Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PLATE TUBULAR LOCKING 4 HOLE L50MM

Facility

$161.00

Service Code	CPT C1713
Hospital Charge Code	8046739
Hospital Revenue Code	278
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: United Healthcare Commercial	$144.90

PLATE TUBULAR LOCKING 4 HOLE L50MM

Facility

$161.00

Service Code	CPT C1713
Hospital Charge Code	8046739
Hospital Revenue Code	278
Min. Negotiated Rate	$80.47
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Aetna of IA Medicare	$91.77
Rate for Payer: Amerigroup Medicaid	$81.26
Rate for Payer: Amerigroup Medicare	$81.30
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$80.50
Rate for Payer: Iowa Total Care Managed Medicaid	$80.47
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Medical Associates Managed Medicare	$80.50
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: Molina Healthcare Managed Medicaid	$81.71
Rate for Payer: Molina Healthcare Managed Medicare	$81.66
Rate for Payer: Oscar Health of IA Commercial	$120.75
Rate for Payer: Partners Health Alliance Commercial	$120.75
Rate for Payer: United Healthcare Commercial	$144.90
Rate for Payer: United Healthcare Managed Medicare	$94.99

PLATE TUBULAR LOCKING 4 HOLE L50MM-1

Facility

$175.00

Service Code	CPT C1713
Hospital Charge Code	8046741
Hospital Revenue Code	278
Min. Negotiated Rate	$122.50
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of IA Commercial	$157.50
Rate for Payer: Aetna of IA Medical Rental Products	$157.50
Rate for Payer: Cash Price	$140.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$131.25
Rate for Payer: Medical Associates Commercial	$131.25
Rate for Payer: Midlands Choice Commercial	$122.50
Rate for Payer: United Healthcare Commercial	$157.50

PLATE TUBULAR LOCKING 4 HOLE L50MM-1

Facility

$175.00

Service Code	CPT C1713
Hospital Charge Code	8046741
Hospital Revenue Code	278
Min. Negotiated Rate	$87.46
Max. Negotiated Rate	$157.50
Rate for Payer: Aetna of IA Commercial	$157.50
Rate for Payer: Aetna of IA Medical Rental Products	$157.50
Rate for Payer: Aetna of IA Medicare	$99.75
Rate for Payer: Amerigroup Medicaid	$88.32
Rate for Payer: Amerigroup Medicare	$88.38
Rate for Payer: Cash Price	$140.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$131.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$87.50
Rate for Payer: Iowa Total Care Managed Medicaid	$87.46
Rate for Payer: Medical Associates Commercial	$131.25
Rate for Payer: Medical Associates Managed Medicare	$87.50
Rate for Payer: Midlands Choice Commercial	$122.50
Rate for Payer: Molina Healthcare Managed Medicaid	$88.81
Rate for Payer: Molina Healthcare Managed Medicare	$88.76
Rate for Payer: Oscar Health of IA Commercial	$131.25
Rate for Payer: Partners Health Alliance Commercial	$131.25
Rate for Payer: United Healthcare Commercial	$157.50
Rate for Payer: United Healthcare Managed Medicare	$103.25

PLATE TUBULAR LOCKING 6 HOLE L50MM

Facility

$271.00

Service Code	CPT C1713
Hospital Charge Code	8046740
Hospital Revenue Code	278
Min. Negotiated Rate	$135.45
Max. Negotiated Rate	$243.90
Rate for Payer: United Healthcare Commercial	$243.90
Rate for Payer: Aetna of IA Commercial	$243.90
Rate for Payer: Aetna of IA Medical Rental Products	$243.90
Rate for Payer: Aetna of IA Medicare	$154.47
Rate for Payer: Amerigroup Medicaid	$136.77
Rate for Payer: Amerigroup Medicare	$136.86
Rate for Payer: Cash Price	$216.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$203.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$135.50
Rate for Payer: Iowa Total Care Managed Medicaid	$135.45
Rate for Payer: Medical Associates Commercial	$203.25
Rate for Payer: Medical Associates Managed Medicare	$135.50
Rate for Payer: Midlands Choice Commercial	$189.70
Rate for Payer: Molina Healthcare Managed Medicaid	$137.53
Rate for Payer: Molina Healthcare Managed Medicare	$137.45
Rate for Payer: Oscar Health of IA Commercial	$203.25
Rate for Payer: Partners Health Alliance Commercial	$203.25
Rate for Payer: United Healthcare Managed Medicare	$159.89

PLATE TUBULAR LOCKING 6 HOLE L50MM

Facility

$271.00

Service Code	CPT C1713
Hospital Charge Code	8046740
Hospital Revenue Code	278
Min. Negotiated Rate	$189.70
Max. Negotiated Rate	$243.90
Rate for Payer: Aetna of IA Commercial	$243.90
Rate for Payer: Aetna of IA Medical Rental Products	$243.90
Rate for Payer: Cash Price	$216.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$203.25
Rate for Payer: Medical Associates Commercial	$203.25
Rate for Payer: Midlands Choice Commercial	$189.70
Rate for Payer: United Healthcare Commercial	$243.90

Pleural Effusion With CC

Facility

$9,694.78

Service Code	MS-DRG 187
Hospital Charge Code	58
Min. Negotiated Rate	$9,554.28
Max. Negotiated Rate	$9,694.78
Rate for Payer: Amerigroup Medicaid	$9,647.95
Rate for Payer: Iowa Total Care Managed Medicaid	$9,554.28
Rate for Payer: Molina Healthcare Managed Medicaid	$9,694.78

Pleural Effusion With MCC

Facility

$12,616.01

Service Code	MS-DRG 186
Hospital Charge Code	57
Min. Negotiated Rate	$12,433.17
Max. Negotiated Rate	$12,616.01
Rate for Payer: Amerigroup Medicaid	$12,555.06
Rate for Payer: Iowa Total Care Managed Medicaid	$12,433.17
Rate for Payer: Molina Healthcare Managed Medicaid	$12,616.01

Pleural Effusion Without CC/MCC

Facility

$5,404.47

Service Code	MS-DRG 188
Hospital Charge Code	59
Min. Negotiated Rate	$5,326.14
Max. Negotiated Rate	$5,404.47
Rate for Payer: Amerigroup Medicaid	$5,378.36
Rate for Payer: Iowa Total Care Managed Medicaid	$5,326.14
Rate for Payer: Molina Healthcare Managed Medicaid	$5,404.47

pneumococcal 13-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$407.42

Service Code	HCPCS 90670
Hospital Charge Code	10429979
Hospital Revenue Code	259
Min. Negotiated Rate	$285.19
Max. Negotiated Rate	$366.68
Rate for Payer: Aetna of IA Commercial	$366.68
Rate for Payer: Aetna of IA Medical Rental Products	$366.68
Rate for Payer: Cash Price	$325.93
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$305.56
Rate for Payer: Medical Associates Commercial	$305.56
Rate for Payer: Midlands Choice Commercial	$285.19
Rate for Payer: United Healthcare Commercial	$366.68

pneumococcal 13-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$407.42

Service Code	HCPCS 90670
Hospital Charge Code	10429979
Hospital Revenue Code	259
Min. Negotiated Rate	$203.63
Max. Negotiated Rate	$366.68
Rate for Payer: Aetna of IA Commercial	$366.68
Rate for Payer: Aetna of IA Medical Rental Products	$366.68
Rate for Payer: Aetna of IA Medicare	$232.23
Rate for Payer: Amerigroup Medicaid	$205.62
Rate for Payer: Amerigroup Medicare	$205.75
Rate for Payer: Cash Price	$325.93
Rate for Payer: Cash Price	$325.93
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$305.56
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$203.71
Rate for Payer: Iowa Total Care Managed Medicaid	$203.63
Rate for Payer: Medical Associates Commercial	$305.56
Rate for Payer: Medical Associates Managed Medicare	$203.71
Rate for Payer: Midlands Choice Commercial	$285.19
Rate for Payer: Molina Healthcare Managed Medicaid	$206.77
Rate for Payer: Molina Healthcare Managed Medicare	$206.64
Rate for Payer: Oscar Health of IA Commercial	$305.56
Rate for Payer: Partners Health Alliance Commercial	$305.56
Rate for Payer: United Healthcare Commercial	$366.68
Rate for Payer: United Healthcare Managed Medicare	$240.38
Rate for Payer: Wellmark IA HMO	$207.70
Rate for Payer: Wellmark IA PPO	$228.47

pneumococcal 20-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$458.11

Service Code	HCPCS 90677
Hospital Charge Code	23914697
Hospital Revenue Code	259
Min. Negotiated Rate	$320.68
Max. Negotiated Rate	$412.30
Rate for Payer: Aetna of IA Commercial	$412.30
Rate for Payer: Aetna of IA Medical Rental Products	$412.30
Rate for Payer: Cash Price	$366.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$343.58
Rate for Payer: Medical Associates Commercial	$343.58
Rate for Payer: Midlands Choice Commercial	$320.68
Rate for Payer: United Healthcare Commercial	$412.30

pneumococcal 20-valent vaccine inj Dip CR Syr 0.5ml [VDMC]

Facility

$458.11

Service Code	HCPCS 90677
Hospital Charge Code	23914697
Hospital Revenue Code	259
Min. Negotiated Rate	$228.96
Max. Negotiated Rate	$412.30
Rate for Payer: Aetna of IA Commercial	$412.30
Rate for Payer: Aetna of IA Medical Rental Products	$412.30
Rate for Payer: Aetna of IA Medicare	$261.12
Rate for Payer: Amerigroup Medicaid	$231.21
Rate for Payer: Amerigroup Medicare	$231.35
Rate for Payer: Cash Price	$366.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$343.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$229.06
Rate for Payer: Iowa Total Care Managed Medicaid	$228.96
Rate for Payer: Medical Associates Commercial	$343.58
Rate for Payer: Medical Associates Managed Medicare	$229.06
Rate for Payer: Midlands Choice Commercial	$320.68
Rate for Payer: Molina Healthcare Managed Medicaid	$232.49
Rate for Payer: Molina Healthcare Managed Medicare	$232.35
Rate for Payer: Oscar Health of IA Commercial	$343.58
Rate for Payer: Partners Health Alliance Commercial	$343.58
Rate for Payer: United Healthcare Commercial	$412.30
Rate for Payer: United Healthcare Managed Medicare	$270.28

pneumococcal 23-valent vaccine Inj Sol 0.5ml [VDMC]

Facility

$227.88

Service Code	HCPCS 90732
Hospital Charge Code	10414054
Hospital Revenue Code	259
Min. Negotiated Rate	$159.52
Max. Negotiated Rate	$205.09
Rate for Payer: Aetna of IA Commercial	$205.09
Rate for Payer: Aetna of IA Medical Rental Products	$205.09
Rate for Payer: Cash Price	$182.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.91
Rate for Payer: Medical Associates Commercial	$170.91
Rate for Payer: Midlands Choice Commercial	$159.52
Rate for Payer: United Healthcare Commercial	$205.09

pneumococcal 23-valent vaccine Inj Sol 0.5ml [VDMC]

Facility

$227.88

Service Code	HCPCS 90732
Hospital Charge Code	10414054
Hospital Revenue Code	259
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$205.09
Rate for Payer: Aetna of IA Commercial	$205.09
Rate for Payer: Aetna of IA Medical Rental Products	$205.09
Rate for Payer: Aetna of IA Medicare	$129.89
Rate for Payer: Amerigroup Medicaid	$115.01
Rate for Payer: Amerigroup Medicare	$115.08
Rate for Payer: Cash Price	$182.30
Rate for Payer: Cash Price	$182.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$170.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$113.94
Rate for Payer: Iowa Total Care Managed Medicaid	$113.89
Rate for Payer: Medical Associates Commercial	$170.91
Rate for Payer: Medical Associates Managed Medicare	$113.94
Rate for Payer: Midlands Choice Commercial	$159.52
Rate for Payer: Molina Healthcare Managed Medicaid	$115.65
Rate for Payer: Molina Healthcare Managed Medicare	$115.58
Rate for Payer: Oscar Health of IA Commercial	$170.91
Rate for Payer: Partners Health Alliance Commercial	$170.91
Rate for Payer: United Healthcare Commercial	$205.09
Rate for Payer: United Healthcare Managed Medicare	$134.45
Rate for Payer: Wellmark IA HMO	$62.00
Rate for Payer: Wellmark IA PPO	$68.20

Pneumothorax With CC

Facility

$8,081.61

Service Code	MS-DRG 200
Hospital Charge Code	71
Min. Negotiated Rate	$7,964.49
Max. Negotiated Rate	$8,081.61
Rate for Payer: Amerigroup Medicaid	$8,042.57
Rate for Payer: Iowa Total Care Managed Medicaid	$7,964.49
Rate for Payer: Molina Healthcare Managed Medicaid	$8,081.61

Pneumothorax With MCC

Facility

$12,289.24

Service Code	MS-DRG 199
Hospital Charge Code	70
Min. Negotiated Rate	$12,111.13
Max. Negotiated Rate	$12,289.24
Rate for Payer: Amerigroup Medicaid	$12,229.87
Rate for Payer: Iowa Total Care Managed Medicaid	$12,111.13
Rate for Payer: Molina Healthcare Managed Medicaid	$12,289.24

Pneumothorax Without CC/MCC

Facility

$6,688.90

Service Code	MS-DRG 201
Hospital Charge Code	72
Min. Negotiated Rate	$6,591.96
Max. Negotiated Rate	$6,688.90
Rate for Payer: Amerigroup Medicaid	$6,656.59
Rate for Payer: Iowa Total Care Managed Medicaid	$6,591.96
Rate for Payer: Molina Healthcare Managed Medicaid	$6,688.90

Poisoning and Toxic Effects of Drugs With MCC

Facility

$9,934.93

Service Code	MS-DRG 917
Hospital Charge Code	635
Min. Negotiated Rate	$9,790.95
Max. Negotiated Rate	$9,934.93
Rate for Payer: Amerigroup Medicaid	$9,886.94
Rate for Payer: Iowa Total Care Managed Medicaid	$9,790.95
Rate for Payer: Molina Healthcare Managed Medicaid	$9,934.93

Poisoning and Toxic Effects of Drugs Without MCC

Facility

$5,087.54

Service Code	MS-DRG 918
Hospital Charge Code	636
Min. Negotiated Rate	$5,013.81
Max. Negotiated Rate	$5,087.54
Rate for Payer: Amerigroup Medicaid	$5,062.96
Rate for Payer: Iowa Total Care Managed Medicaid	$5,013.81
Rate for Payer: Molina Healthcare Managed Medicaid	$5,087.54

poliovirus vaccine, inactivated - Sus MDV [VDMC]

Facility

$98.56

Service Code	HCPCS 90713
Hospital Charge Code	21494404
Hospital Revenue Code	259
Min. Negotiated Rate	$68.99
Max. Negotiated Rate	$88.70
Rate for Payer: Aetna of IA Commercial	$88.70
Rate for Payer: Aetna of IA Medical Rental Products	$88.70
Rate for Payer: Cash Price	$78.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.92
Rate for Payer: Medical Associates Commercial	$73.92
Rate for Payer: Midlands Choice Commercial	$68.99
Rate for Payer: United Healthcare Commercial	$88.70

poliovirus vaccine, inactivated - Sus MDV [VDMC]

Facility

$98.56

Service Code	HCPCS 90713
Hospital Charge Code	21494404
Hospital Revenue Code	259
Min. Negotiated Rate	$49.26
Max. Negotiated Rate	$88.70
Rate for Payer: Aetna of IA Commercial	$88.70
Rate for Payer: Aetna of IA Medical Rental Products	$88.70
Rate for Payer: Aetna of IA Medicare	$56.18
Rate for Payer: Amerigroup Medicaid	$49.74
Rate for Payer: Amerigroup Medicare	$49.77
Rate for Payer: Cash Price	$78.85
Rate for Payer: Cash Price	$78.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.28
Rate for Payer: Iowa Total Care Managed Medicaid	$49.26
Rate for Payer: Medical Associates Commercial	$73.92
Rate for Payer: Medical Associates Managed Medicare	$49.28
Rate for Payer: Midlands Choice Commercial	$68.99
Rate for Payer: Molina Healthcare Managed Medicaid	$50.02
Rate for Payer: Molina Healthcare Managed Medicare	$49.99
Rate for Payer: Oscar Health of IA Commercial	$73.92
Rate for Payer: Partners Health Alliance Commercial	$73.92
Rate for Payer: United Healthcare Commercial	$88.70
Rate for Payer: United Healthcare Managed Medicare	$58.15
Rate for Payer: Wellmark IA HMO	$62.00
Rate for Payer: Wellmark IA PPO	$68.20

polycarbophil 625 mg Tab [VDMC]

Facility

$1.17

Service Code	HCPCS A9270
Hospital Charge Code	10414125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of IA Commercial	$1.05
Rate for Payer: Aetna of IA Medical Rental Products	$1.05
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.88
Rate for Payer: Medical Associates Commercial	$0.88
Rate for Payer: Midlands Choice Commercial	$0.82
Rate for Payer: United Healthcare Commercial	$1.05

polycarbophil 625 mg Tab [VDMC]

Facility

$1.17

Service Code	HCPCS A9270
Hospital Charge Code	10414125
Hospital Revenue Code	259
Min. Negotiated Rate	$0.58
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of IA Commercial	$1.05
Rate for Payer: Aetna of IA Medical Rental Products	$1.05
Rate for Payer: Aetna of IA Medicare	$0.67
Rate for Payer: Amerigroup Medicaid	$0.59
Rate for Payer: Amerigroup Medicare	$0.59
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.59
Rate for Payer: Iowa Total Care Managed Medicaid	$0.58
Rate for Payer: Medical Associates Commercial	$0.88
Rate for Payer: Medical Associates Managed Medicare	$0.59
Rate for Payer: Midlands Choice Commercial	$0.82
Rate for Payer: Molina Healthcare Managed Medicaid	$0.59
Rate for Payer: Molina Healthcare Managed Medicare	$0.59
Rate for Payer: Oscar Health of IA Commercial	$0.88
Rate for Payer: Partners Health Alliance Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.05
Rate for Payer: United Healthcare Managed Medicare	$0.69

polyethylene glycol 3350 Oral Pwdr for Recon [VDMC]

Facility

$21.84

Service Code	HCPCS A9270
Hospital Charge Code	10414194
Hospital Revenue Code	259
Min. Negotiated Rate	$10.92
Max. Negotiated Rate	$19.66
Rate for Payer: Aetna of IA Commercial	$19.66
Rate for Payer: Aetna of IA Medical Rental Products	$19.66
Rate for Payer: Aetna of IA Medicare	$12.45
Rate for Payer: Amerigroup Medicaid	$11.02
Rate for Payer: Amerigroup Medicare	$11.03
Rate for Payer: Cash Price	$17.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.92
Rate for Payer: Iowa Total Care Managed Medicaid	$10.92
Rate for Payer: Medical Associates Commercial	$16.38
Rate for Payer: Medical Associates Managed Medicare	$10.92
Rate for Payer: Midlands Choice Commercial	$15.29
Rate for Payer: Molina Healthcare Managed Medicaid	$11.08
Rate for Payer: Molina Healthcare Managed Medicare	$11.08
Rate for Payer: Oscar Health of IA Commercial	$16.38
Rate for Payer: Partners Health Alliance Commercial	$16.38
Rate for Payer: United Healthcare Commercial	$19.66
Rate for Payer: United Healthcare Managed Medicare	$12.89

Know your out-of-pocket cost for care.

All Charges