Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ACRYSOF IQ VIVITY TORIC 22.5 LENS

Facility

$845.00

Service Code	CPT V2787
Hospital Charge Code	8885211
Hospital Revenue Code	276
Min. Negotiated Rate	$591.50
Max. Negotiated Rate	$760.50
Rate for Payer: Aetna of IA Commercial	$760.50
Rate for Payer: Aetna of IA Medical Rental Products	$760.50
Rate for Payer: Cash Price	$676.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$633.75
Rate for Payer: Medical Associates Commercial	$633.75
Rate for Payer: Midlands Choice Commercial	$591.50
Rate for Payer: United Healthcare Commercial	$760.50

ACRYSOF IQ VIVITY TORIC 22.5 LENS

Facility

$845.00

Service Code	CPT V2787
Hospital Charge Code	8885211
Hospital Revenue Code	276
Min. Negotiated Rate	$422.33
Max. Negotiated Rate	$760.50
Rate for Payer: Aetna of IA Commercial	$760.50
Rate for Payer: Aetna of IA Medical Rental Products	$760.50
Rate for Payer: Aetna of IA Medicare	$481.65
Rate for Payer: Amerigroup Medicaid	$426.47
Rate for Payer: Amerigroup Medicare	$426.72
Rate for Payer: Cash Price	$676.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$633.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$422.50
Rate for Payer: Iowa Total Care Managed Medicaid	$422.33
Rate for Payer: Medical Associates Commercial	$633.75
Rate for Payer: Medical Associates Managed Medicare	$422.50
Rate for Payer: Midlands Choice Commercial	$591.50
Rate for Payer: Molina Healthcare Managed Medicaid	$428.84
Rate for Payer: Molina Healthcare Managed Medicare	$428.58
Rate for Payer: Oscar Health of IA Commercial	$633.75
Rate for Payer: Partners Health Alliance Commercial	$633.75
Rate for Payer: United Healthcare Commercial	$760.50
Rate for Payer: United Healthcare Managed Medicare	$498.55

ACRYSOLF IQ LENS 21.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8893483
Hospital Revenue Code	276
Min. Negotiated Rate	$189.00
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: United Healthcare Commercial	$243.00

ACRYSOLF IQ LENS 21.5

Facility

$270.00

Service Code	CPT V2632
Hospital Charge Code	8893483
Hospital Revenue Code	276
Min. Negotiated Rate	$134.95
Max. Negotiated Rate	$243.00
Rate for Payer: Aetna of IA Commercial	$243.00
Rate for Payer: Aetna of IA Medical Rental Products	$243.00
Rate for Payer: Aetna of IA Medicare	$153.90
Rate for Payer: Amerigroup Medicaid	$136.27
Rate for Payer: Amerigroup Medicare	$136.35
Rate for Payer: Cash Price	$216.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$202.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$134.95
Rate for Payer: Medical Associates Commercial	$202.50
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$189.00
Rate for Payer: Molina Healthcare Managed Medicaid	$137.02
Rate for Payer: Molina Healthcare Managed Medicare	$136.94
Rate for Payer: Oscar Health of IA Commercial	$202.50
Rate for Payer: Partners Health Alliance Commercial	$202.50
Rate for Payer: United Healthcare Commercial	$243.00
Rate for Payer: United Healthcare Managed Medicare	$159.30

activated charcoal (ped) 25 g Oral Susp 120 mL [VDMC]

Facility

$52.24

Service Code	HCPCS A9270
Hospital Charge Code	10377167
Hospital Revenue Code	259
Min. Negotiated Rate	$36.57
Max. Negotiated Rate	$47.02
Rate for Payer: Aetna of IA Commercial	$47.02
Rate for Payer: Aetna of IA Medical Rental Products	$47.02
Rate for Payer: Cash Price	$41.79
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.18
Rate for Payer: Medical Associates Commercial	$39.18
Rate for Payer: Midlands Choice Commercial	$36.57
Rate for Payer: United Healthcare Commercial	$47.02

activated charcoal (ped) 25 g Oral Susp 120 mL [VDMC]

Facility

$52.24

Service Code	HCPCS A9270
Hospital Charge Code	10377167
Hospital Revenue Code	259
Min. Negotiated Rate	$26.11
Max. Negotiated Rate	$47.02
Rate for Payer: Aetna of IA Commercial	$47.02
Rate for Payer: Aetna of IA Medical Rental Products	$47.02
Rate for Payer: Aetna of IA Medicare	$29.78
Rate for Payer: Amerigroup Medicaid	$26.37
Rate for Payer: Amerigroup Medicare	$26.38
Rate for Payer: Cash Price	$41.79
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.12
Rate for Payer: Iowa Total Care Managed Medicaid	$26.11
Rate for Payer: Medical Associates Commercial	$39.18
Rate for Payer: Medical Associates Managed Medicare	$26.12
Rate for Payer: Midlands Choice Commercial	$36.57
Rate for Payer: Molina Healthcare Managed Medicaid	$26.51
Rate for Payer: Molina Healthcare Managed Medicare	$26.50
Rate for Payer: Oscar Health of IA Commercial	$39.18
Rate for Payer: Partners Health Alliance Commercial	$39.18
Rate for Payer: United Healthcare Commercial	$47.02
Rate for Payer: United Healthcare Managed Medicare	$30.82

activated charcoal-sorbitol 50 g Oral Susp 240 mL [VDMC]

Facility

$78.48

Service Code	HCPCS A9270
Hospital Charge Code	10377232
Hospital Revenue Code	259
Min. Negotiated Rate	$54.94
Max. Negotiated Rate	$70.63
Rate for Payer: Aetna of IA Commercial	$70.63
Rate for Payer: Aetna of IA Medical Rental Products	$70.63
Rate for Payer: Cash Price	$62.79
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.86
Rate for Payer: Medical Associates Commercial	$58.86
Rate for Payer: Midlands Choice Commercial	$54.94
Rate for Payer: United Healthcare Commercial	$70.63

activated charcoal-sorbitol 50 g Oral Susp 240 mL [VDMC]

Facility

$78.48

Service Code	HCPCS A9270
Hospital Charge Code	10377232
Hospital Revenue Code	259
Min. Negotiated Rate	$39.22
Max. Negotiated Rate	$70.63
Rate for Payer: Aetna of IA Commercial	$70.63
Rate for Payer: Aetna of IA Medical Rental Products	$70.63
Rate for Payer: Aetna of IA Medicare	$44.73
Rate for Payer: Amerigroup Medicaid	$39.61
Rate for Payer: Amerigroup Medicare	$39.63
Rate for Payer: Cash Price	$62.79
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.86
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$39.24
Rate for Payer: Iowa Total Care Managed Medicaid	$39.22
Rate for Payer: Medical Associates Commercial	$58.86
Rate for Payer: Medical Associates Managed Medicare	$39.24
Rate for Payer: Midlands Choice Commercial	$54.94
Rate for Payer: Molina Healthcare Managed Medicaid	$39.83
Rate for Payer: Molina Healthcare Managed Medicare	$39.81
Rate for Payer: Oscar Health of IA Commercial	$58.86
Rate for Payer: Partners Health Alliance Commercial	$58.86
Rate for Payer: United Healthcare Commercial	$70.63
Rate for Payer: United Healthcare Managed Medicare	$46.30

Acute Adjustment Reaction and Psychosocial Dysfunction

Facility

$5,345.41

Service Code	MS-DRG 880
Hospital Charge Code	610
Min. Negotiated Rate	$5,267.94
Max. Negotiated Rate	$5,345.41
Rate for Payer: Amerigroup Medicaid	$5,319.59
Rate for Payer: Iowa Total Care Managed Medicaid	$5,267.94
Rate for Payer: Molina Healthcare Managed Medicaid	$5,345.41

Acute and Subacute Endocarditis With CC

Facility

$14,157.33

Service Code	MS-DRG 289
Hospital Charge Code	146
Min. Negotiated Rate	$13,952.15
Max. Negotiated Rate	$14,157.33
Rate for Payer: Amerigroup Medicaid	$14,088.94
Rate for Payer: Iowa Total Care Managed Medicaid	$13,952.15
Rate for Payer: Molina Healthcare Managed Medicaid	$14,157.33

Acute and Subacute Endocarditis With MCC

Facility

$18,667.13

Service Code	MS-DRG 288
Hospital Charge Code	145
Min. Negotiated Rate	$18,396.59
Max. Negotiated Rate	$18,667.13
Rate for Payer: Amerigroup Medicaid	$18,576.95
Rate for Payer: Iowa Total Care Managed Medicaid	$18,396.59
Rate for Payer: Molina Healthcare Managed Medicaid	$18,667.13

Acute and Subacute Endocarditis Without CC/MCC

Facility

$10,077.65

Service Code	MS-DRG 290
Hospital Charge Code	147
Min. Negotiated Rate	$9,931.60
Max. Negotiated Rate	$10,077.65
Rate for Payer: Amerigroup Medicaid	$10,028.97
Rate for Payer: Iowa Total Care Managed Medicaid	$9,931.60
Rate for Payer: Molina Healthcare Managed Medicaid	$10,077.65

ACUTE HEPATITIS PROFILE

Facility

$303.00

Service Code	CPT 80074
Hospital Charge Code	8037485
Hospital Revenue Code	302
Min. Negotiated Rate	$52.08
Max. Negotiated Rate	$272.70
Rate for Payer: Aetna of IA Commercial	$272.70
Rate for Payer: Aetna of IA Medical Rental Products	$272.70
Rate for Payer: Aetna of IA Medicare	$172.71
Rate for Payer: Amerigroup Medicaid	$152.92
Rate for Payer: Amerigroup Medicare	$153.02
Rate for Payer: Cash Price	$242.40
Rate for Payer: Cash Price	$242.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$227.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$151.50
Rate for Payer: Iowa Total Care Managed Medicaid	$151.44
Rate for Payer: Medical Associates Commercial	$227.25
Rate for Payer: Medical Associates Managed Medicare	$151.50
Rate for Payer: Midlands Choice Commercial	$212.10
Rate for Payer: Molina Healthcare Managed Medicaid	$153.77
Rate for Payer: Molina Healthcare Managed Medicare	$153.68
Rate for Payer: Oscar Health of IA Commercial	$227.25
Rate for Payer: Partners Health Alliance Commercial	$227.25
Rate for Payer: United Healthcare Commercial	$272.70
Rate for Payer: United Healthcare Managed Medicare	$178.77
Rate for Payer: Wellmark IA HMO	$52.08
Rate for Payer: Wellmark IA PPO	$57.29

ACUTE HEPATITIS PROFILE

Facility

$303.00

Service Code	CPT 80074
Hospital Charge Code	8037485
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$272.70
Rate for Payer: Aetna of IA Commercial	$272.70
Rate for Payer: Aetna of IA Medical Rental Products	$272.70
Rate for Payer: Cash Price	$242.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$227.25
Rate for Payer: Medical Associates Commercial	$227.25
Rate for Payer: Midlands Choice Commercial	$212.10
Rate for Payer: United Healthcare Commercial	$272.70

Acute Leukemia Without Major O.R. Procedures With CC

Facility

$26,998.73

Service Code	MS-DRG 835
Hospital Charge Code	577
Min. Negotiated Rate	$26,607.44
Max. Negotiated Rate	$26,998.73
Rate for Payer: Amerigroup Medicaid	$26,868.30
Rate for Payer: Iowa Total Care Managed Medicaid	$26,607.44
Rate for Payer: Molina Healthcare Managed Medicaid	$26,998.73

Acute Leukemia Without Major O.R. Procedures With MCC

Facility

$61,309.38

Service Code	MS-DRG 834
Hospital Charge Code	576
Min. Negotiated Rate	$60,420.84
Max. Negotiated Rate	$61,309.38
Rate for Payer: Amerigroup Medicaid	$61,013.20
Rate for Payer: Iowa Total Care Managed Medicaid	$60,420.84
Rate for Payer: Molina Healthcare Managed Medicaid	$61,309.38

Acute Leukemia Without Major O.R. Procedures Without CC/MCC

Facility

$11,514.64

Service Code	MS-DRG 836
Hospital Charge Code	578
Min. Negotiated Rate	$11,347.77
Max. Negotiated Rate	$11,514.64
Rate for Payer: Amerigroup Medicaid	$11,459.02
Rate for Payer: Iowa Total Care Managed Medicaid	$11,347.77
Rate for Payer: Molina Healthcare Managed Medicaid	$11,514.64

Acute Major Eye Infections With CC/MCC

Facility

$8,091.45

Service Code	MS-DRG 121
Hospital Charge Code	10
Min. Negotiated Rate	$7,974.19
Max. Negotiated Rate	$8,091.45
Rate for Payer: Amerigroup Medicaid	$8,052.36
Rate for Payer: Iowa Total Care Managed Medicaid	$7,974.19
Rate for Payer: Molina Healthcare Managed Medicaid	$8,091.45

Acute Major Eye Infections Without CC/MCC

Facility

$5,227.31

Service Code	MS-DRG 122
Hospital Charge Code	11
Min. Negotiated Rate	$5,151.55
Max. Negotiated Rate	$5,227.31
Rate for Payer: Amerigroup Medicaid	$5,202.06
Rate for Payer: Iowa Total Care Managed Medicaid	$5,151.55
Rate for Payer: Molina Healthcare Managed Medicaid	$5,227.31

Acute Myocardial Infarction, Discharged Alive With CC

Facility

$7,557.99

Service Code	MS-DRG 281
Hospital Charge Code	138
Min. Negotiated Rate	$7,448.46
Max. Negotiated Rate	$7,557.99
Rate for Payer: Amerigroup Medicaid	$7,521.48
Rate for Payer: Iowa Total Care Managed Medicaid	$7,448.46
Rate for Payer: Molina Healthcare Managed Medicaid	$7,557.99

Acute Myocardial Infarction, Discharged Alive With MCC

Facility

$13,101.24

Service Code	MS-DRG 280
Hospital Charge Code	137
Min. Negotiated Rate	$12,911.36
Max. Negotiated Rate	$13,101.24
Rate for Payer: Amerigroup Medicaid	$13,037.95
Rate for Payer: Iowa Total Care Managed Medicaid	$12,911.36
Rate for Payer: Molina Healthcare Managed Medicaid	$13,101.24

Acute Myocardial Infarction, Discharged Alive Without CC/MCC

Facility

$6,237.14

Service Code	MS-DRG 282
Hospital Charge Code	139
Min. Negotiated Rate	$6,146.74
Max. Negotiated Rate	$6,237.14
Rate for Payer: Amerigroup Medicaid	$6,207.01
Rate for Payer: Iowa Total Care Managed Medicaid	$6,146.74
Rate for Payer: Molina Healthcare Managed Medicaid	$6,237.14

Acute Myocardial Infarction, Expired With CC

Facility

$7,226.30

Service Code	MS-DRG 284
Hospital Charge Code	141
Min. Negotiated Rate	$7,121.57
Max. Negotiated Rate	$7,226.30
Rate for Payer: Amerigroup Medicaid	$7,191.39
Rate for Payer: Iowa Total Care Managed Medicaid	$7,121.57
Rate for Payer: Molina Healthcare Managed Medicaid	$7,226.30

Acute Myocardial Infarction, Expired With MCC

Facility

$10,892.60

Service Code	MS-DRG 283
Hospital Charge Code	140
Min. Negotiated Rate	$10,734.74
Max. Negotiated Rate	$10,892.60
Rate for Payer: Amerigroup Medicaid	$10,839.98
Rate for Payer: Iowa Total Care Managed Medicaid	$10,734.74
Rate for Payer: Molina Healthcare Managed Medicaid	$10,892.60

Acute Myocardial Infarction, Expired Without CC/MCC

Facility

$4,885.78

Service Code	MS-DRG 285
Hospital Charge Code	142
Min. Negotiated Rate	$4,814.97
Max. Negotiated Rate	$4,885.78
Rate for Payer: Amerigroup Medicaid	$4,862.18
Rate for Payer: Iowa Total Care Managed Medicaid	$4,814.97
Rate for Payer: Molina Healthcare Managed Medicaid	$4,885.78

Know your out-of-pocket cost for care.

All Charges