Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

empagliflozin 25 mg Tab UD [VDMC]

Facility

$51.95

Service Code	HCPCS A9270
Hospital Charge Code	23268393
Hospital Revenue Code	259
Min. Negotiated Rate	$36.36
Max. Negotiated Rate	$46.75
Rate for Payer: Aetna of IA Commercial	$46.75
Rate for Payer: Aetna of IA Medical Rental Products	$46.75
Rate for Payer: Cash Price	$41.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$38.96
Rate for Payer: Medical Associates Commercial	$38.96
Rate for Payer: Midlands Choice Commercial	$36.36
Rate for Payer: United Healthcare Commercial	$46.75

empagliflozin 25 mg Tab UD [VDMC]

Facility

$51.95

Service Code	HCPCS A9270
Hospital Charge Code	23268393
Hospital Revenue Code	259
Min. Negotiated Rate	$23.38
Max. Negotiated Rate	$46.75
Rate for Payer: Aetna of IA Commercial	$46.75
Rate for Payer: Aetna of IA Medical Rental Products	$46.75
Rate for Payer: Aetna of IA Medicare	$29.61
Rate for Payer: Amerigroup Medicaid	$29.96
Rate for Payer: Amerigroup Medicare	$23.61
Rate for Payer: Cash Price	$41.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$38.96
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.38
Rate for Payer: Iowa Total Care Managed Medicaid	$29.67
Rate for Payer: Medical Associates Commercial	$38.96
Rate for Payer: Medical Associates Managed Medicare	$23.38
Rate for Payer: Midlands Choice Commercial	$36.36
Rate for Payer: Molina Healthcare Managed Medicaid	$30.11
Rate for Payer: Partners Health Alliance Commercial	$26.88
Rate for Payer: United Healthcare Commercial	$46.75
Rate for Payer: United Healthcare Managed Medicare	$30.65

enalaprilat 1.25 mg/mL 1ml SDV [VDMC]

Facility

$34.39

Service Code	HCPCS J3490
Hospital Charge Code	10385557
Hospital Revenue Code	259
Min. Negotiated Rate	$15.47
Max. Negotiated Rate	$30.95
Rate for Payer: Aetna of IA Commercial	$30.95
Rate for Payer: Aetna of IA Medical Rental Products	$30.95
Rate for Payer: Aetna of IA Medicare	$19.60
Rate for Payer: Amerigroup Medicaid	$19.83
Rate for Payer: Amerigroup Medicare	$15.63
Rate for Payer: Cash Price	$27.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$25.79
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.47
Rate for Payer: Iowa Total Care Managed Medicaid	$19.64
Rate for Payer: Medical Associates Commercial	$25.79
Rate for Payer: Medical Associates Managed Medicare	$15.47
Rate for Payer: Midlands Choice Commercial	$24.07
Rate for Payer: Molina Healthcare Managed Medicaid	$19.93
Rate for Payer: Partners Health Alliance Commercial	$17.80
Rate for Payer: United Healthcare Commercial	$30.95
Rate for Payer: United Healthcare Managed Medicare	$20.29

enalaprilat 1.25 mg/mL 1ml SDV [VDMC]

Facility

$34.39

Service Code	HCPCS J3490
Hospital Charge Code	10385557
Hospital Revenue Code	259
Min. Negotiated Rate	$24.07
Max. Negotiated Rate	$30.95
Rate for Payer: Aetna of IA Commercial	$30.95
Rate for Payer: Aetna of IA Medical Rental Products	$30.95
Rate for Payer: Cash Price	$27.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$25.79
Rate for Payer: Medical Associates Commercial	$25.79
Rate for Payer: Midlands Choice Commercial	$24.07
Rate for Payer: United Healthcare Commercial	$30.95

enalapril maleate 5 mg Tab [VDMC]

Facility

$1.18

Service Code	HCPCS A9270
Hospital Charge Code	10431638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of IA Commercial	$1.06
Rate for Payer: Aetna of IA Medical Rental Products	$1.06
Rate for Payer: Aetna of IA Medicare	$0.67
Rate for Payer: Amerigroup Medicaid	$0.68
Rate for Payer: Amerigroup Medicare	$0.54
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.89
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.53
Rate for Payer: Iowa Total Care Managed Medicaid	$0.68
Rate for Payer: Medical Associates Commercial	$0.89
Rate for Payer: Medical Associates Managed Medicare	$0.53
Rate for Payer: Midlands Choice Commercial	$0.83
Rate for Payer: Molina Healthcare Managed Medicaid	$0.69
Rate for Payer: Partners Health Alliance Commercial	$0.61
Rate for Payer: United Healthcare Commercial	$1.06
Rate for Payer: United Healthcare Managed Medicare	$0.70

enalapril maleate 5 mg Tab [VDMC]

Facility

$1.18

Service Code	HCPCS A9270
Hospital Charge Code	10431638
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of IA Commercial	$1.06
Rate for Payer: Aetna of IA Medical Rental Products	$1.06
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.89
Rate for Payer: Medical Associates Commercial	$0.89
Rate for Payer: Midlands Choice Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.06

ENDO CLIP CARTRIDGE

Facility

$94.00

Hospital Charge Code	8026309
Hospital Revenue Code	272
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of IA Commercial	$84.60
Rate for Payer: Aetna of IA Medical Rental Products	$84.60
Rate for Payer: Aetna of IA Medicare	$53.58
Rate for Payer: Amerigroup Medicaid	$54.22
Rate for Payer: Amerigroup Medicare	$42.72
Rate for Payer: Cash Price	$75.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$42.30
Rate for Payer: Iowa Total Care Managed Medicaid	$53.69
Rate for Payer: Medical Associates Commercial	$70.50
Rate for Payer: Medical Associates Managed Medicare	$42.30
Rate for Payer: Midlands Choice Commercial	$65.80
Rate for Payer: Molina Healthcare Managed Medicaid	$54.48
Rate for Payer: Partners Health Alliance Commercial	$48.64
Rate for Payer: United Healthcare Commercial	$84.60
Rate for Payer: United Healthcare Managed Medicare	$55.46

ENDO CLIP CARTRIDGE

Facility

$94.00

Hospital Charge Code	8026309
Hospital Revenue Code	272
Min. Negotiated Rate	$65.80
Max. Negotiated Rate	$84.60
Rate for Payer: Aetna of IA Commercial	$84.60
Rate for Payer: Aetna of IA Medical Rental Products	$84.60
Rate for Payer: Cash Price	$75.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.50
Rate for Payer: Medical Associates Commercial	$70.50
Rate for Payer: Midlands Choice Commercial	$65.80
Rate for Payer: United Healthcare Commercial	$84.60

ENDOCRINE DISORDERS WITH CC

Facility

$7,891.97

Service Code	MSDRG 644
Min. Negotiated Rate	$7,777.59
Max. Negotiated Rate	$7,891.97
Rate for Payer: Amerigroup Medicaid	$7,853.84
Rate for Payer: Iowa Total Care Managed Medicaid	$7,777.59
Rate for Payer: Molina Healthcare Managed Medicaid	$7,891.97

ENDOCRINE DISORDERS WITH MCC

Facility

$12,506.23

Service Code	MSDRG 643
Min. Negotiated Rate	$12,324.97
Max. Negotiated Rate	$12,506.23
Rate for Payer: Amerigroup Medicaid	$12,445.80
Rate for Payer: Iowa Total Care Managed Medicaid	$12,324.97
Rate for Payer: Molina Healthcare Managed Medicaid	$12,506.23

ENDOCRINE DISORDERS WITHOUT CC/MCC

Facility

$6,089.28

Service Code	MSDRG 645
Min. Negotiated Rate	$6,001.03
Max. Negotiated Rate	$6,089.28
Rate for Payer: Amerigroup Medicaid	$6,059.86
Rate for Payer: Iowa Total Care Managed Medicaid	$6,001.03
Rate for Payer: Molina Healthcare Managed Medicaid	$6,089.28

ENDO GIA 30 2.5 (SULU) LOADING UNIT

Facility

$1,141.00

Hospital Charge Code	8047001
Hospital Revenue Code	272
Min. Negotiated Rate	$513.45
Max. Negotiated Rate	$1,026.90
Rate for Payer: Aetna of IA Commercial	$1,026.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,026.90
Rate for Payer: Aetna of IA Medicare	$650.37
Rate for Payer: Amerigroup Medicaid	$658.13
Rate for Payer: Amerigroup Medicare	$518.58
Rate for Payer: Cash Price	$912.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$855.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$513.45
Rate for Payer: Iowa Total Care Managed Medicaid	$651.74
Rate for Payer: Medical Associates Commercial	$855.75
Rate for Payer: Medical Associates Managed Medicare	$513.45
Rate for Payer: Midlands Choice Commercial	$798.70
Rate for Payer: Molina Healthcare Managed Medicaid	$661.32
Rate for Payer: Partners Health Alliance Commercial	$590.47
Rate for Payer: United Healthcare Commercial	$1,026.90
Rate for Payer: United Healthcare Managed Medicare	$673.19

ENDO GIA 30 2.5 (SULU) LOADING UNIT

Facility

$1,141.00

Hospital Charge Code	8047001
Hospital Revenue Code	272
Min. Negotiated Rate	$798.70
Max. Negotiated Rate	$1,026.90
Rate for Payer: Aetna of IA Commercial	$1,026.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,026.90
Rate for Payer: Cash Price	$912.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$855.75
Rate for Payer: Medical Associates Commercial	$855.75
Rate for Payer: Midlands Choice Commercial	$798.70
Rate for Payer: United Healthcare Commercial	$1,026.90

ENDO GIA 30 3.5 LOAD

Facility

$603.00

Hospital Charge Code	8025853
Hospital Revenue Code	272
Min. Negotiated Rate	$422.10
Max. Negotiated Rate	$542.70
Rate for Payer: Aetna of IA Commercial	$542.70
Rate for Payer: Aetna of IA Medical Rental Products	$542.70
Rate for Payer: Cash Price	$482.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$452.25
Rate for Payer: Medical Associates Commercial	$452.25
Rate for Payer: Midlands Choice Commercial	$422.10
Rate for Payer: United Healthcare Commercial	$542.70

ENDO GIA 30 3.5 LOAD

Facility

$603.00

Hospital Charge Code	8025853
Hospital Revenue Code	272
Min. Negotiated Rate	$271.35
Max. Negotiated Rate	$542.70
Rate for Payer: Aetna of IA Commercial	$542.70
Rate for Payer: Aetna of IA Medical Rental Products	$542.70
Rate for Payer: Aetna of IA Medicare	$343.71
Rate for Payer: Amerigroup Medicaid	$347.81
Rate for Payer: Amerigroup Medicare	$274.06
Rate for Payer: Cash Price	$482.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$452.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$271.35
Rate for Payer: Iowa Total Care Managed Medicaid	$344.43
Rate for Payer: Medical Associates Commercial	$452.25
Rate for Payer: Medical Associates Managed Medicare	$271.35
Rate for Payer: Midlands Choice Commercial	$422.10
Rate for Payer: Molina Healthcare Managed Medicaid	$349.50
Rate for Payer: Partners Health Alliance Commercial	$312.05
Rate for Payer: United Healthcare Commercial	$542.70
Rate for Payer: United Healthcare Managed Medicare	$355.77

Endomysial IgA Antibody DMCL

Facility

$115.00

Service Code	CPT 83516
Hospital Charge Code	8037839
Hospital Revenue Code	302
Min. Negotiated Rate	$51.75
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Aetna of IA Medicare	$65.55
Rate for Payer: Amerigroup Medicaid	$66.33
Rate for Payer: Amerigroup Medicare	$52.27
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.75
Rate for Payer: Iowa Total Care Managed Medicaid	$65.69
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Medical Associates Managed Medicare	$51.75
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: Molina Healthcare Managed Medicaid	$66.65
Rate for Payer: Partners Health Alliance Commercial	$59.51
Rate for Payer: United Healthcare Commercial	$103.50
Rate for Payer: United Healthcare Managed Medicare	$67.85
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

Endomysial IgA Antibody DMCL

Facility

$115.00

Service Code	CPT 83516
Hospital Charge Code	8037839
Hospital Revenue Code	302
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: United Healthcare Commercial	$103.50

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC

Facility

$69,804.94

Service Code	MSDRG 266
Min. Negotiated Rate	$68,793.25
Max. Negotiated Rate	$69,804.94
Rate for Payer: Amerigroup Medicaid	$69,467.69
Rate for Payer: Iowa Total Care Managed Medicaid	$68,793.25
Rate for Payer: Molina Healthcare Managed Medicaid	$69,804.94

ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC

Facility

$58,693.80

Service Code	MSDRG 267
Min. Negotiated Rate	$57,843.14
Max. Negotiated Rate	$58,693.80
Rate for Payer: Amerigroup Medicaid	$58,410.23
Rate for Payer: Iowa Total Care Managed Medicaid	$57,843.14
Rate for Payer: Molina Healthcare Managed Medicaid	$58,693.80

enoxaparin 100 mg/mL 1ml SDV syringe [VDMC]

Facility

$51.20

Service Code	HCPCS J1650
Hospital Charge Code	10385695
Hospital Revenue Code	259
Min. Negotiated Rate	$35.84
Max. Negotiated Rate	$46.08
Rate for Payer: Aetna of IA Commercial	$46.08
Rate for Payer: Aetna of IA Medical Rental Products	$46.08
Rate for Payer: Cash Price	$40.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$38.40
Rate for Payer: Medical Associates Commercial	$38.40
Rate for Payer: Midlands Choice Commercial	$35.84
Rate for Payer: United Healthcare Commercial	$46.08

enoxaparin 100 mg/mL 1ml SDV syringe [VDMC]

Facility

$51.20

Service Code	HCPCS J1650
Hospital Charge Code	10385695
Hospital Revenue Code	259
Min. Negotiated Rate	$23.04
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$46.08
Rate for Payer: Aetna of IA Medical Rental Products	$46.08
Rate for Payer: Aetna of IA Medicare	$29.18
Rate for Payer: Amerigroup Medicaid	$29.53
Rate for Payer: Amerigroup Medicare	$23.27
Rate for Payer: Cash Price	$40.96
Rate for Payer: Cash Price	$40.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$38.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.04
Rate for Payer: Iowa Total Care Managed Medicaid	$29.25
Rate for Payer: Medical Associates Commercial	$38.40
Rate for Payer: Medical Associates Managed Medicare	$23.04
Rate for Payer: Midlands Choice Commercial	$35.84
Rate for Payer: Molina Healthcare Managed Medicaid	$29.68
Rate for Payer: Partners Health Alliance Commercial	$26.50
Rate for Payer: United Healthcare Commercial	$46.08
Rate for Payer: United Healthcare Managed Medicare	$30.21
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

enoxaparin 30 mg/0.3 ml SDV syringe [VDMC]

Facility

$26.50

Service Code	HCPCS J1650
Hospital Charge Code	10607521
Hospital Revenue Code	259
Min. Negotiated Rate	$11.92
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$23.85
Rate for Payer: Aetna of IA Medical Rental Products	$23.85
Rate for Payer: Aetna of IA Medicare	$15.10
Rate for Payer: Amerigroup Medicaid	$15.28
Rate for Payer: Amerigroup Medicare	$12.04
Rate for Payer: Cash Price	$21.20
Rate for Payer: Cash Price	$21.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.87
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.92
Rate for Payer: Iowa Total Care Managed Medicaid	$15.13
Rate for Payer: Medical Associates Commercial	$19.87
Rate for Payer: Medical Associates Managed Medicare	$11.92
Rate for Payer: Midlands Choice Commercial	$18.55
Rate for Payer: Molina Healthcare Managed Medicaid	$15.36
Rate for Payer: Partners Health Alliance Commercial	$13.71
Rate for Payer: United Healthcare Commercial	$23.85
Rate for Payer: United Healthcare Managed Medicare	$15.63
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

enoxaparin 30 mg/0.3 ml SDV syringe [VDMC]

Facility

$26.50

Service Code	HCPCS J1650
Hospital Charge Code	10607521
Hospital Revenue Code	259
Min. Negotiated Rate	$18.55
Max. Negotiated Rate	$23.85
Rate for Payer: Aetna of IA Commercial	$23.85
Rate for Payer: Aetna of IA Medical Rental Products	$23.85
Rate for Payer: Cash Price	$21.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.87
Rate for Payer: Medical Associates Commercial	$19.87
Rate for Payer: Midlands Choice Commercial	$18.55
Rate for Payer: United Healthcare Commercial	$23.85

enoxaparin 40 mg/0.4 mL SDV syringe [VDMC]

Facility

$28.21

Service Code	HCPCS J1650
Hospital Charge Code	10385764
Hospital Revenue Code	259
Min. Negotiated Rate	$12.69
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$25.39
Rate for Payer: Aetna of IA Medical Rental Products	$25.39
Rate for Payer: Aetna of IA Medicare	$16.08
Rate for Payer: Amerigroup Medicaid	$16.27
Rate for Payer: Amerigroup Medicare	$12.82
Rate for Payer: Cash Price	$22.57
Rate for Payer: Cash Price	$22.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.69
Rate for Payer: Iowa Total Care Managed Medicaid	$16.11
Rate for Payer: Medical Associates Commercial	$21.16
Rate for Payer: Medical Associates Managed Medicare	$12.69
Rate for Payer: Midlands Choice Commercial	$19.75
Rate for Payer: Molina Healthcare Managed Medicaid	$16.35
Rate for Payer: Partners Health Alliance Commercial	$14.60
Rate for Payer: United Healthcare Commercial	$25.39
Rate for Payer: United Healthcare Managed Medicare	$16.64
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

enoxaparin 40 mg/0.4 mL SDV syringe [VDMC]

Facility

$28.21

Service Code	HCPCS J1650
Hospital Charge Code	10385764
Hospital Revenue Code	259
Min. Negotiated Rate	$19.75
Max. Negotiated Rate	$25.39
Rate for Payer: Aetna of IA Commercial	$25.39
Rate for Payer: Aetna of IA Medical Rental Products	$25.39
Rate for Payer: Cash Price	$22.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.16
Rate for Payer: Medical Associates Commercial	$21.16
Rate for Payer: Midlands Choice Commercial	$19.75
Rate for Payer: United Healthcare Commercial	$25.39

Know your out-of-pocket cost for care.

All Charges