Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

desmopressin 0.2 mg Tab [VDMC]

Facility

$3.92

Service Code	HCPCS A9270
Hospital Charge Code	10381363
Hospital Revenue Code	259
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$3.53
Rate for Payer: Aetna of IA Commercial	$3.53
Rate for Payer: Aetna of IA Medical Rental Products	$3.53
Rate for Payer: Aetna of IA Medicare	$2.23
Rate for Payer: Amerigroup Medicaid	$1.98
Rate for Payer: Amerigroup Medicare	$1.98
Rate for Payer: Cash Price	$3.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.96
Rate for Payer: Iowa Total Care Managed Medicaid	$1.96
Rate for Payer: Medical Associates Commercial	$2.94
Rate for Payer: Medical Associates Managed Medicare	$1.96
Rate for Payer: Midlands Choice Commercial	$2.74
Rate for Payer: Molina Healthcare Managed Medicaid	$1.99
Rate for Payer: Molina Healthcare Managed Medicare	$1.99
Rate for Payer: Oscar Health of IA Commercial	$2.94
Rate for Payer: Partners Health Alliance Commercial	$2.94
Rate for Payer: United Healthcare Commercial	$3.53
Rate for Payer: United Healthcare Managed Medicare	$2.31

desmopressin 0.2 mg Tab [VDMC]

Facility

$3.92

Service Code	HCPCS A9270
Hospital Charge Code	10381363
Hospital Revenue Code	259
Min. Negotiated Rate	$2.74
Max. Negotiated Rate	$3.53
Rate for Payer: Aetna of IA Commercial	$3.53
Rate for Payer: Aetna of IA Medical Rental Products	$3.53
Rate for Payer: Cash Price	$3.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.94
Rate for Payer: Medical Associates Commercial	$2.94
Rate for Payer: Midlands Choice Commercial	$2.74
Rate for Payer: United Healthcare Commercial	$3.53

desmopressin 4 mcg/mL 1 ml SDV inj [VDMC]

Facility

$201.49

Service Code	HCPCS J2597
Hospital Charge Code	10381499
Hospital Revenue Code	259
Min. Negotiated Rate	$141.04
Max. Negotiated Rate	$181.34
Rate for Payer: Aetna of IA Commercial	$181.34
Rate for Payer: Aetna of IA Medical Rental Products	$181.34
Rate for Payer: Cash Price	$161.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$151.12
Rate for Payer: Medical Associates Commercial	$151.12
Rate for Payer: Midlands Choice Commercial	$141.04
Rate for Payer: United Healthcare Commercial	$181.34

desmopressin 4 mcg/mL 1 ml SDV inj [VDMC]

Facility

$201.49

Service Code	HCPCS J2597
Hospital Charge Code	10381499
Hospital Revenue Code	259
Min. Negotiated Rate	$100.70
Max. Negotiated Rate	$181.34
Rate for Payer: Aetna of IA Commercial	$181.34
Rate for Payer: Aetna of IA Medical Rental Products	$181.34
Rate for Payer: Aetna of IA Medicare	$114.85
Rate for Payer: Amerigroup Medicaid	$101.69
Rate for Payer: Amerigroup Medicare	$101.75
Rate for Payer: Cash Price	$161.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$151.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$100.74
Rate for Payer: Iowa Total Care Managed Medicaid	$100.70
Rate for Payer: Medical Associates Commercial	$151.12
Rate for Payer: Medical Associates Managed Medicare	$100.74
Rate for Payer: Midlands Choice Commercial	$141.04
Rate for Payer: Molina Healthcare Managed Medicaid	$102.26
Rate for Payer: Molina Healthcare Managed Medicare	$102.20
Rate for Payer: Oscar Health of IA Commercial	$151.12
Rate for Payer: Partners Health Alliance Commercial	$151.12
Rate for Payer: United Healthcare Commercial	$181.34
Rate for Payer: United Healthcare Managed Medicare	$118.88

Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

Facility

$1,560.42

Service Code	CPT 64624
Hospital Revenue Code	360
Min. Negotiated Rate	$1,418.56
Max. Negotiated Rate	$1,560.42
Rate for Payer: Wellmark IA HMO	$1,418.56
Rate for Payer: Wellmark IA PPO	$1,560.42

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

Facility

$1,487.44

Service Code	CPT 64634
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint

Facility

$1,487.44

Service Code	CPT 64633
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)

Facility

$1,487.44

Service Code	CPT 64636
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint

Facility

$1,487.44

Service Code	CPT 64635
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

DESTRUCTION OF LESION(S) VULVA SIMPLE

Professional

Both

$630.00

Service Code	CPT 56501
Hospital Charge Code	8825538
Hospital Revenue Code	975
Min. Negotiated Rate	$121.99
Max. Negotiated Rate	$441.00
Rate for Payer: Aetna of IA Medicare	$121.99
Rate for Payer: Amerigroup Medicaid	$126.14
Rate for Payer: Cash Price	$504.00
Rate for Payer: Cash Price	$504.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$146.39
Rate for Payer: Iowa Total Care Managed Medicaid	$124.43
Rate for Payer: Medical Associates Commercial	$231.78
Rate for Payer: Medical Associates Managed Medicare	$121.99
Rate for Payer: Midlands Choice Commercial	$441.00
Rate for Payer: Oscar Health of IA Commercial	$211.04
Rate for Payer: Partners Health Alliance Commercial	$182.98

dexamethasone 0.5 mg Tab [VDMC]

Facility

$1.37

Service Code	HCPCS A9270
Hospital Charge Code	10381637
Hospital Revenue Code	259
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$1.23
Rate for Payer: Aetna of IA Commercial	$1.23
Rate for Payer: Aetna of IA Medical Rental Products	$1.23
Rate for Payer: Aetna of IA Medicare	$0.78
Rate for Payer: Amerigroup Medicaid	$0.69
Rate for Payer: Amerigroup Medicare	$0.69
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.69
Rate for Payer: Iowa Total Care Managed Medicaid	$0.68
Rate for Payer: Medical Associates Commercial	$1.03
Rate for Payer: Medical Associates Managed Medicare	$0.69
Rate for Payer: Midlands Choice Commercial	$0.96
Rate for Payer: Molina Healthcare Managed Medicaid	$0.70
Rate for Payer: Molina Healthcare Managed Medicare	$0.69
Rate for Payer: Oscar Health of IA Commercial	$1.03
Rate for Payer: Partners Health Alliance Commercial	$1.03
Rate for Payer: United Healthcare Commercial	$1.23
Rate for Payer: United Healthcare Managed Medicare	$0.81

dexamethasone 0.5 mg Tab [VDMC]

Facility

$1.37

Service Code	HCPCS A9270
Hospital Charge Code	10381637
Hospital Revenue Code	259
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.23
Rate for Payer: Aetna of IA Commercial	$1.23
Rate for Payer: Aetna of IA Medical Rental Products	$1.23
Rate for Payer: Cash Price	$1.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.03
Rate for Payer: Medical Associates Commercial	$1.03
Rate for Payer: Midlands Choice Commercial	$0.96
Rate for Payer: United Healthcare Commercial	$1.23

dexamethasone 10 mg/mL 1 ml SDV PRESERVATIVE-FREE inj [VDMC]

Facility

$36.31

Service Code	HCPCS J1100
Hospital Charge Code	12738943
Hospital Revenue Code	259
Min. Negotiated Rate	$18.15
Max. Negotiated Rate	$32.68
Rate for Payer: Aetna of IA Commercial	$32.68
Rate for Payer: Aetna of IA Medical Rental Products	$32.68
Rate for Payer: Aetna of IA Medicare	$20.70
Rate for Payer: Amerigroup Medicaid	$18.33
Rate for Payer: Amerigroup Medicare	$18.34
Rate for Payer: Cash Price	$29.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$18.16
Rate for Payer: Iowa Total Care Managed Medicaid	$18.15
Rate for Payer: Medical Associates Commercial	$27.23
Rate for Payer: Medical Associates Managed Medicare	$18.16
Rate for Payer: Midlands Choice Commercial	$25.42
Rate for Payer: Molina Healthcare Managed Medicaid	$18.43
Rate for Payer: Molina Healthcare Managed Medicare	$18.42
Rate for Payer: Oscar Health of IA Commercial	$27.23
Rate for Payer: Partners Health Alliance Commercial	$27.23
Rate for Payer: United Healthcare Commercial	$32.68
Rate for Payer: United Healthcare Managed Medicare	$21.42

dexamethasone 10 mg/mL 1 ml SDV PRESERVATIVE-FREE inj [VDMC]

Facility

$36.31

Service Code	HCPCS J1100
Hospital Charge Code	12738943
Hospital Revenue Code	259
Min. Negotiated Rate	$25.42
Max. Negotiated Rate	$32.68
Rate for Payer: Aetna of IA Commercial	$32.68
Rate for Payer: Aetna of IA Medical Rental Products	$32.68
Rate for Payer: Cash Price	$29.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.23
Rate for Payer: Medical Associates Commercial	$27.23
Rate for Payer: Midlands Choice Commercial	$25.42
Rate for Payer: United Healthcare Commercial	$32.68

dexamethasone 4 mg/mL 5 ml MDV inj [VDMC]

Facility

$23.16

Service Code	HCPCS J1100
Hospital Charge Code	10381834
Hospital Revenue Code	259
Min. Negotiated Rate	$11.58
Max. Negotiated Rate	$20.84
Rate for Payer: Aetna of IA Commercial	$20.84
Rate for Payer: Aetna of IA Medical Rental Products	$20.84
Rate for Payer: Aetna of IA Medicare	$13.20
Rate for Payer: Amerigroup Medicaid	$11.69
Rate for Payer: Amerigroup Medicare	$11.70
Rate for Payer: Cash Price	$18.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.58
Rate for Payer: Iowa Total Care Managed Medicaid	$11.58
Rate for Payer: Medical Associates Commercial	$17.37
Rate for Payer: Medical Associates Managed Medicare	$11.58
Rate for Payer: Midlands Choice Commercial	$16.21
Rate for Payer: Molina Healthcare Managed Medicaid	$11.75
Rate for Payer: Molina Healthcare Managed Medicare	$11.75
Rate for Payer: Oscar Health of IA Commercial	$17.37
Rate for Payer: Partners Health Alliance Commercial	$17.37
Rate for Payer: United Healthcare Commercial	$20.84
Rate for Payer: United Healthcare Managed Medicare	$13.66

dexamethasone 4 mg/mL 5 ml MDV inj [VDMC]

Facility

$23.16

Service Code	HCPCS J1100
Hospital Charge Code	10381834
Hospital Revenue Code	259
Min. Negotiated Rate	$16.21
Max. Negotiated Rate	$20.84
Rate for Payer: Aetna of IA Commercial	$20.84
Rate for Payer: Aetna of IA Medical Rental Products	$20.84
Rate for Payer: Cash Price	$18.53
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.37
Rate for Payer: Medical Associates Commercial	$17.37
Rate for Payer: Midlands Choice Commercial	$16.21
Rate for Payer: United Healthcare Commercial	$20.84

dexamethasone 4 mg Tab [VDMC]

Facility

$4.84

Service Code	HCPCS A9270
Hospital Charge Code	10381765
Hospital Revenue Code	259
Min. Negotiated Rate	$3.39
Max. Negotiated Rate	$4.36
Rate for Payer: Aetna of IA Commercial	$4.36
Rate for Payer: Aetna of IA Medical Rental Products	$4.36
Rate for Payer: Cash Price	$3.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.63
Rate for Payer: Medical Associates Commercial	$3.63
Rate for Payer: Midlands Choice Commercial	$3.39
Rate for Payer: United Healthcare Commercial	$4.36

dexamethasone 4 mg Tab [VDMC]

Facility

$4.84

Service Code	HCPCS A9270
Hospital Charge Code	10381765
Hospital Revenue Code	259
Min. Negotiated Rate	$2.42
Max. Negotiated Rate	$4.36
Rate for Payer: Aetna of IA Commercial	$4.36
Rate for Payer: Aetna of IA Medical Rental Products	$4.36
Rate for Payer: Aetna of IA Medicare	$2.76
Rate for Payer: Amerigroup Medicaid	$2.44
Rate for Payer: Amerigroup Medicare	$2.44
Rate for Payer: Cash Price	$3.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.63
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.42
Rate for Payer: Iowa Total Care Managed Medicaid	$2.42
Rate for Payer: Medical Associates Commercial	$3.63
Rate for Payer: Medical Associates Managed Medicare	$2.42
Rate for Payer: Midlands Choice Commercial	$3.39
Rate for Payer: Molina Healthcare Managed Medicaid	$2.46
Rate for Payer: Molina Healthcare Managed Medicare	$2.45
Rate for Payer: Oscar Health of IA Commercial	$3.63
Rate for Payer: Partners Health Alliance Commercial	$3.63
Rate for Payer: United Healthcare Commercial	$4.36
Rate for Payer: United Healthcare Managed Medicare	$2.86

dexmedetomidine 100 mcg/mL 2 ml SDV inj [VDMC]

Facility

$26.71

Service Code	HCPCS J3490
Hospital Charge Code	11219809
Hospital Revenue Code	259
Min. Negotiated Rate	$18.70
Max. Negotiated Rate	$24.04
Rate for Payer: Aetna of IA Commercial	$24.04
Rate for Payer: Aetna of IA Medical Rental Products	$24.04
Rate for Payer: Cash Price	$21.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.03
Rate for Payer: Medical Associates Commercial	$20.03
Rate for Payer: Midlands Choice Commercial	$18.70
Rate for Payer: United Healthcare Commercial	$24.04

dexmedetomidine 100 mcg/mL 2 ml SDV inj [VDMC]

Facility

$26.71

Service Code	HCPCS J3490
Hospital Charge Code	11219809
Hospital Revenue Code	259
Min. Negotiated Rate	$13.35
Max. Negotiated Rate	$24.04
Rate for Payer: Aetna of IA Commercial	$24.04
Rate for Payer: Aetna of IA Medical Rental Products	$24.04
Rate for Payer: Aetna of IA Medicare	$15.22
Rate for Payer: Amerigroup Medicaid	$13.48
Rate for Payer: Amerigroup Medicare	$13.49
Rate for Payer: Cash Price	$21.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.36
Rate for Payer: Iowa Total Care Managed Medicaid	$13.35
Rate for Payer: Medical Associates Commercial	$20.03
Rate for Payer: Medical Associates Managed Medicare	$13.36
Rate for Payer: Midlands Choice Commercial	$18.70
Rate for Payer: Molina Healthcare Managed Medicaid	$13.56
Rate for Payer: Molina Healthcare Managed Medicare	$13.55
Rate for Payer: Oscar Health of IA Commercial	$20.03
Rate for Payer: Partners Health Alliance Commercial	$20.03
Rate for Payer: United Healthcare Commercial	$24.04
Rate for Payer: United Healthcare Managed Medicare	$15.76

Dextrose 10% in Water intravenous solution 500 mL [VDMC]

Facility

$69.40

Service Code	HCPCS J7799
Hospital Charge Code	10440241
Hospital Revenue Code	259
Min. Negotiated Rate	$48.58
Max. Negotiated Rate	$62.46
Rate for Payer: Aetna of IA Commercial	$62.46
Rate for Payer: Aetna of IA Medical Rental Products	$62.46
Rate for Payer: Cash Price	$55.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.05
Rate for Payer: Medical Associates Commercial	$52.05
Rate for Payer: Midlands Choice Commercial	$48.58
Rate for Payer: United Healthcare Commercial	$62.46

Dextrose 10% in Water intravenous solution 500 mL [VDMC]

Facility

$69.40

Service Code	HCPCS J7799
Hospital Charge Code	10440241
Hospital Revenue Code	259
Min. Negotiated Rate	$34.69
Max. Negotiated Rate	$62.46
Rate for Payer: Aetna of IA Commercial	$62.46
Rate for Payer: Aetna of IA Medical Rental Products	$62.46
Rate for Payer: Aetna of IA Medicare	$39.56
Rate for Payer: Amerigroup Medicaid	$35.03
Rate for Payer: Amerigroup Medicare	$35.05
Rate for Payer: Cash Price	$55.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$34.70
Rate for Payer: Iowa Total Care Managed Medicaid	$34.69
Rate for Payer: Medical Associates Commercial	$52.05
Rate for Payer: Medical Associates Managed Medicare	$34.70
Rate for Payer: Midlands Choice Commercial	$48.58
Rate for Payer: Molina Healthcare Managed Medicaid	$35.22
Rate for Payer: Molina Healthcare Managed Medicare	$35.20
Rate for Payer: Oscar Health of IA Commercial	$52.05
Rate for Payer: Partners Health Alliance Commercial	$52.05
Rate for Payer: United Healthcare Commercial	$62.46
Rate for Payer: United Healthcare Managed Medicare	$40.95

dextrose 40% Oral gel [VDMC]

Facility

$15.64

Service Code	HCPCS A9270
Hospital Charge Code	10392316
Hospital Revenue Code	259
Min. Negotiated Rate	$10.95
Max. Negotiated Rate	$14.08
Rate for Payer: Aetna of IA Commercial	$14.08
Rate for Payer: Aetna of IA Medical Rental Products	$14.08
Rate for Payer: Cash Price	$12.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.73
Rate for Payer: Medical Associates Commercial	$11.73
Rate for Payer: Midlands Choice Commercial	$10.95
Rate for Payer: United Healthcare Commercial	$14.08

dextrose 40% Oral gel [VDMC]

Facility

$15.64

Service Code	HCPCS A9270
Hospital Charge Code	10392316
Hospital Revenue Code	259
Min. Negotiated Rate	$7.82
Max. Negotiated Rate	$14.08
Rate for Payer: Aetna of IA Commercial	$14.08
Rate for Payer: Aetna of IA Medical Rental Products	$14.08
Rate for Payer: Aetna of IA Medicare	$8.91
Rate for Payer: Amerigroup Medicaid	$7.89
Rate for Payer: Amerigroup Medicare	$7.90
Rate for Payer: Cash Price	$12.51
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.73
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.82
Rate for Payer: Iowa Total Care Managed Medicaid	$7.82
Rate for Payer: Medical Associates Commercial	$11.73
Rate for Payer: Medical Associates Managed Medicare	$7.82
Rate for Payer: Midlands Choice Commercial	$10.95
Rate for Payer: Molina Healthcare Managed Medicaid	$7.94
Rate for Payer: Molina Healthcare Managed Medicare	$7.93
Rate for Payer: Oscar Health of IA Commercial	$11.73
Rate for Payer: Partners Health Alliance Commercial	$11.73
Rate for Payer: United Healthcare Commercial	$14.08
Rate for Payer: United Healthcare Managed Medicare	$9.23

Dextrose 5% in Lactated Ringers 1000ml IV [VDMC]

Facility

$65.88

Service Code	HCPCS J7121
Hospital Charge Code	10440304
Hospital Revenue Code	259
Min. Negotiated Rate	$46.12
Max. Negotiated Rate	$59.29
Rate for Payer: Aetna of IA Commercial	$59.29
Rate for Payer: Aetna of IA Medical Rental Products	$59.29
Rate for Payer: Cash Price	$52.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.41
Rate for Payer: Medical Associates Commercial	$49.41
Rate for Payer: Midlands Choice Commercial	$46.12
Rate for Payer: United Healthcare Commercial	$59.29

Know your out-of-pocket cost for care.

All Charges