Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

CONTROL OF NOSEBLEED

Facility

$298.00

Service Code	CPT 30901
Hospital Charge Code	4864904
Hospital Revenue Code	450
Min. Negotiated Rate	$134.10
Max. Negotiated Rate	$268.20
Rate for Payer: Aetna of IA Commercial	$268.20
Rate for Payer: Aetna of IA Medical Rental Products	$268.20
Rate for Payer: Aetna of IA Medicare	$169.86
Rate for Payer: Amerigroup Medicaid	$171.89
Rate for Payer: Amerigroup Medicare	$135.44
Rate for Payer: Cash Price	$238.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$223.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$134.10
Rate for Payer: Iowa Total Care Managed Medicaid	$170.22
Rate for Payer: Medical Associates Commercial	$223.50
Rate for Payer: Medical Associates Managed Medicare	$134.10
Rate for Payer: Midlands Choice Commercial	$208.60
Rate for Payer: Molina Healthcare Managed Medicaid	$172.72
Rate for Payer: Partners Health Alliance Commercial	$154.22
Rate for Payer: United Healthcare Commercial	$268.20
Rate for Payer: United Healthcare Managed Medicare	$175.82

CONTROL OF NOSEBLEED

Professional

Both

$730.00

Service Code	CPT 30903
Hospital Charge Code	7982781
Hospital Revenue Code	981
Min. Negotiated Rate	$340.64
Max. Negotiated Rate	$547.50
Rate for Payer: Cash Price	$584.00
Rate for Payer: Cash Price	$584.00
Rate for Payer: Medical Associates Commercial	$547.50
Rate for Payer: Midlands Choice Commercial	$511.00
Rate for Payer: Partners Health Alliance Commercial	$547.50
Rate for Payer: United Healthcare Commercial	$340.64

CONTROL OF NOSEBLEED

Facility

$255.00

Service Code	CPT 30903
Hospital Charge Code	4864905
Hospital Revenue Code	450
Min. Negotiated Rate	$178.50
Max. Negotiated Rate	$229.50
Rate for Payer: Aetna of IA Commercial	$229.50
Rate for Payer: Aetna of IA Medical Rental Products	$229.50
Rate for Payer: Cash Price	$204.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$191.25
Rate for Payer: Medical Associates Commercial	$191.25
Rate for Payer: Midlands Choice Commercial	$178.50
Rate for Payer: United Healthcare Commercial	$229.50

CONTROL OF NOSEBLEED

Facility

$341.00

Service Code	CPT 30905
Hospital Charge Code	4864906
Hospital Revenue Code	450
Min. Negotiated Rate	$238.70
Max. Negotiated Rate	$306.90
Rate for Payer: Aetna of IA Commercial	$306.90
Rate for Payer: Aetna of IA Medical Rental Products	$306.90
Rate for Payer: Cash Price	$272.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$255.75
Rate for Payer: Medical Associates Commercial	$255.75
Rate for Payer: Midlands Choice Commercial	$238.70
Rate for Payer: United Healthcare Commercial	$306.90

CONTROL OF NOSEBLEED

Professional

Both

$897.00

Service Code	CPT 30905
Hospital Charge Code	7982780
Hospital Revenue Code	981
Min. Negotiated Rate	$505.97
Max. Negotiated Rate	$672.75
Rate for Payer: Cash Price	$717.60
Rate for Payer: Cash Price	$717.60
Rate for Payer: Medical Associates Commercial	$672.75
Rate for Payer: Midlands Choice Commercial	$627.90
Rate for Payer: Partners Health Alliance Commercial	$672.75
Rate for Payer: United Healthcare Commercial	$505.97

CORD ABO/RH

Facility

$52.00

Service Code	CPT 86900
Hospital Charge Code	4022838
Hospital Revenue Code	302
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: United Healthcare Commercial	$46.80

CORD ABO/RH

Facility

$52.00

Service Code	CPT 86900
Hospital Charge Code	4022838
Hospital Revenue Code	302
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Aetna of IA Medicare	$29.64
Rate for Payer: Amerigroup Medicaid	$29.99
Rate for Payer: Amerigroup Medicare	$23.63
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.40
Rate for Payer: Iowa Total Care Managed Medicaid	$29.70
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Medical Associates Managed Medicare	$23.40
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: Molina Healthcare Managed Medicaid	$30.14
Rate for Payer: Partners Health Alliance Commercial	$26.91
Rate for Payer: United Healthcare Commercial	$46.80
Rate for Payer: United Healthcare Managed Medicare	$30.68

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80307
Hospital Charge Code	8558202
Hospital Revenue Code	301
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: United Healthcare Commercial	$258.30

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80307
Hospital Charge Code	8558202
Hospital Revenue Code	301
Min. Negotiated Rate	$129.15
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Aetna of IA Medicare	$163.59
Rate for Payer: Amerigroup Medicaid	$165.54
Rate for Payer: Amerigroup Medicare	$130.44
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$129.15
Rate for Payer: Iowa Total Care Managed Medicaid	$163.93
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Medical Associates Managed Medicare	$129.15
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: Molina Healthcare Managed Medicaid	$166.35
Rate for Payer: Partners Health Alliance Commercial	$148.52
Rate for Payer: United Healthcare Commercial	$258.30
Rate for Payer: United Healthcare Managed Medicare	$169.33

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80301
Hospital Charge Code	7811988
Hospital Revenue Code	301
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: United Healthcare Commercial	$258.30

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80301
Hospital Charge Code	7811988
Hospital Revenue Code	301
Min. Negotiated Rate	$129.15
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Aetna of IA Medicare	$163.59
Rate for Payer: Amerigroup Medicaid	$165.54
Rate for Payer: Amerigroup Medicare	$130.44
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$129.15
Rate for Payer: Iowa Total Care Managed Medicaid	$163.93
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Medical Associates Managed Medicare	$129.15
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: Molina Healthcare Managed Medicaid	$166.35
Rate for Payer: Partners Health Alliance Commercial	$148.52
Rate for Payer: United Healthcare Commercial	$258.30
Rate for Payer: United Healthcare Managed Medicare	$169.33

CORKSCREW BIO 3.7MM X 17.9

Facility

$621.00

Service Code	HCPCS C1713
Hospital Charge Code	8046879
Hospital Revenue Code	278
Min. Negotiated Rate	$434.70
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: United Healthcare Commercial	$558.90

CORKSCREW BIO 3.7MM X 17.9

Facility

$621.00

Service Code	HCPCS C1713
Hospital Charge Code	8046879
Hospital Revenue Code	278
Min. Negotiated Rate	$279.45
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Aetna of IA Medicare	$353.97
Rate for Payer: Amerigroup Medicaid	$358.19
Rate for Payer: Amerigroup Medicare	$282.24
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$279.45
Rate for Payer: Iowa Total Care Managed Medicaid	$354.72
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Medical Associates Managed Medicare	$279.45
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: Molina Healthcare Managed Medicaid	$359.93
Rate for Payer: Partners Health Alliance Commercial	$321.37
Rate for Payer: United Healthcare Commercial	$558.90
Rate for Payer: United Healthcare Managed Medicare	$366.39

CORKSCREW BIO 4.5

Facility

$591.00

Service Code	HCPCS C1713
Hospital Charge Code	8026413
Hospital Revenue Code	278
Min. Negotiated Rate	$413.70
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of IA Commercial	$531.90
Rate for Payer: Aetna of IA Medical Rental Products	$531.90
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$443.25
Rate for Payer: Medical Associates Commercial	$443.25
Rate for Payer: Midlands Choice Commercial	$413.70
Rate for Payer: United Healthcare Commercial	$531.90

CORKSCREW BIO 4.5

Facility

$591.00

Service Code	HCPCS C1713
Hospital Charge Code	8026413
Hospital Revenue Code	278
Min. Negotiated Rate	$265.95
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of IA Commercial	$531.90
Rate for Payer: Aetna of IA Medical Rental Products	$531.90
Rate for Payer: Aetna of IA Medicare	$336.87
Rate for Payer: Amerigroup Medicaid	$340.89
Rate for Payer: Amerigroup Medicare	$268.61
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$443.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$265.95
Rate for Payer: Iowa Total Care Managed Medicaid	$337.58
Rate for Payer: Medical Associates Commercial	$443.25
Rate for Payer: Medical Associates Managed Medicare	$265.95
Rate for Payer: Midlands Choice Commercial	$413.70
Rate for Payer: Molina Healthcare Managed Medicaid	$342.54
Rate for Payer: Partners Health Alliance Commercial	$305.84
Rate for Payer: United Healthcare Commercial	$531.90
Rate for Payer: United Healthcare Managed Medicare	$348.69

CORKSCREW BIO 5.5

Facility

$621.00

Service Code	HCPCS C1713
Hospital Charge Code	8026415
Hospital Revenue Code	278
Min. Negotiated Rate	$279.45
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Aetna of IA Medicare	$353.97
Rate for Payer: Amerigroup Medicaid	$358.19
Rate for Payer: Amerigroup Medicare	$282.24
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$279.45
Rate for Payer: Iowa Total Care Managed Medicaid	$354.72
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Medical Associates Managed Medicare	$279.45
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: Molina Healthcare Managed Medicaid	$359.93
Rate for Payer: Partners Health Alliance Commercial	$321.37
Rate for Payer: United Healthcare Commercial	$558.90
Rate for Payer: United Healthcare Managed Medicare	$366.39

CORKSCREW BIO 5.5

Facility

$621.00

Service Code	HCPCS C1713
Hospital Charge Code	8026415
Hospital Revenue Code	278
Min. Negotiated Rate	$434.70
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: United Healthcare Commercial	$558.90

CORKSCREW BIO 6.5

Facility

$609.00

Service Code	HCPCS C1713
Hospital Charge Code	8026414
Hospital Revenue Code	278
Min. Negotiated Rate	$274.05
Max. Negotiated Rate	$548.10
Rate for Payer: Aetna of IA Commercial	$548.10
Rate for Payer: Aetna of IA Medical Rental Products	$548.10
Rate for Payer: Aetna of IA Medicare	$347.13
Rate for Payer: Amerigroup Medicaid	$351.27
Rate for Payer: Amerigroup Medicare	$276.79
Rate for Payer: Cash Price	$487.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$456.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$274.05
Rate for Payer: Iowa Total Care Managed Medicaid	$347.86
Rate for Payer: Medical Associates Commercial	$456.75
Rate for Payer: Medical Associates Managed Medicare	$274.05
Rate for Payer: Midlands Choice Commercial	$426.30
Rate for Payer: Molina Healthcare Managed Medicaid	$352.98
Rate for Payer: Partners Health Alliance Commercial	$315.16
Rate for Payer: United Healthcare Commercial	$548.10
Rate for Payer: United Healthcare Managed Medicare	$359.31

CORKSCREW BIO 6.5

Facility

$609.00

Service Code	HCPCS C1713
Hospital Charge Code	8026414
Hospital Revenue Code	278
Min. Negotiated Rate	$426.30
Max. Negotiated Rate	$548.10
Rate for Payer: Aetna of IA Commercial	$548.10
Rate for Payer: Aetna of IA Medical Rental Products	$548.10
Rate for Payer: Cash Price	$487.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$456.75
Rate for Payer: Medical Associates Commercial	$456.75
Rate for Payer: Midlands Choice Commercial	$426.30
Rate for Payer: United Healthcare Commercial	$548.10

Coronavirus 2019 Novel (SARS-CoV-2) DMCL

Facility

$338.00

Service Code	CPT 87635
Hospital Charge Code	8944439
Hospital Revenue Code	300
Min. Negotiated Rate	$152.10
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Aetna of IA Medicare	$192.66
Rate for Payer: Amerigroup Medicaid	$194.96
Rate for Payer: Amerigroup Medicare	$153.62
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$152.10
Rate for Payer: Iowa Total Care Managed Medicaid	$193.07
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Medical Associates Managed Medicare	$152.10
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: Molina Healthcare Managed Medicaid	$195.90
Rate for Payer: Partners Health Alliance Commercial	$174.91
Rate for Payer: United Healthcare Commercial	$304.20
Rate for Payer: United Healthcare Managed Medicare	$199.42

Coronavirus 2019 Novel (SARS-CoV-2) DMCL

Facility

$338.00

Service Code	CPT 87635
Hospital Charge Code	8944439
Hospital Revenue Code	300
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: United Healthcare Commercial	$304.20

Coronavirus 2019 Novel (SARS-CoV-2) IgG Ab DMCL

Facility

$150.00

Service Code	CPT 86769
Hospital Charge Code	8788720
Hospital Revenue Code	302
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: United Healthcare Commercial	$135.00

Coronavirus 2019 Novel (SARS-CoV-2) IgG Ab DMCL

Facility

$150.00

Service Code	CPT 86769
Hospital Charge Code	8788720
Hospital Revenue Code	302
Min. Negotiated Rate	$67.50
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Aetna of IA Medicare	$85.50
Rate for Payer: Amerigroup Medicaid	$86.52
Rate for Payer: Amerigroup Medicare	$68.17
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.50
Rate for Payer: Iowa Total Care Managed Medicaid	$85.68
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Medical Associates Managed Medicare	$67.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: Molina Healthcare Managed Medicaid	$86.94
Rate for Payer: Partners Health Alliance Commercial	$77.62
Rate for Payer: United Healthcare Commercial	$135.00
Rate for Payer: United Healthcare Managed Medicare	$88.50

Coronavirus 2019 Novel Screening PCR

Facility

$338.00

Service Code	CPT 87635
Hospital Charge Code	8783451
Hospital Revenue Code	306
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: United Healthcare Commercial	$304.20

Coronavirus 2019 Novel Screening PCR

Facility

$338.00

Service Code	CPT 87635
Hospital Charge Code	8783451
Hospital Revenue Code	306
Min. Negotiated Rate	$152.10
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Aetna of IA Medicare	$192.66
Rate for Payer: Amerigroup Medicaid	$194.96
Rate for Payer: Amerigroup Medicare	$153.62
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$152.10
Rate for Payer: Iowa Total Care Managed Medicaid	$193.07
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Medical Associates Managed Medicare	$152.10
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: Molina Healthcare Managed Medicaid	$195.90
Rate for Payer: Partners Health Alliance Commercial	$174.91
Rate for Payer: United Healthcare Commercial	$304.20
Rate for Payer: United Healthcare Managed Medicare	$199.42

Know your out-of-pocket cost for care.

All Charges