Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

traZODone 50 mg Tab [VDMC]

Facility

$1.32

Service Code	HCPCS A9270
Hospital Charge Code	10426114
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of IA Commercial	$1.19
Rate for Payer: Aetna of IA Medical Rental Products	$1.19
Rate for Payer: Aetna of IA Medicare	$0.75
Rate for Payer: Amerigroup Medicaid	$0.76
Rate for Payer: Amerigroup Medicare	$0.60
Rate for Payer: Cash Price	$1.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.99
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	$0.75
Rate for Payer: Medical Associates Commercial	$0.99
Rate for Payer: Medical Associates Managed Medicare	$0.59
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: Molina Healthcare Managed Medicaid	$0.77
Rate for Payer: Partners Health Alliance Commercial	$0.68
Rate for Payer: United Healthcare Commercial	$1.19
Rate for Payer: United Healthcare Managed Medicare	$0.78

traZODone 50 mg Tab [VDMC]

Facility

$1.32

Service Code	HCPCS A9270
Hospital Charge Code	10426114
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of IA Commercial	$1.19
Rate for Payer: Aetna of IA Medical Rental Products	$1.19
Rate for Payer: Cash Price	$1.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.99
Rate for Payer: Medical Associates Commercial	$0.99
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: United Healthcare Commercial	$1.19

TREAT CLAVICLE FRACTURE

Facility

$624.00

Service Code	CPT 23500
Hospital Charge Code	4864812
Hospital Revenue Code	450
Min. Negotiated Rate	$436.80
Max. Negotiated Rate	$561.60
Rate for Payer: Aetna of IA Commercial	$561.60
Rate for Payer: Aetna of IA Medical Rental Products	$561.60
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.00
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: United Healthcare Commercial	$561.60

TREAT CLAVICLE FRACTURE

Professional

Both

$424.00

Service Code	CPT 23500
Hospital Charge Code	7982813
Hospital Revenue Code	981
Min. Negotiated Rate	$296.80
Max. Negotiated Rate	$330.88
Rate for Payer: Cash Price	$339.20
Rate for Payer: Cash Price	$339.20
Rate for Payer: Medical Associates Commercial	$318.00
Rate for Payer: Midlands Choice Commercial	$296.80
Rate for Payer: Partners Health Alliance Commercial	$318.00
Rate for Payer: United Healthcare Commercial	$330.88

TREAT CLAVICLE FRACTURE

Facility

$624.00

Service Code	CPT 23500
Hospital Charge Code	4864812
Hospital Revenue Code	450
Min. Negotiated Rate	$280.80
Max. Negotiated Rate	$561.60
Rate for Payer: Aetna of IA Commercial	$561.60
Rate for Payer: Aetna of IA Medical Rental Products	$561.60
Rate for Payer: Aetna of IA Medicare	$355.68
Rate for Payer: Amerigroup Medicaid	$359.92
Rate for Payer: Amerigroup Medicare	$283.61
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$280.80
Rate for Payer: Iowa Total Care Managed Medicaid	$356.43
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Medical Associates Managed Medicare	$280.80
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Molina Healthcare Managed Medicaid	$361.67
Rate for Payer: Partners Health Alliance Commercial	$322.92
Rate for Payer: United Healthcare Commercial	$561.60
Rate for Payer: United Healthcare Managed Medicare	$368.16

TREAT DISLOCATION/FRACTURE

Facility

$1,256.00

Service Code	CPT 23665
Hospital Charge Code	7983021
Hospital Revenue Code	450
Min. Negotiated Rate	$879.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: United Healthcare Commercial	$1,130.40

TREAT DISLOCATION/FRACTURE

Professional

Both

$1,228.00

Service Code	CPT 23665
Hospital Charge Code	7982871
Hospital Revenue Code	981
Min. Negotiated Rate	$645.68
Max. Negotiated Rate	$921.00
Rate for Payer: Cash Price	$982.40
Rate for Payer: Cash Price	$982.40
Rate for Payer: Medical Associates Commercial	$921.00
Rate for Payer: Midlands Choice Commercial	$859.60
Rate for Payer: Partners Health Alliance Commercial	$921.00
Rate for Payer: United Healthcare Commercial	$645.68

TREAT DISLOCATION/FRACTURE

Facility

$1,256.00

Service Code	CPT 23665
Hospital Charge Code	7983021
Hospital Revenue Code	450
Min. Negotiated Rate	$565.20
Max. Negotiated Rate	$1,130.40
Rate for Payer: Aetna of IA Commercial	$1,130.40
Rate for Payer: Aetna of IA Medical Rental Products	$1,130.40
Rate for Payer: Aetna of IA Medicare	$715.92
Rate for Payer: Amerigroup Medicaid	$724.46
Rate for Payer: Amerigroup Medicare	$570.85
Rate for Payer: Cash Price	$1,004.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$942.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$565.20
Rate for Payer: Iowa Total Care Managed Medicaid	$717.43
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Medical Associates Managed Medicare	$565.20
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: Molina Healthcare Managed Medicaid	$727.98
Rate for Payer: Partners Health Alliance Commercial	$649.98
Rate for Payer: United Healthcare Commercial	$1,130.40
Rate for Payer: United Healthcare Managed Medicare	$741.04

TREAT ELBOW DISLOCATION

Facility

$1,393.00

Service Code	CPT 24605
Hospital Charge Code	4864833
Hospital Revenue Code	450
Min. Negotiated Rate	$975.10
Max. Negotiated Rate	$1,253.70
Rate for Payer: Aetna of IA Commercial	$1,253.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,253.70
Rate for Payer: Cash Price	$1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,044.75
Rate for Payer: Medical Associates Commercial	$1,044.75
Rate for Payer: Midlands Choice Commercial	$975.10
Rate for Payer: United Healthcare Commercial	$1,253.70

TREAT ELBOW DISLOCATION

Facility

$628.00

Service Code	CPT 24640
Hospital Charge Code	4864835
Hospital Revenue Code	450
Min. Negotiated Rate	$282.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Aetna of IA Medicare	$357.96
Rate for Payer: Amerigroup Medicaid	$362.23
Rate for Payer: Amerigroup Medicare	$285.43
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$282.60
Rate for Payer: Iowa Total Care Managed Medicaid	$358.71
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Medical Associates Managed Medicare	$282.60
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Molina Healthcare Managed Medicaid	$363.99
Rate for Payer: Partners Health Alliance Commercial	$324.99
Rate for Payer: United Healthcare Commercial	$565.20
Rate for Payer: United Healthcare Managed Medicare	$370.52

TREAT ELBOW DISLOCATION

Facility

$628.00

Service Code	CPT 24640
Hospital Charge Code	4864835
Hospital Revenue Code	450
Min. Negotiated Rate	$439.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: United Healthcare Commercial	$565.20

TREAT ELBOW DISLOCATION

Facility

$1,393.00

Service Code	CPT 24605
Hospital Charge Code	4864833
Hospital Revenue Code	450
Min. Negotiated Rate	$626.85
Max. Negotiated Rate	$1,253.70
Rate for Payer: Aetna of IA Commercial	$1,253.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,253.70
Rate for Payer: Aetna of IA Medicare	$794.01
Rate for Payer: Amerigroup Medicaid	$803.48
Rate for Payer: Amerigroup Medicare	$633.12
Rate for Payer: Cash Price	$1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,044.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$626.85
Rate for Payer: Iowa Total Care Managed Medicaid	$795.68
Rate for Payer: Medical Associates Commercial	$1,044.75
Rate for Payer: Medical Associates Managed Medicare	$626.85
Rate for Payer: Midlands Choice Commercial	$975.10
Rate for Payer: Molina Healthcare Managed Medicaid	$807.38
Rate for Payer: Partners Health Alliance Commercial	$720.88
Rate for Payer: United Healthcare Commercial	$1,253.70
Rate for Payer: United Healthcare Managed Medicare	$821.87

TREAT FINGER DISLOCATION

Professional

Both

$788.00

Service Code	CPT 26770
Hospital Charge Code	7982797
Hospital Revenue Code	981
Min. Negotiated Rate	$423.36
Max. Negotiated Rate	$591.00
Rate for Payer: Cash Price	$630.40
Rate for Payer: Cash Price	$630.40
Rate for Payer: Medical Associates Commercial	$591.00
Rate for Payer: Midlands Choice Commercial	$551.60
Rate for Payer: Partners Health Alliance Commercial	$591.00
Rate for Payer: United Healthcare Commercial	$423.36

TREAT FINGER DISLOCATION

Facility

$624.00

Service Code	CPT 26770
Hospital Charge Code	4863411
Hospital Revenue Code	450
Min. Negotiated Rate	$280.80
Max. Negotiated Rate	$561.60
Rate for Payer: Aetna of IA Commercial	$561.60
Rate for Payer: Aetna of IA Medical Rental Products	$561.60
Rate for Payer: Aetna of IA Medicare	$355.68
Rate for Payer: Amerigroup Medicaid	$359.92
Rate for Payer: Amerigroup Medicare	$283.61
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$280.80
Rate for Payer: Iowa Total Care Managed Medicaid	$356.43
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Medical Associates Managed Medicare	$280.80
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Molina Healthcare Managed Medicaid	$361.67
Rate for Payer: Partners Health Alliance Commercial	$322.92
Rate for Payer: United Healthcare Commercial	$561.60
Rate for Payer: United Healthcare Managed Medicare	$368.16

TREAT FINGER DISLOCATION

Facility

$624.00

Service Code	CPT 26770
Hospital Charge Code	4863411
Hospital Revenue Code	450
Min. Negotiated Rate	$436.80
Max. Negotiated Rate	$561.60
Rate for Payer: Aetna of IA Commercial	$561.60
Rate for Payer: Aetna of IA Medical Rental Products	$561.60
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.00
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: United Healthcare Commercial	$561.60

TREAT FINGER FRACTURE EACH

Professional

Both

$1,114.00

Service Code	CPT 26725
Hospital Charge Code	7982800
Hospital Revenue Code	981
Min. Negotiated Rate	$511.47
Max. Negotiated Rate	$835.50
Rate for Payer: Cash Price	$891.20
Rate for Payer: Cash Price	$891.20
Rate for Payer: Medical Associates Commercial	$835.50
Rate for Payer: Midlands Choice Commercial	$779.80
Rate for Payer: Partners Health Alliance Commercial	$835.50
Rate for Payer: United Healthcare Commercial	$511.47

TREAT FINGER FRACTURE EACH

Facility

$748.00

Service Code	CPT 26720
Hospital Charge Code	4863309
Hospital Revenue Code	450
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$673.20
Rate for Payer: Aetna of IA Commercial	$673.20
Rate for Payer: Aetna of IA Medical Rental Products	$673.20
Rate for Payer: Aetna of IA Medicare	$426.36
Rate for Payer: Amerigroup Medicaid	$431.45
Rate for Payer: Amerigroup Medicare	$339.97
Rate for Payer: Cash Price	$598.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$561.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$336.60
Rate for Payer: Iowa Total Care Managed Medicaid	$427.26
Rate for Payer: Medical Associates Commercial	$561.00
Rate for Payer: Medical Associates Managed Medicare	$336.60
Rate for Payer: Midlands Choice Commercial	$523.60
Rate for Payer: Molina Healthcare Managed Medicaid	$433.54
Rate for Payer: Partners Health Alliance Commercial	$387.09
Rate for Payer: United Healthcare Commercial	$673.20
Rate for Payer: United Healthcare Managed Medicare	$441.32

TREAT FINGER FRACTURE EACH

Professional

Both

$1,038.00

Service Code	CPT 26755
Hospital Charge Code	7982799
Hospital Revenue Code	981
Min. Negotiated Rate	$478.26
Max. Negotiated Rate	$778.50
Rate for Payer: Cash Price	$830.40
Rate for Payer: Cash Price	$830.40
Rate for Payer: Medical Associates Commercial	$778.50
Rate for Payer: Midlands Choice Commercial	$726.60
Rate for Payer: Partners Health Alliance Commercial	$778.50
Rate for Payer: United Healthcare Commercial	$478.26

TREAT FINGER FRACTURE EACH

Professional

Both

$1,670.00

Service Code	CPT 26765
Hospital Charge Code	7982798
Hospital Revenue Code	981
Min. Negotiated Rate	$757.41
Max. Negotiated Rate	$1,252.50
Rate for Payer: Cash Price	$1,336.00
Rate for Payer: Cash Price	$1,336.00
Rate for Payer: Medical Associates Commercial	$1,252.50
Rate for Payer: Midlands Choice Commercial	$1,169.00
Rate for Payer: Partners Health Alliance Commercial	$1,252.50
Rate for Payer: United Healthcare Commercial	$757.41

TREAT FINGER FRACTURE EACH

Facility

$4,182.00

Service Code	CPT 26765
Hospital Charge Code	4863388
Hospital Revenue Code	450
Min. Negotiated Rate	$2,927.40
Max. Negotiated Rate	$3,763.80
Rate for Payer: Aetna of IA Commercial	$3,763.80
Rate for Payer: Aetna of IA Medical Rental Products	$3,763.80
Rate for Payer: Cash Price	$3,345.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,136.50
Rate for Payer: Medical Associates Commercial	$3,136.50
Rate for Payer: Midlands Choice Commercial	$2,927.40
Rate for Payer: United Healthcare Commercial	$3,763.80

TREAT FINGER FRACTURE EACH

Facility

$748.00

Service Code	CPT 26755
Hospital Charge Code	4863379
Hospital Revenue Code	450
Min. Negotiated Rate	$523.60
Max. Negotiated Rate	$673.20
Rate for Payer: Aetna of IA Commercial	$673.20
Rate for Payer: Aetna of IA Medical Rental Products	$673.20
Rate for Payer: Cash Price	$598.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$561.00
Rate for Payer: Medical Associates Commercial	$561.00
Rate for Payer: Midlands Choice Commercial	$523.60
Rate for Payer: United Healthcare Commercial	$673.20

TREAT FINGER FRACTURE EACH

Facility

$748.00

Service Code	CPT 26755
Hospital Charge Code	4863379
Hospital Revenue Code	450
Min. Negotiated Rate	$336.60
Max. Negotiated Rate	$673.20
Rate for Payer: Aetna of IA Commercial	$673.20
Rate for Payer: Aetna of IA Medical Rental Products	$673.20
Rate for Payer: Aetna of IA Medicare	$426.36
Rate for Payer: Amerigroup Medicaid	$431.45
Rate for Payer: Amerigroup Medicare	$339.97
Rate for Payer: Cash Price	$598.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$561.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$336.60
Rate for Payer: Iowa Total Care Managed Medicaid	$427.26
Rate for Payer: Medical Associates Commercial	$561.00
Rate for Payer: Medical Associates Managed Medicare	$336.60
Rate for Payer: Midlands Choice Commercial	$523.60
Rate for Payer: Molina Healthcare Managed Medicaid	$433.54
Rate for Payer: Partners Health Alliance Commercial	$387.09
Rate for Payer: United Healthcare Commercial	$673.20
Rate for Payer: United Healthcare Managed Medicare	$441.32

TREAT FINGER FRACTURE EACH

Facility

$4,182.00

Service Code	CPT 26765
Hospital Charge Code	4863388
Hospital Revenue Code	450
Min. Negotiated Rate	$1,881.90
Max. Negotiated Rate	$3,763.80
Rate for Payer: Aetna of IA Commercial	$3,763.80
Rate for Payer: Aetna of IA Medical Rental Products	$3,763.80
Rate for Payer: Aetna of IA Medicare	$2,383.74
Rate for Payer: Amerigroup Medicaid	$2,412.18
Rate for Payer: Amerigroup Medicare	$1,900.72
Rate for Payer: Cash Price	$3,345.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,136.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,881.90
Rate for Payer: Iowa Total Care Managed Medicaid	$2,388.76
Rate for Payer: Medical Associates Commercial	$3,136.50
Rate for Payer: Medical Associates Managed Medicare	$1,881.90
Rate for Payer: Midlands Choice Commercial	$2,927.40
Rate for Payer: Molina Healthcare Managed Medicaid	$2,423.89
Rate for Payer: Partners Health Alliance Commercial	$2,164.18
Rate for Payer: United Healthcare Commercial	$3,763.80
Rate for Payer: United Healthcare Managed Medicare	$2,467.38

TREAT FINGER FRACTURE EACH

Facility

$748.00

Service Code	CPT 26720
Hospital Charge Code	4863309
Hospital Revenue Code	450
Min. Negotiated Rate	$523.60
Max. Negotiated Rate	$673.20
Rate for Payer: Aetna of IA Commercial	$673.20
Rate for Payer: Aetna of IA Medical Rental Products	$673.20
Rate for Payer: Cash Price	$598.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$561.00
Rate for Payer: Medical Associates Commercial	$561.00
Rate for Payer: Midlands Choice Commercial	$523.60
Rate for Payer: United Healthcare Commercial	$673.20

TREAT FINGER FRACTURE EACH

Facility

$748.00

Service Code	CPT 26725
Hospital Charge Code	4863316
Hospital Revenue Code	450
Min. Negotiated Rate	$523.60
Max. Negotiated Rate	$673.20
Rate for Payer: Aetna of IA Commercial	$673.20
Rate for Payer: Aetna of IA Medical Rental Products	$673.20
Rate for Payer: Cash Price	$598.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$561.00
Rate for Payer: Medical Associates Commercial	$561.00
Rate for Payer: Midlands Choice Commercial	$523.60
Rate for Payer: United Healthcare Commercial	$673.20

Know your out-of-pocket cost for care.

All Charges