Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$805.13
Rate for Payer: Medical Associates Commercial	$805.13
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	$483.08
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	$619.20
Rate for Payer: Amerigroup Medicare	$487.91
Rate for Payer: Cash Price	$858.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$805.13
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$483.08
Rate for Payer: Iowa Total Care Managed Medicaid	$613.19
Rate for Payer: Medical Associates Commercial	$805.13
Rate for Payer: Medical Associates Managed Medicare	$483.08
Rate for Payer: Midlands Choice Commercial	$751.45
Rate for Payer: Molina Healthcare Managed Medicaid	$622.20
Rate for Payer: Partners Health Alliance Commercial	$555.54
Rate for Payer: United Healthcare Commercial	$966.15
Rate for Payer: United Healthcare Managed Medicare	$633.37

Penicillin V Potassium 250mg Tab [VDMC]

Facility

$1.27

Service Code	HCPCS A9270
Hospital Charge Code	24496674
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.15
Rate for Payer: Aetna of IA Commercial	$1.15
Rate for Payer: Aetna of IA Medical Rental Products	$1.15
Rate for Payer: Aetna of IA Medicare	$0.73
Rate for Payer: Amerigroup Medicaid	$0.73
Rate for Payer: Amerigroup Medicare	$0.58
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	$0.57
Rate for Payer: Iowa Total Care Managed Medicaid	$0.73
Rate for Payer: Medical Associates Commercial	$0.95
Rate for Payer: Medical Associates Managed Medicare	$0.57
Rate for Payer: Midlands Choice Commercial	$0.89
Rate for Payer: Molina Healthcare Managed Medicaid	$0.74
Rate for Payer: Partners Health Alliance Commercial	$0.66
Rate for Payer: United Healthcare Commercial	$1.15
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	$1.15
Rate for Payer: Aetna of IA Commercial	$1.15
Rate for Payer: Aetna of IA Medical Rental Products	$1.15
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	$1.15

PENIS PROCEDURES WITH CC/MCC

Facility

$26,038.22

Service Code	MSDRG 709
Min. Negotiated Rate	$25,660.84
Max. Negotiated Rate	$26,038.22
Rate for Payer: Amerigroup Medicaid	$25,912.42
Rate for Payer: Iowa Total Care Managed Medicaid	$25,660.84
Rate for Payer: Molina Healthcare Managed Medicaid	$26,038.22

PENIS PROCEDURES WITHOUT CC/MCC

Facility

$12,408.27

Service Code	MSDRG 710
Min. Negotiated Rate	$12,228.43
Max. Negotiated Rate	$12,408.27
Rate for Payer: Amerigroup Medicaid	$12,348.32
Rate for Payer: Iowa Total Care Managed Medicaid	$12,228.43
Rate for Payer: Molina Healthcare Managed Medicaid	$12,408.27

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	$0.72
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	$0.93
Rate for Payer: Amerigroup Medicare	$0.73
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	$0.72
Rate for Payer: Iowa Total Care Managed Medicaid	$0.92
Rate for Payer: Medical Associates Commercial	$1.21
Rate for Payer: Medical Associates Managed Medicare	$0.72
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: Molina Healthcare Managed Medicaid	$0.93
Rate for Payer: Partners Health Alliance Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.45
Rate for Payer: United Healthcare Managed Medicare	$0.95

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	$429.50
Max. Negotiated Rate	$5,033.70
Rate for Payer: Amerigroup Medicaid	$433.71
Rate for Payer: Cash Price	$3,474.40
Rate for Payer: Cash Price	$3,474.40
Rate for Payer: Iowa Total Care Managed Medicaid	$429.50
Rate for Payer: Medical Associates Commercial	$3,257.25
Rate for Payer: Midlands Choice Commercial	$3,040.10
Rate for Payer: Molina Healthcare Managed Medicaid	$431.61
Rate for Payer: Partners Health Alliance Commercial	$3,257.25
Rate for Payer: United Healthcare Commercial	$2,854.50
Rate for Payer: Wellmark IA HMO WHPI	$4,278.70
Rate for Payer: Wellmark IA PPO	$5,033.70

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC

Facility

$28,665.12

Service Code	MSDRG 273
Min. Negotiated Rate	$28,249.67
Max. Negotiated Rate	$28,665.12
Rate for Payer: Amerigroup Medicaid	$28,526.63
Rate for Payer: Iowa Total Care Managed Medicaid	$28,249.67
Rate for Payer: Molina Healthcare Managed Medicaid	$28,665.12

PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC

Facility

$28,665.12

Service Code	MSDRG 274
Min. Negotiated Rate	$28,249.67
Max. Negotiated Rate	$28,665.12
Rate for Payer: Amerigroup Medicaid	$28,526.63
Rate for Payer: Iowa Total Care Managed Medicaid	$28,249.67
Rate for Payer: Molina Healthcare Managed Medicaid	$28,665.12

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITH MCC

Facility

$20,313.75

Service Code	MSDRG 250
Min. Negotiated Rate	$20,019.34
Max. Negotiated Rate	$20,313.75
Rate for Payer: Amerigroup Medicaid	$20,215.61
Rate for Payer: Iowa Total Care Managed Medicaid	$20,019.34
Rate for Payer: Molina Healthcare Managed Medicaid	$20,313.75

PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT INTRALUMINAL DEVICE WITHOUT MCC

Facility

$15,460.79

Service Code	MSDRG 251
Min. Negotiated Rate	$15,236.71
Max. Negotiated Rate	$15,460.79
Rate for Payer: Amerigroup Medicaid	$15,386.09
Rate for Payer: Iowa Total Care Managed Medicaid	$15,236.71
Rate for Payer: Molina Healthcare Managed Medicaid	$15,460.79

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR

Facility

$22,214.40

Service Code	MSDRG 041
Min. Negotiated Rate	$21,892.44
Max. Negotiated Rate	$22,214.40
Rate for Payer: Amerigroup Medicaid	$22,107.07
Rate for Payer: Iowa Total Care Managed Medicaid	$21,892.44
Rate for Payer: Molina Healthcare Managed Medicaid	$22,214.40

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC

Facility

$30,664.86

Service Code	MSDRG 040
Min. Negotiated Rate	$30,220.43
Max. Negotiated Rate	$30,664.86
Rate for Payer: Amerigroup Medicaid	$30,516.70
Rate for Payer: Iowa Total Care Managed Medicaid	$30,220.43
Rate for Payer: Molina Healthcare Managed Medicaid	$30,664.86

PERIPHERAL, CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC

Facility

$11,368.99

Service Code	MSDRG 042
Min. Negotiated Rate	$11,204.22
Max. Negotiated Rate	$11,368.99
Rate for Payer: Amerigroup Medicaid	$11,314.06
Rate for Payer: Iowa Total Care Managed Medicaid	$11,204.22
Rate for Payer: Molina Healthcare Managed Medicaid	$11,368.99

PERIPHERAL VASCULAR DISORDERS WITH CC

Facility

$11,240.63

Service Code	MSDRG 300
Min. Negotiated Rate	$11,077.72
Max. Negotiated Rate	$11,240.63
Rate for Payer: Amerigroup Medicaid	$11,186.32
Rate for Payer: Iowa Total Care Managed Medicaid	$11,077.72
Rate for Payer: Molina Healthcare Managed Medicaid	$11,240.63

PERIPHERAL VASCULAR DISORDERS WITH MCC

Facility

$11,245.13

Service Code	MSDRG 299
Min. Negotiated Rate	$11,082.15
Max. Negotiated Rate	$11,245.13
Rate for Payer: Amerigroup Medicaid	$11,190.80
Rate for Payer: Iowa Total Care Managed Medicaid	$11,082.15
Rate for Payer: Molina Healthcare Managed Medicaid	$11,245.13

PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC

Facility

$6,137.70

Service Code	MSDRG 301
Min. Negotiated Rate	$6,048.75
Max. Negotiated Rate	$6,137.70
Rate for Payer: Amerigroup Medicaid	$6,108.05
Rate for Payer: Iowa Total Care Managed Medicaid	$6,048.75
Rate for Payer: Molina Healthcare Managed Medicaid	$6,137.70

PERITONEAL ADHESIOLYSIS WITH CC

Facility

$21,527.55

Service Code	MSDRG 336
Min. Negotiated Rate	$21,215.55
Max. Negotiated Rate	$21,527.55
Rate for Payer: Amerigroup Medicaid	$21,423.55
Rate for Payer: Iowa Total Care Managed Medicaid	$21,215.55
Rate for Payer: Molina Healthcare Managed Medicaid	$21,527.55

PERITONEAL ADHESIOLYSIS WITH MCC

Facility

$31,843.76

Service Code	MSDRG 335
Min. Negotiated Rate	$31,382.24
Max. Negotiated Rate	$31,843.76
Rate for Payer: Amerigroup Medicaid	$31,689.91
Rate for Payer: Iowa Total Care Managed Medicaid	$31,382.24
Rate for Payer: Molina Healthcare Managed Medicaid	$31,843.76

PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC

Facility

$17,392.97

Service Code	MSDRG 337
Min. Negotiated Rate	$17,140.89
Max. Negotiated Rate	$17,392.97
Rate for Payer: Amerigroup Medicaid	$17,308.94
Rate for Payer: Iowa Total Care Managed Medicaid	$17,140.89
Rate for Payer: Molina Healthcare Managed Medicaid	$17,392.97

PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC

Facility

$26,284.81

Service Code	MSDRG 243
Min. Negotiated Rate	$25,903.86
Max. Negotiated Rate	$26,284.81
Rate for Payer: Amerigroup Medicaid	$26,157.82
Rate for Payer: Iowa Total Care Managed Medicaid	$25,903.86
Rate for Payer: Molina Healthcare Managed Medicaid	$26,284.81

PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC

Facility

$33,023.78

Service Code	MSDRG 242
Min. Negotiated Rate	$32,545.16
Max. Negotiated Rate	$33,023.78
Rate for Payer: Amerigroup Medicaid	$32,864.23
Rate for Payer: Iowa Total Care Managed Medicaid	$32,545.16
Rate for Payer: Molina Healthcare Managed Medicaid	$33,023.78

PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC

Facility

$20,187.64

Service Code	MSDRG 244
Min. Negotiated Rate	$19,895.06
Max. Negotiated Rate	$20,187.64
Rate for Payer: Amerigroup Medicaid	$20,090.11
Rate for Payer: Iowa Total Care Managed Medicaid	$19,895.06
Rate for Payer: Molina Healthcare Managed Medicaid	$20,187.64

Know your out-of-pocket cost for care.

All Charges