Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC

Facility

$8,185.85

Service Code	MSDRG 714
Min. Negotiated Rate	$8,067.21
Max. Negotiated Rate	$8,185.85
Rate for Payer: Amerigroup Medicaid	$8,146.30
Rate for Payer: Iowa Total Care Managed Medicaid	$8,067.21
Rate for Payer: Molina Healthcare Managed Medicaid	$8,185.85

TRANSVERSUS ABDOMINIS PLANE (TAP) BLOCK (ABDOMINAL PLANE BLOCK, RECTUS SHEATH BLOCK) BILATERAL; BY INJECTIONS (INCLUDES IMAGING GUIDANCE, WHEN PERFORMED)

Facility

$2,560.12

Service Code	CPT 64488
Hospital Revenue Code	360
Min. Negotiated Rate	$2,324.10
Max. Negotiated Rate	$2,560.12
Rate for Payer: Wellmark IA HMO WHPI	$2,324.10
Rate for Payer: Wellmark IA PPO	$2,560.12

TRAUMATIC INJURY WITH MCC

Facility

$18,429.99

Service Code	MSDRG 913
Min. Negotiated Rate	$18,162.88
Max. Negotiated Rate	$18,429.99
Rate for Payer: Amerigroup Medicaid	$18,340.95
Rate for Payer: Iowa Total Care Managed Medicaid	$18,162.88
Rate for Payer: Molina Healthcare Managed Medicaid	$18,429.99

TRAUMATIC INJURY WITHOUT MCC

Facility

$6,184.99

Service Code	MSDRG 914
Min. Negotiated Rate	$6,095.35
Max. Negotiated Rate	$6,184.99
Rate for Payer: Amerigroup Medicaid	$6,155.11
Rate for Payer: Iowa Total Care Managed Medicaid	$6,095.35
Rate for Payer: Molina Healthcare Managed Medicaid	$6,184.99

TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC

Facility

$8,999.93

Service Code	MSDRG 086
Min. Negotiated Rate	$8,869.50
Max. Negotiated Rate	$8,999.93
Rate for Payer: Amerigroup Medicaid	$8,956.45
Rate for Payer: Iowa Total Care Managed Medicaid	$8,869.50
Rate for Payer: Molina Healthcare Managed Medicaid	$8,999.93

TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC

Facility

$10,038.08

Service Code	MSDRG 083
Min. Negotiated Rate	$9,892.60
Max. Negotiated Rate	$10,038.08
Rate for Payer: Amerigroup Medicaid	$9,989.59
Rate for Payer: Iowa Total Care Managed Medicaid	$9,892.60
Rate for Payer: Molina Healthcare Managed Medicaid	$10,038.08

TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC

Facility

$15,034.04

Service Code	MSDRG 085
Min. Negotiated Rate	$14,816.15
Max. Negotiated Rate	$15,034.04
Rate for Payer: Amerigroup Medicaid	$14,961.41
Rate for Payer: Iowa Total Care Managed Medicaid	$14,816.15
Rate for Payer: Molina Healthcare Managed Medicaid	$15,034.04

TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC

Facility

$26,969.40

Service Code	MSDRG 082
Min. Negotiated Rate	$26,578.53
Max. Negotiated Rate	$26,969.40
Rate for Payer: Amerigroup Medicaid	$26,839.10
Rate for Payer: Iowa Total Care Managed Medicaid	$26,578.53
Rate for Payer: Molina Healthcare Managed Medicaid	$26,969.40

TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC

Facility

$5,555.57

Service Code	MSDRG 087
Min. Negotiated Rate	$5,475.05
Max. Negotiated Rate	$5,555.57
Rate for Payer: Amerigroup Medicaid	$5,528.73
Rate for Payer: Iowa Total Care Managed Medicaid	$5,475.05
Rate for Payer: Molina Healthcare Managed Medicaid	$5,555.57

TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC

Facility

$6,019.47

Service Code	MSDRG 084
Min. Negotiated Rate	$5,932.23
Max. Negotiated Rate	$6,019.47
Rate for Payer: Amerigroup Medicaid	$5,990.39
Rate for Payer: Iowa Total Care Managed Medicaid	$5,932.23
Rate for Payer: Molina Healthcare Managed Medicaid	$6,019.47

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITH MCC

Facility

$9,998.68

Service Code	MSDRG 604
Min. Negotiated Rate	$9,853.76
Max. Negotiated Rate	$9,998.68
Rate for Payer: Amerigroup Medicaid	$9,950.37
Rate for Payer: Iowa Total Care Managed Medicaid	$9,853.76
Rate for Payer: Molina Healthcare Managed Medicaid	$9,998.68

TRAUMA TO THE SKIN, SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC

Facility

$7,063.25

Service Code	MSDRG 605
Min. Negotiated Rate	$6,960.88
Max. Negotiated Rate	$7,063.25
Rate for Payer: Amerigroup Medicaid	$7,029.13
Rate for Payer: Iowa Total Care Managed Medicaid	$6,960.88
Rate for Payer: Molina Healthcare Managed Medicaid	$7,063.25

traZODone 50 mg Tab [VDMC]

Facility

$1.32

Service Code	HCPCS A9270
Hospital Charge Code	10426114
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of IA Commercial	$1.19
Rate for Payer: Aetna of IA Medical Rental Products	$1.19
Rate for Payer: Aetna of IA Medicare	$0.75
Rate for Payer: Amerigroup Medicaid	$0.76
Rate for Payer: Amerigroup Medicare	$0.60
Rate for Payer: Cash Price	$1.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.99
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.59
Rate for Payer: Iowa Total Care Managed Medicaid	$0.75
Rate for Payer: Medical Associates Commercial	$0.99
Rate for Payer: Medical Associates Managed Medicare	$0.59
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: Molina Healthcare Managed Medicaid	$0.77
Rate for Payer: Partners Health Alliance Commercial	$0.68
Rate for Payer: United Healthcare Commercial	$1.19
Rate for Payer: United Healthcare Managed Medicare	$0.78

traZODone 50 mg Tab [VDMC]

Facility

$1.32

Service Code	HCPCS A9270
Hospital Charge Code	10426114
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.19
Rate for Payer: Aetna of IA Commercial	$1.19
Rate for Payer: Aetna of IA Medical Rental Products	$1.19
Rate for Payer: Cash Price	$1.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.99
Rate for Payer: Medical Associates Commercial	$0.99
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: United Healthcare Commercial	$1.19

TREAT CLAVICLE FRACTURE

Facility

$624.00

Service Code	CPT 23500
Hospital Charge Code	4864812
Hospital Revenue Code	450
Min. Negotiated Rate	$436.80
Max. Negotiated Rate	$561.60
Rate for Payer: Aetna of IA Commercial	$561.60
Rate for Payer: Aetna of IA Medical Rental Products	$561.60
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.00
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: United Healthcare Commercial	$561.60

TREAT CLAVICLE FRACTURE

Professional

Both

$424.00

Service Code	CPT 23500
Hospital Charge Code	7982813
Hospital Revenue Code	981
Min. Negotiated Rate	$160.76
Max. Negotiated Rate	$519.50
Rate for Payer: Amerigroup Medicaid	$162.34
Rate for Payer: Cash Price	$339.20
Rate for Payer: Cash Price	$339.20
Rate for Payer: Iowa Total Care Managed Medicaid	$160.76
Rate for Payer: Medical Associates Commercial	$318.00
Rate for Payer: Midlands Choice Commercial	$296.80
Rate for Payer: Molina Healthcare Managed Medicaid	$161.55
Rate for Payer: Partners Health Alliance Commercial	$318.00
Rate for Payer: United Healthcare Commercial	$330.88
Rate for Payer: Wellmark IA HMO WHPI	$441.60
Rate for Payer: Wellmark IA PPO	$519.50

TREAT CLAVICLE FRACTURE

Facility

$624.00

Service Code	CPT 23500
Hospital Charge Code	4864812
Hospital Revenue Code	450
Min. Negotiated Rate	$280.80
Max. Negotiated Rate	$2,009.51
Rate for Payer: Aetna of IA Commercial	$561.60
Rate for Payer: Aetna of IA Medical Rental Products	$561.60
Rate for Payer: Aetna of IA Medicare	$355.68
Rate for Payer: Amerigroup Medicaid	$359.92
Rate for Payer: Amerigroup Medicare	$283.61
Rate for Payer: Cash Price	$499.20
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$280.80
Rate for Payer: Iowa Total Care Managed Medicaid	$356.43
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Medical Associates Managed Medicare	$280.80
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Molina Healthcare Managed Medicaid	$361.67
Rate for Payer: Partners Health Alliance Commercial	$322.92
Rate for Payer: United Healthcare Commercial	$561.60
Rate for Payer: United Healthcare Managed Medicare	$368.16
Rate for Payer: Wellmark IA HMO WHPI	$1,824.26
Rate for Payer: Wellmark IA PPO	$2,009.51

TREAT DISLOCATION/FRACTURE

Facility

$1,256.00

Service Code	CPT 23665
Hospital Charge Code	7983021
Hospital Revenue Code	450
Min. Negotiated Rate	$565.20
Max. Negotiated Rate	$2,009.51
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	$724.46
Rate for Payer: Amerigroup Medicare	$570.85
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	$565.20
Rate for Payer: Iowa Total Care Managed Medicaid	$717.43
Rate for Payer: Medical Associates Commercial	$942.00
Rate for Payer: Medical Associates Managed Medicare	$565.20
Rate for Payer: Midlands Choice Commercial	$879.20
Rate for Payer: Molina Healthcare Managed Medicaid	$727.98
Rate for Payer: Partners Health Alliance Commercial	$649.98
Rate for Payer: United Healthcare Commercial	$1,130.40
Rate for Payer: United Healthcare Managed Medicare	$741.04
Rate for Payer: Wellmark IA HMO WHPI	$1,824.26
Rate for Payer: Wellmark IA PPO	$2,009.51

TREAT DISLOCATION/FRACTURE

Facility

$1,256.00

Service Code	CPT 23665
Hospital Charge Code	7983021
Hospital Revenue Code	450
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 DISLOCATION/FRACTURE

Professional

Both

$1,228.00

Service Code	CPT 23665
Hospital Charge Code	7982871
Hospital Revenue Code	981
Min. Negotiated Rate	$337.45
Max. Negotiated Rate	$1,004.20
Rate for Payer: Amerigroup Medicaid	$340.75
Rate for Payer: Cash Price	$982.40
Rate for Payer: Cash Price	$982.40
Rate for Payer: Iowa Total Care Managed Medicaid	$337.45
Rate for Payer: Medical Associates Commercial	$921.00
Rate for Payer: Midlands Choice Commercial	$859.60
Rate for Payer: Molina Healthcare Managed Medicaid	$339.10
Rate for Payer: Partners Health Alliance Commercial	$921.00
Rate for Payer: United Healthcare Commercial	$645.68
Rate for Payer: Wellmark IA HMO WHPI	$853.60
Rate for Payer: Wellmark IA PPO	$1,004.20

TREAT ELBOW DISLOCATION

Facility

$1,393.00

Service Code	CPT 24605
Hospital Charge Code	4864833
Hospital Revenue Code	450
Min. Negotiated Rate	$626.85
Max. Negotiated Rate	$2,696.01
Rate for Payer: Aetna of IA Commercial	$1,253.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,253.70
Rate for Payer: Aetna of IA Medicare	$794.01
Rate for Payer: Amerigroup Medicaid	$803.48
Rate for Payer: Amerigroup Medicare	$633.12
Rate for Payer: Cash Price	$1,114.40
Rate for Payer: Cash Price	$1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,044.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$626.85
Rate for Payer: Iowa Total Care Managed Medicaid	$795.68
Rate for Payer: Medical Associates Commercial	$1,044.75
Rate for Payer: Medical Associates Managed Medicare	$626.85
Rate for Payer: Midlands Choice Commercial	$975.10
Rate for Payer: Molina Healthcare Managed Medicaid	$807.38
Rate for Payer: Partners Health Alliance Commercial	$720.88
Rate for Payer: United Healthcare Commercial	$1,253.70
Rate for Payer: United Healthcare Managed Medicare	$821.87
Rate for Payer: Wellmark IA HMO WHPI	$2,447.47
Rate for Payer: Wellmark IA PPO	$2,696.01

TREAT ELBOW DISLOCATION

Facility

$628.00

Service Code	CPT 24640
Hospital Charge Code	4864835
Hospital Revenue Code	450
Min. Negotiated Rate	$282.60
Max. Negotiated Rate	$2,009.51
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Aetna of IA Medicare	$357.96
Rate for Payer: Amerigroup Medicaid	$362.23
Rate for Payer: Amerigroup Medicare	$285.43
Rate for Payer: Cash Price	$502.40
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$282.60
Rate for Payer: Iowa Total Care Managed Medicaid	$358.71
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Medical Associates Managed Medicare	$282.60
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: Molina Healthcare Managed Medicaid	$363.99
Rate for Payer: Partners Health Alliance Commercial	$324.99
Rate for Payer: United Healthcare Commercial	$565.20
Rate for Payer: United Healthcare Managed Medicare	$370.52
Rate for Payer: Wellmark IA HMO WHPI	$1,824.26
Rate for Payer: Wellmark IA PPO	$2,009.51

TREAT ELBOW DISLOCATION

Facility

$628.00

Service Code	CPT 24640
Hospital Charge Code	4864835
Hospital Revenue Code	450
Min. Negotiated Rate	$439.60
Max. Negotiated Rate	$565.20
Rate for Payer: Aetna of IA Commercial	$565.20
Rate for Payer: Aetna of IA Medical Rental Products	$565.20
Rate for Payer: Cash Price	$502.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$471.00
Rate for Payer: Medical Associates Commercial	$471.00
Rate for Payer: Midlands Choice Commercial	$439.60
Rate for Payer: United Healthcare Commercial	$565.20

TREAT ELBOW DISLOCATION

Facility

$1,393.00

Service Code	CPT 24605
Hospital Charge Code	4864833
Hospital Revenue Code	450
Min. Negotiated Rate	$975.10
Max. Negotiated Rate	$1,253.70
Rate for Payer: Aetna of IA Commercial	$1,253.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,253.70
Rate for Payer: Cash Price	$1,114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,044.75
Rate for Payer: Medical Associates Commercial	$1,044.75
Rate for Payer: Midlands Choice Commercial	$975.10
Rate for Payer: United Healthcare Commercial	$1,253.70

TREAT FINGER DISLOCATION

Facility

$624.00

Service Code	CPT 26770
Hospital Charge Code	4863411
Hospital Revenue Code	450
Min. Negotiated Rate	$280.80
Max. Negotiated Rate	$2,009.51
Rate for Payer: Aetna of IA Commercial	$561.60
Rate for Payer: Aetna of IA Medical Rental Products	$561.60
Rate for Payer: Aetna of IA Medicare	$355.68
Rate for Payer: Amerigroup Medicaid	$359.92
Rate for Payer: Amerigroup Medicare	$283.61
Rate for Payer: Cash Price	$499.20
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$468.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$280.80
Rate for Payer: Iowa Total Care Managed Medicaid	$356.43
Rate for Payer: Medical Associates Commercial	$468.00
Rate for Payer: Medical Associates Managed Medicare	$280.80
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Molina Healthcare Managed Medicaid	$361.67
Rate for Payer: Partners Health Alliance Commercial	$322.92
Rate for Payer: United Healthcare Commercial	$561.60
Rate for Payer: United Healthcare Managed Medicare	$368.16
Rate for Payer: Wellmark IA HMO WHPI	$1,824.26
Rate for Payer: Wellmark IA PPO	$2,009.51

Know your out-of-pocket cost for care.

All Charges