Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

hydrOXYzine hydrochloride 25 mg Tab [VDMC]

Facility

$1.59

Service Code	HCPCS A9270
Hospital Charge Code	10395212
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.43
Rate for Payer: Aetna of IA Commercial	$1.43
Rate for Payer: Aetna of IA Medical Rental Products	$1.43
Rate for Payer: Aetna of IA Medicare	$0.91
Rate for Payer: Amerigroup Medicaid	$0.92
Rate for Payer: Amerigroup Medicare	$0.72
Rate for Payer: Cash Price	$1.27
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.72
Rate for Payer: Iowa Total Care Managed Medicaid	$0.91
Rate for Payer: Medical Associates Commercial	$1.19
Rate for Payer: Medical Associates Managed Medicare	$0.72
Rate for Payer: Midlands Choice Commercial	$1.11
Rate for Payer: Molina Healthcare Managed Medicaid	$0.92
Rate for Payer: Partners Health Alliance Commercial	$0.82
Rate for Payer: United Healthcare Commercial	$1.43
Rate for Payer: United Healthcare Managed Medicare	$0.94

HYLAN G-F 20 1MG ( 48MG PER DOSE) CHARGE

Professional

Both

$24.00

Service Code	CPT J7325
Hospital Charge Code	8068951
Hospital Revenue Code	636
Min. Negotiated Rate	$9.16
Max. Negotiated Rate	$18.00
Rate for Payer: Cash Price	$19.20
Rate for Payer: Cash Price	$19.20
Rate for Payer: Medical Associates Commercial	$18.00
Rate for Payer: Midlands Choice Commercial	$16.80
Rate for Payer: Partners Health Alliance Commercial	$18.00
Rate for Payer: United Healthcare Commercial	$9.16

hylan G-F 20 48 mg/6 mL SDV syringe [VDMC]

Facility

$1,824.20

Service Code	HCPCS J7325
Hospital Charge Code	10395352
Hospital Revenue Code	259
Min. Negotiated Rate	$1,276.94
Max. Negotiated Rate	$1,641.78
Rate for Payer: Aetna of IA Commercial	$1,641.78
Rate for Payer: Aetna of IA Medical Rental Products	$1,641.78
Rate for Payer: Cash Price	$1,459.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,368.15
Rate for Payer: Medical Associates Commercial	$1,368.15
Rate for Payer: Midlands Choice Commercial	$1,276.94
Rate for Payer: United Healthcare Commercial	$1,641.78

hylan G-F 20 48 mg/6 mL SDV syringe [VDMC]

Facility

$1,824.20

Service Code	HCPCS J7325
Hospital Charge Code	10395352
Hospital Revenue Code	259
Min. Negotiated Rate	$820.89
Max. Negotiated Rate	$1,641.78
Rate for Payer: Aetna of IA Commercial	$1,641.78
Rate for Payer: Aetna of IA Medical Rental Products	$1,641.78
Rate for Payer: Aetna of IA Medicare	$1,039.79
Rate for Payer: Amerigroup Medicaid	$1,052.20
Rate for Payer: Amerigroup Medicare	$829.10
Rate for Payer: Cash Price	$1,459.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,368.15
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$820.89
Rate for Payer: Iowa Total Care Managed Medicaid	$1,041.98
Rate for Payer: Medical Associates Commercial	$1,368.15
Rate for Payer: Medical Associates Managed Medicare	$820.89
Rate for Payer: Midlands Choice Commercial	$1,276.94
Rate for Payer: Molina Healthcare Managed Medicaid	$1,057.31
Rate for Payer: Partners Health Alliance Commercial	$944.02
Rate for Payer: United Healthcare Commercial	$1,641.78
Rate for Payer: United Healthcare Managed Medicare	$1,076.28

hyoscyamine 0.125 mg Dis Tab [VDMC]

Facility

$1.30

Service Code	HCPCS A9270
Hospital Charge Code	10395421
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of IA Commercial	$1.17
Rate for Payer: Aetna of IA Medical Rental Products	$1.17
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: United Healthcare Commercial	$1.17

hyoscyamine 0.125 mg Dis Tab [VDMC]

Facility

$1.30

Service Code	HCPCS A9270
Hospital Charge Code	10395421
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of IA Commercial	$1.17
Rate for Payer: Aetna of IA Medical Rental Products	$1.17
Rate for Payer: Aetna of IA Medicare	$0.74
Rate for Payer: Amerigroup Medicaid	$0.75
Rate for Payer: Amerigroup Medicare	$0.59
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.59
Rate for Payer: Iowa Total Care Managed Medicaid	$0.74
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Medical Associates Managed Medicare	$0.59
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: Molina Healthcare Managed Medicaid	$0.76
Rate for Payer: Partners Health Alliance Commercial	$0.67
Rate for Payer: United Healthcare Commercial	$1.17
Rate for Payer: United Healthcare Managed Medicare	$0.77

Hysteroscopy surgical with BX of endometrium

Professional

Both

$4,492.00

Service Code	CPT 58558
Hospital Charge Code	8069167
Hospital Revenue Code	975
Min. Negotiated Rate	$2,079.04
Max. Negotiated Rate	$3,369.00
Rate for Payer: Cash Price	$3,593.60
Rate for Payer: Cash Price	$3,593.60
Rate for Payer: Medical Associates Commercial	$3,369.00
Rate for Payer: Midlands Choice Commercial	$3,144.40
Rate for Payer: Partners Health Alliance Commercial	$3,369.00
Rate for Payer: United Healthcare Commercial	$2,079.04

HYSTEROSCOPY; (SURG) W/ BIOPSY

Professional

Both

$4,492.00

Service Code	CPT 58558
Hospital Charge Code	8378880
Hospital Revenue Code	975
Min. Negotiated Rate	$2,079.04
Max. Negotiated Rate	$3,369.00
Rate for Payer: Cash Price	$3,593.60
Rate for Payer: Cash Price	$3,593.60
Rate for Payer: Medical Associates Commercial	$3,369.00
Rate for Payer: Midlands Choice Commercial	$3,144.40
Rate for Payer: Partners Health Alliance Commercial	$3,369.00
Rate for Payer: United Healthcare Commercial	$2,079.04

IB KIT, BC, W/CC FT AND JUMPSTART

Facility

$2,691.00

Service Code	HCPCS C1713
Hospital Charge Code	8783232
Hospital Revenue Code	278
Min. Negotiated Rate	$1,883.70
Max. Negotiated Rate	$2,421.90
Rate for Payer: Aetna of IA Commercial	$2,421.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,421.90
Rate for Payer: Cash Price	$2,152.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,018.25
Rate for Payer: Medical Associates Commercial	$2,018.25
Rate for Payer: Midlands Choice Commercial	$1,883.70
Rate for Payer: United Healthcare Commercial	$2,421.90

IB KIT, BC, W/CC FT AND JUMPSTART

Facility

$2,691.00

Service Code	HCPCS C1713
Hospital Charge Code	8783232
Hospital Revenue Code	278
Min. Negotiated Rate	$1,210.95
Max. Negotiated Rate	$2,421.90
Rate for Payer: Aetna of IA Commercial	$2,421.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,421.90
Rate for Payer: Aetna of IA Medicare	$1,533.87
Rate for Payer: Amerigroup Medicaid	$1,552.17
Rate for Payer: Amerigroup Medicare	$1,223.06
Rate for Payer: Cash Price	$2,152.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,018.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,210.95
Rate for Payer: Iowa Total Care Managed Medicaid	$1,537.10
Rate for Payer: Medical Associates Commercial	$2,018.25
Rate for Payer: Medical Associates Managed Medicare	$1,210.95
Rate for Payer: Midlands Choice Commercial	$1,883.70
Rate for Payer: Molina Healthcare Managed Medicaid	$1,559.70
Rate for Payer: Partners Health Alliance Commercial	$1,392.59
Rate for Payer: United Healthcare Commercial	$2,421.90
Rate for Payer: United Healthcare Managed Medicare	$1,587.69

ibuprofen 100 mg/5 mL 120ml oral suspension [VDMC]

Facility

$24.84

Service Code	HCPCS A9270
Hospital Charge Code	14129440
Hospital Revenue Code	259
Min. Negotiated Rate	$11.18
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna of IA Commercial	$22.36
Rate for Payer: Aetna of IA Medical Rental Products	$22.36
Rate for Payer: Aetna of IA Medicare	$14.16
Rate for Payer: Amerigroup Medicaid	$14.33
Rate for Payer: Amerigroup Medicare	$11.29
Rate for Payer: Cash Price	$19.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.63
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.18
Rate for Payer: Iowa Total Care Managed Medicaid	$14.19
Rate for Payer: Medical Associates Commercial	$18.63
Rate for Payer: Medical Associates Managed Medicare	$11.18
Rate for Payer: Midlands Choice Commercial	$17.39
Rate for Payer: Molina Healthcare Managed Medicaid	$14.40
Rate for Payer: Partners Health Alliance Commercial	$12.86
Rate for Payer: United Healthcare Commercial	$22.36
Rate for Payer: United Healthcare Managed Medicare	$14.66

ibuprofen 100 mg/5 mL 120ml oral suspension [VDMC]

Facility

$24.84

Service Code	HCPCS A9270
Hospital Charge Code	14129440
Hospital Revenue Code	259
Min. Negotiated Rate	$17.39
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna of IA Commercial	$22.36
Rate for Payer: Aetna of IA Medical Rental Products	$22.36
Rate for Payer: Cash Price	$19.87
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.63
Rate for Payer: Medical Associates Commercial	$18.63
Rate for Payer: Midlands Choice Commercial	$17.39
Rate for Payer: United Healthcare Commercial	$22.36

ibuprofen 100 mg/5 mL Cups Oral Susp [VDMC]

Facility

$3.16

Service Code	HCPCS A9270
Hospital Charge Code	10395624
Hospital Revenue Code	259
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.37
Rate for Payer: Medical Associates Commercial	$2.37
Rate for Payer: Midlands Choice Commercial	$2.21
Rate for Payer: United Healthcare Commercial	$2.84

ibuprofen 100 mg/5 mL Cups Oral Susp [VDMC]

Facility

$3.16

Service Code	HCPCS A9270
Hospital Charge Code	10395624
Hospital Revenue Code	259
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.84
Rate for Payer: Aetna of IA Commercial	$2.84
Rate for Payer: Aetna of IA Medical Rental Products	$2.84
Rate for Payer: Aetna of IA Medicare	$1.80
Rate for Payer: Amerigroup Medicaid	$1.82
Rate for Payer: Amerigroup Medicare	$1.43
Rate for Payer: Cash Price	$2.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.42
Rate for Payer: Iowa Total Care Managed Medicaid	$1.80
Rate for Payer: Medical Associates Commercial	$2.37
Rate for Payer: Medical Associates Managed Medicare	$1.42
Rate for Payer: Midlands Choice Commercial	$2.21
Rate for Payer: Molina Healthcare Managed Medicaid	$1.83
Rate for Payer: Partners Health Alliance Commercial	$1.63
Rate for Payer: United Healthcare Commercial	$2.84
Rate for Payer: United Healthcare Managed Medicare	$1.86

ID ABSCESS PERIRECTAL CHARGE

Professional

Both

$1,362.00

Hospital Charge Code	8068983
Hospital Revenue Code	981
Min. Negotiated Rate	$953.40
Max. Negotiated Rate	$1,021.50
Rate for Payer: Cash Price	$1,089.60
Rate for Payer: Medical Associates Commercial	$1,021.50
Rate for Payer: Midlands Choice Commercial	$953.40
Rate for Payer: Partners Health Alliance Commercial	$1,021.50

ID ABSCESS SIMPLE SNGL ER CHARGE

Professional

Both

$316.00

Hospital Charge Code	8068971
Hospital Revenue Code	981
Min. Negotiated Rate	$221.20
Max. Negotiated Rate	$237.00
Rate for Payer: Cash Price	$252.80
Rate for Payer: Medical Associates Commercial	$237.00
Rate for Payer: Midlands Choice Commercial	$221.20
Rate for Payer: Partners Health Alliance Commercial	$237.00

ID ABSCESS SUBFASCIAL

Facility

$2,068.00

Service Code	CPT 20005
Hospital Charge Code	7982942
Hospital Revenue Code	450
Min. Negotiated Rate	$1,447.60
Max. Negotiated Rate	$1,861.20
Rate for Payer: Aetna of IA Commercial	$1,861.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,861.20
Rate for Payer: Cash Price	$1,654.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,551.00
Rate for Payer: Medical Associates Commercial	$1,551.00
Rate for Payer: Midlands Choice Commercial	$1,447.60
Rate for Payer: United Healthcare Commercial	$1,861.20

ID ABSCESS SUBFASCIAL

Professional

Both

$1,036.00

Service Code	CPT 20005
Hospital Charge Code	7982741
Hospital Revenue Code	981
Min. Negotiated Rate	$725.20
Max. Negotiated Rate	$777.00
Rate for Payer: Cash Price	$828.80
Rate for Payer: Medical Associates Commercial	$777.00
Rate for Payer: Midlands Choice Commercial	$725.20
Rate for Payer: Partners Health Alliance Commercial	$777.00

ID ABSCESS SUBFASCIAL

Facility

$2,068.00

Service Code	CPT 20005
Hospital Charge Code	7982942
Hospital Revenue Code	450
Min. Negotiated Rate	$930.60
Max. Negotiated Rate	$1,861.20
Rate for Payer: Aetna of IA Commercial	$1,861.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,861.20
Rate for Payer: Aetna of IA Medicare	$1,178.76
Rate for Payer: Amerigroup Medicaid	$1,192.82
Rate for Payer: Amerigroup Medicare	$939.91
Rate for Payer: Cash Price	$1,654.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,551.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$930.60
Rate for Payer: Iowa Total Care Managed Medicaid	$1,181.24
Rate for Payer: Medical Associates Commercial	$1,551.00
Rate for Payer: Medical Associates Managed Medicare	$930.60
Rate for Payer: Midlands Choice Commercial	$1,447.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1,198.61
Rate for Payer: Partners Health Alliance Commercial	$1,070.19
Rate for Payer: United Healthcare Commercial	$1,861.20
Rate for Payer: United Healthcare Managed Medicare	$1,220.12

ID COMPLEX POSTOP WOUND ER CHARGE

Professional

Both

$702.00

Hospital Charge Code	8068968
Hospital Revenue Code	981
Min. Negotiated Rate	$491.40
Max. Negotiated Rate	$526.50
Rate for Payer: Cash Price	$561.60
Rate for Payer: Medical Associates Commercial	$526.50
Rate for Payer: Midlands Choice Commercial	$491.40
Rate for Payer: Partners Health Alliance Commercial	$526.50

ID Now COVID-19 Test

Facility

$128.00

Service Code	CPT 87635
Hospital Charge Code	8787912
Hospital Revenue Code	306
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: United Healthcare Commercial	$115.20

ID Now COVID-19 Test

Facility

$128.00

Service Code	CPT 87635
Hospital Charge Code	8787912
Hospital Revenue Code	306
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Aetna of IA Medicare	$72.96
Rate for Payer: Amerigroup Medicaid	$73.83
Rate for Payer: Amerigroup Medicare	$58.18
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.60
Rate for Payer: Iowa Total Care Managed Medicaid	$73.11
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Medical Associates Managed Medicare	$57.60
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: Molina Healthcare Managed Medicaid	$74.19
Rate for Payer: Partners Health Alliance Commercial	$66.24
Rate for Payer: United Healthcare Commercial	$115.20
Rate for Payer: United Healthcare Managed Medicare	$75.52

I D OF VULVA/PERINEUM

Professional

Both

$363.00

Service Code	CPT 56405
Hospital Charge Code	7982767
Hospital Revenue Code	981
Min. Negotiated Rate	$194.00
Max. Negotiated Rate	$272.25
Rate for Payer: Cash Price	$290.40
Rate for Payer: Cash Price	$290.40
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Partners Health Alliance Commercial	$272.25
Rate for Payer: United Healthcare Commercial	$194.00

I D OF VULVA/PERINEUM

Facility

$528.00

Service Code	CPT 56405
Hospital Charge Code	4863369
Hospital Revenue Code	450
Min. Negotiated Rate	$369.60
Max. Negotiated Rate	$475.20
Rate for Payer: Aetna of IA Commercial	$475.20
Rate for Payer: Aetna of IA Medical Rental Products	$475.20
Rate for Payer: Cash Price	$422.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$396.00
Rate for Payer: Medical Associates Commercial	$396.00
Rate for Payer: Midlands Choice Commercial	$369.60
Rate for Payer: United Healthcare Commercial	$475.20

I D OF VULVA/PERINEUM

Facility

$528.00

Service Code	CPT 56405
Hospital Charge Code	4863369
Hospital Revenue Code	450
Min. Negotiated Rate	$237.60
Max. Negotiated Rate	$475.20
Rate for Payer: Aetna of IA Commercial	$475.20
Rate for Payer: Aetna of IA Medical Rental Products	$475.20
Rate for Payer: Aetna of IA Medicare	$300.96
Rate for Payer: Amerigroup Medicaid	$304.55
Rate for Payer: Amerigroup Medicare	$239.98
Rate for Payer: Cash Price	$422.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$396.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$237.60
Rate for Payer: Iowa Total Care Managed Medicaid	$301.59
Rate for Payer: Medical Associates Commercial	$396.00
Rate for Payer: Medical Associates Managed Medicare	$237.60
Rate for Payer: Midlands Choice Commercial	$369.60
Rate for Payer: Molina Healthcare Managed Medicaid	$306.03
Rate for Payer: Partners Health Alliance Commercial	$273.24
Rate for Payer: United Healthcare Commercial	$475.20
Rate for Payer: United Healthcare Managed Medicare	$311.52

Know your out-of-pocket cost for care.

All Charges