Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

estradiol 1 mg Tab [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10387396
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Aetna of IA Medicare	$0.85
Rate for Payer: Amerigroup Medicaid	$0.86
Rate for Payer: Amerigroup Medicare	$0.68
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.67
Rate for Payer: Iowa Total Care Managed Medicaid	$0.85
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Medical Associates Managed Medicare	$0.67
Rate for Payer: Midlands Choice Commercial	$1.04
Rate for Payer: Molina Healthcare Managed Medicaid	$0.86
Rate for Payer: Partners Health Alliance Commercial	$0.77
Rate for Payer: United Healthcare Commercial	$1.34
Rate for Payer: United Healthcare Managed Medicare	$0.88

estradiol 1 mg Tab [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10387396
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Midlands Choice Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.34

Estradiol Level DMCL

Facility

$190.00

Service Code	CPT 82670
Hospital Charge Code	8037841
Hospital Revenue Code	301
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of IA Commercial	$171.00
Rate for Payer: Aetna of IA Medical Rental Products	$171.00
Rate for Payer: Aetna of IA Medicare	$108.30
Rate for Payer: Amerigroup Medicaid	$109.59
Rate for Payer: Amerigroup Medicare	$86.36
Rate for Payer: Cash Price	$152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$142.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$85.50
Rate for Payer: Iowa Total Care Managed Medicaid	$108.53
Rate for Payer: Medical Associates Commercial	$142.50
Rate for Payer: Medical Associates Managed Medicare	$85.50
Rate for Payer: Midlands Choice Commercial	$133.00
Rate for Payer: Molina Healthcare Managed Medicaid	$110.12
Rate for Payer: Partners Health Alliance Commercial	$98.33
Rate for Payer: United Healthcare Commercial	$171.00
Rate for Payer: United Healthcare Managed Medicare	$112.10

Estradiol Level DMCL

Facility

$190.00

Service Code	CPT 82670
Hospital Charge Code	8037841
Hospital Revenue Code	301
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of IA Commercial	$171.00
Rate for Payer: Aetna of IA Medical Rental Products	$171.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$142.50
Rate for Payer: Medical Associates Commercial	$142.50
Rate for Payer: Midlands Choice Commercial	$133.00
Rate for Payer: United Healthcare Commercial	$171.00

ESTRIOL UNCONJUGATED

Facility

$146.00

Service Code	CPT 82677
Hospital Charge Code	8037490
Hospital Revenue Code	301
Min. Negotiated Rate	$102.20
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: United Healthcare Commercial	$131.40

ESTRIOL UNCONJUGATED

Facility

$146.00

Service Code	CPT 82677
Hospital Charge Code	8037490
Hospital Revenue Code	301
Min. Negotiated Rate	$65.70
Max. Negotiated Rate	$131.40
Rate for Payer: Aetna of IA Commercial	$131.40
Rate for Payer: Aetna of IA Medical Rental Products	$131.40
Rate for Payer: Aetna of IA Medicare	$83.22
Rate for Payer: Amerigroup Medicaid	$84.21
Rate for Payer: Amerigroup Medicare	$66.36
Rate for Payer: Cash Price	$116.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$109.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.70
Rate for Payer: Iowa Total Care Managed Medicaid	$83.40
Rate for Payer: Medical Associates Commercial	$109.50
Rate for Payer: Medical Associates Managed Medicare	$65.70
Rate for Payer: Midlands Choice Commercial	$102.20
Rate for Payer: Molina Healthcare Managed Medicaid	$84.62
Rate for Payer: Partners Health Alliance Commercial	$75.56
Rate for Payer: United Healthcare Commercial	$131.40
Rate for Payer: United Healthcare Managed Medicare	$86.14

Estrogens Fractionated (E1 and E2) DMCL

Facility

$190.00

Service Code	CPT 82671
Hospital Charge Code	8037842
Hospital Revenue Code	301
Min. Negotiated Rate	$133.00
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of IA Commercial	$171.00
Rate for Payer: Aetna of IA Medical Rental Products	$171.00
Rate for Payer: Cash Price	$152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$142.50
Rate for Payer: Medical Associates Commercial	$142.50
Rate for Payer: Midlands Choice Commercial	$133.00
Rate for Payer: United Healthcare Commercial	$171.00

Estrogens Fractionated (E1 and E2) DMCL

Facility

$190.00

Service Code	CPT 82671
Hospital Charge Code	8037842
Hospital Revenue Code	301
Min. Negotiated Rate	$85.50
Max. Negotiated Rate	$171.00
Rate for Payer: Aetna of IA Commercial	$171.00
Rate for Payer: Aetna of IA Medical Rental Products	$171.00
Rate for Payer: Aetna of IA Medicare	$108.30
Rate for Payer: Amerigroup Medicaid	$109.59
Rate for Payer: Amerigroup Medicare	$86.36
Rate for Payer: Cash Price	$152.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$142.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$85.50
Rate for Payer: Iowa Total Care Managed Medicaid	$108.53
Rate for Payer: Medical Associates Commercial	$142.50
Rate for Payer: Medical Associates Managed Medicare	$85.50
Rate for Payer: Midlands Choice Commercial	$133.00
Rate for Payer: Molina Healthcare Managed Medicaid	$110.12
Rate for Payer: Partners Health Alliance Commercial	$98.33
Rate for Payer: United Healthcare Commercial	$171.00
Rate for Payer: United Healthcare Managed Medicare	$112.10

ETHICON ENDO GIA GUN

Facility

$480.00

Hospital Charge Code	8026300
Hospital Revenue Code	272
Min. Negotiated Rate	$336.00
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of IA Commercial	$432.00
Rate for Payer: Aetna of IA Medical Rental Products	$432.00
Rate for Payer: Cash Price	$384.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$360.00
Rate for Payer: Medical Associates Commercial	$360.00
Rate for Payer: Midlands Choice Commercial	$336.00
Rate for Payer: United Healthcare Commercial	$432.00

ETHICON ENDO GIA GUN

Facility

$480.00

Hospital Charge Code	8026300
Hospital Revenue Code	272
Min. Negotiated Rate	$216.00
Max. Negotiated Rate	$432.00
Rate for Payer: Aetna of IA Commercial	$432.00
Rate for Payer: Aetna of IA Medical Rental Products	$432.00
Rate for Payer: Aetna of IA Medicare	$273.60
Rate for Payer: Amerigroup Medicaid	$276.86
Rate for Payer: Amerigroup Medicare	$218.16
Rate for Payer: Cash Price	$384.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$360.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$216.00
Rate for Payer: Iowa Total Care Managed Medicaid	$274.18
Rate for Payer: Medical Associates Commercial	$360.00
Rate for Payer: Medical Associates Managed Medicare	$216.00
Rate for Payer: Midlands Choice Commercial	$336.00
Rate for Payer: Molina Healthcare Managed Medicaid	$278.21
Rate for Payer: Partners Health Alliance Commercial	$248.40
Rate for Payer: United Healthcare Commercial	$432.00
Rate for Payer: United Healthcare Managed Medicare	$283.20

etomidate 2 mg/mL IV 10 ml SDV [VDMC]

Facility

$28.02

Service Code	HCPCS J3490
Hospital Charge Code	10387670
Hospital Revenue Code	259
Min. Negotiated Rate	$12.61
Max. Negotiated Rate	$25.22
Rate for Payer: Aetna of IA Commercial	$25.22
Rate for Payer: Aetna of IA Medical Rental Products	$25.22
Rate for Payer: Aetna of IA Medicare	$15.97
Rate for Payer: Amerigroup Medicaid	$16.16
Rate for Payer: Amerigroup Medicare	$12.74
Rate for Payer: Cash Price	$22.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.02
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.61
Rate for Payer: Iowa Total Care Managed Medicaid	$16.01
Rate for Payer: Medical Associates Commercial	$21.02
Rate for Payer: Medical Associates Managed Medicare	$12.61
Rate for Payer: Midlands Choice Commercial	$19.62
Rate for Payer: Molina Healthcare Managed Medicaid	$16.24
Rate for Payer: Partners Health Alliance Commercial	$14.50
Rate for Payer: United Healthcare Commercial	$25.22
Rate for Payer: United Healthcare Managed Medicare	$16.53

etomidate 2 mg/mL IV 10 ml SDV [VDMC]

Facility

$28.02

Service Code	HCPCS J3490
Hospital Charge Code	10387670
Hospital Revenue Code	259
Min. Negotiated Rate	$19.62
Max. Negotiated Rate	$25.22
Rate for Payer: Aetna of IA Commercial	$25.22
Rate for Payer: Aetna of IA Medical Rental Products	$25.22
Rate for Payer: Cash Price	$22.42
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.02
Rate for Payer: Medical Associates Commercial	$21.02
Rate for Payer: Midlands Choice Commercial	$19.62
Rate for Payer: United Healthcare Commercial	$25.22

etonogestrel 68 mg Imp[VDMC]

Facility

$2,412.56

Service Code	HCPCS J7307
Hospital Charge Code	12485011
Hospital Revenue Code	259
Min. Negotiated Rate	$1,688.79
Max. Negotiated Rate	$2,171.30
Rate for Payer: Aetna of IA Commercial	$2,171.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,171.30
Rate for Payer: Cash Price	$1,930.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,809.42
Rate for Payer: Medical Associates Commercial	$1,809.42
Rate for Payer: Midlands Choice Commercial	$1,688.79
Rate for Payer: United Healthcare Commercial	$2,171.30

etonogestrel 68 mg Imp[VDMC]

Facility

$2,412.56

Service Code	HCPCS J7307
Hospital Charge Code	12485011
Hospital Revenue Code	259
Min. Negotiated Rate	$1,085.65
Max. Negotiated Rate	$2,171.30
Rate for Payer: Aetna of IA Commercial	$2,171.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,171.30
Rate for Payer: Aetna of IA Medicare	$1,375.16
Rate for Payer: Amerigroup Medicaid	$1,391.56
Rate for Payer: Amerigroup Medicare	$1,096.51
Rate for Payer: Cash Price	$1,930.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,809.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,085.65
Rate for Payer: Iowa Total Care Managed Medicaid	$1,378.05
Rate for Payer: Medical Associates Commercial	$1,809.42
Rate for Payer: Medical Associates Managed Medicare	$1,085.65
Rate for Payer: Midlands Choice Commercial	$1,688.79
Rate for Payer: Molina Healthcare Managed Medicaid	$1,398.32
Rate for Payer: Partners Health Alliance Commercial	$1,248.50
Rate for Payer: United Healthcare Commercial	$2,171.30
Rate for Payer: United Healthcare Managed Medicare	$1,423.41

EVALUATION 60 MIN

Professional

Both

$240.00

Service Code	CPT 90791 AJ\|HO
Hospital Charge Code	8052933
Hospital Revenue Code	900
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$224.11
Rate for Payer: Cash Price	$192.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Medical Associates Commercial	$180.00
Rate for Payer: Midlands Choice Commercial	$168.00
Rate for Payer: Partners Health Alliance Commercial	$180.00
Rate for Payer: United Healthcare Commercial	$224.11

EVALUATION 60 MIN

Professional

Both

$205.00

Service Code	CPT 90791 AJ\|HO
Hospital Charge Code	4919448
Hospital Revenue Code	900
Min. Negotiated Rate	$143.50
Max. Negotiated Rate	$224.11
Rate for Payer: Cash Price	$164.00
Rate for Payer: Cash Price	$164.00
Rate for Payer: Medical Associates Commercial	$153.75
Rate for Payer: Midlands Choice Commercial	$143.50
Rate for Payer: Partners Health Alliance Commercial	$153.75
Rate for Payer: United Healthcare Commercial	$224.11

EVALUATION OF SPEECH SOUND PRODUCTION

Facility

$230.00

Service Code	CPT 92523 GN
Hospital Charge Code	8925747
Hospital Revenue Code	444
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Aetna of IA Medicare	$131.10
Rate for Payer: Amerigroup Medicaid	$132.66
Rate for Payer: Amerigroup Medicare	$104.53
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.50
Rate for Payer: Iowa Total Care Managed Medicaid	$131.38
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Medical Associates Managed Medicare	$103.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: Molina Healthcare Managed Medicaid	$133.31
Rate for Payer: Partners Health Alliance Commercial	$119.03
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70

EVALUATION OF SPEECH SOUND PRODUCTION

Facility

$230.00

Service Code	CPT 92523 GN
Hospital Charge Code	8925747
Hospital Revenue Code	444
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: United Healthcare Commercial	$207.00

Everolimus Level DMCL

Facility

$240.00

Service Code	CPT 80169
Hospital Charge Code	8820559
Hospital Revenue Code	301
Min. Negotiated Rate	$168.00
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna of IA Commercial	$216.00
Rate for Payer: Aetna of IA Medical Rental Products	$216.00
Rate for Payer: Cash Price	$192.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$180.00
Rate for Payer: Medical Associates Commercial	$180.00
Rate for Payer: Midlands Choice Commercial	$168.00
Rate for Payer: United Healthcare Commercial	$216.00

Everolimus Level DMCL

Facility

$240.00

Service Code	CPT 80169
Hospital Charge Code	8820559
Hospital Revenue Code	301
Min. Negotiated Rate	$108.00
Max. Negotiated Rate	$216.00
Rate for Payer: Aetna of IA Commercial	$216.00
Rate for Payer: Aetna of IA Medical Rental Products	$216.00
Rate for Payer: Aetna of IA Medicare	$136.80
Rate for Payer: Amerigroup Medicaid	$138.43
Rate for Payer: Amerigroup Medicare	$109.08
Rate for Payer: Cash Price	$192.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$180.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$108.00
Rate for Payer: Iowa Total Care Managed Medicaid	$137.09
Rate for Payer: Medical Associates Commercial	$180.00
Rate for Payer: Medical Associates Managed Medicare	$108.00
Rate for Payer: Midlands Choice Commercial	$168.00
Rate for Payer: Molina Healthcare Managed Medicaid	$139.10
Rate for Payer: Partners Health Alliance Commercial	$124.20
Rate for Payer: United Healthcare Commercial	$216.00
Rate for Payer: United Healthcare Managed Medicare	$141.60

EXC FACE-MM B9+MARG 0.5 CM/<

Facility

$815.00

Service Code	CPT 11440
Hospital Charge Code	4862822
Hospital Revenue Code	450
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: United Healthcare Commercial	$733.50

EXC FACE-MM B9+MARG 0.5 CM/<

Facility

$815.00

Service Code	CPT 11440
Hospital Charge Code	4862822
Hospital Revenue Code	450
Min. Negotiated Rate	$366.75
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Aetna of IA Medicare	$464.55
Rate for Payer: Amerigroup Medicaid	$470.09
Rate for Payer: Amerigroup Medicare	$370.42
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$366.75
Rate for Payer: Iowa Total Care Managed Medicaid	$465.53
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Medical Associates Managed Medicare	$366.75
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: Molina Healthcare Managed Medicaid	$472.37
Rate for Payer: Partners Health Alliance Commercial	$421.76
Rate for Payer: United Healthcare Commercial	$733.50
Rate for Payer: United Healthcare Managed Medicare	$480.85

EXC FACE-MM B9+MARG 0.6-1 CM

Facility

$815.00

Service Code	CPT 11441
Hospital Charge Code	7982974
Hospital Revenue Code	450
Min. Negotiated Rate	$366.75
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Aetna of IA Medicare	$464.55
Rate for Payer: Amerigroup Medicaid	$470.09
Rate for Payer: Amerigroup Medicare	$370.42
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$366.75
Rate for Payer: Iowa Total Care Managed Medicaid	$465.53
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Medical Associates Managed Medicare	$366.75
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: Molina Healthcare Managed Medicaid	$472.37
Rate for Payer: Partners Health Alliance Commercial	$421.76
Rate for Payer: United Healthcare Commercial	$733.50
Rate for Payer: United Healthcare Managed Medicare	$480.85

EXC FACE-MM B9+MARG 0.6-1 CM

Facility

$815.00

Service Code	CPT 11441
Hospital Charge Code	7982974
Hospital Revenue Code	450
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: United Healthcare Commercial	$733.50

EXC FACE-MM B9+MARG 1.1-2 CM

Facility

$815.00

Service Code	CPT 11442
Hospital Charge Code	7982973
Hospital Revenue Code	450
Min. Negotiated Rate	$570.50
Max. Negotiated Rate	$733.50
Rate for Payer: Aetna of IA Commercial	$733.50
Rate for Payer: Aetna of IA Medical Rental Products	$733.50
Rate for Payer: Cash Price	$652.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$611.25
Rate for Payer: Medical Associates Commercial	$611.25
Rate for Payer: Midlands Choice Commercial	$570.50
Rate for Payer: United Healthcare Commercial	$733.50

Know your out-of-pocket cost for care.

All Charges