Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

trospium chloride 20 mg Tab [VDMC]

Facility

$1.76

Service Code	HCPCS A9270
Hospital Charge Code	10426774
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of IA Commercial	$1.58
Rate for Payer: Aetna of IA Medical Rental Products	$1.58
Rate for Payer: Aetna of IA Medicare	$1.00
Rate for Payer: Amerigroup Medicaid	$0.89
Rate for Payer: Amerigroup Medicare	$0.89
Rate for Payer: Cash Price	$1.41
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.88
Rate for Payer: Iowa Total Care Managed Medicaid	$0.88
Rate for Payer: Medical Associates Commercial	$1.32
Rate for Payer: Medical Associates Managed Medicare	$0.88
Rate for Payer: Midlands Choice Commercial	$1.23
Rate for Payer: Molina Healthcare Managed Medicaid	$0.89
Rate for Payer: Molina Healthcare Managed Medicare	$0.89
Rate for Payer: Oscar Health of IA Commercial	$1.32
Rate for Payer: Partners Health Alliance Commercial	$1.32
Rate for Payer: United Healthcare Commercial	$1.58
Rate for Payer: United Healthcare Managed Medicare	$1.04

trypan blue Ophth 0.06% Sol [VDMC]

Facility

$307.00

Service Code	NDC 68803-0612-10
Hospital Charge Code	10439906
Hospital Revenue Code	259
Min. Negotiated Rate	$214.90
Max. Negotiated Rate	$276.30
Rate for Payer: Aetna of IA Commercial	$276.30
Rate for Payer: Aetna of IA Medical Rental Products	$276.30
Rate for Payer: Cash Price	$245.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$230.25
Rate for Payer: Medical Associates Commercial	$230.25
Rate for Payer: Midlands Choice Commercial	$214.90
Rate for Payer: United Healthcare Commercial	$276.30

trypan blue Ophth 0.06% Sol [VDMC]

Facility

$307.00

Service Code	NDC 68803-0612-10
Hospital Charge Code	10439906
Hospital Revenue Code	259
Min. Negotiated Rate	$153.44
Max. Negotiated Rate	$276.30
Rate for Payer: Aetna of IA Commercial	$276.30
Rate for Payer: Aetna of IA Medical Rental Products	$276.30
Rate for Payer: Aetna of IA Medicare	$174.99
Rate for Payer: Amerigroup Medicaid	$154.94
Rate for Payer: Amerigroup Medicare	$155.04
Rate for Payer: Cash Price	$245.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$230.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$153.50
Rate for Payer: Iowa Total Care Managed Medicaid	$153.44
Rate for Payer: Medical Associates Commercial	$230.25
Rate for Payer: Medical Associates Managed Medicare	$153.50
Rate for Payer: Midlands Choice Commercial	$214.90
Rate for Payer: Molina Healthcare Managed Medicaid	$155.80
Rate for Payer: Molina Healthcare Managed Medicare	$155.71
Rate for Payer: Oscar Health of IA Commercial	$230.25
Rate for Payer: Partners Health Alliance Commercial	$230.25
Rate for Payer: United Healthcare Commercial	$276.30
Rate for Payer: United Healthcare Managed Medicare	$181.13

Tryptase DMCL

Facility

$123.00

Service Code	CPT 83520
Hospital Charge Code	8037820
Hospital Revenue Code	301
Min. Negotiated Rate	$86.10
Max. Negotiated Rate	$110.70
Rate for Payer: Aetna of IA Commercial	$110.70
Rate for Payer: Aetna of IA Medical Rental Products	$110.70
Rate for Payer: Cash Price	$98.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$92.25
Rate for Payer: Medical Associates Commercial	$92.25
Rate for Payer: Midlands Choice Commercial	$86.10
Rate for Payer: United Healthcare Commercial	$110.70

Tryptase DMCL

Facility

$123.00

Service Code	CPT 83520
Hospital Charge Code	8037820
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$110.70
Rate for Payer: Aetna of IA Commercial	$110.70
Rate for Payer: Aetna of IA Medical Rental Products	$110.70
Rate for Payer: Aetna of IA Medicare	$70.11
Rate for Payer: Amerigroup Medicaid	$62.08
Rate for Payer: Amerigroup Medicare	$62.12
Rate for Payer: Cash Price	$98.40
Rate for Payer: Cash Price	$98.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$92.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$61.50
Rate for Payer: Iowa Total Care Managed Medicaid	$61.48
Rate for Payer: Medical Associates Commercial	$92.25
Rate for Payer: Medical Associates Managed Medicare	$61.50
Rate for Payer: Midlands Choice Commercial	$86.10
Rate for Payer: Molina Healthcare Managed Medicaid	$62.42
Rate for Payer: Molina Healthcare Managed Medicare	$62.39
Rate for Payer: Oscar Health of IA Commercial	$92.25
Rate for Payer: Partners Health Alliance Commercial	$92.25
Rate for Payer: United Healthcare Commercial	$110.70
Rate for Payer: United Healthcare Managed Medicare	$72.57
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

TSH

Facility

$137.00

Service Code	CPT 84443
Hospital Charge Code	633844
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of IA Commercial	$123.30
Rate for Payer: Aetna of IA Medical Rental Products	$123.30
Rate for Payer: Aetna of IA Medicare	$78.09
Rate for Payer: Amerigroup Medicaid	$69.14
Rate for Payer: Amerigroup Medicare	$69.18
Rate for Payer: Cash Price	$109.60
Rate for Payer: Cash Price	$109.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$68.50
Rate for Payer: Iowa Total Care Managed Medicaid	$68.47
Rate for Payer: Medical Associates Commercial	$102.75
Rate for Payer: Medical Associates Managed Medicare	$68.50
Rate for Payer: Midlands Choice Commercial	$95.90
Rate for Payer: Molina Healthcare Managed Medicaid	$69.53
Rate for Payer: Molina Healthcare Managed Medicare	$69.49
Rate for Payer: Oscar Health of IA Commercial	$102.75
Rate for Payer: Partners Health Alliance Commercial	$102.75
Rate for Payer: United Healthcare Commercial	$123.30
Rate for Payer: United Healthcare Managed Medicare	$80.83
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

TSH

Facility

$137.00

Service Code	CPT 84443
Hospital Charge Code	633844
Hospital Revenue Code	301
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of IA Commercial	$123.30
Rate for Payer: Aetna of IA Medical Rental Products	$123.30
Rate for Payer: Cash Price	$109.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.75
Rate for Payer: Medical Associates Commercial	$102.75
Rate for Payer: Midlands Choice Commercial	$95.90
Rate for Payer: United Healthcare Commercial	$123.30

tuberculin purified protein derivative 5 TU/0.1 mL ID MDV Sol [VDMC]

Facility

$55.44

Service Code	NDC 49281-0752-21
Hospital Charge Code	10426843
Hospital Revenue Code	259
Min. Negotiated Rate	$38.81
Max. Negotiated Rate	$49.90
Rate for Payer: Aetna of IA Commercial	$49.90
Rate for Payer: Aetna of IA Medical Rental Products	$49.90
Rate for Payer: Cash Price	$44.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$41.58
Rate for Payer: Medical Associates Commercial	$41.58
Rate for Payer: Midlands Choice Commercial	$38.81
Rate for Payer: United Healthcare Commercial	$49.90

tuberculin purified protein derivative 5 TU/0.1 mL ID MDV Sol [VDMC]

Facility

$55.44

Service Code	NDC 49281-0752-21
Hospital Charge Code	10426843
Hospital Revenue Code	259
Min. Negotiated Rate	$27.71
Max. Negotiated Rate	$49.90
Rate for Payer: Aetna of IA Commercial	$49.90
Rate for Payer: Aetna of IA Medical Rental Products	$49.90
Rate for Payer: Aetna of IA Medicare	$31.60
Rate for Payer: Amerigroup Medicaid	$27.98
Rate for Payer: Amerigroup Medicare	$28.00
Rate for Payer: Cash Price	$44.35
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$41.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.72
Rate for Payer: Iowa Total Care Managed Medicaid	$27.71
Rate for Payer: Medical Associates Commercial	$41.58
Rate for Payer: Medical Associates Managed Medicare	$27.72
Rate for Payer: Midlands Choice Commercial	$38.81
Rate for Payer: Molina Healthcare Managed Medicaid	$28.14
Rate for Payer: Molina Healthcare Managed Medicare	$28.12
Rate for Payer: Oscar Health of IA Commercial	$41.58
Rate for Payer: Partners Health Alliance Commercial	$41.58
Rate for Payer: United Healthcare Commercial	$49.90
Rate for Payer: United Healthcare Managed Medicare	$32.71

ULTRASOUND PER 15 MIN

Facility

$99.00

Service Code	CPT 97035 GO
Hospital Charge Code	1373448
Hospital Revenue Code	430
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of IA Commercial	$89.10
Rate for Payer: Aetna of IA Medical Rental Products	$89.10
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.25
Rate for Payer: Medical Associates Commercial	$74.25
Rate for Payer: Midlands Choice Commercial	$69.30
Rate for Payer: United Healthcare Commercial	$89.10

ULTRASOUND PER 15 MIN

Facility

$99.00

Service Code	CPT 97035 GO
Hospital Charge Code	1373448
Hospital Revenue Code	430
Min. Negotiated Rate	$49.48
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of IA Commercial	$89.10
Rate for Payer: Aetna of IA Medical Rental Products	$89.10
Rate for Payer: Aetna of IA Medicare	$56.43
Rate for Payer: Amerigroup Medicaid	$49.97
Rate for Payer: Amerigroup Medicare	$50.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.50
Rate for Payer: Iowa Total Care Managed Medicaid	$49.48
Rate for Payer: Medical Associates Commercial	$74.25
Rate for Payer: Medical Associates Managed Medicare	$49.50
Rate for Payer: Midlands Choice Commercial	$69.30
Rate for Payer: Molina Healthcare Managed Medicaid	$50.24
Rate for Payer: Molina Healthcare Managed Medicare	$50.21
Rate for Payer: Oscar Health of IA Commercial	$74.25
Rate for Payer: Partners Health Alliance Commercial	$74.25
Rate for Payer: United Healthcare Commercial	$89.10
Rate for Payer: United Healthcare Managed Medicare	$58.41

ULTRASOUND PER 15 MIN APPLICATION

Facility

$99.00

Service Code	CPT 97035 GP
Hospital Charge Code	1374021
Hospital Revenue Code	420
Min. Negotiated Rate	$69.30
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of IA Commercial	$89.10
Rate for Payer: Aetna of IA Medical Rental Products	$89.10
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.25
Rate for Payer: Medical Associates Commercial	$74.25
Rate for Payer: Midlands Choice Commercial	$69.30
Rate for Payer: United Healthcare Commercial	$89.10

ULTRASOUND PER 15 MIN APPLICATION

Facility

$99.00

Service Code	CPT 97035 GP
Hospital Charge Code	1374021
Hospital Revenue Code	420
Min. Negotiated Rate	$49.48
Max. Negotiated Rate	$89.10
Rate for Payer: Aetna of IA Commercial	$89.10
Rate for Payer: Aetna of IA Medical Rental Products	$89.10
Rate for Payer: Aetna of IA Medicare	$56.43
Rate for Payer: Amerigroup Medicaid	$49.97
Rate for Payer: Amerigroup Medicare	$50.00
Rate for Payer: Cash Price	$79.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$74.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.50
Rate for Payer: Iowa Total Care Managed Medicaid	$49.48
Rate for Payer: Medical Associates Commercial	$74.25
Rate for Payer: Medical Associates Managed Medicare	$49.50
Rate for Payer: Midlands Choice Commercial	$69.30
Rate for Payer: Molina Healthcare Managed Medicaid	$50.24
Rate for Payer: Molina Healthcare Managed Medicare	$50.21
Rate for Payer: Oscar Health of IA Commercial	$74.25
Rate for Payer: Partners Health Alliance Commercial	$74.25
Rate for Payer: United Healthcare Commercial	$89.10
Rate for Payer: United Healthcare Managed Medicare	$58.41

umeclidinium 62.5 mcg (0.0625 mg)/inh Pow [VDMC]

Facility

$162.28

Service Code	HCPCS A9270
Hospital Charge Code	11223551
Hospital Revenue Code	259
Min. Negotiated Rate	$113.60
Max. Negotiated Rate	$146.05
Rate for Payer: Aetna of IA Commercial	$146.05
Rate for Payer: Aetna of IA Medical Rental Products	$146.05
Rate for Payer: Cash Price	$129.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$121.71
Rate for Payer: Medical Associates Commercial	$121.71
Rate for Payer: Midlands Choice Commercial	$113.60
Rate for Payer: United Healthcare Commercial	$146.05

umeclidinium 62.5 mcg (0.0625 mg)/inh Pow [VDMC]

Facility

$162.28

Service Code	HCPCS A9270
Hospital Charge Code	11223551
Hospital Revenue Code	259
Min. Negotiated Rate	$81.11
Max. Negotiated Rate	$146.05
Rate for Payer: Aetna of IA Commercial	$146.05
Rate for Payer: Aetna of IA Medical Rental Products	$146.05
Rate for Payer: Aetna of IA Medicare	$92.50
Rate for Payer: Amerigroup Medicaid	$81.90
Rate for Payer: Amerigroup Medicare	$81.95
Rate for Payer: Cash Price	$129.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$121.71
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.14
Rate for Payer: Iowa Total Care Managed Medicaid	$81.11
Rate for Payer: Medical Associates Commercial	$121.71
Rate for Payer: Medical Associates Managed Medicare	$81.14
Rate for Payer: Midlands Choice Commercial	$113.60
Rate for Payer: Molina Healthcare Managed Medicaid	$82.36
Rate for Payer: Molina Healthcare Managed Medicare	$82.31
Rate for Payer: Oscar Health of IA Commercial	$121.71
Rate for Payer: Partners Health Alliance Commercial	$121.71
Rate for Payer: United Healthcare Commercial	$146.05
Rate for Payer: United Healthcare Managed Medicare	$95.75

Uncomplicated Peptic Ulcer With MCC

Facility

$12,905.37

Service Code	MS-DRG 383
Hospital Charge Code	224
Min. Negotiated Rate	$12,718.34
Max. Negotiated Rate	$12,905.37
Rate for Payer: Amerigroup Medicaid	$12,843.03
Rate for Payer: Iowa Total Care Managed Medicaid	$12,718.34
Rate for Payer: Molina Healthcare Managed Medicaid	$12,905.37

Uncomplicated Peptic Ulcer Without MCC

Facility

$8,751.88

Service Code	MS-DRG 384
Hospital Charge Code	225
Min. Negotiated Rate	$8,625.04
Max. Negotiated Rate	$8,751.88
Rate for Payer: Amerigroup Medicaid	$8,709.60
Rate for Payer: Iowa Total Care Managed Medicaid	$8,625.04
Rate for Payer: Molina Healthcare Managed Medicaid	$8,751.88

Unlisted Dental Surgery

Facility

$3,851.25

Service Code	CPT 41899
Min. Negotiated Rate	$3,501.14
Max. Negotiated Rate	$3,851.25
Rate for Payer: Wellmark IA HMO	$3,501.14
Rate for Payer: Wellmark IA PPO	$3,851.25

Unlisted procedure, dentoalveolar structures

Facility

$3,851.25

Service Code	CPT 41899
Hospital Revenue Code	360
Min. Negotiated Rate	$3,501.14
Max. Negotiated Rate	$3,851.25
Rate for Payer: Wellmark IA HMO	$3,501.14
Rate for Payer: Wellmark IA PPO	$3,851.25

Unlisted procedure, foot or toes

Facility

$3,346.57

Service Code	CPT 28899
Hospital Revenue Code	360
Min. Negotiated Rate	$3,042.34
Max. Negotiated Rate	$3,346.57
Rate for Payer: Wellmark IA HMO	$3,042.34
Rate for Payer: Wellmark IA PPO	$3,346.57

Upper Limb and Toe Amputation for Circulatory System Disorders With CC

Facility

$14,740.00

Service Code	MS-DRG 256
Hospital Charge Code	118
Min. Negotiated Rate	$14,526.38
Max. Negotiated Rate	$14,740.00
Rate for Payer: Amerigroup Medicaid	$14,668.80
Rate for Payer: Iowa Total Care Managed Medicaid	$14,526.38
Rate for Payer: Molina Healthcare Managed Medicaid	$14,740.00

Upper Limb and Toe Amputation for Circulatory System Disorders With MCC

Facility

$15,048.07

Service Code	MS-DRG 255
Hospital Charge Code	117
Min. Negotiated Rate	$14,829.98
Max. Negotiated Rate	$15,048.07
Rate for Payer: Amerigroup Medicaid	$14,975.38
Rate for Payer: Iowa Total Care Managed Medicaid	$14,829.98
Rate for Payer: Molina Healthcare Managed Medicaid	$15,048.07

Upper Limb and Toe Amputation for Circulatory System Disorders Without CC/MCC

Facility

$11,430.00

Service Code	MS-DRG 257
Hospital Charge Code	119
Min. Negotiated Rate	$11,264.35
Max. Negotiated Rate	$11,430.00
Rate for Payer: Amerigroup Medicaid	$11,374.78
Rate for Payer: Iowa Total Care Managed Medicaid	$11,264.35
Rate for Payer: Molina Healthcare Managed Medicaid	$11,430.00

Urea topical 20% Cream 85 gram [VDMC]

Facility

$25.88

Service Code	HCPCS A9270
Hospital Charge Code	17100134
Hospital Revenue Code	259
Min. Negotiated Rate	$18.12
Max. Negotiated Rate	$23.29
Rate for Payer: Aetna of IA Commercial	$23.29
Rate for Payer: Aetna of IA Medical Rental Products	$23.29
Rate for Payer: Cash Price	$20.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.41
Rate for Payer: Medical Associates Commercial	$19.41
Rate for Payer: Midlands Choice Commercial	$18.12
Rate for Payer: United Healthcare Commercial	$23.29

Urea topical 20% Cream 85 gram [VDMC]

Facility

$25.88

Service Code	HCPCS A9270
Hospital Charge Code	17100134
Hospital Revenue Code	259
Min. Negotiated Rate	$12.93
Max. Negotiated Rate	$23.29
Rate for Payer: Aetna of IA Commercial	$23.29
Rate for Payer: Aetna of IA Medical Rental Products	$23.29
Rate for Payer: Aetna of IA Medicare	$14.75
Rate for Payer: Amerigroup Medicaid	$13.06
Rate for Payer: Amerigroup Medicare	$13.07
Rate for Payer: Cash Price	$20.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.41
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.94
Rate for Payer: Iowa Total Care Managed Medicaid	$12.93
Rate for Payer: Medical Associates Commercial	$19.41
Rate for Payer: Medical Associates Managed Medicare	$12.94
Rate for Payer: Midlands Choice Commercial	$18.12
Rate for Payer: Molina Healthcare Managed Medicaid	$13.13
Rate for Payer: Molina Healthcare Managed Medicare	$13.13
Rate for Payer: Oscar Health of IA Commercial	$19.41
Rate for Payer: Partners Health Alliance Commercial	$19.41
Rate for Payer: United Healthcare Commercial	$23.29
Rate for Payer: United Healthcare Managed Medicare	$15.27

Know your out-of-pocket cost for care.

All Charges