Van Diest Medical Center

All Charges

Charge

Type

Price

ketorolac 60 mg/mL 2 ml SDV inj

Facility IP

$23.15

Service Code	CPT J1885
Hospital Charge Code	43791258
Hospital Revenue Code	636
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$20.84
Rate for Payer: Aetna of IA Commercial	$20.84
Rate for Payer: Aetna of IA Medical Rental Products	$20.84
Rate for Payer: Cash Price	$18.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.36
Rate for Payer: Medical Associates Commercial	$17.36
Rate for Payer: Midlands Choice Commercial	$16.20
Rate for Payer: United Healthcare Commercial	$20.84

ketotifen 0.025% 5 ml Ophth Sol

Facility OP

$41.48

Service Code	CPT A9270
Hospital Charge Code	43700153
Hospital Revenue Code	637
Min. Negotiated Rate	$20.73
Max. Negotiated Rate	$37.33
Rate for Payer: Aetna of IA Commercial	$37.33
Rate for Payer: Aetna of IA Medical Rental Products	$37.33
Rate for Payer: Aetna of IA Medicare	$23.64
Rate for Payer: Amerigroup Medicaid	$20.93
Rate for Payer: Amerigroup Medicare	$20.95
Rate for Payer: Cash Price	$33.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$31.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.74
Rate for Payer: Iowa Total Care Managed Medicaid	$20.73
Rate for Payer: Medical Associates Commercial	$31.11
Rate for Payer: Medical Associates Managed Medicare	$20.74
Rate for Payer: Midlands Choice Commercial	$29.04
Rate for Payer: Molina Healthcare Managed Medicaid	$21.05
Rate for Payer: Partners Health Alliance Commercial	$31.11
Rate for Payer: United Healthcare Commercial	$37.33
Rate for Payer: United Healthcare Managed Medicare	$24.47

ketotifen 0.025% 5 ml Ophth Sol

Facility IP

$41.48

Service Code	CPT A9270
Hospital Charge Code	43700153
Hospital Revenue Code	637
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$37.33
Rate for Payer: Aetna of IA Commercial	$37.33
Rate for Payer: Aetna of IA Medical Rental Products	$37.33
Rate for Payer: Cash Price	$33.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$31.11
Rate for Payer: Medical Associates Commercial	$31.11
Rate for Payer: Midlands Choice Commercial	$29.04
Rate for Payer: United Healthcare Commercial	$37.33

Kidney and Ureter Procedures for Neoplasm With CC

Facility IP

$14,945.71

Service Code	MS-DRG 657
Hospital Charge Code	439
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,945.71
Rate for Payer: Amerigroup Medicaid	$14,873.51
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$14,729.11
Rate for Payer: Molina Healthcare Managed Medicaid	$14,945.71

Kidney and Ureter Procedures for Neoplasm With MCC

Facility IP

$24,166.08

Service Code	MS-DRG 656
Hospital Charge Code	438
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$24,166.08
Rate for Payer: Amerigroup Medicaid	$24,049.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$23,815.85
Rate for Payer: Molina Healthcare Managed Medicaid	$24,166.08

Kidney and Ureter Procedures for Neoplasm Without CC/MCC

Facility IP

$12,698.68

Service Code	MS-DRG 658
Hospital Charge Code	440
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$12,698.68
Rate for Payer: Amerigroup Medicaid	$12,637.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$12,514.65
Rate for Payer: Molina Healthcare Managed Medicaid	$12,698.68

Kidney and Ureter Procedures for Non-neoplasm With CC

Facility IP

$10,175.08

Service Code	MS-DRG 660
Hospital Charge Code	442
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$10,175.08
Rate for Payer: Amerigroup Medicaid	$10,125.93
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$10,027.62
Rate for Payer: Molina Healthcare Managed Medicaid	$10,175.08

Kidney and Ureter Procedures for Non-neoplasm With MCC

Facility IP

$17,118.91

Service Code	MS-DRG 659
Hospital Charge Code	441
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$17,118.91
Rate for Payer: Amerigroup Medicaid	$17,036.21
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$16,870.81
Rate for Payer: Molina Healthcare Managed Medicaid	$17,118.91

Kidney and Ureter Procedures for Non-neoplasm Without CC/MCC

Facility IP

$8,562.90

Service Code	MS-DRG 661
Hospital Charge Code	443
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,562.90
Rate for Payer: Amerigroup Medicaid	$8,521.53
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$8,438.80
Rate for Payer: Molina Healthcare Managed Medicaid	$8,562.90

Kidney and Urinary Tract Infections With MCC

Facility IP

$8,911.32

Service Code	MS-DRG 689
Hospital Charge Code	464
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,911.32
Rate for Payer: Amerigroup Medicaid	$8,868.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$8,782.17
Rate for Payer: Molina Healthcare Managed Medicaid	$8,911.32

Kidney and Urinary Tract Infections Without MCC

Facility IP

$6,206.63

Service Code	MS-DRG 690
Hospital Charge Code	465
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$6,206.63
Rate for Payer: Amerigroup Medicaid	$6,176.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$6,116.67
Rate for Payer: Molina Healthcare Managed Medicaid	$6,206.63

Kidney and Urinary Tract Neoplasms With CC

Facility IP

$8,053.07

Service Code	MS-DRG 687
Hospital Charge Code	462
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,053.07
Rate for Payer: Amerigroup Medicaid	$8,014.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7,936.35
Rate for Payer: Molina Healthcare Managed Medicaid	$8,053.07

Kidney and Urinary Tract Neoplasms With MCC

Facility IP

$12,074.67

Service Code	MS-DRG 686
Hospital Charge Code	461
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$12,074.67
Rate for Payer: Amerigroup Medicaid	$12,016.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$11,899.68
Rate for Payer: Molina Healthcare Managed Medicaid	$12,074.67

Kidney and Urinary Tract Neoplasms Without CC/MCC

Facility IP

$6,746.98

Service Code	MS-DRG 688
Hospital Charge Code	463
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$6,746.98
Rate for Payer: Amerigroup Medicaid	$6,714.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$6,649.20
Rate for Payer: Molina Healthcare Managed Medicaid	$6,746.98

Kidney and Urinary Tract Signs and Symptoms With MCC

Facility IP

$11,186.89

Service Code	MS-DRG 695
Hospital Charge Code	468
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,186.89
Rate for Payer: Amerigroup Medicaid	$11,132.85
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$11,024.76
Rate for Payer: Molina Healthcare Managed Medicaid	$11,186.89

Kidney and Urinary Tract Signs and Symptoms Without MCC

Facility IP

$4,282.44

Service Code	MS-DRG 696
Hospital Charge Code	469
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$4,282.44
Rate for Payer: Amerigroup Medicaid	$4,261.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$4,220.37
Rate for Payer: Molina Healthcare Managed Medicaid	$4,282.44

Kidney Transplant

Facility IP

$134,083.23

Service Code	MS-DRG 652
Hospital Charge Code	434
Min. Negotiated Rate	$132,139.99
Max. Negotiated Rate	$134,083.23
Rate for Payer: Amerigroup Medicaid	$133,435.48
Rate for Payer: Iowa Total Care Managed Medicaid	$132,139.99
Rate for Payer: Molina Healthcare Managed Medicaid	$134,083.23

Kidney Transplant With Hemodialysis With MCC

Facility IP

$95,487.17

Service Code	MS-DRG 650
Hospital Charge Code	432
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$95,487.17
Rate for Payer: Amerigroup Medicaid	$95,025.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$94,103.30
Rate for Payer: Molina Healthcare Managed Medicaid	$95,487.17

Kidney Transplant With Hemodialysis Without MCC

Facility IP

$36,353.94

Service Code	MS-DRG 651
Hospital Charge Code	433
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$36,353.94
Rate for Payer: Amerigroup Medicaid	$36,178.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$35,827.07
Rate for Payer: Molina Healthcare Managed Medicaid	$36,353.94

KIT FOR 3.5MM PUSHLOCK WITH SPEAR AND DRILL

Facility OP

$540.00

Service Code	CPT C1713
Hospital Charge Code	8026315
Hospital Revenue Code	278
Min. Negotiated Rate	$269.89
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of IA Commercial	$486.00
Rate for Payer: Aetna of IA Medical Rental Products	$486.00
Rate for Payer: Aetna of IA Medicare	$307.80
Rate for Payer: Amerigroup Medicaid	$272.54
Rate for Payer: Amerigroup Medicare	$272.70
Rate for Payer: Cash Price	$432.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$270.00
Rate for Payer: Iowa Total Care Managed Medicaid	$269.89
Rate for Payer: Medical Associates Commercial	$405.00
Rate for Payer: Medical Associates Managed Medicare	$270.00
Rate for Payer: Midlands Choice Commercial	$378.00
Rate for Payer: Molina Healthcare Managed Medicaid	$274.05
Rate for Payer: Partners Health Alliance Commercial	$405.00
Rate for Payer: United Healthcare Commercial	$486.00
Rate for Payer: United Healthcare Managed Medicare	$318.60

KIT FOR 3.5MM PUSHLOCK WITH SPEAR AND DRILL

Facility IP

$540.00

Service Code	CPT C1713
Hospital Charge Code	8026315
Hospital Revenue Code	278
Min. Negotiated Rate	$378.00
Max. Negotiated Rate	$486.00
Rate for Payer: Aetna of IA Commercial	$486.00
Rate for Payer: Aetna of IA Medical Rental Products	$486.00
Rate for Payer: Cash Price	$432.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$405.00
Rate for Payer: Medical Associates Commercial	$405.00
Rate for Payer: Midlands Choice Commercial	$378.00
Rate for Payer: United Healthcare Commercial	$486.00

Knee Procedures Without Principal Diagnosis of Infection With CC/MCC

Facility IP

$18,942.71

Service Code	MS-DRG 488
Hospital Charge Code	307
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$18,942.71
Rate for Payer: Amerigroup Medicaid	$18,851.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$18,668.18
Rate for Payer: Molina Healthcare Managed Medicaid	$18,942.71

Knee Procedures Without Principal Diagnosis of Infection Without CC/MCC

Facility IP

$9,904.42

Service Code	MS-DRG 489
Hospital Charge Code	308
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,904.42
Rate for Payer: Amerigroup Medicaid	$9,856.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$9,760.88
Rate for Payer: Molina Healthcare Managed Medicaid	$9,904.42

Knee Procedures With Principal Diagnosis of Infection With CC

Facility IP

$19,551.96

Service Code	MS-DRG 486
Hospital Charge Code	305
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$19,551.96
Rate for Payer: Amerigroup Medicaid	$19,457.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$19,268.60
Rate for Payer: Molina Healthcare Managed Medicaid	$19,551.96

Knee Procedures With Principal Diagnosis of Infection With MCC

Facility IP

$23,792.07

Service Code	MS-DRG 485
Hospital Charge Code	304
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$23,792.07
Rate for Payer: Amerigroup Medicaid	$23,677.14
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$23,447.26
Rate for Payer: Molina Healthcare Managed Medicaid	$23,792.07

Price Transparency.

All Charges