Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MAGNESIUM

Facility

$64.00

Service Code	CPT 83735
Hospital Charge Code	633781
Hospital Revenue Code	301
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

MAGNESIUM

Facility

$64.00

Service Code	CPT 83735
Hospital Charge Code	633781
Hospital Revenue Code	301
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

magnesium chloride DR 64 mg Tab [VDMC]

Facility

$1.27

Service Code	HCPCS A9270
Hospital Charge Code	10373307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of IA Commercial	$1.14
Rate for Payer: Aetna of IA Medical Rental Products	$1.14
Rate for Payer: Aetna of IA Medicare	$0.72
Rate for Payer: Amerigroup Medicaid	$0.73
Rate for Payer: Amerigroup Medicare	$0.58
Rate for Payer: Cash Price	$1.01
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.57
Rate for Payer: Iowa Total Care Managed Medicaid	$0.72
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Medical Associates Managed Medicare	$0.57
Rate for Payer: Midlands Choice Commercial	$0.89
Rate for Payer: Molina Healthcare Managed Medicaid	$0.73
Rate for Payer: Partners Health Alliance Commercial	$0.66
Rate for Payer: United Healthcare Commercial	$1.14
Rate for Payer: United Healthcare Managed Medicare	$0.75

magnesium chloride DR 64 mg Tab [VDMC]

Facility

$1.27

Service Code	HCPCS A9270
Hospital Charge Code	10373307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of IA Commercial	$1.14
Rate for Payer: Aetna of IA Medical Rental Products	$1.14
Rate for Payer: Cash Price	$1.01
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Midlands Choice Commercial	$0.89
Rate for Payer: United Healthcare Commercial	$1.14

magnesium citrate 8.85% Oral Liq 296 mL [VDMC]

Facility

$13.16

Service Code	HCPCS A9270
Hospital Charge Code	10435641
Hospital Revenue Code	259
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$11.84
Rate for Payer: Aetna of IA Commercial	$11.84
Rate for Payer: Aetna of IA Medical Rental Products	$11.84
Rate for Payer: Cash Price	$10.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.87
Rate for Payer: Medical Associates Commercial	$9.87
Rate for Payer: Midlands Choice Commercial	$9.21
Rate for Payer: United Healthcare Commercial	$11.84

magnesium citrate 8.85% Oral Liq 296 mL [VDMC]

Facility

$13.16

Service Code	HCPCS A9270
Hospital Charge Code	10435641
Hospital Revenue Code	259
Min. Negotiated Rate	$5.92
Max. Negotiated Rate	$11.84
Rate for Payer: Aetna of IA Commercial	$11.84
Rate for Payer: Aetna of IA Medical Rental Products	$11.84
Rate for Payer: Aetna of IA Medicare	$7.50
Rate for Payer: Amerigroup Medicaid	$7.59
Rate for Payer: Amerigroup Medicare	$5.98
Rate for Payer: Cash Price	$10.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.87
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.92
Rate for Payer: Iowa Total Care Managed Medicaid	$7.52
Rate for Payer: Medical Associates Commercial	$9.87
Rate for Payer: Medical Associates Managed Medicare	$5.92
Rate for Payer: Midlands Choice Commercial	$9.21
Rate for Payer: Molina Healthcare Managed Medicaid	$7.63
Rate for Payer: Partners Health Alliance Commercial	$6.81
Rate for Payer: United Healthcare Commercial	$11.84
Rate for Payer: United Healthcare Managed Medicare	$7.76

magnesium hydroxide 24% Oral Conc 10 mL [VDMC]

Facility

$8.98

Service Code	HCPCS A9270
Hospital Charge Code	10435706
Hospital Revenue Code	259
Min. Negotiated Rate	$4.04
Max. Negotiated Rate	$8.08
Rate for Payer: Aetna of IA Commercial	$8.08
Rate for Payer: Aetna of IA Medical Rental Products	$8.08
Rate for Payer: Aetna of IA Medicare	$5.12
Rate for Payer: Amerigroup Medicaid	$5.18
Rate for Payer: Amerigroup Medicare	$4.08
Rate for Payer: Cash Price	$7.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6.74
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.04
Rate for Payer: Iowa Total Care Managed Medicaid	$5.13
Rate for Payer: Medical Associates Commercial	$6.74
Rate for Payer: Medical Associates Managed Medicare	$4.04
Rate for Payer: Midlands Choice Commercial	$6.29
Rate for Payer: Molina Healthcare Managed Medicaid	$5.21
Rate for Payer: Partners Health Alliance Commercial	$4.65
Rate for Payer: United Healthcare Commercial	$8.08
Rate for Payer: United Healthcare Managed Medicare	$5.30

magnesium hydroxide 24% Oral Conc 10 mL [VDMC]

Facility

$8.98

Service Code	HCPCS A9270
Hospital Charge Code	10435706
Hospital Revenue Code	259
Min. Negotiated Rate	$6.29
Max. Negotiated Rate	$8.08
Rate for Payer: Aetna of IA Commercial	$8.08
Rate for Payer: Aetna of IA Medical Rental Products	$8.08
Rate for Payer: Cash Price	$7.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6.74
Rate for Payer: Medical Associates Commercial	$6.74
Rate for Payer: Midlands Choice Commercial	$6.29
Rate for Payer: United Healthcare Commercial	$8.08

magnesium oxide 400 mg Tab [VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	10402061
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: United Healthcare Commercial	$1.00

magnesium oxide 400 mg Tab [VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	10402061
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Aetna of IA Medicare	$0.63
Rate for Payer: Amerigroup Medicaid	$0.64
Rate for Payer: Amerigroup Medicare	$0.50
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.50
Rate for Payer: Iowa Total Care Managed Medicaid	$0.63
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Medical Associates Managed Medicare	$0.50
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: Molina Healthcare Managed Medicaid	$0.64
Rate for Payer: Partners Health Alliance Commercial	$0.57
Rate for Payer: United Healthcare Commercial	$1.00
Rate for Payer: United Healthcare Managed Medicare	$0.66

magnesium sulfate 10 mg/mL-D5% 100ml]VDMC]

Facility

$79.95

Service Code	HCPCS J3475
Hospital Charge Code	14145942
Hospital Revenue Code	259
Min. Negotiated Rate	$35.98
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$71.96
Rate for Payer: Aetna of IA Medical Rental Products	$71.96
Rate for Payer: Aetna of IA Medicare	$45.57
Rate for Payer: Amerigroup Medicaid	$46.12
Rate for Payer: Amerigroup Medicare	$36.34
Rate for Payer: Cash Price	$63.96
Rate for Payer: Cash Price	$63.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$59.96
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.98
Rate for Payer: Iowa Total Care Managed Medicaid	$45.67
Rate for Payer: Medical Associates Commercial	$59.96
Rate for Payer: Medical Associates Managed Medicare	$35.98
Rate for Payer: Midlands Choice Commercial	$55.97
Rate for Payer: Molina Healthcare Managed Medicaid	$46.34
Rate for Payer: Partners Health Alliance Commercial	$41.38
Rate for Payer: United Healthcare Commercial	$71.96
Rate for Payer: United Healthcare Managed Medicare	$47.17
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

magnesium sulfate 10 mg/mL-D5% 100ml]VDMC]

Facility

$79.95

Service Code	HCPCS J3475
Hospital Charge Code	14145942
Hospital Revenue Code	259
Min. Negotiated Rate	$55.97
Max. Negotiated Rate	$71.96
Rate for Payer: Aetna of IA Commercial	$71.96
Rate for Payer: Aetna of IA Medical Rental Products	$71.96
Rate for Payer: Cash Price	$63.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$59.96
Rate for Payer: Medical Associates Commercial	$59.96
Rate for Payer: Midlands Choice Commercial	$55.97
Rate for Payer: United Healthcare Commercial	$71.96

magnesium sulfate 2 g/50 mL-sterile water 50ml [VDMC]

Facility

$96.30

Service Code	HCPCS J3475
Hospital Charge Code	27167226
Hospital Revenue Code	259
Min. Negotiated Rate	$67.41
Max. Negotiated Rate	$86.67
Rate for Payer: Aetna of IA Commercial	$86.67
Rate for Payer: Aetna of IA Medical Rental Products	$86.67
Rate for Payer: Cash Price	$77.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$72.22
Rate for Payer: Medical Associates Commercial	$72.22
Rate for Payer: Midlands Choice Commercial	$67.41
Rate for Payer: United Healthcare Commercial	$86.67

magnesium sulfate 2 g/50 mL-sterile water 50ml [VDMC]

Facility

$96.30

Service Code	HCPCS J3475
Hospital Charge Code	27167226
Hospital Revenue Code	259
Min. Negotiated Rate	$43.34
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$86.67
Rate for Payer: Aetna of IA Medical Rental Products	$86.67
Rate for Payer: Aetna of IA Medicare	$54.89
Rate for Payer: Amerigroup Medicaid	$55.55
Rate for Payer: Amerigroup Medicare	$43.77
Rate for Payer: Cash Price	$77.04
Rate for Payer: Cash Price	$77.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$72.22
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$43.34
Rate for Payer: Iowa Total Care Managed Medicaid	$55.01
Rate for Payer: Medical Associates Commercial	$72.22
Rate for Payer: Medical Associates Managed Medicare	$43.34
Rate for Payer: Midlands Choice Commercial	$67.41
Rate for Payer: Molina Healthcare Managed Medicaid	$55.82
Rate for Payer: Partners Health Alliance Commercial	$49.84
Rate for Payer: United Healthcare Commercial	$86.67
Rate for Payer: United Healthcare Managed Medicare	$56.82
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

magnesium sulfate 40 mg/mL 1000ml bag [VDMC]

Facility

$83.80

Service Code	HCPCS J3475
Hospital Charge Code	10402201
Hospital Revenue Code	259
Min. Negotiated Rate	$58.66
Max. Negotiated Rate	$75.42
Rate for Payer: Aetna of IA Commercial	$75.42
Rate for Payer: Aetna of IA Medical Rental Products	$75.42
Rate for Payer: Cash Price	$67.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$62.85
Rate for Payer: Medical Associates Commercial	$62.85
Rate for Payer: Midlands Choice Commercial	$58.66
Rate for Payer: United Healthcare Commercial	$75.42

magnesium sulfate 40 mg/mL 1000ml bag [VDMC]

Facility

$83.80

Service Code	HCPCS J3475
Hospital Charge Code	10402201
Hospital Revenue Code	259
Min. Negotiated Rate	$37.71
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$75.42
Rate for Payer: Aetna of IA Medical Rental Products	$75.42
Rate for Payer: Aetna of IA Medicare	$47.77
Rate for Payer: Amerigroup Medicaid	$48.34
Rate for Payer: Amerigroup Medicare	$38.09
Rate for Payer: Cash Price	$67.04
Rate for Payer: Cash Price	$67.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$62.85
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$37.71
Rate for Payer: Iowa Total Care Managed Medicaid	$47.87
Rate for Payer: Medical Associates Commercial	$62.85
Rate for Payer: Medical Associates Managed Medicare	$37.71
Rate for Payer: Midlands Choice Commercial	$58.66
Rate for Payer: Molina Healthcare Managed Medicaid	$48.57
Rate for Payer: Partners Health Alliance Commercial	$43.37
Rate for Payer: United Healthcare Commercial	$75.42
Rate for Payer: United Healthcare Managed Medicare	$49.44
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

magnesium sulfate 50% 5gm/10ml SDV [VDMC]

Facility

$29.09

Service Code	HCPCS J3475
Hospital Charge Code	22490376
Hospital Revenue Code	259
Min. Negotiated Rate	$13.09
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$26.18
Rate for Payer: Aetna of IA Medical Rental Products	$26.18
Rate for Payer: Aetna of IA Medicare	$16.58
Rate for Payer: Amerigroup Medicaid	$16.78
Rate for Payer: Amerigroup Medicare	$13.22
Rate for Payer: Cash Price	$23.27
Rate for Payer: Cash Price	$23.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.09
Rate for Payer: Iowa Total Care Managed Medicaid	$16.62
Rate for Payer: Medical Associates Commercial	$21.82
Rate for Payer: Medical Associates Managed Medicare	$13.09
Rate for Payer: Midlands Choice Commercial	$20.36
Rate for Payer: Molina Healthcare Managed Medicaid	$16.86
Rate for Payer: Partners Health Alliance Commercial	$15.05
Rate for Payer: United Healthcare Commercial	$26.18
Rate for Payer: United Healthcare Managed Medicare	$17.16
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

magnesium sulfate 50% 5gm/10ml SDV [VDMC]

Facility

$29.09

Service Code	HCPCS J3475
Hospital Charge Code	22490376
Hospital Revenue Code	259
Min. Negotiated Rate	$20.36
Max. Negotiated Rate	$26.18
Rate for Payer: Aetna of IA Commercial	$26.18
Rate for Payer: Aetna of IA Medical Rental Products	$26.18
Rate for Payer: Cash Price	$23.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.82
Rate for Payer: Medical Associates Commercial	$21.82
Rate for Payer: Midlands Choice Commercial	$20.36
Rate for Payer: United Healthcare Commercial	$26.18

magnesium sulfate 50% Inj Sol 2 mL SDV [VDMC]

Facility

$24.20

Service Code	HCPCS J3475
Hospital Charge Code	10435773
Hospital Revenue Code	259
Min. Negotiated Rate	$10.89
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$21.78
Rate for Payer: Aetna of IA Medical Rental Products	$21.78
Rate for Payer: Aetna of IA Medicare	$13.79
Rate for Payer: Amerigroup Medicaid	$13.96
Rate for Payer: Amerigroup Medicare	$11.00
Rate for Payer: Cash Price	$19.36
Rate for Payer: Cash Price	$19.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.89
Rate for Payer: Iowa Total Care Managed Medicaid	$13.82
Rate for Payer: Medical Associates Commercial	$18.15
Rate for Payer: Medical Associates Managed Medicare	$10.89
Rate for Payer: Midlands Choice Commercial	$16.94
Rate for Payer: Molina Healthcare Managed Medicaid	$14.02
Rate for Payer: Partners Health Alliance Commercial	$12.52
Rate for Payer: United Healthcare Commercial	$21.78
Rate for Payer: United Healthcare Managed Medicare	$14.28
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

magnesium sulfate 50% Inj Sol 2 mL SDV [VDMC]

Facility

$24.20

Service Code	HCPCS J3475
Hospital Charge Code	10435773
Hospital Revenue Code	259
Min. Negotiated Rate	$16.94
Max. Negotiated Rate	$21.78
Rate for Payer: Aetna of IA Commercial	$21.78
Rate for Payer: Aetna of IA Medical Rental Products	$21.78
Rate for Payer: Cash Price	$19.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.15
Rate for Payer: Medical Associates Commercial	$18.15
Rate for Payer: Midlands Choice Commercial	$16.94
Rate for Payer: United Healthcare Commercial	$21.78

MAJOR BLADDER PROCEDURES WITH CC

Facility

$23,867.33

Service Code	MSDRG 654
Min. Negotiated Rate	$23,521.42
Max. Negotiated Rate	$23,867.33
Rate for Payer: Amerigroup Medicaid	$23,752.02
Rate for Payer: Iowa Total Care Managed Medicaid	$23,521.42
Rate for Payer: Molina Healthcare Managed Medicaid	$23,867.33

MAJOR BLADDER PROCEDURES WITH MCC

Facility

$37,863.23

Service Code	MSDRG 653
Min. Negotiated Rate	$37,314.47
Max. Negotiated Rate	$37,863.23
Rate for Payer: Amerigroup Medicaid	$37,680.30
Rate for Payer: Iowa Total Care Managed Medicaid	$37,314.47
Rate for Payer: Molina Healthcare Managed Medicaid	$37,863.23

MAJOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$23,867.33

Service Code	MSDRG 655
Min. Negotiated Rate	$23,521.42
Max. Negotiated Rate	$23,867.33
Rate for Payer: Amerigroup Medicaid	$23,752.02
Rate for Payer: Iowa Total Care Managed Medicaid	$23,521.42
Rate for Payer: Molina Healthcare Managed Medicaid	$23,867.33

MAJOR CHEST PROCEDURES WITH CC

Facility

$25,261.29

Service Code	MSDRG 164
Min. Negotiated Rate	$24,895.18
Max. Negotiated Rate	$25,261.29
Rate for Payer: Amerigroup Medicaid	$25,139.25
Rate for Payer: Iowa Total Care Managed Medicaid	$24,895.18
Rate for Payer: Molina Healthcare Managed Medicaid	$25,261.29

MAJOR CHEST PROCEDURES WITH MCC

Facility

$45,892.57

Service Code	MSDRG 163
Min. Negotiated Rate	$45,227.44
Max. Negotiated Rate	$45,892.57
Rate for Payer: Amerigroup Medicaid	$45,670.85
Rate for Payer: Iowa Total Care Managed Medicaid	$45,227.44
Rate for Payer: Molina Healthcare Managed Medicaid	$45,892.57

Know your out-of-pocket cost for care.

All Charges