Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

VENTRIO MED OVAL HERNIA PATCH

Facility

$1,305.00

Service Code	HCPCS C1781
Hospital Charge Code	8026376
Hospital Revenue Code	278
Min. Negotiated Rate	$587.25
Max. Negotiated Rate	$1,174.50
Rate for Payer: Aetna of IA Commercial	$1,174.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,174.50
Rate for Payer: Aetna of IA Medicare	$743.85
Rate for Payer: Amerigroup Medicaid	$752.72
Rate for Payer: Amerigroup Medicare	$593.12
Rate for Payer: Cash Price	$1,044.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$978.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$587.25
Rate for Payer: Iowa Total Care Managed Medicaid	$745.42
Rate for Payer: Medical Associates Commercial	$978.75
Rate for Payer: Medical Associates Managed Medicare	$587.25
Rate for Payer: Midlands Choice Commercial	$913.50
Rate for Payer: Molina Healthcare Managed Medicaid	$756.38
Rate for Payer: Partners Health Alliance Commercial	$675.34
Rate for Payer: United Healthcare Commercial	$1,174.50
Rate for Payer: United Healthcare Managed Medicare	$769.95

VENTRIO SM CIRCLE HERNIA PATCH

Facility

$945.00

Service Code	HCPCS C1781
Hospital Charge Code	8025828
Hospital Revenue Code	278
Min. Negotiated Rate	$425.25
Max. Negotiated Rate	$850.50
Rate for Payer: Aetna of IA Commercial	$850.50
Rate for Payer: Aetna of IA Medical Rental Products	$850.50
Rate for Payer: Aetna of IA Medicare	$538.65
Rate for Payer: Amerigroup Medicaid	$545.08
Rate for Payer: Amerigroup Medicare	$429.50
Rate for Payer: Cash Price	$756.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$708.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$425.25
Rate for Payer: Iowa Total Care Managed Medicaid	$539.78
Rate for Payer: Medical Associates Commercial	$708.75
Rate for Payer: Medical Associates Managed Medicare	$425.25
Rate for Payer: Midlands Choice Commercial	$661.50
Rate for Payer: Molina Healthcare Managed Medicaid	$547.72
Rate for Payer: Partners Health Alliance Commercial	$489.04
Rate for Payer: United Healthcare Commercial	$850.50
Rate for Payer: United Healthcare Managed Medicare	$557.55

VENTRIO SM CIRCLE HERNIA PATCH

Facility

$945.00

Service Code	HCPCS C1781
Hospital Charge Code	8025828
Hospital Revenue Code	278
Min. Negotiated Rate	$661.50
Max. Negotiated Rate	$850.50
Rate for Payer: Aetna of IA Commercial	$850.50
Rate for Payer: Aetna of IA Medical Rental Products	$850.50
Rate for Payer: Cash Price	$756.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$708.75
Rate for Payer: Medical Associates Commercial	$708.75
Rate for Payer: Midlands Choice Commercial	$661.50
Rate for Payer: United Healthcare Commercial	$850.50

VENTRIO SM OVAL HERNIA PATCH

Facility

$1,087.00

Service Code	HCPCS C1781
Hospital Charge Code	8025936
Hospital Revenue Code	278
Min. Negotiated Rate	$489.15
Max. Negotiated Rate	$978.30
Rate for Payer: Aetna of IA Commercial	$978.30
Rate for Payer: Aetna of IA Medical Rental Products	$978.30
Rate for Payer: Aetna of IA Medicare	$619.59
Rate for Payer: Amerigroup Medicaid	$626.98
Rate for Payer: Amerigroup Medicare	$494.04
Rate for Payer: Cash Price	$869.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$815.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$489.15
Rate for Payer: Iowa Total Care Managed Medicaid	$620.89
Rate for Payer: Medical Associates Commercial	$815.25
Rate for Payer: Medical Associates Managed Medicare	$489.15
Rate for Payer: Midlands Choice Commercial	$760.90
Rate for Payer: Molina Healthcare Managed Medicaid	$630.03
Rate for Payer: Partners Health Alliance Commercial	$562.52
Rate for Payer: United Healthcare Commercial	$978.30
Rate for Payer: United Healthcare Managed Medicare	$641.33

VENTRIO SM OVAL HERNIA PATCH

Facility

$1,087.00

Service Code	HCPCS C1781
Hospital Charge Code	8025936
Hospital Revenue Code	278
Min. Negotiated Rate	$760.90
Max. Negotiated Rate	$978.30
Rate for Payer: Aetna of IA Commercial	$978.30
Rate for Payer: Aetna of IA Medical Rental Products	$978.30
Rate for Payer: Cash Price	$869.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$815.25
Rate for Payer: Medical Associates Commercial	$815.25
Rate for Payer: Midlands Choice Commercial	$760.90
Rate for Payer: United Healthcare Commercial	$978.30

verapamil 120 mg ER Tab [VDMC]

Facility

$1.84

Service Code	HCPCS A9270
Hospital Charge Code	10427939
Hospital Revenue Code	259
Min. Negotiated Rate	$1.29
Max. Negotiated Rate	$1.65
Rate for Payer: Aetna of IA Commercial	$1.65
Rate for Payer: Aetna of IA Medical Rental Products	$1.65
Rate for Payer: Cash Price	$1.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.38
Rate for Payer: Medical Associates Commercial	$1.38
Rate for Payer: Midlands Choice Commercial	$1.29
Rate for Payer: United Healthcare Commercial	$1.65

verapamil 120 mg ER Tab [VDMC]

Facility

$1.84

Service Code	HCPCS A9270
Hospital Charge Code	10427939
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.65
Rate for Payer: Aetna of IA Commercial	$1.65
Rate for Payer: Aetna of IA Medical Rental Products	$1.65
Rate for Payer: Aetna of IA Medicare	$1.05
Rate for Payer: Amerigroup Medicaid	$1.06
Rate for Payer: Amerigroup Medicare	$0.83
Rate for Payer: Cash Price	$1.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.83
Rate for Payer: Iowa Total Care Managed Medicaid	$1.05
Rate for Payer: Medical Associates Commercial	$1.38
Rate for Payer: Medical Associates Managed Medicare	$0.83
Rate for Payer: Midlands Choice Commercial	$1.29
Rate for Payer: Molina Healthcare Managed Medicaid	$1.06
Rate for Payer: Partners Health Alliance Commercial	$0.95
Rate for Payer: United Healthcare Commercial	$1.65
Rate for Payer: United Healthcare Managed Medicare	$1.08

verapamil 180 mg ER Tab [VDMC]

Facility

$1.86

Service Code	HCPCS A9270
Hospital Charge Code	10428008
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of IA Commercial	$1.68
Rate for Payer: Aetna of IA Medical Rental Products	$1.68
Rate for Payer: Aetna of IA Medicare	$1.06
Rate for Payer: Amerigroup Medicaid	$1.07
Rate for Payer: Amerigroup Medicare	$0.85
Rate for Payer: Cash Price	$1.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.84
Rate for Payer: Iowa Total Care Managed Medicaid	$1.06
Rate for Payer: Medical Associates Commercial	$1.40
Rate for Payer: Medical Associates Managed Medicare	$0.84
Rate for Payer: Midlands Choice Commercial	$1.30
Rate for Payer: Molina Healthcare Managed Medicaid	$1.08
Rate for Payer: Partners Health Alliance Commercial	$0.96
Rate for Payer: United Healthcare Commercial	$1.68
Rate for Payer: United Healthcare Managed Medicare	$1.10

verapamil 180 mg ER Tab [VDMC]

Facility

$1.86

Service Code	HCPCS A9270
Hospital Charge Code	10428008
Hospital Revenue Code	259
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of IA Commercial	$1.68
Rate for Payer: Aetna of IA Medical Rental Products	$1.68
Rate for Payer: Cash Price	$1.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.40
Rate for Payer: Medical Associates Commercial	$1.40
Rate for Payer: Midlands Choice Commercial	$1.30
Rate for Payer: United Healthcare Commercial	$1.68

verapamil 2.5 mg/mL 2ml SDV IV Sol [VDMC]

Facility

$36.58

Service Code	HCPCS J3490
Hospital Charge Code	10428077
Hospital Revenue Code	259
Min. Negotiated Rate	$16.46
Max. Negotiated Rate	$32.92
Rate for Payer: Aetna of IA Commercial	$32.92
Rate for Payer: Aetna of IA Medical Rental Products	$32.92
Rate for Payer: Aetna of IA Medicare	$20.85
Rate for Payer: Amerigroup Medicaid	$21.10
Rate for Payer: Amerigroup Medicare	$16.63
Rate for Payer: Cash Price	$29.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.43
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$16.46
Rate for Payer: Iowa Total Care Managed Medicaid	$20.89
Rate for Payer: Medical Associates Commercial	$27.43
Rate for Payer: Medical Associates Managed Medicare	$16.46
Rate for Payer: Midlands Choice Commercial	$25.61
Rate for Payer: Molina Healthcare Managed Medicaid	$21.20
Rate for Payer: Partners Health Alliance Commercial	$18.93
Rate for Payer: United Healthcare Commercial	$32.92
Rate for Payer: United Healthcare Managed Medicare	$21.58

verapamil 2.5 mg/mL 2ml SDV IV Sol [VDMC]

Facility

$36.58

Service Code	HCPCS J3490
Hospital Charge Code	10428077
Hospital Revenue Code	259
Min. Negotiated Rate	$25.61
Max. Negotiated Rate	$32.92
Rate for Payer: Aetna of IA Commercial	$32.92
Rate for Payer: Aetna of IA Medical Rental Products	$32.92
Rate for Payer: Cash Price	$29.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.43
Rate for Payer: Medical Associates Commercial	$27.43
Rate for Payer: Midlands Choice Commercial	$25.61
Rate for Payer: United Healthcare Commercial	$32.92

verapamil 80 mg Tab [VDMC]

Facility

$1.17

Service Code	HCPCS A9270
Hospital Charge Code	10428148
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of IA Commercial	$1.05
Rate for Payer: Aetna of IA Medical Rental Products	$1.05
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.88
Rate for Payer: Medical Associates Commercial	$0.88
Rate for Payer: Midlands Choice Commercial	$0.82
Rate for Payer: United Healthcare Commercial	$1.05

verapamil 80 mg Tab [VDMC]

Facility

$1.17

Service Code	HCPCS A9270
Hospital Charge Code	10428148
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of IA Commercial	$1.05
Rate for Payer: Aetna of IA Medical Rental Products	$1.05
Rate for Payer: Aetna of IA Medicare	$0.67
Rate for Payer: Amerigroup Medicaid	$0.68
Rate for Payer: Amerigroup Medicare	$0.53
Rate for Payer: Cash Price	$0.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.53
Rate for Payer: Iowa Total Care Managed Medicaid	$0.67
Rate for Payer: Medical Associates Commercial	$0.88
Rate for Payer: Medical Associates Managed Medicare	$0.53
Rate for Payer: Midlands Choice Commercial	$0.82
Rate for Payer: Molina Healthcare Managed Medicaid	$0.68
Rate for Payer: Partners Health Alliance Commercial	$0.61
Rate for Payer: United Healthcare Commercial	$1.05
Rate for Payer: United Healthcare Managed Medicare	$0.69

VIRAL CULTURE

Facility

$139.00

Service Code	CPT 87252
Hospital Charge Code	8519126
Hospital Revenue Code	306
Min. Negotiated Rate	$34.03
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: 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	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

VIRAL CULTURE

Facility

$139.00

Service Code	CPT 87252
Hospital Charge Code	8519125
Hospital Revenue Code	306
Min. Negotiated Rate	$34.03
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: 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	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

VIRAL CULTURE

Facility

$139.00

Service Code	CPT 87252
Hospital Charge Code	8519126
Hospital Revenue Code	306
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

VIRAL CULTURE

Facility

$139.00

Service Code	CPT 87252
Hospital Charge Code	8519125
Hospital Revenue Code	306
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

VIRAL ILLNESS WITH MCC

Facility

$10,184.46

Service Code	MSDRG 865
Min. Negotiated Rate	$10,036.86
Max. Negotiated Rate	$10,184.46
Rate for Payer: Amerigroup Medicaid	$10,135.26
Rate for Payer: Iowa Total Care Managed Medicaid	$10,036.86
Rate for Payer: Molina Healthcare Managed Medicaid	$10,184.46

VIRAL ILLNESS WITHOUT MCC

Facility

$5,973.31

Service Code	MSDRG 866
Min. Negotiated Rate	$5,886.74
Max. Negotiated Rate	$5,973.31
Rate for Payer: Amerigroup Medicaid	$5,944.45
Rate for Payer: Iowa Total Care Managed Medicaid	$5,886.74
Rate for Payer: Molina Healthcare Managed Medicaid	$5,973.31

VIRAL MENINGITIS WITH CC/MCC

Facility

$9,973.90

Service Code	MSDRG 075
Min. Negotiated Rate	$9,829.35
Max. Negotiated Rate	$9,973.90
Rate for Payer: Amerigroup Medicaid	$9,925.72
Rate for Payer: Iowa Total Care Managed Medicaid	$9,829.35
Rate for Payer: Molina Healthcare Managed Medicaid	$9,973.90

VIRAL MENINGITIS WITHOUT CC/MCC

Facility

$6,375.28

Service Code	MSDRG 076
Min. Negotiated Rate	$6,282.88
Max. Negotiated Rate	$6,375.28
Rate for Payer: Amerigroup Medicaid	$6,344.48
Rate for Payer: Iowa Total Care Managed Medicaid	$6,282.88
Rate for Payer: Molina Healthcare Managed Medicaid	$6,375.28

Viscosity DMCL

Facility

$100.00

Service Code	CPT 85810
Hospital Charge Code	8519256
Hospital Revenue Code	301
Min. Negotiated Rate	$29.07
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Aetna of IA Medicare	$57.00
Rate for Payer: Amerigroup Medicaid	$57.68
Rate for Payer: Amerigroup Medicare	$45.45
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.00
Rate for Payer: Iowa Total Care Managed Medicaid	$57.12
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Medical Associates Managed Medicare	$45.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: Molina Healthcare Managed Medicaid	$57.96
Rate for Payer: Partners Health Alliance Commercial	$51.75
Rate for Payer: United Healthcare Commercial	$90.00
Rate for Payer: United Healthcare Managed Medicare	$59.00
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

Viscosity DMCL

Facility

$100.00

Service Code	CPT 85810
Hospital Charge Code	8519256
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: United Healthcare Commercial	$90.00

VITAL CAPACITY, TOTAL

Facility

$260.00

Service Code	CPT 94150
Hospital Charge Code	7980861
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

VITAL CAPACITY, TOTAL

Facility

$260.00

Service Code	CPT 94150
Hospital Charge Code	5338941
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

Know your out-of-pocket cost for care.

All Charges