Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Minor Bladder Procedures Without CC/MCC

Facility

$9,209.54

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

$14,875.83

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

$5,206.64

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

$12,069.76

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

$27,574.51

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

$10,231.19

Service Code	MS-DRG 346
Hospital Charge Code	196
Min. Negotiated Rate	$10,082.91
Max. Negotiated Rate	$10,231.19
Rate for Payer: Amerigroup Medicaid	$10,181.77
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 [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	11224793
Hospital Revenue Code	259
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

minoxidil 2.5 mg Tab [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	11224793
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$0.71
Rate for Payer: Oscar Health of IA Commercial	$1.05
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

mirabegron 25 mg Tab [VDMC]

Facility

$57.45

Service Code	HCPCS A9270
Hospital Charge Code	10406338
Hospital Revenue Code	259
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

mirabegron 25 mg Tab [VDMC]

Facility

$57.45

Service Code	HCPCS A9270
Hospital Charge Code	10406338
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$29.14
Rate for Payer: Oscar Health of IA Commercial	$43.09
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

mirtazapine 15 mg Tab [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10406476
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$0.79
Rate for Payer: Oscar Health of IA Commercial	$1.17
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 [VDMC]

Facility

$1.56

Service Code	HCPCS A9270
Hospital Charge Code	10406476
Hospital Revenue Code	259
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

$10,171.15

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

$5,831.64

Service Code	MS-DRG 641
Hospital Charge Code	427
Min. Negotiated Rate	$5,747.12
Max. Negotiated Rate	$5,831.64
Rate for Payer: Amerigroup Medicaid	$5,803.46
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 [VDMC]

Facility

$2.65

Service Code	HCPCS A9270
Hospital Charge Code	10406616
Hospital Revenue Code	259
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

misoprostol 100 mcg Tab [VDMC]

Facility

$2.65

Service Code	HCPCS A9270
Hospital Charge Code	10406616
Hospital Revenue Code	259
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: Molina Healthcare Managed Medicare	$1.34
Rate for Payer: Oscar Health of IA Commercial	$1.99
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 800 mcg suppository[VDMC]

Facility

$43.19

Service Code	NDC 99999-9154-01
Hospital Charge Code	12099757
Hospital Revenue Code	259
Min. Negotiated Rate	$21.59
Max. Negotiated Rate	$38.87
Rate for Payer: Aetna of IA Commercial	$38.87
Rate for Payer: Aetna of IA Medical Rental Products	$38.87
Rate for Payer: Aetna of IA Medicare	$24.62
Rate for Payer: Amerigroup Medicaid	$21.80
Rate for Payer: Amerigroup Medicare	$21.81
Rate for Payer: Cash Price	$34.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$21.60
Rate for Payer: Iowa Total Care Managed Medicaid	$21.59
Rate for Payer: Medical Associates Commercial	$32.39
Rate for Payer: Medical Associates Managed Medicare	$21.60
Rate for Payer: Midlands Choice Commercial	$30.23
Rate for Payer: Molina Healthcare Managed Medicaid	$21.92
Rate for Payer: Molina Healthcare Managed Medicare	$21.91
Rate for Payer: Oscar Health of IA Commercial	$32.39
Rate for Payer: Partners Health Alliance Commercial	$32.39
Rate for Payer: United Healthcare Commercial	$38.87
Rate for Payer: United Healthcare Managed Medicare	$25.48

Misoprostol 800 mcg suppository[VDMC]

Facility

$43.19

Service Code	NDC 99999-9154-01
Hospital Charge Code	12099757
Hospital Revenue Code	259
Min. Negotiated Rate	$30.23
Max. Negotiated Rate	$38.87
Rate for Payer: Aetna of IA Commercial	$38.87
Rate for Payer: Aetna of IA Medical Rental Products	$38.87
Rate for Payer: Cash Price	$34.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.39
Rate for Payer: Medical Associates Commercial	$32.39
Rate for Payer: Midlands Choice Commercial	$30.23
Rate for Payer: United Healthcare Commercial	$38.87

Mitochondrial Antibody DMCL

Facility

$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

Mitochondrial Antibody DMCL

Facility

$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: Molina Healthcare Managed Medicare	$58.33
Rate for Payer: Oscar Health of IA Commercial	$86.25
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

MNT FOLLOW-UP ASSESS EA 15 MIN

Facility

$89.00

Service Code	CPT 97803
Hospital Charge Code	5616790
Hospital Revenue Code	942
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of IA Commercial	$80.10
Rate for Payer: Aetna of IA Medical Rental Products	$80.10
Rate for Payer: Cash Price	$71.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.75
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: United Healthcare Commercial	$80.10

MNT FOLLOW-UP ASSESS EA 15 MIN

Facility

$89.00

Service Code	CPT 97803
Hospital Charge Code	5616790
Hospital Revenue Code	942
Min. Negotiated Rate	$44.48
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of IA Commercial	$80.10
Rate for Payer: Aetna of IA Medical Rental Products	$80.10
Rate for Payer: Aetna of IA Medicare	$50.73
Rate for Payer: Amerigroup Medicaid	$44.92
Rate for Payer: Amerigroup Medicare	$44.94
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cash Price	$71.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.50
Rate for Payer: Iowa Total Care Managed Medicaid	$44.48
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Medical Associates Managed Medicare	$44.50
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: Molina Healthcare Managed Medicaid	$45.17
Rate for Payer: Molina Healthcare Managed Medicare	$45.14
Rate for Payer: Oscar Health of IA Commercial	$66.75
Rate for Payer: Partners Health Alliance Commercial	$66.75
Rate for Payer: United Healthcare Commercial	$80.10
Rate for Payer: United Healthcare Managed Medicare	$52.51
Rate for Payer: Wellmark IA HMO	$70.06
Rate for Payer: Wellmark IA PPO	$77.07

MNT GROUP EA 30 MINUTES

Facility

$89.00

Service Code	CPT 97804
Hospital Charge Code	5616791
Hospital Revenue Code	942
Min. Negotiated Rate	$44.48
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of IA Commercial	$80.10
Rate for Payer: Aetna of IA Medical Rental Products	$80.10
Rate for Payer: Aetna of IA Medicare	$50.73
Rate for Payer: Amerigroup Medicaid	$44.92
Rate for Payer: Amerigroup Medicare	$44.94
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cash Price	$71.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.50
Rate for Payer: Iowa Total Care Managed Medicaid	$44.48
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Medical Associates Managed Medicare	$44.50
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: Molina Healthcare Managed Medicaid	$45.17
Rate for Payer: Molina Healthcare Managed Medicare	$45.14
Rate for Payer: Oscar Health of IA Commercial	$66.75
Rate for Payer: Partners Health Alliance Commercial	$66.75
Rate for Payer: United Healthcare Commercial	$80.10
Rate for Payer: United Healthcare Managed Medicare	$52.51
Rate for Payer: Wellmark IA HMO	$70.06
Rate for Payer: Wellmark IA PPO	$77.07

MNT GROUP EA 30 MINUTES

Facility

$89.00

Service Code	CPT 97804
Hospital Charge Code	5616791
Hospital Revenue Code	942
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of IA Commercial	$80.10
Rate for Payer: Aetna of IA Medical Rental Products	$80.10
Rate for Payer: Cash Price	$71.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.75
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: United Healthcare Commercial	$80.10

MNT INITIAL ASSESS EA 15 MIN

Facility

$89.00

Service Code	CPT 97802
Hospital Charge Code	5616789
Hospital Revenue Code	942
Min. Negotiated Rate	$44.48
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of IA Commercial	$80.10
Rate for Payer: Aetna of IA Medical Rental Products	$80.10
Rate for Payer: Aetna of IA Medicare	$50.73
Rate for Payer: Amerigroup Medicaid	$44.92
Rate for Payer: Amerigroup Medicare	$44.94
Rate for Payer: Cash Price	$71.20
Rate for Payer: Cash Price	$71.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.50
Rate for Payer: Iowa Total Care Managed Medicaid	$44.48
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Medical Associates Managed Medicare	$44.50
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: Molina Healthcare Managed Medicaid	$45.17
Rate for Payer: Molina Healthcare Managed Medicare	$45.14
Rate for Payer: Oscar Health of IA Commercial	$66.75
Rate for Payer: Partners Health Alliance Commercial	$66.75
Rate for Payer: United Healthcare Commercial	$80.10
Rate for Payer: United Healthcare Managed Medicare	$52.51
Rate for Payer: Wellmark IA HMO	$70.06
Rate for Payer: Wellmark IA PPO	$77.07

Know your out-of-pocket cost for care.

All Charges