Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

diphtheria/tetanus/pertussis (DTaP) ped 25 units-10 units-58 mcg/0.5 mL Sus UD [VDMC]

Facility

$61.30

Service Code	HCPCS 90700
Hospital Charge Code	24148567
Hospital Revenue Code	259
Min. Negotiated Rate	$42.91
Max. Negotiated Rate	$55.17
Rate for Payer: Aetna of IA Commercial	$55.17
Rate for Payer: Aetna of IA Medical Rental Products	$55.17
Rate for Payer: Cash Price	$49.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.98
Rate for Payer: Medical Associates Commercial	$45.98
Rate for Payer: Midlands Choice Commercial	$42.91
Rate for Payer: United Healthcare Commercial	$55.17

diphth/haemophilus/pertussis/tetanus/polio SDV [VDMC]

Facility

$128.26

Service Code	HCPCS 90698
Hospital Charge Code	12601246
Hospital Revenue Code	259
Min. Negotiated Rate	$89.78
Max. Negotiated Rate	$115.43
Rate for Payer: Aetna of IA Commercial	$115.43
Rate for Payer: Aetna of IA Medical Rental Products	$115.43
Rate for Payer: Cash Price	$102.61
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.20
Rate for Payer: Medical Associates Commercial	$96.20
Rate for Payer: Midlands Choice Commercial	$89.78
Rate for Payer: United Healthcare Commercial	$115.43

diphth/haemophilus/pertussis/tetanus/polio SDV [VDMC]

Facility

$128.26

Service Code	HCPCS 90698
Hospital Charge Code	12601246
Hospital Revenue Code	259
Min. Negotiated Rate	$62.00
Max. Negotiated Rate	$115.43
Rate for Payer: Aetna of IA Commercial	$115.43
Rate for Payer: Aetna of IA Medical Rental Products	$115.43
Rate for Payer: Aetna of IA Medicare	$73.11
Rate for Payer: Amerigroup Medicaid	$64.73
Rate for Payer: Amerigroup Medicare	$64.77
Rate for Payer: Cash Price	$102.61
Rate for Payer: Cash Price	$102.61
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.13
Rate for Payer: Iowa Total Care Managed Medicaid	$64.10
Rate for Payer: Medical Associates Commercial	$96.20
Rate for Payer: Medical Associates Managed Medicare	$64.13
Rate for Payer: Midlands Choice Commercial	$89.78
Rate for Payer: Molina Healthcare Managed Medicaid	$65.09
Rate for Payer: Molina Healthcare Managed Medicare	$65.05
Rate for Payer: Oscar Health of IA Commercial	$96.20
Rate for Payer: Partners Health Alliance Commercial	$96.20
Rate for Payer: United Healthcare Commercial	$115.43
Rate for Payer: United Healthcare Managed Medicare	$75.67
Rate for Payer: Wellmark IA HMO	$62.00
Rate for Payer: Wellmark IA PPO	$68.20

dipyridamole 25 mg Tab [VDMC]

Facility

$7.35

Service Code	HCPCS A9270
Hospital Charge Code	10383826
Hospital Revenue Code	259
Min. Negotiated Rate	$5.14
Max. Negotiated Rate	$6.62
Rate for Payer: Aetna of IA Commercial	$6.62
Rate for Payer: Aetna of IA Medical Rental Products	$6.62
Rate for Payer: Cash Price	$5.88
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.51
Rate for Payer: Medical Associates Commercial	$5.51
Rate for Payer: Midlands Choice Commercial	$5.14
Rate for Payer: United Healthcare Commercial	$6.62

dipyridamole 25 mg Tab [VDMC]

Facility

$7.35

Service Code	HCPCS A9270
Hospital Charge Code	10383826
Hospital Revenue Code	259
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$6.62
Rate for Payer: Aetna of IA Commercial	$6.62
Rate for Payer: Aetna of IA Medical Rental Products	$6.62
Rate for Payer: Aetna of IA Medicare	$4.19
Rate for Payer: Amerigroup Medicaid	$3.71
Rate for Payer: Amerigroup Medicare	$3.71
Rate for Payer: Cash Price	$5.88
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.51
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.68
Rate for Payer: Iowa Total Care Managed Medicaid	$3.67
Rate for Payer: Medical Associates Commercial	$5.51
Rate for Payer: Medical Associates Managed Medicare	$3.68
Rate for Payer: Midlands Choice Commercial	$5.14
Rate for Payer: Molina Healthcare Managed Medicaid	$3.73
Rate for Payer: Molina Healthcare Managed Medicare	$3.73
Rate for Payer: Oscar Health of IA Commercial	$5.51
Rate for Payer: Partners Health Alliance Commercial	$5.51
Rate for Payer: United Healthcare Commercial	$6.62
Rate for Payer: United Healthcare Managed Medicare	$4.34

dipyridamole 5 mg/mL 10 ml IV SDV [VDMC]

Facility

$87.82

Service Code	HCPCS J1245
Hospital Charge Code	10383895
Hospital Revenue Code	259
Min. Negotiated Rate	$61.47
Max. Negotiated Rate	$79.04
Rate for Payer: Aetna of IA Commercial	$79.04
Rate for Payer: Aetna of IA Medical Rental Products	$79.04
Rate for Payer: Cash Price	$70.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$65.86
Rate for Payer: Medical Associates Commercial	$65.86
Rate for Payer: Midlands Choice Commercial	$61.47
Rate for Payer: United Healthcare Commercial	$79.04

dipyridamole 5 mg/mL 10 ml IV SDV [VDMC]

Facility

$87.82

Service Code	HCPCS J1245
Hospital Charge Code	10383895
Hospital Revenue Code	259
Min. Negotiated Rate	$43.89
Max. Negotiated Rate	$79.04
Rate for Payer: Aetna of IA Commercial	$79.04
Rate for Payer: Aetna of IA Medical Rental Products	$79.04
Rate for Payer: Aetna of IA Medicare	$50.06
Rate for Payer: Amerigroup Medicaid	$44.32
Rate for Payer: Amerigroup Medicare	$44.35
Rate for Payer: Cash Price	$70.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$65.86
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$43.91
Rate for Payer: Iowa Total Care Managed Medicaid	$43.89
Rate for Payer: Medical Associates Commercial	$65.86
Rate for Payer: Medical Associates Managed Medicare	$43.91
Rate for Payer: Midlands Choice Commercial	$61.47
Rate for Payer: Molina Healthcare Managed Medicaid	$44.57
Rate for Payer: Molina Healthcare Managed Medicare	$44.54
Rate for Payer: Oscar Health of IA Commercial	$65.86
Rate for Payer: Partners Health Alliance Commercial	$65.86
Rate for Payer: United Healthcare Commercial	$79.04
Rate for Payer: United Healthcare Managed Medicare	$51.81

Direct Antiglobulin IgG DMCL

Facility

$58.00

Service Code	CPT 86880
Hospital Charge Code	8037837
Hospital Revenue Code	302
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

Direct Antiglobulin IgG DMCL

Facility

$58.00

Service Code	CPT 86880
Hospital Charge Code	8037837
Hospital Revenue Code	302
Min. Negotiated Rate	$28.99
Max. Negotiated Rate	$107.07
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$29.27
Rate for Payer: Amerigroup Medicare	$29.29
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.00
Rate for Payer: Iowa Total Care Managed Medicaid	$28.99
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$29.00
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$29.44
Rate for Payer: Molina Healthcare Managed Medicare	$29.42
Rate for Payer: Oscar Health of IA Commercial	$43.50
Rate for Payer: Partners Health Alliance Commercial	$43.50
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22
Rate for Payer: Wellmark IA HMO	$97.34
Rate for Payer: Wellmark IA PPO	$107.07

Disorders of Liver Except Malignancy, Cirrhosis or Alcoholic Hepatitis With CC

Facility

$8,573.73

Service Code	MS-DRG 442
Hospital Charge Code	268
Min. Negotiated Rate	$8,449.48
Max. Negotiated Rate	$8,573.73
Rate for Payer: Amerigroup Medicaid	$8,532.31
Rate for Payer: Iowa Total Care Managed Medicaid	$8,449.48
Rate for Payer: Molina Healthcare Managed Medicaid	$8,573.73

Disorders of Liver Except Malignancy, Cirrhosis or Alcoholic Hepatitis With MCC

Facility

$14,515.60

Service Code	MS-DRG 441
Hospital Charge Code	267
Min. Negotiated Rate	$14,305.22
Max. Negotiated Rate	$14,515.60
Rate for Payer: Amerigroup Medicaid	$14,445.47
Rate for Payer: Iowa Total Care Managed Medicaid	$14,305.22
Rate for Payer: Molina Healthcare Managed Medicaid	$14,515.60

Disorders of Liver Except Malignancy, Cirrhosis or Alcoholic Hepatitis Without CC/MCC

Facility

$5,777.49

Service Code	MS-DRG 443
Hospital Charge Code	269
Min. Negotiated Rate	$5,693.76
Max. Negotiated Rate	$5,777.49
Rate for Payer: Amerigroup Medicaid	$5,749.58
Rate for Payer: Iowa Total Care Managed Medicaid	$5,693.76
Rate for Payer: Molina Healthcare Managed Medicaid	$5,777.49

Disorders of Pancreas Except Malignancy With CC

Facility

$7,724.33

Service Code	MS-DRG 439
Hospital Charge Code	265
Min. Negotiated Rate	$7,612.38
Max. Negotiated Rate	$7,724.33
Rate for Payer: Amerigroup Medicaid	$7,687.01
Rate for Payer: Iowa Total Care Managed Medicaid	$7,612.38
Rate for Payer: Molina Healthcare Managed Medicaid	$7,724.33

Disorders of Pancreas Except Malignancy With MCC

Facility

$13,372.89

Service Code	MS-DRG 438
Hospital Charge Code	264
Min. Negotiated Rate	$13,179.08
Max. Negotiated Rate	$13,372.89
Rate for Payer: Amerigroup Medicaid	$13,308.29
Rate for Payer: Iowa Total Care Managed Medicaid	$13,179.08
Rate for Payer: Molina Healthcare Managed Medicaid	$13,372.89

Disorders of Pancreas Except Malignancy Without CC/MCC

Facility

$6,594.42

Service Code	MS-DRG 440
Hospital Charge Code	266
Min. Negotiated Rate	$6,498.85
Max. Negotiated Rate	$6,594.42
Rate for Payer: Amerigroup Medicaid	$6,562.56
Rate for Payer: Iowa Total Care Managed Medicaid	$6,498.85
Rate for Payer: Molina Healthcare Managed Medicaid	$6,594.42

Disorders of Personality and Impulse Control

Facility

$5,890.68

Service Code	MS-DRG 883
Hospital Charge Code	613
Min. Negotiated Rate	$5,805.31
Max. Negotiated Rate	$5,890.68
Rate for Payer: Amerigroup Medicaid	$5,862.22
Rate for Payer: Iowa Total Care Managed Medicaid	$5,805.31
Rate for Payer: Molina Healthcare Managed Medicaid	$5,890.68

Disorders of the Biliary Tract With CC

Facility

$10,305.01

Service Code	MS-DRG 445
Hospital Charge Code	271
Min. Negotiated Rate	$10,155.66
Max. Negotiated Rate	$10,305.01
Rate for Payer: Amerigroup Medicaid	$10,255.23
Rate for Payer: Iowa Total Care Managed Medicaid	$10,155.66
Rate for Payer: Molina Healthcare Managed Medicaid	$10,305.01

Disorders of the Biliary Tract With MCC

Facility

$11,874.88

Service Code	MS-DRG 444
Hospital Charge Code	270
Min. Negotiated Rate	$11,702.78
Max. Negotiated Rate	$11,874.88
Rate for Payer: Amerigroup Medicaid	$11,817.51
Rate for Payer: Iowa Total Care Managed Medicaid	$11,702.78
Rate for Payer: Molina Healthcare Managed Medicaid	$11,874.88

Disorders of the Biliary Tract Without CC/MCC

Facility

$7,037.33

Service Code	MS-DRG 446
Hospital Charge Code	272
Min. Negotiated Rate	$6,935.34
Max. Negotiated Rate	$7,037.33
Rate for Payer: Amerigroup Medicaid	$7,003.33
Rate for Payer: Iowa Total Care Managed Medicaid	$6,935.34
Rate for Payer: Molina Healthcare Managed Medicaid	$7,037.33

DISPOSABLE KIT HIP /BLADES

Facility

$810.00

Hospital Charge Code	8047066
Hospital Revenue Code	278
Min. Negotiated Rate	$404.84
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of IA Commercial	$729.00
Rate for Payer: Aetna of IA Medical Rental Products	$729.00
Rate for Payer: Aetna of IA Medicare	$461.70
Rate for Payer: Amerigroup Medicaid	$408.81
Rate for Payer: Amerigroup Medicare	$409.05
Rate for Payer: Cash Price	$648.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$607.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$405.00
Rate for Payer: Iowa Total Care Managed Medicaid	$404.84
Rate for Payer: Medical Associates Commercial	$607.50
Rate for Payer: Medical Associates Managed Medicare	$405.00
Rate for Payer: Midlands Choice Commercial	$567.00
Rate for Payer: Molina Healthcare Managed Medicaid	$411.08
Rate for Payer: Molina Healthcare Managed Medicare	$410.83
Rate for Payer: Oscar Health of IA Commercial	$607.50
Rate for Payer: Partners Health Alliance Commercial	$607.50
Rate for Payer: United Healthcare Commercial	$729.00
Rate for Payer: United Healthcare Managed Medicare	$477.90

DISPOSABLE KIT HIP /BLADES

Facility

$810.00

Hospital Charge Code	8047066
Hospital Revenue Code	278
Min. Negotiated Rate	$567.00
Max. Negotiated Rate	$729.00
Rate for Payer: Aetna of IA Commercial	$729.00
Rate for Payer: Aetna of IA Medical Rental Products	$729.00
Rate for Payer: Cash Price	$648.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$607.50
Rate for Payer: Medical Associates Commercial	$607.50
Rate for Payer: Midlands Choice Commercial	$567.00
Rate for Payer: United Healthcare Commercial	$729.00

divalproex sodium 125 mg DR Cap [VDMC]

Facility

$3.34

Service Code	HCPCS A9270
Hospital Charge Code	10383966
Hospital Revenue Code	259
Min. Negotiated Rate	$2.34
Max. Negotiated Rate	$3.01
Rate for Payer: Aetna of IA Commercial	$3.01
Rate for Payer: Aetna of IA Medical Rental Products	$3.01
Rate for Payer: Cash Price	$2.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.50
Rate for Payer: Medical Associates Commercial	$2.50
Rate for Payer: Midlands Choice Commercial	$2.34
Rate for Payer: United Healthcare Commercial	$3.01

divalproex sodium 125 mg DR Cap [VDMC]

Facility

$3.34

Service Code	HCPCS A9270
Hospital Charge Code	10383966
Hospital Revenue Code	259
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$3.01
Rate for Payer: Aetna of IA Commercial	$3.01
Rate for Payer: Aetna of IA Medical Rental Products	$3.01
Rate for Payer: Aetna of IA Medicare	$1.90
Rate for Payer: Amerigroup Medicaid	$1.69
Rate for Payer: Amerigroup Medicare	$1.69
Rate for Payer: Cash Price	$2.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.67
Rate for Payer: Iowa Total Care Managed Medicaid	$1.67
Rate for Payer: Medical Associates Commercial	$2.50
Rate for Payer: Medical Associates Managed Medicare	$1.67
Rate for Payer: Midlands Choice Commercial	$2.34
Rate for Payer: Molina Healthcare Managed Medicaid	$1.70
Rate for Payer: Molina Healthcare Managed Medicare	$1.69
Rate for Payer: Oscar Health of IA Commercial	$2.50
Rate for Payer: Partners Health Alliance Commercial	$2.50
Rate for Payer: United Healthcare Commercial	$3.01
Rate for Payer: United Healthcare Managed Medicare	$1.97

divalproex sodium 250 mg DR Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10384037
Hospital Revenue Code	259
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of IA Commercial	$1.24
Rate for Payer: Aetna of IA Medical Rental Products	$1.24
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: United Healthcare Commercial	$1.24

divalproex sodium 250 mg DR Tab [VDMC]

Facility

$1.38

Service Code	HCPCS A9270
Hospital Charge Code	10384037
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of IA Commercial	$1.24
Rate for Payer: Aetna of IA Medical Rental Products	$1.24
Rate for Payer: Aetna of IA Medicare	$0.79
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.70
Rate for Payer: Cash Price	$1.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.04
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	$0.69
Rate for Payer: Medical Associates Commercial	$1.04
Rate for Payer: Medical Associates Managed Medicare	$0.69
Rate for Payer: Midlands Choice Commercial	$0.97
Rate for Payer: Molina Healthcare Managed Medicaid	$0.70
Rate for Payer: Molina Healthcare Managed Medicare	$0.70
Rate for Payer: Oscar Health of IA Commercial	$1.04
Rate for Payer: Partners Health Alliance Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.24
Rate for Payer: United Healthcare Managed Medicare	$0.81

Know your out-of-pocket cost for care.

All Charges