Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Percutaneous Cardiovascular Procedures With Non-drug-eluting Stent Without MCC

Facility

$15,579.55

Service Code	MS-DRG 249
Hospital Charge Code	111
Min. Negotiated Rate	$15,353.76
Max. Negotiated Rate	$15,579.55
Rate for Payer: Amerigroup Medicaid	$15,504.29
Rate for Payer: Iowa Total Care Managed Medicaid	$15,353.76
Rate for Payer: Molina Healthcare Managed Medicaid	$15,579.55

Percutaneous Cardiovascular Procedures Without Coronary Artery Stent With MCC

Facility

$17,756.70

Service Code	MS-DRG 250
Hospital Charge Code	112
Min. Negotiated Rate	$17,499.35
Max. Negotiated Rate	$17,756.70
Rate for Payer: Amerigroup Medicaid	$17,670.92
Rate for Payer: Iowa Total Care Managed Medicaid	$17,499.35
Rate for Payer: Molina Healthcare Managed Medicaid	$17,756.70

Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without MCC

Facility

$13,514.62

Service Code	MS-DRG 251
Hospital Charge Code	113
Min. Negotiated Rate	$13,318.75
Max. Negotiated Rate	$13,514.62
Rate for Payer: Amerigroup Medicaid	$13,449.33
Rate for Payer: Iowa Total Care Managed Medicaid	$13,318.75
Rate for Payer: Molina Healthcare Managed Medicaid	$13,514.62

Peripheral, Cranial Nerve and Other Nervous System Procedures With CC or Peripheral Neurostimulator

Facility

$19,418.10

Service Code	MS-DRG 041
Hospital Charge Code	730
Min. Negotiated Rate	$19,136.68
Max. Negotiated Rate	$19,418.10
Rate for Payer: Amerigroup Medicaid	$19,324.29
Rate for Payer: Iowa Total Care Managed Medicaid	$19,136.68
Rate for Payer: Molina Healthcare Managed Medicaid	$19,418.10

Peripheral, Cranial Nerve and Other Nervous System Procedures With MCC

Facility

$26,804.83

Service Code	MS-DRG 040
Hospital Charge Code	729
Min. Negotiated Rate	$26,416.36
Max. Negotiated Rate	$26,804.83
Rate for Payer: Amerigroup Medicaid	$26,675.34
Rate for Payer: Iowa Total Care Managed Medicaid	$26,416.36
Rate for Payer: Molina Healthcare Managed Medicaid	$26,804.83

Peripheral, Cranial Nerve and Other Nervous System Procedures Without CC/MCC

Facility

$9,937.88

Service Code	MS-DRG 042
Hospital Charge Code	731
Min. Negotiated Rate	$9,793.86
Max. Negotiated Rate	$9,937.88
Rate for Payer: Amerigroup Medicaid	$9,889.87
Rate for Payer: Iowa Total Care Managed Medicaid	$9,793.86
Rate for Payer: Molina Healthcare Managed Medicaid	$9,937.88

Peripheral Vascular Disorders With CC

Facility

$9,825.68

Service Code	MS-DRG 300
Hospital Charge Code	157
Min. Negotiated Rate	$9,683.28
Max. Negotiated Rate	$9,825.68
Rate for Payer: Amerigroup Medicaid	$9,778.21
Rate for Payer: Iowa Total Care Managed Medicaid	$9,683.28
Rate for Payer: Molina Healthcare Managed Medicaid	$9,825.68

Peripheral Vascular Disorders With MCC

Facility

$9,829.62

Service Code	MS-DRG 299
Hospital Charge Code	156
Min. Negotiated Rate	$9,687.16
Max. Negotiated Rate	$9,829.62
Rate for Payer: Amerigroup Medicaid	$9,782.14
Rate for Payer: Iowa Total Care Managed Medicaid	$9,687.16
Rate for Payer: Molina Healthcare Managed Medicaid	$9,829.62

Peripheral Vascular Disorders Without CC/MCC

Facility

$5,365.10

Service Code	MS-DRG 301
Hospital Charge Code	158
Min. Negotiated Rate	$5,287.34
Max. Negotiated Rate	$5,365.10
Rate for Payer: Amerigroup Medicaid	$5,339.18
Rate for Payer: Iowa Total Care Managed Medicaid	$5,287.34
Rate for Payer: Molina Healthcare Managed Medicaid	$5,365.10

Peritoneal Adhesiolysis With CC

Facility

$18,817.72

Service Code	MS-DRG 336
Hospital Charge Code	186
Min. Negotiated Rate	$18,545.00
Max. Negotiated Rate	$18,817.72
Rate for Payer: Amerigroup Medicaid	$18,726.81
Rate for Payer: Iowa Total Care Managed Medicaid	$18,545.00
Rate for Payer: Molina Healthcare Managed Medicaid	$18,817.72

Peritoneal Adhesiolysis With MCC

Facility

$27,835.33

Service Code	MS-DRG 335
Hospital Charge Code	185
Min. Negotiated Rate	$27,431.92
Max. Negotiated Rate	$27,835.33
Rate for Payer: Amerigroup Medicaid	$27,700.86
Rate for Payer: Iowa Total Care Managed Medicaid	$27,431.92
Rate for Payer: Molina Healthcare Managed Medicaid	$27,835.33

Peritoneal Adhesiolysis Without CC/MCC

Facility

$15,203.58

Service Code	MS-DRG 337
Hospital Charge Code	187
Min. Negotiated Rate	$14,983.24
Max. Negotiated Rate	$15,203.58
Rate for Payer: Amerigroup Medicaid	$15,130.13
Rate for Payer: Iowa Total Care Managed Medicaid	$14,983.24
Rate for Payer: Molina Healthcare Managed Medicaid	$15,203.58

Permanent Cardiac Pacemaker Implant With CC

Facility

$22,976.13

Service Code	MS-DRG 243
Hospital Charge Code	105
Min. Negotiated Rate	$22,643.14
Max. Negotiated Rate	$22,976.13
Rate for Payer: Amerigroup Medicaid	$22,865.13
Rate for Payer: Iowa Total Care Managed Medicaid	$22,643.14
Rate for Payer: Molina Healthcare Managed Medicaid	$22,976.13

Permanent Cardiac Pacemaker Implant With MCC

Facility

$28,866.82

Service Code	MS-DRG 242
Hospital Charge Code	104
Min. Negotiated Rate	$28,448.46
Max. Negotiated Rate	$28,866.82
Rate for Payer: Amerigroup Medicaid	$28,727.37
Rate for Payer: Iowa Total Care Managed Medicaid	$28,448.46
Rate for Payer: Molina Healthcare Managed Medicaid	$28,866.82

Permanent Cardiac Pacemaker Implant Without CC/MCC

Facility

$17,646.47

Service Code	MS-DRG 244
Hospital Charge Code	106
Min. Negotiated Rate	$17,390.72
Max. Negotiated Rate	$17,646.47
Rate for Payer: Amerigroup Medicaid	$17,561.22
Rate for Payer: Iowa Total Care Managed Medicaid	$17,390.72
Rate for Payer: Molina Healthcare Managed Medicaid	$17,646.47

permethrin Top 1% lotion 59ml [VDMC]

Facility

$10.14

Service Code	NDC 46122-0108-46
Hospital Charge Code	10436709
Hospital Revenue Code	259
Min. Negotiated Rate	$5.07
Max. Negotiated Rate	$9.13
Rate for Payer: Aetna of IA Commercial	$9.13
Rate for Payer: Aetna of IA Medical Rental Products	$9.13
Rate for Payer: Aetna of IA Medicare	$5.78
Rate for Payer: Amerigroup Medicaid	$5.12
Rate for Payer: Amerigroup Medicare	$5.12
Rate for Payer: Cash Price	$8.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.60
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.07
Rate for Payer: Iowa Total Care Managed Medicaid	$5.07
Rate for Payer: Medical Associates Commercial	$7.60
Rate for Payer: Medical Associates Managed Medicare	$5.07
Rate for Payer: Midlands Choice Commercial	$7.10
Rate for Payer: Molina Healthcare Managed Medicaid	$5.15
Rate for Payer: Molina Healthcare Managed Medicare	$5.14
Rate for Payer: Oscar Health of IA Commercial	$7.60
Rate for Payer: Partners Health Alliance Commercial	$7.60
Rate for Payer: United Healthcare Commercial	$9.13
Rate for Payer: United Healthcare Managed Medicare	$5.98

permethrin Top 1% lotion 59ml [VDMC]

Facility

$10.14

Service Code	NDC 46122-0108-46
Hospital Charge Code	10436709
Hospital Revenue Code	259
Min. Negotiated Rate	$7.10
Max. Negotiated Rate	$9.13
Rate for Payer: Aetna of IA Commercial	$9.13
Rate for Payer: Aetna of IA Medical Rental Products	$9.13
Rate for Payer: Cash Price	$8.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.60
Rate for Payer: Medical Associates Commercial	$7.60
Rate for Payer: Midlands Choice Commercial	$7.10
Rate for Payer: United Healthcare Commercial	$9.13

pertuzumab 420 mg/14 mL SDV [VDMC]

Facility

$22,170.60

Service Code	HCPCS J9306
Hospital Charge Code	20430606
Hospital Revenue Code	259
Min. Negotiated Rate	$11,080.87
Max. Negotiated Rate	$19,953.54
Rate for Payer: Aetna of IA Commercial	$19,953.54
Rate for Payer: Aetna of IA Medical Rental Products	$19,953.54
Rate for Payer: Aetna of IA Medicare	$12,637.24
Rate for Payer: Amerigroup Medicaid	$11,189.50
Rate for Payer: Amerigroup Medicare	$11,196.15
Rate for Payer: Cash Price	$17,736.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16,627.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11,085.30
Rate for Payer: Iowa Total Care Managed Medicaid	$11,080.87
Rate for Payer: Medical Associates Commercial	$16,627.95
Rate for Payer: Medical Associates Managed Medicare	$11,085.30
Rate for Payer: Midlands Choice Commercial	$15,519.42
Rate for Payer: Molina Healthcare Managed Medicaid	$11,251.58
Rate for Payer: Molina Healthcare Managed Medicare	$11,244.93
Rate for Payer: Oscar Health of IA Commercial	$16,627.95
Rate for Payer: Partners Health Alliance Commercial	$16,627.95
Rate for Payer: United Healthcare Commercial	$19,953.54
Rate for Payer: United Healthcare Managed Medicare	$13,080.65

pertuzumab 420 mg/14 mL SDV [VDMC]

Facility

$22,170.60

Service Code	HCPCS J9306
Hospital Charge Code	20430606
Hospital Revenue Code	259
Min. Negotiated Rate	$15,519.42
Max. Negotiated Rate	$19,953.54
Rate for Payer: Aetna of IA Commercial	$19,953.54
Rate for Payer: Aetna of IA Medical Rental Products	$19,953.54
Rate for Payer: Cash Price	$17,736.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16,627.95
Rate for Payer: Medical Associates Commercial	$16,627.95
Rate for Payer: Midlands Choice Commercial	$15,519.42
Rate for Payer: United Healthcare Commercial	$19,953.54

PETITE MPJ PLATE LEFT

Facility

$2,178.00

Service Code	CPT C1713
Hospital Charge Code	8884275
Hospital Revenue Code	278
Min. Negotiated Rate	$1,524.60
Max. Negotiated Rate	$1,960.20
Rate for Payer: Aetna of IA Commercial	$1,960.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,960.20
Rate for Payer: Cash Price	$1,742.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,633.50
Rate for Payer: Medical Associates Commercial	$1,633.50
Rate for Payer: Midlands Choice Commercial	$1,524.60
Rate for Payer: United Healthcare Commercial	$1,960.20

PETITE MPJ PLATE LEFT

Facility

$2,178.00

Service Code	CPT C1713
Hospital Charge Code	8884275
Hospital Revenue Code	278
Min. Negotiated Rate	$1,088.56
Max. Negotiated Rate	$1,960.20
Rate for Payer: Aetna of IA Commercial	$1,960.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,960.20
Rate for Payer: Aetna of IA Medicare	$1,241.46
Rate for Payer: Amerigroup Medicaid	$1,099.24
Rate for Payer: Amerigroup Medicare	$1,099.89
Rate for Payer: Cash Price	$1,742.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,633.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,089.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,088.56
Rate for Payer: Medical Associates Commercial	$1,633.50
Rate for Payer: Medical Associates Managed Medicare	$1,089.00
Rate for Payer: Midlands Choice Commercial	$1,524.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1,105.34
Rate for Payer: Molina Healthcare Managed Medicare	$1,104.68
Rate for Payer: Oscar Health of IA Commercial	$1,633.50
Rate for Payer: Partners Health Alliance Commercial	$1,633.50
Rate for Payer: United Healthcare Commercial	$1,960.20
Rate for Payer: United Healthcare Managed Medicare	$1,285.02

PETITE MPJ PLATE, RIGHT

Facility

$297.00

Service Code	CPT C1713
Hospital Charge Code	8812766
Hospital Revenue Code	278
Min. Negotiated Rate	$207.90
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: United Healthcare Commercial	$267.30

PETITE MPJ PLATE, RIGHT

Facility

$297.00

Service Code	CPT C1713
Hospital Charge Code	8812766
Hospital Revenue Code	278
Min. Negotiated Rate	$148.44
Max. Negotiated Rate	$267.30
Rate for Payer: Aetna of IA Commercial	$267.30
Rate for Payer: Aetna of IA Medical Rental Products	$267.30
Rate for Payer: Aetna of IA Medicare	$169.29
Rate for Payer: Amerigroup Medicaid	$149.90
Rate for Payer: Amerigroup Medicare	$149.98
Rate for Payer: Cash Price	$237.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$222.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$148.50
Rate for Payer: Iowa Total Care Managed Medicaid	$148.44
Rate for Payer: Medical Associates Commercial	$222.75
Rate for Payer: Medical Associates Managed Medicare	$148.50
Rate for Payer: Midlands Choice Commercial	$207.90
Rate for Payer: Molina Healthcare Managed Medicaid	$150.73
Rate for Payer: Molina Healthcare Managed Medicare	$150.64
Rate for Payer: Oscar Health of IA Commercial	$222.75
Rate for Payer: Partners Health Alliance Commercial	$222.75
Rate for Payer: United Healthcare Commercial	$267.30
Rate for Payer: United Healthcare Managed Medicare	$175.23

PETITE STEPPED MPG VLC GRIDLOCK PLATE RT

Facility

$2,070.00

Service Code	CPT C1713
Hospital Charge Code	8757684
Hospital Revenue Code	278
Min. Negotiated Rate	$1,449.00
Max. Negotiated Rate	$1,863.00
Rate for Payer: Aetna of IA Commercial	$1,863.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,863.00
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,552.50
Rate for Payer: Medical Associates Commercial	$1,552.50
Rate for Payer: Midlands Choice Commercial	$1,449.00
Rate for Payer: United Healthcare Commercial	$1,863.00

PETITE STEPPED MPG VLC GRIDLOCK PLATE RT

Facility

$2,070.00

Service Code	CPT C1713
Hospital Charge Code	8757684
Hospital Revenue Code	278
Min. Negotiated Rate	$1,034.59
Max. Negotiated Rate	$1,863.00
Rate for Payer: Aetna of IA Commercial	$1,863.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,863.00
Rate for Payer: Aetna of IA Medicare	$1,179.90
Rate for Payer: Amerigroup Medicaid	$1,044.73
Rate for Payer: Amerigroup Medicare	$1,045.35
Rate for Payer: Cash Price	$1,656.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,552.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,035.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,034.59
Rate for Payer: Medical Associates Commercial	$1,552.50
Rate for Payer: Medical Associates Managed Medicare	$1,035.00
Rate for Payer: Midlands Choice Commercial	$1,449.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,050.52
Rate for Payer: Molina Healthcare Managed Medicare	$1,049.90
Rate for Payer: Oscar Health of IA Commercial	$1,552.50
Rate for Payer: Partners Health Alliance Commercial	$1,552.50
Rate for Payer: United Healthcare Commercial	$1,863.00
Rate for Payer: United Healthcare Managed Medicare	$1,221.30

Know your out-of-pocket cost for care.

All Charges