Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

azithromycin 500 mg IV SDV Inj [VDMC]

Facility

$38.40

Service Code	HCPCS J0456
Hospital Charge Code	10368929
Hospital Revenue Code	259
Min. Negotiated Rate	$17.28
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$34.56
Rate for Payer: Aetna of IA Medical Rental Products	$34.56
Rate for Payer: Aetna of IA Medicare	$21.89
Rate for Payer: Amerigroup Medicaid	$22.15
Rate for Payer: Amerigroup Medicare	$17.45
Rate for Payer: Cash Price	$30.72
Rate for Payer: Cash Price	$30.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$28.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$17.28
Rate for Payer: Iowa Total Care Managed Medicaid	$21.93
Rate for Payer: Medical Associates Commercial	$28.80
Rate for Payer: Medical Associates Managed Medicare	$17.28
Rate for Payer: Midlands Choice Commercial	$26.88
Rate for Payer: Molina Healthcare Managed Medicaid	$22.25
Rate for Payer: Partners Health Alliance Commercial	$19.87
Rate for Payer: United Healthcare Commercial	$34.56
Rate for Payer: United Healthcare Managed Medicare	$22.65
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

aztreonam 1 g SDV Inj [VDMC]

Facility

$107.42

Service Code	HCPCS J0457
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 J0457
Hospital Charge Code	10368998
Hospital Revenue Code	259
Min. Negotiated Rate	$48.34
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	$61.96
Rate for Payer: Amerigroup Medicare	$48.82
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	$48.34
Rate for Payer: Iowa Total Care Managed Medicaid	$61.36
Rate for Payer: Medical Associates Commercial	$80.56
Rate for Payer: Medical Associates Managed Medicare	$48.34
Rate for Payer: Midlands Choice Commercial	$75.19
Rate for Payer: Molina Healthcare Managed Medicaid	$62.26
Rate for Payer: Partners Health Alliance Commercial	$55.59
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	$7.09
Max. Negotiated Rate	$14.17
Rate for Payer: Aetna of IA Commercial	$14.17
Rate for Payer: Aetna of IA Medical Rental Products	$14.17
Rate for Payer: Aetna of IA Medicare	$8.98
Rate for Payer: Amerigroup Medicaid	$9.08
Rate for Payer: Amerigroup Medicare	$7.16
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	$7.09
Rate for Payer: Iowa Total Care Managed Medicaid	$9.00
Rate for Payer: Medical Associates Commercial	$11.81
Rate for Payer: Medical Associates Managed Medicare	$7.09
Rate for Payer: Midlands Choice Commercial	$11.02
Rate for Payer: Molina Healthcare Managed Medicaid	$9.13
Rate for Payer: Partners Health Alliance Commercial	$8.15
Rate for Payer: United Healthcare Commercial	$14.17
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	$14.17
Rate for Payer: Aetna of IA Commercial	$14.17
Rate for Payer: Aetna of IA Medical Rental Products	$14.17
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	$14.17

bacitracin Top 500 units/g Oint [VDMC]

Facility

$13.68

Service Code	HCPCS A9270
Hospital Charge Code	10369136
Hospital Revenue Code	259
Min. Negotiated Rate	$9.57
Max. Negotiated Rate	$12.31
Rate for Payer: Aetna of IA Commercial	$12.31
Rate for Payer: Aetna of IA Medical Rental Products	$12.31
Rate for Payer: Cash Price	$10.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.26
Rate for Payer: Medical Associates Commercial	$10.26
Rate for Payer: Midlands Choice Commercial	$9.57
Rate for Payer: United Healthcare Commercial	$12.31

bacitracin Top 500 units/g Oint [VDMC]

Facility

$13.68

Service Code	HCPCS A9270
Hospital Charge Code	10369136
Hospital Revenue Code	259
Min. Negotiated Rate	$6.16
Max. Negotiated Rate	$12.31
Rate for Payer: Aetna of IA Commercial	$12.31
Rate for Payer: Aetna of IA Medical Rental Products	$12.31
Rate for Payer: Aetna of IA Medicare	$7.80
Rate for Payer: Amerigroup Medicaid	$7.89
Rate for Payer: Amerigroup Medicare	$6.22
Rate for Payer: Cash Price	$10.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$10.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.16
Rate for Payer: Iowa Total Care Managed Medicaid	$7.81
Rate for Payer: Medical Associates Commercial	$10.26
Rate for Payer: Medical Associates Managed Medicare	$6.16
Rate for Payer: Midlands Choice Commercial	$9.57
Rate for Payer: Molina Healthcare Managed Medicaid	$7.93
Rate for Payer: Partners Health Alliance Commercial	$7.08
Rate for Payer: United Healthcare Commercial	$12.31
Rate for Payer: United Healthcare Managed Medicare	$8.07

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC

Facility

$17,355.81

Service Code	MSDRG 519
Min. Negotiated Rate	$17,104.27
Max. Negotiated Rate	$17,355.81
Rate for Payer: Amerigroup Medicaid	$17,271.96
Rate for Payer: Iowa Total Care Managed Medicaid	$17,104.27
Rate for Payer: Molina Healthcare Managed Medicaid	$17,355.81

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR

Facility

$18,147.37

Service Code	MSDRG 518
Min. Negotiated Rate	$17,884.36
Max. Negotiated Rate	$18,147.37
Rate for Payer: Amerigroup Medicaid	$18,059.69
Rate for Payer: Iowa Total Care Managed Medicaid	$17,884.36
Rate for Payer: Molina Healthcare Managed Medicaid	$18,147.37

BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC

Facility

$12,139.16

Service Code	MSDRG 520
Min. Negotiated Rate	$11,963.22
Max. Negotiated Rate	$12,139.16
Rate for Payer: Amerigroup Medicaid	$12,080.51
Rate for Payer: Iowa Total Care Managed Medicaid	$11,963.22
Rate for Payer: Molina Healthcare Managed Medicaid	$12,139.16

baclofen 10 mg Tab [VDMC]

Facility

$2.53

Service Code	HCPCS A9270
Hospital Charge Code	10369331
Hospital Revenue Code	259
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$2.27
Rate for Payer: Aetna of IA Commercial	$2.27
Rate for Payer: Aetna of IA Medical Rental Products	$2.27
Rate for Payer: Aetna of IA Medicare	$1.44
Rate for Payer: Amerigroup Medicaid	$1.46
Rate for Payer: Amerigroup Medicare	$1.15
Rate for Payer: Cash Price	$2.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.14
Rate for Payer: Iowa Total Care Managed Medicaid	$1.44
Rate for Payer: Medical Associates Commercial	$1.90
Rate for Payer: Medical Associates Managed Medicare	$1.14
Rate for Payer: Midlands Choice Commercial	$1.77
Rate for Payer: Molina Healthcare Managed Medicaid	$1.46
Rate for Payer: Partners Health Alliance Commercial	$1.31
Rate for Payer: United Healthcare Commercial	$2.27
Rate for Payer: United Healthcare Managed Medicare	$1.49

baclofen 10 mg Tab [VDMC]

Facility

$2.53

Service Code	HCPCS A9270
Hospital Charge Code	10369331
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.27
Rate for Payer: Aetna of IA Commercial	$2.27
Rate for Payer: Aetna of IA Medical Rental Products	$2.27
Rate for Payer: Cash Price	$2.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.90
Rate for Payer: Medical Associates Commercial	$1.90
Rate for Payer: Midlands Choice Commercial	$1.77
Rate for Payer: United Healthcare Commercial	$2.27

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC

Facility

$21,609.75

Service Code	MSDRG 095
Min. Negotiated Rate	$21,296.56
Max. Negotiated Rate	$21,609.75
Rate for Payer: Amerigroup Medicaid	$21,505.35
Rate for Payer: Iowa Total Care Managed Medicaid	$21,296.56
Rate for Payer: Molina Healthcare Managed Medicaid	$21,609.75

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC

Facility

$39,771.76

Service Code	MSDRG 094
Min. Negotiated Rate	$39,195.34
Max. Negotiated Rate	$39,771.76
Rate for Payer: Amerigroup Medicaid	$39,579.61
Rate for Payer: Iowa Total Care Managed Medicaid	$39,195.34
Rate for Payer: Molina Healthcare Managed Medicaid	$39,771.76

BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC

Facility

$21,609.75

Service Code	MSDRG 096
Min. Negotiated Rate	$21,296.56
Max. Negotiated Rate	$21,609.75
Rate for Payer: Amerigroup Medicaid	$21,505.35
Rate for Payer: Iowa Total Care Managed Medicaid	$21,296.56
Rate for Payer: Molina Healthcare Managed Medicaid	$21,609.75

BACTERIAL IDENTIFICATION

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	7734008
Hospital Revenue Code	306
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Aetna of IA Medicare	$33.63
Rate for Payer: Amerigroup Medicaid	$34.03
Rate for Payer: Amerigroup Medicare	$26.82
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.55
Rate for Payer: Iowa Total Care Managed Medicaid	$33.70
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Medical Associates Managed Medicare	$26.55
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: Molina Healthcare Managed Medicaid	$34.20
Rate for Payer: Partners Health Alliance Commercial	$30.53
Rate for Payer: United Healthcare Commercial	$53.10
Rate for Payer: United Healthcare Managed Medicare	$34.81
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

BACTERIAL IDENTIFICATION

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	297663
Hospital Revenue Code	306
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Aetna of IA Medicare	$33.63
Rate for Payer: Amerigroup Medicaid	$34.03
Rate for Payer: Amerigroup Medicare	$26.82
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.55
Rate for Payer: Iowa Total Care Managed Medicaid	$33.70
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Medical Associates Managed Medicare	$26.55
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: Molina Healthcare Managed Medicaid	$34.20
Rate for Payer: Partners Health Alliance Commercial	$30.53
Rate for Payer: United Healthcare Commercial	$53.10
Rate for Payer: United Healthcare Managed Medicare	$34.81
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

BACTERIAL IDENTIFICATION

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	7734008
Hospital Revenue Code	306
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: United Healthcare Commercial	$53.10

BACTERIAL IDENTIFICATION

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	297662
Hospital Revenue Code	306
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: United Healthcare Commercial	$53.10

BACTERIAL IDENTIFICATION

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	297662
Hospital Revenue Code	306
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Aetna of IA Medicare	$33.63
Rate for Payer: Amerigroup Medicaid	$34.03
Rate for Payer: Amerigroup Medicare	$26.82
Rate for Payer: Cash Price	$47.20
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.55
Rate for Payer: Iowa Total Care Managed Medicaid	$33.70
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Medical Associates Managed Medicare	$26.55
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: Molina Healthcare Managed Medicaid	$34.20
Rate for Payer: Partners Health Alliance Commercial	$30.53
Rate for Payer: United Healthcare Commercial	$53.10
Rate for Payer: United Healthcare Managed Medicare	$34.81
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

BACTERIAL IDENTIFICATION

Facility

$59.00

Service Code	CPT 87077
Hospital Charge Code	297663
Hospital Revenue Code	306
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: United Healthcare Commercial	$53.10

balanced Salt irrig Opth 15 ml [VDMC]

Facility

$25.71

Service Code	HCPCS A9270
Hospital Charge Code	10410623
Hospital Revenue Code	259
Min. Negotiated Rate	$11.57
Max. Negotiated Rate	$23.14
Rate for Payer: Aetna of IA Commercial	$23.14
Rate for Payer: Aetna of IA Medical Rental Products	$23.14
Rate for Payer: Aetna of IA Medicare	$14.65
Rate for Payer: Amerigroup Medicaid	$14.83
Rate for Payer: Amerigroup Medicare	$11.68
Rate for Payer: Cash Price	$20.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.57
Rate for Payer: Iowa Total Care Managed Medicaid	$14.68
Rate for Payer: Medical Associates Commercial	$19.28
Rate for Payer: Medical Associates Managed Medicare	$11.57
Rate for Payer: Midlands Choice Commercial	$18.00
Rate for Payer: Molina Healthcare Managed Medicaid	$14.90
Rate for Payer: Partners Health Alliance Commercial	$13.30
Rate for Payer: United Healthcare Commercial	$23.14
Rate for Payer: United Healthcare Managed Medicare	$15.17

balanced Salt irrig Opth 15 ml [VDMC]

Facility

$25.71

Service Code	HCPCS A9270
Hospital Charge Code	10410623
Hospital Revenue Code	259
Min. Negotiated Rate	$18.00
Max. Negotiated Rate	$23.14
Rate for Payer: Aetna of IA Commercial	$23.14
Rate for Payer: Aetna of IA Medical Rental Products	$23.14
Rate for Payer: Cash Price	$20.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.28
Rate for Payer: Medical Associates Commercial	$19.28
Rate for Payer: Midlands Choice Commercial	$18.00
Rate for Payer: United Healthcare Commercial	$23.14

balsalazide 750 mg Cap [VDMC]

Facility

$5.10

Service Code	HCPCS A9270
Hospital Charge Code	10369471
Hospital Revenue Code	259
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$4.59
Rate for Payer: Aetna of IA Commercial	$4.59
Rate for Payer: Aetna of IA Medical Rental Products	$4.59
Rate for Payer: Aetna of IA Medicare	$2.91
Rate for Payer: Amerigroup Medicaid	$2.94
Rate for Payer: Amerigroup Medicare	$2.32
Rate for Payer: Cash Price	$4.08
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.82
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.29
Rate for Payer: Iowa Total Care Managed Medicaid	$2.91
Rate for Payer: Medical Associates Commercial	$3.82
Rate for Payer: Medical Associates Managed Medicare	$2.29
Rate for Payer: Midlands Choice Commercial	$3.57
Rate for Payer: Molina Healthcare Managed Medicaid	$2.96
Rate for Payer: Partners Health Alliance Commercial	$2.64
Rate for Payer: United Healthcare Commercial	$4.59
Rate for Payer: United Healthcare Managed Medicare	$3.01

balsalazide 750 mg Cap [VDMC]

Facility

$5.10

Service Code	HCPCS A9270
Hospital Charge Code	10369471
Hospital Revenue Code	259
Min. Negotiated Rate	$3.57
Max. Negotiated Rate	$4.59
Rate for Payer: Aetna of IA Commercial	$4.59
Rate for Payer: Aetna of IA Medical Rental Products	$4.59
Rate for Payer: Cash Price	$4.08
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.82
Rate for Payer: Medical Associates Commercial	$3.82
Rate for Payer: Midlands Choice Commercial	$3.57
Rate for Payer: United Healthcare Commercial	$4.59

Know your out-of-pocket cost for care.

All Charges