Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

senna 8.6 mg Tab [VDMC]

Facility

$1.12

Service Code	HCPCS A9270
Hospital Charge Code	10420307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.01
Rate for Payer: Aetna of IA Commercial	$1.01
Rate for Payer: Aetna of IA Medical Rental Products	$1.01
Rate for Payer: Aetna of IA Medicare	$0.64
Rate for Payer: Amerigroup Medicaid	$0.57
Rate for Payer: Amerigroup Medicare	$0.57
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.84
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	$0.56
Rate for Payer: Medical Associates Commercial	$0.84
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: Molina Healthcare Managed Medicaid	$0.57
Rate for Payer: Molina Healthcare Managed Medicare	$0.57
Rate for Payer: Oscar Health of IA Commercial	$0.84
Rate for Payer: Partners Health Alliance Commercial	$0.84
Rate for Payer: United Healthcare Commercial	$1.01
Rate for Payer: United Healthcare Managed Medicare	$0.66

senna 8.6 mg Tab [VDMC]

Facility

$1.12

Service Code	HCPCS A9270
Hospital Charge Code	10420307
Hospital Revenue Code	259
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.01
Rate for Payer: Aetna of IA Commercial	$1.01
Rate for Payer: Aetna of IA Medical Rental Products	$1.01
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.84
Rate for Payer: Medical Associates Commercial	$0.84
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: United Healthcare Commercial	$1.01

senna-docusate-8.6 mg-50 mg Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10384311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of IA Commercial	$1.24
Rate for Payer: Aetna of IA Medical Rental Products	$1.24
Rate for Payer: Aetna of IA Medicare	$0.79
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.70
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.69
Rate for Payer: Iowa Total Care Managed Medicaid	$0.69
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Medical Associates Managed Medicare	$0.69
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: Molina Healthcare Managed Medicaid	$0.70
Rate for Payer: Molina Healthcare Managed Medicare	$0.70
Rate for Payer: Oscar Health of IA Commercial	$1.04
Rate for Payer: Partners Health Alliance Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.24
Rate for Payer: United Healthcare Managed Medicare	$0.81

senna-docusate-8.6 mg-50 mg Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10384311
Hospital Revenue Code	259
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of IA Commercial	$1.24
Rate for Payer: Aetna of IA Medical Rental Products	$1.24
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: United Healthcare Commercial	$1.24

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	294946
Hospital Revenue Code	306
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	4210782
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$35.83
Rate for Payer: Amerigroup Medicare	$35.86
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.50
Rate for Payer: Iowa Total Care Managed Medicaid	$35.49
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$35.50
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$36.03
Rate for Payer: Molina Healthcare Managed Medicare	$36.01
Rate for Payer: Oscar Health of IA Commercial	$53.25
Rate for Payer: Partners Health Alliance Commercial	$53.25
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	4210782
Hospital Revenue Code	306
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

SENSITIVITY

Facility

$71.00

Service Code	CPT 87186
Hospital Charge Code	294946
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$35.83
Rate for Payer: Amerigroup Medicare	$35.86
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.50
Rate for Payer: Iowa Total Care Managed Medicaid	$35.49
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$35.50
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$36.03
Rate for Payer: Molina Healthcare Managed Medicare	$36.01
Rate for Payer: Oscar Health of IA Commercial	$53.25
Rate for Payer: Partners Health Alliance Commercial	$53.25
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

SENSORY INTEGRATION/15 MIN

Facility

$153.00

Service Code	CPT 97533 GO
Hospital Charge Code	1373568
Hospital Revenue Code	430
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Aetna of IA Medicare	$87.21
Rate for Payer: Amerigroup Medicaid	$77.22
Rate for Payer: Amerigroup Medicare	$77.26
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.50
Rate for Payer: Iowa Total Care Managed Medicaid	$76.47
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Medical Associates Managed Medicare	$76.50
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: Molina Healthcare Managed Medicaid	$77.65
Rate for Payer: Molina Healthcare Managed Medicare	$77.60
Rate for Payer: Oscar Health of IA Commercial	$114.75
Rate for Payer: Partners Health Alliance Commercial	$114.75
Rate for Payer: United Healthcare Commercial	$137.70
Rate for Payer: United Healthcare Managed Medicare	$90.27

SENSORY INTEGRATION/15 MIN

Facility

$153.00

Service Code	CPT 97533 GO
Hospital Charge Code	1373568
Hospital Revenue Code	430
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: United Healthcare Commercial	$137.70

SENSORY INTEGRATIVE 15 MIN

Facility

$153.00

Service Code	CPT 97533 GN
Hospital Charge Code	1373955
Hospital Revenue Code	440
Min. Negotiated Rate	$76.47
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Aetna of IA Medicare	$87.21
Rate for Payer: Amerigroup Medicaid	$77.22
Rate for Payer: Amerigroup Medicare	$77.26
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.50
Rate for Payer: Iowa Total Care Managed Medicaid	$76.47
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Medical Associates Managed Medicare	$76.50
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: Molina Healthcare Managed Medicaid	$77.65
Rate for Payer: Molina Healthcare Managed Medicare	$77.60
Rate for Payer: Oscar Health of IA Commercial	$114.75
Rate for Payer: Partners Health Alliance Commercial	$114.75
Rate for Payer: United Healthcare Commercial	$137.70
Rate for Payer: United Healthcare Managed Medicare	$90.27

SENSORY INTEGRATIVE 15 MIN

Facility

$153.00

Service Code	CPT 97533 GN
Hospital Charge Code	1373955
Hospital Revenue Code	440
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: United Healthcare Commercial	$137.70

Septic Arthritis With CC

Facility

$8,499.91

Service Code	MS-DRG 549
Hospital Charge Code	356
Min. Negotiated Rate	$8,376.72
Max. Negotiated Rate	$8,499.91
Rate for Payer: Amerigroup Medicaid	$8,458.84
Rate for Payer: Iowa Total Care Managed Medicaid	$8,376.72
Rate for Payer: Molina Healthcare Managed Medicaid	$8,499.91

Septic Arthritis With MCC

Facility

$19,981.09

Service Code	MS-DRG 548
Hospital Charge Code	355
Min. Negotiated Rate	$19,691.51
Max. Negotiated Rate	$19,981.09
Rate for Payer: Amerigroup Medicaid	$19,884.56
Rate for Payer: Iowa Total Care Managed Medicaid	$19,691.51
Rate for Payer: Molina Healthcare Managed Medicaid	$19,981.09

Septic Arthritis Without CC/MCC

Facility

$8,499.91

Service Code	MS-DRG 550
Hospital Charge Code	357
Min. Negotiated Rate	$8,376.72
Max. Negotiated Rate	$8,499.91
Rate for Payer: Amerigroup Medicaid	$8,458.84
Rate for Payer: Iowa Total Care Managed Medicaid	$8,376.72
Rate for Payer: Molina Healthcare Managed Medicaid	$8,499.91

Septicemia or Severe Sepsis With MV >96 Hours

Facility

$61,769.03

Service Code	MS-DRG 870
Hospital Charge Code	606
Min. Negotiated Rate	$60,873.82
Max. Negotiated Rate	$61,769.03
Rate for Payer: Amerigroup Medicaid	$61,470.63
Rate for Payer: Iowa Total Care Managed Medicaid	$60,873.82
Rate for Payer: Molina Healthcare Managed Medicaid	$61,769.03

Septicemia or Severe Sepsis Without MV >96 Hours With MCC

Facility

$14,208.51

Service Code	MS-DRG 871
Hospital Charge Code	607
Min. Negotiated Rate	$14,002.59
Max. Negotiated Rate	$14,208.51
Rate for Payer: Amerigroup Medicaid	$14,139.87
Rate for Payer: Iowa Total Care Managed Medicaid	$14,002.59
Rate for Payer: Molina Healthcare Managed Medicaid	$14,208.51

Septicemia or Severe Sepsis Without MV >96 Hours Without MCC

Facility

$7,838.50

Service Code	MS-DRG 872
Hospital Charge Code	608
Min. Negotiated Rate	$7,724.90
Max. Negotiated Rate	$7,838.50
Rate for Payer: Amerigroup Medicaid	$7,800.63
Rate for Payer: Iowa Total Care Managed Medicaid	$7,724.90
Rate for Payer: Molina Healthcare Managed Medicaid	$7,838.50

sertraline 50 mg Tab [VDMC]

Facility

$1.90

Service Code	HCPCS A9270
Hospital Charge Code	10420378
Hospital Revenue Code	259
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$1.71
Rate for Payer: Aetna of IA Commercial	$1.71
Rate for Payer: Aetna of IA Medical Rental Products	$1.71
Rate for Payer: Cash Price	$1.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.42
Rate for Payer: Medical Associates Commercial	$1.42
Rate for Payer: Midlands Choice Commercial	$1.33
Rate for Payer: United Healthcare Commercial	$1.71

sertraline 50 mg Tab [VDMC]

Facility

$1.90

Service Code	HCPCS A9270
Hospital Charge Code	10420378
Hospital Revenue Code	259
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.71
Rate for Payer: Aetna of IA Commercial	$1.71
Rate for Payer: Aetna of IA Medical Rental Products	$1.71
Rate for Payer: Aetna of IA Medicare	$1.08
Rate for Payer: Amerigroup Medicaid	$0.96
Rate for Payer: Amerigroup Medicare	$0.96
Rate for Payer: Cash Price	$1.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.95
Rate for Payer: Iowa Total Care Managed Medicaid	$0.95
Rate for Payer: Medical Associates Commercial	$1.42
Rate for Payer: Medical Associates Managed Medicare	$0.95
Rate for Payer: Midlands Choice Commercial	$1.33
Rate for Payer: Molina Healthcare Managed Medicaid	$0.96
Rate for Payer: Molina Healthcare Managed Medicare	$0.96
Rate for Payer: Oscar Health of IA Commercial	$1.42
Rate for Payer: Partners Health Alliance Commercial	$1.42
Rate for Payer: United Healthcare Commercial	$1.71
Rate for Payer: United Healthcare Managed Medicare	$1.12

SESAMOIDECTOMY FIRST TOE CHARGE .

Professional

Both

$1,671.00

Service Code	CPT 28315
Hospital Charge Code	8825536
Hospital Revenue Code	975
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$1,169.70
Rate for Payer: Aetna of IA Medicare	$301.70
Rate for Payer: Amerigroup Medicaid	$311.96
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$362.04
Rate for Payer: Iowa Total Care Managed Medicaid	$307.73
Rate for Payer: Medical Associates Commercial	$573.23
Rate for Payer: Medical Associates Managed Medicare	$301.70
Rate for Payer: Midlands Choice Commercial	$1,169.70
Rate for Payer: Oscar Health of IA Commercial	$521.94
Rate for Payer: Partners Health Alliance Commercial	$452.55

sevelamer carbonate 800 mg Tab [VDMC]

Facility

$1.78

Service Code	HCPCS A9270
Hospital Charge Code	10420449
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of IA Commercial	$1.60
Rate for Payer: Aetna of IA Medical Rental Products	$1.60
Rate for Payer: Cash Price	$1.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: United Healthcare Commercial	$1.60

sevelamer carbonate 800 mg Tab [VDMC]

Facility

$1.78

Service Code	HCPCS A9270
Hospital Charge Code	10420449
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of IA Commercial	$1.60
Rate for Payer: Aetna of IA Medical Rental Products	$1.60
Rate for Payer: Aetna of IA Medicare	$1.01
Rate for Payer: Amerigroup Medicaid	$0.90
Rate for Payer: Amerigroup Medicare	$0.90
Rate for Payer: Cash Price	$1.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.89
Rate for Payer: Iowa Total Care Managed Medicaid	$0.89
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Medical Associates Managed Medicare	$0.89
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: Molina Healthcare Managed Medicaid	$0.90
Rate for Payer: Molina Healthcare Managed Medicare	$0.90
Rate for Payer: Oscar Health of IA Commercial	$1.34
Rate for Payer: Partners Health Alliance Commercial	$1.34
Rate for Payer: United Healthcare Commercial	$1.60
Rate for Payer: United Healthcare Managed Medicare	$1.05

SHIGA TOXINS

Facility

$98.00

Service Code	CPT 87427
Hospital Charge Code	7780541
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$49.46
Rate for Payer: Amerigroup Medicare	$49.49
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.00
Rate for Payer: Iowa Total Care Managed Medicaid	$48.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$49.00
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$49.74
Rate for Payer: Molina Healthcare Managed Medicare	$49.71
Rate for Payer: Oscar Health of IA Commercial	$73.50
Rate for Payer: Partners Health Alliance Commercial	$73.50
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

SHIGA TOXINS

Facility

$98.00

Service Code	CPT 87427
Hospital Charge Code	7780541
Hospital Revenue Code	306
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

Know your out-of-pocket cost for care.

All Charges