Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Cholecystectomy Except by Laparoscope Without C.D.E. With CC

Facility

$17,732.10

Service Code	MS-DRG 415
Hospital Charge Code	247
Min. Negotiated Rate	$17,475.11
Max. Negotiated Rate	$17,732.10
Rate for Payer: Amerigroup Medicaid	$17,646.43
Rate for Payer: Iowa Total Care Managed Medicaid	$17,475.11
Rate for Payer: Molina Healthcare Managed Medicaid	$17,732.10

Cholecystectomy Except by Laparoscope Without C.D.E. With MCC

Facility

$21,878.71

Service Code	MS-DRG 414
Hospital Charge Code	246
Min. Negotiated Rate	$21,561.63
Max. Negotiated Rate	$21,878.71
Rate for Payer: Amerigroup Medicaid	$21,773.02
Rate for Payer: Iowa Total Care Managed Medicaid	$21,561.63
Rate for Payer: Molina Healthcare Managed Medicaid	$21,878.71

Cholecystectomy Except by Laparoscope Without C.D.E. Without CC/MCC

Facility

$16,984.07

Service Code	MS-DRG 416
Hospital Charge Code	248
Min. Negotiated Rate	$16,737.92
Max. Negotiated Rate	$16,984.07
Rate for Payer: Amerigroup Medicaid	$16,902.02
Rate for Payer: Iowa Total Care Managed Medicaid	$16,737.92
Rate for Payer: Molina Healthcare Managed Medicaid	$16,984.07

Cholecystectomy With C.D.E. With CC

Facility

$22,404.29

Service Code	MS-DRG 412
Hospital Charge Code	244
Min. Negotiated Rate	$22,079.59
Max. Negotiated Rate	$22,404.29
Rate for Payer: Amerigroup Medicaid	$22,296.06
Rate for Payer: Iowa Total Care Managed Medicaid	$22,079.59
Rate for Payer: Molina Healthcare Managed Medicaid	$22,404.29

Cholecystectomy With C.D.E. With MCC

Facility

$36,942.52

Service Code	MS-DRG 411
Hospital Charge Code	243
Min. Negotiated Rate	$36,407.13
Max. Negotiated Rate	$36,942.52
Rate for Payer: Amerigroup Medicaid	$36,764.06
Rate for Payer: Iowa Total Care Managed Medicaid	$36,407.13
Rate for Payer: Molina Healthcare Managed Medicaid	$36,942.52

Cholecystectomy With C.D.E. Without CC/MCC

Facility

$16,296.09

Service Code	MS-DRG 413
Hospital Charge Code	245
Min. Negotiated Rate	$16,059.91
Max. Negotiated Rate	$16,296.09
Rate for Payer: Amerigroup Medicaid	$16,217.36
Rate for Payer: Iowa Total Care Managed Medicaid	$16,059.91
Rate for Payer: Molina Healthcare Managed Medicaid	$16,296.09

CHOLESTEROL-TOTAL

Facility

$45.00

Service Code	CPT 82465
Hospital Charge Code	633705
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of IA Commercial	$40.50
Rate for Payer: Aetna of IA Medical Rental Products	$40.50
Rate for Payer: Aetna of IA Medicare	$25.65
Rate for Payer: Amerigroup Medicaid	$22.71
Rate for Payer: Amerigroup Medicare	$22.72
Rate for Payer: Cash Price	$36.00
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$22.50
Rate for Payer: Iowa Total Care Managed Medicaid	$22.49
Rate for Payer: Medical Associates Commercial	$33.75
Rate for Payer: Medical Associates Managed Medicare	$22.50
Rate for Payer: Midlands Choice Commercial	$31.50
Rate for Payer: Molina Healthcare Managed Medicaid	$22.84
Rate for Payer: Molina Healthcare Managed Medicare	$22.82
Rate for Payer: Oscar Health of IA Commercial	$33.75
Rate for Payer: Partners Health Alliance Commercial	$33.75
Rate for Payer: United Healthcare Commercial	$40.50
Rate for Payer: United Healthcare Managed Medicare	$26.55
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

CHOLESTEROL-TOTAL

Facility

$45.00

Service Code	CPT 82465
Hospital Charge Code	633705
Hospital Revenue Code	301
Min. Negotiated Rate	$31.50
Max. Negotiated Rate	$40.50
Rate for Payer: Aetna of IA Commercial	$40.50
Rate for Payer: Aetna of IA Medical Rental Products	$40.50
Rate for Payer: Cash Price	$36.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$33.75
Rate for Payer: Medical Associates Commercial	$33.75
Rate for Payer: Midlands Choice Commercial	$31.50
Rate for Payer: United Healthcare Commercial	$40.50

cholestyramine 4 g/5.5 g Pow UD [VDMC]

Facility

$6.31

Service Code	HCPCS A9270GY
Hospital Charge Code	10377709
Hospital Revenue Code	259
Min. Negotiated Rate	$4.42
Max. Negotiated Rate	$5.68
Rate for Payer: Aetna of IA Commercial	$5.68
Rate for Payer: Aetna of IA Medical Rental Products	$5.68
Rate for Payer: Cash Price	$5.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.73
Rate for Payer: Medical Associates Commercial	$4.73
Rate for Payer: Midlands Choice Commercial	$4.42
Rate for Payer: United Healthcare Commercial	$5.68

cholestyramine 4 g/5.5 g Pow UD [VDMC]

Facility

$6.31

Service Code	HCPCS A9270GY
Hospital Charge Code	10377709
Hospital Revenue Code	259
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$5.68
Rate for Payer: Aetna of IA Commercial	$5.68
Rate for Payer: Aetna of IA Medical Rental Products	$5.68
Rate for Payer: Aetna of IA Medicare	$3.60
Rate for Payer: Amerigroup Medicaid	$3.18
Rate for Payer: Amerigroup Medicare	$3.19
Rate for Payer: Cash Price	$5.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.16
Rate for Payer: Iowa Total Care Managed Medicaid	$3.15
Rate for Payer: Medical Associates Commercial	$4.73
Rate for Payer: Medical Associates Managed Medicare	$3.16
Rate for Payer: Midlands Choice Commercial	$4.42
Rate for Payer: Molina Healthcare Managed Medicaid	$3.20
Rate for Payer: Molina Healthcare Managed Medicare	$3.20
Rate for Payer: Oscar Health of IA Commercial	$4.73
Rate for Payer: Partners Health Alliance Commercial	$4.73
Rate for Payer: United Healthcare Commercial	$5.68
Rate for Payer: United Healthcare Managed Medicare	$3.72

chondroitin sulf-sod hyaluron syrg 40 mg-30 mg/mL Ophth Sol 0 mL [VDMC]

Facility

$144.24

Service Code	NDC 08065-1839-05
Hospital Charge Code	10421631
Hospital Revenue Code	259
Min. Negotiated Rate	$72.09
Max. Negotiated Rate	$129.82
Rate for Payer: Aetna of IA Commercial	$129.82
Rate for Payer: Aetna of IA Medical Rental Products	$129.82
Rate for Payer: Aetna of IA Medicare	$82.22
Rate for Payer: Amerigroup Medicaid	$72.80
Rate for Payer: Amerigroup Medicare	$72.84
Rate for Payer: Cash Price	$115.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.12
Rate for Payer: Iowa Total Care Managed Medicaid	$72.09
Rate for Payer: Medical Associates Commercial	$108.18
Rate for Payer: Medical Associates Managed Medicare	$72.12
Rate for Payer: Midlands Choice Commercial	$100.97
Rate for Payer: Molina Healthcare Managed Medicaid	$73.20
Rate for Payer: Molina Healthcare Managed Medicare	$73.16
Rate for Payer: Oscar Health of IA Commercial	$108.18
Rate for Payer: Partners Health Alliance Commercial	$108.18
Rate for Payer: United Healthcare Commercial	$129.82
Rate for Payer: United Healthcare Managed Medicare	$85.10

chondroitin sulf-sod hyaluron syrg 40 mg-30 mg/mL Ophth Sol 0 mL [VDMC]

Facility

$144.24

Service Code	NDC 08065-1839-05
Hospital Charge Code	10421631
Hospital Revenue Code	259
Min. Negotiated Rate	$100.97
Max. Negotiated Rate	$129.82
Rate for Payer: Aetna of IA Commercial	$129.82
Rate for Payer: Aetna of IA Medical Rental Products	$129.82
Rate for Payer: Cash Price	$115.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.18
Rate for Payer: Medical Associates Commercial	$108.18
Rate for Payer: Midlands Choice Commercial	$100.97
Rate for Payer: United Healthcare Commercial	$129.82

Chronic Obstructive Pulmonary Disease With CC

Facility

$7,952.67

Service Code	MS-DRG 191
Hospital Charge Code	62
Min. Negotiated Rate	$7,837.41
Max. Negotiated Rate	$7,952.67
Rate for Payer: Amerigroup Medicaid	$7,914.25
Rate for Payer: Iowa Total Care Managed Medicaid	$7,837.41
Rate for Payer: Molina Healthcare Managed Medicaid	$7,952.67

Chronic Obstructive Pulmonary Disease With MCC

Facility

$9,618.01

Service Code	MS-DRG 190
Hospital Charge Code	61
Min. Negotiated Rate	$9,478.62
Max. Negotiated Rate	$9,618.01
Rate for Payer: Amerigroup Medicaid	$9,571.54
Rate for Payer: Iowa Total Care Managed Medicaid	$9,478.62
Rate for Payer: Molina Healthcare Managed Medicaid	$9,618.01

Chronic Obstructive Pulmonary Disease Without CC/MCC

Facility

$6,273.56

Service Code	MS-DRG 192
Hospital Charge Code	63
Min. Negotiated Rate	$6,182.64
Max. Negotiated Rate	$6,273.56
Rate for Payer: Amerigroup Medicaid	$6,243.25
Rate for Payer: Iowa Total Care Managed Medicaid	$6,182.64
Rate for Payer: Molina Healthcare Managed Medicaid	$6,273.56

cilostazol 100 mg Tab [VDMC]

Facility

$3.56

Service Code	HCPCS A9270
Hospital Charge Code	10377847
Hospital Revenue Code	259
Min. Negotiated Rate	$2.49
Max. Negotiated Rate	$3.20
Rate for Payer: Aetna of IA Commercial	$3.20
Rate for Payer: Aetna of IA Medical Rental Products	$3.20
Rate for Payer: Cash Price	$2.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.67
Rate for Payer: Medical Associates Commercial	$2.67
Rate for Payer: Midlands Choice Commercial	$2.49
Rate for Payer: United Healthcare Commercial	$3.20

cilostazol 100 mg Tab [VDMC]

Facility

$3.56

Service Code	HCPCS A9270
Hospital Charge Code	10377847
Hospital Revenue Code	259
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$3.20
Rate for Payer: Aetna of IA Commercial	$3.20
Rate for Payer: Aetna of IA Medical Rental Products	$3.20
Rate for Payer: Aetna of IA Medicare	$2.03
Rate for Payer: Amerigroup Medicaid	$1.80
Rate for Payer: Amerigroup Medicare	$1.80
Rate for Payer: Cash Price	$2.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.67
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.78
Rate for Payer: Iowa Total Care Managed Medicaid	$1.78
Rate for Payer: Medical Associates Commercial	$2.67
Rate for Payer: Medical Associates Managed Medicare	$1.78
Rate for Payer: Midlands Choice Commercial	$2.49
Rate for Payer: Molina Healthcare Managed Medicaid	$1.81
Rate for Payer: Molina Healthcare Managed Medicare	$1.81
Rate for Payer: Oscar Health of IA Commercial	$2.67
Rate for Payer: Partners Health Alliance Commercial	$2.67
Rate for Payer: United Healthcare Commercial	$3.20
Rate for Payer: United Healthcare Managed Medicare	$2.10

ciprofloxacin 500 mg Tab [VDMC]

Facility

$1.64

Service Code	HCPCS A9270
Hospital Charge Code	10378054
Hospital Revenue Code	259
Min. Negotiated Rate	$0.82
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of IA Commercial	$1.48
Rate for Payer: Aetna of IA Medical Rental Products	$1.48
Rate for Payer: Aetna of IA Medicare	$0.93
Rate for Payer: Amerigroup Medicaid	$0.83
Rate for Payer: Amerigroup Medicare	$0.83
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.82
Rate for Payer: Iowa Total Care Managed Medicaid	$0.82
Rate for Payer: Medical Associates Commercial	$1.23
Rate for Payer: Medical Associates Managed Medicare	$0.82
Rate for Payer: Midlands Choice Commercial	$1.15
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Molina Healthcare Managed Medicare	$0.83
Rate for Payer: Oscar Health of IA Commercial	$1.23
Rate for Payer: Partners Health Alliance Commercial	$1.23
Rate for Payer: United Healthcare Commercial	$1.48
Rate for Payer: United Healthcare Managed Medicare	$0.97

ciprofloxacin 500 mg Tab [VDMC]

Facility

$1.64

Service Code	HCPCS A9270
Hospital Charge Code	10378054
Hospital Revenue Code	259
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of IA Commercial	$1.48
Rate for Payer: Aetna of IA Medical Rental Products	$1.48
Rate for Payer: Cash Price	$1.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.23
Rate for Payer: Medical Associates Commercial	$1.23
Rate for Payer: Midlands Choice Commercial	$1.15
Rate for Payer: United Healthcare Commercial	$1.48

ciprofloxacin-d5w pgbk 400mg/200ml SDV [VDMC]

Facility

$58.35

Service Code	HCPCS J0744
Hospital Charge Code	10429169
Hospital Revenue Code	259
Min. Negotiated Rate	$29.16
Max. Negotiated Rate	$52.52
Rate for Payer: Aetna of IA Commercial	$52.52
Rate for Payer: Aetna of IA Medical Rental Products	$52.52
Rate for Payer: Aetna of IA Medicare	$33.26
Rate for Payer: Amerigroup Medicaid	$29.45
Rate for Payer: Amerigroup Medicare	$29.47
Rate for Payer: Cash Price	$46.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.76
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.18
Rate for Payer: Iowa Total Care Managed Medicaid	$29.16
Rate for Payer: Medical Associates Commercial	$43.76
Rate for Payer: Medical Associates Managed Medicare	$29.18
Rate for Payer: Midlands Choice Commercial	$40.84
Rate for Payer: Molina Healthcare Managed Medicaid	$29.61
Rate for Payer: Molina Healthcare Managed Medicare	$29.60
Rate for Payer: Oscar Health of IA Commercial	$43.76
Rate for Payer: Partners Health Alliance Commercial	$43.76
Rate for Payer: United Healthcare Commercial	$52.52
Rate for Payer: United Healthcare Managed Medicare	$34.43

ciprofloxacin-d5w pgbk 400mg/200ml SDV [VDMC]

Facility

$58.35

Service Code	HCPCS J0744
Hospital Charge Code	10429169
Hospital Revenue Code	259
Min. Negotiated Rate	$40.84
Max. Negotiated Rate	$52.52
Rate for Payer: Aetna of IA Commercial	$52.52
Rate for Payer: Aetna of IA Medical Rental Products	$52.52
Rate for Payer: Cash Price	$46.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.76
Rate for Payer: Medical Associates Commercial	$43.76
Rate for Payer: Midlands Choice Commercial	$40.84
Rate for Payer: United Healthcare Commercial	$52.52

ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus 7.5 ml [VDMC]

Facility

$841.16

Service Code	HCPCS A9270
Hospital Charge Code	14025350
Hospital Revenue Code	259
Min. Negotiated Rate	$588.81
Max. Negotiated Rate	$757.04
Rate for Payer: Aetna of IA Commercial	$757.04
Rate for Payer: Aetna of IA Medical Rental Products	$757.04
Rate for Payer: Cash Price	$672.93
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$630.87
Rate for Payer: Medical Associates Commercial	$630.87
Rate for Payer: Midlands Choice Commercial	$588.81
Rate for Payer: United Healthcare Commercial	$757.04

ciprofloxacin-dexamethasone otic 0.3%-0.1% Sus 7.5 ml [VDMC]

Facility

$841.16

Service Code	HCPCS A9270
Hospital Charge Code	14025350
Hospital Revenue Code	259
Min. Negotiated Rate	$420.41
Max. Negotiated Rate	$757.04
Rate for Payer: Medical Associates Managed Medicare	$420.58
Rate for Payer: Aetna of IA Commercial	$757.04
Rate for Payer: Aetna of IA Medical Rental Products	$757.04
Rate for Payer: Aetna of IA Medicare	$479.46
Rate for Payer: Amerigroup Medicaid	$424.53
Rate for Payer: Amerigroup Medicare	$424.79
Rate for Payer: Cash Price	$672.93
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$630.87
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$420.58
Rate for Payer: Iowa Total Care Managed Medicaid	$420.41
Rate for Payer: Medical Associates Commercial	$630.87
Rate for Payer: Midlands Choice Commercial	$588.81
Rate for Payer: Molina Healthcare Managed Medicaid	$426.89
Rate for Payer: Molina Healthcare Managed Medicare	$426.64
Rate for Payer: Oscar Health of IA Commercial	$630.87
Rate for Payer: Partners Health Alliance Commercial	$630.87
Rate for Payer: United Healthcare Commercial	$757.04
Rate for Payer: United Healthcare Managed Medicare	$496.28

Circulatory Disorders Except AMI, With Cardiac Catheterization With MCC

Facility

$18,175.99

Service Code	MS-DRG 286
Hospital Charge Code	143
Min. Negotiated Rate	$17,912.57
Max. Negotiated Rate	$18,175.99
Rate for Payer: Amerigroup Medicaid	$18,088.18
Rate for Payer: Iowa Total Care Managed Medicaid	$17,912.57
Rate for Payer: Molina Healthcare Managed Medicaid	$18,175.99

Circulatory Disorders Except AMI, With Cardiac Catheterization Without MCC

Facility

$9,604.23

Service Code	MS-DRG 287
Hospital Charge Code	144
Min. Negotiated Rate	$9,465.04
Max. Negotiated Rate	$9,604.23
Rate for Payer: Amerigroup Medicaid	$9,557.83
Rate for Payer: Iowa Total Care Managed Medicaid	$9,465.04
Rate for Payer: Molina Healthcare Managed Medicaid	$9,604.23

Know your out-of-pocket cost for care.

All Charges