Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

FOREIGN BODY REMOVAL NOSE

Professional

Both

$415.00

Service Code	CPT 30300
Hospital Charge Code	7982783
Hospital Revenue Code	981
Min. Negotiated Rate	$285.04
Max. Negotiated Rate	$311.25
Rate for Payer: Cash Price	$332.00
Rate for Payer: Cash Price	$332.00
Rate for Payer: Medical Associates Commercial	$311.25
Rate for Payer: Midlands Choice Commercial	$290.50
Rate for Payer: Partners Health Alliance Commercial	$311.25
Rate for Payer: United Healthcare Commercial	$285.04

FOREIGN BODY REMOVAL SIMPLE

Professional

Both

$365.00

Service Code	CPT 10120
Hospital Charge Code	7982856
Hospital Revenue Code	981
Min. Negotiated Rate	$228.66
Max. Negotiated Rate	$273.75
Rate for Payer: Cash Price	$292.00
Rate for Payer: Cash Price	$292.00
Rate for Payer: Medical Associates Commercial	$273.75
Rate for Payer: Midlands Choice Commercial	$255.50
Rate for Payer: Partners Health Alliance Commercial	$273.75
Rate for Payer: United Healthcare Commercial	$228.66

FRACTURE ASSESSMENT VIA DXA

Facility

$122.00

Service Code	CPT 77086
Hospital Charge Code	8401516
Hospital Revenue Code	320
Min. Negotiated Rate	$85.40
Max. Negotiated Rate	$109.80
Rate for Payer: Aetna of IA Commercial	$109.80
Rate for Payer: Aetna of IA Medical Rental Products	$109.80
Rate for Payer: Cash Price	$97.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$91.50
Rate for Payer: Medical Associates Commercial	$91.50
Rate for Payer: Midlands Choice Commercial	$85.40
Rate for Payer: United Healthcare Commercial	$109.80

FRACTURE ASSESSMENT VIA DXA

Facility

$122.00

Service Code	CPT 77086
Hospital Charge Code	8401516
Hospital Revenue Code	320
Min. Negotiated Rate	$54.90
Max. Negotiated Rate	$109.80
Rate for Payer: Aetna of IA Commercial	$109.80
Rate for Payer: Aetna of IA Medical Rental Products	$109.80
Rate for Payer: Aetna of IA Medicare	$69.54
Rate for Payer: Amerigroup Medicaid	$70.37
Rate for Payer: Amerigroup Medicare	$55.45
Rate for Payer: Cash Price	$97.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$91.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$54.90
Rate for Payer: Iowa Total Care Managed Medicaid	$69.69
Rate for Payer: Medical Associates Commercial	$91.50
Rate for Payer: Medical Associates Managed Medicare	$54.90
Rate for Payer: Midlands Choice Commercial	$85.40
Rate for Payer: Molina Healthcare Managed Medicaid	$70.71
Rate for Payer: Partners Health Alliance Commercial	$63.13
Rate for Payer: United Healthcare Commercial	$109.80
Rate for Payer: United Healthcare Managed Medicare	$71.98

FUNGITELL ASSAY

Facility

$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

FUNGITELL ASSAY

Facility

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037483
Hospital Revenue Code	306
Min. Negotiated Rate	$51.30
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	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
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	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$58.99
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26

furosemide 10 mg/mL Inj Sol 10mL SDV [VDMC]

Facility

$25.48

Service Code	HCPCS J1940
Hospital Charge Code	10391145
Hospital Revenue Code	259
Min. Negotiated Rate	$17.84
Max. Negotiated Rate	$22.94
Rate for Payer: Aetna of IA Commercial	$22.94
Rate for Payer: Aetna of IA Medical Rental Products	$22.94
Rate for Payer: Cash Price	$20.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.11
Rate for Payer: Medical Associates Commercial	$19.11
Rate for Payer: Midlands Choice Commercial	$17.84
Rate for Payer: United Healthcare Commercial	$22.94

furosemide 10 mg/mL Inj Sol 10mL SDV [VDMC]

Facility

$25.48

Service Code	HCPCS J1940
Hospital Charge Code	10391145
Hospital Revenue Code	259
Min. Negotiated Rate	$11.47
Max. Negotiated Rate	$22.94
Rate for Payer: Aetna of IA Commercial	$22.94
Rate for Payer: Aetna of IA Medical Rental Products	$22.94
Rate for Payer: Aetna of IA Medicare	$14.53
Rate for Payer: Amerigroup Medicaid	$14.70
Rate for Payer: Amerigroup Medicare	$11.58
Rate for Payer: Cash Price	$20.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$19.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.47
Rate for Payer: Iowa Total Care Managed Medicaid	$14.56
Rate for Payer: Medical Associates Commercial	$19.11
Rate for Payer: Medical Associates Managed Medicare	$11.47
Rate for Payer: Midlands Choice Commercial	$17.84
Rate for Payer: Molina Healthcare Managed Medicaid	$14.77
Rate for Payer: Partners Health Alliance Commercial	$13.19
Rate for Payer: United Healthcare Commercial	$22.94
Rate for Payer: United Healthcare Managed Medicare	$15.04

furosemide 10 mg/mL Inj Sol 2 mL SDV [VDMC]

Facility

$22.47

Service Code	HCPCS J1940
Hospital Charge Code	10391082
Hospital Revenue Code	259
Min. Negotiated Rate	$15.73
Max. Negotiated Rate	$20.22
Rate for Payer: Aetna of IA Commercial	$20.22
Rate for Payer: Aetna of IA Medical Rental Products	$20.22
Rate for Payer: Cash Price	$17.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.85
Rate for Payer: Medical Associates Commercial	$16.85
Rate for Payer: Midlands Choice Commercial	$15.73
Rate for Payer: United Healthcare Commercial	$20.22

furosemide 10 mg/mL Inj Sol 2 mL SDV [VDMC]

Facility

$22.47

Service Code	HCPCS J1940
Hospital Charge Code	10391082
Hospital Revenue Code	259
Min. Negotiated Rate	$10.11
Max. Negotiated Rate	$20.22
Rate for Payer: Aetna of IA Commercial	$20.22
Rate for Payer: Aetna of IA Medical Rental Products	$20.22
Rate for Payer: Aetna of IA Medicare	$12.81
Rate for Payer: Amerigroup Medicaid	$12.96
Rate for Payer: Amerigroup Medicare	$10.21
Rate for Payer: Cash Price	$17.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.85
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.11
Rate for Payer: Iowa Total Care Managed Medicaid	$12.83
Rate for Payer: Medical Associates Commercial	$16.85
Rate for Payer: Medical Associates Managed Medicare	$10.11
Rate for Payer: Midlands Choice Commercial	$15.73
Rate for Payer: Molina Healthcare Managed Medicaid	$13.02
Rate for Payer: Partners Health Alliance Commercial	$11.63
Rate for Payer: United Healthcare Commercial	$20.22
Rate for Payer: United Healthcare Managed Medicare	$13.25

furosemide 10 mg/mL Inj Sol 4mL [VDMC]

Facility

$22.02

Service Code	HCPCS J1940
Hospital Charge Code	10391216
Hospital Revenue Code	259
Min. Negotiated Rate	$9.91
Max. Negotiated Rate	$19.82
Rate for Payer: Aetna of IA Commercial	$19.82
Rate for Payer: Aetna of IA Medical Rental Products	$19.82
Rate for Payer: Aetna of IA Medicare	$12.55
Rate for Payer: Amerigroup Medicaid	$12.70
Rate for Payer: Amerigroup Medicare	$10.01
Rate for Payer: Cash Price	$17.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.52
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$9.91
Rate for Payer: Iowa Total Care Managed Medicaid	$12.58
Rate for Payer: Medical Associates Commercial	$16.52
Rate for Payer: Medical Associates Managed Medicare	$9.91
Rate for Payer: Midlands Choice Commercial	$15.42
Rate for Payer: Molina Healthcare Managed Medicaid	$12.77
Rate for Payer: Partners Health Alliance Commercial	$11.40
Rate for Payer: United Healthcare Commercial	$19.82
Rate for Payer: United Healthcare Managed Medicare	$12.99

furosemide 10 mg/mL Inj Sol 4mL [VDMC]

Facility

$22.02

Service Code	HCPCS J1940
Hospital Charge Code	10391216
Hospital Revenue Code	259
Min. Negotiated Rate	$15.42
Max. Negotiated Rate	$19.82
Rate for Payer: Aetna of IA Commercial	$19.82
Rate for Payer: Aetna of IA Medical Rental Products	$19.82
Rate for Payer: Cash Price	$17.62
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.52
Rate for Payer: Medical Associates Commercial	$16.52
Rate for Payer: Midlands Choice Commercial	$15.42
Rate for Payer: United Healthcare Commercial	$19.82

furosemide 10 mg/mL Oral Liq 60ml [VDMC]

Facility

$28.48

Service Code	HCPCS A9270
Hospital Charge Code	10391279
Hospital Revenue Code	259
Min. Negotiated Rate	$12.82
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	$16.43
Rate for Payer: Amerigroup Medicare	$12.94
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	$12.82
Rate for Payer: Iowa Total Care Managed Medicaid	$16.27
Rate for Payer: Medical Associates Commercial	$21.36
Rate for Payer: Medical Associates Managed Medicare	$12.82
Rate for Payer: Midlands Choice Commercial	$19.94
Rate for Payer: Molina Healthcare Managed Medicaid	$16.51
Rate for Payer: Partners Health Alliance Commercial	$14.74
Rate for Payer: United Healthcare Commercial	$25.63
Rate for Payer: United Healthcare Managed Medicare	$16.80

furosemide 10 mg/mL Oral Liq 60ml [VDMC]

Facility

$28.48

Service Code	HCPCS A9270
Hospital Charge Code	10391279
Hospital Revenue Code	259
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 [VDMC]

Facility

$1.62

Service Code	HCPCS A9270
Hospital Charge Code	10391344
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of IA Commercial	$1.46
Rate for Payer: Aetna of IA Medical Rental Products	$1.46
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.21
Rate for Payer: Medical Associates Commercial	$1.21
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: United Healthcare Commercial	$1.46

furosemide 20 mg Tab [VDMC]

Facility

$1.62

Service Code	HCPCS A9270
Hospital Charge Code	10391344
Hospital Revenue Code	259
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of IA Commercial	$1.46
Rate for Payer: Aetna of IA Medical Rental Products	$1.46
Rate for Payer: Aetna of IA Medicare	$0.92
Rate for Payer: Amerigroup Medicaid	$0.93
Rate for Payer: Amerigroup Medicare	$0.74
Rate for Payer: Cash Price	$1.30
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.21
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.73
Rate for Payer: Iowa Total Care Managed Medicaid	$0.93
Rate for Payer: Medical Associates Commercial	$1.21
Rate for Payer: Medical Associates Managed Medicare	$0.73
Rate for Payer: Midlands Choice Commercial	$1.13
Rate for Payer: Molina Healthcare Managed Medicaid	$0.94
Rate for Payer: Partners Health Alliance Commercial	$0.84
Rate for Payer: United Healthcare Commercial	$1.46
Rate for Payer: United Healthcare Managed Medicare	$0.96

furosemide 40 mg Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10391413
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of IA Commercial	$1.52
Rate for Payer: Aetna of IA Medical Rental Products	$1.52
Rate for Payer: Aetna of IA Medicare	$0.97
Rate for Payer: Amerigroup Medicaid	$0.98
Rate for Payer: Amerigroup Medicare	$0.77
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.27
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.76
Rate for Payer: Iowa Total Care Managed Medicaid	$0.97
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Medical Associates Managed Medicare	$0.76
Rate for Payer: Midlands Choice Commercial	$1.19
Rate for Payer: Molina Healthcare Managed Medicaid	$0.98
Rate for Payer: Partners Health Alliance Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.52
Rate for Payer: United Healthcare Managed Medicare	$1.00

furosemide 40 mg Tab [VDMC]

Facility

$1.69

Service Code	HCPCS A9270
Hospital Charge Code	10391413
Hospital Revenue Code	259
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.52
Rate for Payer: Aetna of IA Commercial	$1.52
Rate for Payer: Aetna of IA Medical Rental Products	$1.52
Rate for Payer: Cash Price	$1.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.27
Rate for Payer: Medical Associates Commercial	$1.27
Rate for Payer: Midlands Choice Commercial	$1.19
Rate for Payer: United Healthcare Commercial	$1.52

G0105 Medicare High risk normal screening colonoscopy

Professional

Both

$1,046.00

Service Code	CPT G0105
Hospital Charge Code	8799222
Hospital Revenue Code	975
Min. Negotiated Rate	$499.18
Max. Negotiated Rate	$784.50
Rate for Payer: Cash Price	$836.80
Rate for Payer: Cash Price	$836.80
Rate for Payer: Medical Associates Commercial	$784.50
Rate for Payer: Midlands Choice Commercial	$732.20
Rate for Payer: Partners Health Alliance Commercial	$784.50
Rate for Payer: United Healthcare Commercial	$499.18

G0121 COLONOSCOPY SCREENING NON RISK

Professional

Both

$1,049.00

Service Code	HCPCS G0121
Hospital Charge Code	7808122
Hospital Revenue Code	975
Min. Negotiated Rate	$499.68
Max. Negotiated Rate	$786.75
Rate for Payer: Cash Price	$839.20
Rate for Payer: Cash Price	$839.20
Rate for Payer: Medical Associates Commercial	$786.75
Rate for Payer: Midlands Choice Commercial	$734.30
Rate for Payer: Partners Health Alliance Commercial	$786.75
Rate for Payer: United Healthcare Commercial	$499.68

G0239 Pulmonary Rehab

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	5818783
Hospital Revenue Code	948
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: United Healthcare Commercial	$140.40

G0239 Pulmonary Rehab

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	5818783
Hospital Revenue Code	948
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Aetna of IA Medicare	$88.92
Rate for Payer: Amerigroup Medicaid	$89.98
Rate for Payer: Amerigroup Medicare	$70.90
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$70.20
Rate for Payer: Iowa Total Care Managed Medicaid	$89.11
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Medical Associates Managed Medicare	$70.20
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: Molina Healthcare Managed Medicaid	$90.42
Rate for Payer: Partners Health Alliance Commercial	$80.73
Rate for Payer: United Healthcare Commercial	$140.40
Rate for Payer: United Healthcare Managed Medicare	$92.04

gabapentin 100 mg Cap [VDMC]

Facility

$1.31

Service Code	HCPCS A9270
Hospital Charge Code	10391482
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
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	$0.74
Rate for Payer: Amerigroup Medicaid	$0.75
Rate for Payer: Amerigroup Medicare	$0.59
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	$0.59
Rate for Payer: Iowa Total Care Managed Medicaid	$0.75
Rate for Payer: Medical Associates Commercial	$0.98
Rate for Payer: Medical Associates Managed Medicare	$0.59
Rate for Payer: Midlands Choice Commercial	$0.91
Rate for Payer: Molina Healthcare Managed Medicaid	$0.76
Rate for Payer: Partners Health Alliance Commercial	$0.68
Rate for Payer: United Healthcare Commercial	$1.18
Rate for Payer: United Healthcare Managed Medicare	$0.77

gabapentin 100 mg Cap [VDMC]

Facility

$1.31

Service Code	HCPCS A9270
Hospital Charge Code	10391482
Hospital Revenue Code	259
Min. Negotiated Rate	$0.91
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	$0.91
Rate for Payer: United Healthcare Commercial	$1.18

gabapentin 250 mg/5 mL Solution[VDMC]

Facility

$3.71

Service Code	HCPCS A9270
Hospital Charge Code	23101177
Hospital Revenue Code	259
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

Know your out-of-pocket cost for care.

All Charges