Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ADM VACC EA ADDL VACCINE

Facility

$41.00

Service Code	CPT 90472
Hospital Charge Code	4866874
Hospital Revenue Code	771
Min. Negotiated Rate	$20.49
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	$20.69
Rate for Payer: Amerigroup Medicare	$20.70
Rate for Payer: Cash Price	$32.80
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	$20.50
Rate for Payer: Iowa Total Care Managed Medicaid	$20.49
Rate for Payer: Medical Associates Commercial	$30.75
Rate for Payer: Medical Associates Managed Medicare	$20.50
Rate for Payer: Midlands Choice Commercial	$28.70
Rate for Payer: Molina Healthcare Managed Medicaid	$20.81
Rate for Payer: Molina Healthcare Managed Medicare	$20.80
Rate for Payer: Oscar Health of IA Commercial	$30.75
Rate for Payer: Partners Health Alliance Commercial	$30.75
Rate for Payer: United Healthcare Commercial	$36.90
Rate for Payer: United Healthcare Managed Medicare	$24.19
Rate for Payer: Wellmark IA HMO	$32.86
Rate for Payer: Wellmark IA PPO	$36.15

ado-trastuzumab emtansine 100 mg SDV [VDMC]

Facility

$13,235.76

Service Code	HCPCS J9354
Hospital Charge Code	21395175
Hospital Revenue Code	259
Min. Negotiated Rate	$6,615.23
Max. Negotiated Rate	$11,912.18
Rate for Payer: Aetna of IA Commercial	$11,912.18
Rate for Payer: Aetna of IA Medical Rental Products	$11,912.18
Rate for Payer: Aetna of IA Medicare	$7,544.38
Rate for Payer: Amerigroup Medicaid	$6,680.09
Rate for Payer: Amerigroup Medicare	$6,684.06
Rate for Payer: Cash Price	$10,588.61
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,926.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,617.88
Rate for Payer: Iowa Total Care Managed Medicaid	$6,615.23
Rate for Payer: Medical Associates Commercial	$9,926.82
Rate for Payer: Medical Associates Managed Medicare	$6,617.88
Rate for Payer: Midlands Choice Commercial	$9,265.03
Rate for Payer: Molina Healthcare Managed Medicaid	$6,717.15
Rate for Payer: Molina Healthcare Managed Medicare	$6,713.18
Rate for Payer: Oscar Health of IA Commercial	$9,926.82
Rate for Payer: Partners Health Alliance Commercial	$9,926.82
Rate for Payer: United Healthcare Commercial	$11,912.18
Rate for Payer: United Healthcare Managed Medicare	$7,809.10

ado-trastuzumab emtansine 100 mg SDV [VDMC]

Facility

$13,235.76

Service Code	HCPCS J9354
Hospital Charge Code	21395175
Hospital Revenue Code	259
Min. Negotiated Rate	$9,265.03
Max. Negotiated Rate	$11,912.18
Rate for Payer: Aetna of IA Commercial	$11,912.18
Rate for Payer: Aetna of IA Medical Rental Products	$11,912.18
Rate for Payer: Cash Price	$10,588.61
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9,926.82
Rate for Payer: Medical Associates Commercial	$9,926.82
Rate for Payer: Midlands Choice Commercial	$9,265.03
Rate for Payer: United Healthcare Commercial	$11,912.18

Adrenal and Pituitary Procedures With CC/MCC

Facility

$25,281.23

Service Code	MS-DRG 614
Hospital Charge Code	406
Min. Negotiated Rate	$24,914.84
Max. Negotiated Rate	$25,281.23
Rate for Payer: Amerigroup Medicaid	$25,159.10
Rate for Payer: Iowa Total Care Managed Medicaid	$24,914.84
Rate for Payer: Molina Healthcare Managed Medicaid	$25,281.23

Adrenal and Pituitary Procedures Without CC/MCC

Facility

$15,184.88

Service Code	MS-DRG 615
Hospital Charge Code	407
Min. Negotiated Rate	$14,964.81
Max. Negotiated Rate	$15,184.88
Rate for Payer: Amerigroup Medicaid	$15,111.52
Rate for Payer: Iowa Total Care Managed Medicaid	$14,964.81
Rate for Payer: Molina Healthcare Managed Medicaid	$15,184.88

ADRENOCORTICOTROPHIC HORMONE

Facility

$263.00

Service Code	CPT 82024
Hospital Charge Code	8037486
Hospital Revenue Code	301
Min. Negotiated Rate	$184.10
Max. Negotiated Rate	$236.70
Rate for Payer: Aetna of IA Commercial	$236.70
Rate for Payer: Aetna of IA Medical Rental Products	$236.70
Rate for Payer: Cash Price	$210.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$197.25
Rate for Payer: Medical Associates Commercial	$197.25
Rate for Payer: Midlands Choice Commercial	$184.10
Rate for Payer: United Healthcare Commercial	$236.70

ADRENOCORTICOTROPHIC HORMONE

Facility

$263.00

Service Code	CPT 82024
Hospital Charge Code	8037486
Hospital Revenue Code	301
Min. Negotiated Rate	$85.56
Max. Negotiated Rate	$236.70
Rate for Payer: Aetna of IA Commercial	$236.70
Rate for Payer: Aetna of IA Medical Rental Products	$236.70
Rate for Payer: Aetna of IA Medicare	$149.91
Rate for Payer: Amerigroup Medicaid	$132.74
Rate for Payer: Amerigroup Medicare	$132.82
Rate for Payer: Cash Price	$210.40
Rate for Payer: Cash Price	$210.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$197.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$131.50
Rate for Payer: Iowa Total Care Managed Medicaid	$131.45
Rate for Payer: Medical Associates Commercial	$197.25
Rate for Payer: Medical Associates Managed Medicare	$131.50
Rate for Payer: Midlands Choice Commercial	$184.10
Rate for Payer: Molina Healthcare Managed Medicaid	$133.47
Rate for Payer: Molina Healthcare Managed Medicare	$133.39
Rate for Payer: Oscar Health of IA Commercial	$197.25
Rate for Payer: Partners Health Alliance Commercial	$197.25
Rate for Payer: United Healthcare Commercial	$236.70
Rate for Payer: United Healthcare Managed Medicare	$155.17
Rate for Payer: Wellmark IA HMO	$85.56
Rate for Payer: Wellmark IA PPO	$94.12

Aftercare, Musculoskeletal System and Connective Tissue With CC

Facility

$14,784.29

Service Code	MS-DRG 560
Hospital Charge Code	367
Min. Negotiated Rate	$14,570.03
Max. Negotiated Rate	$14,784.29
Rate for Payer: Amerigroup Medicaid	$14,712.87
Rate for Payer: Iowa Total Care Managed Medicaid	$14,570.03
Rate for Payer: Molina Healthcare Managed Medicaid	$14,784.29

Aftercare, Musculoskeletal System and Connective Tissue With MCC

Facility

$14,784.29

Service Code	MS-DRG 559
Hospital Charge Code	366
Min. Negotiated Rate	$14,570.03
Max. Negotiated Rate	$14,784.29
Rate for Payer: Amerigroup Medicaid	$14,712.87
Rate for Payer: Iowa Total Care Managed Medicaid	$14,570.03
Rate for Payer: Molina Healthcare Managed Medicaid	$14,784.29

Aftercare, Musculoskeletal System and Connective Tissue Without CC/MCC

Facility

$6,432.02

Service Code	MS-DRG 561
Hospital Charge Code	368
Min. Negotiated Rate	$6,338.80
Max. Negotiated Rate	$6,432.02
Rate for Payer: Amerigroup Medicaid	$6,400.95
Rate for Payer: Iowa Total Care Managed Medicaid	$6,338.80
Rate for Payer: Molina Healthcare Managed Medicaid	$6,432.02

Aftercare With CC/MCC

Facility

$21,719.26

Service Code	MS-DRG 949
Hospital Charge Code	655
Min. Negotiated Rate	$21,404.49
Max. Negotiated Rate	$21,719.26
Rate for Payer: Amerigroup Medicaid	$21,614.33
Rate for Payer: Iowa Total Care Managed Medicaid	$21,404.49
Rate for Payer: Molina Healthcare Managed Medicaid	$21,719.26

Aftercare Without CC/MCC

Facility

$6,259.77

Service Code	MS-DRG 950
Hospital Charge Code	656
Min. Negotiated Rate	$6,169.05
Max. Negotiated Rate	$6,259.77
Rate for Payer: Amerigroup Medicaid	$6,229.53
Rate for Payer: Iowa Total Care Managed Medicaid	$6,169.05
Rate for Payer: Molina Healthcare Managed Medicaid	$6,259.77

AICD Generator Procedures

Facility

$44,252.48

Service Code	MS-DRG 245
Hospital Charge Code	107
Min. Negotiated Rate	$43,611.14
Max. Negotiated Rate	$44,252.48
Rate for Payer: Amerigroup Medicaid	$44,038.70
Rate for Payer: Iowa Total Care Managed Medicaid	$43,611.14
Rate for Payer: Molina Healthcare Managed Medicaid	$44,252.48

AICD Lead Procedures

Facility

$29,772.32

Service Code	MS-DRG 265
Hospital Charge Code	127
Min. Negotiated Rate	$29,340.84
Max. Negotiated Rate	$29,772.32
Rate for Payer: Amerigroup Medicaid	$29,628.50
Rate for Payer: Iowa Total Care Managed Medicaid	$29,340.84
Rate for Payer: Molina Healthcare Managed Medicaid	$29,772.32

AIRWAY SUCTION-NASOTRACHEAL ONLY

Facility

$176.00

Service Code	CPT 31720
Hospital Charge Code	5338782
Hospital Revenue Code	410
Min. Negotiated Rate	$123.20
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: United Healthcare Commercial	$158.40

AIRWAY SUCTION-NASOTRACHEAL ONLY

Facility

$176.00

Service Code	CPT 31720
Hospital Charge Code	5338782
Hospital Revenue Code	410
Min. Negotiated Rate	$41.54
Max. Negotiated Rate	$158.40
Rate for Payer: Aetna of IA Commercial	$158.40
Rate for Payer: Aetna of IA Medical Rental Products	$158.40
Rate for Payer: Aetna of IA Medicare	$100.32
Rate for Payer: Amerigroup Medicaid	$88.83
Rate for Payer: Amerigroup Medicare	$88.88
Rate for Payer: Cash Price	$140.80
Rate for Payer: Cash Price	$140.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$88.00
Rate for Payer: Iowa Total Care Managed Medicaid	$87.96
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$88.00
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$89.32
Rate for Payer: Molina Healthcare Managed Medicare	$89.27
Rate for Payer: Oscar Health of IA Commercial	$132.00
Rate for Payer: Partners Health Alliance Commercial	$132.00
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84
Rate for Payer: Wellmark IA HMO	$41.54
Rate for Payer: Wellmark IA PPO	$45.69

ALBUMIN

Facility

$47.00

Service Code	CPT 82040
Hospital Charge Code	1620877
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of IA Commercial	$42.30
Rate for Payer: Aetna of IA Medical Rental Products	$42.30
Rate for Payer: Aetna of IA Medicare	$26.79
Rate for Payer: Amerigroup Medicaid	$23.72
Rate for Payer: Amerigroup Medicare	$23.74
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cash Price	$37.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.50
Rate for Payer: Iowa Total Care Managed Medicaid	$23.49
Rate for Payer: Medical Associates Commercial	$35.25
Rate for Payer: Medical Associates Managed Medicare	$23.50
Rate for Payer: Midlands Choice Commercial	$32.90
Rate for Payer: Molina Healthcare Managed Medicaid	$23.85
Rate for Payer: Molina Healthcare Managed Medicare	$23.84
Rate for Payer: Oscar Health of IA Commercial	$35.25
Rate for Payer: Partners Health Alliance Commercial	$35.25
Rate for Payer: United Healthcare Commercial	$42.30
Rate for Payer: United Healthcare Managed Medicare	$27.73
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

ALBUMIN

Facility

$47.00

Service Code	CPT 82040
Hospital Charge Code	8093923
Hospital Revenue Code	301
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of IA Commercial	$42.30
Rate for Payer: Aetna of IA Medical Rental Products	$42.30
Rate for Payer: Cash Price	$37.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.25
Rate for Payer: Medical Associates Commercial	$35.25
Rate for Payer: Midlands Choice Commercial	$32.90
Rate for Payer: United Healthcare Commercial	$42.30

ALBUMIN

Facility

$47.00

Service Code	CPT 82040
Hospital Charge Code	1620877
Hospital Revenue Code	301
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of IA Commercial	$42.30
Rate for Payer: Aetna of IA Medical Rental Products	$42.30
Rate for Payer: Cash Price	$37.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.25
Rate for Payer: Medical Associates Commercial	$35.25
Rate for Payer: Midlands Choice Commercial	$32.90
Rate for Payer: United Healthcare Commercial	$42.30

ALBUMIN

Facility

$47.00

Service Code	CPT 82040
Hospital Charge Code	8093923
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$42.30
Rate for Payer: Aetna of IA Commercial	$42.30
Rate for Payer: Aetna of IA Medical Rental Products	$42.30
Rate for Payer: Aetna of IA Medicare	$26.79
Rate for Payer: Amerigroup Medicaid	$23.72
Rate for Payer: Amerigroup Medicare	$23.74
Rate for Payer: Cash Price	$37.60
Rate for Payer: Cash Price	$37.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.50
Rate for Payer: Iowa Total Care Managed Medicaid	$23.49
Rate for Payer: Medical Associates Commercial	$35.25
Rate for Payer: Medical Associates Managed Medicare	$23.50
Rate for Payer: Midlands Choice Commercial	$32.90
Rate for Payer: Molina Healthcare Managed Medicaid	$23.85
Rate for Payer: Molina Healthcare Managed Medicare	$23.84
Rate for Payer: Oscar Health of IA Commercial	$35.25
Rate for Payer: Partners Health Alliance Commercial	$35.25
Rate for Payer: United Healthcare Commercial	$42.30
Rate for Payer: United Healthcare Managed Medicare	$27.73
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

albumin human 25% IV Sol 50 mL SDV [VDMC]

Facility

$190.00

Service Code	HCPCS P9047
Hospital Charge Code	10364235
Hospital Revenue Code	259
Min. Negotiated Rate	$94.96
Max. Negotiated Rate	$1,444.48
Rate for Payer: Aetna of IA Commercial	$171.00
Rate for Payer: Aetna of IA Medical Rental Products	$171.00
Rate for Payer: Aetna of IA Medicare	$108.30
Rate for Payer: Amerigroup Medicaid	$95.89
Rate for Payer: Amerigroup Medicare	$95.95
Rate for Payer: Cash Price	$152.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$142.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$95.00
Rate for Payer: Iowa Total Care Managed Medicaid	$94.96
Rate for Payer: Medical Associates Commercial	$142.50
Rate for Payer: Medical Associates Managed Medicare	$95.00
Rate for Payer: Midlands Choice Commercial	$133.00
Rate for Payer: Molina Healthcare Managed Medicaid	$96.42
Rate for Payer: Molina Healthcare Managed Medicare	$96.37
Rate for Payer: Oscar Health of IA Commercial	$142.50
Rate for Payer: Partners Health Alliance Commercial	$142.50
Rate for Payer: United Healthcare Commercial	$171.00
Rate for Payer: United Healthcare Managed Medicare	$112.10
Rate for Payer: Wellmark IA HMO	$1,313.16
Rate for Payer: Wellmark IA PPO	$1,444.48

albumin human 25% IV Sol 50 mL SDV [VDMC]

Facility

$190.00

Service Code	HCPCS P9047
Hospital Charge Code	10364235
Hospital Revenue Code	259
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of IA Commercial	$171.00
Rate for Payer: Aetna of IA Medical Rental Products	$171.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$142.50
Rate for Payer: Medical Associates Commercial	$142.50
Rate for Payer: Midlands Choice Commercial	$133.00
Rate for Payer: United Healthcare Commercial	$171.00

albumin human 5% IV Sol 250 mL SDV [VDMC]

Facility

$207.00

Service Code	HCPCS P9045
Hospital Charge Code	26134630
Hospital Revenue Code	259
Min. Negotiated Rate	$103.46
Max. Negotiated Rate	$1,444.48
Rate for Payer: Aetna of IA Commercial	$186.30
Rate for Payer: Aetna of IA Medical Rental Products	$186.30
Rate for Payer: Aetna of IA Medicare	$117.99
Rate for Payer: Amerigroup Medicaid	$104.47
Rate for Payer: Amerigroup Medicare	$104.54
Rate for Payer: Cash Price	$165.60
Rate for Payer: Cash Price	$165.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$155.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.50
Rate for Payer: Iowa Total Care Managed Medicaid	$103.46
Rate for Payer: Medical Associates Commercial	$155.25
Rate for Payer: Medical Associates Managed Medicare	$103.50
Rate for Payer: Midlands Choice Commercial	$144.90
Rate for Payer: Molina Healthcare Managed Medicaid	$105.05
Rate for Payer: Molina Healthcare Managed Medicare	$104.99
Rate for Payer: Oscar Health of IA Commercial	$155.25
Rate for Payer: Partners Health Alliance Commercial	$155.25
Rate for Payer: United Healthcare Commercial	$186.30
Rate for Payer: United Healthcare Managed Medicare	$122.13
Rate for Payer: Wellmark IA HMO	$1,313.16
Rate for Payer: Wellmark IA PPO	$1,444.48

albumin human 5% IV Sol 250 mL SDV [VDMC]

Facility

$207.00

Service Code	HCPCS P9045
Hospital Charge Code	26134630
Hospital Revenue Code	259
Min. Negotiated Rate	$144.90
Max. Negotiated Rate	$186.30
Rate for Payer: Aetna of IA Commercial	$186.30
Rate for Payer: Aetna of IA Medical Rental Products	$186.30
Rate for Payer: Cash Price	$165.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$155.25
Rate for Payer: Medical Associates Commercial	$155.25
Rate for Payer: Midlands Choice Commercial	$144.90
Rate for Payer: United Healthcare Commercial	$186.30

albuterol 0.083% 2.5mg neb Sol 3 mL SDV [VDMC]

Facility

$4.73

Service Code	HCPCS A9270
Hospital Charge Code	10364375
Hospital Revenue Code	259
Min. Negotiated Rate	$2.36
Max. Negotiated Rate	$4.26
Rate for Payer: Aetna of IA Commercial	$4.26
Rate for Payer: Aetna of IA Medical Rental Products	$4.26
Rate for Payer: Aetna of IA Medicare	$2.70
Rate for Payer: Amerigroup Medicaid	$2.39
Rate for Payer: Amerigroup Medicare	$2.39
Rate for Payer: Cash Price	$3.79
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.55
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.36
Rate for Payer: Iowa Total Care Managed Medicaid	$2.36
Rate for Payer: Medical Associates Commercial	$3.55
Rate for Payer: Medical Associates Managed Medicare	$2.36
Rate for Payer: Midlands Choice Commercial	$3.31
Rate for Payer: Molina Healthcare Managed Medicaid	$2.40
Rate for Payer: Molina Healthcare Managed Medicare	$2.40
Rate for Payer: Oscar Health of IA Commercial	$3.55
Rate for Payer: Partners Health Alliance Commercial	$3.55
Rate for Payer: United Healthcare Commercial	$4.26
Rate for Payer: United Healthcare Managed Medicare	$2.79

Know your out-of-pocket cost for care.

All Charges