Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ondansetron 2 mg/mL 2 ML Inj SDV [VDMC]

Facility

$20.96

Service Code	HCPCS J2405
Hospital Charge Code	10410483
Hospital Revenue Code	259
Min. Negotiated Rate	$14.67
Max. Negotiated Rate	$18.86
Rate for Payer: Aetna of IA Commercial	$18.86
Rate for Payer: Aetna of IA Medical Rental Products	$18.86
Rate for Payer: Cash Price	$16.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$15.72
Rate for Payer: Medical Associates Commercial	$15.72
Rate for Payer: Midlands Choice Commercial	$14.67
Rate for Payer: United Healthcare Commercial	$18.86

ondansetron 2 mg/mL 2 ML Inj SDV [VDMC]

Facility

$20.96

Service Code	HCPCS J2405
Hospital Charge Code	10410483
Hospital Revenue Code	259
Min. Negotiated Rate	$10.48
Max. Negotiated Rate	$18.86
Rate for Payer: Aetna of IA Commercial	$18.86
Rate for Payer: Aetna of IA Medical Rental Products	$18.86
Rate for Payer: Aetna of IA Medicare	$11.95
Rate for Payer: Amerigroup Medicaid	$10.58
Rate for Payer: Amerigroup Medicare	$10.58
Rate for Payer: Cash Price	$16.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$15.72
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.48
Rate for Payer: Iowa Total Care Managed Medicaid	$10.48
Rate for Payer: Medical Associates Commercial	$15.72
Rate for Payer: Medical Associates Managed Medicare	$10.48
Rate for Payer: Midlands Choice Commercial	$14.67
Rate for Payer: Molina Healthcare Managed Medicaid	$10.64
Rate for Payer: Molina Healthcare Managed Medicare	$10.63
Rate for Payer: Oscar Health of IA Commercial	$15.72
Rate for Payer: Partners Health Alliance Commercial	$15.72
Rate for Payer: United Healthcare Commercial	$18.86
Rate for Payer: United Healthcare Managed Medicare	$12.37

ondansetron 4 mg Dis Tab [VDMC]

Facility

$2.00

Service Code	HCPCS A9270
Hospital Charge Code	10410554
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
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	$1.01
Rate for Payer: Amerigroup Medicare	$1.01
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	$1.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1.00
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Medical Associates Managed Medicare	$1.00
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.02
Rate for Payer: Molina Healthcare Managed Medicare	$1.01
Rate for Payer: Oscar Health of IA Commercial	$1.50
Rate for Payer: Partners Health Alliance Commercial	$1.50
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Managed Medicare	$1.18

ondansetron 4 mg Dis Tab [VDMC]

Facility

$2.00

Service Code	HCPCS A9270
Hospital Charge Code	10410554
Hospital Revenue Code	259
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

Ongoing

Facility

$143.00

Service Code	CPT 93668
Hospital Charge Code	8663517
Hospital Revenue Code	943
Min. Negotiated Rate	$71.47
Max. Negotiated Rate	$443.98
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$72.17
Rate for Payer: Amerigroup Medicare	$72.22
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$71.50
Rate for Payer: Iowa Total Care Managed Medicaid	$71.47
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$71.50
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$72.57
Rate for Payer: Molina Healthcare Managed Medicare	$72.53
Rate for Payer: Oscar Health of IA Commercial	$107.25
Rate for Payer: Partners Health Alliance Commercial	$107.25
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37
Rate for Payer: Wellmark IA HMO	$403.62
Rate for Payer: Wellmark IA PPO	$443.98

Ongoing

Facility

$143.00

Service Code	CPT 93668
Hospital Charge Code	8663517
Hospital Revenue Code	943
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$128.70

Ongoing - KX

Facility

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663516
Hospital Revenue Code	943
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$128.70

Ongoing - KX

Facility

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663516
Hospital Revenue Code	943
Min. Negotiated Rate	$71.47
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$72.17
Rate for Payer: Amerigroup Medicare	$72.22
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$71.50
Rate for Payer: Iowa Total Care Managed Medicaid	$71.47
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$71.50
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$72.57
Rate for Payer: Molina Healthcare Managed Medicare	$72.53
Rate for Payer: Oscar Health of IA Commercial	$107.25
Rate for Payer: Partners Health Alliance Commercial	$107.25
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37

Open treatment of distal fibular fracture (lateral malleolus), includes internal fixation, when performed

Facility

$9,670.76

Service Code	CPT 27792
Hospital Revenue Code	361
Min. Negotiated Rate	$8,791.60
Max. Negotiated Rate	$9,670.76
Rate for Payer: Wellmark IA HMO	$8,791.60
Rate for Payer: Wellmark IA PPO	$9,670.76

Open treatment of distal tibiofibular joint (syndesmosis) disruption, includes internal fixation, when performed

Facility

$9,670.76

Service Code	CPT 27829
Hospital Revenue Code	360
Min. Negotiated Rate	$8,791.60
Max. Negotiated Rate	$9,670.76
Rate for Payer: Wellmark IA HMO	$8,791.60
Rate for Payer: Wellmark IA PPO	$9,670.76

Open treatment of metatarsal fracture, includes internal fixation, when performed, each

Facility

$9,670.76

Service Code	CPT 28485
Hospital Revenue Code	360
Min. Negotiated Rate	$8,791.60
Max. Negotiated Rate	$9,670.76
Rate for Payer: Wellmark IA HMO	$8,791.60
Rate for Payer: Wellmark IA PPO	$9,670.76

Open treatment of talus fracture, includes internal fixation, when performed

Facility

$9,670.76

Service Code	CPT 28445
Hospital Revenue Code	360
Min. Negotiated Rate	$8,791.60
Max. Negotiated Rate	$9,670.76
Rate for Payer: Wellmark IA HMO	$8,791.60
Rate for Payer: Wellmark IA PPO	$9,670.76

Open treatment of trimalleolar ankle fracture, includes internal fixation, when performed, medial and/or lateral malleolus; without fixation of posterior lip

Facility

$9,670.76

Service Code	CPT 27822
Hospital Revenue Code	360
Min. Negotiated Rate	$8,791.60
Max. Negotiated Rate	$9,670.76
Rate for Payer: Wellmark IA HMO	$8,791.60
Rate for Payer: Wellmark IA PPO	$9,670.76

ophthalmic irrigation, extraocular - Sol [VDMC]

Facility

$29.52

Service Code	HCPCS A9270
Hospital Charge Code	11223386
Hospital Revenue Code	259
Min. Negotiated Rate	$14.75
Max. Negotiated Rate	$26.57
Rate for Payer: Aetna of IA Commercial	$26.57
Rate for Payer: Aetna of IA Medical Rental Products	$26.57
Rate for Payer: Aetna of IA Medicare	$16.83
Rate for Payer: Amerigroup Medicaid	$14.90
Rate for Payer: Amerigroup Medicare	$14.91
Rate for Payer: Cash Price	$23.61
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.14
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.76
Rate for Payer: Iowa Total Care Managed Medicaid	$14.75
Rate for Payer: Medical Associates Commercial	$22.14
Rate for Payer: Medical Associates Managed Medicare	$14.76
Rate for Payer: Midlands Choice Commercial	$20.66
Rate for Payer: Molina Healthcare Managed Medicaid	$14.98
Rate for Payer: Molina Healthcare Managed Medicare	$14.97
Rate for Payer: Oscar Health of IA Commercial	$22.14
Rate for Payer: Partners Health Alliance Commercial	$22.14
Rate for Payer: United Healthcare Commercial	$26.57
Rate for Payer: United Healthcare Managed Medicare	$17.42

ophthalmic irrigation, extraocular - Sol [VDMC]

Facility

$29.52

Service Code	HCPCS A9270
Hospital Charge Code	11223386
Hospital Revenue Code	259
Min. Negotiated Rate	$20.66
Max. Negotiated Rate	$26.57
Rate for Payer: Aetna of IA Commercial	$26.57
Rate for Payer: Aetna of IA Medical Rental Products	$26.57
Rate for Payer: Cash Price	$23.61
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.14
Rate for Payer: Medical Associates Commercial	$22.14
Rate for Payer: Midlands Choice Commercial	$20.66
Rate for Payer: United Healthcare Commercial	$26.57

Orbital Procedures With CC/MCC

Facility

$21,578.51

Service Code	MS-DRG 113
Hospital Charge Code	5
Min. Negotiated Rate	$21,265.78
Max. Negotiated Rate	$21,578.51
Rate for Payer: Amerigroup Medicaid	$21,474.26
Rate for Payer: Iowa Total Care Managed Medicaid	$21,265.78
Rate for Payer: Molina Healthcare Managed Medicaid	$21,578.51

Orbital Procedures Without CC/MCC

Facility

$11,527.44

Service Code	MS-DRG 114
Hospital Charge Code	6
Min. Negotiated Rate	$11,360.37
Max. Negotiated Rate	$11,527.44
Rate for Payer: Amerigroup Medicaid	$11,471.75
Rate for Payer: Iowa Total Care Managed Medicaid	$11,360.37
Rate for Payer: Molina Healthcare Managed Medicaid	$11,527.44

Organic Disturbances and Intellectual Disability

Facility

$6,661.34

Service Code	MS-DRG 884
Hospital Charge Code	614
Min. Negotiated Rate	$6,564.80
Max. Negotiated Rate	$6,661.34
Rate for Payer: Amerigroup Medicaid	$6,629.16
Rate for Payer: Iowa Total Care Managed Medicaid	$6,564.80
Rate for Payer: Molina Healthcare Managed Medicaid	$6,661.34

orphenadrine citrate 60 mg/2ml soln [VDMC]

Facility

$32.40

Service Code	HCPCS J2360
Hospital Charge Code	10429845
Hospital Revenue Code	259
Min. Negotiated Rate	$16.19
Max. Negotiated Rate	$29.16
Rate for Payer: Aetna of IA Commercial	$29.16
Rate for Payer: Aetna of IA Medical Rental Products	$29.16
Rate for Payer: Aetna of IA Medicare	$18.47
Rate for Payer: Amerigroup Medicaid	$16.35
Rate for Payer: Amerigroup Medicare	$16.36
Rate for Payer: Cash Price	$25.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.30
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$16.20
Rate for Payer: Iowa Total Care Managed Medicaid	$16.19
Rate for Payer: Medical Associates Commercial	$24.30
Rate for Payer: Medical Associates Managed Medicare	$16.20
Rate for Payer: Midlands Choice Commercial	$22.68
Rate for Payer: Molina Healthcare Managed Medicaid	$16.44
Rate for Payer: Molina Healthcare Managed Medicare	$16.43
Rate for Payer: Oscar Health of IA Commercial	$24.30
Rate for Payer: Partners Health Alliance Commercial	$24.30
Rate for Payer: United Healthcare Commercial	$29.16
Rate for Payer: United Healthcare Managed Medicare	$19.12

orphenadrine citrate 60 mg/2ml soln [VDMC]

Facility

$32.40

Service Code	HCPCS J2360
Hospital Charge Code	10429845
Hospital Revenue Code	259
Min. Negotiated Rate	$22.68
Max. Negotiated Rate	$29.16
Rate for Payer: Aetna of IA Commercial	$29.16
Rate for Payer: Aetna of IA Medical Rental Products	$29.16
Rate for Payer: Cash Price	$25.92
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.30
Rate for Payer: Medical Associates Commercial	$24.30
Rate for Payer: Midlands Choice Commercial	$22.68
Rate for Payer: United Healthcare Commercial	$29.16

O.R. Procedures for Obesity With CC

Facility

$14,555.95

Service Code	MS-DRG 620
Hospital Charge Code	412
Min. Negotiated Rate	$14,344.99
Max. Negotiated Rate	$14,555.95
Rate for Payer: Amerigroup Medicaid	$14,485.63
Rate for Payer: Iowa Total Care Managed Medicaid	$14,344.99
Rate for Payer: Molina Healthcare Managed Medicaid	$14,555.95

O.R. Procedures for Obesity With MCC

Facility

$24,824.54

Service Code	MS-DRG 619
Hospital Charge Code	411
Min. Negotiated Rate	$24,464.76
Max. Negotiated Rate	$24,824.54
Rate for Payer: Amerigroup Medicaid	$24,704.61
Rate for Payer: Iowa Total Care Managed Medicaid	$24,464.76
Rate for Payer: Molina Healthcare Managed Medicaid	$24,824.54

O.R. Procedures for Obesity Without CC/MCC

Facility

$14,051.04

Service Code	MS-DRG 621
Hospital Charge Code	413
Min. Negotiated Rate	$13,847.40
Max. Negotiated Rate	$14,051.04
Rate for Payer: Amerigroup Medicaid	$13,983.16
Rate for Payer: Iowa Total Care Managed Medicaid	$13,847.40
Rate for Payer: Molina Healthcare Managed Medicaid	$14,051.04

O.R. Procedures With Diagnoses of Other Contact With Health Services With CC

Facility

$10,476.27

Service Code	MS-DRG 940
Hospital Charge Code	649
Min. Negotiated Rate	$10,324.44
Max. Negotiated Rate	$10,476.27
Rate for Payer: Amerigroup Medicaid	$10,425.66
Rate for Payer: Iowa Total Care Managed Medicaid	$10,324.44
Rate for Payer: Molina Healthcare Managed Medicaid	$10,476.27

O.R. Procedures With Diagnoses of Other Contact With Health Services With MCC

Facility

$33,337.25

Service Code	MS-DRG 939
Hospital Charge Code	648
Min. Negotiated Rate	$32,854.10
Max. Negotiated Rate	$33,337.25
Rate for Payer: Amerigroup Medicaid	$33,176.20
Rate for Payer: Iowa Total Care Managed Medicaid	$32,854.10
Rate for Payer: Molina Healthcare Managed Medicaid	$33,337.25

Know your out-of-pocket cost for care.

All Charges