Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

levalbuterol 0.63 mg/3 mL neb Sol SDV [VDMC]

Facility

$8.07

Service Code	HCPCS A9270
Hospital Charge Code	10399370
Hospital Revenue Code	259
Min. Negotiated Rate	$5.65
Max. Negotiated Rate	$7.26
Rate for Payer: Aetna of IA Commercial	$7.26
Rate for Payer: Aetna of IA Medical Rental Products	$7.26
Rate for Payer: Cash Price	$6.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6.05
Rate for Payer: Medical Associates Commercial	$6.05
Rate for Payer: Midlands Choice Commercial	$5.65
Rate for Payer: United Healthcare Commercial	$7.26

levalbuterol 1.25 mg/0.5 mL neb Sol SDV [VDMC]

Facility

$9.81

Service Code	HCPCS A9270
Hospital Charge Code	10429435
Hospital Revenue Code	259
Min. Negotiated Rate	$6.87
Max. Negotiated Rate	$8.83
Rate for Payer: Aetna of IA Commercial	$8.83
Rate for Payer: Aetna of IA Medical Rental Products	$8.83
Rate for Payer: Cash Price	$7.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.36
Rate for Payer: Medical Associates Commercial	$7.36
Rate for Payer: Midlands Choice Commercial	$6.87
Rate for Payer: United Healthcare Commercial	$8.83

levalbuterol 1.25 mg/0.5 mL neb Sol SDV [VDMC]

Facility

$9.81

Service Code	HCPCS A9270
Hospital Charge Code	10429435
Hospital Revenue Code	259
Min. Negotiated Rate	$4.90
Max. Negotiated Rate	$8.83
Rate for Payer: Aetna of IA Commercial	$8.83
Rate for Payer: Aetna of IA Medical Rental Products	$8.83
Rate for Payer: Aetna of IA Medicare	$5.59
Rate for Payer: Amerigroup Medicaid	$4.95
Rate for Payer: Amerigroup Medicare	$4.95
Rate for Payer: Cash Price	$7.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.90
Rate for Payer: Iowa Total Care Managed Medicaid	$4.90
Rate for Payer: Medical Associates Commercial	$7.36
Rate for Payer: Medical Associates Managed Medicare	$4.90
Rate for Payer: Midlands Choice Commercial	$6.87
Rate for Payer: Molina Healthcare Managed Medicaid	$4.98
Rate for Payer: Molina Healthcare Managed Medicare	$4.98
Rate for Payer: Oscar Health of IA Commercial	$7.36
Rate for Payer: Partners Health Alliance Commercial	$7.36
Rate for Payer: United Healthcare Commercial	$8.83
Rate for Payer: United Healthcare Managed Medicare	$5.79

levalbuterol 1.25 mg/3 mL neb Sol SDV [VDMC]

Facility

$8.82

Service Code	HCPCS A9270
Hospital Charge Code	10399441
Hospital Revenue Code	259
Min. Negotiated Rate	$6.17
Max. Negotiated Rate	$7.94
Rate for Payer: Aetna of IA Commercial	$7.94
Rate for Payer: Aetna of IA Medical Rental Products	$7.94
Rate for Payer: Cash Price	$7.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6.62
Rate for Payer: Medical Associates Commercial	$6.62
Rate for Payer: Midlands Choice Commercial	$6.17
Rate for Payer: United Healthcare Commercial	$7.94

levalbuterol 1.25 mg/3 mL neb Sol SDV [VDMC]

Facility

$8.82

Service Code	HCPCS A9270
Hospital Charge Code	10399441
Hospital Revenue Code	259
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$7.94
Rate for Payer: Aetna of IA Commercial	$7.94
Rate for Payer: Aetna of IA Medical Rental Products	$7.94
Rate for Payer: Aetna of IA Medicare	$5.03
Rate for Payer: Amerigroup Medicaid	$4.45
Rate for Payer: Amerigroup Medicare	$4.45
Rate for Payer: Cash Price	$7.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6.62
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.41
Rate for Payer: Iowa Total Care Managed Medicaid	$4.41
Rate for Payer: Medical Associates Commercial	$6.62
Rate for Payer: Medical Associates Managed Medicare	$4.41
Rate for Payer: Midlands Choice Commercial	$6.17
Rate for Payer: Molina Healthcare Managed Medicaid	$4.48
Rate for Payer: Molina Healthcare Managed Medicare	$4.47
Rate for Payer: Oscar Health of IA Commercial	$6.62
Rate for Payer: Partners Health Alliance Commercial	$6.62
Rate for Payer: United Healthcare Commercial	$7.94
Rate for Payer: United Healthcare Managed Medicare	$5.20

LEVEL 1

Professional

Both

$70.00

Service Code	CPT 99281
Hospital Charge Code	7982755
Hospital Revenue Code	981
Min. Negotiated Rate	$10.43
Max. Negotiated Rate	$49.00
Rate for Payer: Aetna of IA Medicare	$10.43
Rate for Payer: Amerigroup Medicaid	$10.78
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cash Price	$56.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.52
Rate for Payer: Iowa Total Care Managed Medicaid	$10.64
Rate for Payer: Medical Associates Commercial	$18.77
Rate for Payer: Medical Associates Managed Medicare	$10.43
Rate for Payer: Midlands Choice Commercial	$49.00
Rate for Payer: Oscar Health of IA Commercial	$17.73
Rate for Payer: Partners Health Alliance Commercial	$15.64

LEVEL 1

Facility

$179.00

Service Code	CPT 99281 25
Hospital Charge Code	6922784
Hospital Revenue Code	450
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: United Healthcare Commercial	$161.10

LEVEL 1

Facility

$179.00

Service Code	CPT 99281 25
Hospital Charge Code	6922784
Hospital Revenue Code	450
Min. Negotiated Rate	$89.46
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Aetna of IA Medicare	$102.03
Rate for Payer: Amerigroup Medicaid	$90.34
Rate for Payer: Amerigroup Medicare	$90.40
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.50
Rate for Payer: Iowa Total Care Managed Medicaid	$89.46
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Medical Associates Managed Medicare	$89.50
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: Molina Healthcare Managed Medicaid	$90.84
Rate for Payer: Molina Healthcare Managed Medicare	$90.79
Rate for Payer: Oscar Health of IA Commercial	$134.25
Rate for Payer: Partners Health Alliance Commercial	$134.25
Rate for Payer: United Healthcare Commercial	$161.10
Rate for Payer: United Healthcare Managed Medicare	$105.61

LEVEL 2

Facility

$249.00

Service Code	CPT 99282 25
Hospital Charge Code	6922786
Hospital Revenue Code	450
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of IA Commercial	$224.10
Rate for Payer: Aetna of IA Medical Rental Products	$224.10
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$186.75
Rate for Payer: Medical Associates Commercial	$186.75
Rate for Payer: Midlands Choice Commercial	$174.30
Rate for Payer: United Healthcare Commercial	$224.10

LEVEL 2

Facility

$249.00

Service Code	CPT 99282 25
Hospital Charge Code	6922786
Hospital Revenue Code	450
Min. Negotiated Rate	$124.45
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of IA Commercial	$224.10
Rate for Payer: Aetna of IA Medical Rental Products	$224.10
Rate for Payer: Aetna of IA Medicare	$141.93
Rate for Payer: Amerigroup Medicaid	$125.67
Rate for Payer: Amerigroup Medicare	$125.74
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$186.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$124.50
Rate for Payer: Iowa Total Care Managed Medicaid	$124.45
Rate for Payer: Medical Associates Commercial	$186.75
Rate for Payer: Medical Associates Managed Medicare	$124.50
Rate for Payer: Midlands Choice Commercial	$174.30
Rate for Payer: Molina Healthcare Managed Medicaid	$126.37
Rate for Payer: Molina Healthcare Managed Medicare	$126.29
Rate for Payer: Oscar Health of IA Commercial	$186.75
Rate for Payer: Partners Health Alliance Commercial	$186.75
Rate for Payer: United Healthcare Commercial	$224.10
Rate for Payer: United Healthcare Managed Medicare	$146.91

LEVEL 2

Professional

Both

$126.00

Service Code	CPT 99282
Hospital Charge Code	7982754
Hospital Revenue Code	981
Min. Negotiated Rate	$38.23
Max. Negotiated Rate	$68.81
Rate for Payer: Aetna of IA Medicare	$38.23
Rate for Payer: Amerigroup Medicaid	$39.53
Rate for Payer: Cash Price	$100.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.88
Rate for Payer: Iowa Total Care Managed Medicaid	$38.99
Rate for Payer: Medical Associates Commercial	$68.81
Rate for Payer: Medical Associates Managed Medicare	$38.23
Rate for Payer: Midlands Choice Commercial	$61.77
Rate for Payer: Oscar Health of IA Commercial	$64.99
Rate for Payer: Partners Health Alliance Commercial	$57.34

Level 2: Extreme Immaturity or Respiratory Distress Syndrome, Neonate

Facility

$37,846.06

Service Code	MS-DRG 7902
Hospital Charge Code	680
Min. Negotiated Rate	$37,297.56
Max. Negotiated Rate	$37,846.06
Rate for Payer: Amerigroup Medicaid	$37,663.23
Rate for Payer: Iowa Total Care Managed Medicaid	$37,297.56
Rate for Payer: Molina Healthcare Managed Medicaid	$37,846.06

Level 2: Full Term Neonate W Major Problems

Facility

$8,531.40

Service Code	MS-DRG 7932
Hospital Charge Code	686
Min. Negotiated Rate	$8,407.76
Max. Negotiated Rate	$8,531.40
Rate for Payer: Amerigroup Medicaid	$8,490.19
Rate for Payer: Iowa Total Care Managed Medicaid	$8,407.76
Rate for Payer: Molina Healthcare Managed Medicaid	$8,531.40

Level 2: Neonates, Died or Transferred to Another Acute Care Facility

Facility

$4,972.39

Service Code	MS-DRG 7892
Hospital Charge Code	678
Min. Negotiated Rate	$4,900.32
Max. Negotiated Rate	$4,972.39
Rate for Payer: Amerigroup Medicaid	$4,948.37
Rate for Payer: Iowa Total Care Managed Medicaid	$4,900.32
Rate for Payer: Molina Healthcare Managed Medicaid	$4,972.39

Level 2: Neonate W Other Significant Problems

Facility

$3,267.68

Service Code	MS-DRG 7942
Hospital Charge Code	688
Min. Negotiated Rate	$3,220.32
Max. Negotiated Rate	$3,267.68
Rate for Payer: Amerigroup Medicaid	$3,251.90
Rate for Payer: Iowa Total Care Managed Medicaid	$3,220.32
Rate for Payer: Molina Healthcare Managed Medicaid	$3,267.68

Level 2: Normal Newborn

Facility

$2,844.46

Service Code	MS-DRG 7952
Hospital Charge Code	690
Min. Negotiated Rate	$2,803.24
Max. Negotiated Rate	$2,844.46
Rate for Payer: Amerigroup Medicaid	$2,830.72
Rate for Payer: Iowa Total Care Managed Medicaid	$2,803.24
Rate for Payer: Molina Healthcare Managed Medicaid	$2,844.46

Level 2: Prematurity W Major Problems

Facility

$22,264.53

Service Code	MS-DRG 7912
Hospital Charge Code	682
Min. Negotiated Rate	$21,941.85
Max. Negotiated Rate	$22,264.53
Rate for Payer: Amerigroup Medicaid	$22,156.97
Rate for Payer: Iowa Total Care Managed Medicaid	$21,941.85
Rate for Payer: Molina Healthcare Managed Medicaid	$22,264.53

Level 2: Prematurity W/O Major Problems

Facility

$8,352.27

Service Code	MS-DRG 7922
Hospital Charge Code	684
Min. Negotiated Rate	$8,231.23
Max. Negotiated Rate	$8,352.27
Rate for Payer: Amerigroup Medicaid	$8,311.92
Rate for Payer: Iowa Total Care Managed Medicaid	$8,231.23
Rate for Payer: Molina Healthcare Managed Medicaid	$8,352.27

LEVEL 3

Facility

$438.00

Service Code	CPT 99283 25
Hospital Charge Code	6922787
Hospital Revenue Code	450
Min. Negotiated Rate	$218.91
Max. Negotiated Rate	$394.20
Rate for Payer: Aetna of IA Commercial	$394.20
Rate for Payer: Aetna of IA Medical Rental Products	$394.20
Rate for Payer: Aetna of IA Medicare	$249.66
Rate for Payer: Amerigroup Medicaid	$221.06
Rate for Payer: Amerigroup Medicare	$221.19
Rate for Payer: Cash Price	$350.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$328.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$219.00
Rate for Payer: Iowa Total Care Managed Medicaid	$218.91
Rate for Payer: Medical Associates Commercial	$328.50
Rate for Payer: Medical Associates Managed Medicare	$219.00
Rate for Payer: Midlands Choice Commercial	$306.60
Rate for Payer: Molina Healthcare Managed Medicaid	$222.28
Rate for Payer: Molina Healthcare Managed Medicare	$222.15
Rate for Payer: Oscar Health of IA Commercial	$328.50
Rate for Payer: Partners Health Alliance Commercial	$328.50
Rate for Payer: United Healthcare Commercial	$394.20
Rate for Payer: United Healthcare Managed Medicare	$258.42

LEVEL 3

Professional

Both

$189.00

Service Code	CPT 99283
Hospital Charge Code	7982753
Hospital Revenue Code	981
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$117.18
Rate for Payer: Aetna of IA Medicare	$65.10
Rate for Payer: Amerigroup Medicaid	$67.31
Rate for Payer: Cash Price	$151.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.12
Rate for Payer: Iowa Total Care Managed Medicaid	$66.40
Rate for Payer: Medical Associates Commercial	$117.18
Rate for Payer: Medical Associates Managed Medicare	$65.10
Rate for Payer: Midlands Choice Commercial	$106.10
Rate for Payer: Oscar Health of IA Commercial	$110.67
Rate for Payer: Partners Health Alliance Commercial	$97.65
Rate for Payer: United Healthcare Commercial	$82.88

LEVEL 3

Facility

$438.00

Service Code	CPT 99283 25
Hospital Charge Code	6922787
Hospital Revenue Code	450
Min. Negotiated Rate	$306.60
Max. Negotiated Rate	$394.20
Rate for Payer: Aetna of IA Commercial	$394.20
Rate for Payer: Aetna of IA Medical Rental Products	$394.20
Rate for Payer: Cash Price	$350.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$328.50
Rate for Payer: Medical Associates Commercial	$328.50
Rate for Payer: Midlands Choice Commercial	$306.60
Rate for Payer: United Healthcare Commercial	$394.20

Level 3: Extreme Immaturity or Respiratory Distress Syndrome, Neonate

Facility

$83,733.36

Service Code	MS-DRG 7907
Hospital Charge Code	681
Min. Negotiated Rate	$82,519.84
Max. Negotiated Rate	$83,733.36
Rate for Payer: Amerigroup Medicaid	$83,328.85
Rate for Payer: Iowa Total Care Managed Medicaid	$82,519.84
Rate for Payer: Molina Healthcare Managed Medicaid	$83,733.36

Level 3: Full Term Neonate W Major Problems

Facility

$13,929.97

Service Code	MS-DRG 7937
Hospital Charge Code	687
Min. Negotiated Rate	$13,728.09
Max. Negotiated Rate	$13,929.97
Rate for Payer: Amerigroup Medicaid	$13,862.68
Rate for Payer: Iowa Total Care Managed Medicaid	$13,728.09
Rate for Payer: Molina Healthcare Managed Medicaid	$13,929.97

Level 3: Neonates, Died or Transferred to Another Acute Care Facility

Facility

$41,582.23

Service Code	MS-DRG 7897
Hospital Charge Code	679
Min. Negotiated Rate	$40,979.59
Max. Negotiated Rate	$41,582.23
Rate for Payer: Amerigroup Medicaid	$41,381.35
Rate for Payer: Iowa Total Care Managed Medicaid	$40,979.59
Rate for Payer: Molina Healthcare Managed Medicaid	$41,582.23

Level 3: Neonate W Other Significant Problems

Facility

$3,267.68

Service Code	MS-DRG 7947
Hospital Charge Code	689
Min. Negotiated Rate	$3,220.32
Max. Negotiated Rate	$3,267.68
Rate for Payer: Amerigroup Medicaid	$3,251.90
Rate for Payer: Iowa Total Care Managed Medicaid	$3,220.32
Rate for Payer: Molina Healthcare Managed Medicaid	$3,267.68

Know your out-of-pocket cost for care.

All Charges