Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PEGGED GLENOID POLY W/PEG SMALL

Facility

$2,835.00

Service Code	CPT C1776
Hospital Charge Code	8047275
Hospital Revenue Code	278
Min. Negotiated Rate	$1,416.93
Max. Negotiated Rate	$2,551.50
Rate for Payer: Aetna of IA Commercial	$2,551.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,551.50
Rate for Payer: Aetna of IA Medicare	$1,615.95
Rate for Payer: Amerigroup Medicaid	$1,430.82
Rate for Payer: Amerigroup Medicare	$1,431.68
Rate for Payer: Cash Price	$2,268.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,126.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,417.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,416.93
Rate for Payer: Medical Associates Commercial	$2,126.25
Rate for Payer: Medical Associates Managed Medicare	$1,417.50
Rate for Payer: Midlands Choice Commercial	$1,984.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,438.76
Rate for Payer: Molina Healthcare Managed Medicare	$1,437.91
Rate for Payer: Oscar Health of IA Commercial	$2,126.25
Rate for Payer: Partners Health Alliance Commercial	$2,126.25
Rate for Payer: United Healthcare Commercial	$2,551.50
Rate for Payer: United Healthcare Managed Medicare	$1,672.65

Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy With CC/MCC

Facility

$16,834.47

Service Code	MS-DRG 734
Hospital Charge Code	495
Min. Negotiated Rate	$16,590.49
Max. Negotiated Rate	$16,834.47
Rate for Payer: Amerigroup Medicaid	$16,753.15
Rate for Payer: Iowa Total Care Managed Medicaid	$16,590.49
Rate for Payer: Molina Healthcare Managed Medicaid	$16,834.47

Pelvic Evisceration, Radical Hysterectomy and Radical Vulvectomy Without CC/MCC

Facility

$16,294.12

Service Code	MS-DRG 735
Hospital Charge Code	496
Min. Negotiated Rate	$16,057.97
Max. Negotiated Rate	$16,294.12
Rate for Payer: Amerigroup Medicaid	$16,215.40
Rate for Payer: Iowa Total Care Managed Medicaid	$16,057.97
Rate for Payer: Molina Healthcare Managed Medicaid	$16,294.12

pembrolizumab 100mg/4ml SDV [VDMC]

Facility

$20,184.72

Service Code	HCPCS J9271
Hospital Charge Code	21395441
Hospital Revenue Code	259
Min. Negotiated Rate	$10,088.32
Max. Negotiated Rate	$18,166.25
Rate for Payer: Aetna of IA Commercial	$18,166.25
Rate for Payer: Aetna of IA Medical Rental Products	$18,166.25
Rate for Payer: Aetna of IA Medicare	$11,505.29
Rate for Payer: Amerigroup Medicaid	$10,187.23
Rate for Payer: Amerigroup Medicare	$10,193.28
Rate for Payer: Cash Price	$16,147.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$15,138.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10,092.36
Rate for Payer: Iowa Total Care Managed Medicaid	$10,088.32
Rate for Payer: Medical Associates Commercial	$15,138.54
Rate for Payer: Medical Associates Managed Medicare	$10,092.36
Rate for Payer: Midlands Choice Commercial	$14,129.30
Rate for Payer: Molina Healthcare Managed Medicaid	$10,243.75
Rate for Payer: Molina Healthcare Managed Medicare	$10,237.69
Rate for Payer: Oscar Health of IA Commercial	$15,138.54
Rate for Payer: Partners Health Alliance Commercial	$15,138.54
Rate for Payer: United Healthcare Commercial	$18,166.25
Rate for Payer: United Healthcare Managed Medicare	$11,908.98

pembrolizumab 100mg/4ml SDV [VDMC]

Facility

$20,184.72

Service Code	HCPCS J9271
Hospital Charge Code	21395441
Hospital Revenue Code	259
Min. Negotiated Rate	$14,129.30
Max. Negotiated Rate	$18,166.25
Rate for Payer: Aetna of IA Commercial	$18,166.25
Rate for Payer: Aetna of IA Medical Rental Products	$18,166.25
Rate for Payer: Cash Price	$16,147.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$15,138.54
Rate for Payer: Medical Associates Commercial	$15,138.54
Rate for Payer: Midlands Choice Commercial	$14,129.30
Rate for Payer: United Healthcare Commercial	$18,166.25

penicillin G benzathine 1,200,000 units/2 mL SDS Sus [VDMC]

Facility

$1,073.50

Service Code	HCPCS J0561
Hospital Charge Code	10432035
Hospital Revenue Code	259
Min. Negotiated Rate	$751.45
Max. Negotiated Rate	$966.15
Rate for Payer: Aetna of IA Commercial	$966.15
Rate for Payer: Aetna of IA Medical Rental Products	$966.15
Rate for Payer: Cash Price	$858.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$805.12
Rate for Payer: Medical Associates Commercial	$805.12
Rate for Payer: Midlands Choice Commercial	$751.45
Rate for Payer: United Healthcare Commercial	$966.15

penicillin G benzathine 1,200,000 units/2 mL SDS Sus [VDMC]

Facility

$1,073.50

Service Code	HCPCS J0561
Hospital Charge Code	10432035
Hospital Revenue Code	259
Min. Negotiated Rate	$536.54
Max. Negotiated Rate	$966.15
Rate for Payer: Aetna of IA Commercial	$966.15
Rate for Payer: Aetna of IA Medical Rental Products	$966.15
Rate for Payer: Aetna of IA Medicare	$611.90
Rate for Payer: Amerigroup Medicaid	$541.80
Rate for Payer: Amerigroup Medicare	$542.12
Rate for Payer: Cash Price	$858.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$805.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$536.75
Rate for Payer: Iowa Total Care Managed Medicaid	$536.54
Rate for Payer: Medical Associates Commercial	$805.12
Rate for Payer: Medical Associates Managed Medicare	$536.75
Rate for Payer: Midlands Choice Commercial	$751.45
Rate for Payer: Molina Healthcare Managed Medicaid	$544.80
Rate for Payer: Molina Healthcare Managed Medicare	$544.48
Rate for Payer: Oscar Health of IA Commercial	$805.12
Rate for Payer: Partners Health Alliance Commercial	$805.12
Rate for Payer: United Healthcare Commercial	$966.15
Rate for Payer: United Healthcare Managed Medicare	$633.36

Penicillin G Potassium 5,000,000 units Pow [VDMC]

Facility

$34.89

Service Code	HCPCS J2540
Hospital Charge Code	24421694
Hospital Revenue Code	259
Min. Negotiated Rate	$24.42
Max. Negotiated Rate	$31.40
Rate for Payer: Aetna of IA Commercial	$31.40
Rate for Payer: Aetna of IA Medical Rental Products	$31.40
Rate for Payer: Cash Price	$27.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.17
Rate for Payer: Medical Associates Commercial	$26.17
Rate for Payer: Midlands Choice Commercial	$24.42
Rate for Payer: United Healthcare Commercial	$31.40

Penicillin G Potassium 5,000,000 units Pow [VDMC]

Facility

$34.89

Service Code	HCPCS J2540
Hospital Charge Code	24421694
Hospital Revenue Code	259
Min. Negotiated Rate	$17.44
Max. Negotiated Rate	$31.40
Rate for Payer: Aetna of IA Commercial	$31.40
Rate for Payer: Aetna of IA Medical Rental Products	$31.40
Rate for Payer: Aetna of IA Medicare	$19.89
Rate for Payer: Amerigroup Medicaid	$17.61
Rate for Payer: Amerigroup Medicare	$17.62
Rate for Payer: Cash Price	$27.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$26.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$17.44
Rate for Payer: Iowa Total Care Managed Medicaid	$17.44
Rate for Payer: Medical Associates Commercial	$26.17
Rate for Payer: Medical Associates Managed Medicare	$17.44
Rate for Payer: Midlands Choice Commercial	$24.42
Rate for Payer: Molina Healthcare Managed Medicaid	$17.71
Rate for Payer: Molina Healthcare Managed Medicare	$17.70
Rate for Payer: Oscar Health of IA Commercial	$26.17
Rate for Payer: Partners Health Alliance Commercial	$26.17
Rate for Payer: United Healthcare Commercial	$31.40
Rate for Payer: United Healthcare Managed Medicare	$20.59

Penicillin V Potassium 250mg Tab [VDMC]

Facility

$1.27

Service Code	HCPCS A9270
Hospital Charge Code	24496674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of IA Commercial	$1.14
Rate for Payer: Aetna of IA Medical Rental Products	$1.14
Rate for Payer: Aetna of IA Medicare	$0.72
Rate for Payer: Amerigroup Medicaid	$0.64
Rate for Payer: Amerigroup Medicare	$0.64
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.63
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$0.89
Rate for Payer: Molina Healthcare Managed Medicaid	$0.64
Rate for Payer: Molina Healthcare Managed Medicare	$0.64
Rate for Payer: Oscar Health of IA Commercial	$0.95
Rate for Payer: Partners Health Alliance Commercial	$0.95
Rate for Payer: United Healthcare Commercial	$1.14
Rate for Payer: United Healthcare Managed Medicare	$0.75

Penicillin V Potassium 250mg Tab [VDMC]

Facility

$1.27

Service Code	HCPCS A9270
Hospital Charge Code	24496674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of IA Commercial	$1.14
Rate for Payer: Aetna of IA Medical Rental Products	$1.14
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.95
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Midlands Choice Commercial	$0.89
Rate for Payer: United Healthcare Commercial	$1.14

Penis Procedures With CC/MCC

Facility

$22,760.58

Service Code	MS-DRG 709
Hospital Charge Code	476
Min. Negotiated Rate	$22,430.72
Max. Negotiated Rate	$22,760.58
Rate for Payer: Amerigroup Medicaid	$22,650.63
Rate for Payer: Iowa Total Care Managed Medicaid	$22,430.72
Rate for Payer: Molina Healthcare Managed Medicaid	$22,760.58

Penis Procedures Without CC/MCC

Facility

$10,846.34

Service Code	MS-DRG 710
Hospital Charge Code	477
Min. Negotiated Rate	$10,689.15
Max. Negotiated Rate	$10,846.34
Rate for Payer: Amerigroup Medicaid	$10,793.95
Rate for Payer: Iowa Total Care Managed Medicaid	$10,689.15
Rate for Payer: Molina Healthcare Managed Medicaid	$10,846.34

pentoxifylline 400 mg ER Tab [VDMC]

Facility

$1.61

Service Code	HCPCS A9270
Hospital Charge Code	10412466
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of IA Commercial	$1.45
Rate for Payer: Aetna of IA Medical Rental Products	$1.45
Rate for Payer: Cash Price	$1.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.21
Rate for Payer: Medical Associates Commercial	$1.21
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: United Healthcare Commercial	$1.45

pentoxifylline 400 mg ER Tab [VDMC]

Facility

$1.61

Service Code	HCPCS A9270
Hospital Charge Code	10412466
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.45
Rate for Payer: Aetna of IA Commercial	$1.45
Rate for Payer: Aetna of IA Medical Rental Products	$1.45
Rate for Payer: Aetna of IA Medicare	$0.92
Rate for Payer: Amerigroup Medicaid	$0.81
Rate for Payer: Amerigroup Medicare	$0.81
Rate for Payer: Cash Price	$1.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.21
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.81
Rate for Payer: Iowa Total Care Managed Medicaid	$0.80
Rate for Payer: Medical Associates Commercial	$1.21
Rate for Payer: Medical Associates Managed Medicare	$0.81
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: Molina Healthcare Managed Medicaid	$0.82
Rate for Payer: Molina Healthcare Managed Medicare	$0.82
Rate for Payer: Oscar Health of IA Commercial	$1.21
Rate for Payer: Partners Health Alliance Commercial	$1.21
Rate for Payer: United Healthcare Commercial	$1.45
Rate for Payer: United Healthcare Managed Medicare	$0.95

peramivir 200mg/20ml inj [VDMC]

Facility

$1,286.67

Service Code	HCPCS C9451
Hospital Charge Code	10429912
Hospital Revenue Code	636
Min. Negotiated Rate	$643.08
Max. Negotiated Rate	$1,158.00
Rate for Payer: Aetna of IA Commercial	$1,158.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,158.00
Rate for Payer: Aetna of IA Medicare	$733.40
Rate for Payer: Amerigroup Medicaid	$649.38
Rate for Payer: Amerigroup Medicare	$649.77
Rate for Payer: Cash Price	$1,029.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$965.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$643.34
Rate for Payer: Iowa Total Care Managed Medicaid	$643.08
Rate for Payer: Medical Associates Commercial	$965.00
Rate for Payer: Medical Associates Managed Medicare	$643.34
Rate for Payer: Midlands Choice Commercial	$900.67
Rate for Payer: Molina Healthcare Managed Medicaid	$652.99
Rate for Payer: Molina Healthcare Managed Medicare	$652.60
Rate for Payer: Oscar Health of IA Commercial	$965.00
Rate for Payer: Partners Health Alliance Commercial	$965.00
Rate for Payer: United Healthcare Commercial	$1,158.00
Rate for Payer: United Healthcare Managed Medicare	$759.14

peramivir 200mg/20ml inj [VDMC]

Facility

$1,286.67

Service Code	HCPCS C9451
Hospital Charge Code	10429912
Hospital Revenue Code	636
Min. Negotiated Rate	$900.67
Max. Negotiated Rate	$1,158.00
Rate for Payer: Aetna of IA Commercial	$1,158.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,158.00
Rate for Payer: Cash Price	$1,029.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$965.00
Rate for Payer: Medical Associates Commercial	$965.00
Rate for Payer: Midlands Choice Commercial	$900.67
Rate for Payer: United Healthcare Commercial	$1,158.00

peramivir 20 mg/mL 20ml SDV Sol [VDMC]

Facility

$1,286.67

Service Code	HCPCS J2547
Hospital Charge Code	11360552
Hospital Revenue Code	259
Min. Negotiated Rate	$900.67
Max. Negotiated Rate	$1,158.00
Rate for Payer: Aetna of IA Commercial	$1,158.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,158.00
Rate for Payer: Cash Price	$1,029.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$965.00
Rate for Payer: Medical Associates Commercial	$965.00
Rate for Payer: Midlands Choice Commercial	$900.67
Rate for Payer: United Healthcare Commercial	$1,158.00

peramivir 20 mg/mL 20ml SDV Sol [VDMC]

Facility

$1,286.67

Service Code	HCPCS J2547
Hospital Charge Code	11360552
Hospital Revenue Code	259
Min. Negotiated Rate	$643.08
Max. Negotiated Rate	$1,158.00
Rate for Payer: Aetna of IA Commercial	$1,158.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,158.00
Rate for Payer: Aetna of IA Medicare	$733.40
Rate for Payer: Amerigroup Medicaid	$649.38
Rate for Payer: Amerigroup Medicare	$649.77
Rate for Payer: Cash Price	$1,029.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$965.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$643.34
Rate for Payer: Iowa Total Care Managed Medicaid	$643.08
Rate for Payer: Medical Associates Commercial	$965.00
Rate for Payer: Medical Associates Managed Medicare	$643.34
Rate for Payer: Midlands Choice Commercial	$900.67
Rate for Payer: Molina Healthcare Managed Medicaid	$652.99
Rate for Payer: Molina Healthcare Managed Medicare	$652.60
Rate for Payer: Oscar Health of IA Commercial	$965.00
Rate for Payer: Partners Health Alliance Commercial	$965.00
Rate for Payer: United Healthcare Commercial	$1,158.00
Rate for Payer: United Healthcare Managed Medicare	$759.14

PERC IMPL NS ELECTRODE ARRAY EPIDURAL

Professional

Both

$4,343.00

Service Code	CPT 63650
Hospital Charge Code	8015898
Hospital Revenue Code	975
Min. Negotiated Rate	$379.43
Max. Negotiated Rate	$744.40
Rate for Payer: Aetna of IA Medicare	$379.43
Rate for Payer: Amerigroup Medicaid	$392.33
Rate for Payer: Cash Price	$3,474.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$455.32
Rate for Payer: Iowa Total Care Managed Medicaid	$387.02
Rate for Payer: Medical Associates Commercial	$720.92
Rate for Payer: Medical Associates Managed Medicare	$379.43
Rate for Payer: Midlands Choice Commercial	$744.40
Rate for Payer: Oscar Health of IA Commercial	$656.41
Rate for Payer: Partners Health Alliance Commercial	$569.14

Percutaneous and Other Intracardiac Procedures With MCC

Facility

$25,056.82

Service Code	MS-DRG 273
Hospital Charge Code	135
Min. Negotiated Rate	$24,693.68
Max. Negotiated Rate	$25,056.82
Rate for Payer: Amerigroup Medicaid	$24,935.77
Rate for Payer: Iowa Total Care Managed Medicaid	$24,693.68
Rate for Payer: Molina Healthcare Managed Medicaid	$25,056.82

Percutaneous and Other Intracardiac Procedures Without MCC

Facility

$25,056.82

Service Code	MS-DRG 274
Hospital Charge Code	136
Min. Negotiated Rate	$24,693.68
Max. Negotiated Rate	$25,056.82
Rate for Payer: Amerigroup Medicaid	$24,935.77
Rate for Payer: Iowa Total Care Managed Medicaid	$24,693.68
Rate for Payer: Molina Healthcare Managed Medicaid	$25,056.82

Percutaneous Cardiovascular Procedures With Drug-eluting Stent With MCC or 4+ Arteries or Stents

Facility

$25,214.30

Service Code	MS-DRG 246
Hospital Charge Code	108
Min. Negotiated Rate	$24,848.87
Max. Negotiated Rate	$25,214.30
Rate for Payer: Amerigroup Medicaid	$25,092.49
Rate for Payer: Iowa Total Care Managed Medicaid	$24,848.87
Rate for Payer: Molina Healthcare Managed Medicaid	$25,214.30

Percutaneous Cardiovascular Procedures With Drug-eluting Stent Without MCC

Facility

$16,680.93

Service Code	MS-DRG 247
Hospital Charge Code	109
Min. Negotiated Rate	$16,439.18
Max. Negotiated Rate	$16,680.93
Rate for Payer: Amerigroup Medicaid	$16,600.35
Rate for Payer: Iowa Total Care Managed Medicaid	$16,439.18
Rate for Payer: Molina Healthcare Managed Medicaid	$16,680.93

Percutaneous Cardiovascular Procedures With Non-drug-eluting Stent With MCC or 4+ Arteries or Stents

Facility

$29,145.36

Service Code	MS-DRG 248
Hospital Charge Code	110
Min. Negotiated Rate	$28,722.97
Max. Negotiated Rate	$29,145.36
Rate for Payer: Amerigroup Medicaid	$29,004.56
Rate for Payer: Iowa Total Care Managed Medicaid	$28,722.97
Rate for Payer: Molina Healthcare Managed Medicaid	$29,145.36

Know your out-of-pocket cost for care.

All Charges