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	$18.45
Max. Negotiated Rate	$41.39
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	$23.65
Rate for Payer: Amerigroup Medicare	$18.63
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	$18.45
Rate for Payer: Iowa Total Care Managed Medicaid	$23.42
Rate for Payer: Medical Associates Commercial	$30.75
Rate for Payer: Medical Associates Managed Medicare	$18.45
Rate for Payer: Midlands Choice Commercial	$28.70
Rate for Payer: Molina Healthcare Managed Medicaid	$23.76
Rate for Payer: Partners Health Alliance Commercial	$21.22
Rate for Payer: United Healthcare Commercial	$36.90
Rate for Payer: United Healthcare Managed Medicare	$24.19
Rate for Payer: Wellmark IA HMO WHPI	$37.58
Rate for Payer: Wellmark IA PPO	$41.39

ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC

Facility

$28,921.85

Service Code	MSDRG 614
Min. Negotiated Rate	$28,502.68
Max. Negotiated Rate	$28,921.85
Rate for Payer: Amerigroup Medicaid	$28,782.11
Rate for Payer: Iowa Total Care Managed Medicaid	$28,502.68
Rate for Payer: Molina Healthcare Managed Medicaid	$28,921.85

ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC

Facility

$17,371.57

Service Code	MSDRG 615
Min. Negotiated Rate	$17,119.80
Max. Negotiated Rate	$17,371.57
Rate for Payer: Amerigroup Medicaid	$17,287.64
Rate for Payer: Iowa Total Care Managed Medicaid	$17,119.80
Rate for Payer: Molina Healthcare Managed Medicaid	$17,371.57

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	$82.95
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	$151.70
Rate for Payer: Amerigroup Medicare	$119.53
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	$118.35
Rate for Payer: Iowa Total Care Managed Medicaid	$150.23
Rate for Payer: Medical Associates Commercial	$197.25
Rate for Payer: Medical Associates Managed Medicare	$118.35
Rate for Payer: Midlands Choice Commercial	$184.10
Rate for Payer: Molina Healthcare Managed Medicaid	$152.43
Rate for Payer: Partners Health Alliance Commercial	$136.10
Rate for Payer: United Healthcare Commercial	$236.70
Rate for Payer: United Healthcare Managed Medicare	$155.17
Rate for Payer: Wellmark IA HMO WHPI	$82.95
Rate for Payer: Wellmark IA PPO	$91.38

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC

Facility

$16,913.30

Service Code	MSDRG 560
Min. Negotiated Rate	$16,668.17
Max. Negotiated Rate	$16,913.30
Rate for Payer: Amerigroup Medicaid	$16,831.59
Rate for Payer: Iowa Total Care Managed Medicaid	$16,668.17
Rate for Payer: Molina Healthcare Managed Medicaid	$16,913.30

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$16,913.30

Service Code	MSDRG 559
Min. Negotiated Rate	$16,668.17
Max. Negotiated Rate	$16,913.30
Rate for Payer: Amerigroup Medicaid	$16,831.59
Rate for Payer: Iowa Total Care Managed Medicaid	$16,668.17
Rate for Payer: Molina Healthcare Managed Medicaid	$16,913.30

AFTERCARE, MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC

Facility

$7,358.26

Service Code	MSDRG 561
Min. Negotiated Rate	$7,251.62
Max. Negotiated Rate	$7,358.26
Rate for Payer: Amerigroup Medicaid	$7,322.71
Rate for Payer: Iowa Total Care Managed Medicaid	$7,251.62
Rate for Payer: Molina Healthcare Managed Medicaid	$7,358.26

AFTERCARE WITH CC/MCC

Facility

$24,846.93

Service Code	MSDRG 949
Min. Negotiated Rate	$24,486.82
Max. Negotiated Rate	$24,846.93
Rate for Payer: Amerigroup Medicaid	$24,726.89
Rate for Payer: Iowa Total Care Managed Medicaid	$24,486.82
Rate for Payer: Molina Healthcare Managed Medicaid	$24,846.93

AFTERCARE WITHOUT CC/MCC

Facility

$7,161.21

Service Code	MSDRG 950
Min. Negotiated Rate	$7,057.42
Max. Negotiated Rate	$7,161.21
Rate for Payer: Amerigroup Medicaid	$7,126.62
Rate for Payer: Iowa Total Care Managed Medicaid	$7,057.42
Rate for Payer: Molina Healthcare Managed Medicaid	$7,161.21

AICD GENERATOR PROCEDURES

Facility

$50,625.05

Service Code	MSDRG 245
Min. Negotiated Rate	$49,891.33
Max. Negotiated Rate	$50,625.05
Rate for Payer: Amerigroup Medicaid	$50,380.46
Rate for Payer: Iowa Total Care Managed Medicaid	$49,891.33
Rate for Payer: Molina Healthcare Managed Medicaid	$50,625.05

AICD LEAD PROCEDURES

Facility

$34,059.68

Service Code	MSDRG 265
Min. Negotiated Rate	$33,566.04
Max. Negotiated Rate	$34,059.68
Rate for Payer: Amerigroup Medicaid	$33,895.12
Rate for Payer: Iowa Total Care Managed Medicaid	$33,566.04
Rate for Payer: Molina Healthcare Managed Medicaid	$34,059.68

AIRWAY SUCTION-NASOTRACHEAL ONLY

Facility

$176.00

Service Code	CPT 31720
Hospital Charge Code	5338782
Hospital Revenue Code	410
Min. Negotiated Rate	$79.20
Max. Negotiated Rate	$203.84
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	$101.52
Rate for Payer: Amerigroup Medicare	$79.99
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	$79.20
Rate for Payer: Iowa Total Care Managed Medicaid	$100.53
Rate for Payer: Medical Associates Commercial	$132.00
Rate for Payer: Medical Associates Managed Medicare	$79.20
Rate for Payer: Midlands Choice Commercial	$123.20
Rate for Payer: Molina Healthcare Managed Medicaid	$102.01
Rate for Payer: Partners Health Alliance Commercial	$91.08
Rate for Payer: United Healthcare Commercial	$158.40
Rate for Payer: United Healthcare Managed Medicare	$103.84
Rate for Payer: Wellmark IA HMO WHPI	$185.05
Rate for Payer: Wellmark IA PPO	$203.84

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

ALBUMIN

Facility

$47.00

Service Code	CPT 82040
Hospital Charge Code	1620877
Hospital Revenue Code	301
Min. Negotiated Rate	$21.15
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	$27.11
Rate for Payer: Amerigroup Medicare	$21.36
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	$21.15
Rate for Payer: Iowa Total Care Managed Medicaid	$26.85
Rate for Payer: Medical Associates Commercial	$35.25
Rate for Payer: Medical Associates Managed Medicare	$21.15
Rate for Payer: Midlands Choice Commercial	$32.90
Rate for Payer: Molina Healthcare Managed Medicaid	$27.24
Rate for Payer: Partners Health Alliance Commercial	$24.32
Rate for Payer: United Healthcare Commercial	$42.30
Rate for Payer: United Healthcare Managed Medicare	$27.73
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

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	$21.15
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	$27.11
Rate for Payer: Amerigroup Medicare	$21.36
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	$21.15
Rate for Payer: Iowa Total Care Managed Medicaid	$26.85
Rate for Payer: Medical Associates Commercial	$35.25
Rate for Payer: Medical Associates Managed Medicare	$21.15
Rate for Payer: Midlands Choice Commercial	$32.90
Rate for Payer: Molina Healthcare Managed Medicaid	$27.24
Rate for Payer: Partners Health Alliance Commercial	$24.32
Rate for Payer: United Healthcare Commercial	$42.30
Rate for Payer: United Healthcare Managed Medicare	$27.73
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

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	$85.50
Max. Negotiated Rate	$505.31
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	$109.59
Rate for Payer: Amerigroup Medicare	$86.36
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	$85.50
Rate for Payer: Iowa Total Care Managed Medicaid	$108.53
Rate for Payer: Medical Associates Commercial	$142.50
Rate for Payer: Medical Associates Managed Medicare	$85.50
Rate for Payer: Midlands Choice Commercial	$133.00
Rate for Payer: Molina Healthcare Managed Medicaid	$110.12
Rate for Payer: Partners Health Alliance Commercial	$98.32
Rate for Payer: United Healthcare Commercial	$171.00
Rate for Payer: United Healthcare Managed Medicare	$112.10
Rate for Payer: Wellmark IA HMO WHPI	$458.72
Rate for Payer: Wellmark IA PPO	$505.31

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	$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

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	$93.15
Max. Negotiated Rate	$581.85
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	$119.40
Rate for Payer: Amerigroup Medicare	$94.08
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	$93.15
Rate for Payer: Iowa Total Care Managed Medicaid	$118.24
Rate for Payer: Medical Associates Commercial	$155.25
Rate for Payer: Medical Associates Managed Medicare	$93.15
Rate for Payer: Midlands Choice Commercial	$144.90
Rate for Payer: Molina Healthcare Managed Medicaid	$119.98
Rate for Payer: Partners Health Alliance Commercial	$107.12
Rate for Payer: United Healthcare Commercial	$186.30
Rate for Payer: United Healthcare Managed Medicare	$122.13
Rate for Payer: Wellmark IA HMO WHPI	$528.21
Rate for Payer: Wellmark IA PPO	$581.85

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

Facility

$5.10

Service Code	HCPCS A9270
Hospital Charge Code	10364375
Hospital Revenue Code	259
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$4.59
Rate for Payer: Aetna of IA Commercial	$4.59
Rate for Payer: Aetna of IA Medical Rental Products	$4.59
Rate for Payer: Aetna of IA Medicare	$2.91
Rate for Payer: Amerigroup Medicaid	$2.94
Rate for Payer: Amerigroup Medicare	$2.32
Rate for Payer: Cash Price	$4.08
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.30
Rate for Payer: Iowa Total Care Managed Medicaid	$2.92
Rate for Payer: Medical Associates Commercial	$3.83
Rate for Payer: Medical Associates Managed Medicare	$2.30
Rate for Payer: Midlands Choice Commercial	$3.57
Rate for Payer: Molina Healthcare Managed Medicaid	$2.96
Rate for Payer: Partners Health Alliance Commercial	$2.64
Rate for Payer: United Healthcare Commercial	$4.59
Rate for Payer: United Healthcare Managed Medicare	$3.01

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

Facility

$5.10

Service Code	HCPCS A9270
Hospital Charge Code	10364375
Hospital Revenue Code	259
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$4.59
Rate for Payer: Aetna of IA Commercial	$4.59
Rate for Payer: Aetna of IA Medical Rental Products	$4.59
Rate for Payer: Cash Price	$4.08
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.83
Rate for Payer: Medical Associates Commercial	$3.83
Rate for Payer: Midlands Choice Commercial	$3.57
Rate for Payer: United Healthcare Commercial	$4.59

albuterol 0.5% 5mg/ml 20ml Inh Sol [VDMC]

Facility

$180.64

Service Code	HCPCS A9270
Hospital Charge Code	10364446
Hospital Revenue Code	259
Min. Negotiated Rate	$81.29
Max. Negotiated Rate	$162.58
Rate for Payer: Aetna of IA Commercial	$162.58
Rate for Payer: Aetna of IA Medical Rental Products	$162.58
Rate for Payer: Aetna of IA Medicare	$102.96
Rate for Payer: Amerigroup Medicaid	$104.19
Rate for Payer: Amerigroup Medicare	$82.10
Rate for Payer: Cash Price	$144.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.29
Rate for Payer: Iowa Total Care Managed Medicaid	$103.18
Rate for Payer: Medical Associates Commercial	$135.48
Rate for Payer: Medical Associates Managed Medicare	$81.29
Rate for Payer: Midlands Choice Commercial	$126.45
Rate for Payer: Molina Healthcare Managed Medicaid	$104.70
Rate for Payer: Partners Health Alliance Commercial	$93.48
Rate for Payer: United Healthcare Commercial	$162.58
Rate for Payer: United Healthcare Managed Medicare	$106.58

Know your out-of-pocket cost for care.

All Charges