Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

APPLY SHORT LEG CAST

Professional

Both

$184.00

Service Code	CPT 29405
Hospital Charge Code	7982787
Hospital Revenue Code	981
Min. Negotiated Rate	$111.37
Max. Negotiated Rate	$182.00
Rate for Payer: Amerigroup Medicaid	$112.47
Rate for Payer: Cash Price	$147.20
Rate for Payer: Cash Price	$147.20
Rate for Payer: Iowa Total Care Managed Medicaid	$111.37
Rate for Payer: Medical Associates Commercial	$138.00
Rate for Payer: Midlands Choice Commercial	$128.80
Rate for Payer: Molina Healthcare Managed Medicaid	$111.92
Rate for Payer: Partners Health Alliance Commercial	$138.00
Rate for Payer: United Healthcare Commercial	$119.31
Rate for Payer: Wellmark IA HMO WHPI	$154.70
Rate for Payer: Wellmark IA PPO	$182.00

APPLY SHORT LEG CAST

Facility

$229.00

Service Code	CPT 29405
Hospital Charge Code	4864891
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

APPLY SHORT LEG CAST

Facility

$229.00

Service Code	CPT 29405
Hospital Charge Code	4864891
Hospital Revenue Code	450
Min. Negotiated Rate	$103.05
Max. Negotiated Rate	$499.84
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$453.76
Rate for Payer: Wellmark IA PPO	$499.84

APPLY TENS UNIT

Facility

$61.00

Service Code	CPT 64550 GP
Hospital Charge Code	4658837
Hospital Revenue Code	420
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: 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

APPLY TENS UNIT

Facility

$61.00

Service Code	CPT 64550 GP
Hospital Charge Code	4658837
Hospital Revenue Code	420
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

aprepitant 32 mg/4.4 mL EMU [VDMC]

Facility

$228.04

Service Code	HCPCS C9145
Hospital Charge Code	26695660
Hospital Revenue Code	259
Min. Negotiated Rate	$102.62
Max. Negotiated Rate	$205.23
Rate for Payer: Aetna of IA Commercial	$205.23
Rate for Payer: Aetna of IA Medical Rental Products	$205.23
Rate for Payer: Aetna of IA Medicare	$129.98
Rate for Payer: Amerigroup Medicaid	$131.53
Rate for Payer: Amerigroup Medicare	$103.64
Rate for Payer: Cash Price	$182.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$102.62
Rate for Payer: Iowa Total Care Managed Medicaid	$130.25
Rate for Payer: Medical Associates Commercial	$171.03
Rate for Payer: Medical Associates Managed Medicare	$102.62
Rate for Payer: Midlands Choice Commercial	$159.63
Rate for Payer: Molina Healthcare Managed Medicaid	$132.17
Rate for Payer: Partners Health Alliance Commercial	$118.01
Rate for Payer: United Healthcare Commercial	$205.23
Rate for Payer: United Healthcare Managed Medicare	$134.54

aprepitant 32 mg/4.4 mL EMU [VDMC]

Facility

$228.04

Service Code	HCPCS C9145
Hospital Charge Code	26695660
Hospital Revenue Code	259
Min. Negotiated Rate	$159.63
Max. Negotiated Rate	$205.23
Rate for Payer: Aetna of IA Commercial	$205.23
Rate for Payer: Aetna of IA Medical Rental Products	$205.23
Rate for Payer: Cash Price	$182.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.03
Rate for Payer: Medical Associates Commercial	$171.03
Rate for Payer: Midlands Choice Commercial	$159.63
Rate for Payer: United Healthcare Commercial	$205.23

arformoterol 15 mcg/2 mL Sol [VDMC]

Facility

$12.59

Service Code	HCPCS J7605
Hospital Charge Code	10606303
Hospital Revenue Code	259
Min. Negotiated Rate	$5.66
Max. Negotiated Rate	$221.80
Rate for Payer: Aetna of IA Commercial	$11.33
Rate for Payer: Aetna of IA Medical Rental Products	$11.33
Rate for Payer: Aetna of IA Medicare	$7.17
Rate for Payer: Amerigroup Medicaid	$7.26
Rate for Payer: Amerigroup Medicare	$5.72
Rate for Payer: Cash Price	$10.07
Rate for Payer: Cash Price	$10.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.44
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.66
Rate for Payer: Iowa Total Care Managed Medicaid	$7.19
Rate for Payer: Medical Associates Commercial	$9.44
Rate for Payer: Medical Associates Managed Medicare	$5.66
Rate for Payer: Midlands Choice Commercial	$8.81
Rate for Payer: Molina Healthcare Managed Medicaid	$7.29
Rate for Payer: Partners Health Alliance Commercial	$6.51
Rate for Payer: United Healthcare Commercial	$11.33
Rate for Payer: United Healthcare Managed Medicare	$7.43
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

arformoterol 15 mcg/2 mL Sol [VDMC]

Facility

$12.59

Service Code	HCPCS J7605
Hospital Charge Code	10606303
Hospital Revenue Code	259
Min. Negotiated Rate	$8.81
Max. Negotiated Rate	$11.33
Rate for Payer: Aetna of IA Commercial	$11.33
Rate for Payer: Aetna of IA Medical Rental Products	$11.33
Rate for Payer: Cash Price	$10.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$9.44
Rate for Payer: Medical Associates Commercial	$9.44
Rate for Payer: Midlands Choice Commercial	$8.81
Rate for Payer: United Healthcare Commercial	$11.33

ARIPiprazole 5 mg Tab [VDMC]

Facility

$2.07

Service Code	HCPCS A9270
Hospital Charge Code	10367551
Hospital Revenue Code	259
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of IA Commercial	$1.86
Rate for Payer: Aetna of IA Medical Rental Products	$1.86
Rate for Payer: Aetna of IA Medicare	$1.18
Rate for Payer: Amerigroup Medicaid	$1.19
Rate for Payer: Amerigroup Medicare	$0.94
Rate for Payer: Cash Price	$1.65
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	$1.86
Rate for Payer: United Healthcare Managed Medicare	$1.22

ARIPiprazole 5 mg Tab [VDMC]

Facility

$2.07

Service Code	HCPCS A9270
Hospital Charge Code	10367551
Hospital Revenue Code	259
Min. Negotiated Rate	$1.45
Max. Negotiated Rate	$1.86
Rate for Payer: Aetna of IA Commercial	$1.86
Rate for Payer: Aetna of IA Medical Rental Products	$1.86
Rate for Payer: Cash Price	$1.65
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	$1.86

ARSENAL ANKLE SCREW DRILL BIT 4.0MM

Facility

$432.00

Service Code	HCPCS C1713
Hospital Charge Code	8986283
Hospital Revenue Code	278
Min. Negotiated Rate	$302.40
Max. Negotiated Rate	$388.80
Rate for Payer: Aetna of IA Commercial	$388.80
Rate for Payer: Aetna of IA Medical Rental Products	$388.80
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$324.00
Rate for Payer: Medical Associates Commercial	$324.00
Rate for Payer: Midlands Choice Commercial	$302.40
Rate for Payer: United Healthcare Commercial	$388.80

ARSENAL ANKLE SCREW DRILL BIT 4.0MM

Facility

$432.00

Service Code	HCPCS C1713
Hospital Charge Code	8986283
Hospital Revenue Code	278
Min. Negotiated Rate	$194.40
Max. Negotiated Rate	$388.80
Rate for Payer: Aetna of IA Commercial	$388.80
Rate for Payer: Aetna of IA Medical Rental Products	$388.80
Rate for Payer: Aetna of IA Medicare	$246.24
Rate for Payer: Amerigroup Medicaid	$249.18
Rate for Payer: Amerigroup Medicare	$196.34
Rate for Payer: Cash Price	$345.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$324.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$194.40
Rate for Payer: Iowa Total Care Managed Medicaid	$246.76
Rate for Payer: Medical Associates Commercial	$324.00
Rate for Payer: Medical Associates Managed Medicare	$194.40
Rate for Payer: Midlands Choice Commercial	$302.40
Rate for Payer: Molina Healthcare Managed Medicaid	$250.39
Rate for Payer: Partners Health Alliance Commercial	$223.56
Rate for Payer: United Healthcare Commercial	$388.80
Rate for Payer: United Healthcare Managed Medicare	$254.88

ARSENIC

Facility

$129.00

Service Code	CPT 82175
Hospital Charge Code	8093926
Hospital Revenue Code	301
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of IA Commercial	$116.10
Rate for Payer: Aetna of IA Medical Rental Products	$116.10
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.75
Rate for Payer: Medical Associates Commercial	$96.75
Rate for Payer: Midlands Choice Commercial	$90.30
Rate for Payer: United Healthcare Commercial	$116.10

ARSENIC

Facility

$129.00

Service Code	CPT 82175
Hospital Charge Code	8093926
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of IA Commercial	$116.10
Rate for Payer: Aetna of IA Medical Rental Products	$116.10
Rate for Payer: Aetna of IA Medicare	$73.53
Rate for Payer: Amerigroup Medicaid	$74.41
Rate for Payer: Amerigroup Medicare	$58.63
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$58.05
Rate for Payer: Iowa Total Care Managed Medicaid	$73.68
Rate for Payer: Medical Associates Commercial	$96.75
Rate for Payer: Medical Associates Managed Medicare	$58.05
Rate for Payer: Midlands Choice Commercial	$90.30
Rate for Payer: Molina Healthcare Managed Medicaid	$74.77
Rate for Payer: Partners Health Alliance Commercial	$66.76
Rate for Payer: United Healthcare Commercial	$116.10
Rate for Payer: United Healthcare Managed Medicare	$76.11
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

ARTERIAL PUNCTURE

Facility

$93.00

Service Code	CPT 36600
Hospital Charge Code	5338932
Hospital Revenue Code	300
Min. Negotiated Rate	$41.85
Max. Negotiated Rate	$459.23
Rate for Payer: Aetna of IA Commercial	$83.70
Rate for Payer: Aetna of IA Medical Rental Products	$83.70
Rate for Payer: Aetna of IA Medicare	$53.01
Rate for Payer: Amerigroup Medicaid	$53.64
Rate for Payer: Amerigroup Medicare	$42.27
Rate for Payer: Cash Price	$74.40
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.85
Rate for Payer: Iowa Total Care Managed Medicaid	$53.12
Rate for Payer: Medical Associates Commercial	$69.75
Rate for Payer: Medical Associates Managed Medicare	$41.85
Rate for Payer: Midlands Choice Commercial	$65.10
Rate for Payer: Molina Healthcare Managed Medicaid	$53.90
Rate for Payer: Partners Health Alliance Commercial	$48.13
Rate for Payer: United Healthcare Commercial	$83.70
Rate for Payer: United Healthcare Managed Medicare	$54.87
Rate for Payer: Wellmark IA HMO WHPI	$416.89
Rate for Payer: Wellmark IA PPO	$459.23

ARTERIAL PUNCTURE

Facility

$93.00

Service Code	CPT 36600
Hospital Charge Code	5338932
Hospital Revenue Code	300
Min. Negotiated Rate	$65.10
Max. Negotiated Rate	$83.70
Rate for Payer: Aetna of IA Commercial	$83.70
Rate for Payer: Aetna of IA Medical Rental Products	$83.70
Rate for Payer: Cash Price	$74.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.75
Rate for Payer: Medical Associates Commercial	$69.75
Rate for Payer: Midlands Choice Commercial	$65.10
Rate for Payer: United Healthcare Commercial	$83.70

ARTHORODESIS GREAT TOE METATARSOPHALANGEAL JOINT

Professional

Both

$2,746.00

Service Code	CPT 28750
Hospital Charge Code	8825537
Hospital Revenue Code	975
Min. Negotiated Rate	$529.96
Max. Negotiated Rate	$2,059.50
Rate for Payer: Amerigroup Medicaid	$535.16
Rate for Payer: Cash Price	$2,196.80
Rate for Payer: Cash Price	$2,196.80
Rate for Payer: Iowa Total Care Managed Medicaid	$529.96
Rate for Payer: Medical Associates Commercial	$2,059.50
Rate for Payer: Midlands Choice Commercial	$1,922.20
Rate for Payer: Molina Healthcare Managed Medicaid	$532.56
Rate for Payer: Partners Health Alliance Commercial	$2,059.50
Rate for Payer: United Healthcare Commercial	$1,218.02
Rate for Payer: Wellmark IA HMO WHPI	$1,474.40
Rate for Payer: Wellmark IA PPO	$1,734.60

ARTHROCENTESIS ASPIR/INJ INTERM JT/BURS W/US

Professional

Both

$189.00

Service Code	CPT 20606
Hospital Charge Code	8804745
Hospital Revenue Code	983
Min. Negotiated Rate	$72.35
Max. Negotiated Rate	$200.50
Rate for Payer: Amerigroup Medicaid	$73.06
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Iowa Total Care Managed Medicaid	$72.35
Rate for Payer: Medical Associates Commercial	$141.75
Rate for Payer: Midlands Choice Commercial	$132.30
Rate for Payer: Molina Healthcare Managed Medicaid	$72.70
Rate for Payer: Partners Health Alliance Commercial	$141.75
Rate for Payer: United Healthcare Commercial	$128.00
Rate for Payer: Wellmark IA HMO WHPI	$170.50
Rate for Payer: Wellmark IA PPO	$200.50

ARTHROCENTESIS MAJOR JOINT/BURSA

Professional

Both

$201.00

Service Code	CPT 20610
Hospital Charge Code	8037761
Hospital Revenue Code	975
Min. Negotiated Rate	$67.41
Max. Negotiated Rate	$150.75
Rate for Payer: Amerigroup Medicaid	$68.07
Rate for Payer: Cash Price	$160.80
Rate for Payer: Cash Price	$160.80
Rate for Payer: Iowa Total Care Managed Medicaid	$67.41
Rate for Payer: Medical Associates Commercial	$150.75
Rate for Payer: Midlands Choice Commercial	$140.70
Rate for Payer: Molina Healthcare Managed Medicaid	$67.74
Rate for Payer: Partners Health Alliance Commercial	$150.75
Rate for Payer: United Healthcare Commercial	$93.60
Rate for Payer: Wellmark IA HMO WHPI	$123.30
Rate for Payer: Wellmark IA PPO	$145.00

ARTHROPLASTY, ACETABULAR AND PROXIMAL FEMORAL PROSTHETIC REPLACEMENT (TOTAL HIP ARTHROPLASTY), WITH OR WITHOUT AUTOGRAFT OR ALLOGRAFT

Facility

$27,359.99

Service Code	CPT 27130
Hospital Revenue Code	360
Min. Negotiated Rate	$24,837.69
Max. Negotiated Rate	$27,359.99
Rate for Payer: Wellmark IA HMO WHPI	$24,837.69
Rate for Payer: Wellmark IA PPO	$27,359.99

ARTHROPLASTY, INTERCARPAL OR CARPOMETACARPAL JOINTS; INTERPOSITION (EG, TENDON)

Facility

$8,645.67

Service Code	CPT 25447
Hospital Revenue Code	360
Min. Negotiated Rate	$7,848.63
Max. Negotiated Rate	$8,645.67
Rate for Payer: Wellmark IA HMO WHPI	$7,848.63
Rate for Payer: Wellmark IA PPO	$8,645.67

ARTHROPLASTY, INTERPHALANGEAL JOINT; EACH JOINT

Facility

$8,645.67

Service Code	CPT 26535
Hospital Revenue Code	360
Min. Negotiated Rate	$7,848.63
Max. Negotiated Rate	$8,645.67
Rate for Payer: Wellmark IA HMO WHPI	$7,848.63
Rate for Payer: Wellmark IA PPO	$8,645.67

ARTHROSCOPY

Facility

$18,851.11

Service Code	MSDRG 509
Min. Negotiated Rate	$18,577.89
Max. Negotiated Rate	$18,851.11
Rate for Payer: Amerigroup Medicaid	$18,760.03
Rate for Payer: Iowa Total Care Managed Medicaid	$18,577.89
Rate for Payer: Molina Healthcare Managed Medicaid	$18,851.11

ascorbic acid 500 mg/mL 50ml SDV Sol [VDMC]

Facility

$1,015.60

Service Code	NDC 67157-0101-50
Hospital Charge Code	22372240
Hospital Revenue Code	259
Min. Negotiated Rate	$710.92
Max. Negotiated Rate	$914.04
Rate for Payer: Aetna of IA Commercial	$914.04
Rate for Payer: Aetna of IA Medical Rental Products	$914.04
Rate for Payer: Cash Price	$812.48
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$761.70
Rate for Payer: Medical Associates Commercial	$761.70
Rate for Payer: Midlands Choice Commercial	$710.92
Rate for Payer: United Healthcare Commercial	$914.04

Know your out-of-pocket cost for care.

All Charges