Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MASTECTOMY FOR GYNECOMASTIA

Facility

$2,997.48

Service Code	CPT 19300
Hospital Revenue Code	360
Min. Negotiated Rate	$2,721.14
Max. Negotiated Rate	$2,997.48
Rate for Payer: Wellmark IA HMO WHPI	$2,721.14
Rate for Payer: Wellmark IA PPO	$2,997.48

MASTECTOMY FOR MALIGNANCY WITH CC/MCC

Facility

$17,611.41

Service Code	MSDRG 582
Min. Negotiated Rate	$17,356.16
Max. Negotiated Rate	$17,611.41
Rate for Payer: Amerigroup Medicaid	$17,526.32
Rate for Payer: Iowa Total Care Managed Medicaid	$17,356.16
Rate for Payer: Molina Healthcare Managed Medicaid	$17,611.41

MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC

Facility

$17,494.30

Service Code	MSDRG 583
Min. Negotiated Rate	$17,240.76
Max. Negotiated Rate	$17,494.30
Rate for Payer: Amerigroup Medicaid	$17,409.78
Rate for Payer: Iowa Total Care Managed Medicaid	$17,240.76
Rate for Payer: Molina Healthcare Managed Medicaid	$17,494.30

MAXIMUM BREATHING CAPACITY

Facility

$260.00

Service Code	CPT 94200
Hospital Charge Code	5338937
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

MAXIMUM BREATHING CAPACITY

Facility

$260.00

Service Code	CPT 94200
Hospital Charge Code	5338937
Hospital Revenue Code	460
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Aetna of IA Medicare	$148.20
Rate for Payer: Amerigroup Medicaid	$149.97
Rate for Payer: Amerigroup Medicare	$118.17
Rate for Payer: Cash Price	$208.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$117.00
Rate for Payer: Iowa Total Care Managed Medicaid	$148.51
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$117.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$150.70
Rate for Payer: Partners Health Alliance Commercial	$134.55
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40
Rate for Payer: Wellmark IA HMO WHPI	$185.05
Rate for Payer: Wellmark IA PPO	$203.84

MCL Referred Isolate DMCL

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	8037732
Hospital Revenue Code	306
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Aetna of IA Medicare	$33.63
Rate for Payer: Amerigroup Medicaid	$34.03
Rate for Payer: Amerigroup Medicare	$26.82
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.55
Rate for Payer: Iowa Total Care Managed Medicaid	$33.70
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Medical Associates Managed Medicare	$26.55
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: Molina Healthcare Managed Medicaid	$34.20
Rate for Payer: Partners Health Alliance Commercial	$30.53
Rate for Payer: United Healthcare Commercial	$53.10
Rate for Payer: United Healthcare Managed Medicare	$34.81
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

MCL Referred Isolate DMCL

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	8037732
Hospital Revenue Code	306
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: United Healthcare Commercial	$53.10

measles/mumps/rubella/varicella virus vaccine SDV - Pow UD[VDMC]

Facility

$508.42

Service Code	HCPCS 90710
Hospital Charge Code	12455541
Hospital Revenue Code	259
Min. Negotiated Rate	$80.12
Max. Negotiated Rate	$457.58
Rate for Payer: Aetna of IA Commercial	$457.58
Rate for Payer: Aetna of IA Medical Rental Products	$457.58
Rate for Payer: Aetna of IA Medicare	$289.80
Rate for Payer: Amerigroup Medicaid	$293.26
Rate for Payer: Amerigroup Medicare	$231.08
Rate for Payer: Cash Price	$406.74
Rate for Payer: Cash Price	$406.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$381.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$228.79
Rate for Payer: Iowa Total Care Managed Medicaid	$290.41
Rate for Payer: Medical Associates Commercial	$381.32
Rate for Payer: Medical Associates Managed Medicare	$228.79
Rate for Payer: Midlands Choice Commercial	$355.90
Rate for Payer: Molina Healthcare Managed Medicaid	$294.68
Rate for Payer: Partners Health Alliance Commercial	$263.11
Rate for Payer: United Healthcare Commercial	$457.58
Rate for Payer: United Healthcare Managed Medicare	$299.97
Rate for Payer: Wellmark IA HMO WHPI	$80.12
Rate for Payer: Wellmark IA PPO	$88.25

measles/mumps/rubella/varicella virus vaccine SDV - Pow UD[VDMC]

Facility

$508.42

Service Code	HCPCS 90710
Hospital Charge Code	12455541
Hospital Revenue Code	259
Min. Negotiated Rate	$355.90
Max. Negotiated Rate	$457.58
Rate for Payer: Aetna of IA Commercial	$457.58
Rate for Payer: Aetna of IA Medical Rental Products	$457.58
Rate for Payer: Cash Price	$406.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$381.32
Rate for Payer: Medical Associates Commercial	$381.32
Rate for Payer: Midlands Choice Commercial	$355.90
Rate for Payer: United Healthcare Commercial	$457.58

mEAsles/mumps/rubella virus vaccine SubQ Inj [VDMC]

Facility

$195.95

Service Code	HCPCS 90707
Hospital Charge Code	10402343
Hospital Revenue Code	259
Min. Negotiated Rate	$80.12
Max. Negotiated Rate	$176.36
Rate for Payer: Aetna of IA Commercial	$176.36
Rate for Payer: Aetna of IA Medical Rental Products	$176.36
Rate for Payer: Aetna of IA Medicare	$111.69
Rate for Payer: Amerigroup Medicaid	$113.03
Rate for Payer: Amerigroup Medicare	$89.06
Rate for Payer: Cash Price	$156.76
Rate for Payer: Cash Price	$156.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$146.97
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$88.18
Rate for Payer: Iowa Total Care Managed Medicaid	$111.93
Rate for Payer: Medical Associates Commercial	$146.97
Rate for Payer: Medical Associates Managed Medicare	$88.18
Rate for Payer: Midlands Choice Commercial	$137.17
Rate for Payer: Molina Healthcare Managed Medicaid	$113.57
Rate for Payer: Partners Health Alliance Commercial	$101.41
Rate for Payer: United Healthcare Commercial	$176.36
Rate for Payer: United Healthcare Managed Medicare	$115.61
Rate for Payer: Wellmark IA HMO WHPI	$80.12
Rate for Payer: Wellmark IA PPO	$88.25

mEAsles/mumps/rubella virus vaccine SubQ Inj [VDMC]

Facility

$195.95

Service Code	HCPCS 90707
Hospital Charge Code	10402343
Hospital Revenue Code	259
Min. Negotiated Rate	$137.17
Max. Negotiated Rate	$176.36
Rate for Payer: Aetna of IA Commercial	$176.36
Rate for Payer: Aetna of IA Medical Rental Products	$176.36
Rate for Payer: Cash Price	$156.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$146.97
Rate for Payer: Medical Associates Commercial	$146.97
Rate for Payer: Midlands Choice Commercial	$137.17
Rate for Payer: United Healthcare Commercial	$176.36

meclizine 25 mg Tab [VDMC]

Facility

$2.39

Service Code	HCPCS A9270
Hospital Charge Code	10402412
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna of IA Commercial	$2.15
Rate for Payer: Aetna of IA Medical Rental Products	$2.15
Rate for Payer: Cash Price	$1.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.79
Rate for Payer: Medical Associates Commercial	$1.79
Rate for Payer: Midlands Choice Commercial	$1.67
Rate for Payer: United Healthcare Commercial	$2.15

meclizine 25 mg Tab [VDMC]

Facility

$2.39

Service Code	HCPCS A9270
Hospital Charge Code	10402412
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$2.15
Rate for Payer: Aetna of IA Commercial	$2.15
Rate for Payer: Aetna of IA Medical Rental Products	$2.15
Rate for Payer: Aetna of IA Medicare	$1.36
Rate for Payer: Amerigroup Medicaid	$1.38
Rate for Payer: Amerigroup Medicare	$1.09
Rate for Payer: Cash Price	$1.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.79
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.08
Rate for Payer: Iowa Total Care Managed Medicaid	$1.37
Rate for Payer: Medical Associates Commercial	$1.79
Rate for Payer: Medical Associates Managed Medicare	$1.08
Rate for Payer: Midlands Choice Commercial	$1.67
Rate for Payer: Molina Healthcare Managed Medicaid	$1.39
Rate for Payer: Partners Health Alliance Commercial	$1.24
Rate for Payer: United Healthcare Commercial	$2.15
Rate for Payer: United Healthcare Managed Medicare	$1.41

MEDICAL BACK PROBLEMS WITH MCC

Facility

$15,318.92

Service Code	MSDRG 551
Min. Negotiated Rate	$15,096.90
Max. Negotiated Rate	$15,318.92
Rate for Payer: Amerigroup Medicaid	$15,244.91
Rate for Payer: Iowa Total Care Managed Medicaid	$15,096.90
Rate for Payer: Molina Healthcare Managed Medicaid	$15,318.92

MEDICAL BACK PROBLEMS WITHOUT MCC

Facility

$7,081.27

Service Code	MSDRG 552
Min. Negotiated Rate	$6,978.64
Max. Negotiated Rate	$7,081.27
Rate for Payer: Amerigroup Medicaid	$7,047.06
Rate for Payer: Iowa Total Care Managed Medicaid	$6,978.64
Rate for Payer: Molina Healthcare Managed Medicaid	$7,081.27

medroxyPROGESTERone 10 mg Tab [VDMC]

Facility

$1.57

Service Code	HCPCS A9270
Hospital Charge Code	10402481
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$1.42
Rate for Payer: Aetna of IA Commercial	$1.42
Rate for Payer: Aetna of IA Medical Rental Products	$1.42
Rate for Payer: Aetna of IA Medicare	$0.90
Rate for Payer: Amerigroup Medicaid	$0.91
Rate for Payer: Amerigroup Medicare	$0.72
Rate for Payer: Cash Price	$1.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.71
Rate for Payer: Iowa Total Care Managed Medicaid	$0.90
Rate for Payer: Medical Associates Commercial	$1.18
Rate for Payer: Medical Associates Managed Medicare	$0.71
Rate for Payer: Midlands Choice Commercial	$1.10
Rate for Payer: Molina Healthcare Managed Medicaid	$0.91
Rate for Payer: Partners Health Alliance Commercial	$0.81
Rate for Payer: United Healthcare Commercial	$1.42
Rate for Payer: United Healthcare Managed Medicare	$0.93

medroxyPROGESTERone 10 mg Tab [VDMC]

Facility

$1.57

Service Code	HCPCS A9270
Hospital Charge Code	10402481
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$1.42
Rate for Payer: Aetna of IA Commercial	$1.42
Rate for Payer: Aetna of IA Medical Rental Products	$1.42
Rate for Payer: Cash Price	$1.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.18
Rate for Payer: Medical Associates Commercial	$1.18
Rate for Payer: Midlands Choice Commercial	$1.10
Rate for Payer: United Healthcare Commercial	$1.42

medroxyPROGESTERone 150 mg/mL IM Susp SDV [VDMC]

Facility

$146.55

Service Code	HCPCS J1050
Hospital Charge Code	10402550
Hospital Revenue Code	259
Min. Negotiated Rate	$65.95
Max. Negotiated Rate	$131.89
Rate for Payer: Aetna of IA Commercial	$131.89
Rate for Payer: Aetna of IA Medical Rental Products	$131.89
Rate for Payer: Aetna of IA Medicare	$83.53
Rate for Payer: Amerigroup Medicaid	$84.53
Rate for Payer: Amerigroup Medicare	$66.60
Rate for Payer: Cash Price	$117.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.95
Rate for Payer: Iowa Total Care Managed Medicaid	$83.71
Rate for Payer: Medical Associates Commercial	$109.91
Rate for Payer: Medical Associates Managed Medicare	$65.95
Rate for Payer: Midlands Choice Commercial	$102.58
Rate for Payer: Molina Healthcare Managed Medicaid	$84.94
Rate for Payer: Partners Health Alliance Commercial	$75.84
Rate for Payer: United Healthcare Commercial	$131.89
Rate for Payer: United Healthcare Managed Medicare	$86.46

medroxyPROGESTERone 150 mg/mL IM Susp SDV [VDMC]

Facility

$146.55

Service Code	HCPCS J1050
Hospital Charge Code	10402550
Hospital Revenue Code	259
Min. Negotiated Rate	$102.58
Max. Negotiated Rate	$131.89
Rate for Payer: Aetna of IA Commercial	$131.89
Rate for Payer: Aetna of IA Medical Rental Products	$131.89
Rate for Payer: Cash Price	$117.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.91
Rate for Payer: Medical Associates Commercial	$109.91
Rate for Payer: Midlands Choice Commercial	$102.58
Rate for Payer: United Healthcare Commercial	$131.89

medroxyPROGESTERone 2.5 mg Tab [VDMC]

Facility

$1.37

Service Code	HCPCS A9270
Hospital Charge Code	10402617
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$1.23
Rate for Payer: Aetna of IA Commercial	$1.23
Rate for Payer: Aetna of IA Medical Rental Products	$1.23
Rate for Payer: Aetna of IA Medicare	$0.78
Rate for Payer: Amerigroup Medicaid	$0.79
Rate for Payer: Amerigroup Medicare	$0.62
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.62
Rate for Payer: Iowa Total Care Managed Medicaid	$0.78
Rate for Payer: Medical Associates Commercial	$1.03
Rate for Payer: Medical Associates Managed Medicare	$0.62
Rate for Payer: Midlands Choice Commercial	$0.96
Rate for Payer: Molina Healthcare Managed Medicaid	$0.79
Rate for Payer: Partners Health Alliance Commercial	$0.71
Rate for Payer: United Healthcare Commercial	$1.23
Rate for Payer: United Healthcare Managed Medicare	$0.81

medroxyPROGESTERone 2.5 mg Tab [VDMC]

Facility

$1.37

Service Code	HCPCS A9270
Hospital Charge Code	10402617
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.23
Rate for Payer: Aetna of IA Commercial	$1.23
Rate for Payer: Aetna of IA Medical Rental Products	$1.23
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.03
Rate for Payer: Medical Associates Commercial	$1.03
Rate for Payer: Midlands Choice Commercial	$0.96
Rate for Payer: United Healthcare Commercial	$1.23

Med/Surg

Facility

$1,400.00

Hospital Charge Code	4903043
Hospital Revenue Code	110
Min. Negotiated Rate	$980.00
Max. Negotiated Rate	$2,580.60
Rate for Payer: Aetna of IA Commercial	$1,260.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,260.00
Rate for Payer: Aetna of IA Medicare	$2,258.00
Rate for Payer: Amerigroup Medicare	$2,266.44
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Cash Price	$1,120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,050.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,244.00
Rate for Payer: Medical Associates Commercial	$1,050.00
Rate for Payer: Medical Associates Managed Medicare	$2,244.00
Rate for Payer: Midlands Choice Commercial	$980.00
Rate for Payer: Partners Health Alliance Commercial	$2,580.60
Rate for Payer: United Healthcare Commercial	$1,260.00
Rate for Payer: United Healthcare Managed Medicare	$1,306.00

Med/Surg: SNF

Facility

$1,000.00

Hospital Charge Code	4903043
Hospital Revenue Code	119
Min. Negotiated Rate	$700.00
Max. Negotiated Rate	$2,580.60
Rate for Payer: Aetna of IA Commercial	$900.00
Rate for Payer: Aetna of IA Medical Rental Products	$900.00
Rate for Payer: Aetna of IA Medicare	$2,258.00
Rate for Payer: Amerigroup Medicaid	$1,846.10
Rate for Payer: Amerigroup Medicare	$2,081.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$750.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,081.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,828.18
Rate for Payer: Medical Associates Commercial	$750.00
Rate for Payer: Medical Associates Managed Medicare	$2,081.00
Rate for Payer: Midlands Choice Commercial	$700.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,855.06
Rate for Payer: Partners Health Alliance Commercial	$2,580.60
Rate for Payer: United Healthcare Commercial	$900.00
Rate for Payer: United Healthcare Managed Medicare	$1,306.00

megestrol 40 mg/mL 10ml cup Sus [VDMC]

Facility

$18.68

Service Code	HCPCS A9270
Hospital Charge Code	11517858
Hospital Revenue Code	259
Min. Negotiated Rate	$13.08
Max. Negotiated Rate	$16.81
Rate for Payer: Aetna of IA Commercial	$16.81
Rate for Payer: Aetna of IA Medical Rental Products	$16.81
Rate for Payer: Cash Price	$14.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$14.01
Rate for Payer: Medical Associates Commercial	$14.01
Rate for Payer: Midlands Choice Commercial	$13.08
Rate for Payer: United Healthcare Commercial	$16.81

megestrol 40 mg/mL 10ml cup Sus [VDMC]

Facility

$18.68

Service Code	HCPCS A9270
Hospital Charge Code	11517858
Hospital Revenue Code	259
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$16.81
Rate for Payer: Aetna of IA Commercial	$16.81
Rate for Payer: Aetna of IA Medical Rental Products	$16.81
Rate for Payer: Aetna of IA Medicare	$10.65
Rate for Payer: Amerigroup Medicaid	$10.77
Rate for Payer: Amerigroup Medicare	$8.49
Rate for Payer: Cash Price	$14.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$14.01
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.41
Rate for Payer: Iowa Total Care Managed Medicaid	$10.67
Rate for Payer: Medical Associates Commercial	$14.01
Rate for Payer: Medical Associates Managed Medicare	$8.41
Rate for Payer: Midlands Choice Commercial	$13.08
Rate for Payer: Molina Healthcare Managed Medicaid	$10.83
Rate for Payer: Partners Health Alliance Commercial	$9.67
Rate for Payer: United Healthcare Commercial	$16.81
Rate for Payer: United Healthcare Managed Medicare	$11.02

Know your out-of-pocket cost for care.

All Charges