Van Diest Medical Center

All Charges

Charge

Type

Price

APPLY TENS UNIT

Facility OP

$61.00

Service Code	CPT 64550 GP
Hospital Charge Code	4658837
Hospital Revenue Code	420
Min. Negotiated Rate	$30.49
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: 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: Partners Health Alliance Commercial	$45.75
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99

APPLY TENS UNIT

Facility IP

$61.00

Service Code	CPT 64550 GP
Hospital Charge Code	4658837
Hospital Revenue Code	420
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

aprepitant 130 mg/18 mL EMU SDV

Facility IP

$992.96

Service Code	CPT J0185
Hospital Charge Code	43700270
Hospital Revenue Code	636
Min. Negotiated Rate	$695.07
Max. Negotiated Rate	$893.66
Rate for Payer: Aetna of IA Commercial	$893.66
Rate for Payer: Aetna of IA Medical Rental Products	$893.66
Rate for Payer: Cash Price	$794.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$744.72
Rate for Payer: Medical Associates Commercial	$744.72
Rate for Payer: Midlands Choice Commercial	$695.07
Rate for Payer: United Healthcare Commercial	$893.66

aprepitant 130 mg/18 mL EMU SDV

Facility OP

$992.96

Service Code	CPT J0185
Hospital Charge Code	43700270
Hospital Revenue Code	636
Min. Negotiated Rate	$496.28
Max. Negotiated Rate	$893.66
Rate for Payer: Aetna of IA Commercial	$893.66
Rate for Payer: Aetna of IA Medical Rental Products	$893.66
Rate for Payer: Aetna of IA Medicare	$565.99
Rate for Payer: Amerigroup Medicaid	$501.15
Rate for Payer: Amerigroup Medicare	$501.44
Rate for Payer: Cash Price	$794.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$744.72
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$496.48
Rate for Payer: Iowa Total Care Managed Medicaid	$496.28
Rate for Payer: Medical Associates Commercial	$744.72
Rate for Payer: Medical Associates Managed Medicare	$496.48
Rate for Payer: Midlands Choice Commercial	$695.07
Rate for Payer: Molina Healthcare Managed Medicaid	$503.93
Rate for Payer: Partners Health Alliance Commercial	$744.72
Rate for Payer: United Healthcare Commercial	$893.66
Rate for Payer: United Healthcare Managed Medicare	$585.85

aprepitant 32 mg/4.4 mL EMU

Facility IP

$233.40

Service Code	CPT C9145
Hospital Charge Code	43799935
Hospital Revenue Code	636
Min. Negotiated Rate	$163.38
Max. Negotiated Rate	$210.06
Rate for Payer: Aetna of IA Commercial	$210.06
Rate for Payer: Aetna of IA Medical Rental Products	$210.06
Rate for Payer: Cash Price	$186.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$175.05
Rate for Payer: Medical Associates Commercial	$175.05
Rate for Payer: Midlands Choice Commercial	$163.38
Rate for Payer: United Healthcare Commercial	$210.06

aprepitant 32 mg/4.4 mL EMU

Facility OP

$233.40

Service Code	CPT C9145
Hospital Charge Code	43799935
Hospital Revenue Code	636
Min. Negotiated Rate	$116.65
Max. Negotiated Rate	$210.06
Rate for Payer: Aetna of IA Commercial	$210.06
Rate for Payer: Aetna of IA Medical Rental Products	$210.06
Rate for Payer: Aetna of IA Medicare	$133.04
Rate for Payer: Amerigroup Medicaid	$117.80
Rate for Payer: Amerigroup Medicare	$117.87
Rate for Payer: Cash Price	$186.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$175.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$116.70
Rate for Payer: Iowa Total Care Managed Medicaid	$116.65
Rate for Payer: Medical Associates Commercial	$175.05
Rate for Payer: Medical Associates Managed Medicare	$116.70
Rate for Payer: Midlands Choice Commercial	$163.38
Rate for Payer: Molina Healthcare Managed Medicaid	$118.45
Rate for Payer: Partners Health Alliance Commercial	$175.05
Rate for Payer: United Healthcare Commercial	$210.06
Rate for Payer: United Healthcare Managed Medicare	$137.71

arformoterol 15 mcg/2 mL Sol

Facility OP

$17.98

Service Code	CPT J7605
Hospital Charge Code	43722177
Hospital Revenue Code	637
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$16.18
Rate for Payer: Aetna of IA Commercial	$16.18
Rate for Payer: Aetna of IA Medical Rental Products	$16.18
Rate for Payer: Aetna of IA Medicare	$10.25
Rate for Payer: Amerigroup Medicaid	$9.07
Rate for Payer: Amerigroup Medicare	$9.08
Rate for Payer: Cash Price	$14.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8.99
Rate for Payer: Iowa Total Care Managed Medicaid	$8.99
Rate for Payer: Medical Associates Commercial	$13.48
Rate for Payer: Medical Associates Managed Medicare	$8.99
Rate for Payer: Midlands Choice Commercial	$12.59
Rate for Payer: Molina Healthcare Managed Medicaid	$9.12
Rate for Payer: Partners Health Alliance Commercial	$13.48
Rate for Payer: United Healthcare Commercial	$16.18
Rate for Payer: United Healthcare Managed Medicare	$10.61

arformoterol 15 mcg/2 mL Sol

Facility IP

$17.98

Service Code	CPT J7605
Hospital Charge Code	43722177
Hospital Revenue Code	637
Min. Negotiated Rate	$12.59
Max. Negotiated Rate	$16.18
Rate for Payer: Aetna of IA Commercial	$16.18
Rate for Payer: Aetna of IA Medical Rental Products	$16.18
Rate for Payer: Cash Price	$14.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.48
Rate for Payer: Medical Associates Commercial	$13.48
Rate for Payer: Midlands Choice Commercial	$12.59
Rate for Payer: United Healthcare Commercial	$16.18

ARIPiprazole 5 mg Tab

Facility IP

$2.07

Service Code	CPT A9270
Hospital Charge Code	43799918
Hospital Revenue Code	637
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of IA Commercial	$1.86
Rate for Payer: Aetna of IA Medical Rental Products	$1.86
Rate for Payer: Cash Price	$1.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.55
Rate for Payer: Medical Associates Commercial	$1.55
Rate for Payer: Midlands Choice Commercial	$1.45
Rate for Payer: United Healthcare Commercial	$1.86

ARIPiprazole 5 mg Tab

Facility OP

$2.07

Service Code	CPT A9270
Hospital Charge Code	43799918
Hospital Revenue Code	637
Min. Negotiated Rate	$1.03
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of IA Commercial	$1.86
Rate for Payer: Aetna of IA Medical Rental Products	$1.86
Rate for Payer: Aetna of IA Medicare	$1.18
Rate for Payer: Amerigroup Medicaid	$1.04
Rate for Payer: Amerigroup Medicare	$1.05
Rate for Payer: Cash Price	$1.65
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.55
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.04
Rate for Payer: Iowa Total Care Managed Medicaid	$1.03
Rate for Payer: Medical Associates Commercial	$1.55
Rate for Payer: Medical Associates Managed Medicare	$1.04
Rate for Payer: Midlands Choice Commercial	$1.45
Rate for Payer: Molina Healthcare Managed Medicaid	$1.05
Rate for Payer: Partners Health Alliance Commercial	$1.55
Rate for Payer: United Healthcare Commercial	$1.86
Rate for Payer: United Healthcare Managed Medicare	$1.22

ARSENIC

Facility IP

$129.00

Service Code	CPT 82175
Hospital Charge Code	8093926
Hospital Revenue Code	301
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of IA Commercial	$116.10
Rate for Payer: Aetna of IA Medical Rental Products	$116.10
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.75
Rate for Payer: Medical Associates Commercial	$96.75
Rate for Payer: Midlands Choice Commercial	$90.30
Rate for Payer: United Healthcare Commercial	$116.10

ARSENIC

Facility OP

$129.00

Service Code	CPT 82175
Hospital Charge Code	8093926
Hospital Revenue Code	301
Min. Negotiated Rate	$37.20
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of IA Commercial	$116.10
Rate for Payer: Aetna of IA Medical Rental Products	$116.10
Rate for Payer: Aetna of IA Medicare	$73.53
Rate for Payer: Amerigroup Medicaid	$65.11
Rate for Payer: Amerigroup Medicare	$65.14
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.50
Rate for Payer: Iowa Total Care Managed Medicaid	$64.47
Rate for Payer: Medical Associates Commercial	$96.75
Rate for Payer: Medical Associates Managed Medicare	$64.50
Rate for Payer: Midlands Choice Commercial	$90.30
Rate for Payer: Molina Healthcare Managed Medicaid	$65.47
Rate for Payer: Partners Health Alliance Commercial	$96.75
Rate for Payer: United Healthcare Commercial	$116.10
Rate for Payer: United Healthcare Managed Medicare	$76.11
Rate for Payer: Wellmark IA HMO	$37.20
Rate for Payer: Wellmark IA PPO	$40.92

ARTERIAL PUNCTURE

Facility OP

$93.00

Service Code	CPT 36600
Hospital Charge Code	5338932
Hospital Revenue Code	300
Min. Negotiated Rate	$46.48
Max. Negotiated Rate	$387.38
Rate for Payer: Aetna of IA Commercial	$83.70
Rate for Payer: Aetna of IA Medical Rental Products	$83.70
Rate for Payer: Aetna of IA Medicare	$53.01
Rate for Payer: Amerigroup Medicaid	$46.94
Rate for Payer: Amerigroup Medicare	$46.96
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$46.50
Rate for Payer: Iowa Total Care Managed Medicaid	$46.48
Rate for Payer: Medical Associates Commercial	$69.75
Rate for Payer: Medical Associates Managed Medicare	$46.50
Rate for Payer: Midlands Choice Commercial	$65.10
Rate for Payer: Molina Healthcare Managed Medicaid	$47.20
Rate for Payer: Partners Health Alliance Commercial	$69.75
Rate for Payer: United Healthcare Commercial	$83.70
Rate for Payer: United Healthcare Managed Medicare	$54.87
Rate for Payer: Wellmark IA HMO	$352.16
Rate for Payer: Wellmark IA PPO	$387.38

ARTERIAL PUNCTURE

Facility IP

$93.00

Service Code	CPT 36600
Hospital Charge Code	5338932
Hospital Revenue Code	300
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of IA Commercial	$83.70
Rate for Payer: Aetna of IA Medical Rental Products	$83.70
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.75
Rate for Payer: Medical Associates Commercial	$69.75
Rate for Payer: Midlands Choice Commercial	$65.10
Rate for Payer: United Healthcare Commercial	$83.70

ARTHORODESIS GREAT TOE METATARSOPHALANGEAL JOINT

Professional

$2,746.00

Service Code	CPT 28750
Hospital Charge Code	8825537
Hospital Revenue Code	975
Min. Negotiated Rate	$528.17
Max. Negotiated Rate	$1,922.20
Rate for Payer: Aetna of IA Medicare	$528.17
Rate for Payer: Amerigroup Medicaid	$546.13
Rate for Payer: Cash Price	$2,196.80
Rate for Payer: Cash Price	$2,196.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$633.80
Rate for Payer: Iowa Total Care Managed Medicaid	$538.73
Rate for Payer: Medical Associates Commercial	$1,003.52
Rate for Payer: Medical Associates Managed Medicare	$528.17
Rate for Payer: Midlands Choice Commercial	$1,922.20
Rate for Payer: Partners Health Alliance Commercial	$792.26
Rate for Payer: Wellmark IA HMO	$1,100.00
Rate for Payer: Wellmark IA PPO	$1,291.00

Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance

Facility OP

$705.87

Service Code	CPT 20610
Hospital Revenue Code	490
Min. Negotiated Rate	$641.70
Max. Negotiated Rate	$705.87
Rate for Payer: Wellmark IA HMO	$641.70
Rate for Payer: Wellmark IA PPO	$705.87

ARTHROCENTESIS MAJOR JOINT/BURSA

Professional

$201.00

Service Code	CPT 20610
Hospital Charge Code	8037761
Hospital Revenue Code	975
Min. Negotiated Rate	$40.97
Max. Negotiated Rate	$140.70
Rate for Payer: Aetna of IA Medicare	$40.97
Rate for Payer: Amerigroup Medicaid	$42.36
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.16
Rate for Payer: Iowa Total Care Managed Medicaid	$41.79
Rate for Payer: Medical Associates Commercial	$77.84
Rate for Payer: Medical Associates Managed Medicare	$40.97
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Partners Health Alliance Commercial	$61.46
Rate for Payer: Wellmark IA HMO	$80.00
Rate for Payer: Wellmark IA PPO	$94.00

Arthrodesis, great toe; interphalangeal joint

Facility OP

$4,658.74

Service Code	CPT 28755
Hospital Revenue Code	360
Min. Negotiated Rate	$4,235.22
Max. Negotiated Rate	$4,658.74
Rate for Payer: Wellmark IA HMO	$4,235.22
Rate for Payer: Wellmark IA PPO	$4,658.74

Arthrodesis, great toe; metatarsophalangeal joint

Facility OP

$9,738.28

Service Code	CPT 28750
Hospital Revenue Code	360
Min. Negotiated Rate	$8,852.98
Max. Negotiated Rate	$9,738.28
Rate for Payer: Wellmark IA HMO	$8,852.98
Rate for Payer: Wellmark IA PPO	$9,738.28

Arthroscopy

Facility IP

$16,478.17

Service Code	MS-DRG 509
Hospital Charge Code	326
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$16,478.17
Rate for Payer: Amerigroup Medicaid	$16,398.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$16,239.36
Rate for Payer: Molina Healthcare Managed Medicaid	$16,478.17

Arthrotomy, with synovectomy, ankle;

Facility OP

$6,163.92

Service Code	CPT 27625
Hospital Revenue Code	360
Min. Negotiated Rate	$5,603.56
Max. Negotiated Rate	$6,163.92
Rate for Payer: Wellmark IA HMO	$5,603.56
Rate for Payer: Wellmark IA PPO	$6,163.92

ASA/butalbital/caffeine 325 MG-50 MG-40 MG

Facility OP

$6.90

Service Code	CPT A9270
Hospital Charge Code	43722018
Hospital Revenue Code	637
Min. Negotiated Rate	$3.45
Max. Negotiated Rate	$6.21
Rate for Payer: Aetna of IA Commercial	$6.21
Rate for Payer: Aetna of IA Medical Rental Products	$6.21
Rate for Payer: Aetna of IA Medicare	$3.93
Rate for Payer: Amerigroup Medicaid	$3.48
Rate for Payer: Amerigroup Medicare	$3.48
Rate for Payer: Cash Price	$5.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3.45
Rate for Payer: Iowa Total Care Managed Medicaid	$3.45
Rate for Payer: Medical Associates Commercial	$5.18
Rate for Payer: Medical Associates Managed Medicare	$3.45
Rate for Payer: Midlands Choice Commercial	$4.83
Rate for Payer: Molina Healthcare Managed Medicaid	$3.50
Rate for Payer: Partners Health Alliance Commercial	$5.18
Rate for Payer: United Healthcare Commercial	$6.21
Rate for Payer: United Healthcare Managed Medicare	$4.07

ASA/butalbital/caffeine 325 MG-50 MG-40 MG

Facility IP

$6.90

Service Code	CPT A9270
Hospital Charge Code	43722018
Hospital Revenue Code	637
Min. Negotiated Rate	$4.83
Max. Negotiated Rate	$6.21
Rate for Payer: Aetna of IA Commercial	$6.21
Rate for Payer: Aetna of IA Medical Rental Products	$6.21
Rate for Payer: Cash Price	$5.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5.18
Rate for Payer: Medical Associates Commercial	$5.18
Rate for Payer: Midlands Choice Commercial	$4.83
Rate for Payer: United Healthcare Commercial	$6.21

ascorbic acid 500 mg Tab

Facility IP

$1.11

Service Code	CPT A9270
Hospital Charge Code	43702478
Hospital Revenue Code	637
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: United Healthcare Commercial	$1.00

ascorbic acid 500 mg Tab

Facility OP

$1.11

Service Code	CPT A9270
Hospital Charge Code	43702478
Hospital Revenue Code	637
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.00
Rate for Payer: Aetna of IA Commercial	$1.00
Rate for Payer: Aetna of IA Medical Rental Products	$1.00
Rate for Payer: Aetna of IA Medicare	$0.63
Rate for Payer: Amerigroup Medicaid	$0.56
Rate for Payer: Amerigroup Medicare	$0.56
Rate for Payer: Cash Price	$0.89
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.56
Rate for Payer: Iowa Total Care Managed Medicaid	$0.55
Rate for Payer: Medical Associates Commercial	$0.83
Rate for Payer: Medical Associates Managed Medicare	$0.56
Rate for Payer: Midlands Choice Commercial	$0.78
Rate for Payer: Molina Healthcare Managed Medicaid	$0.56
Rate for Payer: Partners Health Alliance Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.00
Rate for Payer: United Healthcare Managed Medicare	$0.65

Price Transparency.

All Charges