Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Gastrointestinal Hemorrhage With MCC

Facility

$13,888.63

Service Code	MS-DRG 377
Hospital Charge Code	218
Min. Negotiated Rate	$13,687.35
Max. Negotiated Rate	$13,888.63
Rate for Payer: Amerigroup Medicaid	$13,821.54
Rate for Payer: Iowa Total Care Managed Medicaid	$13,687.35
Rate for Payer: Molina Healthcare Managed Medicaid	$13,888.63

Gastrointestinal Hemorrhage Without CC/MCC

Facility

$5,780.45

Service Code	MS-DRG 379
Hospital Charge Code	220
Min. Negotiated Rate	$5,696.68
Max. Negotiated Rate	$5,780.45
Rate for Payer: Amerigroup Medicaid	$5,752.53
Rate for Payer: Iowa Total Care Managed Medicaid	$5,696.68
Rate for Payer: Molina Healthcare Managed Medicaid	$5,780.45

Gastrointestinal Obstruction With CC

Facility

$7,544.21

Service Code	MS-DRG 389
Hospital Charge Code	230
Min. Negotiated Rate	$7,434.87
Max. Negotiated Rate	$7,544.21
Rate for Payer: Amerigroup Medicaid	$7,507.76
Rate for Payer: Iowa Total Care Managed Medicaid	$7,434.87
Rate for Payer: Molina Healthcare Managed Medicaid	$7,544.21

Gastrointestinal Obstruction With MCC

Facility

$9,929.02

Service Code	MS-DRG 388
Hospital Charge Code	229
Min. Negotiated Rate	$9,785.13
Max. Negotiated Rate	$9,929.02
Rate for Payer: Amerigroup Medicaid	$9,881.06
Rate for Payer: Iowa Total Care Managed Medicaid	$9,785.13
Rate for Payer: Molina Healthcare Managed Medicaid	$9,929.02

Gastrointestinal Obstruction Without CC/MCC

Facility

$5,162.34

Service Code	MS-DRG 390
Hospital Charge Code	231
Min. Negotiated Rate	$5,087.53
Max. Negotiated Rate	$5,162.34
Rate for Payer: Amerigroup Medicaid	$5,137.40
Rate for Payer: Iowa Total Care Managed Medicaid	$5,087.53
Rate for Payer: Molina Healthcare Managed Medicaid	$5,162.34

Gastroscope Biopsy Charge

Facility

$95.00

Hospital Charge Code	8051947
Hospital Revenue Code	750
Min. Negotiated Rate	$47.48
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of IA Commercial	$85.50
Rate for Payer: Aetna of IA Medical Rental Products	$85.50
Rate for Payer: Aetna of IA Medicare	$54.15
Rate for Payer: Amerigroup Medicaid	$47.95
Rate for Payer: Amerigroup Medicare	$47.98
Rate for Payer: Cash Price	$76.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$71.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$47.50
Rate for Payer: Iowa Total Care Managed Medicaid	$47.48
Rate for Payer: Medical Associates Commercial	$71.25
Rate for Payer: Medical Associates Managed Medicare	$47.50
Rate for Payer: Midlands Choice Commercial	$66.50
Rate for Payer: Molina Healthcare Managed Medicaid	$48.21
Rate for Payer: Molina Healthcare Managed Medicare	$48.18
Rate for Payer: Oscar Health of IA Commercial	$71.25
Rate for Payer: Partners Health Alliance Commercial	$71.25
Rate for Payer: United Healthcare Commercial	$85.50
Rate for Payer: United Healthcare Managed Medicare	$56.05

Gastroscope Biopsy Charge

Facility

$95.00

Hospital Charge Code	8051947
Hospital Revenue Code	750
Min. Negotiated Rate	$66.50
Max. Negotiated Rate	$85.50
Rate for Payer: Aetna of IA Commercial	$85.50
Rate for Payer: Aetna of IA Medical Rental Products	$85.50
Rate for Payer: Cash Price	$76.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$71.25
Rate for Payer: Medical Associates Commercial	$71.25
Rate for Payer: Midlands Choice Commercial	$66.50
Rate for Payer: United Healthcare Commercial	$85.50

Gastroscopy

Facility

$2,615.00

Hospital Charge Code	7745193
Hospital Revenue Code	750
Min. Negotiated Rate	$1,830.50
Max. Negotiated Rate	$2,353.50
Rate for Payer: Aetna of IA Commercial	$2,353.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,353.50
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,961.25
Rate for Payer: Medical Associates Commercial	$1,961.25
Rate for Payer: Midlands Choice Commercial	$1,830.50
Rate for Payer: United Healthcare Commercial	$2,353.50

Gastroscopy

Facility

$2,615.00

Hospital Charge Code	7745193
Hospital Revenue Code	750
Min. Negotiated Rate	$1,306.98
Max. Negotiated Rate	$2,353.50
Rate for Payer: Aetna of IA Commercial	$2,353.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,353.50
Rate for Payer: Aetna of IA Medicare	$1,490.55
Rate for Payer: Amerigroup Medicaid	$1,319.79
Rate for Payer: Amerigroup Medicare	$1,320.58
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,961.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,307.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,306.98
Rate for Payer: Medical Associates Commercial	$1,961.25
Rate for Payer: Medical Associates Managed Medicare	$1,307.50
Rate for Payer: Midlands Choice Commercial	$1,830.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,327.11
Rate for Payer: Molina Healthcare Managed Medicare	$1,326.33
Rate for Payer: Oscar Health of IA Commercial	$1,961.25
Rate for Payer: Partners Health Alliance Commercial	$1,961.25
Rate for Payer: United Healthcare Commercial	$2,353.50
Rate for Payer: United Healthcare Managed Medicare	$1,542.85

Gastroscopy Dilat Esophag Dial

Facility

$2,615.00

Hospital Charge Code	7745192
Hospital Revenue Code	750
Min. Negotiated Rate	$1,830.50
Max. Negotiated Rate	$2,353.50
Rate for Payer: Aetna of IA Commercial	$2,353.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,353.50
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,961.25
Rate for Payer: Medical Associates Commercial	$1,961.25
Rate for Payer: Midlands Choice Commercial	$1,830.50
Rate for Payer: United Healthcare Commercial	$2,353.50

Gastroscopy Dilat Esophag Dial

Facility

$2,615.00

Hospital Charge Code	7745192
Hospital Revenue Code	750
Min. Negotiated Rate	$1,306.98
Max. Negotiated Rate	$2,353.50
Rate for Payer: Aetna of IA Commercial	$2,353.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,353.50
Rate for Payer: Aetna of IA Medicare	$1,490.55
Rate for Payer: Amerigroup Medicaid	$1,319.79
Rate for Payer: Amerigroup Medicare	$1,320.58
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,961.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,307.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,306.98
Rate for Payer: Medical Associates Commercial	$1,961.25
Rate for Payer: Medical Associates Managed Medicare	$1,307.50
Rate for Payer: Midlands Choice Commercial	$1,830.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,327.11
Rate for Payer: Molina Healthcare Managed Medicare	$1,326.33
Rate for Payer: Oscar Health of IA Commercial	$1,961.25
Rate for Payer: Partners Health Alliance Commercial	$1,961.25
Rate for Payer: United Healthcare Commercial	$2,353.50
Rate for Payer: United Healthcare Managed Medicare	$1,542.85

Gastroscopy with Biopsy

Facility

$2,615.00

Hospital Charge Code	8055105
Hospital Revenue Code	750
Min. Negotiated Rate	$1,830.50
Max. Negotiated Rate	$2,353.50
Rate for Payer: Aetna of IA Commercial	$2,353.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,353.50
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,961.25
Rate for Payer: Medical Associates Commercial	$1,961.25
Rate for Payer: Midlands Choice Commercial	$1,830.50
Rate for Payer: United Healthcare Commercial	$2,353.50

Gastroscopy with Biopsy

Facility

$2,615.00

Hospital Charge Code	8055105
Hospital Revenue Code	750
Min. Negotiated Rate	$1,306.98
Max. Negotiated Rate	$2,353.50
Rate for Payer: Aetna of IA Commercial	$2,353.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,353.50
Rate for Payer: Aetna of IA Medicare	$1,490.55
Rate for Payer: Amerigroup Medicaid	$1,319.79
Rate for Payer: Amerigroup Medicare	$1,320.58
Rate for Payer: Cash Price	$2,092.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,961.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,307.50
Rate for Payer: Iowa Total Care Managed Medicaid	$1,306.98
Rate for Payer: Medical Associates Commercial	$1,961.25
Rate for Payer: Medical Associates Managed Medicare	$1,307.50
Rate for Payer: Midlands Choice Commercial	$1,830.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,327.11
Rate for Payer: Molina Healthcare Managed Medicare	$1,326.33
Rate for Payer: Oscar Health of IA Commercial	$1,961.25
Rate for Payer: Partners Health Alliance Commercial	$1,961.25
Rate for Payer: United Healthcare Commercial	$2,353.50
Rate for Payer: United Healthcare Managed Medicare	$1,542.85

GC PROBE

Facility

$128.00

Service Code	CPT 87591
Hospital Charge Code	8093934
Hospital Revenue Code	306
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: United Healthcare Commercial	$115.20

GC PROBE

Facility

$128.00

Service Code	CPT 87591
Hospital Charge Code	8093934
Hospital Revenue Code	306
Min. Negotiated Rate	$63.97
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Aetna of IA Medicare	$72.96
Rate for Payer: Amerigroup Medicaid	$64.60
Rate for Payer: Amerigroup Medicare	$64.64
Rate for Payer: Cash Price	$102.40
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$64.00
Rate for Payer: Iowa Total Care Managed Medicaid	$63.97
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Medical Associates Managed Medicare	$64.00
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: Molina Healthcare Managed Medicaid	$64.96
Rate for Payer: Molina Healthcare Managed Medicare	$64.92
Rate for Payer: Oscar Health of IA Commercial	$96.00
Rate for Payer: Partners Health Alliance Commercial	$96.00
Rate for Payer: United Healthcare Commercial	$115.20
Rate for Payer: United Healthcare Managed Medicare	$75.52
Rate for Payer: Wellmark IA HMO	$68.82
Rate for Payer: Wellmark IA PPO	$75.70

gemcitabine 100 mg/mL 20ml MDV [VDMC]

Facility

$276.96

Service Code	HCPCS J9201
Hospital Charge Code	21260983
Hospital Revenue Code	259
Min. Negotiated Rate	$138.42
Max. Negotiated Rate	$249.26
Rate for Payer: Aetna of IA Commercial	$249.26
Rate for Payer: Aetna of IA Medical Rental Products	$249.26
Rate for Payer: Aetna of IA Medicare	$157.87
Rate for Payer: Amerigroup Medicaid	$139.78
Rate for Payer: Amerigroup Medicare	$139.86
Rate for Payer: Cash Price	$221.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$207.72
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$138.48
Rate for Payer: Iowa Total Care Managed Medicaid	$138.42
Rate for Payer: Medical Associates Commercial	$207.72
Rate for Payer: Medical Associates Managed Medicare	$138.48
Rate for Payer: Midlands Choice Commercial	$193.87
Rate for Payer: Molina Healthcare Managed Medicaid	$140.56
Rate for Payer: Molina Healthcare Managed Medicare	$140.47
Rate for Payer: Oscar Health of IA Commercial	$207.72
Rate for Payer: Partners Health Alliance Commercial	$207.72
Rate for Payer: United Healthcare Commercial	$249.26
Rate for Payer: United Healthcare Managed Medicare	$163.41

gemcitabine 100 mg/mL 20ml MDV [VDMC]

Facility

$276.96

Service Code	HCPCS J9201
Hospital Charge Code	21260983
Hospital Revenue Code	259
Min. Negotiated Rate	$193.87
Max. Negotiated Rate	$249.26
Rate for Payer: Aetna of IA Commercial	$249.26
Rate for Payer: Aetna of IA Medical Rental Products	$249.26
Rate for Payer: Cash Price	$221.57
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$207.72
Rate for Payer: Medical Associates Commercial	$207.72
Rate for Payer: Midlands Choice Commercial	$193.87
Rate for Payer: United Healthcare Commercial	$249.26

gemcitabine 100 mg/mL 2ml MDV [VDMC]

Facility

$69.44

Service Code	HCPCS J9201
Hospital Charge Code	21261238
Hospital Revenue Code	259
Min. Negotiated Rate	$34.71
Max. Negotiated Rate	$62.50
Rate for Payer: Aetna of IA Commercial	$62.50
Rate for Payer: Aetna of IA Medical Rental Products	$62.50
Rate for Payer: Aetna of IA Medicare	$39.58
Rate for Payer: Amerigroup Medicaid	$35.05
Rate for Payer: Amerigroup Medicare	$35.07
Rate for Payer: Cash Price	$55.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.08
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$34.72
Rate for Payer: Iowa Total Care Managed Medicaid	$34.71
Rate for Payer: Medical Associates Commercial	$52.08
Rate for Payer: Medical Associates Managed Medicare	$34.72
Rate for Payer: Midlands Choice Commercial	$48.61
Rate for Payer: Molina Healthcare Managed Medicaid	$35.24
Rate for Payer: Molina Healthcare Managed Medicare	$35.22
Rate for Payer: Oscar Health of IA Commercial	$52.08
Rate for Payer: Partners Health Alliance Commercial	$52.08
Rate for Payer: United Healthcare Commercial	$62.50
Rate for Payer: United Healthcare Managed Medicare	$40.97

gemcitabine 100 mg/mL 2ml MDV [VDMC]

Facility

$69.44

Service Code	HCPCS J9201
Hospital Charge Code	21261238
Hospital Revenue Code	259
Min. Negotiated Rate	$48.61
Max. Negotiated Rate	$62.50
Rate for Payer: Aetna of IA Commercial	$62.50
Rate for Payer: Aetna of IA Medical Rental Products	$62.50
Rate for Payer: Cash Price	$55.55
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.08
Rate for Payer: Medical Associates Commercial	$52.08
Rate for Payer: Midlands Choice Commercial	$48.61
Rate for Payer: United Healthcare Commercial	$62.50

Gemcitabine 1gm/26.3ml SDV [VDMC]

Facility

$95.40

Service Code	HCPCS J9201
Hospital Charge Code	17504012
Hospital Revenue Code	259
Min. Negotiated Rate	$47.68
Max. Negotiated Rate	$85.86
Rate for Payer: Aetna of IA Commercial	$85.86
Rate for Payer: Aetna of IA Medical Rental Products	$85.86
Rate for Payer: Aetna of IA Medicare	$54.38
Rate for Payer: Amerigroup Medicaid	$48.15
Rate for Payer: Amerigroup Medicare	$48.18
Rate for Payer: Cash Price	$76.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$71.55
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$47.70
Rate for Payer: Iowa Total Care Managed Medicaid	$47.68
Rate for Payer: Medical Associates Commercial	$71.55
Rate for Payer: Medical Associates Managed Medicare	$47.70
Rate for Payer: Midlands Choice Commercial	$66.78
Rate for Payer: Molina Healthcare Managed Medicaid	$48.42
Rate for Payer: Molina Healthcare Managed Medicare	$48.39
Rate for Payer: Oscar Health of IA Commercial	$71.55
Rate for Payer: Partners Health Alliance Commercial	$71.55
Rate for Payer: United Healthcare Commercial	$85.86
Rate for Payer: United Healthcare Managed Medicare	$56.29

Gemcitabine 1gm/26.3ml SDV [VDMC]

Facility

$95.40

Service Code	HCPCS J9201
Hospital Charge Code	17504012
Hospital Revenue Code	259
Min. Negotiated Rate	$66.78
Max. Negotiated Rate	$85.86
Rate for Payer: Aetna of IA Commercial	$85.86
Rate for Payer: Aetna of IA Medical Rental Products	$85.86
Rate for Payer: Cash Price	$76.32
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$71.55
Rate for Payer: Medical Associates Commercial	$71.55
Rate for Payer: Midlands Choice Commercial	$66.78
Rate for Payer: United Healthcare Commercial	$85.86

gemfibrozil 600 mg Tab [VDMC]

Facility

$1.87

Service Code	HCPCS A9270
Hospital Charge Code	10391618
Hospital Revenue Code	259
Min. Negotiated Rate	$0.93
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of IA Commercial	$1.68
Rate for Payer: Aetna of IA Medical Rental Products	$1.68
Rate for Payer: Aetna of IA Medicare	$1.07
Rate for Payer: Amerigroup Medicaid	$0.94
Rate for Payer: Amerigroup Medicare	$0.94
Rate for Payer: Cash Price	$1.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.94
Rate for Payer: Iowa Total Care Managed Medicaid	$0.93
Rate for Payer: Medical Associates Commercial	$1.40
Rate for Payer: Medical Associates Managed Medicare	$0.94
Rate for Payer: Midlands Choice Commercial	$1.31
Rate for Payer: Molina Healthcare Managed Medicaid	$0.95
Rate for Payer: Molina Healthcare Managed Medicare	$0.95
Rate for Payer: Oscar Health of IA Commercial	$1.40
Rate for Payer: Partners Health Alliance Commercial	$1.40
Rate for Payer: United Healthcare Commercial	$1.68
Rate for Payer: United Healthcare Managed Medicare	$1.10

gemfibrozil 600 mg Tab [VDMC]

Facility

$1.87

Service Code	HCPCS A9270
Hospital Charge Code	10391618
Hospital Revenue Code	259
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$1.68
Rate for Payer: Aetna of IA Commercial	$1.68
Rate for Payer: Aetna of IA Medical Rental Products	$1.68
Rate for Payer: Cash Price	$1.50
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.40
Rate for Payer: Medical Associates Commercial	$1.40
Rate for Payer: Midlands Choice Commercial	$1.31
Rate for Payer: United Healthcare Commercial	$1.68

GENERAL ANESTHESIA I

Facility

$926.00

Hospital Charge Code	8059074
Hospital Revenue Code	370
Min. Negotiated Rate	$462.81
Max. Negotiated Rate	$833.40
Rate for Payer: Aetna of IA Commercial	$833.40
Rate for Payer: Aetna of IA Medical Rental Products	$833.40
Rate for Payer: Aetna of IA Medicare	$527.82
Rate for Payer: Amerigroup Medicaid	$467.35
Rate for Payer: Amerigroup Medicare	$467.63
Rate for Payer: Cash Price	$740.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$694.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$463.00
Rate for Payer: Iowa Total Care Managed Medicaid	$462.81
Rate for Payer: Medical Associates Commercial	$694.50
Rate for Payer: Medical Associates Managed Medicare	$463.00
Rate for Payer: Midlands Choice Commercial	$648.20
Rate for Payer: Molina Healthcare Managed Medicaid	$469.94
Rate for Payer: Molina Healthcare Managed Medicare	$469.67
Rate for Payer: Oscar Health of IA Commercial	$694.50
Rate for Payer: Partners Health Alliance Commercial	$694.50
Rate for Payer: United Healthcare Commercial	$833.40
Rate for Payer: United Healthcare Managed Medicare	$546.34

GENERAL ANESTHESIA I

Facility

$926.00

Hospital Charge Code	8059074
Hospital Revenue Code	370
Min. Negotiated Rate	$648.20
Max. Negotiated Rate	$833.40
Rate for Payer: Aetna of IA Commercial	$833.40
Rate for Payer: Aetna of IA Medical Rental Products	$833.40
Rate for Payer: Cash Price	$740.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$694.50
Rate for Payer: Medical Associates Commercial	$694.50
Rate for Payer: Midlands Choice Commercial	$648.20
Rate for Payer: United Healthcare Commercial	$833.40

Know your out-of-pocket cost for care.

All Charges