Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr [VDMC]

Facility

$177.48

Service Code	HCPCS A9270
Hospital Charge Code	10390465
Hospital Revenue Code	259
Min. Negotiated Rate	$124.24
Max. Negotiated Rate	$159.73
Rate for Payer: Aetna of IA Commercial	$159.73
Rate for Payer: Aetna of IA Medical Rental Products	$159.73
Rate for Payer: Cash Price	$141.98
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$133.11
Rate for Payer: Medical Associates Commercial	$133.11
Rate for Payer: Midlands Choice Commercial	$124.24
Rate for Payer: United Healthcare Commercial	$159.73

fluticasone-salmeterol 500 mcg-50 mcg Inh Pwdr [VDMC]

Facility

$17.55

Service Code	HCPCS A9270
Hospital Charge Code	10390530
Hospital Revenue Code	259
Min. Negotiated Rate	$12.28
Max. Negotiated Rate	$15.79
Rate for Payer: Aetna of IA Commercial	$15.79
Rate for Payer: Aetna of IA Medical Rental Products	$15.79
Rate for Payer: Cash Price	$14.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.16
Rate for Payer: Medical Associates Commercial	$13.16
Rate for Payer: Midlands Choice Commercial	$12.28
Rate for Payer: United Healthcare Commercial	$15.79

fluticasone-salmeterol 500 mcg-50 mcg Inh Pwdr [VDMC]

Facility

$17.55

Service Code	HCPCS A9270
Hospital Charge Code	10390530
Hospital Revenue Code	259
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$15.79
Rate for Payer: Aetna of IA Commercial	$15.79
Rate for Payer: Aetna of IA Medical Rental Products	$15.79
Rate for Payer: Aetna of IA Medicare	$10.00
Rate for Payer: Amerigroup Medicaid	$10.12
Rate for Payer: Amerigroup Medicare	$7.97
Rate for Payer: Cash Price	$14.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13.16
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.90
Rate for Payer: Iowa Total Care Managed Medicaid	$10.02
Rate for Payer: Medical Associates Commercial	$13.16
Rate for Payer: Medical Associates Managed Medicare	$7.90
Rate for Payer: Midlands Choice Commercial	$12.28
Rate for Payer: Molina Healthcare Managed Medicaid	$10.17
Rate for Payer: Partners Health Alliance Commercial	$9.08
Rate for Payer: United Healthcare Commercial	$15.79
Rate for Payer: United Healthcare Managed Medicare	$10.35

fluvoxaMINE 100 mg Tab [VDMC]

Facility

$1.80

Service Code	HCPCS A9270
Hospital Charge Code	10390595
Hospital Revenue Code	259
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of IA Commercial	$1.62
Rate for Payer: Aetna of IA Medical Rental Products	$1.62
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.35
Rate for Payer: Medical Associates Commercial	$1.35
Rate for Payer: Midlands Choice Commercial	$1.26
Rate for Payer: United Healthcare Commercial	$1.62

fluvoxaMINE 100 mg Tab [VDMC]

Facility

$1.80

Service Code	HCPCS A9270
Hospital Charge Code	10390595
Hospital Revenue Code	259
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of IA Commercial	$1.62
Rate for Payer: Aetna of IA Medical Rental Products	$1.62
Rate for Payer: Aetna of IA Medicare	$1.03
Rate for Payer: Amerigroup Medicaid	$1.04
Rate for Payer: Amerigroup Medicare	$0.82
Rate for Payer: Cash Price	$1.44
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.35
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.81
Rate for Payer: Iowa Total Care Managed Medicaid	$1.03
Rate for Payer: Medical Associates Commercial	$1.35
Rate for Payer: Medical Associates Managed Medicare	$0.81
Rate for Payer: Midlands Choice Commercial	$1.26
Rate for Payer: Molina Healthcare Managed Medicaid	$1.04
Rate for Payer: Partners Health Alliance Commercial	$0.93
Rate for Payer: United Healthcare Commercial	$1.62
Rate for Payer: United Healthcare Managed Medicare	$1.06

FNA W/O IMAGE

Facility

$553.00

Service Code	CPT 10021
Hospital Charge Code	4860787
Hospital Revenue Code	450
Min. Negotiated Rate	$387.10
Max. Negotiated Rate	$497.70
Rate for Payer: Aetna of IA Commercial	$497.70
Rate for Payer: Aetna of IA Medical Rental Products	$497.70
Rate for Payer: Cash Price	$442.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$414.75
Rate for Payer: Medical Associates Commercial	$414.75
Rate for Payer: Midlands Choice Commercial	$387.10
Rate for Payer: United Healthcare Commercial	$497.70

FNA W/O IMAGE

Facility

$553.00

Service Code	CPT 10021
Hospital Charge Code	4860787
Hospital Revenue Code	450
Min. Negotiated Rate	$248.85
Max. Negotiated Rate	$497.70
Rate for Payer: Aetna of IA Commercial	$497.70
Rate for Payer: Aetna of IA Medical Rental Products	$497.70
Rate for Payer: Aetna of IA Medicare	$315.21
Rate for Payer: Amerigroup Medicaid	$318.97
Rate for Payer: Amerigroup Medicare	$251.34
Rate for Payer: Cash Price	$442.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$414.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$248.85
Rate for Payer: Iowa Total Care Managed Medicaid	$315.87
Rate for Payer: Medical Associates Commercial	$414.75
Rate for Payer: Medical Associates Managed Medicare	$248.85
Rate for Payer: Midlands Choice Commercial	$387.10
Rate for Payer: Molina Healthcare Managed Medicaid	$320.52
Rate for Payer: Partners Health Alliance Commercial	$286.18
Rate for Payer: United Healthcare Commercial	$497.70
Rate for Payer: United Healthcare Managed Medicare	$326.27

FOLATE (FOLIC ACID)

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	8093933
Hospital Revenue Code	302
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Aetna of IA Medicare	$57.00
Rate for Payer: Amerigroup Medicaid	$57.68
Rate for Payer: Amerigroup Medicare	$45.45
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.00
Rate for Payer: Iowa Total Care Managed Medicaid	$57.12
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Medical Associates Managed Medicare	$45.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: Molina Healthcare Managed Medicaid	$57.96
Rate for Payer: Partners Health Alliance Commercial	$51.75
Rate for Payer: United Healthcare Commercial	$90.00
Rate for Payer: United Healthcare Managed Medicare	$59.00
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

FOLATE (FOLIC ACID)

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	8093933
Hospital Revenue Code	302
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: United Healthcare Commercial	$90.00

Folate Level

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	1628894
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: United Healthcare Commercial	$90.00

Folate Level

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	1628894
Hospital Revenue Code	301
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Aetna of IA Medicare	$57.00
Rate for Payer: Amerigroup Medicaid	$57.68
Rate for Payer: Amerigroup Medicare	$45.45
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.00
Rate for Payer: Iowa Total Care Managed Medicaid	$57.12
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Medical Associates Managed Medicare	$45.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: Molina Healthcare Managed Medicaid	$57.96
Rate for Payer: Partners Health Alliance Commercial	$51.75
Rate for Payer: United Healthcare Commercial	$90.00
Rate for Payer: United Healthcare Managed Medicare	$59.00
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

Folate Level

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	8220859
Hospital Revenue Code	301
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Aetna of IA Medicare	$57.00
Rate for Payer: Amerigroup Medicaid	$57.68
Rate for Payer: Amerigroup Medicare	$45.45
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.00
Rate for Payer: Iowa Total Care Managed Medicaid	$57.12
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Medical Associates Managed Medicare	$45.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: Molina Healthcare Managed Medicaid	$57.96
Rate for Payer: Partners Health Alliance Commercial	$51.75
Rate for Payer: United Healthcare Commercial	$90.00
Rate for Payer: United Healthcare Managed Medicare	$59.00
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

Folate Level

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	8220859
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: United Healthcare Commercial	$90.00

Folate Level DMCL

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	8037847
Hospital Revenue Code	301
Min. Negotiated Rate	$45.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Aetna of IA Medicare	$57.00
Rate for Payer: Amerigroup Medicaid	$57.68
Rate for Payer: Amerigroup Medicare	$45.45
Rate for Payer: Cash Price	$80.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.00
Rate for Payer: Iowa Total Care Managed Medicaid	$57.12
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Medical Associates Managed Medicare	$45.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: Molina Healthcare Managed Medicaid	$57.96
Rate for Payer: Partners Health Alliance Commercial	$51.75
Rate for Payer: United Healthcare Commercial	$90.00
Rate for Payer: United Healthcare Managed Medicare	$59.00
Rate for Payer: Wellmark IA HMO WHPI	$61.68
Rate for Payer: Wellmark IA PPO	$67.95

Folate Level DMCL

Facility

$100.00

Service Code	CPT 82746
Hospital Charge Code	8037847
Hospital Revenue Code	301
Min. Negotiated Rate	$70.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of IA Commercial	$90.00
Rate for Payer: Aetna of IA Medical Rental Products	$90.00
Rate for Payer: Cash Price	$80.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$75.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$70.00
Rate for Payer: United Healthcare Commercial	$90.00

FOLEY CATH INSERTION

Professional

Both

$169.00

Service Code	CPT 51702
Hospital Charge Code	7822796
Hospital Revenue Code	981
Min. Negotiated Rate	$63.18
Max. Negotiated Rate	$137.80
Rate for Payer: Amerigroup Medicaid	$63.80
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Iowa Total Care Managed Medicaid	$63.18
Rate for Payer: Medical Associates Commercial	$126.75
Rate for Payer: Midlands Choice Commercial	$118.30
Rate for Payer: Molina Healthcare Managed Medicaid	$63.49
Rate for Payer: Partners Health Alliance Commercial	$126.75
Rate for Payer: United Healthcare Commercial	$92.14
Rate for Payer: Wellmark IA HMO WHPI	$117.10
Rate for Payer: Wellmark IA PPO	$137.80

FOLEY CATH SCHEDULED

Facility

$242.00

Service Code	CPT 51702
Hospital Charge Code	8012933
Hospital Revenue Code	761
Min. Negotiated Rate	$169.40
Max. Negotiated Rate	$217.80
Rate for Payer: Aetna of IA Commercial	$217.80
Rate for Payer: Aetna of IA Medical Rental Products	$217.80
Rate for Payer: Cash Price	$193.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$181.50
Rate for Payer: Medical Associates Commercial	$181.50
Rate for Payer: Midlands Choice Commercial	$169.40
Rate for Payer: United Healthcare Commercial	$217.80

FOLEY CATH SCHEDULED

Facility

$242.00

Service Code	CPT 51702
Hospital Charge Code	8012933
Hospital Revenue Code	761
Min. Negotiated Rate	$108.90
Max. Negotiated Rate	$267.88
Rate for Payer: Aetna of IA Commercial	$217.80
Rate for Payer: Aetna of IA Medical Rental Products	$217.80
Rate for Payer: Aetna of IA Medicare	$137.94
Rate for Payer: Amerigroup Medicaid	$139.59
Rate for Payer: Amerigroup Medicare	$109.99
Rate for Payer: Cash Price	$193.60
Rate for Payer: Cash Price	$193.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$181.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$108.90
Rate for Payer: Iowa Total Care Managed Medicaid	$138.23
Rate for Payer: Medical Associates Commercial	$181.50
Rate for Payer: Medical Associates Managed Medicare	$108.90
Rate for Payer: Midlands Choice Commercial	$169.40
Rate for Payer: Molina Healthcare Managed Medicaid	$140.26
Rate for Payer: Partners Health Alliance Commercial	$125.24
Rate for Payer: United Healthcare Commercial	$217.80
Rate for Payer: United Healthcare Managed Medicare	$142.78
Rate for Payer: Wellmark IA HMO WHPI	$243.19
Rate for Payer: Wellmark IA PPO	$267.88

folic acid 1 mg Tab [VDMC]

Facility

$1.66

Service Code	HCPCS A9270
Hospital Charge Code	10390664
Hospital Revenue Code	259
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of IA Commercial	$1.49
Rate for Payer: Aetna of IA Medical Rental Products	$1.49
Rate for Payer: Aetna of IA Medicare	$0.95
Rate for Payer: Amerigroup Medicaid	$0.96
Rate for Payer: Amerigroup Medicare	$0.75
Rate for Payer: Cash Price	$1.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.24
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.75
Rate for Payer: Iowa Total Care Managed Medicaid	$0.95
Rate for Payer: Medical Associates Commercial	$1.24
Rate for Payer: Medical Associates Managed Medicare	$0.75
Rate for Payer: Midlands Choice Commercial	$1.16
Rate for Payer: Molina Healthcare Managed Medicaid	$0.96
Rate for Payer: Partners Health Alliance Commercial	$0.86
Rate for Payer: United Healthcare Commercial	$1.49
Rate for Payer: United Healthcare Managed Medicare	$0.98

folic acid 1 mg Tab [VDMC]

Facility

$1.66

Service Code	HCPCS A9270
Hospital Charge Code	10390664
Hospital Revenue Code	259
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.49
Rate for Payer: Aetna of IA Commercial	$1.49
Rate for Payer: Aetna of IA Medical Rental Products	$1.49
Rate for Payer: Cash Price	$1.33
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.24
Rate for Payer: Medical Associates Commercial	$1.24
Rate for Payer: Midlands Choice Commercial	$1.16
Rate for Payer: United Healthcare Commercial	$1.49

Follicle Stimulating Hormone DMCL

Facility

$135.00

Service Code	CPT 83001
Hospital Charge Code	8037848
Hospital Revenue Code	301
Min. Negotiated Rate	$94.50
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of IA Commercial	$121.50
Rate for Payer: Aetna of IA Medical Rental Products	$121.50
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$101.25
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: United Healthcare Commercial	$121.50

Follicle Stimulating Hormone DMCL

Facility

$135.00

Service Code	CPT 83001
Hospital Charge Code	8037848
Hospital Revenue Code	301
Min. Negotiated Rate	$49.63
Max. Negotiated Rate	$121.50
Rate for Payer: Aetna of IA Commercial	$121.50
Rate for Payer: Aetna of IA Medical Rental Products	$121.50
Rate for Payer: Aetna of IA Medicare	$76.95
Rate for Payer: Amerigroup Medicaid	$77.87
Rate for Payer: Amerigroup Medicare	$61.36
Rate for Payer: Cash Price	$108.00
Rate for Payer: Cash Price	$108.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$101.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$60.75
Rate for Payer: Iowa Total Care Managed Medicaid	$77.11
Rate for Payer: Medical Associates Commercial	$101.25
Rate for Payer: Medical Associates Managed Medicare	$60.75
Rate for Payer: Midlands Choice Commercial	$94.50
Rate for Payer: Molina Healthcare Managed Medicaid	$78.25
Rate for Payer: Partners Health Alliance Commercial	$69.86
Rate for Payer: United Healthcare Commercial	$121.50
Rate for Payer: United Healthcare Managed Medicare	$79.65
Rate for Payer: Wellmark IA HMO WHPI	$49.63
Rate for Payer: Wellmark IA PPO	$54.67

FOOT PROCEDURES WITH CC

Facility

$14,726.65

Service Code	MSDRG 504
Min. Negotiated Rate	$14,513.22
Max. Negotiated Rate	$14,726.65
Rate for Payer: Amerigroup Medicaid	$14,655.50
Rate for Payer: Iowa Total Care Managed Medicaid	$14,513.22
Rate for Payer: Molina Healthcare Managed Medicaid	$14,726.65

FOOT PROCEDURES WITH MCC

Facility

$29,606.44

Service Code	MSDRG 503
Min. Negotiated Rate	$29,177.35
Max. Negotiated Rate	$29,606.44
Rate for Payer: Amerigroup Medicaid	$29,463.40
Rate for Payer: Iowa Total Care Managed Medicaid	$29,177.35
Rate for Payer: Molina Healthcare Managed Medicaid	$29,606.44

FOOT PROCEDURES WITHOUT CC/MCC

Facility

$14,290.90

Service Code	MSDRG 505
Min. Negotiated Rate	$14,083.78
Max. Negotiated Rate	$14,290.90
Rate for Payer: Amerigroup Medicaid	$14,221.86
Rate for Payer: Iowa Total Care Managed Medicaid	$14,083.78
Rate for Payer: Molina Healthcare Managed Medicaid	$14,290.90

Know your out-of-pocket cost for care.

All Charges