Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab[VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	11361372
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: United Healthcare Commercial	$1.00

multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab[VDMC]

Facility

$1.11

Service Code	HCPCS A9270
Hospital Charge Code	11361372
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Aetna of IA Medicare	$0.63
Rate for Payer: Amerigroup Medicaid	$0.64
Rate for Payer: Amerigroup Medicare	$0.51
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.50
Rate for Payer: Iowa Total Care Managed Medicaid	$0.64
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Medical Associates Managed Medicare	$0.50
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: Molina Healthcare Managed Medicaid	$0.64
Rate for Payer: Partners Health Alliance Commercial	$0.58
Rate for Payer: United Healthcare Commercial	$1.00
Rate for Payer: United Healthcare Managed Medicare	$0.66

Mumps Virus IgG Antibody DMCL

Facility

$124.00

Service Code	CPT 86735
Hospital Charge Code	8037744
Hospital Revenue Code	302
Min. Negotiated Rate	$86.80
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of IA Commercial	$111.60
Rate for Payer: Aetna of IA Medical Rental Products	$111.60
Rate for Payer: Cash Price	$99.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.00
Rate for Payer: Medical Associates Commercial	$93.00
Rate for Payer: Midlands Choice Commercial	$86.80
Rate for Payer: United Healthcare Commercial	$111.60

Mumps Virus IgG Antibody DMCL

Facility

$124.00

Service Code	CPT 86735
Hospital Charge Code	8037744
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$111.60
Rate for Payer: Aetna of IA Commercial	$111.60
Rate for Payer: Aetna of IA Medical Rental Products	$111.60
Rate for Payer: Aetna of IA Medicare	$70.68
Rate for Payer: Amerigroup Medicaid	$71.52
Rate for Payer: Amerigroup Medicare	$56.36
Rate for Payer: Cash Price	$99.20
Rate for Payer: Cash Price	$99.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.80
Rate for Payer: Iowa Total Care Managed Medicaid	$70.83
Rate for Payer: Medical Associates Commercial	$93.00
Rate for Payer: Medical Associates Managed Medicare	$55.80
Rate for Payer: Midlands Choice Commercial	$86.80
Rate for Payer: Molina Healthcare Managed Medicaid	$71.87
Rate for Payer: Partners Health Alliance Commercial	$64.17
Rate for Payer: United Healthcare Commercial	$111.60
Rate for Payer: United Healthcare Managed Medicare	$73.16
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

MUPIROCIN 2% OINTMENT

Facility

$41.00

Hospital Charge Code	8013713
Hospital Revenue Code	637
Min. Negotiated Rate	$18.45
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of IA Commercial	$36.90
Rate for Payer: Aetna of IA Medical Rental Products	$36.90
Rate for Payer: Aetna of IA Medicare	$23.37
Rate for Payer: Amerigroup Medicaid	$23.65
Rate for Payer: Amerigroup Medicare	$18.63
Rate for Payer: Cash Price	$32.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.45
Rate for Payer: Iowa Total Care Managed Medicaid	$23.42
Rate for Payer: Medical Associates Commercial	$30.75
Rate for Payer: Medical Associates Managed Medicare	$18.45
Rate for Payer: Midlands Choice Commercial	$28.70
Rate for Payer: Molina Healthcare Managed Medicaid	$23.76
Rate for Payer: Partners Health Alliance Commercial	$21.22
Rate for Payer: United Healthcare Commercial	$36.90
Rate for Payer: United Healthcare Managed Medicare	$24.19

MUPIROCIN 2% OINTMENT

Facility

$41.00

Hospital Charge Code	8013713
Hospital Revenue Code	637
Min. Negotiated Rate	$28.70
Max. Negotiated Rate	$36.90
Rate for Payer: Aetna of IA Commercial	$36.90
Rate for Payer: Aetna of IA Medical Rental Products	$36.90
Rate for Payer: Cash Price	$32.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$30.75
Rate for Payer: Medical Associates Commercial	$30.75
Rate for Payer: Midlands Choice Commercial	$28.70
Rate for Payer: United Healthcare Commercial	$36.90

mupirocin Top 2% Oint [VDMC]

Facility

$31.96

Service Code	HCPCS A9270
Hospital Charge Code	10436449
Hospital Revenue Code	259
Min. Negotiated Rate	$14.38
Max. Negotiated Rate	$28.76
Rate for Payer: Aetna of IA Commercial	$28.76
Rate for Payer: Aetna of IA Medical Rental Products	$28.76
Rate for Payer: Aetna of IA Medicare	$18.22
Rate for Payer: Amerigroup Medicaid	$18.43
Rate for Payer: Amerigroup Medicare	$14.53
Rate for Payer: Cash Price	$25.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.97
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.38
Rate for Payer: Iowa Total Care Managed Medicaid	$18.26
Rate for Payer: Medical Associates Commercial	$23.97
Rate for Payer: Medical Associates Managed Medicare	$14.38
Rate for Payer: Midlands Choice Commercial	$22.37
Rate for Payer: Molina Healthcare Managed Medicaid	$18.52
Rate for Payer: Partners Health Alliance Commercial	$16.54
Rate for Payer: United Healthcare Commercial	$28.76
Rate for Payer: United Healthcare Managed Medicare	$18.86

mupirocin Top 2% Oint [VDMC]

Facility

$31.96

Service Code	HCPCS A9270
Hospital Charge Code	10436449
Hospital Revenue Code	259
Min. Negotiated Rate	$22.37
Max. Negotiated Rate	$28.76
Rate for Payer: Aetna of IA Commercial	$28.76
Rate for Payer: Aetna of IA Medical Rental Products	$28.76
Rate for Payer: Cash Price	$25.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.97
Rate for Payer: Medical Associates Commercial	$23.97
Rate for Payer: Midlands Choice Commercial	$22.37
Rate for Payer: United Healthcare Commercial	$28.76

mycophenolate mofetil 250 mg Cap [VDMC]

Facility

$2.45

Service Code	HCPCS A9270
Hospital Charge Code	10407718
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$2.20
Rate for Payer: Aetna of IA Commercial	$2.20
Rate for Payer: Aetna of IA Medical Rental Products	$2.20
Rate for Payer: Cash Price	$1.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.84
Rate for Payer: Medical Associates Commercial	$1.84
Rate for Payer: Midlands Choice Commercial	$1.71
Rate for Payer: United Healthcare Commercial	$2.20

mycophenolate mofetil 250 mg Cap [VDMC]

Facility

$2.45

Service Code	HCPCS A9270
Hospital Charge Code	10407718
Hospital Revenue Code	259
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$2.20
Rate for Payer: Aetna of IA Commercial	$2.20
Rate for Payer: Aetna of IA Medical Rental Products	$2.20
Rate for Payer: Aetna of IA Medicare	$1.39
Rate for Payer: Amerigroup Medicaid	$1.41
Rate for Payer: Amerigroup Medicare	$1.11
Rate for Payer: Cash Price	$1.96
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.84
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.10
Rate for Payer: Iowa Total Care Managed Medicaid	$1.40
Rate for Payer: Medical Associates Commercial	$1.84
Rate for Payer: Medical Associates Managed Medicare	$1.10
Rate for Payer: Midlands Choice Commercial	$1.71
Rate for Payer: Molina Healthcare Managed Medicaid	$1.42
Rate for Payer: Partners Health Alliance Commercial	$1.27
Rate for Payer: United Healthcare Commercial	$2.20
Rate for Payer: United Healthcare Managed Medicare	$1.44

Mycoplasma Pneumonia antibody

Facility

$114.00

Service Code	CPT 86738
Hospital Charge Code	4108792
Hospital Revenue Code	302
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

Mycoplasma Pneumonia antibody

Facility

$114.00

Service Code	CPT 86738
Hospital Charge Code	4108792
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$59.00
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC

Facility

$23,553.19

Service Code	MSDRG 827
Min. Negotiated Rate	$23,211.83
Max. Negotiated Rate	$23,553.19
Rate for Payer: Amerigroup Medicaid	$23,439.39
Rate for Payer: Iowa Total Care Managed Medicaid	$23,211.83
Rate for Payer: Molina Healthcare Managed Medicaid	$23,553.19

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC

Facility

$56,727.85

Service Code	MSDRG 826
Min. Negotiated Rate	$55,905.68
Max. Negotiated Rate	$56,727.85
Rate for Payer: Amerigroup Medicaid	$56,453.77
Rate for Payer: Iowa Total Care Managed Medicaid	$55,905.68
Rate for Payer: Molina Healthcare Managed Medicaid	$56,727.85

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC

Facility

$15,881.91

Service Code	MSDRG 828
Min. Negotiated Rate	$15,651.73
Max. Negotiated Rate	$15,881.91
Rate for Payer: Amerigroup Medicaid	$15,805.17
Rate for Payer: Iowa Total Care Managed Medicaid	$15,651.73
Rate for Payer: Molina Healthcare Managed Medicaid	$15,881.91

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC

Facility

$22,661.41

Service Code	MSDRG 829
Min. Negotiated Rate	$22,332.98
Max. Negotiated Rate	$22,661.41
Rate for Payer: Amerigroup Medicaid	$22,551.93
Rate for Payer: Iowa Total Care Managed Medicaid	$22,332.98
Rate for Payer: Molina Healthcare Managed Medicaid	$22,661.41

MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC

Facility

$15,815.47

Service Code	MSDRG 830
Min. Negotiated Rate	$15,586.26
Max. Negotiated Rate	$15,815.47
Rate for Payer: Amerigroup Medicaid	$15,739.06
Rate for Payer: Iowa Total Care Managed Medicaid	$15,586.26
Rate for Payer: Molina Healthcare Managed Medicaid	$15,815.47

nabumetone 500 mg Tab [VDMC]

Facility

$1.34

Service Code	HCPCS A9270
Hospital Charge Code	10407789
Hospital Revenue Code	259
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Aetna of IA Medicare	$0.76
Rate for Payer: Amerigroup Medicaid	$0.77
Rate for Payer: Amerigroup Medicare	$0.61
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.60
Rate for Payer: Iowa Total Care Managed Medicaid	$0.76
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Medical Associates Managed Medicare	$0.60
Rate for Payer: Midlands Choice Commercial	$0.94
Rate for Payer: Molina Healthcare Managed Medicaid	$0.77
Rate for Payer: Partners Health Alliance Commercial	$0.69
Rate for Payer: United Healthcare Commercial	$1.20
Rate for Payer: United Healthcare Managed Medicare	$0.79

nabumetone 500 mg Tab [VDMC]

Facility

$1.34

Service Code	HCPCS A9270
Hospital Charge Code	10407789
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Midlands Choice Commercial	$0.94
Rate for Payer: United Healthcare Commercial	$1.20

naloxone 0.4 mg/mL 1 ml Inj Sol [VDMC]

Facility

$30.67

Service Code	HCPCS J2310
Hospital Charge Code	10408193
Hospital Revenue Code	259
Min. Negotiated Rate	$21.47
Max. Negotiated Rate	$27.60
Rate for Payer: Aetna of IA Commercial	$27.60
Rate for Payer: Aetna of IA Medical Rental Products	$27.60
Rate for Payer: Cash Price	$24.54
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.00
Rate for Payer: Medical Associates Commercial	$23.00
Rate for Payer: Midlands Choice Commercial	$21.47
Rate for Payer: United Healthcare Commercial	$27.60

naloxone 0.4 mg/mL 1 ml Inj Sol [VDMC]

Facility

$30.67

Service Code	HCPCS J2310
Hospital Charge Code	10408193
Hospital Revenue Code	259
Min. Negotiated Rate	$13.80
Max. Negotiated Rate	$27.60
Rate for Payer: Aetna of IA Commercial	$27.60
Rate for Payer: Aetna of IA Medical Rental Products	$27.60
Rate for Payer: Aetna of IA Medicare	$17.48
Rate for Payer: Amerigroup Medicaid	$17.69
Rate for Payer: Amerigroup Medicare	$13.94
Rate for Payer: Cash Price	$24.54
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.80
Rate for Payer: Iowa Total Care Managed Medicaid	$17.52
Rate for Payer: Medical Associates Commercial	$23.00
Rate for Payer: Medical Associates Managed Medicare	$13.80
Rate for Payer: Midlands Choice Commercial	$21.47
Rate for Payer: Molina Healthcare Managed Medicaid	$17.78
Rate for Payer: Partners Health Alliance Commercial	$15.87
Rate for Payer: United Healthcare Commercial	$27.60
Rate for Payer: United Healthcare Managed Medicare	$18.10

naloxone 1 mg/mL Inj Sol [VDMC]

Facility

$141.42

Service Code	HCPCS J2310
Hospital Charge Code	10408262
Hospital Revenue Code	259
Min. Negotiated Rate	$63.64
Max. Negotiated Rate	$127.27
Rate for Payer: Aetna of IA Commercial	$127.27
Rate for Payer: Aetna of IA Medical Rental Products	$127.27
Rate for Payer: Aetna of IA Medicare	$80.61
Rate for Payer: Amerigroup Medicaid	$81.57
Rate for Payer: Amerigroup Medicare	$64.27
Rate for Payer: Cash Price	$113.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$106.06
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$63.64
Rate for Payer: Iowa Total Care Managed Medicaid	$80.78
Rate for Payer: Medical Associates Commercial	$106.06
Rate for Payer: Medical Associates Managed Medicare	$63.64
Rate for Payer: Midlands Choice Commercial	$98.99
Rate for Payer: Molina Healthcare Managed Medicaid	$81.96
Rate for Payer: Partners Health Alliance Commercial	$73.18
Rate for Payer: United Healthcare Commercial	$127.27
Rate for Payer: United Healthcare Managed Medicare	$83.44

naloxone 1 mg/mL Inj Sol [VDMC]

Facility

$141.42

Service Code	HCPCS J2310
Hospital Charge Code	10408262
Hospital Revenue Code	259
Min. Negotiated Rate	$98.99
Max. Negotiated Rate	$127.27
Rate for Payer: Aetna of IA Commercial	$127.27
Rate for Payer: Aetna of IA Medical Rental Products	$127.27
Rate for Payer: Cash Price	$113.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$106.06
Rate for Payer: Medical Associates Commercial	$106.06
Rate for Payer: Midlands Choice Commercial	$98.99
Rate for Payer: United Healthcare Commercial	$127.27

naltrexone 50 mg Tab[VDMC]

Facility

$9.55

Service Code	HCPCS A9270
Hospital Charge Code	11391896
Hospital Revenue Code	259
Min. Negotiated Rate	$4.30
Max. Negotiated Rate	$8.60
Rate for Payer: Aetna of IA Commercial	$8.60
Rate for Payer: Aetna of IA Medical Rental Products	$8.60
Rate for Payer: Aetna of IA Medicare	$5.44
Rate for Payer: Amerigroup Medicaid	$5.51
Rate for Payer: Amerigroup Medicare	$4.34
Rate for Payer: Cash Price	$7.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.30
Rate for Payer: Iowa Total Care Managed Medicaid	$5.46
Rate for Payer: Medical Associates Commercial	$7.16
Rate for Payer: Medical Associates Managed Medicare	$4.30
Rate for Payer: Midlands Choice Commercial	$6.69
Rate for Payer: Molina Healthcare Managed Medicaid	$5.54
Rate for Payer: Partners Health Alliance Commercial	$4.94
Rate for Payer: United Healthcare Commercial	$8.60
Rate for Payer: United Healthcare Managed Medicare	$5.64

naltrexone 50 mg Tab[VDMC]

Facility

$9.55

Service Code	HCPCS A9270
Hospital Charge Code	11391896
Hospital Revenue Code	259
Min. Negotiated Rate	$6.69
Max. Negotiated Rate	$8.60
Rate for Payer: Aetna of IA Commercial	$8.60
Rate for Payer: Aetna of IA Medical Rental Products	$8.60
Rate for Payer: Cash Price	$7.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.16
Rate for Payer: Medical Associates Commercial	$7.16
Rate for Payer: Midlands Choice Commercial	$6.69
Rate for Payer: United Healthcare Commercial	$8.60

Know your out-of-pocket cost for care.

All Charges