Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

hylan G-F 20 48 mg/6 mL SDV syringe [VDMC]

Facility

$1,824.20

Service Code	HCPCS J7325
Hospital Charge Code	10395352
Hospital Revenue Code	259
Min. Negotiated Rate	$911.74
Max. Negotiated Rate	$1,641.78
Rate for Payer: Aetna of IA Commercial	$1,641.78
Rate for Payer: Aetna of IA Medical Rental Products	$1,641.78
Rate for Payer: Aetna of IA Medicare	$1,039.79
Rate for Payer: Amerigroup Medicaid	$920.67
Rate for Payer: Amerigroup Medicare	$921.22
Rate for Payer: Cash Price	$1,459.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,368.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$912.10
Rate for Payer: Iowa Total Care Managed Medicaid	$911.74
Rate for Payer: Medical Associates Commercial	$1,368.15
Rate for Payer: Medical Associates Managed Medicare	$912.10
Rate for Payer: Midlands Choice Commercial	$1,276.94
Rate for Payer: Molina Healthcare Managed Medicaid	$925.78
Rate for Payer: Molina Healthcare Managed Medicare	$925.23
Rate for Payer: Oscar Health of IA Commercial	$1,368.15
Rate for Payer: Partners Health Alliance Commercial	$1,368.15
Rate for Payer: United Healthcare Commercial	$1,641.78
Rate for Payer: United Healthcare Managed Medicare	$1,076.28

hyoscyamine 0.125 mg Dis Tab [VDMC]

Facility

$1.30

Service Code	HCPCS A9270
Hospital Charge Code	10395421
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of IA Commercial	$1.17
Rate for Payer: Aetna of IA Medical Rental Products	$1.17
Rate for Payer: Aetna of IA Medicare	$0.74
Rate for Payer: Amerigroup Medicaid	$0.66
Rate for Payer: Amerigroup Medicare	$0.66
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	$0.65
Rate for Payer: Iowa Total Care Managed Medicaid	$0.65
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Medical Associates Managed Medicare	$0.65
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: Molina Healthcare Managed Medicaid	$0.66
Rate for Payer: Molina Healthcare Managed Medicare	$0.66
Rate for Payer: Oscar Health of IA Commercial	$0.98
Rate for Payer: Partners Health Alliance Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.17
Rate for Payer: United Healthcare Managed Medicare	$0.77

hyoscyamine 0.125 mg Dis Tab [VDMC]

Facility

$1.30

Service Code	HCPCS A9270
Hospital Charge Code	10395421
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of IA Commercial	$1.17
Rate for Payer: Aetna of IA Medical Rental Products	$1.17
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	$1.17

Hypertension With MCC

Facility

$8,093.42

Service Code	MS-DRG 304
Hospital Charge Code	161
Min. Negotiated Rate	$7,976.12
Max. Negotiated Rate	$8,093.42
Rate for Payer: Amerigroup Medicaid	$8,054.32
Rate for Payer: Iowa Total Care Managed Medicaid	$7,976.12
Rate for Payer: Molina Healthcare Managed Medicaid	$8,093.42

Hypertension Without MCC

Facility

$6,236.15

Service Code	MS-DRG 305
Hospital Charge Code	162
Min. Negotiated Rate	$6,145.78
Max. Negotiated Rate	$6,236.15
Rate for Payer: Amerigroup Medicaid	$6,206.03
Rate for Payer: Iowa Total Care Managed Medicaid	$6,145.78
Rate for Payer: Molina Healthcare Managed Medicaid	$6,236.15

Hypertensive Encephalopathy With CC

Facility

$7,560.94

Service Code	MS-DRG 078
Hospital Charge Code	758
Min. Negotiated Rate	$7,451.37
Max. Negotiated Rate	$7,560.94
Rate for Payer: Amerigroup Medicaid	$7,524.42
Rate for Payer: Iowa Total Care Managed Medicaid	$7,451.37
Rate for Payer: Molina Healthcare Managed Medicaid	$7,560.94

Hypertensive Encephalopathy With MCC

Facility

$11,785.31

Service Code	MS-DRG 077
Hospital Charge Code	757
Min. Negotiated Rate	$11,614.51
Max. Negotiated Rate	$11,785.31
Rate for Payer: Amerigroup Medicaid	$11,728.37
Rate for Payer: Iowa Total Care Managed Medicaid	$11,614.51
Rate for Payer: Molina Healthcare Managed Medicaid	$11,785.31

Hypertensive Encephalopathy Without CC/MCC

Facility

$7,560.94

Service Code	MS-DRG 079
Hospital Charge Code	759
Min. Negotiated Rate	$7,451.37
Max. Negotiated Rate	$7,560.94
Rate for Payer: Amerigroup Medicaid	$7,524.42
Rate for Payer: Iowa Total Care Managed Medicaid	$7,451.37
Rate for Payer: Molina Healthcare Managed Medicaid	$7,560.94

Hysteroscopy surgical with BX of endometrium

Professional

Both

$4,492.00

Service Code	CPT 58558
Hospital Charge Code	8069167
Hospital Revenue Code	975
Min. Negotiated Rate	$208.15
Max. Negotiated Rate	$415.93
Rate for Payer: Aetna of IA Medicare	$208.15
Rate for Payer: Amerigroup Medicaid	$215.23
Rate for Payer: Cash Price	$3,593.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.78
Rate for Payer: Iowa Total Care Managed Medicaid	$212.31
Rate for Payer: Medical Associates Commercial	$395.48
Rate for Payer: Medical Associates Managed Medicare	$208.15
Rate for Payer: Midlands Choice Commercial	$415.93
Rate for Payer: Oscar Health of IA Commercial	$360.10
Rate for Payer: Partners Health Alliance Commercial	$312.22

ibandronate 1 mg/mL IV Sol [VDMC]

Facility

$730.04

Service Code	HCPCS J1740
Hospital Charge Code	10395490
Hospital Revenue Code	259
Min. Negotiated Rate	$511.03
Max. Negotiated Rate	$657.04
Rate for Payer: Aetna of IA Commercial	$657.04
Rate for Payer: Aetna of IA Medical Rental Products	$657.04
Rate for Payer: Cash Price	$584.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$547.53
Rate for Payer: Medical Associates Commercial	$547.53
Rate for Payer: Midlands Choice Commercial	$511.03
Rate for Payer: United Healthcare Commercial	$657.04

ibandronate 1 mg/mL IV Sol [VDMC]

Facility

$730.04

Service Code	HCPCS J1740
Hospital Charge Code	10395490
Hospital Revenue Code	259
Min. Negotiated Rate	$364.87
Max. Negotiated Rate	$657.04
Rate for Payer: Aetna of IA Commercial	$657.04
Rate for Payer: Aetna of IA Medical Rental Products	$657.04
Rate for Payer: Aetna of IA Medicare	$416.12
Rate for Payer: Amerigroup Medicaid	$368.45
Rate for Payer: Amerigroup Medicare	$368.67
Rate for Payer: Cash Price	$584.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$547.53
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$365.02
Rate for Payer: Iowa Total Care Managed Medicaid	$364.87
Rate for Payer: Medical Associates Commercial	$547.53
Rate for Payer: Medical Associates Managed Medicare	$365.02
Rate for Payer: Midlands Choice Commercial	$511.03
Rate for Payer: Molina Healthcare Managed Medicaid	$370.50
Rate for Payer: Molina Healthcare Managed Medicare	$370.28
Rate for Payer: Oscar Health of IA Commercial	$547.53
Rate for Payer: Partners Health Alliance Commercial	$547.53
Rate for Payer: United Healthcare Commercial	$657.04
Rate for Payer: United Healthcare Managed Medicare	$430.72

IB KIT, BC, W/CC FT AND JUMPSTART

Facility

$2,691.00

Service Code	CPT C1713
Hospital Charge Code	8783232
Hospital Revenue Code	278
Min. Negotiated Rate	$1,344.96
Max. Negotiated Rate	$2,421.90
Rate for Payer: Aetna of IA Commercial	$2,421.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,421.90
Rate for Payer: Aetna of IA Medicare	$1,533.87
Rate for Payer: Amerigroup Medicaid	$1,358.15
Rate for Payer: Amerigroup Medicare	$1,358.96
Rate for Payer: Cash Price	$2,152.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,018.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,345.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,344.96
Rate for Payer: Medical Associates Commercial	$2,018.25
Rate for Payer: Medical Associates Managed Medicare	$1,345.50
Rate for Payer: Midlands Choice Commercial	$1,883.70
Rate for Payer: Molina Healthcare Managed Medicaid	$1,365.68
Rate for Payer: Molina Healthcare Managed Medicare	$1,364.88
Rate for Payer: Oscar Health of IA Commercial	$2,018.25
Rate for Payer: Partners Health Alliance Commercial	$2,018.25
Rate for Payer: United Healthcare Commercial	$2,421.90
Rate for Payer: United Healthcare Managed Medicare	$1,587.69

IB KIT, BC, W/CC FT AND JUMPSTART

Facility

$2,691.00

Service Code	CPT C1713
Hospital Charge Code	8783232
Hospital Revenue Code	278
Min. Negotiated Rate	$1,883.70
Max. Negotiated Rate	$2,421.90
Rate for Payer: Aetna of IA Commercial	$2,421.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,421.90
Rate for Payer: Cash Price	$2,152.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,018.25
Rate for Payer: Medical Associates Commercial	$2,018.25
Rate for Payer: Midlands Choice Commercial	$1,883.70
Rate for Payer: United Healthcare Commercial	$2,421.90

ibuprofen 100 mg/5 mL 120ml oral suspension [VDMC]

Facility

$17.44

Service Code	HCPCS A9270
Hospital Charge Code	14129440
Hospital Revenue Code	259
Min. Negotiated Rate	$8.72
Max. Negotiated Rate	$15.70
Rate for Payer: Aetna of IA Commercial	$15.70
Rate for Payer: Aetna of IA Medical Rental Products	$15.70
Rate for Payer: Aetna of IA Medicare	$9.94
Rate for Payer: Amerigroup Medicaid	$8.80
Rate for Payer: Amerigroup Medicare	$8.81
Rate for Payer: Cash Price	$13.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.08
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.72
Rate for Payer: Iowa Total Care Managed Medicaid	$8.72
Rate for Payer: Medical Associates Commercial	$13.08
Rate for Payer: Medical Associates Managed Medicare	$8.72
Rate for Payer: Midlands Choice Commercial	$12.21
Rate for Payer: Molina Healthcare Managed Medicaid	$8.85
Rate for Payer: Molina Healthcare Managed Medicare	$8.85
Rate for Payer: Oscar Health of IA Commercial	$13.08
Rate for Payer: Partners Health Alliance Commercial	$13.08
Rate for Payer: United Healthcare Commercial	$15.70
Rate for Payer: United Healthcare Managed Medicare	$10.29

ibuprofen 100 mg/5 mL 120ml oral suspension [VDMC]

Facility

$17.44

Service Code	HCPCS A9270
Hospital Charge Code	14129440
Hospital Revenue Code	259
Min. Negotiated Rate	$12.21
Max. Negotiated Rate	$15.70
Rate for Payer: Aetna of IA Commercial	$15.70
Rate for Payer: Aetna of IA Medical Rental Products	$15.70
Rate for Payer: Cash Price	$13.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.08
Rate for Payer: Medical Associates Commercial	$13.08
Rate for Payer: Midlands Choice Commercial	$12.21
Rate for Payer: United Healthcare Commercial	$15.70

ibuprofen 100 mg/5 mL Cups Oral Susp [VDMC]

Facility

$2.78

Service Code	HCPCS A9270
Hospital Charge Code	10395624
Hospital Revenue Code	259
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of IA Commercial	$2.50
Rate for Payer: Aetna of IA Medical Rental Products	$2.50
Rate for Payer: Cash Price	$2.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.08
Rate for Payer: Medical Associates Commercial	$2.08
Rate for Payer: Midlands Choice Commercial	$1.95
Rate for Payer: United Healthcare Commercial	$2.50

ibuprofen 100 mg/5 mL Cups Oral Susp [VDMC]

Facility

$2.78

Service Code	HCPCS A9270
Hospital Charge Code	10395624
Hospital Revenue Code	259
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.50
Rate for Payer: Aetna of IA Commercial	$2.50
Rate for Payer: Aetna of IA Medical Rental Products	$2.50
Rate for Payer: Aetna of IA Medicare	$1.58
Rate for Payer: Amerigroup Medicaid	$1.40
Rate for Payer: Amerigroup Medicare	$1.40
Rate for Payer: Cash Price	$2.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.08
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.39
Rate for Payer: Iowa Total Care Managed Medicaid	$1.39
Rate for Payer: Medical Associates Commercial	$2.08
Rate for Payer: Medical Associates Managed Medicare	$1.39
Rate for Payer: Midlands Choice Commercial	$1.95
Rate for Payer: Molina Healthcare Managed Medicaid	$1.41
Rate for Payer: Molina Healthcare Managed Medicare	$1.41
Rate for Payer: Oscar Health of IA Commercial	$2.08
Rate for Payer: Partners Health Alliance Commercial	$2.08
Rate for Payer: United Healthcare Commercial	$2.50
Rate for Payer: United Healthcare Managed Medicare	$1.64

ID ABSCESS PERIRECTAL CHARGE

Professional

Both

$1,362.00

Hospital Charge Code	8068983
Hospital Revenue Code	981
Min. Negotiated Rate	$953.40
Max. Negotiated Rate	$1,021.50
Rate for Payer: Cash Price	$1,089.60
Rate for Payer: Medical Associates Commercial	$1,021.50
Rate for Payer: Midlands Choice Commercial	$953.40

ID ABSCESS SIMPLE SNGL ER CHARGE

Professional

Both

$316.00

Hospital Charge Code	8068971
Hospital Revenue Code	981
Min. Negotiated Rate	$221.20
Max. Negotiated Rate	$237.00
Rate for Payer: Cash Price	$252.80
Rate for Payer: Medical Associates Commercial	$237.00
Rate for Payer: Midlands Choice Commercial	$221.20

ID ABSCESS SUBFASCIAL

Professional

Both

$1,036.00

Service Code	CPT 20005
Hospital Charge Code	7982741
Hospital Revenue Code	981
Min. Negotiated Rate	$725.20
Max. Negotiated Rate	$777.00
Rate for Payer: Cash Price	$828.80
Rate for Payer: Medical Associates Commercial	$777.00
Rate for Payer: Midlands Choice Commercial	$725.20

ID COMPLEX POSTOP WOUND ER CHARGE

Professional

Both

$702.00

Hospital Charge Code	8068968
Hospital Revenue Code	981
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$526.50
Rate for Payer: Cash Price	$561.60
Rate for Payer: Medical Associates Commercial	$526.50
Rate for Payer: Midlands Choice Commercial	$491.40

ID Now COVID-19 Test

Facility

$128.00

Service Code	CPT 87635
Hospital Charge Code	8787912
Hospital Revenue Code	306
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: United Healthcare Commercial	$115.20

ID Now COVID-19 Test

Facility

$128.00

Service Code	CPT 87635
Hospital Charge Code	8787912
Hospital Revenue Code	306
Min. Negotiated Rate	$63.97
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Aetna of IA Medicare	$72.96
Rate for Payer: Amerigroup Medicaid	$64.60
Rate for Payer: Amerigroup Medicare	$64.64
Rate for Payer: Cash Price	$102.40
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.00
Rate for Payer: Iowa Total Care Managed Medicaid	$63.97
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Medical Associates Managed Medicare	$64.00
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: Molina Healthcare Managed Medicaid	$64.96
Rate for Payer: Molina Healthcare Managed Medicare	$64.92
Rate for Payer: Oscar Health of IA Commercial	$96.00
Rate for Payer: Partners Health Alliance Commercial	$96.00
Rate for Payer: United Healthcare Commercial	$115.20
Rate for Payer: United Healthcare Managed Medicare	$75.52
Rate for Payer: Wellmark IA HMO	$68.82
Rate for Payer: Wellmark IA PPO	$75.70

I D OF VULVA/PERINEUM

Professional

Both

$363.00

Service Code	CPT 56405
Hospital Charge Code	7982767
Hospital Revenue Code	981
Min. Negotiated Rate	$115.61
Max. Negotiated Rate	$254.10
Rate for Payer: Aetna of IA Medicare	$115.61
Rate for Payer: Amerigroup Medicaid	$119.54
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$138.73
Rate for Payer: Iowa Total Care Managed Medicaid	$117.92
Rate for Payer: Medical Associates Commercial	$208.10
Rate for Payer: Medical Associates Managed Medicare	$115.61
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Oscar Health of IA Commercial	$200.01
Rate for Payer: Partners Health Alliance Commercial	$173.42

ID Only

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	8089012
Hospital Revenue Code	306
Min. Negotiated Rate	$29.49
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Aetna of IA Medicare	$33.63
Rate for Payer: Amerigroup Medicaid	$29.78
Rate for Payer: Amerigroup Medicare	$29.80
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.50
Rate for Payer: Iowa Total Care Managed Medicaid	$29.49
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Medical Associates Managed Medicare	$29.50
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: Molina Healthcare Managed Medicaid	$29.94
Rate for Payer: Molina Healthcare Managed Medicare	$29.92
Rate for Payer: Oscar Health of IA Commercial	$44.25
Rate for Payer: Partners Health Alliance Commercial	$44.25
Rate for Payer: United Healthcare Commercial	$53.10
Rate for Payer: United Healthcare Managed Medicare	$34.81
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

Know your out-of-pocket cost for care.

All Charges