Van Diest Medical Center

All Charges

Charge

Type

Price

Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh Without MCC

Facility IP

$6,259.77

Service Code	MS-DRG 563
Hospital Charge Code	370
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$6,259.77
Rate for Payer: Amerigroup Medicaid	$6,229.53
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$6,169.05
Rate for Payer: Molina Healthcare Managed Medicaid	$6,259.77

Full Term Neonate With Major Problems

Facility IP

$5,229.28

Service Code	MS-DRG 793
Hospital Charge Code	535
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$5,229.28
Rate for Payer: Amerigroup Medicaid	$5,204.01
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$5,153.49
Rate for Payer: Molina Healthcare Managed Medicaid	$5,229.28

Full Thickness Burn Without Skin Graft or Inhalation Injury

Facility IP

$8,446.76

Service Code	MS-DRG 934
Hospital Charge Code	646
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,446.76
Rate for Payer: Amerigroup Medicaid	$8,405.95
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$8,324.34
Rate for Payer: Molina Healthcare Managed Medicaid	$8,446.76

Full Thickness Burn With Skin Graft or Inhalation Injury With CC/MCC

Facility IP

$31,975.05

Service Code	MS-DRG 928
Hospital Charge Code	643
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$31,975.05
Rate for Payer: Amerigroup Medicaid	$31,820.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$31,511.65
Rate for Payer: Molina Healthcare Managed Medicaid	$31,975.05

Full Thickness Burn With Skin Graft or Inhalation Injury Without CC/MCC

Facility IP

$19,154.32

Service Code	MS-DRG 929
Hospital Charge Code	644
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$19,154.32
Rate for Payer: Amerigroup Medicaid	$19,061.79
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$18,876.72
Rate for Payer: Molina Healthcare Managed Medicaid	$19,154.32

FUNGITELL ASSAY

Facility OP

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037483
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$57.54
Rate for Payer: Amerigroup Medicare	$57.57
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.00
Rate for Payer: Iowa Total Care Managed Medicaid	$56.98
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$57.00
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$57.86
Rate for Payer: Partners Health Alliance Commercial	$85.50
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

FUNGITELL ASSAY

Facility IP

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037483
Hospital Revenue Code	306
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

furosemide 10 mg/mL Inj Sol 10mL SDV

Facility IP

$26.40

Service Code	CPT J1940
Hospital Charge Code	43723489
Hospital Revenue Code	636
Min. Negotiated Rate	$18.48
Max. Negotiated Rate	$23.76
Rate for Payer: Aetna of IA Commercial	$23.76
Rate for Payer: Aetna of IA Medical Rental Products	$23.76
Rate for Payer: Cash Price	$21.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.80
Rate for Payer: Medical Associates Commercial	$19.80
Rate for Payer: Midlands Choice Commercial	$18.48
Rate for Payer: United Healthcare Commercial	$23.76

furosemide 10 mg/mL Inj Sol 10mL SDV

Facility OP

$26.40

Service Code	CPT J1940
Hospital Charge Code	43723489
Hospital Revenue Code	636
Min. Negotiated Rate	$13.19
Max. Negotiated Rate	$23.76
Rate for Payer: Aetna of IA Commercial	$23.76
Rate for Payer: Aetna of IA Medical Rental Products	$23.76
Rate for Payer: Aetna of IA Medicare	$15.05
Rate for Payer: Amerigroup Medicaid	$13.32
Rate for Payer: Amerigroup Medicare	$13.33
Rate for Payer: Cash Price	$21.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.20
Rate for Payer: Iowa Total Care Managed Medicaid	$13.19
Rate for Payer: Medical Associates Commercial	$19.80
Rate for Payer: Medical Associates Managed Medicare	$13.20
Rate for Payer: Midlands Choice Commercial	$18.48
Rate for Payer: Molina Healthcare Managed Medicaid	$13.40
Rate for Payer: Partners Health Alliance Commercial	$19.80
Rate for Payer: United Healthcare Commercial	$23.76
Rate for Payer: United Healthcare Managed Medicare	$15.58

furosemide 10 mg/mL Inj Sol 2 mL SDV

Facility IP

$23.68

Service Code	CPT J1940
Hospital Charge Code	43755028
Hospital Revenue Code	636
Min. Negotiated Rate	$16.58
Max. Negotiated Rate	$21.31
Rate for Payer: Aetna of IA Commercial	$21.31
Rate for Payer: Aetna of IA Medical Rental Products	$21.31
Rate for Payer: Cash Price	$18.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.76
Rate for Payer: Medical Associates Commercial	$17.76
Rate for Payer: Midlands Choice Commercial	$16.58
Rate for Payer: United Healthcare Commercial	$21.31

furosemide 10 mg/mL Inj Sol 2 mL SDV

Facility OP

$23.68

Service Code	CPT J1940
Hospital Charge Code	43755028
Hospital Revenue Code	636
Min. Negotiated Rate	$11.84
Max. Negotiated Rate	$21.31
Rate for Payer: Aetna of IA Commercial	$21.31
Rate for Payer: Aetna of IA Medical Rental Products	$21.31
Rate for Payer: Aetna of IA Medicare	$13.50
Rate for Payer: Amerigroup Medicaid	$11.95
Rate for Payer: Amerigroup Medicare	$11.96
Rate for Payer: Cash Price	$18.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.76
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.84
Rate for Payer: Iowa Total Care Managed Medicaid	$11.84
Rate for Payer: Medical Associates Commercial	$17.76
Rate for Payer: Medical Associates Managed Medicare	$11.84
Rate for Payer: Midlands Choice Commercial	$16.58
Rate for Payer: Molina Healthcare Managed Medicaid	$12.02
Rate for Payer: Partners Health Alliance Commercial	$17.76
Rate for Payer: United Healthcare Commercial	$21.31
Rate for Payer: United Healthcare Managed Medicare	$13.97

furosemide 10 mg/mL Inj Sol 4mL

Facility OP

$23.88

Service Code	CPT J1940
Hospital Charge Code	43714823
Hospital Revenue Code	636
Min. Negotiated Rate	$11.94
Max. Negotiated Rate	$21.49
Rate for Payer: Aetna of IA Commercial	$21.49
Rate for Payer: Aetna of IA Medical Rental Products	$21.49
Rate for Payer: Aetna of IA Medicare	$13.61
Rate for Payer: Amerigroup Medicaid	$12.05
Rate for Payer: Amerigroup Medicare	$12.06
Rate for Payer: Cash Price	$19.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.94
Rate for Payer: Iowa Total Care Managed Medicaid	$11.94
Rate for Payer: Medical Associates Commercial	$17.91
Rate for Payer: Medical Associates Managed Medicare	$11.94
Rate for Payer: Midlands Choice Commercial	$16.72
Rate for Payer: Molina Healthcare Managed Medicaid	$12.12
Rate for Payer: Partners Health Alliance Commercial	$17.91
Rate for Payer: United Healthcare Commercial	$21.49
Rate for Payer: United Healthcare Managed Medicare	$14.09

furosemide 10 mg/mL Inj Sol 4mL

Facility IP

$23.88

Service Code	CPT J1940
Hospital Charge Code	43714823
Hospital Revenue Code	636
Min. Negotiated Rate	$16.72
Max. Negotiated Rate	$21.49
Rate for Payer: Aetna of IA Commercial	$21.49
Rate for Payer: Aetna of IA Medical Rental Products	$21.49
Rate for Payer: Cash Price	$19.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$17.91
Rate for Payer: Medical Associates Commercial	$17.91
Rate for Payer: Midlands Choice Commercial	$16.72
Rate for Payer: United Healthcare Commercial	$21.49

furosemide 10 mg/mL Oral Liq 60ml

Facility OP

$28.48

Service Code	CPT A9270
Hospital Charge Code	43701430
Hospital Revenue Code	637
Min. Negotiated Rate	$14.23
Max. Negotiated Rate	$25.63
Rate for Payer: Aetna of IA Commercial	$25.63
Rate for Payer: Aetna of IA Medical Rental Products	$25.63
Rate for Payer: Aetna of IA Medicare	$16.23
Rate for Payer: Amerigroup Medicaid	$14.37
Rate for Payer: Amerigroup Medicare	$14.38
Rate for Payer: Cash Price	$22.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.24
Rate for Payer: Iowa Total Care Managed Medicaid	$14.23
Rate for Payer: Medical Associates Commercial	$21.36
Rate for Payer: Medical Associates Managed Medicare	$14.24
Rate for Payer: Midlands Choice Commercial	$19.94
Rate for Payer: Molina Healthcare Managed Medicaid	$14.45
Rate for Payer: Partners Health Alliance Commercial	$21.36
Rate for Payer: United Healthcare Commercial	$25.63
Rate for Payer: United Healthcare Managed Medicare	$16.80

furosemide 10 mg/mL Oral Liq 60ml

Facility IP

$28.48

Service Code	CPT A9270
Hospital Charge Code	43701430
Hospital Revenue Code	637
Min. Negotiated Rate	$19.94
Max. Negotiated Rate	$25.63
Rate for Payer: Aetna of IA Commercial	$25.63
Rate for Payer: Aetna of IA Medical Rental Products	$25.63
Rate for Payer: Cash Price	$22.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.36
Rate for Payer: Medical Associates Commercial	$21.36
Rate for Payer: Midlands Choice Commercial	$19.94
Rate for Payer: United Healthcare Commercial	$25.63

furosemide 20 mg Tab

Facility OP

$1.31

Service Code	CPT A9270
Hospital Charge Code	43701460
Hospital Revenue Code	637
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of IA Commercial	$1.18
Rate for Payer: Aetna of IA Medical Rental Products	$1.18
Rate for Payer: Aetna of IA Medicare	$0.75
Rate for Payer: Amerigroup Medicaid	$0.66
Rate for Payer: Amerigroup Medicare	$0.66
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.66
Rate for Payer: Iowa Total Care Managed Medicaid	$0.65
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Medical Associates Managed Medicare	$0.66
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: Molina Healthcare Managed Medicaid	$0.66
Rate for Payer: Partners Health Alliance Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.18
Rate for Payer: United Healthcare Managed Medicare	$0.77

furosemide 20 mg Tab

Facility IP

$1.31

Service Code	CPT A9270
Hospital Charge Code	43701460
Hospital Revenue Code	637
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of IA Commercial	$1.18
Rate for Payer: Aetna of IA Medical Rental Products	$1.18
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: United Healthcare Commercial	$1.18

furosemide 40 mg Tab

Facility IP

$1.33

Service Code	CPT A9270
Hospital Charge Code	43701462
Hospital Revenue Code	637
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: United Healthcare Commercial	$1.20

furosemide 40 mg Tab

Facility OP

$1.33

Service Code	CPT A9270
Hospital Charge Code	43701462
Hospital Revenue Code	637
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of IA Commercial	$1.20
Rate for Payer: Aetna of IA Medical Rental Products	$1.20
Rate for Payer: Aetna of IA Medicare	$0.76
Rate for Payer: Amerigroup Medicaid	$0.67
Rate for Payer: Amerigroup Medicare	$0.67
Rate for Payer: Cash Price	$1.07
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.00
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	$0.66
Rate for Payer: Medical Associates Commercial	$1.00
Rate for Payer: Medical Associates Managed Medicare	$0.67
Rate for Payer: Midlands Choice Commercial	$0.93
Rate for Payer: Molina Healthcare Managed Medicaid	$0.67
Rate for Payer: Partners Health Alliance Commercial	$1.00
Rate for Payer: United Healthcare Commercial	$1.20
Rate for Payer: United Healthcare Managed Medicare	$0.78

G0105 Medicare High risk normal screening colonoscopy

Professional

$1,046.00

Service Code	CPT G0105
Hospital Charge Code	8799222
Hospital Revenue Code	975
Min. Negotiated Rate	$165.95
Max. Negotiated Rate	$732.20
Rate for Payer: Aetna of IA Medicare	$165.95
Rate for Payer: Amerigroup Medicaid	$171.59
Rate for Payer: Cash Price	$836.80
Rate for Payer: Cash Price	$836.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.95
Rate for Payer: Iowa Total Care Managed Medicaid	$169.27
Rate for Payer: Medical Associates Commercial	$315.30
Rate for Payer: Medical Associates Managed Medicare	$165.95
Rate for Payer: Midlands Choice Commercial	$732.20
Rate for Payer: Partners Health Alliance Commercial	$248.92
Rate for Payer: Wellmark IA HMO	$345.00
Rate for Payer: Wellmark IA PPO	$405.00

G0121 COLONOSCOPY SCREENING NON RISK

Professional

$1,049.00

Service Code	CPT G0121
Hospital Charge Code	7808122
Hospital Revenue Code	975
Min. Negotiated Rate	$166.10
Max. Negotiated Rate	$734.30
Rate for Payer: Aetna of IA Medicare	$166.10
Rate for Payer: Amerigroup Medicaid	$171.75
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cash Price	$839.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$166.10
Rate for Payer: Iowa Total Care Managed Medicaid	$169.42
Rate for Payer: Medical Associates Commercial	$315.59
Rate for Payer: Medical Associates Managed Medicare	$166.10
Rate for Payer: Midlands Choice Commercial	$734.30
Rate for Payer: Partners Health Alliance Commercial	$249.15
Rate for Payer: Wellmark IA HMO	$341.00
Rate for Payer: Wellmark IA PPO	$400.00

gabapentin 100 mg Cap

Facility OP

$1.31

Service Code	CPT A9270
Hospital Charge Code	43705914
Hospital Revenue Code	637
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of IA Commercial	$1.18
Rate for Payer: Aetna of IA Medical Rental Products	$1.18
Rate for Payer: Aetna of IA Medicare	$0.75
Rate for Payer: Amerigroup Medicaid	$0.66
Rate for Payer: Amerigroup Medicare	$0.66
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.66
Rate for Payer: Iowa Total Care Managed Medicaid	$0.65
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Medical Associates Managed Medicare	$0.66
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: Molina Healthcare Managed Medicaid	$0.66
Rate for Payer: Partners Health Alliance Commercial	$0.98
Rate for Payer: United Healthcare Commercial	$1.18
Rate for Payer: United Healthcare Managed Medicare	$0.77

gabapentin 100 mg Cap

Facility IP

$1.31

Service Code	CPT A9270
Hospital Charge Code	43705914
Hospital Revenue Code	637
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.18
Rate for Payer: Aetna of IA Commercial	$1.18
Rate for Payer: Aetna of IA Medical Rental Products	$1.18
Rate for Payer: Cash Price	$1.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.98
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Midlands Choice Commercial	$0.92
Rate for Payer: United Healthcare Commercial	$1.18

gabapentin 250 mg/5 mL Solution

Facility IP

$3.71

Service Code	CPT A9270
Hospital Charge Code	43700550
Hospital Revenue Code	637
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$3.34
Rate for Payer: Aetna of IA Commercial	$3.34
Rate for Payer: Aetna of IA Medical Rental Products	$3.34
Rate for Payer: Cash Price	$2.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.78
Rate for Payer: Medical Associates Commercial	$2.78
Rate for Payer: Midlands Choice Commercial	$2.60
Rate for Payer: United Healthcare Commercial	$3.34

gabapentin 250 mg/5 mL Solution

Facility OP

$3.71

Service Code	CPT A9270
Hospital Charge Code	43700550
Hospital Revenue Code	637
Min. Negotiated Rate	$1.85
Max. Negotiated Rate	$3.34
Rate for Payer: Aetna of IA Commercial	$3.34
Rate for Payer: Aetna of IA Medical Rental Products	$3.34
Rate for Payer: Aetna of IA Medicare	$2.11
Rate for Payer: Amerigroup Medicaid	$1.87
Rate for Payer: Amerigroup Medicare	$1.87
Rate for Payer: Cash Price	$2.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.78
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.86
Rate for Payer: Iowa Total Care Managed Medicaid	$1.85
Rate for Payer: Medical Associates Commercial	$2.78
Rate for Payer: Medical Associates Managed Medicare	$1.86
Rate for Payer: Midlands Choice Commercial	$2.60
Rate for Payer: Molina Healthcare Managed Medicaid	$1.88
Rate for Payer: Partners Health Alliance Commercial	$2.78
Rate for Payer: United Healthcare Commercial	$3.34
Rate for Payer: United Healthcare Managed Medicare	$2.19

Price Transparency.

All Charges