Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Anti-Thrombin Antigen DMCL

Facility

$103.00

Service Code	CPT 85301
Hospital Charge Code	8037482
Hospital Revenue Code	305
Min. Negotiated Rate	$72.10
Max. Negotiated Rate	$92.70
Rate for Payer: Aetna of IA Commercial	$92.70
Rate for Payer: Aetna of IA Medical Rental Products	$92.70
Rate for Payer: Cash Price	$82.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$77.25
Rate for Payer: Medical Associates Commercial	$77.25
Rate for Payer: Midlands Choice Commercial	$72.10
Rate for Payer: United Healthcare Commercial	$92.70

Anti Xa Heparin UFH DMCL

Facility

$58.00

Service Code	CPT 85335
Hospital Charge Code	8818432
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

Anti Xa Heparin UFH DMCL

Facility

$58.00

Service Code	CPT 85335
Hospital Charge Code	8818432
Hospital Revenue Code	301
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$33.45
Rate for Payer: Amerigroup Medicare	$26.36
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.10
Rate for Payer: Iowa Total Care Managed Medicaid	$33.13
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$26.10
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$33.62
Rate for Payer: Partners Health Alliance Commercial	$30.02
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22

ANUS SURGERY PROCEDURE

Facility

$1,894.00

Service Code	CPT 46999
Hospital Charge Code	7982911
Hospital Revenue Code	450
Min. Negotiated Rate	$852.30
Max. Negotiated Rate	$1,704.60
Rate for Payer: Aetna of IA Commercial	$1,704.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,704.60
Rate for Payer: Aetna of IA Medicare	$1,079.58
Rate for Payer: Amerigroup Medicaid	$1,092.46
Rate for Payer: Amerigroup Medicare	$860.82
Rate for Payer: Cash Price	$1,515.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,420.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$852.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1,081.85
Rate for Payer: Medical Associates Commercial	$1,420.50
Rate for Payer: Medical Associates Managed Medicare	$852.30
Rate for Payer: Midlands Choice Commercial	$1,325.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,097.76
Rate for Payer: Partners Health Alliance Commercial	$980.14
Rate for Payer: United Healthcare Commercial	$1,704.60
Rate for Payer: United Healthcare Managed Medicare	$1,117.46

ANUS SURGERY PROCEDURE

Facility

$1,894.00

Service Code	CPT 46999
Hospital Charge Code	7982911
Hospital Revenue Code	450
Min. Negotiated Rate	$1,325.80
Max. Negotiated Rate	$1,704.60
Rate for Payer: Aetna of IA Commercial	$1,704.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,704.60
Rate for Payer: Cash Price	$1,515.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,420.50
Rate for Payer: Medical Associates Commercial	$1,420.50
Rate for Payer: Midlands Choice Commercial	$1,325.80
Rate for Payer: United Healthcare Commercial	$1,704.60

APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [VDMC]

Facility

$1.53

Service Code	HCPCS A9270
Hospital Charge Code	10367413
Hospital Revenue Code	259
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of IA Commercial	$1.37
Rate for Payer: Aetna of IA Medical Rental Products	$1.37
Rate for Payer: Aetna of IA Medicare	$0.87
Rate for Payer: Amerigroup Medicaid	$0.88
Rate for Payer: Amerigroup Medicare	$0.69
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.14
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.69
Rate for Payer: Iowa Total Care Managed Medicaid	$0.87
Rate for Payer: Medical Associates Commercial	$1.14
Rate for Payer: Medical Associates Managed Medicare	$0.69
Rate for Payer: Midlands Choice Commercial	$1.07
Rate for Payer: Molina Healthcare Managed Medicaid	$0.88
Rate for Payer: Partners Health Alliance Commercial	$0.79
Rate for Payer: United Healthcare Commercial	$1.37
Rate for Payer: United Healthcare Managed Medicare	$0.90

APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [VDMC]

Facility

$1.53

Service Code	HCPCS A9270
Hospital Charge Code	10367413
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of IA Commercial	$1.37
Rate for Payer: Aetna of IA Medical Rental Products	$1.37
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.14
Rate for Payer: Medical Associates Commercial	$1.14
Rate for Payer: Midlands Choice Commercial	$1.07
Rate for Payer: United Healthcare Commercial	$1.37

apixaban 5 mg Tab UD [VDMC]

Facility

$28.89

Service Code	HCPCS A9270
Hospital Charge Code	10367482
Hospital Revenue Code	259
Min. Negotiated Rate	$13.00
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna of IA Commercial	$26.00
Rate for Payer: Aetna of IA Medical Rental Products	$26.00
Rate for Payer: Aetna of IA Medicare	$16.47
Rate for Payer: Amerigroup Medicaid	$16.66
Rate for Payer: Amerigroup Medicare	$13.13
Rate for Payer: Cash Price	$23.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.66
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.00
Rate for Payer: Iowa Total Care Managed Medicaid	$16.50
Rate for Payer: Medical Associates Commercial	$21.66
Rate for Payer: Medical Associates Managed Medicare	$13.00
Rate for Payer: Midlands Choice Commercial	$20.22
Rate for Payer: Molina Healthcare Managed Medicaid	$16.74
Rate for Payer: Partners Health Alliance Commercial	$14.95
Rate for Payer: United Healthcare Commercial	$26.00
Rate for Payer: United Healthcare Managed Medicare	$17.04

apixaban 5 mg Tab UD [VDMC]

Facility

$28.89

Service Code	HCPCS A9270
Hospital Charge Code	10367482
Hospital Revenue Code	259
Min. Negotiated Rate	$20.22
Max. Negotiated Rate	$26.00
Rate for Payer: Aetna of IA Commercial	$26.00
Rate for Payer: Aetna of IA Medical Rental Products	$26.00
Rate for Payer: Cash Price	$23.11
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.66
Rate for Payer: Medical Associates Commercial	$21.66
Rate for Payer: Midlands Choice Commercial	$20.22
Rate for Payer: United Healthcare Commercial	$26.00

Apolipoprotein B DMCL

Facility

$75.00

Service Code	CPT 82172
Hospital Charge Code	8938406
Hospital Revenue Code	301
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of IA Commercial	$67.50
Rate for Payer: Aetna of IA Medical Rental Products	$67.50
Rate for Payer: Cash Price	$60.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.25
Rate for Payer: Medical Associates Commercial	$56.25
Rate for Payer: Midlands Choice Commercial	$52.50
Rate for Payer: United Healthcare Commercial	$67.50

Apolipoprotein B DMCL

Facility

$75.00

Service Code	CPT 82172
Hospital Charge Code	8938406
Hospital Revenue Code	301
Min. Negotiated Rate	$33.75
Max. Negotiated Rate	$67.50
Rate for Payer: Aetna of IA Commercial	$67.50
Rate for Payer: Aetna of IA Medical Rental Products	$67.50
Rate for Payer: Aetna of IA Medicare	$42.75
Rate for Payer: Amerigroup Medicaid	$43.26
Rate for Payer: Amerigroup Medicare	$34.09
Rate for Payer: Cash Price	$60.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$56.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$33.75
Rate for Payer: Iowa Total Care Managed Medicaid	$42.84
Rate for Payer: Medical Associates Commercial	$56.25
Rate for Payer: Medical Associates Managed Medicare	$33.75
Rate for Payer: Midlands Choice Commercial	$52.50
Rate for Payer: Molina Healthcare Managed Medicaid	$43.47
Rate for Payer: Partners Health Alliance Commercial	$38.81
Rate for Payer: United Healthcare Commercial	$67.50
Rate for Payer: United Healthcare Managed Medicare	$44.25

APPLICATION LONG LEG SPLINT

Professional

Both

$218.00

Service Code	CPT 29505
Hospital Charge Code	7982786
Hospital Revenue Code	981
Min. Negotiated Rate	$126.86
Max. Negotiated Rate	$163.50
Rate for Payer: Cash Price	$174.40
Rate for Payer: Cash Price	$174.40
Rate for Payer: Medical Associates Commercial	$163.50
Rate for Payer: Midlands Choice Commercial	$152.60
Rate for Payer: Partners Health Alliance Commercial	$163.50
Rate for Payer: United Healthcare Commercial	$126.86

APPLICATION LOWER LEG SPLINT

Professional

Both

$197.00

Service Code	CPT 29515
Hospital Charge Code	7982785
Hospital Revenue Code	981
Min. Negotiated Rate	$106.13
Max. Negotiated Rate	$147.75
Rate for Payer: Cash Price	$157.60
Rate for Payer: Cash Price	$157.60
Rate for Payer: Medical Associates Commercial	$147.75
Rate for Payer: Midlands Choice Commercial	$137.90
Rate for Payer: Partners Health Alliance Commercial	$147.75
Rate for Payer: United Healthcare Commercial	$106.13

APPLICATION OF FINGER SPLINT

Professional

Both

$112.00

Service Code	CPT 29130
Hospital Charge Code	7982788
Hospital Revenue Code	981
Min. Negotiated Rate	$61.97
Max. Negotiated Rate	$84.00
Rate for Payer: Cash Price	$89.60
Rate for Payer: Cash Price	$89.60
Rate for Payer: Medical Associates Commercial	$84.00
Rate for Payer: Midlands Choice Commercial	$78.40
Rate for Payer: Partners Health Alliance Commercial	$84.00
Rate for Payer: United Healthcare Commercial	$61.97

APPLICATION OF FOREARM CAST

Facility

$229.00

Service Code	CPT 29075
Hospital Charge Code	4864878
Hospital Revenue Code	450
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: United Healthcare Commercial	$206.10

APPLICATION OF FOREARM CAST

Facility

$229.00

Service Code	CPT 29075
Hospital Charge Code	4864878
Hospital Revenue Code	450
Min. Negotiated Rate	$103.05
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Aetna of IA Medicare	$130.53
Rate for Payer: Amerigroup Medicaid	$132.09
Rate for Payer: Amerigroup Medicare	$104.08
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.05
Rate for Payer: Iowa Total Care Managed Medicaid	$130.80
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Medical Associates Managed Medicare	$103.05
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: Molina Healthcare Managed Medicaid	$132.73
Rate for Payer: Partners Health Alliance Commercial	$118.51
Rate for Payer: United Healthcare Commercial	$206.10
Rate for Payer: United Healthcare Managed Medicare	$135.11

APPLICATION OF LONG ARM CAST

Facility

$229.00

Service Code	CPT 29065
Hospital Charge Code	4864876
Hospital Revenue Code	450
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: United Healthcare Commercial	$206.10

APPLICATION OF LONG ARM CAST

Facility

$229.00

Service Code	CPT 29065
Hospital Charge Code	4864876
Hospital Revenue Code	450
Min. Negotiated Rate	$103.05
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Aetna of IA Medicare	$130.53
Rate for Payer: Amerigroup Medicaid	$132.09
Rate for Payer: Amerigroup Medicare	$104.08
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.05
Rate for Payer: Iowa Total Care Managed Medicaid	$130.80
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Medical Associates Managed Medicare	$103.05
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: Molina Healthcare Managed Medicaid	$132.73
Rate for Payer: Partners Health Alliance Commercial	$118.51
Rate for Payer: United Healthcare Commercial	$206.10
Rate for Payer: United Healthcare Managed Medicare	$135.11

APPLICATION OF LONG LEG CAST

Facility

$229.00

Service Code	CPT 29345
Hospital Charge Code	4864890
Hospital Revenue Code	450
Min. Negotiated Rate	$103.05
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Aetna of IA Medicare	$130.53
Rate for Payer: Amerigroup Medicaid	$132.09
Rate for Payer: Amerigroup Medicare	$104.08
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.05
Rate for Payer: Iowa Total Care Managed Medicaid	$130.80
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Medical Associates Managed Medicare	$103.05
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: Molina Healthcare Managed Medicaid	$132.73
Rate for Payer: Partners Health Alliance Commercial	$118.51
Rate for Payer: United Healthcare Commercial	$206.10
Rate for Payer: United Healthcare Managed Medicare	$135.11

APPLICATION OF LONG LEG CAST

Facility

$229.00

Service Code	CPT 29345
Hospital Charge Code	4864890
Hospital Revenue Code	450
Min. Negotiated Rate	$160.30
Max. Negotiated Rate	$206.10
Rate for Payer: Aetna of IA Commercial	$206.10
Rate for Payer: Aetna of IA Medical Rental Products	$206.10
Rate for Payer: Cash Price	$183.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.75
Rate for Payer: Medical Associates Commercial	$171.75
Rate for Payer: Midlands Choice Commercial	$160.30
Rate for Payer: United Healthcare Commercial	$206.10

APPLICATION TOTAL CONTACT CAST

Facility

$406.00

Service Code	CPT 29445
Hospital Charge Code	8013707
Hospital Revenue Code	510
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: United Healthcare Commercial	$365.40

APPLICATION TOTAL CONTACT CAST

Facility

$406.00

Service Code	CPT 29445
Hospital Charge Code	8013707
Hospital Revenue Code	510
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Aetna of IA Medicare	$231.42
Rate for Payer: Amerigroup Medicaid	$234.18
Rate for Payer: Amerigroup Medicare	$184.53
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$182.70
Rate for Payer: Iowa Total Care Managed Medicaid	$231.91
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Medical Associates Managed Medicare	$182.70
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: Molina Healthcare Managed Medicaid	$235.32
Rate for Payer: Partners Health Alliance Commercial	$210.10
Rate for Payer: United Healthcare Commercial	$365.40
Rate for Payer: United Healthcare Managed Medicare	$239.54

APPL SKIN SUB < 100 1ST 25 CM FEET/TOES

Facility

$569.00

Service Code	CPT 15275
Hospital Charge Code	8013703
Hospital Revenue Code	510
Min. Negotiated Rate	$256.05
Max. Negotiated Rate	$512.10
Rate for Payer: Aetna of IA Commercial	$512.10
Rate for Payer: Aetna of IA Medical Rental Products	$512.10
Rate for Payer: Aetna of IA Medicare	$324.33
Rate for Payer: Amerigroup Medicaid	$328.20
Rate for Payer: Amerigroup Medicare	$258.61
Rate for Payer: Cash Price	$455.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$426.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$256.05
Rate for Payer: Iowa Total Care Managed Medicaid	$325.01
Rate for Payer: Medical Associates Commercial	$426.75
Rate for Payer: Medical Associates Managed Medicare	$256.05
Rate for Payer: Midlands Choice Commercial	$398.30
Rate for Payer: Molina Healthcare Managed Medicaid	$329.79
Rate for Payer: Partners Health Alliance Commercial	$294.46
Rate for Payer: United Healthcare Commercial	$512.10
Rate for Payer: United Healthcare Managed Medicare	$335.71

APPL SKIN SUB < 100 1ST 25 CM FEET/TOES

Facility

$569.00

Service Code	CPT 15275
Hospital Charge Code	8013703
Hospital Revenue Code	510
Min. Negotiated Rate	$398.30
Max. Negotiated Rate	$512.10
Rate for Payer: Aetna of IA Commercial	$512.10
Rate for Payer: Aetna of IA Medical Rental Products	$512.10
Rate for Payer: Cash Price	$455.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$426.75
Rate for Payer: Medical Associates Commercial	$426.75
Rate for Payer: Midlands Choice Commercial	$398.30
Rate for Payer: United Healthcare Commercial	$512.10

APPL SKIN SUB < 100 1ST 25 CM LEG/ANKLE

Facility

$711.00

Service Code	CPT 15271
Hospital Charge Code	7438782
Hospital Revenue Code	510
Min. Negotiated Rate	$319.95
Max. Negotiated Rate	$639.90
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Aetna of IA Medicare	$405.27
Rate for Payer: Amerigroup Medicaid	$410.10
Rate for Payer: Amerigroup Medicare	$323.15
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$319.95
Rate for Payer: Iowa Total Care Managed Medicaid	$406.12
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Medical Associates Managed Medicare	$319.95
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: Molina Healthcare Managed Medicaid	$412.10
Rate for Payer: Partners Health Alliance Commercial	$367.94
Rate for Payer: United Healthcare Commercial	$639.90
Rate for Payer: United Healthcare Managed Medicare	$419.49

Know your out-of-pocket cost for care.

All Charges