Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [VDMC]

Facility

$1.54

Service Code	HCPCS A9270
Hospital Charge Code	10367413
Hospital Revenue Code	259
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$1.39
Rate for Payer: Aetna of IA Commercial	$1.39
Rate for Payer: Aetna of IA Medical Rental Products	$1.39
Rate for Payer: Cash Price	$1.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.16
Rate for Payer: Medical Associates Commercial	$1.16
Rate for Payer: Midlands Choice Commercial	$1.08
Rate for Payer: United Healthcare Commercial	$1.39

apixaban 5 mg Tab UD [VDMC]

Facility

$28.34

Service Code	HCPCS A9270
Hospital Charge Code	10367482
Hospital Revenue Code	259
Min. Negotiated Rate	$19.84
Max. Negotiated Rate	$25.51
Rate for Payer: Aetna of IA Commercial	$25.51
Rate for Payer: Aetna of IA Medical Rental Products	$25.51
Rate for Payer: Cash Price	$22.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.26
Rate for Payer: Medical Associates Commercial	$21.26
Rate for Payer: Midlands Choice Commercial	$19.84
Rate for Payer: United Healthcare Commercial	$25.51

apixaban 5 mg Tab UD [VDMC]

Facility

$28.34

Service Code	HCPCS A9270
Hospital Charge Code	10367482
Hospital Revenue Code	259
Min. Negotiated Rate	$14.16
Max. Negotiated Rate	$25.51
Rate for Payer: Aetna of IA Commercial	$25.51
Rate for Payer: Aetna of IA Medical Rental Products	$25.51
Rate for Payer: Aetna of IA Medicare	$16.15
Rate for Payer: Amerigroup Medicaid	$14.30
Rate for Payer: Amerigroup Medicare	$14.31
Rate for Payer: Cash Price	$22.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.26
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.17
Rate for Payer: Iowa Total Care Managed Medicaid	$14.16
Rate for Payer: Medical Associates Commercial	$21.26
Rate for Payer: Medical Associates Managed Medicare	$14.17
Rate for Payer: Midlands Choice Commercial	$19.84
Rate for Payer: Molina Healthcare Managed Medicaid	$14.38
Rate for Payer: Molina Healthcare Managed Medicare	$14.37
Rate for Payer: Oscar Health of IA Commercial	$21.26
Rate for Payer: Partners Health Alliance Commercial	$21.26
Rate for Payer: United Healthcare Commercial	$25.51
Rate for Payer: United Healthcare Managed Medicare	$16.72

Apolipoprotein B DMCL

Facility

$75.00

Service Code	CPT 82172
Hospital Charge Code	8938406
Hospital Revenue Code	301
Min. Negotiated Rate	$37.48
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of IA Commercial	$67.50
Rate for Payer: Aetna of IA Medical Rental Products	$67.50
Rate for Payer: Aetna of IA Medicare	$42.75
Rate for Payer: Amerigroup Medicaid	$37.85
Rate for Payer: Amerigroup Medicare	$37.88
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$37.50
Rate for Payer: Iowa Total Care Managed Medicaid	$37.48
Rate for Payer: Medical Associates Commercial	$56.25
Rate for Payer: Medical Associates Managed Medicare	$37.50
Rate for Payer: Midlands Choice Commercial	$52.50
Rate for Payer: Molina Healthcare Managed Medicaid	$38.06
Rate for Payer: Molina Healthcare Managed Medicare	$38.04
Rate for Payer: Oscar Health of IA Commercial	$56.25
Rate for Payer: Partners Health Alliance Commercial	$56.25
Rate for Payer: United Healthcare Commercial	$67.50
Rate for Payer: United Healthcare Managed Medicare	$44.25
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

Apolipoprotein B DMCL

Facility

$75.00

Service Code	CPT 82172
Hospital Charge Code	8938406
Hospital Revenue Code	301
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of IA Commercial	$67.50
Rate for Payer: Aetna of IA Medical Rental Products	$67.50
Rate for Payer: Cash Price	$60.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.25
Rate for Payer: Medical Associates Commercial	$56.25
Rate for Payer: Midlands Choice Commercial	$52.50
Rate for Payer: United Healthcare Commercial	$67.50

Appendectomy With Complicated Principal Diagnosis With CC

Facility

$15,202.60

Service Code	MS-DRG 339
Hospital Charge Code	189
Min. Negotiated Rate	$14,982.27
Max. Negotiated Rate	$15,202.60
Rate for Payer: Amerigroup Medicaid	$15,129.16
Rate for Payer: Iowa Total Care Managed Medicaid	$14,982.27
Rate for Payer: Molina Healthcare Managed Medicaid	$15,202.60

Appendectomy With Complicated Principal Diagnosis With MCC

Facility

$16,452.58

Service Code	MS-DRG 338
Hospital Charge Code	188
Min. Negotiated Rate	$16,214.13
Max. Negotiated Rate	$16,452.58
Rate for Payer: Amerigroup Medicaid	$16,373.10
Rate for Payer: Iowa Total Care Managed Medicaid	$16,214.13
Rate for Payer: Molina Healthcare Managed Medicaid	$16,452.58

Appendectomy With Complicated Principal Diagnosis Without CC/MCC

Facility

$10,637.68

Service Code	MS-DRG 340
Hospital Charge Code	190
Min. Negotiated Rate	$10,483.51
Max. Negotiated Rate	$10,637.68
Rate for Payer: Amerigroup Medicaid	$10,586.29
Rate for Payer: Iowa Total Care Managed Medicaid	$10,483.51
Rate for Payer: Molina Healthcare Managed Medicaid	$10,637.68

Appendectomy Without Complicated Principal Diagnosis With CC

Facility

$11,349.29

Service Code	MS-DRG 342
Hospital Charge Code	192
Min. Negotiated Rate	$11,184.81
Max. Negotiated Rate	$11,349.29
Rate for Payer: Amerigroup Medicaid	$11,294.46
Rate for Payer: Iowa Total Care Managed Medicaid	$11,184.81
Rate for Payer: Molina Healthcare Managed Medicaid	$11,349.29

Appendectomy Without Complicated Principal Diagnosis With MCC

Facility

$15,920.11

Service Code	MS-DRG 341
Hospital Charge Code	191
Min. Negotiated Rate	$15,689.38
Max. Negotiated Rate	$15,920.11
Rate for Payer: Amerigroup Medicaid	$15,843.20
Rate for Payer: Iowa Total Care Managed Medicaid	$15,689.38
Rate for Payer: Molina Healthcare Managed Medicaid	$15,920.11

Appendectomy Without Complicated Principal Diagnosis Without CC/MCC

Facility

$8,414.28

Service Code	MS-DRG 343
Hospital Charge Code	193
Min. Negotiated Rate	$8,292.33
Max. Negotiated Rate	$8,414.28
Rate for Payer: Amerigroup Medicaid	$8,373.63
Rate for Payer: Iowa Total Care Managed Medicaid	$8,292.33
Rate for Payer: Molina Healthcare Managed Medicaid	$8,414.28

APPLICATION LONG LEG SPLINT

Professional

Both

$218.00

Service Code	CPT 29505
Hospital Charge Code	7982786
Hospital Revenue Code	981
Min. Negotiated Rate	$47.41
Max. Negotiated Rate	$152.60
Rate for Payer: Aetna of IA Medicare	$47.41
Rate for Payer: Amerigroup Medicaid	$49.02
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cash Price	$174.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.89
Rate for Payer: Iowa Total Care Managed Medicaid	$48.36
Rate for Payer: Medical Associates Commercial	$85.34
Rate for Payer: Medical Associates Managed Medicare	$47.41
Rate for Payer: Midlands Choice Commercial	$152.60
Rate for Payer: Oscar Health of IA Commercial	$82.02
Rate for Payer: Partners Health Alliance Commercial	$71.12

APPLICATION LOWER LEG SPLINT

Professional

Both

$197.00

Service Code	CPT 29515
Hospital Charge Code	7982785
Hospital Revenue Code	981
Min. Negotiated Rate	$45.28
Max. Negotiated Rate	$137.90
Rate for Payer: Aetna of IA Medicare	$45.28
Rate for Payer: Amerigroup Medicaid	$46.82
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cash Price	$157.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.34
Rate for Payer: Iowa Total Care Managed Medicaid	$46.19
Rate for Payer: Medical Associates Commercial	$81.50
Rate for Payer: Medical Associates Managed Medicare	$45.28
Rate for Payer: Midlands Choice Commercial	$137.90
Rate for Payer: Oscar Health of IA Commercial	$78.33
Rate for Payer: Partners Health Alliance Commercial	$67.92

Application of a uniplane (pins or wires in 1 plane), unilateral, external fixation system

Facility

$7,259.89

Service Code	CPT 20690
Hospital Revenue Code	360
Min. Negotiated Rate	$6,599.90
Max. Negotiated Rate	$7,259.89
Rate for Payer: Wellmark IA HMO	$6,599.90
Rate for Payer: Wellmark IA PPO	$7,259.89

APPLICATION OF FINGER SPLINT

Professional

Both

$112.00

Service Code	CPT 29130
Hospital Charge Code	7982788
Hospital Revenue Code	981
Min. Negotiated Rate	$26.09
Max. Negotiated Rate	$78.40
Rate for Payer: Aetna of IA Medicare	$26.09
Rate for Payer: Amerigroup Medicaid	$26.98
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$31.31
Rate for Payer: Iowa Total Care Managed Medicaid	$26.61
Rate for Payer: Medical Associates Commercial	$46.96
Rate for Payer: Medical Associates Managed Medicare	$26.09
Rate for Payer: Midlands Choice Commercial	$78.40
Rate for Payer: Oscar Health of IA Commercial	$45.14
Rate for Payer: Partners Health Alliance Commercial	$39.14

APPLICATION TOTAL CONTACT CAST

Facility

$406.00

Service Code	CPT 29445
Hospital Charge Code	8013707
Hospital Revenue Code	510
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: United Healthcare Commercial	$365.40

APPLICATION TOTAL CONTACT CAST

Facility

$406.00

Service Code	CPT 29445
Hospital Charge Code	8013707
Hospital Revenue Code	510
Min. Negotiated Rate	$202.92
Max. Negotiated Rate	$445.35
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Aetna of IA Medicare	$231.42
Rate for Payer: Amerigroup Medicaid	$204.91
Rate for Payer: Amerigroup Medicare	$205.03
Rate for Payer: Cash Price	$324.80
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$203.00
Rate for Payer: Iowa Total Care Managed Medicaid	$202.92
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Medical Associates Managed Medicare	$203.00
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: Molina Healthcare Managed Medicaid	$206.04
Rate for Payer: Molina Healthcare Managed Medicare	$205.92
Rate for Payer: Oscar Health of IA Commercial	$304.50
Rate for Payer: Partners Health Alliance Commercial	$304.50
Rate for Payer: United Healthcare Commercial	$365.40
Rate for Payer: United Healthcare Managed Medicare	$239.54
Rate for Payer: Wellmark IA HMO	$404.86
Rate for Payer: Wellmark IA PPO	$445.35

APPL SKIN SUB < 100 1ST 25 CM FEET/TOES

Facility

$569.00

Service Code	CPT 15275
Hospital Charge Code	8013703
Hospital Revenue Code	510
Min. Negotiated Rate	$398.30
Max. Negotiated Rate	$512.10
Rate for Payer: Aetna of IA Commercial	$512.10
Rate for Payer: Aetna of IA Medical Rental Products	$512.10
Rate for Payer: Cash Price	$455.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$426.75
Rate for Payer: Medical Associates Commercial	$426.75
Rate for Payer: Midlands Choice Commercial	$398.30
Rate for Payer: United Healthcare Commercial	$512.10

APPL SKIN SUB < 100 1ST 25 CM FEET/TOES

Facility

$569.00

Service Code	CPT 15275
Hospital Charge Code	8013703
Hospital Revenue Code	510
Min. Negotiated Rate	$284.39
Max. Negotiated Rate	$2,985.11
Rate for Payer: Aetna of IA Commercial	$512.10
Rate for Payer: Aetna of IA Medical Rental Products	$512.10
Rate for Payer: Aetna of IA Medicare	$324.33
Rate for Payer: Amerigroup Medicaid	$287.17
Rate for Payer: Amerigroup Medicare	$287.34
Rate for Payer: Cash Price	$455.20
Rate for Payer: Cash Price	$455.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$426.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$284.50
Rate for Payer: Iowa Total Care Managed Medicaid	$284.39
Rate for Payer: Medical Associates Commercial	$426.75
Rate for Payer: Medical Associates Managed Medicare	$284.50
Rate for Payer: Midlands Choice Commercial	$398.30
Rate for Payer: Molina Healthcare Managed Medicaid	$288.77
Rate for Payer: Molina Healthcare Managed Medicare	$288.60
Rate for Payer: Oscar Health of IA Commercial	$426.75
Rate for Payer: Partners Health Alliance Commercial	$426.75
Rate for Payer: United Healthcare Commercial	$512.10
Rate for Payer: United Healthcare Managed Medicare	$335.71
Rate for Payer: Wellmark IA HMO	$2,713.74
Rate for Payer: Wellmark IA PPO	$2,985.11

APPL SKIN SUB < 100 1ST 25 CM LEG/ANKLE

Facility

$711.00

Service Code	CPT 15271
Hospital Charge Code	7438782
Hospital Revenue Code	510
Min. Negotiated Rate	$497.70
Max. Negotiated Rate	$639.90
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: United Healthcare Commercial	$639.90

APPL SKIN SUB < 100 1ST 25 CM LEG/ANKLE

Facility

$711.00

Service Code	CPT 15271
Hospital Charge Code	7438782
Hospital Revenue Code	510
Min. Negotiated Rate	$355.36
Max. Negotiated Rate	$2,985.11
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Aetna of IA Medicare	$405.27
Rate for Payer: Amerigroup Medicaid	$358.84
Rate for Payer: Amerigroup Medicare	$359.06
Rate for Payer: Cash Price	$568.80
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$355.50
Rate for Payer: Iowa Total Care Managed Medicaid	$355.36
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Medical Associates Managed Medicare	$355.50
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: Molina Healthcare Managed Medicaid	$360.83
Rate for Payer: Molina Healthcare Managed Medicare	$360.62
Rate for Payer: Oscar Health of IA Commercial	$533.25
Rate for Payer: Partners Health Alliance Commercial	$533.25
Rate for Payer: United Healthcare Commercial	$639.90
Rate for Payer: United Healthcare Managed Medicare	$419.49
Rate for Payer: Wellmark IA HMO	$2,713.74
Rate for Payer: Wellmark IA PPO	$2,985.11

APPL SKIN SUB 1ST 100 SQ CM FEET/TOES

Facility

$824.00

Service Code	CPT 15277
Hospital Charge Code	8013705
Hospital Revenue Code	510
Min. Negotiated Rate	$576.80
Max. Negotiated Rate	$741.60
Rate for Payer: Aetna of IA Commercial	$741.60
Rate for Payer: Aetna of IA Medical Rental Products	$741.60
Rate for Payer: Cash Price	$659.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$618.00
Rate for Payer: Medical Associates Commercial	$618.00
Rate for Payer: Midlands Choice Commercial	$576.80
Rate for Payer: United Healthcare Commercial	$741.60

APPL SKIN SUB 1ST 100 SQ CM FEET/TOES

Facility

$824.00

Service Code	CPT 15277
Hospital Charge Code	8013705
Hospital Revenue Code	510
Min. Negotiated Rate	$411.84
Max. Negotiated Rate	$2,985.11
Rate for Payer: Aetna of IA Commercial	$741.60
Rate for Payer: Aetna of IA Medical Rental Products	$741.60
Rate for Payer: Aetna of IA Medicare	$469.68
Rate for Payer: Amerigroup Medicaid	$415.87
Rate for Payer: Amerigroup Medicare	$416.12
Rate for Payer: Cash Price	$659.20
Rate for Payer: Cash Price	$659.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$618.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$412.00
Rate for Payer: Iowa Total Care Managed Medicaid	$411.84
Rate for Payer: Medical Associates Commercial	$618.00
Rate for Payer: Medical Associates Managed Medicare	$412.00
Rate for Payer: Midlands Choice Commercial	$576.80
Rate for Payer: Molina Healthcare Managed Medicaid	$418.18
Rate for Payer: Molina Healthcare Managed Medicare	$417.93
Rate for Payer: Oscar Health of IA Commercial	$618.00
Rate for Payer: Partners Health Alliance Commercial	$618.00
Rate for Payer: United Healthcare Commercial	$741.60
Rate for Payer: United Healthcare Managed Medicare	$486.16
Rate for Payer: Wellmark IA HMO	$2,713.74
Rate for Payer: Wellmark IA PPO	$2,985.11

APPL SKIN SUB 1ST 100 SQ CM LEG/ANKLE

Facility

$930.00

Service Code	CPT 15273
Hospital Charge Code	8013701
Hospital Revenue Code	510
Min. Negotiated Rate	$651.00
Max. Negotiated Rate	$837.00
Rate for Payer: Aetna of IA Commercial	$837.00
Rate for Payer: Aetna of IA Medical Rental Products	$837.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$697.50
Rate for Payer: Medical Associates Commercial	$697.50
Rate for Payer: Midlands Choice Commercial	$651.00
Rate for Payer: United Healthcare Commercial	$837.00

APPL SKIN SUB 1ST 100 SQ CM LEG/ANKLE

Facility

$930.00

Service Code	CPT 15273
Hospital Charge Code	8013701
Hospital Revenue Code	510
Min. Negotiated Rate	$464.81
Max. Negotiated Rate	$2,985.11
Rate for Payer: Aetna of IA Commercial	$837.00
Rate for Payer: Aetna of IA Medical Rental Products	$837.00
Rate for Payer: Aetna of IA Medicare	$530.10
Rate for Payer: Amerigroup Medicaid	$469.37
Rate for Payer: Amerigroup Medicare	$469.65
Rate for Payer: Cash Price	$744.00
Rate for Payer: Cash Price	$744.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$697.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$465.00
Rate for Payer: Iowa Total Care Managed Medicaid	$464.81
Rate for Payer: Medical Associates Commercial	$697.50
Rate for Payer: Medical Associates Managed Medicare	$465.00
Rate for Payer: Midlands Choice Commercial	$651.00
Rate for Payer: Molina Healthcare Managed Medicaid	$471.98
Rate for Payer: Molina Healthcare Managed Medicare	$471.70
Rate for Payer: Oscar Health of IA Commercial	$697.50
Rate for Payer: Partners Health Alliance Commercial	$697.50
Rate for Payer: United Healthcare Commercial	$837.00
Rate for Payer: United Healthcare Managed Medicare	$548.70
Rate for Payer: Wellmark IA HMO	$2,713.74
Rate for Payer: Wellmark IA PPO	$2,985.11

Know your out-of-pocket cost for care.

All Charges