Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

ampicillin-sulbactam 1.5 GM Inj SDV [VDMC]

Facility

$25.04

Service Code	HCPCS J0295
Hospital Charge Code	10367141
Hospital Revenue Code	259
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$22.54
Rate for Payer: Aetna of IA Commercial	$22.54
Rate for Payer: Aetna of IA Medical Rental Products	$22.54
Rate for Payer: Aetna of IA Medicare	$14.27
Rate for Payer: Amerigroup Medicaid	$12.64
Rate for Payer: Amerigroup Medicare	$12.65
Rate for Payer: Cash Price	$20.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.78
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.52
Rate for Payer: Iowa Total Care Managed Medicaid	$12.51
Rate for Payer: Medical Associates Commercial	$18.78
Rate for Payer: Medical Associates Managed Medicare	$12.52
Rate for Payer: Midlands Choice Commercial	$17.53
Rate for Payer: Molina Healthcare Managed Medicaid	$12.71
Rate for Payer: Molina Healthcare Managed Medicare	$12.70
Rate for Payer: Oscar Health of IA Commercial	$18.78
Rate for Payer: Partners Health Alliance Commercial	$18.78
Rate for Payer: United Healthcare Commercial	$22.54
Rate for Payer: United Healthcare Managed Medicare	$14.77

ampicillin-sulbactam 3 GM Inj SDV [VDMC]

Facility

$31.59

Service Code	HCPCS J0295
Hospital Charge Code	10367210
Hospital Revenue Code	259
Min. Negotiated Rate	$22.11
Max. Negotiated Rate	$28.43
Rate for Payer: Aetna of IA Commercial	$28.43
Rate for Payer: Aetna of IA Medical Rental Products	$28.43
Rate for Payer: Cash Price	$25.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.69
Rate for Payer: Medical Associates Commercial	$23.69
Rate for Payer: Midlands Choice Commercial	$22.11
Rate for Payer: United Healthcare Commercial	$28.43

ampicillin-sulbactam 3 GM Inj SDV [VDMC]

Facility

$31.59

Service Code	HCPCS J0295
Hospital Charge Code	10367210
Hospital Revenue Code	259
Min. Negotiated Rate	$15.79
Max. Negotiated Rate	$28.43
Rate for Payer: Aetna of IA Commercial	$28.43
Rate for Payer: Aetna of IA Medical Rental Products	$28.43
Rate for Payer: Aetna of IA Medicare	$18.01
Rate for Payer: Amerigroup Medicaid	$15.94
Rate for Payer: Amerigroup Medicare	$15.95
Rate for Payer: Cash Price	$25.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.69
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$15.80
Rate for Payer: Iowa Total Care Managed Medicaid	$15.79
Rate for Payer: Medical Associates Commercial	$23.69
Rate for Payer: Medical Associates Managed Medicare	$15.80
Rate for Payer: Midlands Choice Commercial	$22.11
Rate for Payer: Molina Healthcare Managed Medicaid	$16.03
Rate for Payer: Molina Healthcare Managed Medicare	$16.02
Rate for Payer: Oscar Health of IA Commercial	$23.69
Rate for Payer: Partners Health Alliance Commercial	$23.69
Rate for Payer: United Healthcare Commercial	$28.43
Rate for Payer: United Healthcare Managed Medicare	$18.64

AMPUTATE METATARSAL WITH TOE SINGLE

Professional

Both

$1,453.00

Service Code	CPT 28810
Hospital Charge Code	8825539
Hospital Revenue Code	975
Min. Negotiated Rate	$385.00
Max. Negotiated Rate	$1,017.10
Rate for Payer: Aetna of IA Medicare	$385.00
Rate for Payer: Amerigroup Medicaid	$398.09
Rate for Payer: Cash Price	$1,162.40
Rate for Payer: Cash Price	$1,162.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$462.00
Rate for Payer: Iowa Total Care Managed Medicaid	$392.70
Rate for Payer: Medical Associates Commercial	$731.50
Rate for Payer: Medical Associates Managed Medicare	$385.00
Rate for Payer: Midlands Choice Commercial	$1,017.10
Rate for Payer: Oscar Health of IA Commercial	$666.05
Rate for Payer: Partners Health Alliance Commercial	$577.50

Amputation for Circulatory System Disorders Except Upper Limb and Toe With CC

Facility

$25,874.72

Service Code	MS-DRG 240
Hospital Charge Code	102
Min. Negotiated Rate	$25,499.72
Max. Negotiated Rate	$25,874.72
Rate for Payer: Amerigroup Medicaid	$25,749.72
Rate for Payer: Iowa Total Care Managed Medicaid	$25,499.72
Rate for Payer: Molina Healthcare Managed Medicaid	$25,874.72

Amputation for Circulatory System Disorders Except Upper Limb and Toe With MCC

Facility

$44,251.50

Service Code	MS-DRG 239
Hospital Charge Code	101
Min. Negotiated Rate	$43,610.17
Max. Negotiated Rate	$44,251.50
Rate for Payer: Amerigroup Medicaid	$44,037.72
Rate for Payer: Iowa Total Care Managed Medicaid	$43,610.17
Rate for Payer: Molina Healthcare Managed Medicaid	$44,251.50

Amputation for Circulatory System Disorders Except Upper Limb and Toe Without CC/MCC

Facility

$15,667.16

Service Code	MS-DRG 241
Hospital Charge Code	103
Min. Negotiated Rate	$15,440.10
Max. Negotiated Rate	$15,667.16
Rate for Payer: Amerigroup Medicaid	$15,591.47
Rate for Payer: Iowa Total Care Managed Medicaid	$15,440.10
Rate for Payer: Molina Healthcare Managed Medicaid	$15,667.16

Amputation for Musculoskeletal System and Connective Tissue Disorders With CC

Facility

$20,747.81

Service Code	MS-DRG 475
Hospital Charge Code	295
Min. Negotiated Rate	$20,447.11
Max. Negotiated Rate	$20,747.81
Rate for Payer: Amerigroup Medicaid	$20,647.58
Rate for Payer: Iowa Total Care Managed Medicaid	$20,447.11
Rate for Payer: Molina Healthcare Managed Medicaid	$20,747.81

Amputation for Musculoskeletal System and Connective Tissue Disorders With MCC

Facility

$24,284.19

Service Code	MS-DRG 474
Hospital Charge Code	294
Min. Negotiated Rate	$23,932.25
Max. Negotiated Rate	$24,284.19
Rate for Payer: Amerigroup Medicaid	$24,166.88
Rate for Payer: Iowa Total Care Managed Medicaid	$23,932.25
Rate for Payer: Molina Healthcare Managed Medicaid	$24,284.19

Amputation for Musculoskeletal System and Connective Tissue Disorders Without CC/MCC

Facility

$9,309.94

Service Code	MS-DRG 476
Hospital Charge Code	296
Min. Negotiated Rate	$9,175.01
Max. Negotiated Rate	$9,309.94
Rate for Payer: Amerigroup Medicaid	$9,264.96
Rate for Payer: Iowa Total Care Managed Medicaid	$9,175.01
Rate for Payer: Molina Healthcare Managed Medicaid	$9,309.94

Amputation, metatarsal, with toe, single

Facility

$9,738.28

Service Code	CPT 28810
Hospital Revenue Code	360
Min. Negotiated Rate	$8,852.98
Max. Negotiated Rate	$9,738.28
Rate for Payer: Wellmark IA HMO	$8,852.98
Rate for Payer: Wellmark IA PPO	$9,738.28

Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders With CC

Facility

$15,515.58

Service Code	MS-DRG 617
Hospital Charge Code	409
Min. Negotiated Rate	$15,290.72
Max. Negotiated Rate	$15,515.58
Rate for Payer: Amerigroup Medicaid	$15,440.63
Rate for Payer: Iowa Total Care Managed Medicaid	$15,290.72
Rate for Payer: Molina Healthcare Managed Medicaid	$15,515.58

Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders With MCC

Facility

$20,458.44

Service Code	MS-DRG 616
Hospital Charge Code	408
Min. Negotiated Rate	$20,161.94
Max. Negotiated Rate	$20,458.44
Rate for Payer: Amerigroup Medicaid	$20,359.61
Rate for Payer: Iowa Total Care Managed Medicaid	$20,161.94
Rate for Payer: Molina Healthcare Managed Medicaid	$20,458.44

Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders Without CC/MCC

Facility

$7,439.88

Service Code	MS-DRG 618
Hospital Charge Code	410
Min. Negotiated Rate	$7,332.06
Max. Negotiated Rate	$7,439.88
Rate for Payer: Amerigroup Medicaid	$7,403.94
Rate for Payer: Iowa Total Care Managed Medicaid	$7,332.06
Rate for Payer: Molina Healthcare Managed Medicaid	$7,439.88

Amputation, toe; interphalangeal joint

Facility

$4,658.74

Service Code	CPT 28825
Hospital Revenue Code	360
Min. Negotiated Rate	$4,235.22
Max. Negotiated Rate	$4,658.74
Rate for Payer: Wellmark IA HMO	$4,235.22
Rate for Payer: Wellmark IA PPO	$4,658.74

Amputation, toe; metatarsophalangeal joint

Facility

$4,658.74

Service Code	CPT 28820
Hospital Revenue Code	360
Min. Negotiated Rate	$4,235.22
Max. Negotiated Rate	$4,658.74
Rate for Payer: Wellmark IA HMO	$4,235.22
Rate for Payer: Wellmark IA PPO	$4,658.74

AMYLASE

Facility

$64.00

Service Code	CPT 82150
Hospital Charge Code	631567
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$32.30
Rate for Payer: Amerigroup Medicare	$32.32
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.00
Rate for Payer: Iowa Total Care Managed Medicaid	$31.99
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$32.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$32.48
Rate for Payer: Molina Healthcare Managed Medicare	$32.46
Rate for Payer: Oscar Health of IA Commercial	$48.00
Rate for Payer: Partners Health Alliance Commercial	$48.00
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

AMYLASE

Facility

$64.00

Service Code	CPT 82150
Hospital Charge Code	631567
Hospital Revenue Code	301
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

Anal and Stomal Procedures With CC

Facility

$11,057.95

Service Code	MS-DRG 348
Hospital Charge Code	198
Min. Negotiated Rate	$10,897.69
Max. Negotiated Rate	$11,057.95
Rate for Payer: Amerigroup Medicaid	$11,004.53
Rate for Payer: Iowa Total Care Managed Medicaid	$10,897.69
Rate for Payer: Molina Healthcare Managed Medicaid	$11,057.95

Anal and Stomal Procedures With MCC

Facility

$24,234.00

Service Code	MS-DRG 347
Hospital Charge Code	197
Min. Negotiated Rate	$23,882.78
Max. Negotiated Rate	$24,234.00
Rate for Payer: Amerigroup Medicaid	$24,116.92
Rate for Payer: Iowa Total Care Managed Medicaid	$23,882.78
Rate for Payer: Molina Healthcare Managed Medicaid	$24,234.00

Anal and Stomal Procedures Without CC/MCC

Facility

$9,553.05

Service Code	MS-DRG 349
Hospital Charge Code	199
Min. Negotiated Rate	$9,414.60
Max. Negotiated Rate	$9,553.05
Rate for Payer: Amerigroup Medicaid	$9,506.90
Rate for Payer: Iowa Total Care Managed Medicaid	$9,414.60
Rate for Payer: Molina Healthcare Managed Medicaid	$9,553.05

ANCA Screen DMCL

Facility

$115.00

Service Code	CPT 86255
Hospital Charge Code	8037494
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Aetna of IA Medicare	$65.55
Rate for Payer: Amerigroup Medicaid	$58.04
Rate for Payer: Amerigroup Medicare	$58.08
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.50
Rate for Payer: Iowa Total Care Managed Medicaid	$57.48
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Medical Associates Managed Medicare	$57.50
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: Molina Healthcare Managed Medicaid	$58.36
Rate for Payer: Molina Healthcare Managed Medicare	$58.33
Rate for Payer: Oscar Health of IA Commercial	$86.25
Rate for Payer: Partners Health Alliance Commercial	$86.25
Rate for Payer: United Healthcare Commercial	$103.50
Rate for Payer: United Healthcare Managed Medicare	$67.85
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

ANCA Screen DMCL

Facility

$115.00

Service Code	CPT 86255
Hospital Charge Code	8037494
Hospital Revenue Code	302
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: United Healthcare Commercial	$103.50

ANCHOR SUTURE 2.5MM

Facility

$788.40

Service Code	CPT C1713
Hospital Charge Code	8871630
Hospital Revenue Code	278
Min. Negotiated Rate	$394.04
Max. Negotiated Rate	$709.56
Rate for Payer: Aetna of IA Commercial	$709.56
Rate for Payer: Aetna of IA Medical Rental Products	$709.56
Rate for Payer: Aetna of IA Medicare	$449.39
Rate for Payer: Amerigroup Medicaid	$397.91
Rate for Payer: Amerigroup Medicare	$398.14
Rate for Payer: Cash Price	$630.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$591.30
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$394.20
Rate for Payer: Iowa Total Care Managed Medicaid	$394.04
Rate for Payer: Medical Associates Commercial	$591.30
Rate for Payer: Medical Associates Managed Medicare	$394.20
Rate for Payer: Midlands Choice Commercial	$551.88
Rate for Payer: Molina Healthcare Managed Medicaid	$400.11
Rate for Payer: Molina Healthcare Managed Medicare	$399.88
Rate for Payer: Oscar Health of IA Commercial	$591.30
Rate for Payer: Partners Health Alliance Commercial	$591.30
Rate for Payer: United Healthcare Commercial	$709.56
Rate for Payer: United Healthcare Managed Medicare	$465.16

ANCHOR SUTURE 2.5MM

Facility

$788.40

Service Code	CPT C1713
Hospital Charge Code	8871630
Hospital Revenue Code	278
Min. Negotiated Rate	$551.88
Max. Negotiated Rate	$709.56
Rate for Payer: Aetna of IA Commercial	$709.56
Rate for Payer: Aetna of IA Medical Rental Products	$709.56
Rate for Payer: Cash Price	$630.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$591.30
Rate for Payer: Medical Associates Commercial	$591.30
Rate for Payer: Midlands Choice Commercial	$551.88
Rate for Payer: United Healthcare Commercial	$709.56

Know your out-of-pocket cost for care.

All Charges