Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$8.06
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	$8.14
Rate for Payer: Amerigroup Medicare	$8.14
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	$8.06
Rate for Payer: Iowa Total Care Managed Medicaid	$8.06
Rate for Payer: Medical Associates Commercial	$12.09
Rate for Payer: Medical Associates Managed Medicare	$8.06
Rate for Payer: Midlands Choice Commercial	$11.28
Rate for Payer: Molina Healthcare Managed Medicaid	$8.18
Rate for Payer: Molina Healthcare Managed Medicare	$8.18
Rate for Payer: Oscar Health of IA Commercial	$12.09
Rate for Payer: Partners Health Alliance Commercial	$12.09
Rate for Payer: United Healthcare Commercial	$14.51
Rate for Payer: United Healthcare Managed Medicare	$9.51

simethicone 80 mg Chew Tab [VDMC]

Facility

$1.06

Service Code	HCPCS A9270
Hospital Charge Code	10420782
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of IA Commercial	$0.95
Rate for Payer: Aetna of IA Medical Rental Products	$0.95
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Midlands Choice Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$0.95

simethicone 80 mg Chew Tab [VDMC]

Facility

$1.06

Service Code	HCPCS A9270
Hospital Charge Code	10420782
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.95
Rate for Payer: Aetna of IA Commercial	$0.95
Rate for Payer: Aetna of IA Medical Rental Products	$0.95
Rate for Payer: Aetna of IA Medicare	$0.60
Rate for Payer: Amerigroup Medicaid	$0.53
Rate for Payer: Amerigroup Medicare	$0.54
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.53
Rate for Payer: Iowa Total Care Managed Medicaid	$0.53
Rate for Payer: Medical Associates Commercial	$0.80
Rate for Payer: Medical Associates Managed Medicare	$0.53
Rate for Payer: Midlands Choice Commercial	$0.74
Rate for Payer: Molina Healthcare Managed Medicaid	$0.54
Rate for Payer: Molina Healthcare Managed Medicare	$0.54
Rate for Payer: Oscar Health of IA Commercial	$0.80
Rate for Payer: Partners Health Alliance Commercial	$0.80
Rate for Payer: United Healthcare Commercial	$0.95
Rate for Payer: United Healthcare Managed Medicare	$0.63

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	$260.40
Max. Negotiated Rate	$856.59
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	$262.95
Rate for Payer: Amerigroup Medicare	$263.10
Rate for Payer: Cash Price	$416.80
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	$260.50
Rate for Payer: Iowa Total Care Managed Medicaid	$260.40
Rate for Payer: Medical Associates Commercial	$390.75
Rate for Payer: Medical Associates Managed Medicare	$260.50
Rate for Payer: Midlands Choice Commercial	$364.70
Rate for Payer: Molina Healthcare Managed Medicaid	$264.41
Rate for Payer: Molina Healthcare Managed Medicare	$264.25
Rate for Payer: Oscar Health of IA Commercial	$390.75
Rate for Payer: Partners Health Alliance Commercial	$390.75
Rate for Payer: United Healthcare Commercial	$468.90
Rate for Payer: United Healthcare Managed Medicare	$307.39
Rate for Payer: Wellmark IA HMO	$778.72
Rate for Payer: Wellmark IA PPO	$856.59

Simple Pneumonia and Pleurisy With CC

Facility

$6,955.63

Service Code	MS-DRG 194
Hospital Charge Code	65
Min. Negotiated Rate	$6,854.83
Max. Negotiated Rate	$6,955.63
Rate for Payer: Amerigroup Medicaid	$6,922.03
Rate for Payer: Iowa Total Care Managed Medicaid	$6,854.83
Rate for Payer: Molina Healthcare Managed Medicaid	$6,955.63

Simple Pneumonia and Pleurisy With MCC

Facility

$10,653.43

Service Code	MS-DRG 193
Hospital Charge Code	64
Min. Negotiated Rate	$10,499.03
Max. Negotiated Rate	$10,653.43
Rate for Payer: Amerigroup Medicaid	$10,601.97
Rate for Payer: Iowa Total Care Managed Medicaid	$10,499.03
Rate for Payer: Molina Healthcare Managed Medicaid	$10,653.43

Simple Pneumonia and Pleurisy Without CC/MCC

Facility

$4,821.80

Service Code	MS-DRG 195
Hospital Charge Code	66
Min. Negotiated Rate	$4,751.91
Max. Negotiated Rate	$4,821.80
Rate for Payer: Amerigroup Medicaid	$4,798.50
Rate for Payer: Iowa Total Care Managed Medicaid	$4,751.91
Rate for Payer: Molina Healthcare Managed Medicaid	$4,821.80

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less

Facility

$598.11

Service Code	CPT 12011
Hospital Revenue Code	490
Min. Negotiated Rate	$543.74
Max. Negotiated Rate	$598.11
Rate for Payer: Wellmark IA HMO	$543.74
Rate for Payer: Wellmark IA PPO	$598.11

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm

Facility

$598.11

Service Code	CPT 12013
Hospital Revenue Code	490
Min. Negotiated Rate	$543.74
Max. Negotiated Rate	$598.11
Rate for Payer: Wellmark IA HMO	$543.74
Rate for Payer: Wellmark IA PPO	$598.11

Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 7.6 cm to 12.5 cm

Facility

$598.11

Service Code	CPT 12015
Hospital Revenue Code	490
Min. Negotiated Rate	$543.74
Max. Negotiated Rate	$598.11
Rate for Payer: Wellmark IA HMO	$543.74
Rate for Payer: Wellmark IA PPO	$598.11

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less

Facility

$598.11

Service Code	CPT 12001
Hospital Revenue Code	490
Min. Negotiated Rate	$543.74
Max. Negotiated Rate	$598.11
Rate for Payer: Wellmark IA HMO	$543.74
Rate for Payer: Wellmark IA PPO	$598.11

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.6 cm to 7.5 cm

Facility

$598.11

Service Code	CPT 12002
Hospital Revenue Code	490
Min. Negotiated Rate	$543.74
Max. Negotiated Rate	$598.11
Rate for Payer: Wellmark IA HMO	$543.74
Rate for Payer: Wellmark IA PPO	$598.11

Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 7.6 cm to 12.5 cm

Facility

$598.11

Service Code	CPT 12004
Hospital Revenue Code	490
Min. Negotiated Rate	$543.74
Max. Negotiated Rate	$598.11
Rate for Payer: Wellmark IA HMO	$543.74
Rate for Payer: Wellmark IA PPO	$598.11

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

SIMPLE SPIROMETRY

Facility

$260.00

Service Code	CPT 94010
Hospital Charge Code	7826320
Hospital Revenue Code	460
Min. Negotiated Rate	$129.95
Max. Negotiated Rate	$282.35
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	$131.22
Rate for Payer: Amerigroup Medicare	$131.30
Rate for Payer: Cash Price	$208.00
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	$130.00
Rate for Payer: Iowa Total Care Managed Medicaid	$129.95
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$130.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$131.95
Rate for Payer: Molina Healthcare Managed Medicare	$131.87
Rate for Payer: Oscar Health of IA Commercial	$195.00
Rate for Payer: Partners Health Alliance Commercial	$195.00
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40
Rate for Payer: Wellmark IA HMO	$256.68
Rate for Payer: Wellmark IA PPO	$282.35

Simultaneous Pancreas and Kidney Transplant

Facility

$135,189.52

Service Code	MS-DRG 008
Hospital Charge Code	699
Min. Negotiated Rate	$133,230.25
Max. Negotiated Rate	$135,189.52
Rate for Payer: Amerigroup Medicaid	$134,536.43
Rate for Payer: Iowa Total Care Managed Medicaid	$133,230.25
Rate for Payer: Molina Healthcare Managed Medicaid	$135,189.52

Simultaneous Pancreas and Kidney Transplant With Hemodialysis

Facility

$65,585.92

Service Code	MS-DRG 019
Hospital Charge Code	708
Min. Negotiated Rate	$64,635.40
Max. Negotiated Rate	$65,585.92
Rate for Payer: Amerigroup Medicaid	$65,269.08
Rate for Payer: Iowa Total Care Managed Medicaid	$64,635.40
Rate for Payer: Molina Healthcare Managed Medicaid	$65,585.92

simvastatin 20 mg Tab [VDMC]

Facility

$1.47

Service Code	HCPCS A9270
Hospital Charge Code	10420922
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.32
Rate for Payer: Aetna of IA Commercial	$1.32
Rate for Payer: Aetna of IA Medical Rental Products	$1.32
Rate for Payer: Aetna of IA Medicare	$0.84
Rate for Payer: Amerigroup Medicaid	$0.74
Rate for Payer: Amerigroup Medicare	$0.74
Rate for Payer: Cash Price	$1.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.74
Rate for Payer: Iowa Total Care Managed Medicaid	$0.73
Rate for Payer: Medical Associates Commercial	$1.10
Rate for Payer: Medical Associates Managed Medicare	$0.74
Rate for Payer: Midlands Choice Commercial	$1.03
Rate for Payer: Molina Healthcare Managed Medicaid	$0.75
Rate for Payer: Molina Healthcare Managed Medicare	$0.75
Rate for Payer: Oscar Health of IA Commercial	$1.10
Rate for Payer: Partners Health Alliance Commercial	$1.10
Rate for Payer: United Healthcare Commercial	$1.32
Rate for Payer: United Healthcare Managed Medicare	$0.87

simvastatin 20 mg Tab [VDMC]

Facility

$1.47

Service Code	HCPCS A9270
Hospital Charge Code	10420922
Hospital Revenue Code	259
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.32
Rate for Payer: Aetna of IA Commercial	$1.32
Rate for Payer: Aetna of IA Medical Rental Products	$1.32
Rate for Payer: Cash Price	$1.18
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.10
Rate for Payer: Medical Associates Commercial	$1.10
Rate for Payer: Midlands Choice Commercial	$1.03
Rate for Payer: United Healthcare Commercial	$1.32

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

SINGLE PULSE OXIMETRY

Facility

$10.00

Service Code	CPT 94760
Hospital Charge Code	5338940
Hospital Revenue Code	410
Min. Negotiated Rate	$5.00
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: Aetna of IA Medicare	$5.70
Rate for Payer: Amerigroup Medicaid	$5.05
Rate for Payer: Amerigroup Medicare	$5.05
Rate for Payer: Cash Price	$8.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.00
Rate for Payer: Iowa Total Care Managed Medicaid	$5.00
Rate for Payer: Medical Associates Commercial	$7.50
Rate for Payer: Medical Associates Managed Medicare	$5.00
Rate for Payer: Midlands Choice Commercial	$7.00
Rate for Payer: Molina Healthcare Managed Medicaid	$5.08
Rate for Payer: Molina Healthcare Managed Medicare	$5.07
Rate for Payer: Oscar Health of IA Commercial	$7.50
Rate for Payer: Partners Health Alliance Commercial	$7.50
Rate for Payer: United Healthcare Commercial	$9.00
Rate for Payer: United Healthcare Managed Medicare	$5.90

Sinus and Mastoid Procedures With CC/MCC

Facility

$21,074.58

Service Code	MS-DRG 135
Hospital Charge Code	15
Min. Negotiated Rate	$20,769.15
Max. Negotiated Rate	$21,074.58
Rate for Payer: Amerigroup Medicaid	$20,972.77
Rate for Payer: Iowa Total Care Managed Medicaid	$20,769.15
Rate for Payer: Molina Healthcare Managed Medicaid	$21,074.58

Sinus and Mastoid Procedures Without CC/MCC

Facility

$12,360.10

Service Code	MS-DRG 136
Hospital Charge Code	16
Min. Negotiated Rate	$12,180.97
Max. Negotiated Rate	$12,360.10
Rate for Payer: Amerigroup Medicaid	$12,300.39
Rate for Payer: Iowa Total Care Managed Medicaid	$12,180.97
Rate for Payer: Molina Healthcare Managed Medicaid	$12,360.10

Know your out-of-pocket cost for care.

All Charges