Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

colchicine 0.6 mg Tab [VDMC]

Facility

$1.71

Service Code	HCPCS A9270
Hospital Charge Code	22541047
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of IA Commercial	$1.54
Rate for Payer: Aetna of IA Medical Rental Products	$1.54
Rate for Payer: Aetna of IA Medicare	$0.97
Rate for Payer: Amerigroup Medicaid	$0.99
Rate for Payer: Amerigroup Medicare	$0.78
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.77
Rate for Payer: Iowa Total Care Managed Medicaid	$0.98
Rate for Payer: Medical Associates Commercial	$1.28
Rate for Payer: Medical Associates Managed Medicare	$0.77
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: Molina Healthcare Managed Medicaid	$0.99
Rate for Payer: Partners Health Alliance Commercial	$0.88
Rate for Payer: United Healthcare Commercial	$1.54
Rate for Payer: United Healthcare Managed Medicare	$1.01

colchicine 0.6 mg Tab [VDMC]

Facility

$1.71

Service Code	HCPCS A9270
Hospital Charge Code	22541047
Hospital Revenue Code	259
Min. Negotiated Rate	$1.20
Max. Negotiated Rate	$1.54
Rate for Payer: Aetna of IA Commercial	$1.54
Rate for Payer: Aetna of IA Medical Rental Products	$1.54
Rate for Payer: Cash Price	$1.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.28
Rate for Payer: Medical Associates Commercial	$1.28
Rate for Payer: Midlands Choice Commercial	$1.20
Rate for Payer: United Healthcare Commercial	$1.54

colesevelam 3.75 g Pow [VDMC]

Facility

$14.81

Service Code	HCPCS A9270
Hospital Charge Code	10379367
Hospital Revenue Code	259
Min. Negotiated Rate	$10.36
Max. Negotiated Rate	$13.32
Rate for Payer: Aetna of IA Commercial	$13.32
Rate for Payer: Aetna of IA Medical Rental Products	$13.32
Rate for Payer: Cash Price	$11.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.10
Rate for Payer: Medical Associates Commercial	$11.10
Rate for Payer: Midlands Choice Commercial	$10.36
Rate for Payer: United Healthcare Commercial	$13.32

colesevelam 3.75 g Pow [VDMC]

Facility

$14.81

Service Code	HCPCS A9270
Hospital Charge Code	10379367
Hospital Revenue Code	259
Min. Negotiated Rate	$6.66
Max. Negotiated Rate	$13.32
Rate for Payer: Aetna of IA Commercial	$13.32
Rate for Payer: Aetna of IA Medical Rental Products	$13.32
Rate for Payer: Aetna of IA Medicare	$8.44
Rate for Payer: Amerigroup Medicaid	$8.54
Rate for Payer: Amerigroup Medicare	$6.73
Rate for Payer: Cash Price	$11.84
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$11.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$6.66
Rate for Payer: Iowa Total Care Managed Medicaid	$8.46
Rate for Payer: Medical Associates Commercial	$11.10
Rate for Payer: Medical Associates Managed Medicare	$6.66
Rate for Payer: Midlands Choice Commercial	$10.36
Rate for Payer: Molina Healthcare Managed Medicaid	$8.58
Rate for Payer: Partners Health Alliance Commercial	$7.66
Rate for Payer: United Healthcare Commercial	$13.32
Rate for Payer: United Healthcare Managed Medicare	$8.74

colesevelam 625 mg Tab [VDMC]

Facility

$2.05

Service Code	HCPCS A9270
Hospital Charge Code	10379436
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of IA Commercial	$1.85
Rate for Payer: Aetna of IA Medical Rental Products	$1.85
Rate for Payer: Aetna of IA Medicare	$1.17
Rate for Payer: Amerigroup Medicaid	$1.18
Rate for Payer: Amerigroup Medicare	$0.93
Rate for Payer: Cash Price	$1.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.92
Rate for Payer: Iowa Total Care Managed Medicaid	$1.17
Rate for Payer: Medical Associates Commercial	$1.54
Rate for Payer: Medical Associates Managed Medicare	$0.92
Rate for Payer: Midlands Choice Commercial	$1.44
Rate for Payer: Molina Healthcare Managed Medicaid	$1.19
Rate for Payer: Partners Health Alliance Commercial	$1.06
Rate for Payer: United Healthcare Commercial	$1.85
Rate for Payer: United Healthcare Managed Medicare	$1.21

colesevelam 625 mg Tab [VDMC]

Facility

$2.05

Service Code	HCPCS A9270
Hospital Charge Code	10379436
Hospital Revenue Code	259
Min. Negotiated Rate	$1.44
Max. Negotiated Rate	$1.85
Rate for Payer: Aetna of IA Commercial	$1.85
Rate for Payer: Aetna of IA Medical Rental Products	$1.85
Rate for Payer: Cash Price	$1.64
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.54
Rate for Payer: Medical Associates Commercial	$1.54
Rate for Payer: Midlands Choice Commercial	$1.44
Rate for Payer: United Healthcare Commercial	$1.85

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	$1.65
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	$2.12
Rate for Payer: Amerigroup Medicare	$1.67
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	$1.65
Rate for Payer: Iowa Total Care Managed Medicaid	$2.10
Rate for Payer: Medical Associates Commercial	$2.75
Rate for Payer: Medical Associates Managed Medicare	$1.65
Rate for Payer: Midlands Choice Commercial	$2.57
Rate for Payer: Molina Healthcare Managed Medicaid	$2.13
Rate for Payer: Partners Health Alliance Commercial	$1.90
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	$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 30 GRAM

Facility

$581.00

Hospital Charge Code	8013715
Hospital Revenue Code	250
Min. Negotiated Rate	$261.45
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	$335.12
Rate for Payer: Amerigroup Medicare	$264.06
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	$261.45
Rate for Payer: Iowa Total Care Managed Medicaid	$331.87
Rate for Payer: Medical Associates Commercial	$435.75
Rate for Payer: Medical Associates Managed Medicare	$261.45
Rate for Payer: Midlands Choice Commercial	$406.70
Rate for Payer: Molina Healthcare Managed Medicaid	$336.75
Rate for Payer: Partners Health Alliance Commercial	$300.67
Rate for Payer: United Healthcare Commercial	$522.90
Rate for Payer: United Healthcare Managed Medicare	$342.79

collagenase Top 250 units/g Oint [VDMC]

Facility

$1,079.60

Service Code	HCPCS A9270
Hospital Charge Code	10379574
Hospital Revenue Code	259
Min. Negotiated Rate	$485.82
Max. Negotiated Rate	$971.64
Rate for Payer: Aetna of IA Commercial	$971.64
Rate for Payer: Aetna of IA Medical Rental Products	$971.64
Rate for Payer: Aetna of IA Medicare	$615.37
Rate for Payer: Amerigroup Medicaid	$622.71
Rate for Payer: Amerigroup Medicare	$490.68
Rate for Payer: Cash Price	$863.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$809.70
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$485.82
Rate for Payer: Iowa Total Care Managed Medicaid	$616.67
Rate for Payer: Medical Associates Commercial	$809.70
Rate for Payer: Medical Associates Managed Medicare	$485.82
Rate for Payer: Midlands Choice Commercial	$755.72
Rate for Payer: Molina Healthcare Managed Medicaid	$625.74
Rate for Payer: Partners Health Alliance Commercial	$558.69
Rate for Payer: United Healthcare Commercial	$971.64
Rate for Payer: United Healthcare Managed Medicare	$636.96

collagenase Top 250 units/g Oint [VDMC]

Facility

$1,079.60

Service Code	HCPCS A9270
Hospital Charge Code	10379574
Hospital Revenue Code	259
Min. Negotiated Rate	$755.72
Max. Negotiated Rate	$971.64
Rate for Payer: Aetna of IA Commercial	$971.64
Rate for Payer: Aetna of IA Medical Rental Products	$971.64
Rate for Payer: Cash Price	$863.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$809.70
Rate for Payer: Medical Associates Commercial	$809.70
Rate for Payer: Midlands Choice Commercial	$755.72
Rate for Payer: United Healthcare Commercial	$971.64

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	$1,251.00
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: Aetna of IA Medicare	$1,584.60
Rate for Payer: Amerigroup Medicaid	$1,603.50
Rate for Payer: Amerigroup Medicare	$1,263.51
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	$1,251.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,587.94
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Medical Associates Managed Medicare	$1,251.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,611.29
Rate for Payer: Partners Health Alliance Commercial	$1,438.65
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	$89.55
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	$114.78
Rate for Payer: Amerigroup Medicare	$90.45
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	$89.55
Rate for Payer: Iowa Total Care Managed Medicaid	$113.67
Rate for Payer: Medical Associates Commercial	$149.25
Rate for Payer: Medical Associates Managed Medicare	$89.55
Rate for Payer: Midlands Choice Commercial	$139.30
Rate for Payer: Molina Healthcare Managed Medicaid	$115.34
Rate for Payer: Partners Health Alliance Commercial	$102.98
Rate for Payer: United Healthcare Commercial	$179.10
Rate for Payer: United Healthcare Managed Medicare	$117.41

COLONOSCOPY, FLEXIBLE; WITH BAND LIGATION(S) (EG, HEMORRHOIDS)

Facility

$2,844.40

Service Code	CPT 45398
Hospital Revenue Code	750
Min. Negotiated Rate	$2,582.18
Max. Negotiated Rate	$2,844.40
Rate for Payer: Wellmark IA HMO WHPI	$2,582.18
Rate for Payer: Wellmark IA PPO	$2,844.40

COLONOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$2,844.40

Service Code	CPT 45380
Hospital Revenue Code	360
Min. Negotiated Rate	$2,582.18
Max. Negotiated Rate	$2,844.40
Rate for Payer: Wellmark IA HMO WHPI	$2,582.18
Rate for Payer: Wellmark IA PPO	$2,844.40

Colonoscopy with Biopsy

Facility

$2,780.00

Hospital Charge Code	1376936
Hospital Revenue Code	750
Min. Negotiated Rate	$1,251.00
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: Aetna of IA Medicare	$1,584.60
Rate for Payer: Amerigroup Medicaid	$1,603.50
Rate for Payer: Amerigroup Medicare	$1,263.51
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	$1,251.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,587.94
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Medical Associates Managed Medicare	$1,251.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,611.29
Rate for Payer: Partners Health Alliance Commercial	$1,438.65
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	$1,251.00
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: Aetna of IA Medicare	$1,584.60
Rate for Payer: Amerigroup Medicaid	$1,603.50
Rate for Payer: Amerigroup Medicare	$1,263.51
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	$1,251.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,587.94
Rate for Payer: Medical Associates Commercial	$2,085.00
Rate for Payer: Medical Associates Managed Medicare	$1,251.00
Rate for Payer: Midlands Choice Commercial	$1,946.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,611.29
Rate for Payer: Partners Health Alliance Commercial	$1,438.65
Rate for Payer: United Healthcare Commercial	$2,502.00
Rate for Payer: United Healthcare Managed Medicare	$1,640.20

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

$397.00

Hospital Charge Code	8051946
Hospital Revenue Code	750
Min. Negotiated Rate	$178.65
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	$228.99
Rate for Payer: Amerigroup Medicare	$180.44
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	$178.65
Rate for Payer: Iowa Total Care Managed Medicaid	$226.77
Rate for Payer: Medical Associates Commercial	$297.75
Rate for Payer: Medical Associates Managed Medicare	$178.65
Rate for Payer: Midlands Choice Commercial	$277.90
Rate for Payer: Molina Healthcare Managed Medicaid	$230.10
Rate for Payer: Partners Health Alliance Commercial	$205.45
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

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL AT HIGH RISK

Facility

$2,844.40

Service Code	CPT G0105
Hospital Revenue Code	750
Min. Negotiated Rate	$2,582.18
Max. Negotiated Rate	$2,844.40
Rate for Payer: Wellmark IA HMO WHPI	$2,582.18
Rate for Payer: Wellmark IA PPO	$2,844.40

Know your out-of-pocket cost for care.

All Charges