Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Traumatic Stupor and Coma <1 Hour With CC

Facility

$7,867.05

Service Code	MS-DRG 086
Hospital Charge Code	766
Min. Negotiated Rate	$7,753.03
Max. Negotiated Rate	$7,867.05
Rate for Payer: Amerigroup Medicaid	$7,829.04
Rate for Payer: Iowa Total Care Managed Medicaid	$7,753.03
Rate for Payer: Molina Healthcare Managed Medicaid	$7,867.05

Traumatic Stupor and Coma >1 Hour With CC

Facility

$8,774.51

Service Code	MS-DRG 083
Hospital Charge Code	763
Min. Negotiated Rate	$8,647.35
Max. Negotiated Rate	$8,774.51
Rate for Payer: Amerigroup Medicaid	$8,732.12
Rate for Payer: Iowa Total Care Managed Medicaid	$8,647.35
Rate for Payer: Molina Healthcare Managed Medicaid	$8,774.51

Traumatic Stupor and Coma <1 Hour With MCC

Facility

$13,141.59

Service Code	MS-DRG 085
Hospital Charge Code	765
Min. Negotiated Rate	$12,951.13
Max. Negotiated Rate	$13,141.59
Rate for Payer: Amerigroup Medicaid	$13,078.11
Rate for Payer: Iowa Total Care Managed Medicaid	$12,951.13
Rate for Payer: Molina Healthcare Managed Medicaid	$13,141.59

Traumatic Stupor and Coma >1 Hour With MCC

Facility

$23,574.56

Service Code	MS-DRG 082
Hospital Charge Code	762
Min. Negotiated Rate	$23,232.90
Max. Negotiated Rate	$23,574.56
Rate for Payer: Amerigroup Medicaid	$23,460.67
Rate for Payer: Iowa Total Care Managed Medicaid	$23,232.90
Rate for Payer: Molina Healthcare Managed Medicaid	$23,574.56

Traumatic Stupor and Coma <1 Hour Without CC/MCC

Facility

$4,856.25

Service Code	MS-DRG 087
Hospital Charge Code	767
Min. Negotiated Rate	$4,785.87
Max. Negotiated Rate	$4,856.25
Rate for Payer: Amerigroup Medicaid	$4,832.79
Rate for Payer: Iowa Total Care Managed Medicaid	$4,785.87
Rate for Payer: Molina Healthcare Managed Medicaid	$4,856.25

Traumatic Stupor and Coma >1 Hour Without CC/MCC

Facility

$5,261.75

Service Code	MS-DRG 084
Hospital Charge Code	764
Min. Negotiated Rate	$5,185.50
Max. Negotiated Rate	$5,261.75
Rate for Payer: Amerigroup Medicaid	$5,236.33
Rate for Payer: Iowa Total Care Managed Medicaid	$5,185.50
Rate for Payer: Molina Healthcare Managed Medicaid	$5,261.75

Trauma to the Skin, Subcutaneous Tissue and Breast With MCC

Facility

$8,740.07

Service Code	MS-DRG 604
Hospital Charge Code	402
Min. Negotiated Rate	$8,613.40
Max. Negotiated Rate	$8,740.07
Rate for Payer: Amerigroup Medicaid	$8,697.85
Rate for Payer: Iowa Total Care Managed Medicaid	$8,613.40
Rate for Payer: Molina Healthcare Managed Medicaid	$8,740.07

Trauma to the Skin, Subcutaneous Tissue and Breast Without MCC

Facility

$6,174.15

Service Code	MS-DRG 605
Hospital Charge Code	403
Min. Negotiated Rate	$6,084.67
Max. Negotiated Rate	$6,174.15
Rate for Payer: Amerigroup Medicaid	$6,144.32
Rate for Payer: Iowa Total Care Managed Medicaid	$6,084.67
Rate for Payer: Molina Healthcare Managed Medicaid	$6,174.15

travoprost 0.004% Ophth Sol [VDMC]

Facility

$595.88

Service Code	HCPCS A9270
Hospital Charge Code	10439650
Hospital Revenue Code	259
Min. Negotiated Rate	$417.12
Max. Negotiated Rate	$536.29
Rate for Payer: Aetna of IA Commercial	$536.29
Rate for Payer: Aetna of IA Medical Rental Products	$536.29
Rate for Payer: Cash Price	$476.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$446.91
Rate for Payer: Medical Associates Commercial	$446.91
Rate for Payer: Midlands Choice Commercial	$417.12
Rate for Payer: United Healthcare Commercial	$536.29

travoprost 0.004% Ophth Sol [VDMC]

Facility

$595.88

Service Code	HCPCS A9270
Hospital Charge Code	10439650
Hospital Revenue Code	259
Min. Negotiated Rate	$297.82
Max. Negotiated Rate	$536.29
Rate for Payer: Aetna of IA Commercial	$536.29
Rate for Payer: Aetna of IA Medical Rental Products	$536.29
Rate for Payer: Aetna of IA Medicare	$339.65
Rate for Payer: Amerigroup Medicaid	$300.74
Rate for Payer: Amerigroup Medicare	$300.92
Rate for Payer: Cash Price	$476.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$446.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$297.94
Rate for Payer: Iowa Total Care Managed Medicaid	$297.82
Rate for Payer: Medical Associates Commercial	$446.91
Rate for Payer: Medical Associates Managed Medicare	$297.94
Rate for Payer: Midlands Choice Commercial	$417.12
Rate for Payer: Molina Healthcare Managed Medicaid	$302.41
Rate for Payer: Molina Healthcare Managed Medicare	$302.23
Rate for Payer: Oscar Health of IA Commercial	$446.91
Rate for Payer: Partners Health Alliance Commercial	$446.91
Rate for Payer: United Healthcare Commercial	$536.29
Rate for Payer: United Healthcare Managed Medicare	$351.57

traZODone 50 mg Tab [VDMC]

Facility

$1.14

Service Code	HCPCS A9270
Hospital Charge Code	10426114
Hospital Revenue Code	259
Min. Negotiated Rate	$0.80
Max. Negotiated Rate	$1.03
Rate for Payer: Medical Associates Commercial	$0.86
Rate for Payer: Aetna of IA Commercial	$1.03
Rate for Payer: Aetna of IA Medical Rental Products	$1.03
Rate for Payer: Cash Price	$0.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.86
Rate for Payer: Midlands Choice Commercial	$0.80
Rate for Payer: United Healthcare Commercial	$1.03

traZODone 50 mg Tab [VDMC]

Facility

$1.14

Service Code	HCPCS A9270
Hospital Charge Code	10426114
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$1.03
Rate for Payer: Aetna of IA Commercial	$1.03
Rate for Payer: Aetna of IA Medical Rental Products	$1.03
Rate for Payer: Aetna of IA Medicare	$0.65
Rate for Payer: Amerigroup Medicaid	$0.58
Rate for Payer: Amerigroup Medicare	$0.58
Rate for Payer: Cash Price	$0.91
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.86
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.57
Rate for Payer: Iowa Total Care Managed Medicaid	$0.57
Rate for Payer: Medical Associates Commercial	$0.86
Rate for Payer: Medical Associates Managed Medicare	$0.57
Rate for Payer: Midlands Choice Commercial	$0.80
Rate for Payer: Molina Healthcare Managed Medicaid	$0.58
Rate for Payer: Molina Healthcare Managed Medicare	$0.58
Rate for Payer: Oscar Health of IA Commercial	$0.86
Rate for Payer: Partners Health Alliance Commercial	$0.86
Rate for Payer: United Healthcare Commercial	$1.03
Rate for Payer: United Healthcare Managed Medicare	$0.67

TREAT CLAVICLE FRACTURE

Professional

Both

$424.00

Service Code	CPT 23500
Hospital Charge Code	7982813
Hospital Revenue Code	981
Min. Negotiated Rate	$214.38
Max. Negotiated Rate	$385.88
Rate for Payer: Aetna of IA Medicare	$214.38
Rate for Payer: Amerigroup Medicaid	$221.67
Rate for Payer: Cash Price	$339.20
Rate for Payer: Cash Price	$339.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$257.26
Rate for Payer: Iowa Total Care Managed Medicaid	$218.67
Rate for Payer: Medical Associates Commercial	$385.88
Rate for Payer: Medical Associates Managed Medicare	$214.38
Rate for Payer: Midlands Choice Commercial	$296.80
Rate for Payer: Oscar Health of IA Commercial	$370.88
Rate for Payer: Partners Health Alliance Commercial	$321.57

TREAT DISLOCATION/FRACTURE

Professional

Both

$1,228.00

Service Code	CPT 23665
Hospital Charge Code	7982871
Hospital Revenue Code	981
Min. Negotiated Rate	$371.29
Max. Negotiated Rate	$859.60
Rate for Payer: Aetna of IA Medicare	$371.29
Rate for Payer: Amerigroup Medicaid	$383.91
Rate for Payer: Cash Price	$982.40
Rate for Payer: Cash Price	$982.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$445.55
Rate for Payer: Iowa Total Care Managed Medicaid	$378.72
Rate for Payer: Medical Associates Commercial	$668.32
Rate for Payer: Medical Associates Managed Medicare	$371.29
Rate for Payer: Midlands Choice Commercial	$859.60
Rate for Payer: Oscar Health of IA Commercial	$642.33
Rate for Payer: Partners Health Alliance Commercial	$556.94

TREAT FINGER DISLOCATION

Professional

Both

$788.00

Service Code	CPT 26770
Hospital Charge Code	7982797
Hospital Revenue Code	981
Min. Negotiated Rate	$246.35
Max. Negotiated Rate	$551.60
Rate for Payer: Aetna of IA Medicare	$246.35
Rate for Payer: Amerigroup Medicaid	$254.73
Rate for Payer: Cash Price	$630.40
Rate for Payer: Cash Price	$630.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.62
Rate for Payer: Iowa Total Care Managed Medicaid	$251.28
Rate for Payer: Medical Associates Commercial	$443.43
Rate for Payer: Medical Associates Managed Medicare	$246.35
Rate for Payer: Midlands Choice Commercial	$551.60
Rate for Payer: Oscar Health of IA Commercial	$426.19
Rate for Payer: Partners Health Alliance Commercial	$369.52

TREAT FINGER FRACTURE EACH

Professional

Both

$1,038.00

Service Code	CPT 26755
Hospital Charge Code	7982799
Hospital Revenue Code	981
Min. Negotiated Rate	$255.85
Max. Negotiated Rate	$726.60
Rate for Payer: Aetna of IA Medicare	$255.85
Rate for Payer: Amerigroup Medicaid	$264.55
Rate for Payer: Cash Price	$830.40
Rate for Payer: Cash Price	$830.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$307.02
Rate for Payer: Iowa Total Care Managed Medicaid	$260.97
Rate for Payer: Medical Associates Commercial	$460.53
Rate for Payer: Medical Associates Managed Medicare	$255.85
Rate for Payer: Midlands Choice Commercial	$726.60
Rate for Payer: Oscar Health of IA Commercial	$442.62
Rate for Payer: Partners Health Alliance Commercial	$383.78

TREAT FINGER FRACTURE EACH

Professional

Both

$1,670.00

Service Code	CPT 26765
Hospital Charge Code	7982798
Hospital Revenue Code	981
Min. Negotiated Rate	$462.60
Max. Negotiated Rate	$1,169.00
Rate for Payer: Aetna of IA Medicare	$462.60
Rate for Payer: Amerigroup Medicaid	$478.33
Rate for Payer: Cash Price	$1,336.00
Rate for Payer: Cash Price	$1,336.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$555.12
Rate for Payer: Iowa Total Care Managed Medicaid	$471.85
Rate for Payer: Medical Associates Commercial	$832.68
Rate for Payer: Medical Associates Managed Medicare	$462.60
Rate for Payer: Midlands Choice Commercial	$1,169.00
Rate for Payer: Oscar Health of IA Commercial	$800.30
Rate for Payer: Partners Health Alliance Commercial	$693.90

TREAT FINGER FRACTURE EACH

Professional

Both

$1,114.00

Service Code	CPT 26725
Hospital Charge Code	7982800
Hospital Revenue Code	981
Min. Negotiated Rate	$284.51
Max. Negotiated Rate	$779.80
Rate for Payer: Aetna of IA Medicare	$284.51
Rate for Payer: Amerigroup Medicaid	$294.18
Rate for Payer: Cash Price	$891.20
Rate for Payer: Cash Price	$891.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$341.41
Rate for Payer: Iowa Total Care Managed Medicaid	$290.20
Rate for Payer: Medical Associates Commercial	$512.12
Rate for Payer: Medical Associates Managed Medicare	$284.51
Rate for Payer: Midlands Choice Commercial	$779.80
Rate for Payer: Oscar Health of IA Commercial	$492.20
Rate for Payer: Partners Health Alliance Commercial	$426.76

TREAT FRACTURE OF RADIUS

Professional

Both

$1,409.00

Service Code	CPT 25505
Hospital Charge Code	7982869
Hospital Revenue Code	981
Min. Negotiated Rate	$427.06
Max. Negotiated Rate	$986.30
Rate for Payer: Aetna of IA Medicare	$427.06
Rate for Payer: Amerigroup Medicaid	$441.58
Rate for Payer: Cash Price	$1,127.20
Rate for Payer: Cash Price	$1,127.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$512.47
Rate for Payer: Iowa Total Care Managed Medicaid	$435.60
Rate for Payer: Medical Associates Commercial	$768.71
Rate for Payer: Medical Associates Managed Medicare	$427.06
Rate for Payer: Midlands Choice Commercial	$986.30
Rate for Payer: Oscar Health of IA Commercial	$738.81
Rate for Payer: Partners Health Alliance Commercial	$640.59

TREAT FRACTURE RADIUS ULNA

Facility

$1,256.00

Service Code	CPT 25565
Hospital Charge Code	4864848
Hospital Revenue Code	761
Min. Negotiated Rate	$627.75
Max. Negotiated Rate	$3,346.57
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	$633.90
Rate for Payer: Amerigroup Medicare	$634.28
Rate for Payer: Cash Price	$1,004.80
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	$628.00
Rate for Payer: Iowa Total Care Managed Medicaid	$627.75
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Medical Associates Managed Medicare	$628.00
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: Molina Healthcare Managed Medicaid	$637.42
Rate for Payer: Molina Healthcare Managed Medicare	$637.04
Rate for Payer: Oscar Health of IA Commercial	$942.00
Rate for Payer: Partners Health Alliance Commercial	$942.00
Rate for Payer: United Healthcare Commercial	$1,130.40
Rate for Payer: United Healthcare Managed Medicare	$741.04
Rate for Payer: Wellmark IA HMO	$3,042.34
Rate for Payer: Wellmark IA PPO	$3,346.57

TREAT FRACTURE RADIUS ULNA

Professional

Both

$920.00

Service Code	CPT 25560
Hospital Charge Code	7982807
Hospital Revenue Code	981
Min. Negotiated Rate	$243.41
Max. Negotiated Rate	$644.00
Rate for Payer: Aetna of IA Medicare	$243.41
Rate for Payer: Amerigroup Medicaid	$251.69
Rate for Payer: Cash Price	$736.00
Rate for Payer: Cash Price	$736.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$292.09
Rate for Payer: Iowa Total Care Managed Medicaid	$248.28
Rate for Payer: Medical Associates Commercial	$438.14
Rate for Payer: Medical Associates Managed Medicare	$243.41
Rate for Payer: Midlands Choice Commercial	$644.00
Rate for Payer: Oscar Health of IA Commercial	$421.10
Rate for Payer: Partners Health Alliance Commercial	$365.12

TREAT FRACTURE RADIUS ULNA

Facility

$1,256.00

Service Code	CPT 25565
Hospital Charge Code	4864848
Hospital Revenue Code	761
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 FRACTURE RADIUS/ULNA

Professional

Both

$1,805.00

Service Code	CPT 25605
Hospital Charge Code	7982805
Hospital Revenue Code	981
Min. Negotiated Rate	$471.64
Max. Negotiated Rate	$1,263.50
Rate for Payer: Aetna of IA Medicare	$471.64
Rate for Payer: Amerigroup Medicaid	$487.68
Rate for Payer: Cash Price	$1,444.00
Rate for Payer: Cash Price	$1,444.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$565.97
Rate for Payer: Iowa Total Care Managed Medicaid	$481.07
Rate for Payer: Medical Associates Commercial	$848.95
Rate for Payer: Medical Associates Managed Medicare	$471.64
Rate for Payer: Midlands Choice Commercial	$1,263.50
Rate for Payer: Oscar Health of IA Commercial	$815.94
Rate for Payer: Partners Health Alliance Commercial	$707.46

TREAT FRACTURE RADIUS/ULNA

Professional

Both

$1,087.00

Service Code	CPT 25600
Hospital Charge Code	7982806
Hospital Revenue Code	981
Min. Negotiated Rate	$304.19
Max. Negotiated Rate	$760.90
Rate for Payer: Aetna of IA Medicare	$304.19
Rate for Payer: Amerigroup Medicaid	$314.53
Rate for Payer: Cash Price	$869.60
Rate for Payer: Cash Price	$869.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$365.03
Rate for Payer: Iowa Total Care Managed Medicaid	$310.27
Rate for Payer: Medical Associates Commercial	$547.54
Rate for Payer: Medical Associates Managed Medicare	$304.19
Rate for Payer: Midlands Choice Commercial	$760.90
Rate for Payer: Oscar Health of IA Commercial	$526.25
Rate for Payer: Partners Health Alliance Commercial	$456.28

TREAT HAND DISLOCATION

Professional

Both

$2,085.00

Service Code	CPT 26686
Hospital Charge Code	7982867
Hospital Revenue Code	981
Min. Negotiated Rate	$566.80
Max. Negotiated Rate	$1,459.50
Rate for Payer: Aetna of IA Medicare	$566.80
Rate for Payer: Amerigroup Medicaid	$586.07
Rate for Payer: Cash Price	$1,668.00
Rate for Payer: Cash Price	$1,668.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$680.16
Rate for Payer: Iowa Total Care Managed Medicaid	$578.14
Rate for Payer: Medical Associates Commercial	$1,020.24
Rate for Payer: Medical Associates Managed Medicare	$566.80
Rate for Payer: Midlands Choice Commercial	$1,459.50
Rate for Payer: Oscar Health of IA Commercial	$980.56
Rate for Payer: Partners Health Alliance Commercial	$850.20

Know your out-of-pocket cost for care.

All Charges