Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

cholecalciferol 125 mcg (5000 intl units) Cap [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10431573
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: United Healthcare Commercial	$0.96

cholecalciferol 25mcg (1000 intl units) tablet [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10431441
Hospital Revenue Code	259
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Aetna of IA Medicare	$0.61
Rate for Payer: Amerigroup Medicaid	$0.62
Rate for Payer: Amerigroup Medicare	$0.49
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.48
Rate for Payer: Iowa Total Care Managed Medicaid	$0.61
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Medical Associates Managed Medicare	$0.48
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: Molina Healthcare Managed Medicaid	$0.62
Rate for Payer: Partners Health Alliance Commercial	$0.55
Rate for Payer: United Healthcare Commercial	$0.96
Rate for Payer: United Healthcare Managed Medicare	$0.63

cholecalciferol 25mcg (1000 intl units) tablet [VDMC]

Facility

$1.07

Service Code	HCPCS A9270
Hospital Charge Code	10431441
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of IA Commercial	$0.96
Rate for Payer: Aetna of IA Medical Rental Products	$0.96
Rate for Payer: Cash Price	$0.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Midlands Choice Commercial	$0.75
Rate for Payer: United Healthcare Commercial	$0.96

cholecalciferol 50 mcg (2000 intl units) Cap [VDMC]

Facility

$2.19

Service Code	HCPCS A9270
Hospital Charge Code	10431508
Hospital Revenue Code	259
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of IA Commercial	$1.97
Rate for Payer: Aetna of IA Medical Rental Products	$1.97
Rate for Payer: Aetna of IA Medicare	$1.25
Rate for Payer: Amerigroup Medicaid	$1.27
Rate for Payer: Amerigroup Medicare	$1.00
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.65
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.99
Rate for Payer: Iowa Total Care Managed Medicaid	$1.25
Rate for Payer: Medical Associates Commercial	$1.65
Rate for Payer: Medical Associates Managed Medicare	$0.99
Rate for Payer: Midlands Choice Commercial	$1.54
Rate for Payer: Molina Healthcare Managed Medicaid	$1.27
Rate for Payer: Partners Health Alliance Commercial	$1.14
Rate for Payer: United Healthcare Commercial	$1.97
Rate for Payer: United Healthcare Managed Medicare	$1.29

cholecalciferol 50 mcg (2000 intl units) Cap [VDMC]

Facility

$2.19

Service Code	HCPCS A9270
Hospital Charge Code	10431508
Hospital Revenue Code	259
Min. Negotiated Rate	$1.54
Max. Negotiated Rate	$1.97
Rate for Payer: Aetna of IA Commercial	$1.97
Rate for Payer: Aetna of IA Medical Rental Products	$1.97
Rate for Payer: Cash Price	$1.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.65
Rate for Payer: Medical Associates Commercial	$1.65
Rate for Payer: Midlands Choice Commercial	$1.54
Rate for Payer: United Healthcare Commercial	$1.97

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC

Facility

$20,285.60

Service Code	MSDRG 415
Min. Negotiated Rate	$19,991.60
Max. Negotiated Rate	$20,285.60
Rate for Payer: Amerigroup Medicaid	$20,187.59
Rate for Payer: Iowa Total Care Managed Medicaid	$19,991.60
Rate for Payer: Molina Healthcare Managed Medicaid	$20,285.60

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC

Facility

$25,029.34

Service Code	MSDRG 414
Min. Negotiated Rate	$24,666.59
Max. Negotiated Rate	$25,029.34
Rate for Payer: Amerigroup Medicaid	$24,908.42
Rate for Payer: Iowa Total Care Managed Medicaid	$24,666.59
Rate for Payer: Molina Healthcare Managed Medicaid	$25,029.34

CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$19,429.86

Service Code	MSDRG 416
Min. Negotiated Rate	$19,148.26
Max. Negotiated Rate	$19,429.86
Rate for Payer: Amerigroup Medicaid	$19,335.99
Rate for Payer: Iowa Total Care Managed Medicaid	$19,148.26
Rate for Payer: Molina Healthcare Managed Medicaid	$19,429.86

CHOLECYSTECTOMY WITH C.D.E. WITH CC

Facility

$25,630.61

Service Code	MSDRG 412
Min. Negotiated Rate	$25,259.15
Max. Negotiated Rate	$25,630.61
Rate for Payer: Amerigroup Medicaid	$25,506.78
Rate for Payer: Iowa Total Care Managed Medicaid	$25,259.15
Rate for Payer: Molina Healthcare Managed Medicaid	$25,630.61

CHOLECYSTECTOMY WITH C.D.E. WITH MCC

Facility

$42,262.42

Service Code	MSDRG 411
Min. Negotiated Rate	$41,649.90
Max. Negotiated Rate	$42,262.42
Rate for Payer: Amerigroup Medicaid	$42,058.24
Rate for Payer: Iowa Total Care Managed Medicaid	$41,649.90
Rate for Payer: Molina Healthcare Managed Medicaid	$42,262.42

CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC

Facility

$18,642.80

Service Code	MSDRG 413
Min. Negotiated Rate	$18,372.61
Max. Negotiated Rate	$18,642.80
Rate for Payer: Amerigroup Medicaid	$18,552.73
Rate for Payer: Iowa Total Care Managed Medicaid	$18,372.61
Rate for Payer: Molina Healthcare Managed Medicaid	$18,642.80

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

CHOLESTEROL-TOTAL

Facility

$45.00

Service Code	CPT 82465
Hospital Charge Code	633705
Hospital Revenue Code	301
Min. Negotiated Rate	$20.25
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	$25.96
Rate for Payer: Amerigroup Medicare	$20.45
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	$20.25
Rate for Payer: Iowa Total Care Managed Medicaid	$25.70
Rate for Payer: Medical Associates Commercial	$33.75
Rate for Payer: Medical Associates Managed Medicare	$20.25
Rate for Payer: Midlands Choice Commercial	$31.50
Rate for Payer: Molina Healthcare Managed Medicaid	$26.08
Rate for Payer: Partners Health Alliance Commercial	$23.29
Rate for Payer: United Healthcare Commercial	$40.50
Rate for Payer: United Healthcare Managed Medicare	$26.55
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

cholestyramine 4 g/5.5 g Pow UD [VDMC]

Facility

$7.05

Service Code	HCPCS A9270
Hospital Charge Code	10377709
Hospital Revenue Code	259
Min. Negotiated Rate	$4.93
Max. Negotiated Rate	$6.34
Rate for Payer: Aetna of IA Commercial	$6.34
Rate for Payer: Aetna of IA Medical Rental Products	$6.34
Rate for Payer: Cash Price	$5.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.29
Rate for Payer: Medical Associates Commercial	$5.29
Rate for Payer: Midlands Choice Commercial	$4.93
Rate for Payer: United Healthcare Commercial	$6.34

cholestyramine 4 g/5.5 g Pow UD [VDMC]

Facility

$7.05

Service Code	HCPCS A9270
Hospital Charge Code	10377709
Hospital Revenue Code	259
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$6.34
Rate for Payer: Aetna of IA Commercial	$6.34
Rate for Payer: Aetna of IA Medical Rental Products	$6.34
Rate for Payer: Aetna of IA Medicare	$4.02
Rate for Payer: Amerigroup Medicaid	$4.06
Rate for Payer: Amerigroup Medicare	$3.20
Rate for Payer: Cash Price	$5.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.29
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.17
Rate for Payer: Iowa Total Care Managed Medicaid	$4.03
Rate for Payer: Medical Associates Commercial	$5.29
Rate for Payer: Medical Associates Managed Medicare	$3.17
Rate for Payer: Midlands Choice Commercial	$4.93
Rate for Payer: Molina Healthcare Managed Medicaid	$4.08
Rate for Payer: Partners Health Alliance Commercial	$3.65
Rate for Payer: United Healthcare Commercial	$6.34
Rate for Payer: United Healthcare Managed Medicare	$4.16

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	$64.91
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	$83.20
Rate for Payer: Amerigroup Medicare	$65.56
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	$64.91
Rate for Payer: Iowa Total Care Managed Medicaid	$82.39
Rate for Payer: Medical Associates Commercial	$108.18
Rate for Payer: Medical Associates Managed Medicare	$64.91
Rate for Payer: Midlands Choice Commercial	$100.97
Rate for Payer: Molina Healthcare Managed Medicaid	$83.60
Rate for Payer: Partners Health Alliance Commercial	$74.64
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

$9,097.89

Service Code	MSDRG 191
Min. Negotiated Rate	$8,966.04
Max. Negotiated Rate	$9,097.89
Rate for Payer: Amerigroup Medicaid	$9,053.94
Rate for Payer: Iowa Total Care Managed Medicaid	$8,966.04
Rate for Payer: Molina Healthcare Managed Medicaid	$9,097.89

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC

Facility

$11,003.05

Service Code	MSDRG 190
Min. Negotiated Rate	$10,843.58
Max. Negotiated Rate	$11,003.05
Rate for Payer: Amerigroup Medicaid	$10,949.89
Rate for Payer: Iowa Total Care Managed Medicaid	$10,843.58
Rate for Payer: Molina Healthcare Managed Medicaid	$11,003.05

CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC

Facility

$7,176.98

Service Code	MSDRG 192
Min. Negotiated Rate	$7,072.96
Max. Negotiated Rate	$7,176.98
Rate for Payer: Amerigroup Medicaid	$7,142.30
Rate for Payer: Iowa Total Care Managed Medicaid	$7,072.96
Rate for Payer: Molina Healthcare Managed Medicaid	$7,176.98

cilostazol 100 mg Tab [VDMC]

Facility

$3.79

Service Code	HCPCS A9270
Hospital Charge Code	10377847
Hospital Revenue Code	259
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$3.41
Rate for Payer: Aetna of IA Commercial	$3.41
Rate for Payer: Aetna of IA Medical Rental Products	$3.41
Rate for Payer: Cash Price	$3.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.85
Rate for Payer: Medical Associates Commercial	$2.85
Rate for Payer: Midlands Choice Commercial	$2.66
Rate for Payer: United Healthcare Commercial	$3.41

cilostazol 100 mg Tab [VDMC]

Facility

$3.79

Service Code	HCPCS A9270
Hospital Charge Code	10377847
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$3.41
Rate for Payer: Aetna of IA Commercial	$3.41
Rate for Payer: Aetna of IA Medical Rental Products	$3.41
Rate for Payer: Aetna of IA Medicare	$2.16
Rate for Payer: Amerigroup Medicaid	$2.19
Rate for Payer: Amerigroup Medicare	$1.72
Rate for Payer: Cash Price	$3.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.85
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.71
Rate for Payer: Iowa Total Care Managed Medicaid	$2.17
Rate for Payer: Medical Associates Commercial	$2.85
Rate for Payer: Medical Associates Managed Medicare	$1.71
Rate for Payer: Midlands Choice Commercial	$2.66
Rate for Payer: Molina Healthcare Managed Medicaid	$2.20
Rate for Payer: Partners Health Alliance Commercial	$1.96
Rate for Payer: United Healthcare Commercial	$3.41
Rate for Payer: United Healthcare Managed Medicare	$2.24

ciprofloxacin 500 mg Tab [VDMC]

Facility

$1.64

Service Code	HCPCS A9270
Hospital Charge Code	10378054
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.47
Rate for Payer: Aetna of IA Commercial	$1.47
Rate for Payer: Aetna of IA Medical Rental Products	$1.47
Rate for Payer: Aetna of IA Medicare	$0.93
Rate for Payer: Amerigroup Medicaid	$0.94
Rate for Payer: Amerigroup Medicare	$0.74
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	$0.74
Rate for Payer: Iowa Total Care Managed Medicaid	$0.94
Rate for Payer: Medical Associates Commercial	$1.23
Rate for Payer: Medical Associates Managed Medicare	$0.74
Rate for Payer: Midlands Choice Commercial	$1.15
Rate for Payer: Molina Healthcare Managed Medicaid	$0.95
Rate for Payer: Partners Health Alliance Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.47
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	$1.47
Rate for Payer: Aetna of IA Commercial	$1.47
Rate for Payer: Aetna of IA Medical Rental Products	$1.47
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	$1.47

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

Facility

$60.64

Service Code	HCPCS J0744
Hospital Charge Code	10429169
Hospital Revenue Code	259
Min. Negotiated Rate	$42.45
Max. Negotiated Rate	$54.58
Rate for Payer: Aetna of IA Commercial	$54.58
Rate for Payer: Aetna of IA Medical Rental Products	$54.58
Rate for Payer: Cash Price	$48.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.48
Rate for Payer: Medical Associates Commercial	$45.48
Rate for Payer: Midlands Choice Commercial	$42.45
Rate for Payer: United Healthcare Commercial	$54.58

Know your out-of-pocket cost for care.

All Charges