Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MOD SEDAT ENDO SERVICE >5YRS

Professional

Both

$192.00

Service Code	HCPCS G0500
Hospital Charge Code	8068958
Hospital Revenue Code	964
Min. Negotiated Rate	$83.78
Max. Negotiated Rate	$144.00
Rate for Payer: Cash Price	$153.60
Rate for Payer: Cash Price	$153.60
Rate for Payer: Medical Associates Commercial	$144.00
Rate for Payer: Midlands Choice Commercial	$134.40
Rate for Payer: Partners Health Alliance Commercial	$144.00
Rate for Payer: United Healthcare Commercial	$83.78

MOD SED SAME PHYS/QHP <5 YRS

Professional

Both

$254.00

Service Code	CPT 99151
Hospital Charge Code	8068972
Hospital Revenue Code	975
Min. Negotiated Rate	$111.28
Max. Negotiated Rate	$190.50
Rate for Payer: Cash Price	$203.20
Rate for Payer: Cash Price	$203.20
Rate for Payer: Medical Associates Commercial	$190.50
Rate for Payer: Midlands Choice Commercial	$177.80
Rate for Payer: Partners Health Alliance Commercial	$190.50
Rate for Payer: United Healthcare Commercial	$111.28

MOD SED SAME PHYS/QHP 5/>YRS

Professional

Both

$169.00

Service Code	CPT 99152
Hospital Charge Code	8068979
Hospital Revenue Code	975
Min. Negotiated Rate	$75.68
Max. Negotiated Rate	$126.75
Rate for Payer: Cash Price	$135.20
Rate for Payer: Cash Price	$135.20
Rate for Payer: Medical Associates Commercial	$126.75
Rate for Payer: Midlands Choice Commercial	$118.30
Rate for Payer: Partners Health Alliance Commercial	$126.75
Rate for Payer: United Healthcare Commercial	$75.68

MOD SED SAME PHYS/QHP EA

Professional

Both

$36.00

Service Code	CPT 99153
Hospital Charge Code	8069194
Hospital Revenue Code	981
Min. Negotiated Rate	$15.44
Max. Negotiated Rate	$27.00
Rate for Payer: Cash Price	$28.80
Rate for Payer: Cash Price	$28.80
Rate for Payer: Medical Associates Commercial	$27.00
Rate for Payer: Midlands Choice Commercial	$25.20
Rate for Payer: Partners Health Alliance Commercial	$27.00
Rate for Payer: United Healthcare Commercial	$15.44

MODULAR HIP SYSTEM 155MM X 16MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026267
Hospital Revenue Code	278
Min. Negotiated Rate	$3,673.35
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Aetna of IA Medicare	$4,652.91
Rate for Payer: Amerigroup Medicaid	$4,708.42
Rate for Payer: Amerigroup Medicare	$3,710.08
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,673.35
Rate for Payer: Iowa Total Care Managed Medicaid	$4,662.71
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Medical Associates Managed Medicare	$3,673.35
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: Molina Healthcare Managed Medicaid	$4,731.27
Rate for Payer: Partners Health Alliance Commercial	$4,224.35
Rate for Payer: United Healthcare Commercial	$7,346.70
Rate for Payer: United Healthcare Managed Medicare	$4,816.17

MODULAR HIP SYSTEM 155MM X 16MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026267
Hospital Revenue Code	278
Min. Negotiated Rate	$5,714.10
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: United Healthcare Commercial	$7,346.70

MODULAR HIP SYSTEM 155MM X 18MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026268
Hospital Revenue Code	278
Min. Negotiated Rate	$3,673.35
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Aetna of IA Medicare	$4,652.91
Rate for Payer: Amerigroup Medicaid	$4,708.42
Rate for Payer: Amerigroup Medicare	$3,710.08
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,673.35
Rate for Payer: Iowa Total Care Managed Medicaid	$4,662.71
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Medical Associates Managed Medicare	$3,673.35
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: Molina Healthcare Managed Medicaid	$4,731.27
Rate for Payer: Partners Health Alliance Commercial	$4,224.35
Rate for Payer: United Healthcare Commercial	$7,346.70
Rate for Payer: United Healthcare Managed Medicare	$4,816.17

MODULAR HIP SYSTEM 155MM X 18MM

Facility

$8,163.00

Service Code	HCPCS C1776
Hospital Charge Code	8026268
Hospital Revenue Code	278
Min. Negotiated Rate	$5,714.10
Max. Negotiated Rate	$7,346.70
Rate for Payer: Aetna of IA Commercial	$7,346.70
Rate for Payer: Aetna of IA Medical Rental Products	$7,346.70
Rate for Payer: Cash Price	$6,530.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,122.25
Rate for Payer: Medical Associates Commercial	$6,122.25
Rate for Payer: Midlands Choice Commercial	$5,714.10
Rate for Payer: United Healthcare Commercial	$7,346.70

MODULAR HIP SYSTEM 17MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046936
Hospital Revenue Code	278
Min. Negotiated Rate	$3,739.95
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Aetna of IA Medicare	$4,737.27
Rate for Payer: Amerigroup Medicaid	$4,793.78
Rate for Payer: Amerigroup Medicare	$3,777.35
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,739.95
Rate for Payer: Iowa Total Care Managed Medicaid	$4,747.24
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Medical Associates Managed Medicare	$3,739.95
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: Molina Healthcare Managed Medicaid	$4,817.06
Rate for Payer: Partners Health Alliance Commercial	$4,300.94
Rate for Payer: United Healthcare Commercial	$7,479.90
Rate for Payer: United Healthcare Managed Medicare	$4,903.49

MODULAR HIP SYSTEM 17MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046936
Hospital Revenue Code	278
Min. Negotiated Rate	$5,817.70
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: United Healthcare Commercial	$7,479.90

MODULAR HIP SYSTEM 195MM X 16MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046935
Hospital Revenue Code	278
Min. Negotiated Rate	$5,817.70
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: United Healthcare Commercial	$7,479.90

MODULAR HIP SYSTEM 195MM X 16MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046935
Hospital Revenue Code	278
Min. Negotiated Rate	$3,739.95
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Aetna of IA Medicare	$4,737.27
Rate for Payer: Amerigroup Medicaid	$4,793.78
Rate for Payer: Amerigroup Medicare	$3,777.35
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,739.95
Rate for Payer: Iowa Total Care Managed Medicaid	$4,747.24
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Medical Associates Managed Medicare	$3,739.95
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: Molina Healthcare Managed Medicaid	$4,817.06
Rate for Payer: Partners Health Alliance Commercial	$4,300.94
Rate for Payer: United Healthcare Commercial	$7,479.90
Rate for Payer: United Healthcare Managed Medicare	$4,903.49

MODULAR HIP SYSTEM 195MM X 20MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046937
Hospital Revenue Code	278
Min. Negotiated Rate	$5,817.70
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: United Healthcare Commercial	$7,479.90

MODULAR HIP SYSTEM 195MM X 20MM

Facility

$8,311.00

Service Code	HCPCS C1776
Hospital Charge Code	8046937
Hospital Revenue Code	278
Min. Negotiated Rate	$3,739.95
Max. Negotiated Rate	$7,479.90
Rate for Payer: Aetna of IA Commercial	$7,479.90
Rate for Payer: Aetna of IA Medical Rental Products	$7,479.90
Rate for Payer: Aetna of IA Medicare	$4,737.27
Rate for Payer: Amerigroup Medicaid	$4,793.78
Rate for Payer: Amerigroup Medicare	$3,777.35
Rate for Payer: Cash Price	$6,648.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$6,233.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,739.95
Rate for Payer: Iowa Total Care Managed Medicaid	$4,747.24
Rate for Payer: Medical Associates Commercial	$6,233.25
Rate for Payer: Medical Associates Managed Medicare	$3,739.95
Rate for Payer: Midlands Choice Commercial	$5,817.70
Rate for Payer: Molina Healthcare Managed Medicaid	$4,817.06
Rate for Payer: Partners Health Alliance Commercial	$4,300.94
Rate for Payer: United Healthcare Commercial	$7,479.90
Rate for Payer: United Healthcare Managed Medicare	$4,903.49

mometasone Nasal 50 mcg/inh Spry [VDMC]

Facility

$111.08

Service Code	HCPCS A9270
Hospital Charge Code	10406687
Hospital Revenue Code	259
Min. Negotiated Rate	$49.99
Max. Negotiated Rate	$99.97
Rate for Payer: Aetna of IA Commercial	$99.97
Rate for Payer: Aetna of IA Medical Rental Products	$99.97
Rate for Payer: Aetna of IA Medicare	$63.32
Rate for Payer: Amerigroup Medicaid	$64.07
Rate for Payer: Amerigroup Medicare	$50.49
Rate for Payer: Cash Price	$88.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.31
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.99
Rate for Payer: Iowa Total Care Managed Medicaid	$63.45
Rate for Payer: Medical Associates Commercial	$83.31
Rate for Payer: Medical Associates Managed Medicare	$49.99
Rate for Payer: Midlands Choice Commercial	$77.76
Rate for Payer: Molina Healthcare Managed Medicaid	$64.38
Rate for Payer: Partners Health Alliance Commercial	$57.48
Rate for Payer: United Healthcare Commercial	$99.97
Rate for Payer: United Healthcare Managed Medicare	$65.54

mometasone Nasal 50 mcg/inh Spry [VDMC]

Facility

$111.08

Service Code	HCPCS A9270
Hospital Charge Code	10406687
Hospital Revenue Code	259
Min. Negotiated Rate	$77.76
Max. Negotiated Rate	$99.97
Rate for Payer: Aetna of IA Commercial	$99.97
Rate for Payer: Aetna of IA Medical Rental Products	$99.97
Rate for Payer: Cash Price	$88.86
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.31
Rate for Payer: Medical Associates Commercial	$83.31
Rate for Payer: Midlands Choice Commercial	$77.76
Rate for Payer: United Healthcare Commercial	$99.97

MONO-SPOT

Facility

$58.00

Service Code	CPT 86308
Hospital Charge Code	4022812
Hospital Revenue Code	302
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

MONO-SPOT

Facility

$58.00

Service Code	CPT 86308
Hospital Charge Code	4022812
Hospital Revenue Code	302
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$33.45
Rate for Payer: Amerigroup Medicare	$26.36
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.10
Rate for Payer: Iowa Total Care Managed Medicaid	$33.13
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$26.10
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$33.62
Rate for Payer: Partners Health Alliance Commercial	$30.02
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22

montelukast 10 mg Tab [VDMC]

Facility

$2.09

Service Code	HCPCS A9270
Hospital Charge Code	10406752
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of IA Commercial	$1.88
Rate for Payer: Aetna of IA Medical Rental Products	$1.88
Rate for Payer: Aetna of IA Medicare	$1.19
Rate for Payer: Amerigroup Medicaid	$1.20
Rate for Payer: Amerigroup Medicare	$0.95
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.56
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	$1.19
Rate for Payer: Medical Associates Commercial	$1.56
Rate for Payer: Medical Associates Managed Medicare	$0.94
Rate for Payer: Midlands Choice Commercial	$1.46
Rate for Payer: Molina Healthcare Managed Medicaid	$1.21
Rate for Payer: Partners Health Alliance Commercial	$1.08
Rate for Payer: United Healthcare Commercial	$1.88
Rate for Payer: United Healthcare Managed Medicare	$1.23

montelukast 10 mg Tab [VDMC]

Facility

$2.09

Service Code	HCPCS A9270
Hospital Charge Code	10406752
Hospital Revenue Code	259
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna of IA Commercial	$1.88
Rate for Payer: Aetna of IA Medical Rental Products	$1.88
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.56
Rate for Payer: Medical Associates Commercial	$1.56
Rate for Payer: Midlands Choice Commercial	$1.46
Rate for Payer: United Healthcare Commercial	$1.88

montelukast 4 mg Chew Tab [VDMC]

Facility

$1.43

Service Code	HCPCS A9270
Hospital Charge Code	10406821
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: United Healthcare Commercial	$1.29

montelukast 4 mg Chew Tab [VDMC]

Facility

$1.43

Service Code	HCPCS A9270
Hospital Charge Code	10406821
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Aetna of IA Medicare	$0.82
Rate for Payer: Amerigroup Medicaid	$0.83
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.82
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Managed Medicare	$0.85

morphine 0.5 mg/mL 10 ml preservative-free Sol [VDMC]

Facility

$60.45

Service Code	HCPCS J2274
Hospital Charge Code	11225094
Hospital Revenue Code	259
Min. Negotiated Rate	$42.31
Max. Negotiated Rate	$54.40
Rate for Payer: Aetna of IA Commercial	$54.40
Rate for Payer: Aetna of IA Medical Rental Products	$54.40
Rate for Payer: Cash Price	$48.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.34
Rate for Payer: Medical Associates Commercial	$45.34
Rate for Payer: Midlands Choice Commercial	$42.31
Rate for Payer: United Healthcare Commercial	$54.40

morphine 0.5 mg/mL 10 ml preservative-free Sol [VDMC]

Facility

$60.45

Service Code	HCPCS J2274
Hospital Charge Code	11225094
Hospital Revenue Code	259
Min. Negotiated Rate	$27.20
Max. Negotiated Rate	$54.40
Rate for Payer: Aetna of IA Commercial	$54.40
Rate for Payer: Aetna of IA Medical Rental Products	$54.40
Rate for Payer: Aetna of IA Medicare	$34.46
Rate for Payer: Amerigroup Medicaid	$34.87
Rate for Payer: Amerigroup Medicare	$27.47
Rate for Payer: Cash Price	$48.36
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.20
Rate for Payer: Iowa Total Care Managed Medicaid	$34.53
Rate for Payer: Medical Associates Commercial	$45.34
Rate for Payer: Medical Associates Managed Medicare	$27.20
Rate for Payer: Midlands Choice Commercial	$42.31
Rate for Payer: Molina Healthcare Managed Medicaid	$35.04
Rate for Payer: Partners Health Alliance Commercial	$31.28
Rate for Payer: United Healthcare Commercial	$54.40
Rate for Payer: United Healthcare Managed Medicare	$35.66

morphine 10 mg/mL 1 ml PF vial [VDMC]

Facility

$48.27

Service Code	HCPCS J2274
Hospital Charge Code	15031446
Hospital Revenue Code	259
Min. Negotiated Rate	$33.79
Max. Negotiated Rate	$43.44
Rate for Payer: Aetna of IA Commercial	$43.44
Rate for Payer: Aetna of IA Medical Rental Products	$43.44
Rate for Payer: Cash Price	$38.61
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$36.20
Rate for Payer: Medical Associates Commercial	$36.20
Rate for Payer: Midlands Choice Commercial	$33.79
Rate for Payer: United Healthcare Commercial	$43.44

Know your out-of-pocket cost for care.

All Charges