Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

colesevelam 625 mg Tab [VDMC]

Facility

$2.67

Service Code	HCPCS A9270
Hospital Charge Code	10379436
Hospital Revenue Code	259
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$2.40
Rate for Payer: Aetna of IA Commercial	$2.40
Rate for Payer: Aetna of IA Medical Rental Products	$2.40
Rate for Payer: Aetna of IA Medicare	$1.52
Rate for Payer: Amerigroup Medicaid	$1.35
Rate for Payer: Amerigroup Medicare	$1.35
Rate for Payer: Cash Price	$2.13
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.34
Rate for Payer: Iowa Total Care Managed Medicaid	$1.33
Rate for Payer: Medical Associates Commercial	$2.00
Rate for Payer: Medical Associates Managed Medicare	$1.34
Rate for Payer: Midlands Choice Commercial	$1.87
Rate for Payer: Molina Healthcare Managed Medicaid	$1.36
Rate for Payer: Molina Healthcare Managed Medicare	$1.35
Rate for Payer: Oscar Health of IA Commercial	$2.00
Rate for Payer: Partners Health Alliance Commercial	$2.00
Rate for Payer: United Healthcare Commercial	$2.40
Rate for Payer: United Healthcare Managed Medicare	$1.58

Colestipol HCL 1 g Tab [VDMC]

Facility

$3.67

Service Code	HCPCS A9270
Hospital Charge Code	10379505
Hospital Revenue Code	259
Min. Negotiated Rate	$2.57
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of IA Commercial	$3.30
Rate for Payer: Aetna of IA Medical Rental Products	$3.30
Rate for Payer: Cash Price	$2.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.75
Rate for Payer: Medical Associates Commercial	$2.75
Rate for Payer: Midlands Choice Commercial	$2.57
Rate for Payer: United Healthcare Commercial	$3.30

Colestipol HCL 1 g Tab [VDMC]

Facility

$3.67

Service Code	HCPCS A9270
Hospital Charge Code	10379505
Hospital Revenue Code	259
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$3.30
Rate for Payer: Aetna of IA Commercial	$3.30
Rate for Payer: Aetna of IA Medical Rental Products	$3.30
Rate for Payer: Aetna of IA Medicare	$2.09
Rate for Payer: Amerigroup Medicaid	$1.85
Rate for Payer: Amerigroup Medicare	$1.85
Rate for Payer: Cash Price	$2.94
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.84
Rate for Payer: Iowa Total Care Managed Medicaid	$1.83
Rate for Payer: Medical Associates Commercial	$2.75
Rate for Payer: Medical Associates Managed Medicare	$1.84
Rate for Payer: Midlands Choice Commercial	$2.57
Rate for Payer: Molina Healthcare Managed Medicaid	$1.86
Rate for Payer: Molina Healthcare Managed Medicare	$1.86
Rate for Payer: Oscar Health of IA Commercial	$2.75
Rate for Payer: Partners Health Alliance Commercial	$2.75
Rate for Payer: United Healthcare Commercial	$3.30
Rate for Payer: United Healthcare Managed Medicare	$2.17

COLLAGENASE 30 GRAM

Facility

$581.00

Hospital Charge Code	8013715
Hospital Revenue Code	250
Min. Negotiated Rate	$290.38
Max. Negotiated Rate	$522.90
Rate for Payer: Aetna of IA Commercial	$522.90
Rate for Payer: Aetna of IA Medical Rental Products	$522.90
Rate for Payer: Aetna of IA Medicare	$331.17
Rate for Payer: Amerigroup Medicaid	$293.23
Rate for Payer: Amerigroup Medicare	$293.40
Rate for Payer: Cash Price	$464.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$435.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$290.50
Rate for Payer: Iowa Total Care Managed Medicaid	$290.38
Rate for Payer: Medical Associates Commercial	$435.75
Rate for Payer: Medical Associates Managed Medicare	$290.50
Rate for Payer: Midlands Choice Commercial	$406.70
Rate for Payer: Molina Healthcare Managed Medicaid	$294.86
Rate for Payer: Molina Healthcare Managed Medicare	$294.68
Rate for Payer: Oscar Health of IA Commercial	$435.75
Rate for Payer: Partners Health Alliance Commercial	$435.75
Rate for Payer: United Healthcare Commercial	$522.90
Rate for Payer: United Healthcare Managed Medicare	$342.79

COLLAGENASE 30 GRAM

Facility

$581.00

Hospital Charge Code	8013715
Hospital Revenue Code	250
Min. Negotiated Rate	$406.70
Max. Negotiated Rate	$522.90
Rate for Payer: Aetna of IA Commercial	$522.90
Rate for Payer: Aetna of IA Medical Rental Products	$522.90
Rate for Payer: Cash Price	$464.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$435.75
Rate for Payer: Medical Associates Commercial	$435.75
Rate for Payer: Midlands Choice Commercial	$406.70
Rate for Payer: United Healthcare Commercial	$522.90

collagenase Top 250 units/g Oint [VDMC]

Facility

$1,018.92

Service Code	HCPCS A9270
Hospital Charge Code	10379574
Hospital Revenue Code	259
Min. Negotiated Rate	$509.26
Max. Negotiated Rate	$917.03
Rate for Payer: Aetna of IA Commercial	$917.03
Rate for Payer: Aetna of IA Medical Rental Products	$917.03
Rate for Payer: Aetna of IA Medicare	$580.78
Rate for Payer: Amerigroup Medicaid	$514.25
Rate for Payer: Amerigroup Medicare	$514.55
Rate for Payer: Cash Price	$815.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$764.19
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$509.46
Rate for Payer: Iowa Total Care Managed Medicaid	$509.26
Rate for Payer: Medical Associates Commercial	$764.19
Rate for Payer: Medical Associates Managed Medicare	$509.46
Rate for Payer: Midlands Choice Commercial	$713.24
Rate for Payer: Molina Healthcare Managed Medicaid	$517.10
Rate for Payer: Molina Healthcare Managed Medicare	$516.80
Rate for Payer: Oscar Health of IA Commercial	$764.19
Rate for Payer: Partners Health Alliance Commercial	$764.19
Rate for Payer: United Healthcare Commercial	$917.03
Rate for Payer: United Healthcare Managed Medicare	$601.16

collagenase Top 250 units/g Oint [VDMC]

Facility

$1,018.92

Service Code	HCPCS A9270
Hospital Charge Code	10379574
Hospital Revenue Code	259
Min. Negotiated Rate	$713.24
Max. Negotiated Rate	$917.03
Rate for Payer: Aetna of IA Commercial	$917.03
Rate for Payer: Aetna of IA Medical Rental Products	$917.03
Rate for Payer: Cash Price	$815.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$764.19
Rate for Payer: Medical Associates Commercial	$764.19
Rate for Payer: Midlands Choice Commercial	$713.24
Rate for Payer: United Healthcare Commercial	$917.03

Colonoscopy

Facility

$2,780.00

Hospital Charge Code	1376935
Hospital Revenue Code	750
Min. Negotiated Rate	$1,946.00
Max. Negotiated Rate	$2,502.00
Rate for Payer: Aetna of IA Commercial	$2,502.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,502.00
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,085.00
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: United Healthcare Commercial	$2,502.00

Colonoscopy

Facility

$2,780.00

Hospital Charge Code	1376935
Hospital Revenue Code	750
Min. Negotiated Rate	$1,389.44
Max. Negotiated Rate	$2,502.00
Rate for Payer: Aetna of IA Commercial	$2,502.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,502.00
Rate for Payer: Aetna of IA Medicare	$1,584.60
Rate for Payer: Amerigroup Medicaid	$1,403.07
Rate for Payer: Amerigroup Medicare	$1,403.90
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,085.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,390.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,389.44
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Medical Associates Managed Medicare	$1,390.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,410.85
Rate for Payer: Molina Healthcare Managed Medicare	$1,410.02
Rate for Payer: Oscar Health of IA Commercial	$2,085.00
Rate for Payer: Partners Health Alliance Commercial	$2,085.00
Rate for Payer: United Healthcare Commercial	$2,502.00
Rate for Payer: United Healthcare Managed Medicare	$1,640.20

Colonoscopy Biopsy Charge

Facility

$199.00

Hospital Charge Code	7825138
Hospital Revenue Code	750
Min. Negotiated Rate	$139.30
Max. Negotiated Rate	$179.10
Rate for Payer: Aetna of IA Commercial	$179.10
Rate for Payer: Aetna of IA Medical Rental Products	$179.10
Rate for Payer: Cash Price	$159.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$149.25
Rate for Payer: Medical Associates Commercial	$149.25
Rate for Payer: Midlands Choice Commercial	$139.30
Rate for Payer: United Healthcare Commercial	$179.10

Colonoscopy Biopsy Charge

Facility

$199.00

Hospital Charge Code	7825138
Hospital Revenue Code	750
Min. Negotiated Rate	$99.46
Max. Negotiated Rate	$179.10
Rate for Payer: Aetna of IA Commercial	$179.10
Rate for Payer: Aetna of IA Medical Rental Products	$179.10
Rate for Payer: Aetna of IA Medicare	$113.43
Rate for Payer: Amerigroup Medicaid	$100.44
Rate for Payer: Amerigroup Medicare	$100.50
Rate for Payer: Cash Price	$159.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$149.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.50
Rate for Payer: Iowa Total Care Managed Medicaid	$99.46
Rate for Payer: Medical Associates Commercial	$149.25
Rate for Payer: Medical Associates Managed Medicare	$99.50
Rate for Payer: Midlands Choice Commercial	$139.30
Rate for Payer: Molina Healthcare Managed Medicaid	$100.99
Rate for Payer: Molina Healthcare Managed Medicare	$100.93
Rate for Payer: Oscar Health of IA Commercial	$149.25
Rate for Payer: Partners Health Alliance Commercial	$149.25
Rate for Payer: United Healthcare Commercial	$179.10
Rate for Payer: United Healthcare Managed Medicare	$117.41

Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility

$2,522.04

Service Code	CPT 45378
Hospital Revenue Code	750
Min. Negotiated Rate	$2,292.76
Max. Negotiated Rate	$2,522.04
Rate for Payer: Wellmark IA HMO	$2,292.76
Rate for Payer: Wellmark IA PPO	$2,522.04

Colonoscopy, flexible; with band ligation(s) (eg, hemorrhoids)

Facility

$2,857.58

Service Code	CPT 45398
Hospital Revenue Code	360
Min. Negotiated Rate	$2,597.80
Max. Negotiated Rate	$2,857.58
Rate for Payer: Wellmark IA HMO	$2,597.80
Rate for Payer: Wellmark IA PPO	$2,857.58

Colonoscopy, flexible; with biopsy, single or multiple

Facility

$2,522.04

Service Code	CPT 45380
Hospital Revenue Code	750
Min. Negotiated Rate	$2,292.76
Max. Negotiated Rate	$2,522.04
Rate for Payer: Wellmark IA HMO	$2,292.76
Rate for Payer: Wellmark IA PPO	$2,522.04

Colonoscopy, flexible; with directed submucosal injection(s), any substance

Facility

$2,857.58

Service Code	CPT 45381
Hospital Revenue Code	750
Min. Negotiated Rate	$2,597.80
Max. Negotiated Rate	$2,857.58
Rate for Payer: Wellmark IA HMO	$2,597.80
Rate for Payer: Wellmark IA PPO	$2,857.58

Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

Facility

$2,857.58

Service Code	CPT 45385
Hospital Revenue Code	360
Min. Negotiated Rate	$2,597.80
Max. Negotiated Rate	$2,857.58
Rate for Payer: Wellmark IA HMO	$2,597.80
Rate for Payer: Wellmark IA PPO	$2,857.58

Colonoscopy with Biopsy

Facility

$2,780.00

Hospital Charge Code	1376936
Hospital Revenue Code	750
Min. Negotiated Rate	$1,389.44
Max. Negotiated Rate	$2,502.00
Rate for Payer: Aetna of IA Commercial	$2,502.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,502.00
Rate for Payer: Aetna of IA Medicare	$1,584.60
Rate for Payer: Amerigroup Medicaid	$1,403.07
Rate for Payer: Amerigroup Medicare	$1,403.90
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,085.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,390.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,389.44
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Medical Associates Managed Medicare	$1,390.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,410.85
Rate for Payer: Molina Healthcare Managed Medicare	$1,410.02
Rate for Payer: Oscar Health of IA Commercial	$2,085.00
Rate for Payer: Partners Health Alliance Commercial	$2,085.00
Rate for Payer: United Healthcare Commercial	$2,502.00
Rate for Payer: United Healthcare Managed Medicare	$1,640.20

Colonoscopy with Biopsy

Facility

$2,780.00

Hospital Charge Code	1376936
Hospital Revenue Code	750
Min. Negotiated Rate	$1,946.00
Max. Negotiated Rate	$2,502.00
Rate for Payer: Aetna of IA Commercial	$2,502.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,502.00
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,085.00
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: United Healthcare Commercial	$2,502.00

Colonoscopy w/polypec/fulgurat

Facility

$2,780.00

Hospital Charge Code	1376941
Hospital Revenue Code	750
Min. Negotiated Rate	$1,946.00
Max. Negotiated Rate	$2,502.00
Rate for Payer: Aetna of IA Commercial	$2,502.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,502.00
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,085.00
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: United Healthcare Commercial	$2,502.00

Colonoscopy w/polypec/fulgurat

Facility

$2,780.00

Hospital Charge Code	1376941
Hospital Revenue Code	750
Min. Negotiated Rate	$1,389.44
Max. Negotiated Rate	$2,502.00
Rate for Payer: Aetna of IA Commercial	$2,502.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,502.00
Rate for Payer: Aetna of IA Medicare	$1,584.60
Rate for Payer: Amerigroup Medicaid	$1,403.07
Rate for Payer: Amerigroup Medicare	$1,403.90
Rate for Payer: Cash Price	$2,224.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,085.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,390.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,389.44
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Medical Associates Managed Medicare	$1,390.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,410.85
Rate for Payer: Molina Healthcare Managed Medicare	$1,410.02
Rate for Payer: Oscar Health of IA Commercial	$2,085.00
Rate for Payer: Partners Health Alliance Commercial	$2,085.00
Rate for Payer: United Healthcare Commercial	$2,502.00
Rate for Payer: United Healthcare Managed Medicare	$1,640.20

Colonoscopy w/Polypec/Fulgurat

Facility

$397.00

Hospital Charge Code	8051946
Hospital Revenue Code	750
Min. Negotiated Rate	$198.42
Max. Negotiated Rate	$357.30
Rate for Payer: Aetna of IA Commercial	$357.30
Rate for Payer: Aetna of IA Medical Rental Products	$357.30
Rate for Payer: Aetna of IA Medicare	$226.29
Rate for Payer: Amerigroup Medicaid	$200.37
Rate for Payer: Amerigroup Medicare	$200.48
Rate for Payer: Cash Price	$317.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$297.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$198.50
Rate for Payer: Iowa Total Care Managed Medicaid	$198.42
Rate for Payer: Medical Associates Commercial	$297.75
Rate for Payer: Medical Associates Managed Medicare	$198.50
Rate for Payer: Midlands Choice Commercial	$277.90
Rate for Payer: Molina Healthcare Managed Medicaid	$201.48
Rate for Payer: Molina Healthcare Managed Medicare	$201.36
Rate for Payer: Oscar Health of IA Commercial	$297.75
Rate for Payer: Partners Health Alliance Commercial	$297.75
Rate for Payer: United Healthcare Commercial	$357.30
Rate for Payer: United Healthcare Managed Medicare	$234.23

Colonoscopy w/Polypec/Fulgurat

Facility

$397.00

Hospital Charge Code	8051946
Hospital Revenue Code	750
Min. Negotiated Rate	$277.90
Max. Negotiated Rate	$357.30
Rate for Payer: Aetna of IA Commercial	$357.30
Rate for Payer: Aetna of IA Medical Rental Products	$357.30
Rate for Payer: Cash Price	$317.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$297.75
Rate for Payer: Medical Associates Commercial	$297.75
Rate for Payer: Midlands Choice Commercial	$277.90
Rate for Payer: United Healthcare Commercial	$357.30

Colposcopy of cervix w/loop electrode bx of cervix

Professional

Both

$1,024.00

Service Code	CPT 57460
Hospital Charge Code	8068975
Hospital Revenue Code	975
Min. Negotiated Rate	$143.94
Max. Negotiated Rate	$716.80
Rate for Payer: Aetna of IA Medicare	$143.94
Rate for Payer: Amerigroup Medicaid	$148.83
Rate for Payer: Cash Price	$819.20
Rate for Payer: Cash Price	$819.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.73
Rate for Payer: Iowa Total Care Managed Medicaid	$146.82
Rate for Payer: Medical Associates Commercial	$273.49
Rate for Payer: Medical Associates Managed Medicare	$143.94
Rate for Payer: Midlands Choice Commercial	$716.80
Rate for Payer: Oscar Health of IA Commercial	$249.02
Rate for Payer: Partners Health Alliance Commercial	$215.91

Combined Anterior and Posterior Spinal Fusion With CC

Facility

$42,774.15

Service Code	MS-DRG 454
Hospital Charge Code	274
Min. Negotiated Rate	$42,154.23
Max. Negotiated Rate	$42,774.15
Rate for Payer: Amerigroup Medicaid	$42,567.51
Rate for Payer: Iowa Total Care Managed Medicaid	$42,154.23
Rate for Payer: Molina Healthcare Managed Medicaid	$42,774.15

Combined Anterior and Posterior Spinal Fusion With MCC

Facility

$63,679.44

Service Code	MS-DRG 453
Hospital Charge Code	273
Min. Negotiated Rate	$62,756.55
Max. Negotiated Rate	$63,679.44
Rate for Payer: Amerigroup Medicaid	$63,371.81
Rate for Payer: Iowa Total Care Managed Medicaid	$62,756.55
Rate for Payer: Molina Healthcare Managed Medicaid	$63,679.44

Know your out-of-pocket cost for care.

All Charges