Van Diest Medical Center

All Charges

Charge

Type

Price

mineral oil 100% Liq 473 ml

Facility OP

$19.42

Service Code	CPT A9270
Hospital Charge Code	43701474
Hospital Revenue Code	637
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$17.48
Rate for Payer: Aetna of IA Commercial	$17.48
Rate for Payer: Aetna of IA Medical Rental Products	$17.48
Rate for Payer: Aetna of IA Medicare	$11.07
Rate for Payer: Amerigroup Medicaid	$9.80
Rate for Payer: Amerigroup Medicare	$9.81
Rate for Payer: Cash Price	$15.54
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$14.56
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$9.71
Rate for Payer: Iowa Total Care Managed Medicaid	$9.71
Rate for Payer: Medical Associates Commercial	$14.56
Rate for Payer: Medical Associates Managed Medicare	$9.71
Rate for Payer: Midlands Choice Commercial	$13.59
Rate for Payer: Molina Healthcare Managed Medicaid	$9.86
Rate for Payer: Partners Health Alliance Commercial	$14.56
Rate for Payer: United Healthcare Commercial	$17.48
Rate for Payer: United Healthcare Managed Medicare	$11.46

MINI 4 HOLE ST

Facility OP

$133.00

Service Code	CPT C1713
Hospital Charge Code	8046726
Hospital Revenue Code	278
Min. Negotiated Rate	$66.47
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Aetna of IA Medicare	$75.81
Rate for Payer: Amerigroup Medicaid	$67.13
Rate for Payer: Amerigroup Medicare	$67.16
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$66.50
Rate for Payer: Iowa Total Care Managed Medicaid	$66.47
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Medical Associates Managed Medicare	$66.50
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: Molina Healthcare Managed Medicaid	$67.50
Rate for Payer: Partners Health Alliance Commercial	$99.75
Rate for Payer: United Healthcare Commercial	$119.70
Rate for Payer: United Healthcare Managed Medicare	$78.47

MINI 4 HOLE ST

Facility IP

$133.00

Service Code	CPT C1713
Hospital Charge Code	8046726
Hospital Revenue Code	278
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: United Healthcare Commercial	$119.70

minocycline 50 mg Cap

Facility OP

$1.87

Service Code	CPT A9270
Hospital Charge Code	43769401
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of IA Commercial	$1.68
Rate for Payer: Aetna of IA Medical Rental Products	$1.68
Rate for Payer: Aetna of IA Medicare	$1.07
Rate for Payer: Amerigroup Medicaid	$0.94
Rate for Payer: Amerigroup Medicare	$0.94
Rate for Payer: Cash Price	$1.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.94
Rate for Payer: Iowa Total Care Managed Medicaid	$0.93
Rate for Payer: Medical Associates Commercial	$1.40
Rate for Payer: Medical Associates Managed Medicare	$0.94
Rate for Payer: Midlands Choice Commercial	$1.31
Rate for Payer: Molina Healthcare Managed Medicaid	$0.95
Rate for Payer: Partners Health Alliance Commercial	$1.40
Rate for Payer: United Healthcare Commercial	$1.68
Rate for Payer: United Healthcare Managed Medicare	$1.10

minocycline 50 mg Cap

Facility IP

$1.87

Service Code	CPT A9270
Hospital Charge Code	43769401
Hospital Revenue Code	637
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of IA Commercial	$1.68
Rate for Payer: Aetna of IA Medical Rental Products	$1.68
Rate for Payer: Cash Price	$1.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.40
Rate for Payer: Medical Associates Commercial	$1.40
Rate for Payer: Midlands Choice Commercial	$1.31
Rate for Payer: United Healthcare Commercial	$1.68

Minor Bladder Procedures With CC

Facility IP

$9,209.54

Service Code	MS-DRG 663
Hospital Charge Code	445
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,209.54
Rate for Payer: Amerigroup Medicaid	$9,165.05
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	$9,076.07
Rate for Payer: Molina Healthcare Managed Medicaid	$9,209.54

Minor Bladder Procedures With MCC

Facility IP

$28,844.19

Service Code	MS-DRG 662
Hospital Charge Code	444
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$28,844.19
Rate for Payer: Amerigroup Medicaid	$28,704.84
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	$28,426.16
Rate for Payer: Molina Healthcare Managed Medicaid	$28,844.19

Minor Bladder Procedures Without CC/MCC

Facility IP

$9,209.54

Service Code	MS-DRG 664
Hospital Charge Code	446
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,209.54
Rate for Payer: Amerigroup Medicaid	$9,165.05
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	$9,076.07
Rate for Payer: Molina Healthcare Managed Medicaid	$9,209.54

Minor Skin Disorders With MCC

Facility IP

$14,875.83

Service Code	MS-DRG 606
Hospital Charge Code	404
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,875.83
Rate for Payer: Amerigroup Medicaid	$14,803.96
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	$14,660.24
Rate for Payer: Molina Healthcare Managed Medicaid	$14,875.83

Minor Skin Disorders Without MCC

Facility IP

$5,206.64

Service Code	MS-DRG 607
Hospital Charge Code	405
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$5,206.64
Rate for Payer: Amerigroup Medicaid	$5,181.49
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	$5,131.18
Rate for Payer: Molina Healthcare Managed Medicaid	$5,206.64

Minor Small and Large Bowel Procedures With CC

Facility IP

$12,069.76

Service Code	MS-DRG 345
Hospital Charge Code	195
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$12,069.76
Rate for Payer: Amerigroup Medicaid	$12,011.45
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	$11,894.83
Rate for Payer: Molina Healthcare Managed Medicaid	$12,069.76

Minor Small and Large Bowel Procedures With MCC

Facility IP

$27,574.51

Service Code	MS-DRG 344
Hospital Charge Code	194
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$27,574.51
Rate for Payer: Amerigroup Medicaid	$27,441.30
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	$27,174.88
Rate for Payer: Molina Healthcare Managed Medicaid	$27,574.51

Minor Small and Large Bowel Procedures Without CC/MCC

Facility IP

$10,231.19

Service Code	MS-DRG 346
Hospital Charge Code	196
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$10,231.19
Rate for Payer: Amerigroup Medicaid	$10,181.77
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	$10,082.91
Rate for Payer: Molina Healthcare Managed Medicaid	$10,231.19

minoxidil 2.5 mg Tab

Facility OP

$1.40

Service Code	CPT A9270
Hospital Charge Code	43700383
Hospital Revenue Code	637
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Aetna of IA Medicare	$0.80
Rate for Payer: Amerigroup Medicaid	$0.71
Rate for Payer: Amerigroup Medicare	$0.71
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.70
Rate for Payer: Iowa Total Care Managed Medicaid	$0.70
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Medical Associates Managed Medicare	$0.70
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Partners Health Alliance Commercial	$1.05
Rate for Payer: United Healthcare Commercial	$1.26
Rate for Payer: United Healthcare Managed Medicare	$0.83

minoxidil 2.5 mg Tab

Facility IP

$1.40

Service Code	CPT A9270
Hospital Charge Code	43700383
Hospital Revenue Code	637
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.26

mirabegron 25 mg Tab

Facility OP

$57.45

Service Code	CPT A9270
Hospital Charge Code	43700418
Hospital Revenue Code	637
Min. Negotiated Rate	$28.71
Max. Negotiated Rate	$51.70
Rate for Payer: Aetna of IA Commercial	$51.70
Rate for Payer: Aetna of IA Medical Rental Products	$51.70
Rate for Payer: Aetna of IA Medicare	$32.75
Rate for Payer: Amerigroup Medicaid	$29.00
Rate for Payer: Amerigroup Medicare	$29.01
Rate for Payer: Cash Price	$45.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.09
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.72
Rate for Payer: Iowa Total Care Managed Medicaid	$28.71
Rate for Payer: Medical Associates Commercial	$43.09
Rate for Payer: Medical Associates Managed Medicare	$28.72
Rate for Payer: Midlands Choice Commercial	$40.22
Rate for Payer: Molina Healthcare Managed Medicaid	$29.16
Rate for Payer: Partners Health Alliance Commercial	$43.09
Rate for Payer: United Healthcare Commercial	$51.70
Rate for Payer: United Healthcare Managed Medicare	$33.90

mirabegron 25 mg Tab

Facility IP

$57.45

Service Code	CPT A9270
Hospital Charge Code	43700418
Hospital Revenue Code	637
Min. Negotiated Rate	$40.22
Max. Negotiated Rate	$51.70
Rate for Payer: Aetna of IA Commercial	$51.70
Rate for Payer: Aetna of IA Medical Rental Products	$51.70
Rate for Payer: Cash Price	$45.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.09
Rate for Payer: Medical Associates Commercial	$43.09
Rate for Payer: Midlands Choice Commercial	$40.22
Rate for Payer: United Healthcare Commercial	$51.70

mirtazapine 15 mg Tab

Facility OP

$1.56

Service Code	CPT A9270
Hospital Charge Code	43701011
Hospital Revenue Code	637
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Aetna of IA Medicare	$0.89
Rate for Payer: Amerigroup Medicaid	$0.79
Rate for Payer: Amerigroup Medicare	$0.79
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.78
Rate for Payer: Iowa Total Care Managed Medicaid	$0.78
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Medical Associates Managed Medicare	$0.78
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: Molina Healthcare Managed Medicaid	$0.79
Rate for Payer: Partners Health Alliance Commercial	$1.17
Rate for Payer: United Healthcare Commercial	$1.40
Rate for Payer: United Healthcare Managed Medicare	$0.92

mirtazapine 15 mg Tab

Facility IP

$1.56

Service Code	CPT A9270
Hospital Charge Code	43701011
Hospital Revenue Code	637
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of IA Commercial	$1.40
Rate for Payer: Aetna of IA Medical Rental Products	$1.40
Rate for Payer: Cash Price	$1.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.17
Rate for Payer: Medical Associates Commercial	$1.17
Rate for Payer: Midlands Choice Commercial	$1.09
Rate for Payer: United Healthcare Commercial	$1.40

Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes With MCC

Facility IP

$10,171.15

Service Code	MS-DRG 640
Hospital Charge Code	426
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$10,171.15
Rate for Payer: Amerigroup Medicaid	$10,122.02
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	$10,023.74
Rate for Payer: Molina Healthcare Managed Medicaid	$10,171.15

Miscellaneous Disorders of Nutrition, Metabolism, Fluids and Electrolytes Without MCC

Facility IP

$5,831.64

Service Code	MS-DRG 641
Hospital Charge Code	427
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$5,831.64
Rate for Payer: Amerigroup Medicaid	$5,803.46
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	$5,747.12
Rate for Payer: Molina Healthcare Managed Medicaid	$5,831.64

misoprostol 100 mcg Tab

Facility OP

$2.65

Service Code	CPT A9270
Hospital Charge Code	43722489
Hospital Revenue Code	637
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna of IA Commercial	$2.38
Rate for Payer: Aetna of IA Medical Rental Products	$2.38
Rate for Payer: Aetna of IA Medicare	$1.51
Rate for Payer: Amerigroup Medicaid	$1.34
Rate for Payer: Amerigroup Medicare	$1.34
Rate for Payer: Cash Price	$2.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.99
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.32
Rate for Payer: Iowa Total Care Managed Medicaid	$1.32
Rate for Payer: Medical Associates Commercial	$1.99
Rate for Payer: Medical Associates Managed Medicare	$1.32
Rate for Payer: Midlands Choice Commercial	$1.86
Rate for Payer: Molina Healthcare Managed Medicaid	$1.34
Rate for Payer: Partners Health Alliance Commercial	$1.99
Rate for Payer: United Healthcare Commercial	$2.38
Rate for Payer: United Healthcare Managed Medicare	$1.56

misoprostol 100 mcg Tab

Facility IP

$2.65

Service Code	CPT A9270
Hospital Charge Code	43722489
Hospital Revenue Code	637
Min. Negotiated Rate	$1.86
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna of IA Commercial	$2.38
Rate for Payer: Aetna of IA Medical Rental Products	$2.38
Rate for Payer: Cash Price	$2.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.99
Rate for Payer: Medical Associates Commercial	$1.99
Rate for Payer: Midlands Choice Commercial	$1.86
Rate for Payer: United Healthcare Commercial	$2.38

Mitochondrial Antibody DMCL

Facility OP

$115.00

Service Code	CPT 83516
Hospital Charge Code	8037743
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Aetna of IA Medicare	$65.55
Rate for Payer: Amerigroup Medicaid	$58.04
Rate for Payer: Amerigroup Medicare	$58.08
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.50
Rate for Payer: Iowa Total Care Managed Medicaid	$57.48
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Medical Associates Managed Medicare	$57.50
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: Molina Healthcare Managed Medicaid	$58.36
Rate for Payer: Partners Health Alliance Commercial	$86.25
Rate for Payer: United Healthcare Commercial	$103.50
Rate for Payer: United Healthcare Managed Medicare	$67.85
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Mitochondrial Antibody DMCL

Facility IP

$115.00

Service Code	CPT 83516
Hospital Charge Code	8037743
Hospital Revenue Code	302
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: United Healthcare Commercial	$103.50

Price Transparency.

All Charges