Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

indomethacin 25 mg Cap [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10396322
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of IA Commercial	$1.12
Rate for Payer: Aetna of IA Medical Rental Products	$1.12
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.12

indomethacin 25 mg Cap [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10396322
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of IA Commercial	$1.12
Rate for Payer: Aetna of IA Medical Rental Products	$1.12
Rate for Payer: Aetna of IA Medicare	$0.71
Rate for Payer: Amerigroup Medicaid	$0.63
Rate for Payer: Amerigroup Medicare	$0.63
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.63
Rate for Payer: Iowa Total Care Managed Medicaid	$0.62
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Medical Associates Managed Medicare	$0.63
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: Molina Healthcare Managed Medicaid	$0.63
Rate for Payer: Molina Healthcare Managed Medicare	$0.63
Rate for Payer: Oscar Health of IA Commercial	$0.94
Rate for Payer: Partners Health Alliance Commercial	$0.94
Rate for Payer: United Healthcare Commercial	$1.12
Rate for Payer: United Healthcare Managed Medicare	$0.74

Infections, Female Reproductive System With CC

Facility

$7,964.48

Service Code	MS-DRG 758
Hospital Charge Code	516
Min. Negotiated Rate	$7,849.05
Max. Negotiated Rate	$7,964.48
Rate for Payer: Amerigroup Medicaid	$7,926.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7,849.05
Rate for Payer: Molina Healthcare Managed Medicaid	$7,964.48

Infections, Female Reproductive System With MCC

Facility

$14,985.08

Service Code	MS-DRG 757
Hospital Charge Code	515
Min. Negotiated Rate	$14,767.91
Max. Negotiated Rate	$14,985.08
Rate for Payer: Amerigroup Medicaid	$14,912.69
Rate for Payer: Iowa Total Care Managed Medicaid	$14,767.91
Rate for Payer: Molina Healthcare Managed Medicaid	$14,985.08

Infections, Female Reproductive System Without CC/MCC

Facility

$6,254.86

Service Code	MS-DRG 759
Hospital Charge Code	517
Min. Negotiated Rate	$6,164.21
Max. Negotiated Rate	$6,254.86
Rate for Payer: Amerigroup Medicaid	$6,224.64
Rate for Payer: Iowa Total Care Managed Medicaid	$6,164.21
Rate for Payer: Molina Healthcare Managed Medicaid	$6,254.86

Infectious and Parasitic Diseases With O.R. Procedures With CC

Facility

$15,720.30

Service Code	MS-DRG 854
Hospital Charge Code	593
Min. Negotiated Rate	$15,492.47
Max. Negotiated Rate	$15,720.30
Rate for Payer: Amerigroup Medicaid	$15,644.36
Rate for Payer: Iowa Total Care Managed Medicaid	$15,492.47
Rate for Payer: Molina Healthcare Managed Medicaid	$15,720.30

Infectious and Parasitic Diseases With O.R. Procedures With MCC

Facility

$36,175.80

Service Code	MS-DRG 853
Hospital Charge Code	592
Min. Negotiated Rate	$35,651.51
Max. Negotiated Rate	$36,175.80
Rate for Payer: Amerigroup Medicaid	$36,001.03
Rate for Payer: Iowa Total Care Managed Medicaid	$35,651.51
Rate for Payer: Molina Healthcare Managed Medicaid	$36,175.80

Infectious and Parasitic Diseases With O.R. Procedures Without CC/MCC

Facility

$9,321.75

Service Code	MS-DRG 855
Hospital Charge Code	594
Min. Negotiated Rate	$9,186.65
Max. Negotiated Rate	$9,321.75
Rate for Payer: Amerigroup Medicaid	$9,276.72
Rate for Payer: Iowa Total Care Managed Medicaid	$9,186.65
Rate for Payer: Molina Healthcare Managed Medicaid	$9,321.75

Inflammation of the Male Reproductive System With MCC

Facility

$8,470.38

Service Code	MS-DRG 727
Hospital Charge Code	491
Min. Negotiated Rate	$8,347.62
Max. Negotiated Rate	$8,470.38
Rate for Payer: Amerigroup Medicaid	$8,429.46
Rate for Payer: Iowa Total Care Managed Medicaid	$8,347.62
Rate for Payer: Molina Healthcare Managed Medicaid	$8,470.38

Inflammation of the Male Reproductive System Without MCC

Facility

$7,811.92

Service Code	MS-DRG 728
Hospital Charge Code	492
Min. Negotiated Rate	$7,698.70
Max. Negotiated Rate	$7,811.92
Rate for Payer: Amerigroup Medicaid	$7,774.18
Rate for Payer: Iowa Total Care Managed Medicaid	$7,698.70
Rate for Payer: Molina Healthcare Managed Medicaid	$7,811.92

Inflammatory Bowel Disease With CC

Facility

$10,177.06

Service Code	MS-DRG 386
Hospital Charge Code	227
Min. Negotiated Rate	$10,029.57
Max. Negotiated Rate	$10,177.06
Rate for Payer: Amerigroup Medicaid	$10,127.90
Rate for Payer: Iowa Total Care Managed Medicaid	$10,029.57
Rate for Payer: Molina Healthcare Managed Medicaid	$10,177.06

Inflammatory Bowel Disease With MCC

Facility

$12,506.75

Service Code	MS-DRG 385
Hospital Charge Code	226
Min. Negotiated Rate	$12,325.50
Max. Negotiated Rate	$12,506.75
Rate for Payer: Amerigroup Medicaid	$12,446.33
Rate for Payer: Iowa Total Care Managed Medicaid	$12,325.50
Rate for Payer: Molina Healthcare Managed Medicaid	$12,506.75

Inflammatory Bowel Disease Without CC/MCC

Facility

$8,430.03

Service Code	MS-DRG 387
Hospital Charge Code	228
Min. Negotiated Rate	$8,307.86
Max. Negotiated Rate	$8,430.03
Rate for Payer: Amerigroup Medicaid	$8,389.31
Rate for Payer: Iowa Total Care Managed Medicaid	$8,307.86
Rate for Payer: Molina Healthcare Managed Medicaid	$8,430.03

inFLIXimab 100 mg SDV Pow [VDMC]

Facility

$973.38

Service Code	HCPCS J1745
Hospital Charge Code	12420566
Hospital Revenue Code	259
Min. Negotiated Rate	$486.50
Max. Negotiated Rate	$876.04
Rate for Payer: Aetna of IA Commercial	$876.04
Rate for Payer: Aetna of IA Medical Rental Products	$876.04
Rate for Payer: Aetna of IA Medicare	$554.83
Rate for Payer: Amerigroup Medicaid	$491.26
Rate for Payer: Amerigroup Medicare	$491.56
Rate for Payer: Cash Price	$778.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$730.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$486.69
Rate for Payer: Iowa Total Care Managed Medicaid	$486.50
Rate for Payer: Medical Associates Commercial	$730.04
Rate for Payer: Medical Associates Managed Medicare	$486.69
Rate for Payer: Midlands Choice Commercial	$681.37
Rate for Payer: Molina Healthcare Managed Medicaid	$493.99
Rate for Payer: Molina Healthcare Managed Medicare	$493.70
Rate for Payer: Oscar Health of IA Commercial	$730.04
Rate for Payer: Partners Health Alliance Commercial	$730.04
Rate for Payer: United Healthcare Commercial	$876.04
Rate for Payer: United Healthcare Managed Medicare	$574.29

inFLIXimab 100 mg SDV Pow [VDMC]

Facility

$973.38

Service Code	HCPCS J1745
Hospital Charge Code	12420566
Hospital Revenue Code	259
Min. Negotiated Rate	$681.37
Max. Negotiated Rate	$876.04
Rate for Payer: Aetna of IA Commercial	$876.04
Rate for Payer: Aetna of IA Medical Rental Products	$876.04
Rate for Payer: Cash Price	$778.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$730.04
Rate for Payer: Medical Associates Commercial	$730.04
Rate for Payer: Midlands Choice Commercial	$681.37
Rate for Payer: United Healthcare Commercial	$876.04

inFLIXimab-abda 100 mg SDV Pow [VDMC]

Facility

$1,482.96

Service Code	HCPCS Q5104
Hospital Charge Code	24795850
Hospital Revenue Code	259
Min. Negotiated Rate	$1,038.07
Max. Negotiated Rate	$1,334.66
Rate for Payer: Aetna of IA Commercial	$1,334.66
Rate for Payer: Aetna of IA Medical Rental Products	$1,334.66
Rate for Payer: Cash Price	$1,186.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,112.22
Rate for Payer: Medical Associates Commercial	$1,112.22
Rate for Payer: Midlands Choice Commercial	$1,038.07
Rate for Payer: United Healthcare Commercial	$1,334.66

inFLIXimab-abda 100 mg SDV Pow [VDMC]

Facility

$1,482.96

Service Code	HCPCS Q5104
Hospital Charge Code	24795850
Hospital Revenue Code	259
Min. Negotiated Rate	$741.18
Max. Negotiated Rate	$1,334.66
Rate for Payer: Aetna of IA Commercial	$1,334.66
Rate for Payer: Aetna of IA Medical Rental Products	$1,334.66
Rate for Payer: Aetna of IA Medicare	$845.29
Rate for Payer: Amerigroup Medicaid	$748.45
Rate for Payer: Amerigroup Medicare	$748.89
Rate for Payer: Cash Price	$1,186.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,112.22
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$741.48
Rate for Payer: Iowa Total Care Managed Medicaid	$741.18
Rate for Payer: Medical Associates Commercial	$1,112.22
Rate for Payer: Medical Associates Managed Medicare	$741.48
Rate for Payer: Midlands Choice Commercial	$1,038.07
Rate for Payer: Molina Healthcare Managed Medicaid	$752.60
Rate for Payer: Molina Healthcare Managed Medicare	$752.16
Rate for Payer: Oscar Health of IA Commercial	$1,112.22
Rate for Payer: Partners Health Alliance Commercial	$1,112.22
Rate for Payer: United Healthcare Commercial	$1,334.66
Rate for Payer: United Healthcare Managed Medicare	$874.95

inFLIXimab axxq 100 mg Pow [VDMC]

Facility

$1,045.70

Service Code	HCPCS Q5121
Hospital Charge Code	24236862
Hospital Revenue Code	259
Min. Negotiated Rate	$522.64
Max. Negotiated Rate	$941.13
Rate for Payer: Aetna of IA Commercial	$941.13
Rate for Payer: Aetna of IA Medical Rental Products	$941.13
Rate for Payer: Aetna of IA Medicare	$596.05
Rate for Payer: Amerigroup Medicaid	$527.76
Rate for Payer: Amerigroup Medicare	$528.08
Rate for Payer: Cash Price	$836.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$784.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$522.85
Rate for Payer: Iowa Total Care Managed Medicaid	$522.64
Rate for Payer: Medical Associates Commercial	$784.28
Rate for Payer: Medical Associates Managed Medicare	$522.85
Rate for Payer: Midlands Choice Commercial	$731.99
Rate for Payer: Molina Healthcare Managed Medicaid	$530.69
Rate for Payer: Molina Healthcare Managed Medicare	$530.38
Rate for Payer: Oscar Health of IA Commercial	$784.28
Rate for Payer: Partners Health Alliance Commercial	$784.28
Rate for Payer: United Healthcare Commercial	$941.13
Rate for Payer: United Healthcare Managed Medicare	$616.96

inFLIXimab axxq 100 mg Pow [VDMC]

Facility

$1,045.70

Service Code	HCPCS Q5121
Hospital Charge Code	24236862
Hospital Revenue Code	259
Min. Negotiated Rate	$731.99
Max. Negotiated Rate	$941.13
Rate for Payer: Aetna of IA Commercial	$941.13
Rate for Payer: Aetna of IA Medical Rental Products	$941.13
Rate for Payer: Cash Price	$836.56
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$784.28
Rate for Payer: Medical Associates Commercial	$784.28
Rate for Payer: Midlands Choice Commercial	$731.99
Rate for Payer: United Healthcare Commercial	$941.13

inFLIXimab-dyyb 100 mg Pow SDV [VDMC]

Facility

$1,016.76

Service Code	HCPCS Q5103
Hospital Charge Code	20049518
Hospital Revenue Code	259
Min. Negotiated Rate	$711.73
Max. Negotiated Rate	$915.08
Rate for Payer: Aetna of IA Commercial	$915.08
Rate for Payer: Aetna of IA Medical Rental Products	$915.08
Rate for Payer: Cash Price	$813.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$762.57
Rate for Payer: Medical Associates Commercial	$762.57
Rate for Payer: Midlands Choice Commercial	$711.73
Rate for Payer: United Healthcare Commercial	$915.08

inFLIXimab-dyyb 100 mg Pow SDV [VDMC]

Facility

$1,016.76

Service Code	HCPCS Q5103
Hospital Charge Code	20049518
Hospital Revenue Code	259
Min. Negotiated Rate	$508.18
Max. Negotiated Rate	$915.08
Rate for Payer: Aetna of IA Commercial	$915.08
Rate for Payer: Aetna of IA Medical Rental Products	$915.08
Rate for Payer: Aetna of IA Medicare	$579.55
Rate for Payer: Amerigroup Medicaid	$513.16
Rate for Payer: Amerigroup Medicare	$513.46
Rate for Payer: Cash Price	$813.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$762.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$508.38
Rate for Payer: Iowa Total Care Managed Medicaid	$508.18
Rate for Payer: Medical Associates Commercial	$762.57
Rate for Payer: Medical Associates Managed Medicare	$508.38
Rate for Payer: Midlands Choice Commercial	$711.73
Rate for Payer: Molina Healthcare Managed Medicaid	$516.01
Rate for Payer: Molina Healthcare Managed Medicare	$515.70
Rate for Payer: Oscar Health of IA Commercial	$762.57
Rate for Payer: Partners Health Alliance Commercial	$762.57
Rate for Payer: United Healthcare Commercial	$915.08
Rate for Payer: United Healthcare Managed Medicare	$599.89

INFLUENZA AB

Facility

$82.00

Service Code	CPT 87804
Hospital Charge Code	4110785
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$41.39
Rate for Payer: Amerigroup Medicare	$41.41
Rate for Payer: Cash Price	$65.60
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.00
Rate for Payer: Iowa Total Care Managed Medicaid	$40.98
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$41.00
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$41.62
Rate for Payer: Molina Healthcare Managed Medicare	$41.59
Rate for Payer: Oscar Health of IA Commercial	$61.50
Rate for Payer: Partners Health Alliance Commercial	$61.50
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

INFLUENZA AB

Facility

$82.00

Service Code	CPT 87804
Hospital Charge Code	4110785
Hospital Revenue Code	306
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

influenza QUAD Syringe virus vaccine, inactivated preservative-free quadrivalent Sus [VDMC]

Facility

$31.30

Service Code	HCPCS 90686
Hospital Charge Code	12288085
Hospital Revenue Code	259
Min. Negotiated Rate	$21.91
Max. Negotiated Rate	$28.17
Rate for Payer: Aetna of IA Commercial	$28.17
Rate for Payer: Aetna of IA Medical Rental Products	$28.17
Rate for Payer: Cash Price	$25.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.48
Rate for Payer: Medical Associates Commercial	$23.48
Rate for Payer: Midlands Choice Commercial	$21.91
Rate for Payer: United Healthcare Commercial	$28.17

influenza QUAD Syringe virus vaccine, inactivated preservative-free quadrivalent Sus [VDMC]

Facility

$31.30

Service Code	HCPCS 90686
Hospital Charge Code	12288085
Hospital Revenue Code	259
Min. Negotiated Rate	$15.64
Max. Negotiated Rate	$68.20
Rate for Payer: Aetna of IA Commercial	$28.17
Rate for Payer: Aetna of IA Medical Rental Products	$28.17
Rate for Payer: Aetna of IA Medicare	$17.84
Rate for Payer: Amerigroup Medicaid	$15.80
Rate for Payer: Amerigroup Medicare	$15.81
Rate for Payer: Cash Price	$25.04
Rate for Payer: Cash Price	$25.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.65
Rate for Payer: Iowa Total Care Managed Medicaid	$15.64
Rate for Payer: Medical Associates Commercial	$23.48
Rate for Payer: Medical Associates Managed Medicare	$15.65
Rate for Payer: Midlands Choice Commercial	$21.91
Rate for Payer: Molina Healthcare Managed Medicaid	$15.88
Rate for Payer: Molina Healthcare Managed Medicare	$15.88
Rate for Payer: Oscar Health of IA Commercial	$23.48
Rate for Payer: Partners Health Alliance Commercial	$23.48
Rate for Payer: United Healthcare Commercial	$28.17
Rate for Payer: United Healthcare Managed Medicare	$18.47
Rate for Payer: Wellmark IA HMO	$62.00
Rate for Payer: Wellmark IA PPO	$68.20

Know your out-of-pocket cost for care.

All Charges