Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SHORT LESSER METZ-PLATE

Facility

$1,602.00

Service Code	HCPCS C1713
Hospital Charge Code	8807701
Hospital Revenue Code	278
Min. Negotiated Rate	$1,121.40
Max. Negotiated Rate	$1,441.80
Rate for Payer: Aetna of IA Commercial	$1,441.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,441.80
Rate for Payer: Cash Price	$1,281.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,201.50
Rate for Payer: Medical Associates Commercial	$1,201.50
Rate for Payer: Midlands Choice Commercial	$1,121.40
Rate for Payer: United Healthcare Commercial	$1,441.80

SHORT LESSER METZ-PLATE

Facility

$1,602.00

Service Code	HCPCS C1713
Hospital Charge Code	8807701
Hospital Revenue Code	278
Min. Negotiated Rate	$720.90
Max. Negotiated Rate	$1,441.80
Rate for Payer: Aetna of IA Commercial	$1,441.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,441.80
Rate for Payer: Aetna of IA Medicare	$913.14
Rate for Payer: Amerigroup Medicaid	$924.03
Rate for Payer: Amerigroup Medicare	$728.11
Rate for Payer: Cash Price	$1,281.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,201.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$720.90
Rate for Payer: Iowa Total Care Managed Medicaid	$915.06
Rate for Payer: Medical Associates Commercial	$1,201.50
Rate for Payer: Medical Associates Managed Medicare	$720.90
Rate for Payer: Midlands Choice Commercial	$1,121.40
Rate for Payer: Molina Healthcare Managed Medicaid	$928.52
Rate for Payer: Partners Health Alliance Commercial	$829.03
Rate for Payer: United Healthcare Commercial	$1,441.80
Rate for Payer: United Healthcare Managed Medicare	$945.18

SIGMOIDOSCOPY W TATTOOING

Professional

Both

$1,025.00

Service Code	CPT 45335
Hospital Charge Code	8825541
Hospital Revenue Code	975
Min. Negotiated Rate	$398.94
Max. Negotiated Rate	$768.75
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Partners Health Alliance Commercial	$768.75
Rate for Payer: United Healthcare Commercial	$398.94

SI JOINT INJECT W FLUOROSCOPY

Professional

Both

$413.00

Service Code	CPT 27096
Hospital Charge Code	8059059
Hospital Revenue Code	964
Min. Negotiated Rate	$245.76
Max. Negotiated Rate	$309.75
Rate for Payer: Cash Price	$330.40
Rate for Payer: Cash Price	$330.40
Rate for Payer: Medical Associates Commercial	$309.75
Rate for Payer: Midlands Choice Commercial	$289.10
Rate for Payer: Partners Health Alliance Commercial	$309.75
Rate for Payer: United Healthcare Commercial	$245.76

SI JOINT INJ W FLUOROSCOPY

Professional

Both

$532.00

Service Code	CPT 27096
Hospital Charge Code	8015252
Hospital Revenue Code	975
Min. Negotiated Rate	$245.76
Max. Negotiated Rate	$399.00
Rate for Payer: Cash Price	$425.60
Rate for Payer: Cash Price	$425.60
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Partners Health Alliance Commercial	$399.00
Rate for Payer: United Healthcare Commercial	$245.76

silver nitrate Top Stick [VDMC]

Facility

$10.33

Service Code	NDC 12870-0001-02
Hospital Charge Code	10420587
Hospital Revenue Code	259
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$9.29
Rate for Payer: Aetna of IA Commercial	$9.29
Rate for Payer: Aetna of IA Medical Rental Products	$9.29
Rate for Payer: Aetna of IA Medicare	$5.89
Rate for Payer: Amerigroup Medicaid	$5.96
Rate for Payer: Amerigroup Medicare	$4.69
Rate for Payer: Cash Price	$8.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.65
Rate for Payer: Iowa Total Care Managed Medicaid	$5.90
Rate for Payer: Medical Associates Commercial	$7.75
Rate for Payer: Medical Associates Managed Medicare	$4.65
Rate for Payer: Midlands Choice Commercial	$7.23
Rate for Payer: Molina Healthcare Managed Medicaid	$5.99
Rate for Payer: Partners Health Alliance Commercial	$5.34
Rate for Payer: United Healthcare Commercial	$9.29
Rate for Payer: United Healthcare Managed Medicare	$6.09

silver nitrate Top Stick [VDMC]

Facility

$10.33

Service Code	NDC 12870-0001-02
Hospital Charge Code	10420587
Hospital Revenue Code	259
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$9.29
Rate for Payer: Aetna of IA Commercial	$9.29
Rate for Payer: Aetna of IA Medical Rental Products	$9.29
Rate for Payer: Cash Price	$8.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.75
Rate for Payer: Medical Associates Commercial	$7.75
Rate for Payer: Midlands Choice Commercial	$7.23
Rate for Payer: United Healthcare Commercial	$9.29

silver sulfADIAZINE Top 1% Crm 400 gm [VDMC]

Facility

$209.76

Service Code	HCPCS A9270
Hospital Charge Code	10437891
Hospital Revenue Code	259
Min. Negotiated Rate	$94.39
Max. Negotiated Rate	$188.78
Rate for Payer: Aetna of IA Commercial	$188.78
Rate for Payer: Aetna of IA Medical Rental Products	$188.78
Rate for Payer: Aetna of IA Medicare	$119.56
Rate for Payer: Amerigroup Medicaid	$120.99
Rate for Payer: Amerigroup Medicare	$95.34
Rate for Payer: Cash Price	$167.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$94.39
Rate for Payer: Iowa Total Care Managed Medicaid	$119.81
Rate for Payer: Medical Associates Commercial	$157.32
Rate for Payer: Medical Associates Managed Medicare	$94.39
Rate for Payer: Midlands Choice Commercial	$146.83
Rate for Payer: Molina Healthcare Managed Medicaid	$121.58
Rate for Payer: Partners Health Alliance Commercial	$108.55
Rate for Payer: United Healthcare Commercial	$188.78
Rate for Payer: United Healthcare Managed Medicare	$123.76

silver sulfADIAZINE Top 1% Crm 400 gm [VDMC]

Facility

$209.76

Service Code	HCPCS A9270
Hospital Charge Code	10437891
Hospital Revenue Code	259
Min. Negotiated Rate	$146.83
Max. Negotiated Rate	$188.78
Rate for Payer: Aetna of IA Commercial	$188.78
Rate for Payer: Aetna of IA Medical Rental Products	$188.78
Rate for Payer: Cash Price	$167.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.32
Rate for Payer: Medical Associates Commercial	$157.32
Rate for Payer: Midlands Choice Commercial	$146.83
Rate for Payer: United Healthcare Commercial	$188.78

silver sulfADIAZINE Top 1% Crm 50 gm [VDMC]

Facility

$53.08

Service Code	HCPCS A9270
Hospital Charge Code	10437826
Hospital Revenue Code	259
Min. Negotiated Rate	$37.16
Max. Negotiated Rate	$47.77
Rate for Payer: Aetna of IA Commercial	$47.77
Rate for Payer: Aetna of IA Medical Rental Products	$47.77
Rate for Payer: Cash Price	$42.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.81
Rate for Payer: Medical Associates Commercial	$39.81
Rate for Payer: Midlands Choice Commercial	$37.16
Rate for Payer: United Healthcare Commercial	$47.77

silver sulfADIAZINE Top 1% Crm 50 gm [VDMC]

Facility

$53.08

Service Code	HCPCS A9270
Hospital Charge Code	10437826
Hospital Revenue Code	259
Min. Negotiated Rate	$23.89
Max. Negotiated Rate	$47.77
Rate for Payer: Aetna of IA Commercial	$47.77
Rate for Payer: Aetna of IA Medical Rental Products	$47.77
Rate for Payer: Aetna of IA Medicare	$30.26
Rate for Payer: Amerigroup Medicaid	$30.62
Rate for Payer: Amerigroup Medicare	$24.12
Rate for Payer: Cash Price	$42.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.81
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.89
Rate for Payer: Iowa Total Care Managed Medicaid	$30.32
Rate for Payer: Medical Associates Commercial	$39.81
Rate for Payer: Medical Associates Managed Medicare	$23.89
Rate for Payer: Midlands Choice Commercial	$37.16
Rate for Payer: Molina Healthcare Managed Medicaid	$30.77
Rate for Payer: Partners Health Alliance Commercial	$27.47
Rate for Payer: United Healthcare Commercial	$47.77
Rate for Payer: United Healthcare Managed Medicare	$31.32

silver sulfADIAZINE topical 1% Crm 25 gm [VDMC]

Facility

$26.84

Service Code	HCPCS A9270
Hospital Charge Code	27608899
Hospital Revenue Code	259
Min. Negotiated Rate	$12.08
Max. Negotiated Rate	$24.16
Rate for Payer: Aetna of IA Commercial	$24.16
Rate for Payer: Aetna of IA Medical Rental Products	$24.16
Rate for Payer: Aetna of IA Medicare	$15.30
Rate for Payer: Amerigroup Medicaid	$15.48
Rate for Payer: Amerigroup Medicare	$12.20
Rate for Payer: Cash Price	$21.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.13
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.08
Rate for Payer: Iowa Total Care Managed Medicaid	$15.33
Rate for Payer: Medical Associates Commercial	$20.13
Rate for Payer: Medical Associates Managed Medicare	$12.08
Rate for Payer: Midlands Choice Commercial	$18.79
Rate for Payer: Molina Healthcare Managed Medicaid	$15.56
Rate for Payer: Partners Health Alliance Commercial	$13.89
Rate for Payer: United Healthcare Commercial	$24.16
Rate for Payer: United Healthcare Managed Medicare	$15.84

silver sulfADIAZINE topical 1% Crm 25 gm [VDMC]

Facility

$26.84

Service Code	HCPCS A9270
Hospital Charge Code	27608899
Hospital Revenue Code	259
Min. Negotiated Rate	$18.79
Max. Negotiated Rate	$24.16
Rate for Payer: Aetna of IA Commercial	$24.16
Rate for Payer: Aetna of IA Medical Rental Products	$24.16
Rate for Payer: Cash Price	$21.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.13
Rate for Payer: Medical Associates Commercial	$20.13
Rate for Payer: Midlands Choice Commercial	$18.79
Rate for Payer: United Healthcare Commercial	$24.16

simethicone 125 mg Chew Tab [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	23583620
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.91
Rate for Payer: Medical Associates Commercial	$0.91
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.10

simethicone 125 mg Chew Tab [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	23583620
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Aetna of IA Medicare	$0.69
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.55
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.55
Rate for Payer: Iowa Total Care Managed Medicaid	$0.69
Rate for Payer: Medical Associates Commercial	$0.91
Rate for Payer: Medical Associates Managed Medicare	$0.55
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Partners Health Alliance Commercial	$0.63
Rate for Payer: United Healthcare Commercial	$1.10
Rate for Payer: United Healthcare Managed Medicare	$0.72

simethicone 40 mg/0.6 mL Liq 30ml [VDMC]

Facility

$16.12

Service Code	HCPCS A9270
Hospital Charge Code	10420717
Hospital Revenue Code	259
Min. Negotiated Rate	$11.28
Max. Negotiated Rate	$14.51
Rate for Payer: Aetna of IA Commercial	$14.51
Rate for Payer: Aetna of IA Medical Rental Products	$14.51
Rate for Payer: Cash Price	$12.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.09
Rate for Payer: Medical Associates Commercial	$12.09
Rate for Payer: Midlands Choice Commercial	$11.28
Rate for Payer: United Healthcare Commercial	$14.51

simethicone 40 mg/0.6 mL Liq 30ml [VDMC]

Facility

$16.12

Service Code	HCPCS A9270
Hospital Charge Code	10420717
Hospital Revenue Code	259
Min. Negotiated Rate	$7.25
Max. Negotiated Rate	$14.51
Rate for Payer: Aetna of IA Commercial	$14.51
Rate for Payer: Aetna of IA Medical Rental Products	$14.51
Rate for Payer: Aetna of IA Medicare	$9.19
Rate for Payer: Amerigroup Medicaid	$9.30
Rate for Payer: Amerigroup Medicare	$7.33
Rate for Payer: Cash Price	$12.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.09
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.25
Rate for Payer: Iowa Total Care Managed Medicaid	$9.21
Rate for Payer: Medical Associates Commercial	$12.09
Rate for Payer: Medical Associates Managed Medicare	$7.25
Rate for Payer: Midlands Choice Commercial	$11.28
Rate for Payer: Molina Healthcare Managed Medicaid	$9.34
Rate for Payer: Partners Health Alliance Commercial	$8.34
Rate for Payer: United Healthcare Commercial	$14.51
Rate for Payer: United Healthcare Managed Medicare	$9.51

SIMPLE BLADDER IRRIGATE LAVAGE/INSTIL

Professional

Both

$123.00

Service Code	CPT 51700
Hospital Charge Code	8799196
Hospital Revenue Code	975
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$112.78
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cash Price	$98.40
Rate for Payer: Medical Associates Commercial	$92.25
Rate for Payer: Midlands Choice Commercial	$86.10
Rate for Payer: Partners Health Alliance Commercial	$92.25
Rate for Payer: United Healthcare Commercial	$112.78

SIMPLE CPAP SUBSQ

Facility

$521.00

Service Code	CPT 94660
Hospital Charge Code	5800782
Hospital Revenue Code	410
Min. Negotiated Rate	$364.70
Max. Negotiated Rate	$468.90
Rate for Payer: Aetna of IA Commercial	$468.90
Rate for Payer: Aetna of IA Medical Rental Products	$468.90
Rate for Payer: Cash Price	$416.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$390.75
Rate for Payer: Medical Associates Commercial	$390.75
Rate for Payer: Midlands Choice Commercial	$364.70
Rate for Payer: United Healthcare Commercial	$468.90

SIMPLE CPAP SUBSQ

Facility

$521.00

Service Code	CPT 94660
Hospital Charge Code	5800782
Hospital Revenue Code	410
Min. Negotiated Rate	$234.45
Max. Negotiated Rate	$468.90
Rate for Payer: Aetna of IA Commercial	$468.90
Rate for Payer: Aetna of IA Medical Rental Products	$468.90
Rate for Payer: Aetna of IA Medicare	$296.97
Rate for Payer: Amerigroup Medicaid	$300.51
Rate for Payer: Amerigroup Medicare	$236.79
Rate for Payer: Cash Price	$416.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$390.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$234.45
Rate for Payer: Iowa Total Care Managed Medicaid	$297.60
Rate for Payer: Medical Associates Commercial	$390.75
Rate for Payer: Medical Associates Managed Medicare	$234.45
Rate for Payer: Midlands Choice Commercial	$364.70
Rate for Payer: Molina Healthcare Managed Medicaid	$301.97
Rate for Payer: Partners Health Alliance Commercial	$269.62
Rate for Payer: United Healthcare Commercial	$468.90
Rate for Payer: United Healthcare Managed Medicare	$307.39

SIMPLE SPIROMETRY

Facility

$260.00

Service Code	CPT 94010
Hospital Charge Code	7826320
Hospital Revenue Code	460
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Aetna of IA Medicare	$148.20
Rate for Payer: Amerigroup Medicaid	$149.97
Rate for Payer: Amerigroup Medicare	$118.17
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$117.00
Rate for Payer: Iowa Total Care Managed Medicaid	$148.51
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$117.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$150.70
Rate for Payer: Partners Health Alliance Commercial	$134.55
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40

SIMPLE SPIROMETRY

Facility

$260.00

Service Code	CPT 94010
Hospital Charge Code	7826320
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

simvastatin 20 mg Tab [VDMC]

Facility

$1.60

Service Code	HCPCS A9270
Hospital Charge Code	10420922
Hospital Revenue Code	259
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of IA Commercial	$1.44
Rate for Payer: Aetna of IA Medical Rental Products	$1.44
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.20
Rate for Payer: Medical Associates Commercial	$1.20
Rate for Payer: Midlands Choice Commercial	$1.12
Rate for Payer: United Healthcare Commercial	$1.44

simvastatin 20 mg Tab [VDMC]

Facility

$1.60

Service Code	HCPCS A9270
Hospital Charge Code	10420922
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of IA Commercial	$1.44
Rate for Payer: Aetna of IA Medical Rental Products	$1.44
Rate for Payer: Aetna of IA Medicare	$0.91
Rate for Payer: Amerigroup Medicaid	$0.92
Rate for Payer: Amerigroup Medicare	$0.73
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.20
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	$1.20
Rate for Payer: Medical Associates Managed Medicare	$0.72
Rate for Payer: Midlands Choice Commercial	$1.12
Rate for Payer: Molina Healthcare Managed Medicaid	$0.93
Rate for Payer: Partners Health Alliance Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.44
Rate for Payer: United Healthcare Managed Medicare	$0.94

SINGLE PULSE OXIMETRY

Facility

$10.00

Service Code	CPT 94760
Hospital Charge Code	5338940
Hospital Revenue Code	410
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of IA Commercial	$9.00
Rate for Payer: Aetna of IA Medical Rental Products	$9.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.50
Rate for Payer: Medical Associates Commercial	$7.50
Rate for Payer: Midlands Choice Commercial	$7.00
Rate for Payer: United Healthcare Commercial	$9.00

Know your out-of-pocket cost for care.

All Charges