Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

NON-STRES TEST (COB)

Facility

$461.00

Service Code	CPT 59025
Hospital Charge Code	4126788
Hospital Revenue Code	720
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$414.90
Rate for Payer: Aetna of IA Commercial	$414.90
Rate for Payer: Aetna of IA Medical Rental Products	$414.90
Rate for Payer: Cash Price	$368.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$345.75
Rate for Payer: Medical Associates Commercial	$345.75
Rate for Payer: Midlands Choice Commercial	$322.70
Rate for Payer: United Healthcare Commercial	$414.90

NON-STRES TEST (COB)

Facility

$461.00

Service Code	CPT 59025
Hospital Charge Code	4096783
Hospital Revenue Code	720
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$414.90
Rate for Payer: Aetna of IA Commercial	$414.90
Rate for Payer: Aetna of IA Medical Rental Products	$414.90
Rate for Payer: Cash Price	$368.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$345.75
Rate for Payer: Medical Associates Commercial	$345.75
Rate for Payer: Midlands Choice Commercial	$322.70
Rate for Payer: United Healthcare Commercial	$414.90

NONTRAUMATIC STUPOR AND COMA WITH MCC

Facility

$23,561.07

Service Code	MSDRG 080
Min. Negotiated Rate	$23,219.59
Max. Negotiated Rate	$23,561.07
Rate for Payer: Amerigroup Medicaid	$23,447.24
Rate for Payer: Iowa Total Care Managed Medicaid	$23,219.59
Rate for Payer: Molina Healthcare Managed Medicaid	$23,561.07

NONTRAUMATIC STUPOR AND COMA WITHOUT MCC

Facility

$6,170.35

Service Code	MSDRG 081
Min. Negotiated Rate	$6,080.93
Max. Negotiated Rate	$6,170.35
Rate for Payer: Amerigroup Medicaid	$6,140.54
Rate for Payer: Iowa Total Care Managed Medicaid	$6,080.93
Rate for Payer: Molina Healthcare Managed Medicaid	$6,170.35

norEPINEPHrine 1 mg/mL 4 ml SDV IV Sol [VDMC]

Facility

$32.14

Service Code	NDC 43066-0997-10
Hospital Charge Code	10409340
Hospital Revenue Code	259
Min. Negotiated Rate	$14.46
Max. Negotiated Rate	$28.93
Rate for Payer: Aetna of IA Commercial	$28.93
Rate for Payer: Aetna of IA Medical Rental Products	$28.93
Rate for Payer: Aetna of IA Medicare	$18.32
Rate for Payer: Amerigroup Medicaid	$18.54
Rate for Payer: Amerigroup Medicare	$14.61
Rate for Payer: Cash Price	$25.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.46
Rate for Payer: Iowa Total Care Managed Medicaid	$18.36
Rate for Payer: Medical Associates Commercial	$24.11
Rate for Payer: Medical Associates Managed Medicare	$14.46
Rate for Payer: Midlands Choice Commercial	$22.50
Rate for Payer: Molina Healthcare Managed Medicaid	$18.63
Rate for Payer: Partners Health Alliance Commercial	$16.63
Rate for Payer: United Healthcare Commercial	$28.93
Rate for Payer: United Healthcare Managed Medicare	$18.96

norEPINEPHrine 1 mg/mL 4 ml SDV IV Sol [VDMC]

Facility

$32.14

Service Code	NDC 43066-0997-10
Hospital Charge Code	10409340
Hospital Revenue Code	259
Min. Negotiated Rate	$22.50
Max. Negotiated Rate	$28.93
Rate for Payer: Aetna of IA Commercial	$28.93
Rate for Payer: Aetna of IA Medical Rental Products	$28.93
Rate for Payer: Cash Price	$25.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.11
Rate for Payer: Medical Associates Commercial	$24.11
Rate for Payer: Midlands Choice Commercial	$22.50
Rate for Payer: United Healthcare Commercial	$28.93

NOREPINEPHRINE 4 MG/250 ML-D5W [VDMC]

Facility

$123.58

Service Code	HCPCS J3490
Hospital Charge Code	23229588
Hospital Revenue Code	259
Min. Negotiated Rate	$86.51
Max. Negotiated Rate	$111.22
Rate for Payer: Aetna of IA Commercial	$111.22
Rate for Payer: Aetna of IA Medical Rental Products	$111.22
Rate for Payer: Cash Price	$98.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$92.68
Rate for Payer: Medical Associates Commercial	$92.68
Rate for Payer: Midlands Choice Commercial	$86.51
Rate for Payer: United Healthcare Commercial	$111.22

NOREPINEPHRINE 4 MG/250 ML-D5W [VDMC]

Facility

$123.58

Service Code	HCPCS J3490
Hospital Charge Code	23229588
Hospital Revenue Code	259
Min. Negotiated Rate	$55.61
Max. Negotiated Rate	$111.22
Rate for Payer: Aetna of IA Commercial	$111.22
Rate for Payer: Aetna of IA Medical Rental Products	$111.22
Rate for Payer: Aetna of IA Medicare	$70.44
Rate for Payer: Amerigroup Medicaid	$71.28
Rate for Payer: Amerigroup Medicare	$56.17
Rate for Payer: Cash Price	$98.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$92.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.61
Rate for Payer: Iowa Total Care Managed Medicaid	$70.59
Rate for Payer: Medical Associates Commercial	$92.68
Rate for Payer: Medical Associates Managed Medicare	$55.61
Rate for Payer: Midlands Choice Commercial	$86.51
Rate for Payer: Molina Healthcare Managed Medicaid	$71.63
Rate for Payer: Partners Health Alliance Commercial	$63.95
Rate for Payer: United Healthcare Commercial	$111.22
Rate for Payer: United Healthcare Managed Medicare	$72.91

NORMAL NEWBORN

Facility

$3,254.07

Service Code	MSDRG 795
Min. Negotiated Rate	$3,206.91
Max. Negotiated Rate	$3,254.07
Rate for Payer: Amerigroup Medicaid	$3,238.35
Rate for Payer: Iowa Total Care Managed Medicaid	$3,206.91
Rate for Payer: Molina Healthcare Managed Medicaid	$3,254.07

nortriptyline 10 mg Cap [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	10409407
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Aetna of IA Medicare	$0.80
Rate for Payer: Amerigroup Medicaid	$0.81
Rate for Payer: Amerigroup Medicare	$0.64
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.63
Rate for Payer: Iowa Total Care Managed Medicaid	$0.80
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Medical Associates Managed Medicare	$0.63
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: Molina Healthcare Managed Medicaid	$0.81
Rate for Payer: Partners Health Alliance Commercial	$0.73
Rate for Payer: United Healthcare Commercial	$1.26
Rate for Payer: United Healthcare Managed Medicare	$0.83

nortriptyline 10 mg Cap [VDMC]

Facility

$1.40

Service Code	HCPCS A9270
Hospital Charge Code	10409407
Hospital Revenue Code	259
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.26
Rate for Payer: Aetna of IA Commercial	$1.26
Rate for Payer: Aetna of IA Medical Rental Products	$1.26
Rate for Payer: Cash Price	$1.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.05
Rate for Payer: Medical Associates Commercial	$1.05
Rate for Payer: Midlands Choice Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.26

nortriptyline 25 mg Cap [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10409478
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of IA Commercial	$1.12
Rate for Payer: Aetna of IA Medical Rental Products	$1.12
Rate for Payer: Aetna of IA Medicare	$0.71
Rate for Payer: Amerigroup Medicaid	$0.72
Rate for Payer: Amerigroup Medicare	$0.57
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.56
Rate for Payer: Iowa Total Care Managed Medicaid	$0.71
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.87
Rate for Payer: Molina Healthcare Managed Medicaid	$0.72
Rate for Payer: Partners Health Alliance Commercial	$0.65
Rate for Payer: United Healthcare Commercial	$1.12
Rate for Payer: United Healthcare Managed Medicare	$0.74

nortriptyline 25 mg Cap [VDMC]

Facility

$1.25

Service Code	HCPCS A9270
Hospital Charge Code	10409478
Hospital Revenue Code	259
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of IA Commercial	$1.12
Rate for Payer: Aetna of IA Medical Rental Products	$1.12
Rate for Payer: Cash Price	$1.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.94
Rate for Payer: Medical Associates Commercial	$0.94
Rate for Payer: Midlands Choice Commercial	$0.87
Rate for Payer: United Healthcare Commercial	$1.12

NOVAFIXPATCH 4x4cm

Facility

$3,960.00

Service Code	HCPCS Q4208
Hospital Charge Code	8822525
Hospital Revenue Code	278
Min. Negotiated Rate	$2,772.00
Max. Negotiated Rate	$3,564.00
Rate for Payer: Aetna of IA Commercial	$3,564.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,564.00
Rate for Payer: Cash Price	$3,168.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,970.00
Rate for Payer: Medical Associates Commercial	$2,970.00
Rate for Payer: Midlands Choice Commercial	$2,772.00
Rate for Payer: United Healthcare Commercial	$3,564.00

NOVAFIXPATCH 4x4cm

Facility

$3,960.00

Service Code	HCPCS Q4208
Hospital Charge Code	8822525
Hospital Revenue Code	278
Min. Negotiated Rate	$1,782.00
Max. Negotiated Rate	$3,564.00
Rate for Payer: Aetna of IA Commercial	$3,564.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,564.00
Rate for Payer: Aetna of IA Medicare	$2,257.20
Rate for Payer: Amerigroup Medicaid	$2,284.13
Rate for Payer: Amerigroup Medicare	$1,799.82
Rate for Payer: Cash Price	$3,168.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,970.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,782.00
Rate for Payer: Iowa Total Care Managed Medicaid	$2,261.95
Rate for Payer: Medical Associates Commercial	$2,970.00
Rate for Payer: Medical Associates Managed Medicare	$1,782.00
Rate for Payer: Midlands Choice Commercial	$2,772.00
Rate for Payer: Molina Healthcare Managed Medicaid	$2,295.22
Rate for Payer: Partners Health Alliance Commercial	$2,049.30
Rate for Payer: United Healthcare Commercial	$3,564.00
Rate for Payer: United Healthcare Managed Medicare	$2,336.40

N-Terminal pro Brain Natriuretic Peptide

Facility

$231.00

Service Code	CPT 83880
Hospital Charge Code	1503769
Hospital Revenue Code	301
Min. Negotiated Rate	$103.95
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of IA Commercial	$207.90
Rate for Payer: Aetna of IA Medical Rental Products	$207.90
Rate for Payer: Aetna of IA Medicare	$131.67
Rate for Payer: Amerigroup Medicaid	$133.24
Rate for Payer: Amerigroup Medicare	$104.99
Rate for Payer: Cash Price	$184.80
Rate for Payer: Cash Price	$184.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$173.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.95
Rate for Payer: Iowa Total Care Managed Medicaid	$131.95
Rate for Payer: Medical Associates Commercial	$173.25
Rate for Payer: Medical Associates Managed Medicare	$103.95
Rate for Payer: Midlands Choice Commercial	$161.70
Rate for Payer: Molina Healthcare Managed Medicaid	$133.89
Rate for Payer: Partners Health Alliance Commercial	$119.54
Rate for Payer: United Healthcare Commercial	$207.90
Rate for Payer: United Healthcare Managed Medicare	$136.29
Rate for Payer: Wellmark IA HMO WHPI	$121.95
Rate for Payer: Wellmark IA PPO	$134.33

N-Terminal pro Brain Natriuretic Peptide

Facility

$231.00

Service Code	CPT 83880
Hospital Charge Code	1503769
Hospital Revenue Code	301
Min. Negotiated Rate	$161.70
Max. Negotiated Rate	$207.90
Rate for Payer: Aetna of IA Commercial	$207.90
Rate for Payer: Aetna of IA Medical Rental Products	$207.90
Rate for Payer: Cash Price	$184.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$173.25
Rate for Payer: Medical Associates Commercial	$173.25
Rate for Payer: Midlands Choice Commercial	$161.70
Rate for Payer: United Healthcare Commercial	$207.90

NURSEMAIDS ELBOW CHILD

Professional

Both

$388.00

Service Code	CPT 24640
Hospital Charge Code	7982808
Hospital Revenue Code	981
Min. Negotiated Rate	$148.61
Max. Negotiated Rate	$291.00
Rate for Payer: Amerigroup Medicaid	$150.07
Rate for Payer: Cash Price	$310.40
Rate for Payer: Cash Price	$310.40
Rate for Payer: Iowa Total Care Managed Medicaid	$148.61
Rate for Payer: Medical Associates Commercial	$291.00
Rate for Payer: Midlands Choice Commercial	$271.60
Rate for Payer: Molina Healthcare Managed Medicaid	$149.34
Rate for Payer: Partners Health Alliance Commercial	$291.00
Rate for Payer: United Healthcare Commercial	$155.57
Rate for Payer: Wellmark IA HMO WHPI	$198.80
Rate for Payer: Wellmark IA PPO	$233.80

nystatin 100000 units/mL Sus UD 5 mL [VDMC]

Facility

$7.61

Service Code	HCPCS A9270
Hospital Charge Code	10431892
Hospital Revenue Code	259
Min. Negotiated Rate	$3.43
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna of IA Commercial	$6.85
Rate for Payer: Aetna of IA Medical Rental Products	$6.85
Rate for Payer: Aetna of IA Medicare	$4.34
Rate for Payer: Amerigroup Medicaid	$4.39
Rate for Payer: Amerigroup Medicare	$3.46
Rate for Payer: Cash Price	$6.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.71
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.43
Rate for Payer: Iowa Total Care Managed Medicaid	$4.35
Rate for Payer: Medical Associates Commercial	$5.71
Rate for Payer: Medical Associates Managed Medicare	$3.43
Rate for Payer: Midlands Choice Commercial	$5.33
Rate for Payer: Molina Healthcare Managed Medicaid	$4.41
Rate for Payer: Partners Health Alliance Commercial	$3.94
Rate for Payer: United Healthcare Commercial	$6.85
Rate for Payer: United Healthcare Managed Medicare	$4.49

nystatin 100000 units/mL Sus UD 5 mL [VDMC]

Facility

$7.61

Service Code	HCPCS A9270
Hospital Charge Code	10431892
Hospital Revenue Code	259
Min. Negotiated Rate	$5.33
Max. Negotiated Rate	$6.85
Rate for Payer: Aetna of IA Commercial	$6.85
Rate for Payer: Aetna of IA Medical Rental Products	$6.85
Rate for Payer: Cash Price	$6.09
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.71
Rate for Payer: Medical Associates Commercial	$5.71
Rate for Payer: Midlands Choice Commercial	$5.33
Rate for Payer: United Healthcare Commercial	$6.85

nystatin Top 100,000 units/g Crm 15 gm [VDMC]

Facility

$30.00

Service Code	HCPCS A9270
Hospital Charge Code	10409549
Hospital Revenue Code	259
Min. Negotiated Rate	$13.50
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of IA Commercial	$27.00
Rate for Payer: Aetna of IA Medical Rental Products	$27.00
Rate for Payer: Aetna of IA Medicare	$17.10
Rate for Payer: Amerigroup Medicaid	$17.30
Rate for Payer: Amerigroup Medicare	$13.64
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.50
Rate for Payer: Iowa Total Care Managed Medicaid	$17.14
Rate for Payer: Medical Associates Commercial	$22.50
Rate for Payer: Medical Associates Managed Medicare	$13.50
Rate for Payer: Midlands Choice Commercial	$21.00
Rate for Payer: Molina Healthcare Managed Medicaid	$17.39
Rate for Payer: Partners Health Alliance Commercial	$15.53
Rate for Payer: United Healthcare Commercial	$27.00
Rate for Payer: United Healthcare Managed Medicare	$17.70

nystatin Top 100,000 units/g Crm 15 gm [VDMC]

Facility

$30.00

Service Code	HCPCS A9270
Hospital Charge Code	10409549
Hospital Revenue Code	259
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna of IA Commercial	$27.00
Rate for Payer: Aetna of IA Medical Rental Products	$27.00
Rate for Payer: Cash Price	$24.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$22.50
Rate for Payer: Medical Associates Commercial	$22.50
Rate for Payer: Midlands Choice Commercial	$21.00
Rate for Payer: United Healthcare Commercial	$27.00

nystatin Top 100,000 units/g Oint 15 gm [VDMC]

Facility

$19.60

Service Code	HCPCS A9270
Hospital Charge Code	10409679
Hospital Revenue Code	259
Min. Negotiated Rate	$13.72
Max. Negotiated Rate	$17.64
Rate for Payer: Aetna of IA Commercial	$17.64
Rate for Payer: Aetna of IA Medical Rental Products	$17.64
Rate for Payer: Cash Price	$15.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$14.70
Rate for Payer: Medical Associates Commercial	$14.70
Rate for Payer: Midlands Choice Commercial	$13.72
Rate for Payer: United Healthcare Commercial	$17.64

nystatin Top 100,000 units/g Oint 15 gm [VDMC]

Facility

$19.60

Service Code	HCPCS A9270
Hospital Charge Code	10409679
Hospital Revenue Code	259
Min. Negotiated Rate	$8.82
Max. Negotiated Rate	$17.64
Rate for Payer: Aetna of IA Commercial	$17.64
Rate for Payer: Aetna of IA Medical Rental Products	$17.64
Rate for Payer: Aetna of IA Medicare	$11.17
Rate for Payer: Amerigroup Medicaid	$11.31
Rate for Payer: Amerigroup Medicare	$8.91
Rate for Payer: Cash Price	$15.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$14.70
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.82
Rate for Payer: Iowa Total Care Managed Medicaid	$11.20
Rate for Payer: Medical Associates Commercial	$14.70
Rate for Payer: Medical Associates Managed Medicare	$8.82
Rate for Payer: Midlands Choice Commercial	$13.72
Rate for Payer: Molina Healthcare Managed Medicaid	$11.36
Rate for Payer: Partners Health Alliance Commercial	$10.14
Rate for Payer: United Healthcare Commercial	$17.64
Rate for Payer: United Healthcare Managed Medicare	$11.56

nystatin Top 100,000 units/g Pwdr 15 gm [VDMC]

Facility

$36.64

Service Code	HCPCS A9270
Hospital Charge Code	10409744
Hospital Revenue Code	259
Min. Negotiated Rate	$16.49
Max. Negotiated Rate	$32.98
Rate for Payer: Aetna of IA Commercial	$32.98
Rate for Payer: Aetna of IA Medical Rental Products	$32.98
Rate for Payer: Aetna of IA Medicare	$20.88
Rate for Payer: Amerigroup Medicaid	$21.13
Rate for Payer: Amerigroup Medicare	$16.65
Rate for Payer: Cash Price	$29.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$27.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$16.49
Rate for Payer: Iowa Total Care Managed Medicaid	$20.93
Rate for Payer: Medical Associates Commercial	$27.48
Rate for Payer: Medical Associates Managed Medicare	$16.49
Rate for Payer: Midlands Choice Commercial	$25.65
Rate for Payer: Molina Healthcare Managed Medicaid	$21.24
Rate for Payer: Partners Health Alliance Commercial	$18.96
Rate for Payer: United Healthcare Commercial	$32.98
Rate for Payer: United Healthcare Managed Medicare	$21.62

Know your out-of-pocket cost for care.

All Charges