Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

folic acid 1 mg Tab [VDMC]

Facility

$1.66

Service Code	HCPCS A9270
Hospital Charge Code	10390664
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of IA Commercial	$1.49
Rate for Payer: Aetna of IA Medical Rental Products	$1.49
Rate for Payer: Aetna of IA Medicare	$0.95
Rate for Payer: Amerigroup Medicaid	$0.84
Rate for Payer: Amerigroup Medicare	$0.84
Rate for Payer: Cash Price	$1.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.83
Rate for Payer: Iowa Total Care Managed Medicaid	$0.83
Rate for Payer: Medical Associates Commercial	$1.24
Rate for Payer: Medical Associates Managed Medicare	$0.83
Rate for Payer: Midlands Choice Commercial	$1.16
Rate for Payer: Molina Healthcare Managed Medicaid	$0.84
Rate for Payer: Molina Healthcare Managed Medicare	$0.84
Rate for Payer: Oscar Health of IA Commercial	$1.24
Rate for Payer: Partners Health Alliance Commercial	$1.24
Rate for Payer: United Healthcare Commercial	$1.49
Rate for Payer: United Healthcare Managed Medicare	$0.98

Follicle Stimulating Hormone DMCL

Facility

$135.00

Service Code	CPT 83001
Hospital Charge Code	8037848
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

Follicle Stimulating Hormone DMCL

Facility

$135.00

Service Code	CPT 83001
Hospital Charge Code	8037848
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
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	$68.13
Rate for Payer: Amerigroup Medicare	$68.18
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	$67.50
Rate for Payer: Iowa Total Care Managed Medicaid	$67.47
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Medical Associates Managed Medicare	$67.50
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: Molina Healthcare Managed Medicaid	$68.51
Rate for Payer: Molina Healthcare Managed Medicare	$68.47
Rate for Payer: Oscar Health of IA Commercial	$101.25
Rate for Payer: Partners Health Alliance Commercial	$101.25
Rate for Payer: United Healthcare Commercial	$121.50
Rate for Payer: United Healthcare Managed Medicare	$79.65
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Foot Procedures With CC

Facility

$12,872.90

Service Code	MS-DRG 504
Hospital Charge Code	321
Min. Negotiated Rate	$12,686.33
Max. Negotiated Rate	$12,872.90
Rate for Payer: Amerigroup Medicaid	$12,810.71
Rate for Payer: Iowa Total Care Managed Medicaid	$12,686.33
Rate for Payer: Molina Healthcare Managed Medicaid	$12,872.90

Foot Procedures With MCC

Facility

$25,879.65

Service Code	MS-DRG 503
Hospital Charge Code	320
Min. Negotiated Rate	$25,504.58
Max. Negotiated Rate	$25,879.65
Rate for Payer: Amerigroup Medicaid	$25,754.62
Rate for Payer: Iowa Total Care Managed Medicaid	$25,504.58
Rate for Payer: Molina Healthcare Managed Medicaid	$25,879.65

Foot Procedures Without CC/MCC

Facility

$12,491.99

Service Code	MS-DRG 505
Hospital Charge Code	322
Min. Negotiated Rate	$12,310.95
Max. Negotiated Rate	$12,491.99
Rate for Payer: Amerigroup Medicaid	$12,431.65
Rate for Payer: Iowa Total Care Managed Medicaid	$12,310.95
Rate for Payer: Molina Healthcare Managed Medicaid	$12,491.99

FOREIGN BODY REMOVAL EAR

Professional

Both

$210.00

Service Code	CPT 69200
Hospital Charge Code	7982760
Hospital Revenue Code	981
Min. Negotiated Rate	$43.00
Max. Negotiated Rate	$147.00
Rate for Payer: Aetna of IA Medicare	$43.00
Rate for Payer: Amerigroup Medicaid	$44.46
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$51.60
Rate for Payer: Iowa Total Care Managed Medicaid	$43.86
Rate for Payer: Medical Associates Commercial	$77.40
Rate for Payer: Medical Associates Managed Medicare	$43.00
Rate for Payer: Midlands Choice Commercial	$147.00
Rate for Payer: Oscar Health of IA Commercial	$74.39
Rate for Payer: Partners Health Alliance Commercial	$64.50

FOREIGN BODY REMOVAL NOSE

Professional

Both

$415.00

Service Code	CPT 30300
Hospital Charge Code	7982783
Hospital Revenue Code	981
Min. Negotiated Rate	$111.93
Max. Negotiated Rate	$290.50
Rate for Payer: Aetna of IA Medicare	$111.93
Rate for Payer: Amerigroup Medicaid	$115.74
Rate for Payer: Cash Price	$332.00
Rate for Payer: Cash Price	$332.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.32
Rate for Payer: Iowa Total Care Managed Medicaid	$114.17
Rate for Payer: Medical Associates Commercial	$201.47
Rate for Payer: Medical Associates Managed Medicare	$111.93
Rate for Payer: Midlands Choice Commercial	$290.50
Rate for Payer: Oscar Health of IA Commercial	$193.64
Rate for Payer: Partners Health Alliance Commercial	$167.90

FOREIGN BODY REMOVAL SIMPLE

Professional

Both

$365.00

Service Code	CPT 10120
Hospital Charge Code	7982856
Hospital Revenue Code	981
Min. Negotiated Rate	$96.60
Max. Negotiated Rate	$255.50
Rate for Payer: Aetna of IA Medicare	$96.60
Rate for Payer: Amerigroup Medicaid	$99.88
Rate for Payer: Cash Price	$292.00
Rate for Payer: Cash Price	$292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$115.92
Rate for Payer: Iowa Total Care Managed Medicaid	$98.53
Rate for Payer: Medical Associates Commercial	$173.88
Rate for Payer: Medical Associates Managed Medicare	$96.60
Rate for Payer: Midlands Choice Commercial	$255.50
Rate for Payer: Oscar Health of IA Commercial	$167.12
Rate for Payer: Partners Health Alliance Commercial	$144.90

fosaprepitant 150 mg Pow[VDMC]

Facility

$1,154.72

Service Code	HCPCS J1453
Hospital Charge Code	13338918
Hospital Revenue Code	259
Min. Negotiated Rate	$808.30
Max. Negotiated Rate	$1,039.25
Rate for Payer: Aetna of IA Commercial	$1,039.25
Rate for Payer: Aetna of IA Medical Rental Products	$1,039.25
Rate for Payer: Cash Price	$923.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$866.04
Rate for Payer: Medical Associates Commercial	$866.04
Rate for Payer: Midlands Choice Commercial	$808.30
Rate for Payer: United Healthcare Commercial	$1,039.25

fosaprepitant 150 mg Pow[VDMC]

Facility

$1,154.72

Service Code	HCPCS J1453
Hospital Charge Code	13338918
Hospital Revenue Code	259
Min. Negotiated Rate	$577.13
Max. Negotiated Rate	$1,039.25
Rate for Payer: Aetna of IA Commercial	$1,039.25
Rate for Payer: Aetna of IA Medical Rental Products	$1,039.25
Rate for Payer: Aetna of IA Medicare	$658.19
Rate for Payer: Amerigroup Medicaid	$582.79
Rate for Payer: Amerigroup Medicare	$583.13
Rate for Payer: Cash Price	$923.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$866.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$577.36
Rate for Payer: Iowa Total Care Managed Medicaid	$577.13
Rate for Payer: Medical Associates Commercial	$866.04
Rate for Payer: Medical Associates Managed Medicare	$577.36
Rate for Payer: Midlands Choice Commercial	$808.30
Rate for Payer: Molina Healthcare Managed Medicaid	$586.02
Rate for Payer: Molina Healthcare Managed Medicare	$585.67
Rate for Payer: Oscar Health of IA Commercial	$866.04
Rate for Payer: Partners Health Alliance Commercial	$866.04
Rate for Payer: United Healthcare Commercial	$1,039.25
Rate for Payer: United Healthcare Managed Medicare	$681.28

fosinopril 10 mg Tab [VDMC]

Facility

$1.42

Service Code	HCPCS A9270
Hospital Charge Code	10391013
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
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	$1.06
Rate for Payer: Medical Associates Commercial	$1.06
Rate for Payer: Midlands Choice Commercial	$0.99
Rate for Payer: United Healthcare Commercial	$1.28

fosinopril 10 mg Tab [VDMC]

Facility

$1.42

Service Code	HCPCS A9270
Hospital Charge Code	10391013
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
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	$0.72
Rate for Payer: Amerigroup Medicare	$0.72
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.06
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.71
Rate for Payer: Iowa Total Care Managed Medicaid	$0.71
Rate for Payer: Medical Associates Commercial	$1.06
Rate for Payer: Medical Associates Managed Medicare	$0.71
Rate for Payer: Midlands Choice Commercial	$0.99
Rate for Payer: Molina Healthcare Managed Medicaid	$0.72
Rate for Payer: Molina Healthcare Managed Medicare	$0.72
Rate for Payer: Oscar Health of IA Commercial	$1.06
Rate for Payer: Partners Health Alliance Commercial	$1.06
Rate for Payer: United Healthcare Commercial	$1.28
Rate for Payer: United Healthcare Managed Medicare	$0.84

Fractures of Femur With MCC

Facility

$13,907.34

Service Code	MS-DRG 533
Hospital Charge Code	340
Min. Negotiated Rate	$13,705.78
Max. Negotiated Rate	$13,907.34
Rate for Payer: Amerigroup Medicaid	$13,840.15
Rate for Payer: Iowa Total Care Managed Medicaid	$13,705.78
Rate for Payer: Molina Healthcare Managed Medicaid	$13,907.34

Fractures of Femur Without MCC

Facility

$4,390.70

Service Code	MS-DRG 534
Hospital Charge Code	341
Min. Negotiated Rate	$4,327.06
Max. Negotiated Rate	$4,390.70
Rate for Payer: Amerigroup Medicaid	$4,369.49
Rate for Payer: Iowa Total Care Managed Medicaid	$4,327.06
Rate for Payer: Molina Healthcare Managed Medicaid	$4,390.70

Fractures of Hip and Pelvis With MCC

Facility

$9,672.14

Service Code	MS-DRG 535
Hospital Charge Code	342
Min. Negotiated Rate	$9,531.96
Max. Negotiated Rate	$9,672.14
Rate for Payer: Amerigroup Medicaid	$9,625.41
Rate for Payer: Iowa Total Care Managed Medicaid	$9,531.96
Rate for Payer: Molina Healthcare Managed Medicaid	$9,672.14

Fractures of Hip and Pelvis Without MCC

Facility

$7,944.79

Service Code	MS-DRG 536
Hospital Charge Code	343
Min. Negotiated Rate	$7,829.65
Max. Negotiated Rate	$7,944.79
Rate for Payer: Amerigroup Medicaid	$7,906.41
Rate for Payer: Iowa Total Care Managed Medicaid	$7,829.65
Rate for Payer: Molina Healthcare Managed Medicaid	$7,944.79

Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh With MCC

Facility

$8,837.50

Service Code	MS-DRG 562
Hospital Charge Code	369
Min. Negotiated Rate	$8,709.42
Max. Negotiated Rate	$8,837.50
Rate for Payer: Amerigroup Medicaid	$8,794.81
Rate for Payer: Iowa Total Care Managed Medicaid	$8,709.42
Rate for Payer: Molina Healthcare Managed Medicaid	$8,837.50

Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh Without MCC

Facility

$6,259.77

Service Code	MS-DRG 563
Hospital Charge Code	370
Min. Negotiated Rate	$6,169.05
Max. Negotiated Rate	$6,259.77
Rate for Payer: Amerigroup Medicaid	$6,229.53
Rate for Payer: Iowa Total Care Managed Medicaid	$6,169.05
Rate for Payer: Molina Healthcare Managed Medicaid	$6,259.77

Full Term Neonate With Major Problems

Facility

$5,229.28

Service Code	MS-DRG 793
Hospital Charge Code	535
Min. Negotiated Rate	$5,153.49
Max. Negotiated Rate	$5,229.28
Rate for Payer: Amerigroup Medicaid	$5,204.01
Rate for Payer: Iowa Total Care Managed Medicaid	$5,153.49
Rate for Payer: Molina Healthcare Managed Medicaid	$5,229.28

Full Thickness Burn Without Skin Graft or Inhalation Injury

Facility

$8,446.76

Service Code	MS-DRG 934
Hospital Charge Code	646
Min. Negotiated Rate	$8,324.34
Max. Negotiated Rate	$8,446.76
Rate for Payer: Amerigroup Medicaid	$8,405.95
Rate for Payer: Iowa Total Care Managed Medicaid	$8,324.34
Rate for Payer: Molina Healthcare Managed Medicaid	$8,446.76

Full Thickness Burn With Skin Graft or Inhalation Injury With CC/MCC

Facility

$31,975.05

Service Code	MS-DRG 928
Hospital Charge Code	643
Min. Negotiated Rate	$31,511.65
Max. Negotiated Rate	$31,975.05
Rate for Payer: Amerigroup Medicaid	$31,820.58
Rate for Payer: Iowa Total Care Managed Medicaid	$31,511.65
Rate for Payer: Molina Healthcare Managed Medicaid	$31,975.05

Full Thickness Burn With Skin Graft or Inhalation Injury Without CC/MCC

Facility

$19,154.32

Service Code	MS-DRG 929
Hospital Charge Code	644
Min. Negotiated Rate	$18,876.72
Max. Negotiated Rate	$19,154.32
Rate for Payer: Amerigroup Medicaid	$19,061.79
Rate for Payer: Iowa Total Care Managed Medicaid	$18,876.72
Rate for Payer: Molina Healthcare Managed Medicaid	$19,154.32

FUNGITELL ASSAY

Facility

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037483
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$57.54
Rate for Payer: Amerigroup Medicare	$57.57
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.00
Rate for Payer: Iowa Total Care Managed Medicaid	$56.98
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$57.00
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$57.86
Rate for Payer: Molina Healthcare Managed Medicare	$57.82
Rate for Payer: Oscar Health of IA Commercial	$85.50
Rate for Payer: Partners Health Alliance Commercial	$85.50
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

FUNGITELL ASSAY

Facility

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037483
Hospital Revenue Code	306
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

Know your out-of-pocket cost for care.

All Charges