Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Autologous Bone Marrow Transplant With CC/MCC

Facility

$63,668.61

Service Code	MS-DRG 016
Hospital Charge Code	705
Min. Negotiated Rate	$62,745.88
Max. Negotiated Rate	$63,668.61
Rate for Payer: Amerigroup Medicaid	$63,361.04
Rate for Payer: Iowa Total Care Managed Medicaid	$62,745.88
Rate for Payer: Molina Healthcare Managed Medicaid	$63,668.61

Autologous Bone Marrow Transplant Without CC/MCC

Facility

$38,836.20

Service Code	MS-DRG 017
Hospital Charge Code	706
Min. Negotiated Rate	$38,273.36
Max. Negotiated Rate	$38,836.20
Rate for Payer: Amerigroup Medicaid	$38,648.59
Rate for Payer: Iowa Total Care Managed Medicaid	$38,273.36
Rate for Payer: Molina Healthcare Managed Medicaid	$38,836.20

azaCITIDine 100 mg SDV Pow[VDMC]

Facility

$395.92

Service Code	HCPCS J9025
Hospital Charge Code	13876917
Hospital Revenue Code	259
Min. Negotiated Rate	$197.88
Max. Negotiated Rate	$356.33
Rate for Payer: Aetna of IA Commercial	$356.33
Rate for Payer: Aetna of IA Medical Rental Products	$356.33
Rate for Payer: Aetna of IA Medicare	$225.67
Rate for Payer: Amerigroup Medicaid	$199.82
Rate for Payer: Amerigroup Medicare	$199.94
Rate for Payer: Cash Price	$316.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$296.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$197.96
Rate for Payer: Iowa Total Care Managed Medicaid	$197.88
Rate for Payer: Medical Associates Commercial	$296.94
Rate for Payer: Medical Associates Managed Medicare	$197.96
Rate for Payer: Midlands Choice Commercial	$277.14
Rate for Payer: Molina Healthcare Managed Medicaid	$200.93
Rate for Payer: Molina Healthcare Managed Medicare	$200.81
Rate for Payer: Oscar Health of IA Commercial	$296.94
Rate for Payer: Partners Health Alliance Commercial	$296.94
Rate for Payer: United Healthcare Commercial	$356.33
Rate for Payer: United Healthcare Managed Medicare	$233.59

azaCITIDine 100 mg SDV Pow[VDMC]

Facility

$395.92

Service Code	HCPCS J9025
Hospital Charge Code	13876917
Hospital Revenue Code	259
Min. Negotiated Rate	$277.14
Max. Negotiated Rate	$356.33
Rate for Payer: Aetna of IA Commercial	$356.33
Rate for Payer: Aetna of IA Medical Rental Products	$356.33
Rate for Payer: Cash Price	$316.74
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$296.94
Rate for Payer: Medical Associates Commercial	$296.94
Rate for Payer: Midlands Choice Commercial	$277.14
Rate for Payer: United Healthcare Commercial	$356.33

azaTHIOprine 50 mg Tab [VDMC]

Facility

$2.61

Service Code	HCPCS A9270
Hospital Charge Code	10368791
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna of IA Commercial	$2.35
Rate for Payer: Aetna of IA Medical Rental Products	$2.35
Rate for Payer: Aetna of IA Medicare	$1.49
Rate for Payer: Amerigroup Medicaid	$1.32
Rate for Payer: Amerigroup Medicare	$1.32
Rate for Payer: Cash Price	$2.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.96
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1.30
Rate for Payer: Medical Associates Commercial	$1.96
Rate for Payer: Medical Associates Managed Medicare	$1.30
Rate for Payer: Midlands Choice Commercial	$1.83
Rate for Payer: Molina Healthcare Managed Medicaid	$1.32
Rate for Payer: Molina Healthcare Managed Medicare	$1.32
Rate for Payer: Oscar Health of IA Commercial	$1.96
Rate for Payer: Partners Health Alliance Commercial	$1.96
Rate for Payer: United Healthcare Commercial	$2.35
Rate for Payer: United Healthcare Managed Medicare	$1.54

azaTHIOprine 50 mg Tab [VDMC]

Facility

$2.61

Service Code	HCPCS A9270
Hospital Charge Code	10368791
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna of IA Commercial	$2.35
Rate for Payer: Aetna of IA Medical Rental Products	$2.35
Rate for Payer: Cash Price	$2.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.96
Rate for Payer: Medical Associates Commercial	$1.96
Rate for Payer: Midlands Choice Commercial	$1.83
Rate for Payer: United Healthcare Commercial	$2.35

azithromycin 200 mg/5 mL Oral Liq 15 ml [VDMC]

Facility

$47.84

Service Code	HCPCS Q0144
Hospital Charge Code	10368860
Hospital Revenue Code	259
Min. Negotiated Rate	$33.49
Max. Negotiated Rate	$43.06
Rate for Payer: Aetna of IA Commercial	$43.06
Rate for Payer: Aetna of IA Medical Rental Products	$43.06
Rate for Payer: Cash Price	$38.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.88
Rate for Payer: Medical Associates Commercial	$35.88
Rate for Payer: Midlands Choice Commercial	$33.49
Rate for Payer: United Healthcare Commercial	$43.06

azithromycin 200 mg/5 mL Oral Liq 15 ml [VDMC]

Facility

$47.84

Service Code	HCPCS Q0144
Hospital Charge Code	10368860
Hospital Revenue Code	259
Min. Negotiated Rate	$23.91
Max. Negotiated Rate	$43.06
Rate for Payer: Aetna of IA Commercial	$43.06
Rate for Payer: Aetna of IA Medical Rental Products	$43.06
Rate for Payer: Aetna of IA Medicare	$27.27
Rate for Payer: Amerigroup Medicaid	$24.14
Rate for Payer: Amerigroup Medicare	$24.16
Rate for Payer: Cash Price	$38.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$35.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.92
Rate for Payer: Iowa Total Care Managed Medicaid	$23.91
Rate for Payer: Medical Associates Commercial	$35.88
Rate for Payer: Medical Associates Managed Medicare	$23.92
Rate for Payer: Midlands Choice Commercial	$33.49
Rate for Payer: Molina Healthcare Managed Medicaid	$24.28
Rate for Payer: Molina Healthcare Managed Medicare	$24.26
Rate for Payer: Oscar Health of IA Commercial	$35.88
Rate for Payer: Partners Health Alliance Commercial	$35.88
Rate for Payer: United Healthcare Commercial	$43.06
Rate for Payer: United Healthcare Managed Medicare	$28.23

azithromycin 250 mg Tab [VDMC]

Facility

$1.79

Service Code	HCPCS A9270
Hospital Charge Code	10606481
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of IA Commercial	$1.61
Rate for Payer: Aetna of IA Medical Rental Products	$1.61
Rate for Payer: Aetna of IA Medicare	$1.02
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	$0.90
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	$0.90
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: Molina Healthcare Managed Medicaid	$0.91
Rate for Payer: Molina Healthcare Managed Medicare	$0.91
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	$1.61
Rate for Payer: United Healthcare Managed Medicare	$1.06

azithromycin 250 mg Tab [VDMC]

Facility

$1.79

Service Code	HCPCS A9270
Hospital Charge Code	10606481
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.61
Rate for Payer: Aetna of IA Commercial	$1.61
Rate for Payer: Aetna of IA Medical Rental Products	$1.61
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	$1.61

azithromycin 500 mg IV SDV Inj [VDMC]

Facility

$27.10

Service Code	HCPCS J0456
Hospital Charge Code	10368929
Hospital Revenue Code	259
Min. Negotiated Rate	$13.54
Max. Negotiated Rate	$24.39
Rate for Payer: Aetna of IA Commercial	$24.39
Rate for Payer: Aetna of IA Medical Rental Products	$24.39
Rate for Payer: Aetna of IA Medicare	$15.45
Rate for Payer: Amerigroup Medicaid	$13.68
Rate for Payer: Amerigroup Medicare	$13.69
Rate for Payer: Cash Price	$21.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.55
Rate for Payer: Iowa Total Care Managed Medicaid	$13.54
Rate for Payer: Medical Associates Commercial	$20.32
Rate for Payer: Medical Associates Managed Medicare	$13.55
Rate for Payer: Midlands Choice Commercial	$18.97
Rate for Payer: Molina Healthcare Managed Medicaid	$13.75
Rate for Payer: Molina Healthcare Managed Medicare	$13.75
Rate for Payer: Oscar Health of IA Commercial	$20.32
Rate for Payer: Partners Health Alliance Commercial	$20.32
Rate for Payer: United Healthcare Commercial	$24.39
Rate for Payer: United Healthcare Managed Medicare	$15.99

azithromycin 500 mg IV SDV Inj [VDMC]

Facility

$27.10

Service Code	HCPCS J0456
Hospital Charge Code	10368929
Hospital Revenue Code	259
Min. Negotiated Rate	$18.97
Max. Negotiated Rate	$24.39
Rate for Payer: Aetna of IA Commercial	$24.39
Rate for Payer: Aetna of IA Medical Rental Products	$24.39
Rate for Payer: Cash Price	$21.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.32
Rate for Payer: Medical Associates Commercial	$20.32
Rate for Payer: Midlands Choice Commercial	$18.97
Rate for Payer: United Healthcare Commercial	$24.39

aztreonam 1 g SDV Inj [VDMC]

Facility

$107.42

Service Code	HCPCS J3490
Hospital Charge Code	10368998
Hospital Revenue Code	259
Min. Negotiated Rate	$75.19
Max. Negotiated Rate	$96.68
Rate for Payer: Aetna of IA Commercial	$96.68
Rate for Payer: Aetna of IA Medical Rental Products	$96.68
Rate for Payer: Cash Price	$85.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$80.56
Rate for Payer: Medical Associates Commercial	$80.56
Rate for Payer: Midlands Choice Commercial	$75.19
Rate for Payer: United Healthcare Commercial	$96.68

aztreonam 1 g SDV Inj [VDMC]

Facility

$107.42

Service Code	HCPCS J3490
Hospital Charge Code	10368998
Hospital Revenue Code	259
Min. Negotiated Rate	$53.69
Max. Negotiated Rate	$96.68
Rate for Payer: Aetna of IA Commercial	$96.68
Rate for Payer: Aetna of IA Medical Rental Products	$96.68
Rate for Payer: Aetna of IA Medicare	$61.23
Rate for Payer: Amerigroup Medicaid	$54.21
Rate for Payer: Amerigroup Medicare	$54.25
Rate for Payer: Cash Price	$85.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$80.56
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$53.71
Rate for Payer: Iowa Total Care Managed Medicaid	$53.69
Rate for Payer: Medical Associates Commercial	$80.56
Rate for Payer: Medical Associates Managed Medicare	$53.71
Rate for Payer: Midlands Choice Commercial	$75.19
Rate for Payer: Molina Healthcare Managed Medicaid	$54.52
Rate for Payer: Molina Healthcare Managed Medicare	$54.48
Rate for Payer: Oscar Health of IA Commercial	$80.56
Rate for Payer: Partners Health Alliance Commercial	$80.56
Rate for Payer: United Healthcare Commercial	$96.68
Rate for Payer: United Healthcare Managed Medicare	$63.38

bacitracin/neomycin/polymyxin B Top Oint [VDMC]

Facility

$15.75

Service Code	HCPCS A9270
Hospital Charge Code	10369266
Hospital Revenue Code	259
Min. Negotiated Rate	$7.87
Max. Negotiated Rate	$14.18
Rate for Payer: Aetna of IA Commercial	$14.18
Rate for Payer: Aetna of IA Medical Rental Products	$14.18
Rate for Payer: Aetna of IA Medicare	$8.98
Rate for Payer: Amerigroup Medicaid	$7.95
Rate for Payer: Amerigroup Medicare	$7.95
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.81
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.88
Rate for Payer: Iowa Total Care Managed Medicaid	$7.87
Rate for Payer: Medical Associates Commercial	$11.81
Rate for Payer: Medical Associates Managed Medicare	$7.88
Rate for Payer: Midlands Choice Commercial	$11.02
Rate for Payer: Molina Healthcare Managed Medicaid	$7.99
Rate for Payer: Molina Healthcare Managed Medicare	$7.99
Rate for Payer: Oscar Health of IA Commercial	$11.81
Rate for Payer: Partners Health Alliance Commercial	$11.81
Rate for Payer: United Healthcare Commercial	$14.18
Rate for Payer: United Healthcare Managed Medicare	$9.29

bacitracin/neomycin/polymyxin B Top Oint [VDMC]

Facility

$15.75

Service Code	HCPCS A9270
Hospital Charge Code	10369266
Hospital Revenue Code	259
Min. Negotiated Rate	$11.02
Max. Negotiated Rate	$14.18
Rate for Payer: Aetna of IA Commercial	$14.18
Rate for Payer: Aetna of IA Medical Rental Products	$14.18
Rate for Payer: Cash Price	$12.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.81
Rate for Payer: Medical Associates Commercial	$11.81
Rate for Payer: Midlands Choice Commercial	$11.02
Rate for Payer: United Healthcare Commercial	$14.18

bacitracin Top 500 units/g Oint [VDMC]

Facility

$13.09

Service Code	HCPCS A9270
Hospital Charge Code	10369136
Hospital Revenue Code	259
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$11.78
Rate for Payer: Medical Associates Commercial	$9.82
Rate for Payer: Aetna of IA Commercial	$11.78
Rate for Payer: Aetna of IA Medical Rental Products	$11.78
Rate for Payer: Cash Price	$10.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.82
Rate for Payer: Midlands Choice Commercial	$9.16
Rate for Payer: United Healthcare Commercial	$11.78

bacitracin Top 500 units/g Oint [VDMC]

Facility

$13.09

Service Code	HCPCS A9270
Hospital Charge Code	10369136
Hospital Revenue Code	259
Min. Negotiated Rate	$6.54
Max. Negotiated Rate	$11.78
Rate for Payer: Aetna of IA Commercial	$11.78
Rate for Payer: Aetna of IA Medical Rental Products	$11.78
Rate for Payer: Aetna of IA Medicare	$7.46
Rate for Payer: Amerigroup Medicaid	$6.61
Rate for Payer: Amerigroup Medicare	$6.61
Rate for Payer: Cash Price	$10.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.54
Rate for Payer: Iowa Total Care Managed Medicaid	$6.54
Rate for Payer: Medical Associates Commercial	$9.82
Rate for Payer: Medical Associates Managed Medicare	$6.54
Rate for Payer: Midlands Choice Commercial	$9.16
Rate for Payer: Molina Healthcare Managed Medicaid	$6.64
Rate for Payer: Molina Healthcare Managed Medicare	$6.64
Rate for Payer: Oscar Health of IA Commercial	$9.82
Rate for Payer: Partners Health Alliance Commercial	$9.82
Rate for Payer: United Healthcare Commercial	$11.78
Rate for Payer: United Healthcare Managed Medicare	$7.72

Back and Neck Procedures Except Spinal Fusion With CC

Facility

$15,171.10

Service Code	MS-DRG 519
Hospital Charge Code	336
Min. Negotiated Rate	$14,951.23
Max. Negotiated Rate	$15,171.10
Rate for Payer: Amerigroup Medicaid	$15,097.81
Rate for Payer: Iowa Total Care Managed Medicaid	$14,951.23
Rate for Payer: Molina Healthcare Managed Medicaid	$15,171.10

Back and Neck Procedures Except Spinal Fusion With MCC or Disc Device or Neurostimulator

Facility

$15,863.02

Service Code	MS-DRG 518
Hospital Charge Code	335
Min. Negotiated Rate	$15,633.12
Max. Negotiated Rate	$15,863.02
Rate for Payer: Amerigroup Medicaid	$15,786.39
Rate for Payer: Iowa Total Care Managed Medicaid	$15,633.12
Rate for Payer: Molina Healthcare Managed Medicaid	$15,863.02

Back and Neck Procedures Except Spinal Fusion Without CC/MCC

Facility

$10,611.11

Service Code	MS-DRG 520
Hospital Charge Code	337
Min. Negotiated Rate	$10,457.33
Max. Negotiated Rate	$10,611.11
Rate for Payer: Amerigroup Medicaid	$10,559.85
Rate for Payer: Iowa Total Care Managed Medicaid	$10,457.33
Rate for Payer: Molina Healthcare Managed Medicaid	$10,611.11

baclofen 10 mg Tab [VDMC]

Facility

$2.05

Service Code	HCPCS A9270
Hospital Charge Code	10369331
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of IA Commercial	$1.84
Rate for Payer: Aetna of IA Medical Rental Products	$1.84
Rate for Payer: Cash Price	$1.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.54
Rate for Payer: Medical Associates Commercial	$1.54
Rate for Payer: Midlands Choice Commercial	$1.44
Rate for Payer: United Healthcare Commercial	$1.84

baclofen 10 mg Tab [VDMC]

Facility

$2.05

Service Code	HCPCS A9270
Hospital Charge Code	10369331
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.84
Rate for Payer: Aetna of IA Commercial	$1.84
Rate for Payer: Aetna of IA Medical Rental Products	$1.84
Rate for Payer: Aetna of IA Medicare	$1.17
Rate for Payer: Amerigroup Medicaid	$1.03
Rate for Payer: Amerigroup Medicare	$1.04
Rate for Payer: Cash Price	$1.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.02
Rate for Payer: Iowa Total Care Managed Medicaid	$1.02
Rate for Payer: Medical Associates Commercial	$1.54
Rate for Payer: Medical Associates Managed Medicare	$1.02
Rate for Payer: Midlands Choice Commercial	$1.44
Rate for Payer: Molina Healthcare Managed Medicaid	$1.04
Rate for Payer: Molina Healthcare Managed Medicare	$1.04
Rate for Payer: Oscar Health of IA Commercial	$1.54
Rate for Payer: Partners Health Alliance Commercial	$1.54
Rate for Payer: United Healthcare Commercial	$1.84
Rate for Payer: United Healthcare Managed Medicare	$1.21

Bacterial and Tuberculous Infections of Nervous System With CC

Facility

$18,889.57

Service Code	MS-DRG 095
Hospital Charge Code	775
Min. Negotiated Rate	$18,615.81
Max. Negotiated Rate	$18,889.57
Rate for Payer: Amerigroup Medicaid	$18,798.31
Rate for Payer: Iowa Total Care Managed Medicaid	$18,615.81
Rate for Payer: Molina Healthcare Managed Medicaid	$18,889.57

Bacterial and Tuberculous Infections of Nervous System With MCC

Facility

$34,765.38

Service Code	MS-DRG 094
Hospital Charge Code	774
Min. Negotiated Rate	$34,261.53
Max. Negotiated Rate	$34,765.38
Rate for Payer: Amerigroup Medicaid	$34,597.43
Rate for Payer: Iowa Total Care Managed Medicaid	$34,261.53
Rate for Payer: Molina Healthcare Managed Medicaid	$34,765.38

Know your out-of-pocket cost for care.

All Charges