Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$126.45
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: Cash Price	$144.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.48
Rate for Payer: Medical Associates Commercial	$135.48
Rate for Payer: Midlands Choice Commercial	$126.45
Rate for Payer: United Healthcare Commercial	$162.58

albuterol 1.25mg Inh Sol 3 mL [VDMC]

Facility

$6.17

Service Code	HCPCS A9270
Hospital Charge Code	10364304
Hospital Revenue Code	259
Min. Negotiated Rate	$2.78
Max. Negotiated Rate	$5.55
Rate for Payer: Aetna of IA Commercial	$5.55
Rate for Payer: Aetna of IA Medical Rental Products	$5.55
Rate for Payer: Aetna of IA Medicare	$3.52
Rate for Payer: Amerigroup Medicaid	$3.56
Rate for Payer: Amerigroup Medicare	$2.80
Rate for Payer: Cash Price	$4.93
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.63
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.78
Rate for Payer: Iowa Total Care Managed Medicaid	$3.52
Rate for Payer: Medical Associates Commercial	$4.63
Rate for Payer: Medical Associates Managed Medicare	$2.78
Rate for Payer: Midlands Choice Commercial	$4.32
Rate for Payer: Molina Healthcare Managed Medicaid	$3.57
Rate for Payer: Partners Health Alliance Commercial	$3.19
Rate for Payer: United Healthcare Commercial	$5.55
Rate for Payer: United Healthcare Managed Medicare	$3.64

albuterol 1.25mg Inh Sol 3 mL [VDMC]

Facility

$6.17

Service Code	HCPCS A9270
Hospital Charge Code	10364304
Hospital Revenue Code	259
Min. Negotiated Rate	$4.32
Max. Negotiated Rate	$5.55
Rate for Payer: Aetna of IA Commercial	$5.55
Rate for Payer: Aetna of IA Medical Rental Products	$5.55
Rate for Payer: Cash Price	$4.93
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.63
Rate for Payer: Medical Associates Commercial	$4.63
Rate for Payer: Midlands Choice Commercial	$4.32
Rate for Payer: United Healthcare Commercial	$5.55

albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [VDMC]

Facility

$66.98

Service Code	HCPCS A9270
Hospital Charge Code	10364515
Hospital Revenue Code	259
Min. Negotiated Rate	$46.89
Max. Negotiated Rate	$60.28
Rate for Payer: Aetna of IA Commercial	$60.28
Rate for Payer: Aetna of IA Medical Rental Products	$60.28
Rate for Payer: Cash Price	$53.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.23
Rate for Payer: Medical Associates Commercial	$50.23
Rate for Payer: Midlands Choice Commercial	$46.89
Rate for Payer: United Healthcare Commercial	$60.28

albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [VDMC]

Facility

$66.98

Service Code	HCPCS A9270
Hospital Charge Code	10364515
Hospital Revenue Code	259
Min. Negotiated Rate	$30.14
Max. Negotiated Rate	$60.28
Rate for Payer: Aetna of IA Commercial	$60.28
Rate for Payer: Aetna of IA Medical Rental Products	$60.28
Rate for Payer: Aetna of IA Medicare	$38.18
Rate for Payer: Amerigroup Medicaid	$38.63
Rate for Payer: Amerigroup Medicare	$30.44
Rate for Payer: Cash Price	$53.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$50.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.14
Rate for Payer: Iowa Total Care Managed Medicaid	$38.26
Rate for Payer: Medical Associates Commercial	$50.23
Rate for Payer: Medical Associates Managed Medicare	$30.14
Rate for Payer: Midlands Choice Commercial	$46.89
Rate for Payer: Molina Healthcare Managed Medicaid	$38.82
Rate for Payer: Partners Health Alliance Commercial	$34.66
Rate for Payer: United Healthcare Commercial	$60.28
Rate for Payer: United Healthcare Managed Medicare	$39.52

albuterol-ipratropium 0.5mg/3mg neb Sol 3 mL SDV [VDMC]

Facility

$5.84

Service Code	HCPCS A9270
Hospital Charge Code	10364653
Hospital Revenue Code	259
Min. Negotiated Rate	$2.63
Max. Negotiated Rate	$5.26
Rate for Payer: Aetna of IA Commercial	$5.26
Rate for Payer: Aetna of IA Medical Rental Products	$5.26
Rate for Payer: Aetna of IA Medicare	$3.33
Rate for Payer: Amerigroup Medicaid	$3.37
Rate for Payer: Amerigroup Medicare	$2.65
Rate for Payer: Cash Price	$4.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.63
Rate for Payer: Iowa Total Care Managed Medicaid	$3.34
Rate for Payer: Medical Associates Commercial	$4.38
Rate for Payer: Medical Associates Managed Medicare	$2.63
Rate for Payer: Midlands Choice Commercial	$4.09
Rate for Payer: Molina Healthcare Managed Medicaid	$3.38
Rate for Payer: Partners Health Alliance Commercial	$3.02
Rate for Payer: United Healthcare Commercial	$5.26
Rate for Payer: United Healthcare Managed Medicare	$3.45

albuterol-ipratropium 0.5mg/3mg neb Sol 3 mL SDV [VDMC]

Facility

$5.84

Service Code	HCPCS A9270
Hospital Charge Code	10364653
Hospital Revenue Code	259
Min. Negotiated Rate	$4.09
Max. Negotiated Rate	$5.26
Rate for Payer: Aetna of IA Commercial	$5.26
Rate for Payer: Aetna of IA Medical Rental Products	$5.26
Rate for Payer: Cash Price	$4.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.38
Rate for Payer: Medical Associates Commercial	$4.38
Rate for Payer: Midlands Choice Commercial	$4.09
Rate for Payer: United Healthcare Commercial	$5.26

albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aer[VDMC]

Facility

$1,549.16

Service Code	HCPCS A9270
Hospital Charge Code	11449831
Hospital Revenue Code	259
Min. Negotiated Rate	$697.12
Max. Negotiated Rate	$1,394.24
Rate for Payer: Aetna of IA Commercial	$1,394.24
Rate for Payer: Aetna of IA Medical Rental Products	$1,394.24
Rate for Payer: Aetna of IA Medicare	$883.02
Rate for Payer: Amerigroup Medicaid	$893.56
Rate for Payer: Amerigroup Medicare	$704.09
Rate for Payer: Cash Price	$1,239.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,161.87
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$697.12
Rate for Payer: Iowa Total Care Managed Medicaid	$884.88
Rate for Payer: Medical Associates Commercial	$1,161.87
Rate for Payer: Medical Associates Managed Medicare	$697.12
Rate for Payer: Midlands Choice Commercial	$1,084.41
Rate for Payer: Molina Healthcare Managed Medicaid	$897.89
Rate for Payer: Partners Health Alliance Commercial	$801.69
Rate for Payer: United Healthcare Commercial	$1,394.24
Rate for Payer: United Healthcare Managed Medicare	$914.00

albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aer[VDMC]

Facility

$1,549.16

Service Code	HCPCS A9270
Hospital Charge Code	11449831
Hospital Revenue Code	259
Min. Negotiated Rate	$1,084.41
Max. Negotiated Rate	$1,394.24
Rate for Payer: Aetna of IA Commercial	$1,394.24
Rate for Payer: Aetna of IA Medical Rental Products	$1,394.24
Rate for Payer: Cash Price	$1,239.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,161.87
Rate for Payer: Medical Associates Commercial	$1,161.87
Rate for Payer: Midlands Choice Commercial	$1,084.41
Rate for Payer: United Healthcare Commercial	$1,394.24

ALCOHOL

Facility

$139.00

Service Code	HCPCS G0480
Hospital Charge Code	1503765
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

ALCOHOL

Facility

$139.00

Service Code	HCPCS G0480
Hospital Charge Code	1503765
Hospital Revenue Code	301
Min. Negotiated Rate	$62.55
Max. Negotiated Rate	$129.65
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	$117.69
Rate for Payer: Wellmark IA PPO	$129.65

ALCOHOL, DRUG ABUSE OR DEPENDENCE, LEFT AMA

Facility

$5,147.97

Service Code	MSDRG 894
Min. Negotiated Rate	$5,073.36
Max. Negotiated Rate	$5,147.97
Rate for Payer: Amerigroup Medicaid	$5,123.10
Rate for Payer: Iowa Total Care Managed Medicaid	$5,073.36
Rate for Payer: Molina Healthcare Managed Medicaid	$5,147.97

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC

Facility

$13,749.31

Service Code	MSDRG 896
Min. Negotiated Rate	$13,550.03
Max. Negotiated Rate	$13,749.31
Rate for Payer: Amerigroup Medicaid	$13,682.88
Rate for Payer: Iowa Total Care Managed Medicaid	$13,550.03
Rate for Payer: Molina Healthcare Managed Medicaid	$13,749.31

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC

Facility

$7,868.33

Service Code	MSDRG 897
Min. Negotiated Rate	$7,754.29
Max. Negotiated Rate	$7,868.33
Rate for Payer: Amerigroup Medicaid	$7,830.31
Rate for Payer: Iowa Total Care Managed Medicaid	$7,754.29
Rate for Payer: Molina Healthcare Managed Medicaid	$7,868.33

ALCOHOL, DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY

Facility

$11,372.37

Service Code	MSDRG 895
Min. Negotiated Rate	$11,207.55
Max. Negotiated Rate	$11,372.37
Rate for Payer: Amerigroup Medicaid	$11,317.42
Rate for Payer: Iowa Total Care Managed Medicaid	$11,207.55
Rate for Payer: Molina Healthcare Managed Medicaid	$11,372.37

ALDL

Facility

$73.00

Service Code	CPT 83721
Hospital Charge Code	6310783
Hospital Revenue Code	301
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: United Healthcare Commercial	$65.70

ALDL

Facility

$73.00

Service Code	CPT 83721
Hospital Charge Code	6310783
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Aetna of IA Medicare	$41.61
Rate for Payer: Amerigroup Medicaid	$42.11
Rate for Payer: Amerigroup Medicare	$33.18
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.85
Rate for Payer: Iowa Total Care Managed Medicaid	$41.70
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Medical Associates Managed Medicare	$32.85
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: Molina Healthcare Managed Medicaid	$42.31
Rate for Payer: Partners Health Alliance Commercial	$37.78
Rate for Payer: United Healthcare Commercial	$65.70
Rate for Payer: United Healthcare Managed Medicare	$43.07
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

ALDOLASE

Facility

$66.00

Service Code	CPT 82085
Hospital Charge Code	8037487
Hospital Revenue Code	301
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: United Healthcare Commercial	$59.40

ALDOLASE

Facility

$66.00

Service Code	CPT 82085
Hospital Charge Code	8037487
Hospital Revenue Code	301
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Aetna of IA Medicare	$37.62
Rate for Payer: Amerigroup Medicaid	$38.07
Rate for Payer: Amerigroup Medicare	$30.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.70
Rate for Payer: Iowa Total Care Managed Medicaid	$37.70
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Medical Associates Managed Medicare	$29.70
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: Molina Healthcare Managed Medicaid	$38.25
Rate for Payer: Partners Health Alliance Commercial	$34.16
Rate for Payer: United Healthcare Commercial	$59.40
Rate for Payer: United Healthcare Managed Medicare	$38.94
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

ALDOSTERONE

Facility

$277.00

Service Code	CPT 82088
Hospital Charge Code	8037488
Hospital Revenue Code	301
Min. Negotiated Rate	$193.90
Max. Negotiated Rate	$249.30
Rate for Payer: Aetna of IA Commercial	$249.30
Rate for Payer: Aetna of IA Medical Rental Products	$249.30
Rate for Payer: Cash Price	$221.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$207.75
Rate for Payer: Medical Associates Commercial	$207.75
Rate for Payer: Midlands Choice Commercial	$193.90
Rate for Payer: United Healthcare Commercial	$249.30

ALDOSTERONE

Facility

$277.00

Service Code	CPT 82088
Hospital Charge Code	8037488
Hospital Revenue Code	301
Min. Negotiated Rate	$82.95
Max. Negotiated Rate	$249.30
Rate for Payer: Aetna of IA Commercial	$249.30
Rate for Payer: Aetna of IA Medical Rental Products	$249.30
Rate for Payer: Aetna of IA Medicare	$157.89
Rate for Payer: Amerigroup Medicaid	$159.77
Rate for Payer: Amerigroup Medicare	$125.90
Rate for Payer: Cash Price	$221.60
Rate for Payer: Cash Price	$221.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$207.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$124.65
Rate for Payer: Iowa Total Care Managed Medicaid	$158.22
Rate for Payer: Medical Associates Commercial	$207.75
Rate for Payer: Medical Associates Managed Medicare	$124.65
Rate for Payer: Midlands Choice Commercial	$193.90
Rate for Payer: Molina Healthcare Managed Medicaid	$160.55
Rate for Payer: Partners Health Alliance Commercial	$143.35
Rate for Payer: United Healthcare Commercial	$249.30
Rate for Payer: United Healthcare Managed Medicare	$163.43
Rate for Payer: Wellmark IA HMO WHPI	$82.95
Rate for Payer: Wellmark IA PPO	$91.38

al hydroxide/mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL [VDMC]

Facility

$12.36

Service Code	HCPCS A9270
Hospital Charge Code	10364164
Hospital Revenue Code	259
Min. Negotiated Rate	$5.56
Max. Negotiated Rate	$11.13
Rate for Payer: Aetna of IA Commercial	$11.13
Rate for Payer: Aetna of IA Medical Rental Products	$11.13
Rate for Payer: Aetna of IA Medicare	$7.05
Rate for Payer: Amerigroup Medicaid	$7.13
Rate for Payer: Amerigroup Medicare	$5.62
Rate for Payer: Cash Price	$9.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.56
Rate for Payer: Iowa Total Care Managed Medicaid	$7.06
Rate for Payer: Medical Associates Commercial	$9.27
Rate for Payer: Medical Associates Managed Medicare	$5.56
Rate for Payer: Midlands Choice Commercial	$8.65
Rate for Payer: Molina Healthcare Managed Medicaid	$7.17
Rate for Payer: Partners Health Alliance Commercial	$6.40
Rate for Payer: United Healthcare Commercial	$11.13
Rate for Payer: United Healthcare Managed Medicare	$7.29

al hydroxide/mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL [VDMC]

Facility

$12.36

Service Code	HCPCS A9270
Hospital Charge Code	10364164
Hospital Revenue Code	259
Min. Negotiated Rate	$8.65
Max. Negotiated Rate	$11.13
Rate for Payer: Aetna of IA Commercial	$11.13
Rate for Payer: Aetna of IA Medical Rental Products	$11.13
Rate for Payer: Cash Price	$9.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.27
Rate for Payer: Medical Associates Commercial	$9.27
Rate for Payer: Midlands Choice Commercial	$8.65
Rate for Payer: United Healthcare Commercial	$11.13

ALK PHOSPHATASE

Facility

$53.00

Service Code	CPT 84075
Hospital Charge Code	1620878
Hospital Revenue Code	301
Min. Negotiated Rate	$23.85
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of IA Commercial	$47.70
Rate for Payer: Aetna of IA Medical Rental Products	$47.70
Rate for Payer: Aetna of IA Medicare	$30.21
Rate for Payer: Amerigroup Medicaid	$30.57
Rate for Payer: Amerigroup Medicare	$24.09
Rate for Payer: Cash Price	$42.40
Rate for Payer: Cash Price	$42.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.85
Rate for Payer: Iowa Total Care Managed Medicaid	$30.27
Rate for Payer: Medical Associates Commercial	$39.75
Rate for Payer: Medical Associates Managed Medicare	$23.85
Rate for Payer: Midlands Choice Commercial	$37.10
Rate for Payer: Molina Healthcare Managed Medicaid	$30.72
Rate for Payer: Partners Health Alliance Commercial	$27.43
Rate for Payer: United Healthcare Commercial	$47.70
Rate for Payer: United Healthcare Managed Medicare	$31.27
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

ALK PHOSPHATASE

Facility

$53.00

Service Code	CPT 84075
Hospital Charge Code	1620878
Hospital Revenue Code	301
Min. Negotiated Rate	$37.10
Max. Negotiated Rate	$47.70
Rate for Payer: Aetna of IA Commercial	$47.70
Rate for Payer: Aetna of IA Medical Rental Products	$47.70
Rate for Payer: Cash Price	$42.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.75
Rate for Payer: Medical Associates Commercial	$39.75
Rate for Payer: Midlands Choice Commercial	$37.10
Rate for Payer: United Healthcare Commercial	$47.70

Know your out-of-pocket cost for care.

All Charges