Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

tranexamic acid 650 mg Tab [VDMC]

Facility

$11.23

Service Code	HCPCS A9270
Hospital Charge Code	10425976
Hospital Revenue Code	259
Min. Negotiated Rate	$7.86
Max. Negotiated Rate	$10.11
Rate for Payer: Aetna of IA Commercial	$10.11
Rate for Payer: Aetna of IA Medical Rental Products	$10.11
Rate for Payer: Cash Price	$8.98
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.42
Rate for Payer: Medical Associates Commercial	$8.42
Rate for Payer: Midlands Choice Commercial	$7.86
Rate for Payer: United Healthcare Commercial	$10.11

tranexamic acid 650 mg Tab [VDMC]

Facility

$11.23

Service Code	HCPCS A9270
Hospital Charge Code	10425976
Hospital Revenue Code	259
Min. Negotiated Rate	$5.61
Max. Negotiated Rate	$10.11
Rate for Payer: Aetna of IA Commercial	$10.11
Rate for Payer: Aetna of IA Medical Rental Products	$10.11
Rate for Payer: Aetna of IA Medicare	$6.40
Rate for Payer: Amerigroup Medicaid	$5.67
Rate for Payer: Amerigroup Medicare	$5.67
Rate for Payer: Cash Price	$8.98
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.62
Rate for Payer: Iowa Total Care Managed Medicaid	$5.61
Rate for Payer: Medical Associates Commercial	$8.42
Rate for Payer: Medical Associates Managed Medicare	$5.62
Rate for Payer: Midlands Choice Commercial	$7.86
Rate for Payer: Molina Healthcare Managed Medicaid	$5.70
Rate for Payer: Molina Healthcare Managed Medicare	$5.70
Rate for Payer: Oscar Health of IA Commercial	$8.42
Rate for Payer: Partners Health Alliance Commercial	$8.42
Rate for Payer: United Healthcare Commercial	$10.11
Rate for Payer: United Healthcare Managed Medicare	$6.63

TRANSCUTANEOUS BILI

Facility

$61.00

Service Code	CPT 88720
Hospital Charge Code	1099777
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

TRANSCUTANEOUS BILI

Facility

$61.00

Service Code	CPT 88720
Hospital Charge Code	1099777
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$30.79
Rate for Payer: Amerigroup Medicare	$30.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.50
Rate for Payer: Iowa Total Care Managed Medicaid	$30.49
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$30.50
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$30.96
Rate for Payer: Molina Healthcare Managed Medicare	$30.94
Rate for Payer: Oscar Health of IA Commercial	$45.75
Rate for Payer: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

TRANSCUTANEOUS BILI

Facility

$61.00

Service Code	CPT 88720
Hospital Charge Code	8027044
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$30.79
Rate for Payer: Amerigroup Medicare	$30.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.50
Rate for Payer: Iowa Total Care Managed Medicaid	$30.49
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$30.50
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$30.96
Rate for Payer: Molina Healthcare Managed Medicare	$30.94
Rate for Payer: Oscar Health of IA Commercial	$45.75
Rate for Payer: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

TRANSCUTANEOUS BILI

Facility

$61.00

Service Code	CPT 88720
Hospital Charge Code	4882833
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

TRANSCUTANEOUS BILI

Facility

$61.00

Service Code	CPT 88720
Hospital Charge Code	4882833
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$30.79
Rate for Payer: Amerigroup Medicare	$30.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$30.50
Rate for Payer: Iowa Total Care Managed Medicaid	$30.49
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$30.50
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$30.96
Rate for Payer: Molina Healthcare Managed Medicare	$30.94
Rate for Payer: Oscar Health of IA Commercial	$45.75
Rate for Payer: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

TRANSCUTANEOUS BILI

Facility

$61.00

Service Code	CPT 88720
Hospital Charge Code	8027044
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

Transferrin DMCL

Facility

$104.00

Service Code	CPT 84466
Hospital Charge Code	8037819
Hospital Revenue Code	301
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: United Healthcare Commercial	$93.60

Transferrin DMCL

Facility

$104.00

Service Code	CPT 84466
Hospital Charge Code	8037819
Hospital Revenue Code	301
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Aetna of IA Medicare	$59.28
Rate for Payer: Amerigroup Medicaid	$52.49
Rate for Payer: Amerigroup Medicare	$52.52
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$52.00
Rate for Payer: Iowa Total Care Managed Medicaid	$51.98
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Medical Associates Managed Medicare	$52.00
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: Molina Healthcare Managed Medicaid	$52.78
Rate for Payer: Molina Healthcare Managed Medicare	$52.75
Rate for Payer: Oscar Health of IA Commercial	$78.00
Rate for Payer: Partners Health Alliance Commercial	$78.00
Rate for Payer: United Healthcare Commercial	$93.60
Rate for Payer: United Healthcare Managed Medicare	$61.36
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

Transient Ischemia Without Thrombolytic

Facility

$6,229.26

Service Code	MS-DRG 069
Hospital Charge Code	749
Min. Negotiated Rate	$6,138.98
Max. Negotiated Rate	$6,229.26
Rate for Payer: Amerigroup Medicaid	$6,199.17
Rate for Payer: Iowa Total Care Managed Medicaid	$6,138.98
Rate for Payer: Molina Healthcare Managed Medicaid	$6,229.26

Transurethral Procedures With CC

Facility

$13,491.98

Service Code	MS-DRG 669
Hospital Charge Code	451
Min. Negotiated Rate	$13,296.44
Max. Negotiated Rate	$13,491.98
Rate for Payer: Amerigroup Medicaid	$13,426.80
Rate for Payer: Iowa Total Care Managed Medicaid	$13,296.44
Rate for Payer: Molina Healthcare Managed Medicaid	$13,491.98

Transurethral Procedures With MCC

Facility

$15,699.64

Service Code	MS-DRG 668
Hospital Charge Code	450
Min. Negotiated Rate	$15,472.10
Max. Negotiated Rate	$15,699.64
Rate for Payer: Amerigroup Medicaid	$15,623.79
Rate for Payer: Iowa Total Care Managed Medicaid	$15,472.10
Rate for Payer: Molina Healthcare Managed Medicaid	$15,699.64

Transurethral Procedures Without CC/MCC

Facility

$7,947.75

Service Code	MS-DRG 670
Hospital Charge Code	452
Min. Negotiated Rate	$7,832.57
Max. Negotiated Rate	$7,947.75
Rate for Payer: Amerigroup Medicaid	$7,909.36
Rate for Payer: Iowa Total Care Managed Medicaid	$7,832.57
Rate for Payer: Molina Healthcare Managed Medicaid	$7,947.75

Transurethral Prostatectomy With CC/MCC

Facility

$9,469.39

Service Code	MS-DRG 713
Hospital Charge Code	480
Min. Negotiated Rate	$9,332.15
Max. Negotiated Rate	$9,469.39
Rate for Payer: Amerigroup Medicaid	$9,423.65
Rate for Payer: Iowa Total Care Managed Medicaid	$9,332.15
Rate for Payer: Molina Healthcare Managed Medicaid	$9,469.39

Transurethral Prostatectomy Without CC/MCC

Facility

$7,155.43

Service Code	MS-DRG 714
Hospital Charge Code	481
Min. Negotiated Rate	$7,051.73
Max. Negotiated Rate	$7,155.43
Rate for Payer: Amerigroup Medicaid	$7,120.86
Rate for Payer: Iowa Total Care Managed Medicaid	$7,051.73
Rate for Payer: Molina Healthcare Managed Medicaid	$7,155.43

Transversus abdominis plane (TAP) block (abdominal plane block, rectus sheath block) unilateral; by injection(s) (includes imaging guidance, when performed)

Facility

$703.14

Service Code	CPT 64486
Hospital Revenue Code	360
Min. Negotiated Rate	$639.22
Max. Negotiated Rate	$703.14
Rate for Payer: Wellmark IA HMO	$639.22
Rate for Payer: Wellmark IA PPO	$703.14

trastuzumab 150 mg Pow SDV [VDMC]

Facility

$6,283.68

Service Code	HCPCS J9355
Hospital Charge Code	20431208
Hospital Revenue Code	259
Min. Negotiated Rate	$4,398.58
Max. Negotiated Rate	$5,655.31
Rate for Payer: Aetna of IA Commercial	$5,655.31
Rate for Payer: Aetna of IA Medical Rental Products	$5,655.31
Rate for Payer: Cash Price	$5,026.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,712.76
Rate for Payer: Medical Associates Commercial	$4,712.76
Rate for Payer: Midlands Choice Commercial	$4,398.58
Rate for Payer: United Healthcare Commercial	$5,655.31

trastuzumab 150 mg Pow SDV [VDMC]

Facility

$6,283.68

Service Code	HCPCS J9355
Hospital Charge Code	20431208
Hospital Revenue Code	259
Min. Negotiated Rate	$3,140.58
Max. Negotiated Rate	$5,655.31
Rate for Payer: Aetna of IA Commercial	$5,655.31
Rate for Payer: Aetna of IA Medical Rental Products	$5,655.31
Rate for Payer: Aetna of IA Medicare	$3,581.70
Rate for Payer: Amerigroup Medicaid	$3,171.37
Rate for Payer: Amerigroup Medicare	$3,173.26
Rate for Payer: Cash Price	$5,026.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,712.76
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,141.84
Rate for Payer: Iowa Total Care Managed Medicaid	$3,140.58
Rate for Payer: Medical Associates Commercial	$4,712.76
Rate for Payer: Medical Associates Managed Medicare	$3,141.84
Rate for Payer: Midlands Choice Commercial	$4,398.58
Rate for Payer: Molina Healthcare Managed Medicaid	$3,188.97
Rate for Payer: Molina Healthcare Managed Medicare	$3,187.08
Rate for Payer: Oscar Health of IA Commercial	$4,712.76
Rate for Payer: Partners Health Alliance Commercial	$4,712.76
Rate for Payer: United Healthcare Commercial	$5,655.31
Rate for Payer: United Healthcare Managed Medicare	$3,707.37

trastuzumab dttb 150 mg MDV Pow [VDMC]

Facility

$2,316.42

Service Code	HCPCS Q5112
Hospital Charge Code	22292749
Hospital Revenue Code	636
Min. Negotiated Rate	$1,157.75
Max. Negotiated Rate	$2,084.78
Rate for Payer: Aetna of IA Commercial	$2,084.78
Rate for Payer: Aetna of IA Medical Rental Products	$2,084.78
Rate for Payer: Aetna of IA Medicare	$1,320.36
Rate for Payer: Amerigroup Medicaid	$1,169.10
Rate for Payer: Amerigroup Medicare	$1,169.79
Rate for Payer: Cash Price	$1,853.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,737.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,158.21
Rate for Payer: Iowa Total Care Managed Medicaid	$1,157.75
Rate for Payer: Medical Associates Commercial	$1,737.32
Rate for Payer: Medical Associates Managed Medicare	$1,158.21
Rate for Payer: Midlands Choice Commercial	$1,621.49
Rate for Payer: Molina Healthcare Managed Medicaid	$1,175.58
Rate for Payer: Molina Healthcare Managed Medicare	$1,174.89
Rate for Payer: Oscar Health of IA Commercial	$1,737.32
Rate for Payer: Partners Health Alliance Commercial	$1,737.32
Rate for Payer: United Healthcare Commercial	$2,084.78
Rate for Payer: United Healthcare Managed Medicare	$1,366.69

trastuzumab dttb 150 mg MDV Pow [VDMC]

Facility

$2,316.42

Service Code	HCPCS Q5112
Hospital Charge Code	22292749
Hospital Revenue Code	636
Min. Negotiated Rate	$1,621.49
Max. Negotiated Rate	$2,084.78
Rate for Payer: Aetna of IA Commercial	$2,084.78
Rate for Payer: Aetna of IA Medical Rental Products	$2,084.78
Rate for Payer: Cash Price	$1,853.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,737.32
Rate for Payer: Medical Associates Commercial	$1,737.32
Rate for Payer: Midlands Choice Commercial	$1,621.49
Rate for Payer: United Healthcare Commercial	$2,084.78

trastuzumab dttb 420 mg Pow MDV [VDMC]

Facility

$6,305.98

Service Code	HCPCS Q5112
Hospital Charge Code	22292637
Hospital Revenue Code	636
Min. Negotiated Rate	$3,151.73
Max. Negotiated Rate	$5,675.38
Rate for Payer: Aetna of IA Commercial	$5,675.38
Rate for Payer: Aetna of IA Medical Rental Products	$5,675.38
Rate for Payer: Aetna of IA Medicare	$3,594.41
Rate for Payer: Amerigroup Medicaid	$3,182.63
Rate for Payer: Amerigroup Medicare	$3,184.52
Rate for Payer: Cash Price	$5,044.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,729.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,152.99
Rate for Payer: Iowa Total Care Managed Medicaid	$3,151.73
Rate for Payer: Medical Associates Commercial	$4,729.48
Rate for Payer: Medical Associates Managed Medicare	$3,152.99
Rate for Payer: Midlands Choice Commercial	$4,414.19
Rate for Payer: Molina Healthcare Managed Medicaid	$3,200.28
Rate for Payer: Molina Healthcare Managed Medicare	$3,198.39
Rate for Payer: Oscar Health of IA Commercial	$4,729.48
Rate for Payer: Partners Health Alliance Commercial	$4,729.48
Rate for Payer: United Healthcare Commercial	$5,675.38
Rate for Payer: United Healthcare Managed Medicare	$3,720.53

trastuzumab dttb 420 mg Pow MDV [VDMC]

Facility

$6,305.98

Service Code	HCPCS Q5112
Hospital Charge Code	22292637
Hospital Revenue Code	636
Min. Negotiated Rate	$4,414.19
Max. Negotiated Rate	$5,675.38
Rate for Payer: Aetna of IA Commercial	$5,675.38
Rate for Payer: Aetna of IA Medical Rental Products	$5,675.38
Rate for Payer: Cash Price	$5,044.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,729.48
Rate for Payer: Medical Associates Commercial	$4,729.48
Rate for Payer: Midlands Choice Commercial	$4,414.19
Rate for Payer: United Healthcare Commercial	$5,675.38

Traumatic Injury With MCC

Facility

$16,110.06

Service Code	MS-DRG 913
Hospital Charge Code	631
Min. Negotiated Rate	$15,876.59
Max. Negotiated Rate	$16,110.06
Rate for Payer: Amerigroup Medicaid	$16,032.24
Rate for Payer: Iowa Total Care Managed Medicaid	$15,876.59
Rate for Payer: Molina Healthcare Managed Medicaid	$16,110.06

Traumatic Injury Without MCC

Facility

$5,406.44

Service Code	MS-DRG 914
Hospital Charge Code	632
Min. Negotiated Rate	$5,328.08
Max. Negotiated Rate	$5,406.44
Rate for Payer: Amerigroup Medicaid	$5,380.32
Rate for Payer: Iowa Total Care Managed Medicaid	$5,328.08
Rate for Payer: Molina Healthcare Managed Medicaid	$5,406.44

Know your out-of-pocket cost for care.

All Charges