Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

TENDONITIS, MYOSITIS AND BURSITIS WITHOUT MCC

Facility

$7,095.91

Service Code	MSDRG 558
Min. Negotiated Rate	$6,993.06
Max. Negotiated Rate	$7,095.91
Rate for Payer: Amerigroup Medicaid	$7,061.62
Rate for Payer: Iowa Total Care Managed Medicaid	$6,993.06
Rate for Payer: Molina Healthcare Managed Medicaid	$7,095.91

TENDON SHEATH INCISION (EG, FOR TRIGGER FINGER)

Facility

$3,486.38

Service Code	CPT 26055
Hospital Revenue Code	360
Min. Negotiated Rate	$3,164.98
Max. Negotiated Rate	$3,486.38
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

tenecteplase 50 mg IV SDV Inj [VDMC]

Facility

$14,972.44

Service Code	HCPCS J3101
Hospital Charge Code	10423770
Hospital Revenue Code	259
Min. Negotiated Rate	$6,737.60
Max. Negotiated Rate	$13,475.20
Rate for Payer: Aetna of IA Commercial	$13,475.20
Rate for Payer: Aetna of IA Medical Rental Products	$13,475.20
Rate for Payer: Aetna of IA Medicare	$8,534.29
Rate for Payer: Amerigroup Medicaid	$8,636.10
Rate for Payer: Amerigroup Medicare	$6,804.97
Rate for Payer: Cash Price	$11,977.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11,229.33
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6,737.60
Rate for Payer: Iowa Total Care Managed Medicaid	$8,552.26
Rate for Payer: Medical Associates Commercial	$11,229.33
Rate for Payer: Medical Associates Managed Medicare	$6,737.60
Rate for Payer: Midlands Choice Commercial	$10,480.71
Rate for Payer: Molina Healthcare Managed Medicaid	$8,678.03
Rate for Payer: Partners Health Alliance Commercial	$7,748.24
Rate for Payer: United Healthcare Commercial	$13,475.20
Rate for Payer: United Healthcare Managed Medicare	$8,833.74

tenecteplase 50 mg IV SDV Inj [VDMC]

Facility

$14,972.44

Service Code	HCPCS J3101
Hospital Charge Code	10423770
Hospital Revenue Code	259
Min. Negotiated Rate	$10,480.71
Max. Negotiated Rate	$13,475.20
Rate for Payer: Aetna of IA Commercial	$13,475.20
Rate for Payer: Aetna of IA Medical Rental Products	$13,475.20
Rate for Payer: Cash Price	$11,977.95
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11,229.33
Rate for Payer: Medical Associates Commercial	$11,229.33
Rate for Payer: Midlands Choice Commercial	$10,480.71
Rate for Payer: United Healthcare Commercial	$13,475.20

terazosin 1 mg Cap [VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	10423837
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.09
Rate for Payer: Medical Associates Commercial	$1.09
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: United Healthcare Commercial	$1.31

terazosin 1 mg Cap [VDMC]

Facility

$1.46

Service Code	HCPCS A9270
Hospital Charge Code	10423837
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.31
Rate for Payer: Aetna of IA Commercial	$1.31
Rate for Payer: Aetna of IA Medical Rental Products	$1.31
Rate for Payer: Aetna of IA Medicare	$0.83
Rate for Payer: Amerigroup Medicaid	$0.84
Rate for Payer: Amerigroup Medicare	$0.66
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.09
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.66
Rate for Payer: Iowa Total Care Managed Medicaid	$0.83
Rate for Payer: Medical Associates Commercial	$1.09
Rate for Payer: Medical Associates Managed Medicare	$0.66
Rate for Payer: Midlands Choice Commercial	$1.02
Rate for Payer: Molina Healthcare Managed Medicaid	$0.84
Rate for Payer: Partners Health Alliance Commercial	$0.75
Rate for Payer: United Healthcare Commercial	$1.31
Rate for Payer: United Healthcare Managed Medicare	$0.86

terazosin 5 mg Cap [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10423906
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Midlands Choice Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.34

terazosin 5 mg Cap [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10423906
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Aetna of IA Medicare	$0.85
Rate for Payer: Amerigroup Medicaid	$0.86
Rate for Payer: Amerigroup Medicare	$0.68
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.67
Rate for Payer: Iowa Total Care Managed Medicaid	$0.85
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Medical Associates Managed Medicare	$0.67
Rate for Payer: Midlands Choice Commercial	$1.04
Rate for Payer: Molina Healthcare Managed Medicaid	$0.86
Rate for Payer: Partners Health Alliance Commercial	$0.77
Rate for Payer: United Healthcare Commercial	$1.34
Rate for Payer: United Healthcare Managed Medicare	$0.88

terbinafine 250 mg Tab [VDMC]

Facility

$2.07

Service Code	HCPCS A9270
Hospital Charge Code	10423975
Hospital Revenue Code	259
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of IA Commercial	$1.87
Rate for Payer: Aetna of IA Medical Rental Products	$1.87
Rate for Payer: Aetna of IA Medicare	$1.18
Rate for Payer: Amerigroup Medicaid	$1.20
Rate for Payer: Amerigroup Medicare	$0.94
Rate for Payer: Cash Price	$1.66
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	$0.93
Rate for Payer: Iowa Total Care Managed Medicaid	$1.18
Rate for Payer: Medical Associates Commercial	$1.55
Rate for Payer: Medical Associates Managed Medicare	$0.93
Rate for Payer: Midlands Choice Commercial	$1.45
Rate for Payer: Molina Healthcare Managed Medicaid	$1.20
Rate for Payer: Partners Health Alliance Commercial	$1.07
Rate for Payer: United Healthcare Commercial	$1.87
Rate for Payer: United Healthcare Managed Medicare	$1.22

terbinafine 250 mg Tab [VDMC]

Facility

$2.07

Service Code	HCPCS A9270
Hospital Charge Code	10423975
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of IA Commercial	$1.87
Rate for Payer: Aetna of IA Medical Rental Products	$1.87
Rate for Payer: Cash Price	$1.66
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	$1.87

terbinafine topical 1% Cre 15gm [VDMC]

Facility

$33.12

Service Code	HCPCS A9270
Hospital Charge Code	11337009
Hospital Revenue Code	259
Min. Negotiated Rate	$14.90
Max. Negotiated Rate	$29.81
Rate for Payer: Aetna of IA Commercial	$29.81
Rate for Payer: Aetna of IA Medical Rental Products	$29.81
Rate for Payer: Aetna of IA Medicare	$18.88
Rate for Payer: Amerigroup Medicaid	$19.10
Rate for Payer: Amerigroup Medicare	$15.05
Rate for Payer: Cash Price	$26.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.84
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.90
Rate for Payer: Iowa Total Care Managed Medicaid	$18.92
Rate for Payer: Medical Associates Commercial	$24.84
Rate for Payer: Medical Associates Managed Medicare	$14.90
Rate for Payer: Midlands Choice Commercial	$23.18
Rate for Payer: Molina Healthcare Managed Medicaid	$19.20
Rate for Payer: Partners Health Alliance Commercial	$17.14
Rate for Payer: United Healthcare Commercial	$29.81
Rate for Payer: United Healthcare Managed Medicare	$19.54

terbinafine topical 1% Cre 15gm [VDMC]

Facility

$33.12

Service Code	HCPCS A9270
Hospital Charge Code	11337009
Hospital Revenue Code	259
Min. Negotiated Rate	$23.18
Max. Negotiated Rate	$29.81
Rate for Payer: Aetna of IA Commercial	$29.81
Rate for Payer: Aetna of IA Medical Rental Products	$29.81
Rate for Payer: Cash Price	$26.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.84
Rate for Payer: Medical Associates Commercial	$24.84
Rate for Payer: Midlands Choice Commercial	$23.18
Rate for Payer: United Healthcare Commercial	$29.81

terbutaline 1 mg/mL 1 ml Inj SDV [VDMC]

Facility

$25.41

Service Code	HCPCS J3105
Hospital Charge Code	10424044
Hospital Revenue Code	259
Min. Negotiated Rate	$11.44
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$22.87
Rate for Payer: Aetna of IA Medical Rental Products	$22.87
Rate for Payer: Aetna of IA Medicare	$14.48
Rate for Payer: Amerigroup Medicaid	$14.66
Rate for Payer: Amerigroup Medicare	$11.55
Rate for Payer: Cash Price	$20.33
Rate for Payer: Cash Price	$20.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.06
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.44
Rate for Payer: Iowa Total Care Managed Medicaid	$14.52
Rate for Payer: Medical Associates Commercial	$19.06
Rate for Payer: Medical Associates Managed Medicare	$11.44
Rate for Payer: Midlands Choice Commercial	$17.79
Rate for Payer: Molina Healthcare Managed Medicaid	$14.73
Rate for Payer: Partners Health Alliance Commercial	$13.15
Rate for Payer: United Healthcare Commercial	$22.87
Rate for Payer: United Healthcare Managed Medicare	$14.99
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

terbutaline 1 mg/mL 1 ml Inj SDV [VDMC]

Facility

$25.41

Service Code	HCPCS J3105
Hospital Charge Code	10424044
Hospital Revenue Code	259
Min. Negotiated Rate	$17.79
Max. Negotiated Rate	$22.87
Rate for Payer: Aetna of IA Commercial	$22.87
Rate for Payer: Aetna of IA Medical Rental Products	$22.87
Rate for Payer: Cash Price	$20.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.06
Rate for Payer: Medical Associates Commercial	$19.06
Rate for Payer: Midlands Choice Commercial	$17.79
Rate for Payer: United Healthcare Commercial	$22.87

TESTES PROCEDURES WITH CC/MCC

Facility

$23,992.32

Service Code	MSDRG 711
Min. Negotiated Rate	$23,644.59
Max. Negotiated Rate	$23,992.32
Rate for Payer: Amerigroup Medicaid	$23,876.40
Rate for Payer: Iowa Total Care Managed Medicaid	$23,644.59
Rate for Payer: Molina Healthcare Managed Medicaid	$23,992.32

TESTES PROCEDURES WITHOUT CC/MCC

Facility

$9,823.02

Service Code	MSDRG 712
Min. Negotiated Rate	$9,680.66
Max. Negotiated Rate	$9,823.02
Rate for Payer: Amerigroup Medicaid	$9,775.56
Rate for Payer: Iowa Total Care Managed Medicaid	$9,680.66
Rate for Payer: Molina Healthcare Managed Medicaid	$9,823.02

TEST IMPLANT

Facility

$1,000.00

Service Code	HCPCS C1713
Hospital Charge Code	8753463
Hospital Revenue Code	278
Min. Negotiated Rate	$450.00
Max. Negotiated Rate	$900.00
Rate for Payer: Aetna of IA Commercial	$900.00
Rate for Payer: Aetna of IA Medical Rental Products	$900.00
Rate for Payer: Aetna of IA Medicare	$570.00
Rate for Payer: Amerigroup Medicaid	$576.80
Rate for Payer: Amerigroup Medicare	$454.50
Rate for Payer: Cash Price	$800.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$750.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$450.00
Rate for Payer: Iowa Total Care Managed Medicaid	$571.20
Rate for Payer: Medical Associates Commercial	$750.00
Rate for Payer: Medical Associates Managed Medicare	$450.00
Rate for Payer: Midlands Choice Commercial	$700.00
Rate for Payer: Molina Healthcare Managed Medicaid	$579.60
Rate for Payer: Partners Health Alliance Commercial	$517.50
Rate for Payer: United Healthcare Commercial	$900.00
Rate for Payer: United Healthcare Managed Medicare	$590.00

TEST IMPLANT

Facility

$1,000.00

Service Code	HCPCS C1713
Hospital Charge Code	8753463
Hospital Revenue Code	278
Min. Negotiated Rate	$700.00
Max. Negotiated Rate	$900.00
Rate for Payer: Aetna of IA Commercial	$900.00
Rate for Payer: Aetna of IA Medical Rental Products	$900.00
Rate for Payer: Cash Price	$800.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$750.00
Rate for Payer: Medical Associates Commercial	$750.00
Rate for Payer: Midlands Choice Commercial	$700.00
Rate for Payer: United Healthcare Commercial	$900.00

testosterone 75 mg Imp[VDMC]

Facility

$351.28

Service Code	HCPCS J3490
Hospital Charge Code	12491246
Hospital Revenue Code	259
Min. Negotiated Rate	$245.90
Max. Negotiated Rate	$316.16
Rate for Payer: Aetna of IA Commercial	$316.16
Rate for Payer: Aetna of IA Medical Rental Products	$316.16
Rate for Payer: Cash Price	$281.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$263.46
Rate for Payer: Medical Associates Commercial	$263.46
Rate for Payer: Midlands Choice Commercial	$245.90
Rate for Payer: United Healthcare Commercial	$316.16

testosterone 75 mg Imp[VDMC]

Facility

$351.28

Service Code	HCPCS J3490
Hospital Charge Code	12491246
Hospital Revenue Code	259
Min. Negotiated Rate	$158.08
Max. Negotiated Rate	$316.16
Rate for Payer: Aetna of IA Commercial	$316.16
Rate for Payer: Aetna of IA Medical Rental Products	$316.16
Rate for Payer: Aetna of IA Medicare	$200.23
Rate for Payer: Amerigroup Medicaid	$202.62
Rate for Payer: Amerigroup Medicare	$159.66
Rate for Payer: Cash Price	$281.03
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$263.46
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$158.08
Rate for Payer: Iowa Total Care Managed Medicaid	$200.65
Rate for Payer: Medical Associates Commercial	$263.46
Rate for Payer: Medical Associates Managed Medicare	$158.08
Rate for Payer: Midlands Choice Commercial	$245.90
Rate for Payer: Molina Healthcare Managed Medicaid	$203.60
Rate for Payer: Partners Health Alliance Commercial	$181.79
Rate for Payer: United Healthcare Commercial	$316.16
Rate for Payer: United Healthcare Managed Medicare	$207.26

testosterone cypionate 200 mg/mL 1 ml IM SDV [VDMC]

Facility

$107.16

Service Code	HCPCS J1071
Hospital Charge Code	10424113
Hospital Revenue Code	259
Min. Negotiated Rate	$75.01
Max. Negotiated Rate	$96.44
Rate for Payer: Aetna of IA Commercial	$96.44
Rate for Payer: Aetna of IA Medical Rental Products	$96.44
Rate for Payer: Cash Price	$85.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$80.37
Rate for Payer: Medical Associates Commercial	$80.37
Rate for Payer: Midlands Choice Commercial	$75.01
Rate for Payer: United Healthcare Commercial	$96.44

testosterone cypionate 200 mg/mL 1 ml IM SDV [VDMC]

Facility

$107.16

Service Code	HCPCS J1071
Hospital Charge Code	10424113
Hospital Revenue Code	259
Min. Negotiated Rate	$48.22
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$96.44
Rate for Payer: Aetna of IA Medical Rental Products	$96.44
Rate for Payer: Aetna of IA Medicare	$61.08
Rate for Payer: Amerigroup Medicaid	$61.81
Rate for Payer: Amerigroup Medicare	$48.70
Rate for Payer: Cash Price	$85.73
Rate for Payer: Cash Price	$85.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$80.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$48.22
Rate for Payer: Iowa Total Care Managed Medicaid	$61.21
Rate for Payer: Medical Associates Commercial	$80.37
Rate for Payer: Medical Associates Managed Medicare	$48.22
Rate for Payer: Midlands Choice Commercial	$75.01
Rate for Payer: Molina Healthcare Managed Medicaid	$62.11
Rate for Payer: Partners Health Alliance Commercial	$55.46
Rate for Payer: United Healthcare Commercial	$96.44
Rate for Payer: United Healthcare Managed Medicare	$63.22
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

TESTOSTERONE FREE

Facility

$143.00

Service Code	CPT 84402
Hospital Charge Code	8094267
Hospital Revenue Code	301
Min. Negotiated Rate	$49.63
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$82.48
Rate for Payer: Amerigroup Medicare	$64.99
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.35
Rate for Payer: Iowa Total Care Managed Medicaid	$81.68
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$64.35
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$82.88
Rate for Payer: Partners Health Alliance Commercial	$74.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37
Rate for Payer: Wellmark IA HMO WHPI	$49.63
Rate for Payer: Wellmark IA PPO	$54.67

TESTOSTERONE FREE

Facility

$143.00

Service Code	CPT 84402
Hospital Charge Code	8487820
Hospital Revenue Code	301
Min. Negotiated Rate	$49.63
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$82.48
Rate for Payer: Amerigroup Medicare	$64.99
Rate for Payer: Cash Price	$114.40
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.35
Rate for Payer: Iowa Total Care Managed Medicaid	$81.68
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$64.35
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$82.88
Rate for Payer: Partners Health Alliance Commercial	$74.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37
Rate for Payer: Wellmark IA HMO WHPI	$49.63
Rate for Payer: Wellmark IA PPO	$54.67

TESTOSTERONE FREE

Facility

$143.00

Service Code	CPT 84402
Hospital Charge Code	8487820
Hospital Revenue Code	301
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$128.70

Know your out-of-pocket cost for care.

All Charges