Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$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

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

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	$169.50
Rate for Payer: Amerigroup Medicaid	$95.95
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cash Price	$98.40
Rate for Payer: Iowa Total Care Managed Medicaid	$95.02
Rate for Payer: Medical Associates Commercial	$92.25
Rate for Payer: Midlands Choice Commercial	$86.10
Rate for Payer: Molina Healthcare Managed Medicaid	$95.49
Rate for Payer: Partners Health Alliance Commercial	$92.25
Rate for Payer: United Healthcare Commercial	$112.78
Rate for Payer: Wellmark IA HMO WHPI	$144.10
Rate for Payer: Wellmark IA PPO	$169.50

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: 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
Rate for Payer: Wellmark IA HMO WHPI	$346.70
Rate for Payer: Wellmark IA PPO	$381.91

SIMPLE PNEUMONIA AND PLEURISY WITH CC

Facility

$7,957.28

Service Code	MSDRG 194
Min. Negotiated Rate	$7,841.95
Max. Negotiated Rate	$7,957.28
Rate for Payer: Amerigroup Medicaid	$7,918.83
Rate for Payer: Iowa Total Care Managed Medicaid	$7,841.95
Rate for Payer: Molina Healthcare Managed Medicaid	$7,957.28

SIMPLE PNEUMONIA AND PLEURISY WITH MCC

Facility

$12,187.58

Service Code	MSDRG 193
Min. Negotiated Rate	$12,010.94
Max. Negotiated Rate	$12,187.58
Rate for Payer: Amerigroup Medicaid	$12,128.69
Rate for Payer: Iowa Total Care Managed Medicaid	$12,010.94
Rate for Payer: Molina Healthcare Managed Medicaid	$12,187.58

SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC

Facility

$5,516.16

Service Code	MSDRG 195
Min. Negotiated Rate	$5,436.21
Max. Negotiated Rate	$5,516.16
Rate for Payer: Amerigroup Medicaid	$5,489.51
Rate for Payer: Iowa Total Care Managed Medicaid	$5,436.21
Rate for Payer: Molina Healthcare Managed Medicaid	$5,516.16

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: 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
Rate for Payer: Wellmark IA HMO WHPI	$185.05
Rate for Payer: Wellmark IA PPO	$203.84

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

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT

Facility

$154,657.44

Service Code	MSDRG 008
Min. Negotiated Rate	$152,415.96
Max. Negotiated Rate	$154,657.44
Rate for Payer: Amerigroup Medicaid	$153,910.24
Rate for Payer: Iowa Total Care Managed Medicaid	$152,415.96
Rate for Payer: Molina Healthcare Managed Medicaid	$154,657.44

SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS

Facility

$75,030.60

Service Code	MSDRG 019
Min. Negotiated Rate	$73,943.17
Max. Negotiated Rate	$75,030.60
Rate for Payer: Amerigroup Medicaid	$74,668.10
Rate for Payer: Iowa Total Care Managed Medicaid	$73,943.17
Rate for Payer: Molina Healthcare Managed Medicaid	$75,030.60

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

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

SINGLE PULSE OXIMETRY

Facility

$10.00

Service Code	CPT 94760
Hospital Charge Code	5338940
Hospital Revenue Code	410
Min. Negotiated Rate	$4.50
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	$5.77
Rate for Payer: Amerigroup Medicare	$4.54
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	$4.50
Rate for Payer: Iowa Total Care Managed Medicaid	$5.71
Rate for Payer: Medical Associates Commercial	$7.50
Rate for Payer: Medical Associates Managed Medicare	$4.50
Rate for Payer: Midlands Choice Commercial	$7.00
Rate for Payer: Molina Healthcare Managed Medicaid	$5.80
Rate for Payer: Partners Health Alliance Commercial	$5.18
Rate for Payer: United Healthcare Commercial	$9.00
Rate for Payer: United Healthcare Managed Medicare	$5.90

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

SINUS AND MASTOID PROCEDURES WITH CC/MCC

Facility

$24,109.42

Service Code	MSDRG 135
Min. Negotiated Rate	$23,760.00
Max. Negotiated Rate	$24,109.42
Rate for Payer: Amerigroup Medicaid	$23,992.94
Rate for Payer: Iowa Total Care Managed Medicaid	$23,760.00
Rate for Payer: Molina Healthcare Managed Medicaid	$24,109.42

SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC

Facility

$14,140.02

Service Code	MSDRG 136
Min. Negotiated Rate	$13,935.09
Max. Negotiated Rate	$14,140.02
Rate for Payer: Amerigroup Medicaid	$14,071.70
Rate for Payer: Iowa Total Care Managed Medicaid	$13,935.09
Rate for Payer: Molina Healthcare Managed Medicaid	$14,140.02

sitaGLIPtin 50 mg oral tablet [VDMC]

Facility

$58.53

Service Code	HCPCS A9270
Hospital Charge Code	10421132
Hospital Revenue Code	259
Min. Negotiated Rate	$26.34
Max. Negotiated Rate	$52.68
Rate for Payer: Aetna of IA Commercial	$52.68
Rate for Payer: Aetna of IA Medical Rental Products	$52.68
Rate for Payer: Aetna of IA Medicare	$33.36
Rate for Payer: Amerigroup Medicaid	$33.76
Rate for Payer: Amerigroup Medicare	$26.60
Rate for Payer: Cash Price	$46.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.34
Rate for Payer: Iowa Total Care Managed Medicaid	$33.43
Rate for Payer: Medical Associates Commercial	$43.90
Rate for Payer: Medical Associates Managed Medicare	$26.34
Rate for Payer: Midlands Choice Commercial	$40.97
Rate for Payer: Molina Healthcare Managed Medicaid	$33.92
Rate for Payer: Partners Health Alliance Commercial	$30.29
Rate for Payer: United Healthcare Commercial	$52.68
Rate for Payer: United Healthcare Managed Medicare	$34.53

sitaGLIPtin 50 mg oral tablet [VDMC]

Facility

$58.53

Service Code	HCPCS A9270
Hospital Charge Code	10421132
Hospital Revenue Code	259
Min. Negotiated Rate	$40.97
Max. Negotiated Rate	$52.68
Rate for Payer: Aetna of IA Commercial	$52.68
Rate for Payer: Aetna of IA Medical Rental Products	$52.68
Rate for Payer: Cash Price	$46.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.90
Rate for Payer: Medical Associates Commercial	$43.90
Rate for Payer: Midlands Choice Commercial	$40.97
Rate for Payer: United Healthcare Commercial	$52.68

Sjogren's A Antibody DMCL

Facility

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037800
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Aetna of IA Medicare	$77.52
Rate for Payer: Amerigroup Medicaid	$78.44
Rate for Payer: Amerigroup Medicare	$61.81
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$61.20
Rate for Payer: Iowa Total Care Managed Medicaid	$77.68
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Medical Associates Managed Medicare	$61.20
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: Molina Healthcare Managed Medicaid	$78.83
Rate for Payer: Partners Health Alliance Commercial	$70.38
Rate for Payer: United Healthcare Commercial	$122.40
Rate for Payer: United Healthcare Managed Medicare	$80.24
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

Sjogren's A Antibody DMCL

Facility

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037800
Hospital Revenue Code	302
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: United Healthcare Commercial	$122.40

Know your out-of-pocket cost for care.

All Charges