Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MG Mammogram Digital Screening Left.

Facility

$302.00

Service Code	CPT 77067 52\|LT
Hospital Charge Code	4570784
Hospital Revenue Code	403
Min. Negotiated Rate	$211.40
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of IA Commercial	$271.80
Rate for Payer: Aetna of IA Medical Rental Products	$271.80
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$226.50
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: United Healthcare Commercial	$271.80

MG Mammogram Digital Screening Right.

Facility

$302.00

Service Code	CPT 77067 52
Hospital Charge Code	4570787
Hospital Revenue Code	403
Min. Negotiated Rate	$211.40
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of IA Commercial	$271.80
Rate for Payer: Aetna of IA Medical Rental Products	$271.80
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$226.50
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: United Healthcare Commercial	$271.80

MG Mammogram Digital Screening Right.

Facility

$302.00

Service Code	CPT 77067 52
Hospital Charge Code	4570787
Hospital Revenue Code	403
Min. Negotiated Rate	$135.90
Max. Negotiated Rate	$271.80
Rate for Payer: Aetna of IA Commercial	$271.80
Rate for Payer: Aetna of IA Medical Rental Products	$271.80
Rate for Payer: Aetna of IA Medicare	$172.14
Rate for Payer: Amerigroup Medicaid	$174.19
Rate for Payer: Amerigroup Medicare	$137.26
Rate for Payer: Cash Price	$241.60
Rate for Payer: Cash Price	$241.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$226.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.90
Rate for Payer: Iowa Total Care Managed Medicaid	$172.50
Rate for Payer: Medical Associates Commercial	$226.50
Rate for Payer: Medical Associates Managed Medicare	$135.90
Rate for Payer: Midlands Choice Commercial	$211.40
Rate for Payer: Molina Healthcare Managed Medicaid	$175.04
Rate for Payer: Partners Health Alliance Commercial	$156.28
Rate for Payer: United Healthcare Commercial	$271.80
Rate for Payer: Wellmark IA HMO WHPI	$197.81
Rate for Payer: Wellmark IA PPO	$217.90

miconazole Top 2% Crm 15gm [VDMC]

Facility

$16.01

Service Code	HCPCS A9270
Hospital Charge Code	10436187
Hospital Revenue Code	259
Min. Negotiated Rate	$11.21
Max. Negotiated Rate	$14.41
Rate for Payer: Aetna of IA Commercial	$14.41
Rate for Payer: Aetna of IA Medical Rental Products	$14.41
Rate for Payer: Cash Price	$12.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.01
Rate for Payer: Medical Associates Commercial	$12.01
Rate for Payer: Midlands Choice Commercial	$11.21
Rate for Payer: United Healthcare Commercial	$14.41

miconazole Top 2% Crm 15gm [VDMC]

Facility

$16.01

Service Code	HCPCS A9270
Hospital Charge Code	10436187
Hospital Revenue Code	259
Min. Negotiated Rate	$7.21
Max. Negotiated Rate	$14.41
Rate for Payer: Aetna of IA Commercial	$14.41
Rate for Payer: Aetna of IA Medical Rental Products	$14.41
Rate for Payer: Aetna of IA Medicare	$9.13
Rate for Payer: Amerigroup Medicaid	$9.24
Rate for Payer: Amerigroup Medicare	$7.28
Rate for Payer: Cash Price	$12.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.01
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.21
Rate for Payer: Iowa Total Care Managed Medicaid	$9.15
Rate for Payer: Medical Associates Commercial	$12.01
Rate for Payer: Medical Associates Managed Medicare	$7.21
Rate for Payer: Midlands Choice Commercial	$11.21
Rate for Payer: Molina Healthcare Managed Medicaid	$9.28
Rate for Payer: Partners Health Alliance Commercial	$8.29
Rate for Payer: United Healthcare Commercial	$14.41
Rate for Payer: United Healthcare Managed Medicare	$9.45

miconazole topical 2% Cre 45 gm [VDMC]

Facility

$43.42

Service Code	HCPCS A9270
Hospital Charge Code	11222554
Hospital Revenue Code	259
Min. Negotiated Rate	$19.54
Max. Negotiated Rate	$39.08
Rate for Payer: Aetna of IA Commercial	$39.08
Rate for Payer: Aetna of IA Medical Rental Products	$39.08
Rate for Payer: Aetna of IA Medicare	$24.75
Rate for Payer: Amerigroup Medicaid	$25.05
Rate for Payer: Amerigroup Medicare	$19.74
Rate for Payer: Cash Price	$34.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$19.54
Rate for Payer: Iowa Total Care Managed Medicaid	$24.80
Rate for Payer: Medical Associates Commercial	$32.57
Rate for Payer: Medical Associates Managed Medicare	$19.54
Rate for Payer: Midlands Choice Commercial	$30.40
Rate for Payer: Molina Healthcare Managed Medicaid	$25.17
Rate for Payer: Partners Health Alliance Commercial	$22.47
Rate for Payer: United Healthcare Commercial	$39.08
Rate for Payer: United Healthcare Managed Medicare	$25.62

miconazole topical 2% Cre 45 gm [VDMC]

Facility

$43.42

Service Code	HCPCS A9270
Hospital Charge Code	11222554
Hospital Revenue Code	259
Min. Negotiated Rate	$30.40
Max. Negotiated Rate	$39.08
Rate for Payer: Aetna of IA Commercial	$39.08
Rate for Payer: Aetna of IA Medical Rental Products	$39.08
Rate for Payer: Cash Price	$34.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.57
Rate for Payer: Medical Associates Commercial	$32.57
Rate for Payer: Midlands Choice Commercial	$30.40
Rate for Payer: United Healthcare Commercial	$39.08

Micro-Invasive Glaucoma Surgery

Facility

$10,570.84

Service Code	CPT 66991
Min. Negotiated Rate	$9,596.32
Max. Negotiated Rate	$10,570.84
Rate for Payer: Wellmark IA HMO WHPI	$9,596.32
Rate for Payer: Wellmark IA PPO	$10,570.84

midazolam 1 mg/mL 2 ML SDV [VDMC]

Facility

$41.09

Service Code	HCPCS J2250
Hospital Charge Code	10406011
Hospital Revenue Code	259
Min. Negotiated Rate	$18.49
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$36.98
Rate for Payer: Aetna of IA Medical Rental Products	$36.98
Rate for Payer: Aetna of IA Medicare	$23.42
Rate for Payer: Amerigroup Medicaid	$23.70
Rate for Payer: Amerigroup Medicare	$18.67
Rate for Payer: Cash Price	$32.87
Rate for Payer: Cash Price	$32.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.49
Rate for Payer: Iowa Total Care Managed Medicaid	$23.47
Rate for Payer: Medical Associates Commercial	$30.82
Rate for Payer: Medical Associates Managed Medicare	$18.49
Rate for Payer: Midlands Choice Commercial	$28.76
Rate for Payer: Molina Healthcare Managed Medicaid	$23.81
Rate for Payer: Partners Health Alliance Commercial	$21.26
Rate for Payer: United Healthcare Commercial	$36.98
Rate for Payer: United Healthcare Managed Medicare	$24.24
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

midazolam 1 mg/mL 2 ML SDV [VDMC]

Facility

$41.09

Service Code	HCPCS J2250
Hospital Charge Code	10406011
Hospital Revenue Code	259
Min. Negotiated Rate	$28.76
Max. Negotiated Rate	$36.98
Rate for Payer: Aetna of IA Commercial	$36.98
Rate for Payer: Aetna of IA Medical Rental Products	$36.98
Rate for Payer: Cash Price	$32.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.82
Rate for Payer: Medical Associates Commercial	$30.82
Rate for Payer: Midlands Choice Commercial	$28.76
Rate for Payer: United Healthcare Commercial	$36.98

midazolam 1 mg/mL Inj 5 ML SDV [VDMC]

Facility

$42.87

Service Code	HCPCS J2250
Hospital Charge Code	10405940
Hospital Revenue Code	259
Min. Negotiated Rate	$30.01
Max. Negotiated Rate	$38.58
Rate for Payer: Aetna of IA Commercial	$38.58
Rate for Payer: Aetna of IA Medical Rental Products	$38.58
Rate for Payer: Cash Price	$34.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.15
Rate for Payer: Medical Associates Commercial	$32.15
Rate for Payer: Midlands Choice Commercial	$30.01
Rate for Payer: United Healthcare Commercial	$38.58

midazolam 1 mg/mL Inj 5 ML SDV [VDMC]

Facility

$42.87

Service Code	HCPCS J2250
Hospital Charge Code	10405940
Hospital Revenue Code	259
Min. Negotiated Rate	$19.29
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$38.58
Rate for Payer: Aetna of IA Medical Rental Products	$38.58
Rate for Payer: Aetna of IA Medicare	$24.44
Rate for Payer: Amerigroup Medicaid	$24.73
Rate for Payer: Amerigroup Medicare	$19.49
Rate for Payer: Cash Price	$34.30
Rate for Payer: Cash Price	$34.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$19.29
Rate for Payer: Iowa Total Care Managed Medicaid	$24.49
Rate for Payer: Medical Associates Commercial	$32.15
Rate for Payer: Medical Associates Managed Medicare	$19.29
Rate for Payer: Midlands Choice Commercial	$30.01
Rate for Payer: Molina Healthcare Managed Medicaid	$24.85
Rate for Payer: Partners Health Alliance Commercial	$22.19
Rate for Payer: United Healthcare Commercial	$38.58
Rate for Payer: United Healthcare Managed Medicare	$25.29
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

midazolam 1 mg/mL MDV 5 ML vial [VDMC]

Facility

$43.61

Service Code	HCPCS J2250
Hospital Charge Code	13683949
Hospital Revenue Code	259
Min. Negotiated Rate	$19.63
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$39.25
Rate for Payer: Aetna of IA Medical Rental Products	$39.25
Rate for Payer: Aetna of IA Medicare	$24.86
Rate for Payer: Amerigroup Medicaid	$25.16
Rate for Payer: Amerigroup Medicare	$19.82
Rate for Payer: Cash Price	$34.89
Rate for Payer: Cash Price	$34.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.71
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$19.63
Rate for Payer: Iowa Total Care Managed Medicaid	$24.91
Rate for Payer: Medical Associates Commercial	$32.71
Rate for Payer: Medical Associates Managed Medicare	$19.63
Rate for Payer: Midlands Choice Commercial	$30.53
Rate for Payer: Molina Healthcare Managed Medicaid	$25.28
Rate for Payer: Partners Health Alliance Commercial	$22.57
Rate for Payer: United Healthcare Commercial	$39.25
Rate for Payer: United Healthcare Managed Medicare	$25.73
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

midazolam 1 mg/mL MDV 5 ML vial [VDMC]

Facility

$43.61

Service Code	HCPCS J2250
Hospital Charge Code	13683949
Hospital Revenue Code	259
Min. Negotiated Rate	$30.53
Max. Negotiated Rate	$39.25
Rate for Payer: Aetna of IA Commercial	$39.25
Rate for Payer: Aetna of IA Medical Rental Products	$39.25
Rate for Payer: Cash Price	$34.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.71
Rate for Payer: Medical Associates Commercial	$32.71
Rate for Payer: Midlands Choice Commercial	$30.53
Rate for Payer: United Healthcare Commercial	$39.25

midazolam 2 mg/mL Oral Syrup [VDMC]

Facility

$10.01

Service Code	HCPCS A9270
Hospital Charge Code	10406082
Hospital Revenue Code	259
Min. Negotiated Rate	$4.50
Max. Negotiated Rate	$9.01
Rate for Payer: Aetna of IA Commercial	$9.01
Rate for Payer: Aetna of IA Medical Rental Products	$9.01
Rate for Payer: Aetna of IA Medicare	$5.70
Rate for Payer: Amerigroup Medicaid	$5.77
Rate for Payer: Amerigroup Medicare	$4.55
Rate for Payer: Cash Price	$8.01
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.51
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.50
Rate for Payer: Iowa Total Care Managed Medicaid	$5.72
Rate for Payer: Medical Associates Commercial	$7.51
Rate for Payer: Medical Associates Managed Medicare	$4.50
Rate for Payer: Midlands Choice Commercial	$7.00
Rate for Payer: Molina Healthcare Managed Medicaid	$5.80
Rate for Payer: Partners Health Alliance Commercial	$5.18
Rate for Payer: United Healthcare Commercial	$9.01
Rate for Payer: United Healthcare Managed Medicare	$5.90

midazolam 2 mg/mL Oral Syrup [VDMC]

Facility

$10.01

Service Code	HCPCS A9270
Hospital Charge Code	10406082
Hospital Revenue Code	259
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$9.01
Rate for Payer: Aetna of IA Commercial	$9.01
Rate for Payer: Aetna of IA Medical Rental Products	$9.01
Rate for Payer: Cash Price	$8.01
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.51
Rate for Payer: Medical Associates Commercial	$7.51
Rate for Payer: Midlands Choice Commercial	$7.00
Rate for Payer: United Healthcare Commercial	$9.01

midodrine 5 mg Tab [VDMC]

Facility

$2.25

Service Code	HCPCS A9270
Hospital Charge Code	10406147
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of IA Commercial	$2.02
Rate for Payer: Aetna of IA Medical Rental Products	$2.02
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.69
Rate for Payer: Medical Associates Commercial	$1.69
Rate for Payer: Midlands Choice Commercial	$1.57
Rate for Payer: United Healthcare Commercial	$2.02

midodrine 5 mg Tab [VDMC]

Facility

$2.25

Service Code	HCPCS A9270
Hospital Charge Code	10406147
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna of IA Commercial	$2.02
Rate for Payer: Aetna of IA Medical Rental Products	$2.02
Rate for Payer: Aetna of IA Medicare	$1.28
Rate for Payer: Amerigroup Medicaid	$1.30
Rate for Payer: Amerigroup Medicare	$1.02
Rate for Payer: Cash Price	$1.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.69
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.01
Rate for Payer: Iowa Total Care Managed Medicaid	$1.28
Rate for Payer: Medical Associates Commercial	$1.69
Rate for Payer: Medical Associates Managed Medicare	$1.01
Rate for Payer: Midlands Choice Commercial	$1.57
Rate for Payer: Molina Healthcare Managed Medicaid	$1.30
Rate for Payer: Partners Health Alliance Commercial	$1.16
Rate for Payer: United Healthcare Commercial	$2.02
Rate for Payer: United Healthcare Managed Medicare	$1.33

MILEAGE GROUND PER 10TH OF A MILE

Facility

$2.00

Service Code	HCPCS A0425 QN
Hospital Charge Code	5966784
Hospital Revenue Code	540
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Aetna of IA Medicare	$1.14
Rate for Payer: Amerigroup Medicaid	$1.15
Rate for Payer: Amerigroup Medicare	$0.91
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1.14
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Medical Associates Managed Medicare	$0.90
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.16
Rate for Payer: Partners Health Alliance Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Managed Medicare	$1.70

MILEAGE GROUND PER 10TH OF A MILE

Facility

$2.00

Service Code	HCPCS A0425 QN
Hospital Charge Code	5966784
Hospital Revenue Code	540
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: United Healthcare Commercial	$1.80

MINI 4 HOLE ST

Facility

$133.00

Service Code	HCPCS 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

MINI 4 HOLE ST

Facility

$133.00

Service Code	HCPCS C1713
Hospital Charge Code	8046726
Hospital Revenue Code	278
Min. Negotiated Rate	$59.85
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	$76.71
Rate for Payer: Amerigroup Medicare	$60.45
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	$59.85
Rate for Payer: Iowa Total Care Managed Medicaid	$75.97
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Medical Associates Managed Medicare	$59.85
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: Molina Healthcare Managed Medicaid	$77.09
Rate for Payer: Partners Health Alliance Commercial	$68.83
Rate for Payer: United Healthcare Commercial	$119.70
Rate for Payer: United Healthcare Managed Medicare	$78.47

MINOR BLADDER PROCEDURES WITH CC

Facility

$10,535.77

Service Code	MSDRG 663
Min. Negotiated Rate	$10,383.07
Max. Negotiated Rate	$10,535.77
Rate for Payer: Amerigroup Medicaid	$10,484.86
Rate for Payer: Iowa Total Care Managed Medicaid	$10,383.07
Rate for Payer: Molina Healthcare Managed Medicaid	$10,535.77

MINOR BLADDER PROCEDURES WITH MCC

Facility

$32,997.88

Service Code	MSDRG 662
Min. Negotiated Rate	$32,519.64
Max. Negotiated Rate	$32,997.88
Rate for Payer: Amerigroup Medicaid	$32,838.46
Rate for Payer: Iowa Total Care Managed Medicaid	$32,519.64
Rate for Payer: Molina Healthcare Managed Medicaid	$32,997.88

MINOR BLADDER PROCEDURES WITHOUT CC/MCC

Facility

$10,535.77

Service Code	MSDRG 664
Min. Negotiated Rate	$10,383.07
Max. Negotiated Rate	$10,535.77
Rate for Payer: Amerigroup Medicaid	$10,484.86
Rate for Payer: Iowa Total Care Managed Medicaid	$10,383.07
Rate for Payer: Molina Healthcare Managed Medicaid	$10,535.77

Know your out-of-pocket cost for care.

All Charges