Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

indocyanine green 25 mg Pow SDV [VDMC]

Facility

$514.76

Service Code	HCPCS C9776
Hospital Charge Code	27084544
Hospital Revenue Code	259
Min. Negotiated Rate	$360.33
Max. Negotiated Rate	$463.28
Rate for Payer: Aetna of IA Commercial	$463.28
Rate for Payer: Aetna of IA Medical Rental Products	$463.28
Rate for Payer: Cash Price	$411.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$386.07
Rate for Payer: Medical Associates Commercial	$386.07
Rate for Payer: Midlands Choice Commercial	$360.33
Rate for Payer: United Healthcare Commercial	$463.28

indocyanine green 25 mg Pow SDV [VDMC]

Facility

$514.76

Service Code	HCPCS C9776
Hospital Charge Code	27084544
Hospital Revenue Code	259
Min. Negotiated Rate	$231.64
Max. Negotiated Rate	$510.77
Rate for Payer: Aetna of IA Commercial	$463.28
Rate for Payer: Aetna of IA Medical Rental Products	$463.28
Rate for Payer: Aetna of IA Medicare	$293.41
Rate for Payer: Amerigroup Medicaid	$296.91
Rate for Payer: Amerigroup Medicare	$233.96
Rate for Payer: Cash Price	$411.81
Rate for Payer: Cash Price	$411.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$386.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$231.64
Rate for Payer: Iowa Total Care Managed Medicaid	$294.03
Rate for Payer: Medical Associates Commercial	$386.07
Rate for Payer: Medical Associates Managed Medicare	$231.64
Rate for Payer: Midlands Choice Commercial	$360.33
Rate for Payer: Molina Healthcare Managed Medicaid	$298.35
Rate for Payer: Partners Health Alliance Commercial	$266.39
Rate for Payer: United Healthcare Commercial	$463.28
Rate for Payer: United Healthcare Managed Medicare	$303.71
Rate for Payer: Wellmark IA HMO WHPI	$463.69
Rate for Payer: Wellmark IA PPO	$510.77

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	$1.13
Rate for Payer: Aetna of IA Commercial	$1.13
Rate for Payer: Aetna of IA Medical Rental Products	$1.13
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	$1.13

indomethacin 25 mg Cap [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10396322
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of IA Commercial	$1.13
Rate for Payer: Aetna of IA Medical Rental Products	$1.13
Rate for Payer: Aetna of IA Medicare	$0.71
Rate for Payer: Amerigroup Medicaid	$0.72
Rate for Payer: Amerigroup Medicare	$0.57
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	$0.56
Rate for Payer: Iowa Total Care Managed Medicaid	$0.71
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.88
Rate for Payer: Molina Healthcare Managed Medicaid	$0.72
Rate for Payer: Partners Health Alliance Commercial	$0.65
Rate for Payer: United Healthcare Commercial	$1.13
Rate for Payer: United Healthcare Managed Medicare	$0.74

IND. PSYCH 30 ADD ON

Professional

Both

$363.00

Service Code	CPT 90833 AJ\|HO
Hospital Charge Code	5492789
Hospital Revenue Code	914
Min. Negotiated Rate	$29.21
Max. Negotiated Rate	$272.25
Rate for Payer: Amerigroup Medicaid	$29.50
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Iowa Total Care Managed Medicaid	$29.21
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Molina Healthcare Managed Medicaid	$29.36
Rate for Payer: Optum Behavioral Health	$72.23
Rate for Payer: Partners Health Alliance Commercial	$272.25
Rate for Payer: United Healthcare Commercial	$112.18
Rate for Payer: Wellmark IA HMO WHPI	$97.20
Rate for Payer: Wellmark IA PPO	$97.20

IND. PSYCH 45 ADD ON

Professional

Both

$363.00

Service Code	CPT 90836 AJ\|HO
Hospital Charge Code	5492790
Hospital Revenue Code	914
Min. Negotiated Rate	$47.49
Max. Negotiated Rate	$272.25
Rate for Payer: Amerigroup Medicaid	$47.96
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Iowa Total Care Managed Medicaid	$47.49
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Molina Healthcare Managed Medicaid	$47.72
Rate for Payer: Optum Behavioral Health	$83.70
Rate for Payer: Partners Health Alliance Commercial	$272.25
Rate for Payer: United Healthcare Commercial	$142.05
Rate for Payer: Wellmark IA HMO WHPI	$122.80
Rate for Payer: Wellmark IA PPO	$122.80

IND. PSYCH 60 ADD ON

Professional

Both

$363.00

Service Code	CPT 90838 AJ\|HO
Hospital Charge Code	5492791
Hospital Revenue Code	914
Min. Negotiated Rate	$76.45
Max. Negotiated Rate	$272.25
Rate for Payer: Amerigroup Medicaid	$77.20
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Iowa Total Care Managed Medicaid	$76.45
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Molina Healthcare Managed Medicaid	$76.82
Rate for Payer: Optum Behavioral Health	$110.74
Rate for Payer: Partners Health Alliance Commercial	$272.25
Rate for Payer: United Healthcare Commercial	$186.90
Rate for Payer: Wellmark IA HMO WHPI	$162.80
Rate for Payer: Wellmark IA PPO	$162.80

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$9,111.41

Service Code	MSDRG 758
Min. Negotiated Rate	$8,979.35
Max. Negotiated Rate	$9,111.41
Rate for Payer: Amerigroup Medicaid	$9,067.39
Rate for Payer: Iowa Total Care Managed Medicaid	$8,979.35
Rate for Payer: Molina Healthcare Managed Medicaid	$9,111.41

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$17,143.00

Service Code	MSDRG 757
Min. Negotiated Rate	$16,894.54
Max. Negotiated Rate	$17,143.00
Rate for Payer: Amerigroup Medicaid	$17,060.18
Rate for Payer: Iowa Total Care Managed Medicaid	$16,894.54
Rate for Payer: Molina Healthcare Managed Medicaid	$17,143.00

INFECTIONS, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$7,155.58

Service Code	MSDRG 759
Min. Negotiated Rate	$7,051.88
Max. Negotiated Rate	$7,155.58
Rate for Payer: Amerigroup Medicaid	$7,121.01
Rate for Payer: Iowa Total Care Managed Medicaid	$7,051.88
Rate for Payer: Molina Healthcare Managed Medicaid	$7,155.58

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC

Facility

$17,984.10

Service Code	MSDRG 854
Min. Negotiated Rate	$17,723.46
Max. Negotiated Rate	$17,984.10
Rate for Payer: Amerigroup Medicaid	$17,897.22
Rate for Payer: Iowa Total Care Managed Medicaid	$17,723.46
Rate for Payer: Molina Healthcare Managed Medicaid	$17,984.10

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC

Facility

$41,385.28

Service Code	MSDRG 853
Min. Negotiated Rate	$40,785.48
Max. Negotiated Rate	$41,385.28
Rate for Payer: Amerigroup Medicaid	$41,185.34
Rate for Payer: Iowa Total Care Managed Medicaid	$40,785.48
Rate for Payer: Molina Healthcare Managed Medicaid	$41,385.28

INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$10,664.13

Service Code	MSDRG 855
Min. Negotiated Rate	$10,509.57
Max. Negotiated Rate	$10,664.13
Rate for Payer: Amerigroup Medicaid	$10,612.61
Rate for Payer: Iowa Total Care Managed Medicaid	$10,509.57
Rate for Payer: Molina Healthcare Managed Medicaid	$10,664.13

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$9,690.16

Service Code	MSDRG 727
Min. Negotiated Rate	$9,549.72
Max. Negotiated Rate	$9,690.16
Rate for Payer: Amerigroup Medicaid	$9,643.34
Rate for Payer: Iowa Total Care Managed Medicaid	$9,549.72
Rate for Payer: Molina Healthcare Managed Medicaid	$9,690.16

INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC

Facility

$8,936.88

Service Code	MSDRG 728
Min. Negotiated Rate	$8,807.36
Max. Negotiated Rate	$8,936.88
Rate for Payer: Amerigroup Medicaid	$8,893.70
Rate for Payer: Iowa Total Care Managed Medicaid	$8,807.36
Rate for Payer: Molina Healthcare Managed Medicaid	$8,936.88

INFLAMMATORY BOWEL DISEASE WITH CC

Facility

$11,642.60

Service Code	MSDRG 386
Min. Negotiated Rate	$11,473.86
Max. Negotiated Rate	$11,642.60
Rate for Payer: Amerigroup Medicaid	$11,586.35
Rate for Payer: Iowa Total Care Managed Medicaid	$11,473.86
Rate for Payer: Molina Healthcare Managed Medicaid	$11,642.60

INFLAMMATORY BOWEL DISEASE WITH MCC

Facility

$14,307.79

Service Code	MSDRG 385
Min. Negotiated Rate	$14,100.42
Max. Negotiated Rate	$14,307.79
Rate for Payer: Amerigroup Medicaid	$14,238.66
Rate for Payer: Iowa Total Care Managed Medicaid	$14,100.42
Rate for Payer: Molina Healthcare Managed Medicaid	$14,307.79

INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC

Facility

$9,643.99

Service Code	MSDRG 387
Min. Negotiated Rate	$9,504.22
Max. Negotiated Rate	$9,643.99
Rate for Payer: Amerigroup Medicaid	$9,597.40
Rate for Payer: Iowa Total Care Managed Medicaid	$9,504.22
Rate for Payer: Molina Healthcare Managed Medicaid	$9,643.99

inFLIXimab 100 mg SDV Pow [VDMC]

Facility

$973.38

Service Code	HCPCS J1745
Hospital Charge Code	12420566
Hospital Revenue Code	259
Min. Negotiated Rate	$438.02
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	$561.45
Rate for Payer: Amerigroup Medicare	$442.40
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	$438.02
Rate for Payer: Iowa Total Care Managed Medicaid	$555.99
Rate for Payer: Medical Associates Commercial	$730.04
Rate for Payer: Medical Associates Managed Medicare	$438.02
Rate for Payer: Midlands Choice Commercial	$681.37
Rate for Payer: Molina Healthcare Managed Medicaid	$564.17
Rate for Payer: Partners Health Alliance Commercial	$503.72
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

$1,447.32

Service Code	HCPCS Q5104
Hospital Charge Code	24795850
Hospital Revenue Code	259
Min. Negotiated Rate	$1,013.12
Max. Negotiated Rate	$1,302.59
Rate for Payer: Aetna of IA Commercial	$1,302.59
Rate for Payer: Aetna of IA Medical Rental Products	$1,302.59
Rate for Payer: Cash Price	$1,157.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,085.49
Rate for Payer: Medical Associates Commercial	$1,085.49
Rate for Payer: Midlands Choice Commercial	$1,013.12
Rate for Payer: United Healthcare Commercial	$1,302.59

inFLIXimab-abda 100 mg SDV Pow [VDMC]

Facility

$1,447.32

Service Code	HCPCS Q5104
Hospital Charge Code	24795850
Hospital Revenue Code	259
Min. Negotiated Rate	$651.29
Max. Negotiated Rate	$1,302.59
Rate for Payer: Aetna of IA Commercial	$1,302.59
Rate for Payer: Aetna of IA Medical Rental Products	$1,302.59
Rate for Payer: Aetna of IA Medicare	$824.97
Rate for Payer: Amerigroup Medicaid	$834.81
Rate for Payer: Amerigroup Medicare	$657.81
Rate for Payer: Cash Price	$1,157.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,085.49
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$651.29
Rate for Payer: Iowa Total Care Managed Medicaid	$826.71
Rate for Payer: Medical Associates Commercial	$1,085.49
Rate for Payer: Medical Associates Managed Medicare	$651.29
Rate for Payer: Midlands Choice Commercial	$1,013.12
Rate for Payer: Molina Healthcare Managed Medicaid	$838.87
Rate for Payer: Partners Health Alliance Commercial	$748.99
Rate for Payer: United Healthcare Commercial	$1,302.59
Rate for Payer: United Healthcare Managed Medicare	$853.92

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	$470.56
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	$603.16
Rate for Payer: Amerigroup Medicare	$475.27
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	$470.56
Rate for Payer: Iowa Total Care Managed Medicaid	$597.30
Rate for Payer: Medical Associates Commercial	$784.28
Rate for Payer: Medical Associates Managed Medicare	$470.56
Rate for Payer: Midlands Choice Commercial	$731.99
Rate for Payer: Molina Healthcare Managed Medicaid	$606.09
Rate for Payer: Partners Health Alliance Commercial	$541.15
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

Know your out-of-pocket cost for care.

All Charges