Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

trace elements with selenium 10 mcg-1 mg-0.5 mg-60 mcg-5 mg/mL IV Sol 1 mL [VDMC]

Facility

$64.49

Service Code	NDC 00517-8201-25
Hospital Charge Code	10425639
Hospital Revenue Code	259
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$58.04
Rate for Payer: Aetna of IA Commercial	$58.04
Rate for Payer: Aetna of IA Medical Rental Products	$58.04
Rate for Payer: Cash Price	$51.59
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.37
Rate for Payer: Medical Associates Commercial	$48.37
Rate for Payer: Midlands Choice Commercial	$45.14
Rate for Payer: United Healthcare Commercial	$58.04

trace elements with selenium 10 mcg-1 mg-0.5 mg-60 mcg-5 mg/mL IV Sol 1 mL [VDMC]

Facility

$64.49

Service Code	NDC 00517-8201-25
Hospital Charge Code	10425639
Hospital Revenue Code	259
Min. Negotiated Rate	$29.02
Max. Negotiated Rate	$58.04
Rate for Payer: Aetna of IA Commercial	$58.04
Rate for Payer: Aetna of IA Medical Rental Products	$58.04
Rate for Payer: Aetna of IA Medicare	$36.76
Rate for Payer: Amerigroup Medicaid	$37.20
Rate for Payer: Amerigroup Medicare	$29.31
Rate for Payer: Cash Price	$51.59
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.02
Rate for Payer: Iowa Total Care Managed Medicaid	$36.84
Rate for Payer: Medical Associates Commercial	$48.37
Rate for Payer: Medical Associates Managed Medicare	$29.02
Rate for Payer: Midlands Choice Commercial	$45.14
Rate for Payer: Molina Healthcare Managed Medicaid	$37.38
Rate for Payer: Partners Health Alliance Commercial	$33.37
Rate for Payer: United Healthcare Commercial	$58.04
Rate for Payer: United Healthcare Managed Medicare	$38.05

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC

Facility

$29,381.24

Service Code	MSDRG 012
Min. Negotiated Rate	$28,955.42
Max. Negotiated Rate	$29,381.24
Rate for Payer: Amerigroup Medicaid	$29,239.29
Rate for Payer: Iowa Total Care Managed Medicaid	$28,955.42
Rate for Payer: Molina Healthcare Managed Medicaid	$29,381.24

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC

Facility

$39,730.10

Service Code	MSDRG 011
Min. Negotiated Rate	$39,154.28
Max. Negotiated Rate	$39,730.10
Rate for Payer: Amerigroup Medicaid	$39,538.15
Rate for Payer: Iowa Total Care Managed Medicaid	$39,154.28
Rate for Payer: Molina Healthcare Managed Medicaid	$39,730.10

TRACHEOSTOMY FOR FACE, MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC

Facility

$26,632.73

Service Code	MSDRG 013
Min. Negotiated Rate	$26,246.74
Max. Negotiated Rate	$26,632.73
Rate for Payer: Amerigroup Medicaid	$26,504.06
Rate for Payer: Iowa Total Care Managed Medicaid	$26,246.74
Rate for Payer: Molina Healthcare Managed Medicaid	$26,632.73

TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE, MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES

Facility

$114,256.26

Service Code	MSDRG 004
Min. Negotiated Rate	$112,600.33
Max. Negotiated Rate	$114,256.26
Rate for Payer: Amerigroup Medicaid	$113,704.25
Rate for Payer: Iowa Total Care Managed Medicaid	$112,600.33
Rate for Payer: Molina Healthcare Managed Medicaid	$114,256.26

traMADol 50 mg Tab [VDMC]

Facility

$3.36

Service Code	HCPCS A9270
Hospital Charge Code	10425771
Hospital Revenue Code	259
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna of IA Commercial	$3.03
Rate for Payer: Aetna of IA Medical Rental Products	$3.03
Rate for Payer: Cash Price	$2.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.52
Rate for Payer: Medical Associates Commercial	$2.52
Rate for Payer: Midlands Choice Commercial	$2.35
Rate for Payer: United Healthcare Commercial	$3.03

traMADol 50 mg Tab [VDMC]

Facility

$3.36

Service Code	HCPCS A9270
Hospital Charge Code	10425771
Hospital Revenue Code	259
Min. Negotiated Rate	$1.51
Max. Negotiated Rate	$3.03
Rate for Payer: Aetna of IA Commercial	$3.03
Rate for Payer: Aetna of IA Medical Rental Products	$3.03
Rate for Payer: Aetna of IA Medicare	$1.92
Rate for Payer: Amerigroup Medicaid	$1.94
Rate for Payer: Amerigroup Medicare	$1.53
Rate for Payer: Cash Price	$2.69
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.52
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.51
Rate for Payer: Iowa Total Care Managed Medicaid	$1.92
Rate for Payer: Medical Associates Commercial	$2.52
Rate for Payer: Medical Associates Managed Medicare	$1.51
Rate for Payer: Midlands Choice Commercial	$2.35
Rate for Payer: Molina Healthcare Managed Medicaid	$1.95
Rate for Payer: Partners Health Alliance Commercial	$1.74
Rate for Payer: United Healthcare Commercial	$3.03
Rate for Payer: United Healthcare Managed Medicare	$1.98

tranexamic acid 100 mg/mL 10 ml SDV INJ [VDMC]

Facility

$31.86

Service Code	HCPCS J3490
Hospital Charge Code	10425909
Hospital Revenue Code	259
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$28.68
Rate for Payer: Aetna of IA Commercial	$28.68
Rate for Payer: Aetna of IA Medical Rental Products	$28.68
Rate for Payer: Aetna of IA Medicare	$18.16
Rate for Payer: Amerigroup Medicaid	$18.38
Rate for Payer: Amerigroup Medicare	$14.48
Rate for Payer: Cash Price	$25.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.34
Rate for Payer: Iowa Total Care Managed Medicaid	$18.20
Rate for Payer: Medical Associates Commercial	$23.90
Rate for Payer: Medical Associates Managed Medicare	$14.34
Rate for Payer: Midlands Choice Commercial	$22.30
Rate for Payer: Molina Healthcare Managed Medicaid	$18.47
Rate for Payer: Partners Health Alliance Commercial	$16.49
Rate for Payer: United Healthcare Commercial	$28.68
Rate for Payer: United Healthcare Managed Medicare	$18.80

tranexamic acid 100 mg/mL 10 ml SDV INJ [VDMC]

Facility

$31.86

Service Code	HCPCS J3490
Hospital Charge Code	10425909
Hospital Revenue Code	259
Min. Negotiated Rate	$22.30
Max. Negotiated Rate	$28.68
Rate for Payer: Aetna of IA Commercial	$28.68
Rate for Payer: Aetna of IA Medical Rental Products	$28.68
Rate for Payer: Cash Price	$25.49
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.90
Rate for Payer: Medical Associates Commercial	$23.90
Rate for Payer: Midlands Choice Commercial	$22.30
Rate for Payer: United Healthcare Commercial	$28.68

tranexamic acid 650 mg Tab [VDMC]

Facility

$11.23

Service Code	HCPCS A9270
Hospital Charge Code	10425976
Hospital Revenue Code	259
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$10.10
Rate for Payer: Aetna of IA Commercial	$10.10
Rate for Payer: Aetna of IA Medical Rental Products	$10.10
Rate for Payer: Aetna of IA Medicare	$6.40
Rate for Payer: Amerigroup Medicaid	$6.48
Rate for Payer: Amerigroup Medicare	$5.10
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	$5.05
Rate for Payer: Iowa Total Care Managed Medicaid	$6.41
Rate for Payer: Medical Associates Commercial	$8.42
Rate for Payer: Medical Associates Managed Medicare	$5.05
Rate for Payer: Midlands Choice Commercial	$7.86
Rate for Payer: Molina Healthcare Managed Medicaid	$6.51
Rate for Payer: Partners Health Alliance Commercial	$5.81
Rate for Payer: United Healthcare Commercial	$10.10
Rate for Payer: United Healthcare Managed Medicare	$6.62

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	$10.10
Rate for Payer: Aetna of IA Commercial	$10.10
Rate for Payer: Aetna of IA Medical Rental Products	$10.10
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	$10.10

TRANSCUTANEOUS BILI

Facility

$61.00

Service Code	CPT 88720
Hospital Charge Code	8027044
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
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	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
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	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

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	4882833
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
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	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
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	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

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	1099777
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
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	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
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	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

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	$46.80
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: Aetna of IA Medicare	$59.28
Rate for Payer: Amerigroup Medicaid	$59.99
Rate for Payer: Amerigroup Medicare	$47.27
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	$46.80
Rate for Payer: Iowa Total Care Managed Medicaid	$59.40
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Medical Associates Managed Medicare	$46.80
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: Molina Healthcare Managed Medicaid	$60.28
Rate for Payer: Partners Health Alliance Commercial	$53.82
Rate for Payer: United Healthcare Commercial	$93.60
Rate for Payer: United Healthcare Managed Medicare	$61.36
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

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

TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC

Facility

$7,126.31

Service Code	MSDRG 069
Min. Negotiated Rate	$7,023.03
Max. Negotiated Rate	$7,126.31
Rate for Payer: Amerigroup Medicaid	$7,091.88
Rate for Payer: Iowa Total Care Managed Medicaid	$7,023.03
Rate for Payer: Molina Healthcare Managed Medicaid	$7,126.31

TRANSURETHRAL PROCEDURES WITH CC

Facility

$15,434.89

Service Code	MSDRG 669
Min. Negotiated Rate	$15,211.19
Max. Negotiated Rate	$15,434.89
Rate for Payer: Amerigroup Medicaid	$15,360.32
Rate for Payer: Iowa Total Care Managed Medicaid	$15,211.19
Rate for Payer: Molina Healthcare Managed Medicaid	$15,434.89

TRANSURETHRAL PROCEDURES WITH MCC

Facility

$17,960.46

Service Code	MSDRG 668
Min. Negotiated Rate	$17,700.15
Max. Negotiated Rate	$17,960.46
Rate for Payer: Amerigroup Medicaid	$17,873.69
Rate for Payer: Iowa Total Care Managed Medicaid	$17,700.15
Rate for Payer: Molina Healthcare Managed Medicaid	$17,960.46

TRANSURETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$9,092.26

Service Code	MSDRG 670
Min. Negotiated Rate	$8,960.49
Max. Negotiated Rate	$9,092.26
Rate for Payer: Amerigroup Medicaid	$9,048.34
Rate for Payer: Iowa Total Care Managed Medicaid	$8,960.49
Rate for Payer: Molina Healthcare Managed Medicaid	$9,092.26

TRANSURETHRAL PROSTATECTOMY WITH CC/MCC

Facility

$10,833.02

Service Code	MSDRG 713
Min. Negotiated Rate	$10,676.02
Max. Negotiated Rate	$10,833.02
Rate for Payer: Amerigroup Medicaid	$10,780.69
Rate for Payer: Iowa Total Care Managed Medicaid	$10,676.02
Rate for Payer: Molina Healthcare Managed Medicaid	$10,833.02

Know your out-of-pocket cost for care.

All Charges