Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC

Facility

$9,963.77

Service Code	MSDRG 743
Min. Negotiated Rate	$9,819.36
Max. Negotiated Rate	$9,963.77
Rate for Payer: Amerigroup Medicaid	$9,915.63
Rate for Payer: Iowa Total Care Managed Medicaid	$9,819.36
Rate for Payer: Molina Healthcare Managed Medicaid	$9,963.77

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC

Facility

$17,650.82

Service Code	MSDRG 740
Min. Negotiated Rate	$17,395.00
Max. Negotiated Rate	$17,650.82
Rate for Payer: Amerigroup Medicaid	$17,565.54
Rate for Payer: Iowa Total Care Managed Medicaid	$17,395.00
Rate for Payer: Molina Healthcare Managed Medicaid	$17,650.82

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC

Facility

$43,042.72

Service Code	MSDRG 739
Min. Negotiated Rate	$42,418.90
Max. Negotiated Rate	$43,042.72
Rate for Payer: Amerigroup Medicaid	$42,834.77
Rate for Payer: Iowa Total Care Managed Medicaid	$42,418.90
Rate for Payer: Molina Healthcare Managed Medicaid	$43,042.72

UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$14,395.62

Service Code	MSDRG 741
Min. Negotiated Rate	$14,186.98
Max. Negotiated Rate	$14,395.62
Rate for Payer: Amerigroup Medicaid	$14,326.07
Rate for Payer: Iowa Total Care Managed Medicaid	$14,186.98
Rate for Payer: Molina Healthcare Managed Medicaid	$14,395.62

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC

Facility

$20,007.49

Service Code	MSDRG 737
Min. Negotiated Rate	$19,717.51
Max. Negotiated Rate	$20,007.49
Rate for Payer: Amerigroup Medicaid	$19,910.82
Rate for Payer: Iowa Total Care Managed Medicaid	$19,717.51
Rate for Payer: Molina Healthcare Managed Medicaid	$20,007.49

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC

Facility

$47,958.74

Service Code	MSDRG 736
Min. Negotiated Rate	$47,263.66
Max. Negotiated Rate	$47,958.74
Rate for Payer: Amerigroup Medicaid	$47,727.03
Rate for Payer: Iowa Total Care Managed Medicaid	$47,263.66
Rate for Payer: Molina Healthcare Managed Medicaid	$47,958.74

UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC

Facility

$16,075.57

Service Code	MSDRG 738
Min. Negotiated Rate	$15,842.59
Max. Negotiated Rate	$16,075.57
Rate for Payer: Amerigroup Medicaid	$15,997.91
Rate for Payer: Iowa Total Care Managed Medicaid	$15,842.59
Rate for Payer: Molina Healthcare Managed Medicaid	$16,075.57

VAGINA, CERVIX AND VULVA PROCEDURES WITH CC/MCC

Facility

$11,223.74

Service Code	MSDRG 746
Min. Negotiated Rate	$11,061.07
Max. Negotiated Rate	$11,223.74
Rate for Payer: Amerigroup Medicaid	$11,169.51
Rate for Payer: Iowa Total Care Managed Medicaid	$11,061.07
Rate for Payer: Molina Healthcare Managed Medicaid	$11,223.74

VAGINA, CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC

Facility

$9,905.22

Service Code	MSDRG 747
Min. Negotiated Rate	$9,761.66
Max. Negotiated Rate	$9,905.22
Rate for Payer: Amerigroup Medicaid	$9,857.36
Rate for Payer: Iowa Total Care Managed Medicaid	$9,761.66
Rate for Payer: Molina Healthcare Managed Medicaid	$9,905.22

VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C

Facility

$7,518.15

Service Code	MSDRG 768
Min. Negotiated Rate	$7,409.19
Max. Negotiated Rate	$7,518.15
Rate for Payer: Amerigroup Medicaid	$7,481.83
Rate for Payer: Iowa Total Care Managed Medicaid	$7,409.19
Rate for Payer: Molina Healthcare Managed Medicaid	$7,518.15

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC

Facility

$7,152.21

Service Code	MSDRG 806
Min. Negotiated Rate	$7,048.55
Max. Negotiated Rate	$7,152.21
Rate for Payer: Amerigroup Medicaid	$7,117.65
Rate for Payer: Iowa Total Care Managed Medicaid	$7,048.55
Rate for Payer: Molina Healthcare Managed Medicaid	$7,152.21

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC

Facility

$7,908.86

Service Code	MSDRG 805
Min. Negotiated Rate	$7,794.24
Max. Negotiated Rate	$7,908.86
Rate for Payer: Amerigroup Medicaid	$7,870.65
Rate for Payer: Iowa Total Care Managed Medicaid	$7,794.24
Rate for Payer: Molina Healthcare Managed Medicaid	$7,908.86

VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC

Facility

$6,711.95

Service Code	MSDRG 807
Min. Negotiated Rate	$6,614.67
Max. Negotiated Rate	$6,711.95
Rate for Payer: Amerigroup Medicaid	$6,679.52
Rate for Payer: Iowa Total Care Managed Medicaid	$6,614.67
Rate for Payer: Molina Healthcare Managed Medicaid	$6,711.95

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC

Facility

$9,658.63

Service Code	MSDRG 797
Min. Negotiated Rate	$9,518.65
Max. Negotiated Rate	$9,658.63
Rate for Payer: Amerigroup Medicaid	$9,611.97
Rate for Payer: Iowa Total Care Managed Medicaid	$9,518.65
Rate for Payer: Molina Healthcare Managed Medicaid	$9,658.63

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC

Facility

$10,602.20

Service Code	MSDRG 796
Min. Negotiated Rate	$10,448.54
Max. Negotiated Rate	$10,602.20
Rate for Payer: Amerigroup Medicaid	$10,550.98
Rate for Payer: Iowa Total Care Managed Medicaid	$10,448.54
Rate for Payer: Molina Healthcare Managed Medicaid	$10,602.20

VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC

Facility

$9,175.59

Service Code	MSDRG 798
Min. Negotiated Rate	$9,042.60
Max. Negotiated Rate	$9,175.59
Rate for Payer: Amerigroup Medicaid	$9,131.26
Rate for Payer: Iowa Total Care Managed Medicaid	$9,042.60
Rate for Payer: Molina Healthcare Managed Medicaid	$9,175.59

valACYclovir 500 mg Tab [VDMC]

Facility

$1.75

Service Code	HCPCS A9270
Hospital Charge Code	10427042
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
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	$1.01
Rate for Payer: Amerigroup Medicare	$0.80
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.79
Rate for Payer: Iowa Total Care Managed Medicaid	$1.00
Rate for Payer: Medical Associates Commercial	$1.32
Rate for Payer: Medical Associates Managed Medicare	$0.79
Rate for Payer: Midlands Choice Commercial	$1.23
Rate for Payer: Molina Healthcare Managed Medicaid	$1.02
Rate for Payer: Partners Health Alliance Commercial	$0.91
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	$1.23
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	$1.32
Rate for Payer: Medical Associates Commercial	$1.32
Rate for Payer: Midlands Choice Commercial	$1.23
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	$5.78
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	$7.41
Rate for Payer: Amerigroup Medicare	$5.84
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	$5.78
Rate for Payer: Iowa Total Care Managed Medicaid	$7.33
Rate for Payer: Medical Associates Commercial	$9.63
Rate for Payer: Medical Associates Managed Medicare	$5.78
Rate for Payer: Midlands Choice Commercial	$8.99
Rate for Payer: Molina Healthcare Managed Medicaid	$7.44
Rate for Payer: Partners Health Alliance Commercial	$6.65
Rate for Payer: United Healthcare Commercial	$11.56
Rate for Payer: United Healthcare Managed Medicare	$7.58

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

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

Facility

$9.47

Service Code	HCPCS A9270
Hospital Charge Code	10427178
Hospital Revenue Code	259
Min. Negotiated Rate	$4.26
Max. Negotiated Rate	$8.52
Rate for Payer: Aetna of IA Commercial	$8.52
Rate for Payer: Aetna of IA Medical Rental Products	$8.52
Rate for Payer: Aetna of IA Medicare	$5.40
Rate for Payer: Amerigroup Medicaid	$5.46
Rate for Payer: Amerigroup Medicare	$4.30
Rate for Payer: Cash Price	$7.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.26
Rate for Payer: Iowa Total Care Managed Medicaid	$5.41
Rate for Payer: Medical Associates Commercial	$7.10
Rate for Payer: Medical Associates Managed Medicare	$4.26
Rate for Payer: Midlands Choice Commercial	$6.63
Rate for Payer: Molina Healthcare Managed Medicaid	$5.49
Rate for Payer: Partners Health Alliance Commercial	$4.90
Rate for Payer: United Healthcare Commercial	$8.52
Rate for Payer: United Healthcare Managed Medicare	$5.59

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

Facility

$9.47

Service Code	HCPCS A9270
Hospital Charge Code	10427178
Hospital Revenue Code	259
Min. Negotiated Rate	$6.63
Max. Negotiated Rate	$8.52
Rate for Payer: Aetna of IA Commercial	$8.52
Rate for Payer: Aetna of IA Medical Rental Products	$8.52
Rate for Payer: Cash Price	$7.58
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.10
Rate for Payer: Medical Associates Commercial	$7.10
Rate for Payer: Midlands Choice Commercial	$6.63
Rate for Payer: United Healthcare Commercial	$8.52

valproic acid 500 mg/5mL Sol SDV [VDMC]

Facility

$27.21

Service Code	HCPCS J3490
Hospital Charge Code	10427111
Hospital Revenue Code	259
Min. Negotiated Rate	$12.25
Max. Negotiated Rate	$24.49
Rate for Payer: Aetna of IA Commercial	$24.49
Rate for Payer: Aetna of IA Medical Rental Products	$24.49
Rate for Payer: Aetna of IA Medicare	$15.51
Rate for Payer: Amerigroup Medicaid	$15.70
Rate for Payer: Amerigroup Medicare	$12.37
Rate for Payer: Cash Price	$21.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.41
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.25
Rate for Payer: Iowa Total Care Managed Medicaid	$15.54
Rate for Payer: Medical Associates Commercial	$20.41
Rate for Payer: Medical Associates Managed Medicare	$12.25
Rate for Payer: Midlands Choice Commercial	$19.05
Rate for Payer: Molina Healthcare Managed Medicaid	$15.77
Rate for Payer: Partners Health Alliance Commercial	$14.08
Rate for Payer: United Healthcare Commercial	$24.49
Rate for Payer: United Healthcare Managed Medicare	$16.06

valproic acid 500 mg/5mL Sol SDV [VDMC]

Facility

$27.21

Service Code	HCPCS J3490
Hospital Charge Code	10427111
Hospital Revenue Code	259
Min. Negotiated Rate	$19.05
Max. Negotiated Rate	$24.49
Rate for Payer: Aetna of IA Commercial	$24.49
Rate for Payer: Aetna of IA Medical Rental Products	$24.49
Rate for Payer: Cash Price	$21.77
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.41
Rate for Payer: Medical Associates Commercial	$20.41
Rate for Payer: Midlands Choice Commercial	$19.05
Rate for Payer: United Healthcare Commercial	$24.49

Valproic Acid Level DMCL

Facility

$129.00

Service Code	CPT 80164
Hospital Charge Code	8037821
Hospital Revenue Code	301
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of IA Commercial	$116.10
Rate for Payer: Aetna of IA Medical Rental Products	$116.10
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.75
Rate for Payer: Medical Associates Commercial	$96.75
Rate for Payer: Midlands Choice Commercial	$90.30
Rate for Payer: United Healthcare Commercial	$116.10

Know your out-of-pocket cost for care.

All Charges