Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

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

Facility

$332.52

Service Code	HCPCS A9270
Hospital Charge Code	14025350
Hospital Revenue Code	259
Min. Negotiated Rate	$149.63
Max. Negotiated Rate	$299.27
Rate for Payer: Aetna of IA Commercial	$299.27
Rate for Payer: Aetna of IA Medical Rental Products	$299.27
Rate for Payer: Aetna of IA Medicare	$189.54
Rate for Payer: Amerigroup Medicaid	$191.80
Rate for Payer: Amerigroup Medicare	$151.13
Rate for Payer: Cash Price	$266.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$149.63
Rate for Payer: Iowa Total Care Managed Medicaid	$189.94
Rate for Payer: Medical Associates Commercial	$249.39
Rate for Payer: Medical Associates Managed Medicare	$149.63
Rate for Payer: Midlands Choice Commercial	$232.76
Rate for Payer: Molina Healthcare Managed Medicaid	$192.73
Rate for Payer: Partners Health Alliance Commercial	$172.08
Rate for Payer: United Healthcare Commercial	$299.27
Rate for Payer: United Healthcare Managed Medicare	$196.19

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

Facility

$332.52

Service Code	HCPCS A9270
Hospital Charge Code	14025350
Hospital Revenue Code	259
Min. Negotiated Rate	$232.76
Max. Negotiated Rate	$299.27
Rate for Payer: Aetna of IA Commercial	$299.27
Rate for Payer: Aetna of IA Medical Rental Products	$299.27
Rate for Payer: Cash Price	$266.02
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.39
Rate for Payer: Medical Associates Commercial	$249.39
Rate for Payer: Midlands Choice Commercial	$232.76
Rate for Payer: United Healthcare Commercial	$299.27

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITH MCC

Facility

$20,793.42

Service Code	MSDRG 286
Min. Negotiated Rate	$20,492.05
Max. Negotiated Rate	$20,793.42
Rate for Payer: Amerigroup Medicaid	$20,692.96
Rate for Payer: Iowa Total Care Managed Medicaid	$20,492.05
Rate for Payer: Molina Healthcare Managed Medicaid	$20,793.42

CIRCULATORY DISORDERS EXCEPT AMI, WITH CARDIAC CATHETERIZATION WITHOUT MCC

Facility

$10,987.28

Service Code	MSDRG 287
Min. Negotiated Rate	$10,828.04
Max. Negotiated Rate	$10,987.28
Rate for Payer: Amerigroup Medicaid	$10,934.20
Rate for Payer: Iowa Total Care Managed Medicaid	$10,828.04
Rate for Payer: Molina Healthcare Managed Medicaid	$10,987.28

CIRCUM 28 DAYS OR OLDER

Facility

$1,493.00

Service Code	CPT 54161
Hospital Charge Code	7983036
Hospital Revenue Code	450
Min. Negotiated Rate	$671.85
Max. Negotiated Rate	$3,601.97
Rate for Payer: Aetna of IA Commercial	$1,343.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,343.70
Rate for Payer: Aetna of IA Medicare	$851.01
Rate for Payer: Amerigroup Medicaid	$861.16
Rate for Payer: Amerigroup Medicare	$678.57
Rate for Payer: Cash Price	$1,194.40
Rate for Payer: Cash Price	$1,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,119.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$671.85
Rate for Payer: Iowa Total Care Managed Medicaid	$852.80
Rate for Payer: Medical Associates Commercial	$1,119.75
Rate for Payer: Medical Associates Managed Medicare	$671.85
Rate for Payer: Midlands Choice Commercial	$1,045.10
Rate for Payer: Molina Healthcare Managed Medicaid	$865.34
Rate for Payer: Partners Health Alliance Commercial	$772.63
Rate for Payer: United Healthcare Commercial	$1,343.70
Rate for Payer: United Healthcare Managed Medicare	$880.87
Rate for Payer: Wellmark IA HMO WHPI	$3,269.91
Rate for Payer: Wellmark IA PPO	$3,601.97

CIRCUM 28 DAYS OR OLDER

Facility

$1,493.00

Service Code	CPT 54161
Hospital Charge Code	7983036
Hospital Revenue Code	450
Min. Negotiated Rate	$1,045.10
Max. Negotiated Rate	$1,343.70
Rate for Payer: Aetna of IA Commercial	$1,343.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,343.70
Rate for Payer: Cash Price	$1,194.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,119.75
Rate for Payer: Medical Associates Commercial	$1,119.75
Rate for Payer: Midlands Choice Commercial	$1,045.10
Rate for Payer: United Healthcare Commercial	$1,343.70

CIRCUMCISION

Facility

$179.00

Service Code	CPT 54150
Hospital Charge Code	7578787
Hospital Revenue Code	723
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$3,601.97
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Aetna of IA Medicare	$102.03
Rate for Payer: Amerigroup Medicaid	$103.25
Rate for Payer: Amerigroup Medicare	$81.36
Rate for Payer: Cash Price	$143.20
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$80.55
Rate for Payer: Iowa Total Care Managed Medicaid	$102.24
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Medical Associates Managed Medicare	$80.55
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: Molina Healthcare Managed Medicaid	$103.75
Rate for Payer: Partners Health Alliance Commercial	$92.63
Rate for Payer: United Healthcare Commercial	$161.10
Rate for Payer: United Healthcare Managed Medicare	$105.61
Rate for Payer: Wellmark IA HMO WHPI	$3,269.91
Rate for Payer: Wellmark IA PPO	$3,601.97

CIRCUMCISION

Facility

$179.00

Service Code	CPT 54150
Hospital Charge Code	7578787
Hospital Revenue Code	723
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: United Healthcare Commercial	$161.10

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC

Facility

$11,293.55

Service Code	MSDRG 433
Min. Negotiated Rate	$11,129.87
Max. Negotiated Rate	$11,293.55
Rate for Payer: Amerigroup Medicaid	$11,238.99
Rate for Payer: Iowa Total Care Managed Medicaid	$11,129.87
Rate for Payer: Molina Healthcare Managed Medicaid	$11,293.55

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC

Facility

$17,435.75

Service Code	MSDRG 432
Min. Negotiated Rate	$17,183.05
Max. Negotiated Rate	$17,435.75
Rate for Payer: Amerigroup Medicaid	$17,351.52
Rate for Payer: Iowa Total Care Managed Medicaid	$17,183.05
Rate for Payer: Molina Healthcare Managed Medicaid	$17,435.75

CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC

Facility

$7,184.86

Service Code	MSDRG 434
Min. Negotiated Rate	$7,080.73
Max. Negotiated Rate	$7,184.86
Rate for Payer: Amerigroup Medicaid	$7,150.15
Rate for Payer: Iowa Total Care Managed Medicaid	$7,080.73
Rate for Payer: Molina Healthcare Managed Medicaid	$7,184.86

citalopram 20 mg Tab [VDMC]

Facility

$1.18

Service Code	HCPCS A9270
Hospital Charge Code	10378190
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of IA Commercial	$1.06
Rate for Payer: Aetna of IA Medical Rental Products	$1.06
Rate for Payer: Aetna of IA Medicare	$0.67
Rate for Payer: Amerigroup Medicaid	$0.68
Rate for Payer: Amerigroup Medicare	$0.54
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.89
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	$0.68
Rate for Payer: Medical Associates Commercial	$0.89
Rate for Payer: Medical Associates Managed Medicare	$0.53
Rate for Payer: Midlands Choice Commercial	$0.83
Rate for Payer: Molina Healthcare Managed Medicaid	$0.69
Rate for Payer: Partners Health Alliance Commercial	$0.61
Rate for Payer: United Healthcare Commercial	$1.06
Rate for Payer: United Healthcare Managed Medicare	$0.70

citalopram 20 mg Tab [VDMC]

Facility

$1.18

Service Code	HCPCS A9270
Hospital Charge Code	10378190
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of IA Commercial	$1.06
Rate for Payer: Aetna of IA Medical Rental Products	$1.06
Rate for Payer: Cash Price	$0.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.89
Rate for Payer: Medical Associates Commercial	$0.89
Rate for Payer: Midlands Choice Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.06

Facility

$71.00

Service Code	CPT 82550
Hospital Charge Code	4010788
Hospital Revenue Code	301
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

Facility

$71.00

Service Code	CPT 82550
Hospital Charge Code	4010788
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

CKMB

Facility

$139.00

Service Code	CPT 82553
Hospital Charge Code	8093949
Hospital Revenue Code	301
Min. Negotiated Rate	$61.68
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	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

CKMB

Facility

$139.00

Service Code	CPT 82553
Hospital Charge Code	8093949
Hospital Revenue Code	301
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

CKMB and Index DMCL

Facility

$139.00

Service Code	CPT 82553
Hospital Charge Code	8037513
Hospital Revenue Code	301
Min. Negotiated Rate	$61.68
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	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

CKMB and Index DMCL

Facility

$139.00

Service Code	CPT 82553
Hospital Charge Code	8037513
Hospital Revenue Code	301
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

CK MB DMCL

Facility

$71.00

Service Code	CPT 82550
Hospital Charge Code	8037511
Hospital Revenue Code	301
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

CK MB DMCL

Facility

$71.00

Service Code	CPT 82550
Hospital Charge Code	8037511
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

CK Total DMCL

Facility

$71.00

Service Code	CPT 82550
Hospital Charge Code	8037512
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Aetna of IA Medicare	$40.47
Rate for Payer: Amerigroup Medicaid	$40.95
Rate for Payer: Amerigroup Medicare	$32.27
Rate for Payer: Cash Price	$56.80
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.95
Rate for Payer: Iowa Total Care Managed Medicaid	$40.56
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Medical Associates Managed Medicare	$31.95
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: Molina Healthcare Managed Medicaid	$41.15
Rate for Payer: Partners Health Alliance Commercial	$36.74
Rate for Payer: United Healthcare Commercial	$63.90
Rate for Payer: United Healthcare Managed Medicare	$41.89
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

CK Total DMCL

Facility

$71.00

Service Code	CPT 82550
Hospital Charge Code	8037512
Hospital Revenue Code	301
Min. Negotiated Rate	$49.70
Max. Negotiated Rate	$63.90
Rate for Payer: Aetna of IA Commercial	$63.90
Rate for Payer: Aetna of IA Medical Rental Products	$63.90
Rate for Payer: Cash Price	$56.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$53.25
Rate for Payer: Medical Associates Commercial	$53.25
Rate for Payer: Midlands Choice Commercial	$49.70
Rate for Payer: United Healthcare Commercial	$63.90

CLEAR OUTER EAR CANAL

Facility

$144.00

Service Code	CPT 69200
Hospital Charge Code	4866849
Hospital Revenue Code	450
Min. Negotiated Rate	$100.80
Max. Negotiated Rate	$129.60
Rate for Payer: Aetna of IA Commercial	$129.60
Rate for Payer: Aetna of IA Medical Rental Products	$129.60
Rate for Payer: Cash Price	$115.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$108.00
Rate for Payer: Medical Associates Commercial	$108.00
Rate for Payer: Midlands Choice Commercial	$100.80
Rate for Payer: United Healthcare Commercial	$129.60

Know your out-of-pocket cost for care.

All Charges