBAL OCCLUSION

Facility

$1,577.00

Hospital Charge Code	8025903
Hospital Revenue Code	272
Min. Negotiated Rate	$1,103.90
Max. Negotiated Rate	$1,419.30
Rate for Payer: Aetna of IA Commercial	$1,419.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,419.30
Rate for Payer: Cash Price	$1,261.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,182.75
Rate for Payer: Medical Associates Commercial	$1,182.75
Rate for Payer: Midlands Choice Commercial	$1,103.90
Rate for Payer: United Healthcare Commercial	$1,419.30

ESSURE TUBAL OCCLUSION

Facility

$1,577.00

Hospital Charge Code	8025903
Hospital Revenue Code	272
Min. Negotiated Rate	$709.65
Max. Negotiated Rate	$1,419.30
Rate for Payer: Aetna of IA Commercial	$1,419.30
Rate for Payer: Aetna of IA Medical Rental Products	$1,419.30
Rate for Payer: Aetna of IA Medicare	$898.89
Rate for Payer: Amerigroup Medicaid	$909.61
Rate for Payer: Amerigroup Medicare	$716.75
Rate for Payer: Cash Price	$1,261.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,182.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$709.65
Rate for Payer: Iowa Total Care Managed Medicaid	$900.78
Rate for Payer: Medical Associates Commercial	$1,182.75
Rate for Payer: Medical Associates Managed Medicare	$709.65
Rate for Payer: Midlands Choice Commercial	$1,103.90
Rate for Payer: Molina Healthcare Managed Medicaid	$914.03
Rate for Payer: Partners Health Alliance Commercial	$816.10
Rate for Payer: United Healthcare Commercial	$1,419.30
Rate for Payer: United Healthcare Managed Medicare	$930.43

ESTABLISHED PATIENT NURSE ONLY CHARGE

Facility

$30.00

Service Code	CPT 99211
Hospital Charge Code	8068920
Hospital Revenue Code	510
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of IA Commercial	$27.00
Rate for Payer: Aetna of IA Medical Rental Products	$27.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.50
Rate for Payer: Medical Associates Commercial	$22.50
Rate for Payer: Midlands Choice Commercial	$21.00
Rate for Payer: United Healthcare Commercial	$27.00

ESTABLISHED PATIENT NURSE ONLY CHARGE

Facility

$30.00

Service Code	CPT 99211
Hospital Charge Code	8068920
Hospital Revenue Code	510
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of IA Commercial	$27.00
Rate for Payer: Aetna of IA Medical Rental Products	$27.00
Rate for Payer: Aetna of IA Medicare	$17.10
Rate for Payer: Amerigroup Medicaid	$17.30
Rate for Payer: Amerigroup Medicare	$13.63
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.50
Rate for Payer: Iowa Total Care Managed Medicaid	$17.14
Rate for Payer: Medical Associates Commercial	$22.50
Rate for Payer: Medical Associates Managed Medicare	$13.50
Rate for Payer: Midlands Choice Commercial	$21.00
Rate for Payer: Molina Healthcare Managed Medicaid	$17.39
Rate for Payer: Partners Health Alliance Commercial	$15.53
Rate for Payer: United Healthcare Commercial	$27.00
Rate for Payer: United Healthcare Managed Medicare	$17.70

ESTABLISHED PATIENT NURSE ONLY CHARGE

Professional

Both

$30.00

Service Code	CPT 99211
Hospital Charge Code	8068920
Hospital Revenue Code	983
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$24.97
Rate for Payer: Cash Price	$24.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Medical Associates Commercial	$22.50
Rate for Payer: Midlands Choice Commercial	$21.00
Rate for Payer: Partners Health Alliance Commercial	$22.50
Rate for Payer: United Healthcare Commercial	$24.97

ESTAB PATIENT DETAILED

Professional

Both

$357.00

Service Code	CPT 99214
Hospital Charge Code	8101317
Hospital Revenue Code	983
Min. Negotiated Rate	$118.77
Max. Negotiated Rate	$267.75
Rate for Payer: Cash Price	$285.60
Rate for Payer: Cash Price	$285.60
Rate for Payer: Medical Associates Commercial	$267.75
Rate for Payer: Midlands Choice Commercial	$249.90
Rate for Payer: Partners Health Alliance Commercial	$267.75
Rate for Payer: United Healthcare Commercial	$118.77

ESTAB PATIENT EXPANDED

Professional

Both

$244.00

Service Code	CPT 99213
Hospital Charge Code	8101316
Hospital Revenue Code	983
Min. Negotiated Rate	$81.57
Max. Negotiated Rate	$183.00
Rate for Payer: Cash Price	$195.20
Rate for Payer: Cash Price	$195.20
Rate for Payer: Medical Associates Commercial	$183.00
Rate for Payer: Midlands Choice Commercial	$170.80
Rate for Payer: Partners Health Alliance Commercial	$183.00
Rate for Payer: United Healthcare Commercial	$81.57

ESTAB PATIENT FOCUSED

Professional

Both

$148.00

Service Code	CPT 99212
Hospital Charge Code	8101315
Hospital Revenue Code	983
Min. Negotiated Rate	$49.04
Max. Negotiated Rate	$111.00
Rate for Payer: Cash Price	$118.40
Rate for Payer: Cash Price	$118.40
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: Partners Health Alliance Commercial	$111.00
Rate for Payer: United Healthcare Commercial	$49.04

ESTAB PATIENT NURSE ONLY

Facility

$36.00

Service Code	CPT 99211
Hospital Charge Code	4734797
Hospital Revenue Code	760
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of IA Commercial	$32.40
Rate for Payer: Aetna of IA Medical Rental Products	$32.40
Rate for Payer: Aetna of IA Medicare	$20.52
Rate for Payer: Amerigroup Medicaid	$20.76
Rate for Payer: Amerigroup Medicare	$16.36
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$16.20
Rate for Payer: Iowa Total Care Managed Medicaid	$20.56
Rate for Payer: Medical Associates Commercial	$27.00
Rate for Payer: Medical Associates Managed Medicare	$16.20
Rate for Payer: Midlands Choice Commercial	$25.20
Rate for Payer: Molina Healthcare Managed Medicaid	$20.87
Rate for Payer: Partners Health Alliance Commercial	$18.63
Rate for Payer: United Healthcare Commercial	$32.40
Rate for Payer: United Healthcare Managed Medicare	$21.24

ESTAB PATIENT NURSE ONLY

Facility

$36.00

Service Code	CPT 99211
Hospital Charge Code	4734797
Hospital Revenue Code	760
Min. Negotiated Rate	$25.20
Max. Negotiated Rate	$32.40
Rate for Payer: Aetna of IA Commercial	$32.40
Rate for Payer: Aetna of IA Medical Rental Products	$32.40
Rate for Payer: Cash Price	$28.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.00
Rate for Payer: Medical Associates Commercial	$27.00
Rate for Payer: Midlands Choice Commercial	$25.20
Rate for Payer: United Healthcare Commercial	$32.40

Know your out-of-pocket cost for care.

All Charges