Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ACRYSOF IQ VIVITY TORIC 22.5 LENS

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8885211
Hospital Revenue Code	276
Min. Negotiated Rate	$393.75
Max. Negotiated Rate	$787.50
Rate for Payer: Aetna of IA Commercial	$787.50
Rate for Payer: Aetna of IA Medical Rental Products	$787.50
Rate for Payer: Aetna of IA Medicare	$498.75
Rate for Payer: Amerigroup Medicaid	$504.70
Rate for Payer: Amerigroup Medicare	$397.69
Rate for Payer: Cash Price	$700.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$656.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$393.75
Rate for Payer: Iowa Total Care Managed Medicaid	$499.80
Rate for Payer: Medical Associates Commercial	$656.25
Rate for Payer: Medical Associates Managed Medicare	$393.75
Rate for Payer: Midlands Choice Commercial	$612.50
Rate for Payer: Molina Healthcare Managed Medicaid	$507.15
Rate for Payer: Partners Health Alliance Commercial	$452.81
Rate for Payer: United Healthcare Commercial	$787.50
Rate for Payer: United Healthcare Managed Medicare	$516.25

ACRYSOLF IQ LENS 21.5

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8893483
Hospital Revenue Code	276
Min. Negotiated Rate	$393.75
Max. Negotiated Rate	$787.50
Rate for Payer: Aetna of IA Commercial	$787.50
Rate for Payer: Aetna of IA Medical Rental Products	$787.50
Rate for Payer: Aetna of IA Medicare	$498.75
Rate for Payer: Amerigroup Medicaid	$504.70
Rate for Payer: Amerigroup Medicare	$397.69
Rate for Payer: Cash Price	$700.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$656.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$393.75
Rate for Payer: Iowa Total Care Managed Medicaid	$499.80
Rate for Payer: Medical Associates Commercial	$656.25
Rate for Payer: Medical Associates Managed Medicare	$393.75
Rate for Payer: Midlands Choice Commercial	$612.50
Rate for Payer: Molina Healthcare Managed Medicaid	$507.15
Rate for Payer: Partners Health Alliance Commercial	$452.81
Rate for Payer: United Healthcare Commercial	$787.50
Rate for Payer: United Healthcare Managed Medicare	$516.25

ACRYSOLF IQ LENS 21.5

Facility

$875.00

Service Code	HCPCS V2788
Hospital Charge Code	8893483
Hospital Revenue Code	276
Min. Negotiated Rate	$612.50
Max. Negotiated Rate	$787.50
Rate for Payer: Aetna of IA Commercial	$787.50
Rate for Payer: Aetna of IA Medical Rental Products	$787.50
Rate for Payer: Cash Price	$700.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$656.25
Rate for Payer: Medical Associates Commercial	$656.25
Rate for Payer: Midlands Choice Commercial	$612.50
Rate for Payer: United Healthcare Commercial	$787.50

activated charcoal (ped) 25 g Oral Susp 120 mL [VDMC]

Facility

$84.72

Service Code	HCPCS A9270
Hospital Charge Code	10377167
Hospital Revenue Code	259
Min. Negotiated Rate	$38.12
Max. Negotiated Rate	$76.25
Rate for Payer: Aetna of IA Commercial	$76.25
Rate for Payer: Aetna of IA Medical Rental Products	$76.25
Rate for Payer: Aetna of IA Medicare	$48.29
Rate for Payer: Amerigroup Medicaid	$48.87
Rate for Payer: Amerigroup Medicare	$38.51
Rate for Payer: Cash Price	$67.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.12
Rate for Payer: Iowa Total Care Managed Medicaid	$48.39
Rate for Payer: Medical Associates Commercial	$63.54
Rate for Payer: Medical Associates Managed Medicare	$38.12
Rate for Payer: Midlands Choice Commercial	$59.30
Rate for Payer: Molina Healthcare Managed Medicaid	$49.10
Rate for Payer: Partners Health Alliance Commercial	$43.84
Rate for Payer: United Healthcare Commercial	$76.25
Rate for Payer: United Healthcare Managed Medicare	$49.98

activated charcoal (ped) 25 g Oral Susp 120 mL [VDMC]

Facility

$84.72

Service Code	HCPCS A9270
Hospital Charge Code	10377167
Hospital Revenue Code	259
Min. Negotiated Rate	$59.30
Max. Negotiated Rate	$76.25
Rate for Payer: Aetna of IA Commercial	$76.25
Rate for Payer: Aetna of IA Medical Rental Products	$76.25
Rate for Payer: Cash Price	$67.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.54
Rate for Payer: Medical Associates Commercial	$63.54
Rate for Payer: Midlands Choice Commercial	$59.30
Rate for Payer: United Healthcare Commercial	$76.25

activated charcoal-sorbitol 50 g Oral Susp 240 mL [VDMC]

Facility

$86.28

Service Code	HCPCS A9270
Hospital Charge Code	10377232
Hospital Revenue Code	259
Min. Negotiated Rate	$60.40
Max. Negotiated Rate	$77.65
Rate for Payer: Aetna of IA Commercial	$77.65
Rate for Payer: Aetna of IA Medical Rental Products	$77.65
Rate for Payer: Cash Price	$69.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.71
Rate for Payer: Medical Associates Commercial	$64.71
Rate for Payer: Midlands Choice Commercial	$60.40
Rate for Payer: United Healthcare Commercial	$77.65

activated charcoal-sorbitol 50 g Oral Susp 240 mL [VDMC]

Facility

$86.28

Service Code	HCPCS A9270
Hospital Charge Code	10377232
Hospital Revenue Code	259
Min. Negotiated Rate	$38.83
Max. Negotiated Rate	$77.65
Rate for Payer: Aetna of IA Commercial	$77.65
Rate for Payer: Aetna of IA Medical Rental Products	$77.65
Rate for Payer: Aetna of IA Medicare	$49.18
Rate for Payer: Amerigroup Medicaid	$49.77
Rate for Payer: Amerigroup Medicare	$39.21
Rate for Payer: Cash Price	$69.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.71
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.83
Rate for Payer: Iowa Total Care Managed Medicaid	$49.28
Rate for Payer: Medical Associates Commercial	$64.71
Rate for Payer: Medical Associates Managed Medicare	$38.83
Rate for Payer: Midlands Choice Commercial	$60.40
Rate for Payer: Molina Healthcare Managed Medicaid	$50.01
Rate for Payer: Partners Health Alliance Commercial	$44.65
Rate for Payer: United Healthcare Commercial	$77.65
Rate for Payer: United Healthcare Managed Medicare	$50.91

ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION

Facility

$6,115.18

Service Code	MSDRG 880
Min. Negotiated Rate	$6,026.55
Max. Negotiated Rate	$6,115.18
Rate for Payer: Amerigroup Medicaid	$6,085.64
Rate for Payer: Iowa Total Care Managed Medicaid	$6,026.55
Rate for Payer: Molina Healthcare Managed Medicaid	$6,115.18

ACUTE AND SUBACUTE ENDOCARDITIS WITH CC

Facility

$16,196.05

Service Code	MSDRG 289
Min. Negotiated Rate	$15,961.32
Max. Negotiated Rate	$16,196.05
Rate for Payer: Amerigroup Medicaid	$16,117.80
Rate for Payer: Iowa Total Care Managed Medicaid	$15,961.32
Rate for Payer: Molina Healthcare Managed Medicaid	$16,196.05

ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC

Facility

$21,355.28

Service Code	MSDRG 288
Min. Negotiated Rate	$21,045.77
Max. Negotiated Rate	$21,355.28
Rate for Payer: Amerigroup Medicaid	$21,252.10
Rate for Payer: Iowa Total Care Managed Medicaid	$21,045.77
Rate for Payer: Molina Healthcare Managed Medicaid	$21,355.28

ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC

Facility

$11,528.88

Service Code	MSDRG 290
Min. Negotiated Rate	$11,361.79
Max. Negotiated Rate	$11,528.88
Rate for Payer: Amerigroup Medicaid	$11,473.18
Rate for Payer: Iowa Total Care Managed Medicaid	$11,361.79
Rate for Payer: Molina Healthcare Managed Medicaid	$11,528.88

ACUTE HEPATITIS PROFILE

Facility

$303.00

Service Code	CPT 80074
Hospital Charge Code	8037485
Hospital Revenue Code	302
Min. Negotiated Rate	$212.10
Max. Negotiated Rate	$272.70
Rate for Payer: Aetna of IA Commercial	$272.70
Rate for Payer: Aetna of IA Medical Rental Products	$272.70
Rate for Payer: Cash Price	$242.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$227.25
Rate for Payer: Medical Associates Commercial	$227.25
Rate for Payer: Midlands Choice Commercial	$212.10
Rate for Payer: United Healthcare Commercial	$272.70

ACUTE HEPATITIS PROFILE

Facility

$303.00

Service Code	CPT 80074
Hospital Charge Code	8037485
Hospital Revenue Code	302
Min. Negotiated Rate	$60.97
Max. Negotiated Rate	$272.70
Rate for Payer: Aetna of IA Commercial	$272.70
Rate for Payer: Aetna of IA Medical Rental Products	$272.70
Rate for Payer: Aetna of IA Medicare	$172.71
Rate for Payer: Amerigroup Medicaid	$174.77
Rate for Payer: Amerigroup Medicare	$137.71
Rate for Payer: Cash Price	$242.40
Rate for Payer: Cash Price	$242.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$227.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$136.35
Rate for Payer: Iowa Total Care Managed Medicaid	$173.07
Rate for Payer: Medical Associates Commercial	$227.25
Rate for Payer: Medical Associates Managed Medicare	$136.35
Rate for Payer: Midlands Choice Commercial	$212.10
Rate for Payer: Molina Healthcare Managed Medicaid	$175.62
Rate for Payer: Partners Health Alliance Commercial	$156.80
Rate for Payer: United Healthcare Commercial	$272.70
Rate for Payer: United Healthcare Managed Medicare	$178.77
Rate for Payer: Wellmark IA HMO WHPI	$60.97
Rate for Payer: Wellmark IA PPO	$67.17

ACUTE LEUKEMIA WITH CC

Facility

$30,886.68

Service Code	MSDRG 835
Min. Negotiated Rate	$30,439.03
Max. Negotiated Rate	$30,886.68
Rate for Payer: Amerigroup Medicaid	$30,737.45
Rate for Payer: Iowa Total Care Managed Medicaid	$30,439.03
Rate for Payer: Molina Healthcare Managed Medicaid	$30,886.68

ACUTE LEUKEMIA WITH MCC

Facility

$70,138.23

Service Code	MSDRG 834
Min. Negotiated Rate	$69,121.71
Max. Negotiated Rate	$70,138.23
Rate for Payer: Amerigroup Medicaid	$69,799.37
Rate for Payer: Iowa Total Care Managed Medicaid	$69,121.71
Rate for Payer: Molina Healthcare Managed Medicaid	$70,138.23

ACUTE LEUKEMIA WITHOUT CC/MCC

Facility

$13,172.80

Service Code	MSDRG 836
Min. Negotiated Rate	$12,981.89
Max. Negotiated Rate	$13,172.80
Rate for Payer: Amerigroup Medicaid	$13,109.16
Rate for Payer: Iowa Total Care Managed Medicaid	$12,981.89
Rate for Payer: Molina Healthcare Managed Medicaid	$13,172.80

ACUTE MAJOR EYE INFECTIONS WITH CC/MCC

Facility

$9,256.66

Service Code	MSDRG 121
Min. Negotiated Rate	$9,122.50
Max. Negotiated Rate	$9,256.66
Rate for Payer: Amerigroup Medicaid	$9,211.93
Rate for Payer: Iowa Total Care Managed Medicaid	$9,122.50
Rate for Payer: Molina Healthcare Managed Medicaid	$9,256.66

ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC

Facility

$5,980.06

Service Code	MSDRG 122
Min. Negotiated Rate	$5,893.39
Max. Negotiated Rate	$5,980.06
Rate for Payer: Amerigroup Medicaid	$5,951.17
Rate for Payer: Iowa Total Care Managed Medicaid	$5,893.39
Rate for Payer: Molina Healthcare Managed Medicaid	$5,980.06

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH CC

Facility

$8,646.38

Service Code	MSDRG 281
Min. Negotiated Rate	$8,521.06
Max. Negotiated Rate	$8,646.38
Rate for Payer: Amerigroup Medicaid	$8,604.60
Rate for Payer: Iowa Total Care Managed Medicaid	$8,521.06
Rate for Payer: Molina Healthcare Managed Medicaid	$8,646.38

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITH MCC

Facility

$14,987.88

Service Code	MSDRG 280
Min. Negotiated Rate	$14,770.66
Max. Negotiated Rate	$14,987.88
Rate for Payer: Amerigroup Medicaid	$14,915.47
Rate for Payer: Iowa Total Care Managed Medicaid	$14,770.66
Rate for Payer: Molina Healthcare Managed Medicaid	$14,987.88

ACUTE MYOCARDIAL INFARCTION, DISCHARGED ALIVE WITHOUT CC/MCC

Facility

$7,135.32

Service Code	MSDRG 282
Min. Negotiated Rate	$7,031.90
Max. Negotiated Rate	$7,135.32
Rate for Payer: Amerigroup Medicaid	$7,100.84
Rate for Payer: Iowa Total Care Managed Medicaid	$7,031.90
Rate for Payer: Molina Healthcare Managed Medicaid	$7,135.32

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH CC

Facility

$8,266.92

Service Code	MSDRG 284
Min. Negotiated Rate	$8,147.11
Max. Negotiated Rate	$8,266.92
Rate for Payer: Amerigroup Medicaid	$8,226.98
Rate for Payer: Iowa Total Care Managed Medicaid	$8,147.11
Rate for Payer: Molina Healthcare Managed Medicaid	$8,266.92

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITH MCC

Facility

$12,461.19

Service Code	MSDRG 283
Min. Negotiated Rate	$12,280.59
Max. Negotiated Rate	$12,461.19
Rate for Payer: Amerigroup Medicaid	$12,400.98
Rate for Payer: Iowa Total Care Managed Medicaid	$12,280.59
Rate for Payer: Molina Healthcare Managed Medicaid	$12,461.19

ACUTE MYOCARDIAL INFARCTION, EXPIRED WITHOUT CC/MCC

Facility

$5,589.35

Service Code	MSDRG 285
Min. Negotiated Rate	$5,508.34
Max. Negotiated Rate	$5,589.35
Rate for Payer: Amerigroup Medicaid	$5,562.35
Rate for Payer: Iowa Total Care Managed Medicaid	$5,508.34
Rate for Payer: Molina Healthcare Managed Medicaid	$5,589.35

acyclovir 400 mg Tab [VDMC]

Facility

$1.24

Service Code	HCPCS A9270
Hospital Charge Code	10363815
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of IA Commercial	$1.12
Rate for Payer: Aetna of IA Medical Rental Products	$1.12
Rate for Payer: Aetna of IA Medicare	$0.71
Rate for Payer: Amerigroup Medicaid	$0.72
Rate for Payer: Amerigroup Medicare	$0.56
Rate for Payer: Cash Price	$0.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.93
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.56
Rate for Payer: Iowa Total Care Managed Medicaid	$0.71
Rate for Payer: Medical Associates Commercial	$0.93
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.87
Rate for Payer: Molina Healthcare Managed Medicaid	$0.72
Rate for Payer: Partners Health Alliance Commercial	$0.64
Rate for Payer: United Healthcare Commercial	$1.12
Rate for Payer: United Healthcare Managed Medicare	$0.73

Know your out-of-pocket cost for care.

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