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	$9.83
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	$12.60
Rate for Payer: Amerigroup Medicare	$9.93
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	$9.83
Rate for Payer: Iowa Total Care Managed Medicaid	$12.48
Rate for Payer: Medical Associates Commercial	$16.38
Rate for Payer: Medical Associates Managed Medicare	$9.83
Rate for Payer: Midlands Choice Commercial	$15.29
Rate for Payer: Molina Healthcare Managed Medicaid	$12.66
Rate for Payer: Partners Health Alliance Commercial	$11.30
Rate for Payer: United Healthcare Commercial	$19.66
Rate for Payer: United Healthcare Managed Medicare	$12.89

polyethylene glycol 3350 - Pow 17 gm UD [VDMC]

Facility

$5.36

Service Code	HCPCS A9270
Hospital Charge Code	11221532
Hospital Revenue Code	259
Min. Negotiated Rate	$2.41
Max. Negotiated Rate	$4.82
Rate for Payer: Aetna of IA Commercial	$4.82
Rate for Payer: Aetna of IA Medical Rental Products	$4.82
Rate for Payer: Aetna of IA Medicare	$3.05
Rate for Payer: Amerigroup Medicaid	$3.09
Rate for Payer: Amerigroup Medicare	$2.44
Rate for Payer: Cash Price	$4.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.02
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.41
Rate for Payer: Iowa Total Care Managed Medicaid	$3.06
Rate for Payer: Medical Associates Commercial	$4.02
Rate for Payer: Medical Associates Managed Medicare	$2.41
Rate for Payer: Midlands Choice Commercial	$3.75
Rate for Payer: Molina Healthcare Managed Medicaid	$3.11
Rate for Payer: Partners Health Alliance Commercial	$2.77
Rate for Payer: United Healthcare Commercial	$4.82
Rate for Payer: United Healthcare Managed Medicare	$3.16

polyethylene glycol 3350 - Pow 17 gm UD [VDMC]

Facility

$5.36

Service Code	HCPCS A9270
Hospital Charge Code	11221532
Hospital Revenue Code	259
Min. Negotiated Rate	$3.75
Max. Negotiated Rate	$4.82
Rate for Payer: Aetna of IA Commercial	$4.82
Rate for Payer: Aetna of IA Medical Rental Products	$4.82
Rate for Payer: Cash Price	$4.29
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.02
Rate for Payer: Medical Associates Commercial	$4.02
Rate for Payer: Midlands Choice Commercial	$3.75
Rate for Payer: United Healthcare Commercial	$4.82

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	$30.49
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	$80.18
Rate for Payer: Amerigroup Medicare	$63.18
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	$62.55
Rate for Payer: Iowa Total Care Managed Medicaid	$79.40
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$62.55
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$80.56
Rate for Payer: Partners Health Alliance Commercial	$71.93
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC

Facility

$13,232.48

Service Code	MSDRG 862
Min. Negotiated Rate	$13,040.70
Max. Negotiated Rate	$13,232.48
Rate for Payer: Amerigroup Medicaid	$13,168.55
Rate for Payer: Iowa Total Care Managed Medicaid	$13,040.70
Rate for Payer: Molina Healthcare Managed Medicaid	$13,232.48

POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC

Facility

$9,871.44

Service Code	MSDRG 863
Min. Negotiated Rate	$9,728.37
Max. Negotiated Rate	$9,871.44
Rate for Payer: Amerigroup Medicaid	$9,823.75
Rate for Payer: Iowa Total Care Managed Medicaid	$9,728.37
Rate for Payer: Molina Healthcare Managed Medicaid	$9,871.44

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC

Facility

$16,881.77

Service Code	MSDRG 857
Min. Negotiated Rate	$16,637.10
Max. Negotiated Rate	$16,881.77
Rate for Payer: Amerigroup Medicaid	$16,800.21
Rate for Payer: Iowa Total Care Managed Medicaid	$16,637.10
Rate for Payer: Molina Healthcare Managed Medicaid	$16,881.77

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC

Facility

$28,734.93

Service Code	MSDRG 856
Min. Negotiated Rate	$28,318.47
Max. Negotiated Rate	$28,734.93
Rate for Payer: Amerigroup Medicaid	$28,596.10
Rate for Payer: Iowa Total Care Managed Medicaid	$28,318.47
Rate for Payer: Molina Healthcare Managed Medicaid	$28,734.93

POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$13,813.49

Service Code	MSDRG 858
Min. Negotiated Rate	$13,613.28
Max. Negotiated Rate	$13,813.49
Rate for Payer: Amerigroup Medicaid	$13,746.75
Rate for Payer: Iowa Total Care Managed Medicaid	$13,613.28
Rate for Payer: Molina Healthcare Managed Medicaid	$13,813.49

POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES

Facility

$10,140.55

Service Code	MSDRG 769
Min. Negotiated Rate	$9,993.58
Max. Negotiated Rate	$10,140.55
Rate for Payer: Amerigroup Medicaid	$10,091.56
Rate for Payer: Iowa Total Care Managed Medicaid	$9,993.58
Rate for Payer: Molina Healthcare Managed Medicaid	$10,140.55

POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES

Facility

$4,739.24

Service Code	MSDRG 776
Min. Negotiated Rate	$4,670.55
Max. Negotiated Rate	$4,739.24
Rate for Payer: Amerigroup Medicaid	$4,716.34
Rate for Payer: Iowa Total Care Managed Medicaid	$4,670.55
Rate for Payer: Molina Healthcare Managed Medicaid	$4,739.24

POST TITANIUM 4.5MM X 25MM

Facility

$180.00

Service Code	HCPCS 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	HCPCS C1713
Hospital Charge Code	8026177
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
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: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
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	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
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	HCPCS C1713
Hospital Charge Code	8047048
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
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: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
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	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
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	HCPCS 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 4.5MMX30MM

Facility

$180.00

Service Code	HCPCS 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 4.5MMX30MM

Facility

$180.00

Service Code	HCPCS C1713
Hospital Charge Code	8047049
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
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: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
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	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/WASHER TITANIUM 4.5MM X 35.7MM

Facility

$180.00

Service Code	HCPCS C1713
Hospital Charge Code	8047051
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
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: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
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	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

POST/WASHER TITANIUM 4.5MM X 35.7MM

Facility

$180.00

Service Code	HCPCS 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 35MM

Facility

$180.00

Service Code	HCPCS 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	HCPCS C1713
Hospital Charge Code	8047050
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
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: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
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	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
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	HCPCS 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	HCPCS C1713
Hospital Charge Code	8047052
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
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: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
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	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
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	HCPCS C1713
Hospital Charge Code	8047053
Hospital Revenue Code	278
Min. Negotiated Rate	$81.00
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: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$103.82
Rate for Payer: Amerigroup Medicare	$81.81
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	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$102.82
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$104.33
Rate for Payer: Partners Health Alliance Commercial	$93.15
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