Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$15.29
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: Cash Price	$17.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.38
Rate for Payer: Medical Associates Commercial	$16.38
Rate for Payer: Midlands Choice Commercial	$15.29
Rate for Payer: United Healthcare Commercial	$19.66

polyethylene glycol 3350 - Pow 17 gm UD [VDMC]

Facility

$5.96

Service Code	HCPCS A9270
Hospital Charge Code	11221532
Hospital Revenue Code	259
Min. Negotiated Rate	$4.17
Max. Negotiated Rate	$5.36
Rate for Payer: Aetna of IA Commercial	$5.36
Rate for Payer: Aetna of IA Medical Rental Products	$5.36
Rate for Payer: Cash Price	$4.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.47
Rate for Payer: Medical Associates Commercial	$4.47
Rate for Payer: Midlands Choice Commercial	$4.17
Rate for Payer: United Healthcare Commercial	$5.36

polyethylene glycol 3350 - Pow 17 gm UD [VDMC]

Facility

$5.96

Service Code	HCPCS A9270
Hospital Charge Code	11221532
Hospital Revenue Code	259
Min. Negotiated Rate	$2.98
Max. Negotiated Rate	$5.36
Rate for Payer: Aetna of IA Commercial	$5.36
Rate for Payer: Aetna of IA Medical Rental Products	$5.36
Rate for Payer: Aetna of IA Medicare	$3.40
Rate for Payer: Amerigroup Medicaid	$3.01
Rate for Payer: Amerigroup Medicare	$3.01
Rate for Payer: Cash Price	$4.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.47
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.98
Rate for Payer: Iowa Total Care Managed Medicaid	$2.98
Rate for Payer: Medical Associates Commercial	$4.47
Rate for Payer: Medical Associates Managed Medicare	$2.98
Rate for Payer: Midlands Choice Commercial	$4.17
Rate for Payer: Molina Healthcare Managed Medicaid	$3.02
Rate for Payer: Molina Healthcare Managed Medicare	$3.02
Rate for Payer: Oscar Health of IA Commercial	$4.47
Rate for Payer: Partners Health Alliance Commercial	$4.47
Rate for Payer: United Healthcare Commercial	$5.36
Rate for Payer: United Healthcare Managed Medicare	$3.52

Porphobilinogen Urine Timed DMCL

Facility

$139.00

Service Code	CPT 84110
Hospital Charge Code	8037737
Hospital Revenue Code	301
Min. Negotiated Rate	$97.30
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: United Healthcare Commercial	$125.10

Porphobilinogen Urine Timed DMCL

Facility

$139.00

Service Code	CPT 84110
Hospital Charge Code	8037737
Hospital Revenue Code	301
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Molina Healthcare Managed Medicare	$70.50
Rate for Payer: Oscar Health of IA Commercial	$104.25
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

Postoperative and Post-traumatic Infections With MCC

Facility

$11,566.81

Service Code	MS-DRG 862
Hospital Charge Code	598
Min. Negotiated Rate	$11,399.17
Max. Negotiated Rate	$11,566.81
Rate for Payer: Amerigroup Medicaid	$11,510.93
Rate for Payer: Iowa Total Care Managed Medicaid	$11,399.17
Rate for Payer: Molina Healthcare Managed Medicaid	$11,566.81

Postoperative and Post-traumatic Infections Without MCC

Facility

$8,628.85

Service Code	MS-DRG 863
Hospital Charge Code	599
Min. Negotiated Rate	$8,503.79
Max. Negotiated Rate	$8,628.85
Rate for Payer: Amerigroup Medicaid	$8,587.16
Rate for Payer: Iowa Total Care Managed Medicaid	$8,503.79
Rate for Payer: Molina Healthcare Managed Medicaid	$8,628.85

Postoperative or Post-traumatic Infections With O.R. Procedures With CC

Facility

$14,756.73

Service Code	MS-DRG 857
Hospital Charge Code	596
Min. Negotiated Rate	$14,542.86
Max. Negotiated Rate	$14,756.73
Rate for Payer: Amerigroup Medicaid	$14,685.44
Rate for Payer: Iowa Total Care Managed Medicaid	$14,542.86
Rate for Payer: Molina Healthcare Managed Medicaid	$14,756.73

Postoperative or Post-traumatic Infections With O.R. Procedures With MCC

Facility

$25,117.85

Service Code	MS-DRG 856
Hospital Charge Code	595
Min. Negotiated Rate	$24,753.82
Max. Negotiated Rate	$25,117.85
Rate for Payer: Amerigroup Medicaid	$24,996.50
Rate for Payer: Iowa Total Care Managed Medicaid	$24,753.82
Rate for Payer: Molina Healthcare Managed Medicaid	$25,117.85

Postoperative or Post-traumatic Infections With O.R. Procedures Without CC/MCC

Facility

$12,074.67

Service Code	MS-DRG 858
Hospital Charge Code	597
Min. Negotiated Rate	$11,899.68
Max. Negotiated Rate	$12,074.67
Rate for Payer: Amerigroup Medicaid	$12,016.34
Rate for Payer: Iowa Total Care Managed Medicaid	$11,899.68
Rate for Payer: Molina Healthcare Managed Medicaid	$12,074.67

Postpartum and Post Abortion Diagnoses With O.R. Procedures

Facility

$8,864.08

Service Code	MS-DRG 769
Hospital Charge Code	521
Min. Negotiated Rate	$8,735.62
Max. Negotiated Rate	$8,864.08
Rate for Payer: Amerigroup Medicaid	$8,821.26
Rate for Payer: Iowa Total Care Managed Medicaid	$8,735.62
Rate for Payer: Molina Healthcare Managed Medicaid	$8,864.08

Postpartum and Post Abortion Diagnoses Without O.R. Procedures

Facility

$4,142.67

Service Code	MS-DRG 776
Hospital Charge Code	523
Min. Negotiated Rate	$4,082.63
Max. Negotiated Rate	$4,142.67
Rate for Payer: Amerigroup Medicaid	$4,122.66
Rate for Payer: Iowa Total Care Managed Medicaid	$4,082.63
Rate for Payer: Molina Healthcare Managed Medicaid	$4,142.67

POST TITANIUM 4.5MM X 25MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8026177
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

POST TITANIUM 4.5MM X 25MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8026177
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/WASHER TITANIUM 4.5MM X 27.5MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047048
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

POST/WASHER TITANIUM 4.5MM X 27.5MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047048
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/WASHER TITANIUM 4.5MMX30MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047049
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/WASHER TITANIUM 4.5MMX30MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047049
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

POST/WASHER TITANIUM 4.5MM X 35.7MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047051
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

POST/WASHER TITANIUM 4.5MM X 35.7MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047051
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/ WASHER TITANIUM 4.5MM X 35MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047050
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

POST/ WASHER TITANIUM 4.5MM X 35MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047050
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/WASHER TITANIUM 4.5MM X 42.5MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047052
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

POST/WASHER TITANIUM 4.5MM X 42.5MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047052
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/WASHER TITANIUM 4.5MM X 45MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8047053
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

Know your out-of-pocket cost for care.

All Charges