Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$44.55
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	$57.10
Rate for Payer: Amerigroup Medicare	$45.00
Rate for Payer: Cash Price	$79.20
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	$44.55
Rate for Payer: Iowa Total Care Managed Medicaid	$56.55
Rate for Payer: Medical Associates Commercial	$74.25
Rate for Payer: Medical Associates Managed Medicare	$44.55
Rate for Payer: Midlands Choice Commercial	$69.30
Rate for Payer: Molina Healthcare Managed Medicaid	$57.38
Rate for Payer: Partners Health Alliance Commercial	$51.23
Rate for Payer: United Healthcare Commercial	$89.10
Rate for Payer: United Healthcare Managed Medicare	$58.41
Rate for Payer: Wellmark IA HMO WHPI	$73.74
Rate for Payer: Wellmark IA PPO	$81.22

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	$73.03
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	$93.60
Rate for Payer: Amerigroup Medicare	$73.76
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	$73.03
Rate for Payer: Iowa Total Care Managed Medicaid	$92.69
Rate for Payer: Medical Associates Commercial	$121.71
Rate for Payer: Medical Associates Managed Medicare	$73.03
Rate for Payer: Midlands Choice Commercial	$113.60
Rate for Payer: Molina Healthcare Managed Medicaid	$94.06
Rate for Payer: Partners Health Alliance Commercial	$83.98
Rate for Payer: United Healthcare Commercial	$146.05
Rate for Payer: United Healthcare Managed Medicare	$95.75

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

UNCOMPLICATED PEPTIC ULCER WITH MCC

Facility

$14,763.81

Service Code	MSDRG 383
Min. Negotiated Rate	$14,549.84
Max. Negotiated Rate	$14,763.81
Rate for Payer: Amerigroup Medicaid	$14,692.48
Rate for Payer: Iowa Total Care Managed Medicaid	$14,549.84
Rate for Payer: Molina Healthcare Managed Medicaid	$14,763.81

UNCOMPLICATED PEPTIC ULCER WITHOUT MCC

Facility

$10,012.19

Service Code	MSDRG 384
Min. Negotiated Rate	$9,867.08
Max. Negotiated Rate	$10,012.19
Rate for Payer: Amerigroup Medicaid	$9,963.82
Rate for Payer: Iowa Total Care Managed Medicaid	$9,867.08
Rate for Payer: Molina Healthcare Managed Medicaid	$10,012.19

Unlisted Dental Surgery

Facility

$3,918.28

Service Code	CPT 41899
Min. Negotiated Rate	$3,557.05
Max. Negotiated Rate	$3,918.28
Rate for Payer: Wellmark IA HMO WHPI	$3,557.05
Rate for Payer: Wellmark IA PPO	$3,918.28

UNLISTED PROCEDURE, ARTHROSCOPY

Facility

$5,349.07

Service Code	CPT 29999
Hospital Revenue Code	360
Min. Negotiated Rate	$4,855.94
Max. Negotiated Rate	$5,349.07
Rate for Payer: Wellmark IA HMO WHPI	$4,855.94
Rate for Payer: Wellmark IA PPO	$5,349.07

UNLISTED PROCEDURE, DENTOALVEOLAR STRUCTURES

Facility

$3,918.28

Service Code	CPT 41899
Hospital Revenue Code	490
Min. Negotiated Rate	$3,557.05
Max. Negotiated Rate	$3,918.28
Rate for Payer: Wellmark IA HMO WHPI	$3,557.05
Rate for Payer: Wellmark IA PPO	$3,918.28

U PLATE SMALL

Facility

$2,970.00

Service Code	HCPCS C1713
Hospital Charge Code	8968466
Hospital Revenue Code	278
Min. Negotiated Rate	$1,336.50
Max. Negotiated Rate	$2,673.00
Rate for Payer: Aetna of IA Commercial	$2,673.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,673.00
Rate for Payer: Aetna of IA Medicare	$1,692.90
Rate for Payer: Amerigroup Medicaid	$1,713.10
Rate for Payer: Amerigroup Medicare	$1,349.86
Rate for Payer: Cash Price	$2,376.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,227.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,336.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,696.46
Rate for Payer: Medical Associates Commercial	$2,227.50
Rate for Payer: Medical Associates Managed Medicare	$1,336.50
Rate for Payer: Midlands Choice Commercial	$2,079.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,721.41
Rate for Payer: Partners Health Alliance Commercial	$1,536.98
Rate for Payer: United Healthcare Commercial	$2,673.00
Rate for Payer: United Healthcare Managed Medicare	$1,752.30

U PLATE SMALL

Facility

$2,970.00

Service Code	HCPCS C1713
Hospital Charge Code	8968466
Hospital Revenue Code	278
Min. Negotiated Rate	$2,079.00
Max. Negotiated Rate	$2,673.00
Rate for Payer: Aetna of IA Commercial	$2,673.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,673.00
Rate for Payer: Cash Price	$2,376.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,227.50
Rate for Payer: Medical Associates Commercial	$2,227.50
Rate for Payer: Midlands Choice Commercial	$2,079.00
Rate for Payer: United Healthcare Commercial	$2,673.00

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC

Facility

$16,862.63

Service Code	MSDRG 256
Min. Negotiated Rate	$16,618.24
Max. Negotiated Rate	$16,862.63
Rate for Payer: Amerigroup Medicaid	$16,781.16
Rate for Payer: Iowa Total Care Managed Medicaid	$16,618.24
Rate for Payer: Molina Healthcare Managed Medicaid	$16,862.63

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC

Facility

$17,215.06

Service Code	MSDRG 255
Min. Negotiated Rate	$16,965.56
Max. Negotiated Rate	$17,215.06
Rate for Payer: Amerigroup Medicaid	$17,131.89
Rate for Payer: Iowa Total Care Managed Medicaid	$16,965.56
Rate for Payer: Molina Healthcare Managed Medicaid	$17,215.06

UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC

Facility

$13,075.97

Service Code	MSDRG 257
Min. Negotiated Rate	$12,886.46
Max. Negotiated Rate	$13,075.97
Rate for Payer: Amerigroup Medicaid	$13,012.80
Rate for Payer: Iowa Total Care Managed Medicaid	$12,886.46
Rate for Payer: Molina Healthcare Managed Medicaid	$13,075.97

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	$11.65
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	$14.93
Rate for Payer: Amerigroup Medicare	$11.76
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	$11.65
Rate for Payer: Iowa Total Care Managed Medicaid	$14.78
Rate for Payer: Medical Associates Commercial	$19.41
Rate for Payer: Medical Associates Managed Medicare	$11.65
Rate for Payer: Midlands Choice Commercial	$18.12
Rate for Payer: Molina Healthcare Managed Medicaid	$15.00
Rate for Payer: Partners Health Alliance Commercial	$13.39
Rate for Payer: United Healthcare Commercial	$23.29
Rate for Payer: United Healthcare Managed Medicare	$15.27

URETHRAL PROCEDURES WITH CC/MCC

Facility

$20,010.86

Service Code	MSDRG 671
Min. Negotiated Rate	$19,720.84
Max. Negotiated Rate	$20,010.86
Rate for Payer: Amerigroup Medicaid	$19,914.18
Rate for Payer: Iowa Total Care Managed Medicaid	$19,720.84
Rate for Payer: Molina Healthcare Managed Medicaid	$20,010.86

URETHRAL PROCEDURES WITHOUT CC/MCC

Facility

$10,219.37

Service Code	MSDRG 672
Min. Negotiated Rate	$10,071.26
Max. Negotiated Rate	$10,219.37
Rate for Payer: Amerigroup Medicaid	$10,169.99
Rate for Payer: Iowa Total Care Managed Medicaid	$10,071.26
Rate for Payer: Molina Healthcare Managed Medicaid	$10,219.37

URETHRAL STRICTURE

Facility

$6,653.40

Service Code	MSDRG 697
Min. Negotiated Rate	$6,556.97
Max. Negotiated Rate	$6,653.40
Rate for Payer: Amerigroup Medicaid	$6,621.25
Rate for Payer: Iowa Total Care Managed Medicaid	$6,556.97
Rate for Payer: Molina Healthcare Managed Medicaid	$6,653.40

URIC ACID

Facility

$46.00

Service Code	CPT 84550
Hospital Charge Code	633858
Hospital Revenue Code	301
Min. Negotiated Rate	$32.20
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: United Healthcare Commercial	$41.40

URIC ACID

Facility

$46.00

Service Code	CPT 84550
Hospital Charge Code	633858
Hospital Revenue Code	301
Min. Negotiated Rate	$20.70
Max. Negotiated Rate	$41.40
Rate for Payer: Aetna of IA Commercial	$41.40
Rate for Payer: Aetna of IA Medical Rental Products	$41.40
Rate for Payer: Aetna of IA Medicare	$26.22
Rate for Payer: Amerigroup Medicaid	$26.53
Rate for Payer: Amerigroup Medicare	$20.91
Rate for Payer: Cash Price	$36.80
Rate for Payer: Cash Price	$36.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$34.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$20.70
Rate for Payer: Iowa Total Care Managed Medicaid	$26.28
Rate for Payer: Medical Associates Commercial	$34.50
Rate for Payer: Medical Associates Managed Medicare	$20.70
Rate for Payer: Midlands Choice Commercial	$32.20
Rate for Payer: Molina Healthcare Managed Medicaid	$26.66
Rate for Payer: Partners Health Alliance Commercial	$23.80
Rate for Payer: United Healthcare Commercial	$41.40
Rate for Payer: United Healthcare Managed Medicare	$27.14
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

Uric Acid Urine Timed DMCL

Facility

$61.00

Service Code	CPT 84560
Hospital Charge Code	8037740
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	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

Uric Acid Urine Timed DMCL

Facility

$61.00

Service Code	CPT 84560
Hospital Charge Code	8037740
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

URINALYSIS BY DIPSTICK, AUTO W/O MICRO

Facility

$31.00

Service Code	CPT 81003
Hospital Charge Code	4006795
Hospital Revenue Code	307
Min. Negotiated Rate	$21.70
Max. Negotiated Rate	$27.90
Rate for Payer: Aetna of IA Commercial	$27.90
Rate for Payer: Aetna of IA Medical Rental Products	$27.90
Rate for Payer: Cash Price	$24.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.25
Rate for Payer: Medical Associates Commercial	$23.25
Rate for Payer: Midlands Choice Commercial	$21.70
Rate for Payer: United Healthcare Commercial	$27.90

URINALYSIS BY DIPSTICK, AUTO W/O MICRO

Facility

$31.00

Service Code	CPT 81003
Hospital Charge Code	4006797
Hospital Revenue Code	307
Min. Negotiated Rate	$13.95
Max. Negotiated Rate	$28.12
Rate for Payer: Aetna of IA Commercial	$27.90
Rate for Payer: Aetna of IA Medical Rental Products	$27.90
Rate for Payer: Aetna of IA Medicare	$17.67
Rate for Payer: Amerigroup Medicaid	$17.88
Rate for Payer: Amerigroup Medicare	$14.09
Rate for Payer: Cash Price	$24.80
Rate for Payer: Cash Price	$24.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.95
Rate for Payer: Iowa Total Care Managed Medicaid	$17.71
Rate for Payer: Medical Associates Commercial	$23.25
Rate for Payer: Medical Associates Managed Medicare	$13.95
Rate for Payer: Midlands Choice Commercial	$21.70
Rate for Payer: Molina Healthcare Managed Medicaid	$17.97
Rate for Payer: Partners Health Alliance Commercial	$16.04
Rate for Payer: United Healthcare Commercial	$27.90
Rate for Payer: United Healthcare Managed Medicare	$18.29
Rate for Payer: Wellmark IA HMO WHPI	$25.52
Rate for Payer: Wellmark IA PPO	$28.12

Know your out-of-pocket cost for care.

All Charges