Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

FOREIGN BODY REMOVAL EAR

Professional

Both

$210.00

Service Code	CPT 69200
Hospital Charge Code	7982760
Hospital Revenue Code	981
Min. Negotiated Rate	$56.19
Max. Negotiated Rate	$181.50
Rate for Payer: Amerigroup Medicaid	$56.74
Rate for Payer: Cash Price	$168.00
Rate for Payer: Cash Price	$168.00
Rate for Payer: Iowa Total Care Managed Medicaid	$56.19
Rate for Payer: Medical Associates Commercial	$157.50
Rate for Payer: Midlands Choice Commercial	$147.00
Rate for Payer: Molina Healthcare Managed Medicaid	$56.47
Rate for Payer: Partners Health Alliance Commercial	$157.50
Rate for Payer: United Healthcare Commercial	$122.05
Rate for Payer: Wellmark IA HMO WHPI	$154.30
Rate for Payer: Wellmark IA PPO	$181.50

FOREIGN BODY REMOVAL NOSE

Professional

Both

$415.00

Service Code	CPT 30300
Hospital Charge Code	7982783
Hospital Revenue Code	981
Min. Negotiated Rate	$82.73
Max. Negotiated Rate	$469.20
Rate for Payer: Amerigroup Medicaid	$83.54
Rate for Payer: Cash Price	$332.00
Rate for Payer: Cash Price	$332.00
Rate for Payer: Iowa Total Care Managed Medicaid	$82.73
Rate for Payer: Medical Associates Commercial	$311.25
Rate for Payer: Midlands Choice Commercial	$290.50
Rate for Payer: Molina Healthcare Managed Medicaid	$83.14
Rate for Payer: Partners Health Alliance Commercial	$311.25
Rate for Payer: United Healthcare Commercial	$285.04
Rate for Payer: Wellmark IA HMO WHPI	$398.80
Rate for Payer: Wellmark IA PPO	$469.20

FOREIGN BODY REMOVAL SIMPLE

Professional

Both

$365.00

Service Code	CPT 10120
Hospital Charge Code	7982856
Hospital Revenue Code	981
Min. Negotiated Rate	$82.40
Max. Negotiated Rate	$328.20
Rate for Payer: Amerigroup Medicaid	$83.20
Rate for Payer: Cash Price	$292.00
Rate for Payer: Cash Price	$292.00
Rate for Payer: Iowa Total Care Managed Medicaid	$82.40
Rate for Payer: Medical Associates Commercial	$273.75
Rate for Payer: Midlands Choice Commercial	$255.50
Rate for Payer: Molina Healthcare Managed Medicaid	$82.80
Rate for Payer: Partners Health Alliance Commercial	$273.75
Rate for Payer: United Healthcare Commercial	$228.66
Rate for Payer: Wellmark IA HMO WHPI	$279.00
Rate for Payer: Wellmark IA PPO	$328.20

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	$243.67
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: 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	$63.14
Rate for Payer: United Healthcare Commercial	$109.80
Rate for Payer: United Healthcare Managed Medicare	$71.98
Rate for Payer: Wellmark IA HMO WHPI	$221.21
Rate for Payer: Wellmark IA PPO	$243.67

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

FRACTURES OF FEMUR WITH MCC

Facility

$15,910.06

Service Code	MSDRG 533
Min. Negotiated Rate	$15,679.47
Max. Negotiated Rate	$15,910.06
Rate for Payer: Amerigroup Medicaid	$15,833.19
Rate for Payer: Iowa Total Care Managed Medicaid	$15,679.47
Rate for Payer: Molina Healthcare Managed Medicaid	$15,910.06

FRACTURES OF FEMUR WITHOUT MCC

Facility

$5,022.98

Service Code	MSDRG 534
Min. Negotiated Rate	$4,950.18
Max. Negotiated Rate	$5,022.98
Rate for Payer: Amerigroup Medicaid	$4,998.72
Rate for Payer: Iowa Total Care Managed Medicaid	$4,950.18
Rate for Payer: Molina Healthcare Managed Medicaid	$5,022.98

FRACTURES OF HIP AND PELVIS WITH MCC

Facility

$11,064.98

Service Code	MSDRG 535
Min. Negotiated Rate	$10,904.61
Max. Negotiated Rate	$11,064.98
Rate for Payer: Amerigroup Medicaid	$11,011.52
Rate for Payer: Iowa Total Care Managed Medicaid	$10,904.61
Rate for Payer: Molina Healthcare Managed Medicaid	$11,064.98

FRACTURES OF HIP AND PELVIS WITHOUT MCC

Facility

$9,088.89

Service Code	MSDRG 536
Min. Negotiated Rate	$8,957.16
Max. Negotiated Rate	$9,088.89
Rate for Payer: Amerigroup Medicaid	$9,044.97
Rate for Payer: Iowa Total Care Managed Medicaid	$8,957.16
Rate for Payer: Molina Healthcare Managed Medicaid	$9,088.89

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITH MCC

Facility

$10,110.15

Service Code	MSDRG 562
Min. Negotiated Rate	$9,963.62
Max. Negotiated Rate	$10,110.15
Rate for Payer: Amerigroup Medicaid	$10,061.30
Rate for Payer: Iowa Total Care Managed Medicaid	$9,963.62
Rate for Payer: Molina Healthcare Managed Medicaid	$10,110.15

FRACTURE, SPRAIN, STRAIN AND DISLOCATION EXCEPT FEMUR, HIP, PELVIS AND THIGH WITHOUT MCC

Facility

$7,161.21

Service Code	MSDRG 563
Min. Negotiated Rate	$7,057.42
Max. Negotiated Rate	$7,161.21
Rate for Payer: Amerigroup Medicaid	$7,126.62
Rate for Payer: Iowa Total Care Managed Medicaid	$7,057.42
Rate for Payer: Molina Healthcare Managed Medicaid	$7,161.21

FULL TERM NEONATE WITH MAJOR PROBLEMS

Facility

$5,982.32

Service Code	MSDRG 793
Min. Negotiated Rate	$5,895.61
Max. Negotiated Rate	$5,982.32
Rate for Payer: Amerigroup Medicaid	$5,953.41
Rate for Payer: Iowa Total Care Managed Medicaid	$5,895.61
Rate for Payer: Molina Healthcare Managed Medicaid	$5,982.32

FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY

Facility

$9,663.13

Service Code	MSDRG 934
Min. Negotiated Rate	$9,523.08
Max. Negotiated Rate	$9,663.13
Rate for Payer: Amerigroup Medicaid	$9,616.45
Rate for Payer: Iowa Total Care Managed Medicaid	$9,523.08
Rate for Payer: Molina Healthcare Managed Medicaid	$9,663.13

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC

Facility

$36,579.61

Service Code	MSDRG 928
Min. Negotiated Rate	$36,049.46
Max. Negotiated Rate	$36,579.61
Rate for Payer: Amerigroup Medicaid	$36,402.89
Rate for Payer: Iowa Total Care Managed Medicaid	$36,049.46
Rate for Payer: Molina Healthcare Managed Medicaid	$36,579.61

FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC

Facility

$21,912.64

Service Code	MSDRG 929
Min. Negotiated Rate	$21,595.05
Max. Negotiated Rate	$21,912.64
Rate for Payer: Amerigroup Medicaid	$21,806.77
Rate for Payer: Iowa Total Care Managed Medicaid	$21,595.05
Rate for Payer: Molina Healthcare Managed Medicaid	$21,912.64

FUNGITELL ASSAY

Facility

$114.00

Service Code	CPT 87449
Hospital Charge Code	8037483
Hospital Revenue Code	306
Min. Negotiated Rate	$34.03
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: 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	$59.00
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

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

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	$221.80
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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 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	$221.80
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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 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	$221.80
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$201.36
Rate for Payer: Wellmark IA PPO	$221.80

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	$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 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

Know your out-of-pocket cost for care.

All Charges