Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MINOR SKIN DISORDERS WITH MCC

Facility

$17,018.02

Service Code	MSDRG 606
Min. Negotiated Rate	$16,771.37
Max. Negotiated Rate	$17,018.02
Rate for Payer: Amerigroup Medicaid	$16,935.80
Rate for Payer: Iowa Total Care Managed Medicaid	$16,771.37
Rate for Payer: Molina Healthcare Managed Medicaid	$17,018.02

MINOR SKIN DISORDERS WITHOUT MCC

Facility

$5,956.42

Service Code	MSDRG 607
Min. Negotiated Rate	$5,870.09
Max. Negotiated Rate	$5,956.42
Rate for Payer: Amerigroup Medicaid	$5,927.64
Rate for Payer: Iowa Total Care Managed Medicaid	$5,870.09
Rate for Payer: Molina Healthcare Managed Medicaid	$5,956.42

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$13,807.86

Service Code	MSDRG 345
Min. Negotiated Rate	$13,607.74
Max. Negotiated Rate	$13,807.86
Rate for Payer: Amerigroup Medicaid	$13,741.15
Rate for Payer: Iowa Total Care Managed Medicaid	$13,607.74
Rate for Payer: Molina Healthcare Managed Medicaid	$13,807.86

MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$31,545.37

Service Code	MSDRG 344
Min. Negotiated Rate	$31,088.18
Max. Negotiated Rate	$31,545.37
Rate for Payer: Amerigroup Medicaid	$31,392.96
Rate for Payer: Iowa Total Care Managed Medicaid	$31,088.18
Rate for Payer: Molina Healthcare Managed Medicaid	$31,545.37

MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$11,704.53

Service Code	MSDRG 346
Min. Negotiated Rate	$11,534.89
Max. Negotiated Rate	$11,704.53
Rate for Payer: Amerigroup Medicaid	$11,647.98
Rate for Payer: Iowa Total Care Managed Medicaid	$11,534.89
Rate for Payer: Molina Healthcare Managed Medicaid	$11,704.53

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	$0.63
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	$0.81
Rate for Payer: Amerigroup Medicare	$0.64
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	$0.63
Rate for Payer: Iowa Total Care Managed Medicaid	$0.80
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Medical Associates Managed Medicare	$0.63
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: Molina Healthcare Managed Medicaid	$0.81
Rate for Payer: Partners Health Alliance Commercial	$0.72
Rate for Payer: United Healthcare Commercial	$1.26
Rate for Payer: United Healthcare Managed Medicare	$0.82

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	$51.71
Rate for Payer: Aetna of IA Commercial	$51.71
Rate for Payer: Aetna of IA Medical Rental Products	$51.71
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	$51.71

mirabegron 25 mg Tab [VDMC]

Facility

$57.45

Service Code	HCPCS A9270
Hospital Charge Code	10406338
Hospital Revenue Code	259
Min. Negotiated Rate	$25.85
Max. Negotiated Rate	$51.71
Rate for Payer: Aetna of IA Commercial	$51.71
Rate for Payer: Aetna of IA Medical Rental Products	$51.71
Rate for Payer: Aetna of IA Medicare	$32.75
Rate for Payer: Amerigroup Medicaid	$33.14
Rate for Payer: Amerigroup Medicare	$26.11
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	$25.85
Rate for Payer: Iowa Total Care Managed Medicaid	$32.82
Rate for Payer: Medical Associates Commercial	$43.09
Rate for Payer: Medical Associates Managed Medicare	$25.85
Rate for Payer: Midlands Choice Commercial	$40.22
Rate for Payer: Molina Healthcare Managed Medicaid	$33.30
Rate for Payer: Partners Health Alliance Commercial	$29.73
Rate for Payer: United Healthcare Commercial	$51.71
Rate for Payer: United Healthcare Managed Medicare	$33.90

mirtazapine 15 mg Tab [VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	10406476
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Aetna of IA Medicare	$0.83
Rate for Payer: Amerigroup Medicaid	$0.84
Rate for Payer: Amerigroup Medicare	$0.66
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.66
Rate for Payer: Iowa Total Care Managed Medicaid	$0.83
Rate for Payer: Medical Associates Commercial	$1.10
Rate for Payer: Medical Associates Managed Medicare	$0.66
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: Molina Healthcare Managed Medicaid	$0.85
Rate for Payer: Partners Health Alliance Commercial	$0.76
Rate for Payer: United Healthcare Commercial	$1.31
Rate for Payer: United Healthcare Managed Medicare	$0.86

mirtazapine 15 mg Tab [VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	10406476
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.10
Rate for Payer: Medical Associates Commercial	$1.10
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: United Healthcare Commercial	$1.31

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITH MCC

Facility

$11,635.85

Service Code	MSDRG 640
Min. Negotiated Rate	$11,467.21
Max. Negotiated Rate	$11,635.85
Rate for Payer: Amerigroup Medicaid	$11,579.63
Rate for Payer: Iowa Total Care Managed Medicaid	$11,467.21
Rate for Payer: Molina Healthcare Managed Medicaid	$11,635.85

MISCELLANEOUS DISORDERS OF NUTRITION, METABOLISM, FLUIDS AND ELECTROLYTES WITHOUT MCC

Facility

$6,671.41

Service Code	MSDRG 641
Min. Negotiated Rate	$6,574.72
Max. Negotiated Rate	$6,671.41
Rate for Payer: Amerigroup Medicaid	$6,639.18
Rate for Payer: Iowa Total Care Managed Medicaid	$6,574.72
Rate for Payer: Molina Healthcare Managed Medicaid	$6,671.41

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	$2.39
Rate for Payer: Aetna of IA Commercial	$2.39
Rate for Payer: Aetna of IA Medical Rental Products	$2.39
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	$2.39

misoprostol 100 mcg Tab [VDMC]

Facility

$2.65

Service Code	HCPCS A9270
Hospital Charge Code	10406616
Hospital Revenue Code	259
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$2.39
Rate for Payer: Aetna of IA Commercial	$2.39
Rate for Payer: Aetna of IA Medical Rental Products	$2.39
Rate for Payer: Aetna of IA Medicare	$1.51
Rate for Payer: Amerigroup Medicaid	$1.53
Rate for Payer: Amerigroup Medicare	$1.20
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	$1.19
Rate for Payer: Iowa Total Care Managed Medicaid	$1.51
Rate for Payer: Medical Associates Commercial	$1.99
Rate for Payer: Medical Associates Managed Medicare	$1.19
Rate for Payer: Midlands Choice Commercial	$1.86
Rate for Payer: Molina Healthcare Managed Medicaid	$1.54
Rate for Payer: Partners Health Alliance Commercial	$1.37
Rate for Payer: United Healthcare Commercial	$2.39
Rate for Payer: United Healthcare Managed Medicare	$1.56

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	$51.75
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	$66.33
Rate for Payer: Amerigroup Medicare	$52.27
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	$51.75
Rate for Payer: Iowa Total Care Managed Medicaid	$65.69
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Medical Associates Managed Medicare	$51.75
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: Molina Healthcare Managed Medicaid	$66.65
Rate for Payer: Partners Health Alliance Commercial	$59.51
Rate for Payer: United Healthcare Commercial	$103.50
Rate for Payer: United Healthcare Managed Medicare	$67.85
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

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	$40.05
Max. Negotiated Rate	$135.11
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	$51.34
Rate for Payer: Amerigroup Medicare	$40.45
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	$40.05
Rate for Payer: Iowa Total Care Managed Medicaid	$50.84
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Medical Associates Managed Medicare	$40.05
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: Molina Healthcare Managed Medicaid	$51.58
Rate for Payer: Partners Health Alliance Commercial	$46.06
Rate for Payer: United Healthcare Commercial	$80.10
Rate for Payer: United Healthcare Managed Medicare	$52.51
Rate for Payer: Wellmark IA HMO WHPI	$122.66
Rate for Payer: Wellmark IA PPO	$135.11

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 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 GROUP EA 30 MINUTES

Facility

$89.00

Service Code	CPT 97804
Hospital Charge Code	5616791
Hospital Revenue Code	942
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$135.11
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	$51.34
Rate for Payer: Amerigroup Medicare	$40.45
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	$40.05
Rate for Payer: Iowa Total Care Managed Medicaid	$50.84
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Medical Associates Managed Medicare	$40.05
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: Molina Healthcare Managed Medicaid	$51.58
Rate for Payer: Partners Health Alliance Commercial	$46.06
Rate for Payer: United Healthcare Commercial	$80.10
Rate for Payer: United Healthcare Managed Medicare	$52.51
Rate for Payer: Wellmark IA HMO WHPI	$122.66
Rate for Payer: Wellmark IA PPO	$135.11

MNT INITIAL ASSESS EA 15 MIN

Facility

$89.00

Service Code	CPT 97802
Hospital Charge Code	5616789
Hospital Revenue Code	942
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$135.11
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	$51.34
Rate for Payer: Amerigroup Medicare	$40.45
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	$40.05
Rate for Payer: Iowa Total Care Managed Medicaid	$50.84
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Medical Associates Managed Medicare	$40.05
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: Molina Healthcare Managed Medicaid	$51.58
Rate for Payer: Partners Health Alliance Commercial	$46.06
Rate for Payer: United Healthcare Commercial	$80.10
Rate for Payer: United Healthcare Managed Medicare	$52.51
Rate for Payer: Wellmark IA HMO WHPI	$122.66
Rate for Payer: Wellmark IA PPO	$135.11

MNT INITIAL ASSESS EA 15 MIN

Facility

$89.00

Service Code	CPT 97802
Hospital Charge Code	5616789
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

modafinil 100 mg Tab [VDMC]

Facility

$3.64

Service Code	HCPCS A9270
Hospital Charge Code	10610465
Hospital Revenue Code	259
Min. Negotiated Rate	$2.55
Max. Negotiated Rate	$3.28
Rate for Payer: Aetna of IA Commercial	$3.28
Rate for Payer: Aetna of IA Medical Rental Products	$3.28
Rate for Payer: Cash Price	$2.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.73
Rate for Payer: Medical Associates Commercial	$2.73
Rate for Payer: Midlands Choice Commercial	$2.55
Rate for Payer: United Healthcare Commercial	$3.28

modafinil 100 mg Tab [VDMC]

Facility

$3.64

Service Code	HCPCS A9270
Hospital Charge Code	10610465
Hospital Revenue Code	259
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$3.28
Rate for Payer: Aetna of IA Commercial	$3.28
Rate for Payer: Aetna of IA Medical Rental Products	$3.28
Rate for Payer: Aetna of IA Medicare	$2.08
Rate for Payer: Amerigroup Medicaid	$2.10
Rate for Payer: Amerigroup Medicare	$1.65
Rate for Payer: Cash Price	$2.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.64
Rate for Payer: Iowa Total Care Managed Medicaid	$2.08
Rate for Payer: Medical Associates Commercial	$2.73
Rate for Payer: Medical Associates Managed Medicare	$1.64
Rate for Payer: Midlands Choice Commercial	$2.55
Rate for Payer: Molina Healthcare Managed Medicaid	$2.11
Rate for Payer: Partners Health Alliance Commercial	$1.88
Rate for Payer: United Healthcare Commercial	$3.28
Rate for Payer: United Healthcare Managed Medicare	$2.15

Know your out-of-pocket cost for care.

All Charges