Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

US UE Venous Duplex Right

Facility

$582.00

Service Code	CPT 93971
Hospital Charge Code	1169905
Hospital Revenue Code	921
Min. Negotiated Rate	$407.40
Max. Negotiated Rate	$523.80
Rate for Payer: Aetna of IA Commercial	$523.80
Rate for Payer: Aetna of IA Medical Rental Products	$523.80
Rate for Payer: Cash Price	$465.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$436.50
Rate for Payer: Medical Associates Commercial	$436.50
Rate for Payer: Midlands Choice Commercial	$407.40
Rate for Payer: United Healthcare Commercial	$523.80

US UE Venous Duplex Right

Facility

$582.00

Service Code	CPT 93971
Hospital Charge Code	1169905
Hospital Revenue Code	921
Min. Negotiated Rate	$191.58
Max. Negotiated Rate	$523.80
Rate for Payer: Aetna of IA Commercial	$523.80
Rate for Payer: Aetna of IA Medical Rental Products	$523.80
Rate for Payer: Aetna of IA Medicare	$331.74
Rate for Payer: Amerigroup Medicaid	$293.74
Rate for Payer: Amerigroup Medicare	$293.91
Rate for Payer: Cash Price	$465.60
Rate for Payer: Cash Price	$465.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$436.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$291.00
Rate for Payer: Iowa Total Care Managed Medicaid	$290.88
Rate for Payer: Medical Associates Commercial	$436.50
Rate for Payer: Medical Associates Managed Medicare	$291.00
Rate for Payer: Midlands Choice Commercial	$407.40
Rate for Payer: Molina Healthcare Managed Medicaid	$295.36
Rate for Payer: Molina Healthcare Managed Medicare	$295.19
Rate for Payer: Oscar Health of IA Commercial	$436.50
Rate for Payer: Partners Health Alliance Commercial	$436.50
Rate for Payer: United Healthcare Commercial	$523.80
Rate for Payer: United Healthcare Managed Medicare	$343.38
Rate for Payer: Wellmark IA HMO	$191.58
Rate for Payer: Wellmark IA PPO	$210.74

Uterine and Adnexa Procedures for Non-malignancy With CC/MCC

Facility

$11,262.67

Service Code	MS-DRG 742
Hospital Charge Code	503
Min. Negotiated Rate	$11,099.45
Max. Negotiated Rate	$11,262.67
Rate for Payer: Amerigroup Medicaid	$11,208.26
Rate for Payer: Iowa Total Care Managed Medicaid	$11,099.45
Rate for Payer: Molina Healthcare Managed Medicaid	$11,262.67

Uterine and Adnexa Procedures for Non-malignancy Without CC/MCC

Facility

$8,709.56

Service Code	MS-DRG 743
Hospital Charge Code	504
Min. Negotiated Rate	$8,583.33
Max. Negotiated Rate	$8,709.56
Rate for Payer: Amerigroup Medicaid	$8,667.48
Rate for Payer: Iowa Total Care Managed Medicaid	$8,583.33
Rate for Payer: Molina Healthcare Managed Medicaid	$8,709.56

Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy With CC

Facility

$15,428.97

Service Code	MS-DRG 740
Hospital Charge Code	501
Min. Negotiated Rate	$15,205.36
Max. Negotiated Rate	$15,428.97
Rate for Payer: Amerigroup Medicaid	$15,354.44
Rate for Payer: Iowa Total Care Managed Medicaid	$15,205.36
Rate for Payer: Molina Healthcare Managed Medicaid	$15,428.97

Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy With MCC

Facility

$37,624.60

Service Code	MS-DRG 739
Hospital Charge Code	500
Min. Negotiated Rate	$37,079.32
Max. Negotiated Rate	$37,624.60
Rate for Payer: Amerigroup Medicaid	$37,442.84
Rate for Payer: Iowa Total Care Managed Medicaid	$37,079.32
Rate for Payer: Molina Healthcare Managed Medicaid	$37,624.60

Uterine and Adnexa Procedures for Non-ovarian and Non-adnexal Malignancy Without CC/MCC

Facility

$12,583.53

Service Code	MS-DRG 741
Hospital Charge Code	502
Min. Negotiated Rate	$12,401.16
Max. Negotiated Rate	$12,583.53
Rate for Payer: Amerigroup Medicaid	$12,522.74
Rate for Payer: Iowa Total Care Managed Medicaid	$12,401.16
Rate for Payer: Molina Healthcare Managed Medicaid	$12,583.53

Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy With CC

Facility

$17,488.98

Service Code	MS-DRG 737
Hospital Charge Code	498
Min. Negotiated Rate	$17,235.52
Max. Negotiated Rate	$17,488.98
Rate for Payer: Amerigroup Medicaid	$17,404.50
Rate for Payer: Iowa Total Care Managed Medicaid	$17,235.52
Rate for Payer: Molina Healthcare Managed Medicaid	$17,488.98

Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy With MCC

Facility

$41,921.80

Service Code	MS-DRG 736
Hospital Charge Code	497
Min. Negotiated Rate	$41,314.23
Max. Negotiated Rate	$41,921.80
Rate for Payer: Amerigroup Medicaid	$41,719.27
Rate for Payer: Iowa Total Care Managed Medicaid	$41,314.23
Rate for Payer: Molina Healthcare Managed Medicaid	$41,921.80

Uterine and Adnexa Procedures for Ovarian or Adnexal Malignancy Without CC/MCC

Facility

$14,052.02

Service Code	MS-DRG 738
Hospital Charge Code	499
Min. Negotiated Rate	$13,848.37
Max. Negotiated Rate	$14,052.02
Rate for Payer: Amerigroup Medicaid	$13,984.13
Rate for Payer: Iowa Total Care Managed Medicaid	$13,848.37
Rate for Payer: Molina Healthcare Managed Medicaid	$14,052.02

Vagina, Cervix and Vulva Procedures With CC/MCC

Facility

$9,810.92

Service Code	MS-DRG 746
Hospital Charge Code	507
Min. Negotiated Rate	$9,668.73
Max. Negotiated Rate	$9,810.92
Rate for Payer: Amerigroup Medicaid	$9,763.52
Rate for Payer: Iowa Total Care Managed Medicaid	$9,668.73
Rate for Payer: Molina Healthcare Managed Medicaid	$9,810.92

Vagina, Cervix and Vulva Procedures Without CC/MCC

Facility

$8,658.38

Service Code	MS-DRG 747
Hospital Charge Code	508
Min. Negotiated Rate	$8,532.89
Max. Negotiated Rate	$8,658.38
Rate for Payer: Amerigroup Medicaid	$8,616.55
Rate for Payer: Iowa Total Care Managed Medicaid	$8,532.89
Rate for Payer: Molina Healthcare Managed Medicaid	$8,658.38

Vaginal Delivery With O.R. Procedures Except Sterilization And/or D&C

Facility

$6,571.78

Service Code	MS-DRG 768
Hospital Charge Code	520
Min. Negotiated Rate	$6,476.54
Max. Negotiated Rate	$6,571.78
Rate for Payer: Amerigroup Medicaid	$6,540.04
Rate for Payer: Iowa Total Care Managed Medicaid	$6,476.54
Rate for Payer: Molina Healthcare Managed Medicaid	$6,571.78

Vaginal Delivery Without Sterilization or D&C With CC

Facility

$6,251.91

Service Code	MS-DRG 806
Hospital Charge Code	548
Min. Negotiated Rate	$6,161.30
Max. Negotiated Rate	$6,251.91
Rate for Payer: Amerigroup Medicaid	$6,221.70
Rate for Payer: Iowa Total Care Managed Medicaid	$6,161.30
Rate for Payer: Molina Healthcare Managed Medicaid	$6,251.91

Vaginal Delivery Without Sterilization or D&C With MCC

Facility

$6,913.31

Service Code	MS-DRG 805
Hospital Charge Code	547
Min. Negotiated Rate	$6,813.12
Max. Negotiated Rate	$6,913.31
Rate for Payer: Amerigroup Medicaid	$6,879.92
Rate for Payer: Iowa Total Care Managed Medicaid	$6,813.12
Rate for Payer: Molina Healthcare Managed Medicaid	$6,913.31

Vaginal Delivery Without Sterilization or D&C Without CC/MCC

Facility

$5,867.06

Service Code	MS-DRG 807
Hospital Charge Code	549
Min. Negotiated Rate	$5,782.03
Max. Negotiated Rate	$5,867.06
Rate for Payer: Amerigroup Medicaid	$5,838.72
Rate for Payer: Iowa Total Care Managed Medicaid	$5,782.03
Rate for Payer: Molina Healthcare Managed Medicaid	$5,867.06

Vaginal Delivery With Sterilization And/or D&C With CC

Facility

$8,442.83

Service Code	MS-DRG 797
Hospital Charge Code	539
Min. Negotiated Rate	$8,320.47
Max. Negotiated Rate	$8,442.83
Rate for Payer: Amerigroup Medicaid	$8,402.04
Rate for Payer: Iowa Total Care Managed Medicaid	$8,320.47
Rate for Payer: Molina Healthcare Managed Medicaid	$8,442.83

Vaginal Delivery With Sterilization And/or D&C With MCC

Facility

$9,267.62

Service Code	MS-DRG 796
Hospital Charge Code	538
Min. Negotiated Rate	$9,133.30
Max. Negotiated Rate	$9,267.62
Rate for Payer: Amerigroup Medicaid	$9,222.85
Rate for Payer: Iowa Total Care Managed Medicaid	$9,133.30
Rate for Payer: Molina Healthcare Managed Medicaid	$9,267.62

Vaginal Delivery With Sterilization And/or D&C Without CC/MCC

Facility

$8,020.59

Service Code	MS-DRG 798
Hospital Charge Code	540
Min. Negotiated Rate	$7,904.35
Max. Negotiated Rate	$8,020.59
Rate for Payer: Amerigroup Medicaid	$7,981.84
Rate for Payer: Iowa Total Care Managed Medicaid	$7,904.35
Rate for Payer: Molina Healthcare Managed Medicaid	$8,020.59

valACYclovir 500 mg Tab [VDMC]

Facility

$1.75

Service Code	HCPCS A9270
Hospital Charge Code	10427042
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of IA Commercial	$1.58
Rate for Payer: Aetna of IA Medical Rental Products	$1.58
Rate for Payer: Aetna of IA Medicare	$1.00
Rate for Payer: Amerigroup Medicaid	$0.88
Rate for Payer: Amerigroup Medicare	$0.88
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.88
Rate for Payer: Iowa Total Care Managed Medicaid	$0.87
Rate for Payer: Medical Associates Commercial	$1.31
Rate for Payer: Medical Associates Managed Medicare	$0.88
Rate for Payer: Midlands Choice Commercial	$1.22
Rate for Payer: Molina Healthcare Managed Medicaid	$0.89
Rate for Payer: Molina Healthcare Managed Medicare	$0.89
Rate for Payer: Oscar Health of IA Commercial	$1.31
Rate for Payer: Partners Health Alliance Commercial	$1.31
Rate for Payer: United Healthcare Commercial	$1.58
Rate for Payer: United Healthcare Managed Medicare	$1.03

valACYclovir 500 mg Tab [VDMC]

Facility

$1.75

Service Code	HCPCS A9270
Hospital Charge Code	10427042
Hospital Revenue Code	259
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of IA Commercial	$1.58
Rate for Payer: Aetna of IA Medical Rental Products	$1.58
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.31
Rate for Payer: Medical Associates Commercial	$1.31
Rate for Payer: Midlands Choice Commercial	$1.22
Rate for Payer: United Healthcare Commercial	$1.58

valGANciclovir 450 mg Tab [VDMC]

Facility

$12.84

Service Code	HCPCS A9270
Hospital Charge Code	15958832
Hospital Revenue Code	259
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$11.56
Rate for Payer: Aetna of IA Commercial	$11.56
Rate for Payer: Aetna of IA Medical Rental Products	$11.56
Rate for Payer: Cash Price	$10.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.63
Rate for Payer: Medical Associates Commercial	$9.63
Rate for Payer: Midlands Choice Commercial	$8.99
Rate for Payer: United Healthcare Commercial	$11.56

valGANciclovir 450 mg Tab [VDMC]

Facility

$12.84

Service Code	HCPCS A9270
Hospital Charge Code	15958832
Hospital Revenue Code	259
Min. Negotiated Rate	$6.42
Max. Negotiated Rate	$11.56
Rate for Payer: Aetna of IA Commercial	$11.56
Rate for Payer: Aetna of IA Medical Rental Products	$11.56
Rate for Payer: Aetna of IA Medicare	$7.32
Rate for Payer: Amerigroup Medicaid	$6.48
Rate for Payer: Amerigroup Medicare	$6.48
Rate for Payer: Cash Price	$10.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.63
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.42
Rate for Payer: Iowa Total Care Managed Medicaid	$6.42
Rate for Payer: Medical Associates Commercial	$9.63
Rate for Payer: Medical Associates Managed Medicare	$6.42
Rate for Payer: Midlands Choice Commercial	$8.99
Rate for Payer: Molina Healthcare Managed Medicaid	$6.52
Rate for Payer: Molina Healthcare Managed Medicare	$6.51
Rate for Payer: Oscar Health of IA Commercial	$9.63
Rate for Payer: Partners Health Alliance Commercial	$9.63
Rate for Payer: United Healthcare Commercial	$11.56
Rate for Payer: United Healthcare Managed Medicare	$7.58

valproic acid 250 mg/5 mL Oral Syrup [VDMC]

Facility

$5.59

Service Code	HCPCS A9270
Hospital Charge Code	10427178
Hospital Revenue Code	259
Min. Negotiated Rate	$3.91
Max. Negotiated Rate	$5.03
Rate for Payer: Aetna of IA Commercial	$5.03
Rate for Payer: Aetna of IA Medical Rental Products	$5.03
Rate for Payer: Cash Price	$4.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.19
Rate for Payer: Medical Associates Commercial	$4.19
Rate for Payer: Midlands Choice Commercial	$3.91
Rate for Payer: United Healthcare Commercial	$5.03

valproic acid 250 mg/5 mL Oral Syrup [VDMC]

Facility

$5.59

Service Code	HCPCS A9270
Hospital Charge Code	10427178
Hospital Revenue Code	259
Min. Negotiated Rate	$2.79
Max. Negotiated Rate	$5.03
Rate for Payer: Aetna of IA Commercial	$5.03
Rate for Payer: Aetna of IA Medical Rental Products	$5.03
Rate for Payer: Aetna of IA Medicare	$3.19
Rate for Payer: Amerigroup Medicaid	$2.82
Rate for Payer: Amerigroup Medicare	$2.82
Rate for Payer: Cash Price	$4.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.80
Rate for Payer: Iowa Total Care Managed Medicaid	$2.79
Rate for Payer: Medical Associates Commercial	$4.19
Rate for Payer: Medical Associates Managed Medicare	$2.80
Rate for Payer: Midlands Choice Commercial	$3.91
Rate for Payer: Molina Healthcare Managed Medicaid	$2.84
Rate for Payer: Molina Healthcare Managed Medicare	$2.84
Rate for Payer: Oscar Health of IA Commercial	$4.19
Rate for Payer: Partners Health Alliance Commercial	$4.19
Rate for Payer: United Healthcare Commercial	$5.03
Rate for Payer: United Healthcare Managed Medicare	$3.30

Know your out-of-pocket cost for care.

All Charges