Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

EXC LESION 2.1-3 ER CHARGE

Professional

Both

$483.00

Hospital Charge Code	8069183
Hospital Revenue Code	981
Min. Negotiated Rate	$338.10
Max. Negotiated Rate	$362.25
Rate for Payer: Cash Price	$386.40
Rate for Payer: Medical Associates Commercial	$362.25
Rate for Payer: Midlands Choice Commercial	$338.10

EXC LESION < 2 ER CHARGE

Professional

Both

$483.00

Hospital Charge Code	8069031
Hospital Revenue Code	981
Min. Negotiated Rate	$338.10
Max. Negotiated Rate	$362.25
Rate for Payer: Cash Price	$386.40
Rate for Payer: Medical Associates Commercial	$362.25
Rate for Payer: Midlands Choice Commercial	$338.10

EXC LESION > 3.1 ER CHARGE

Professional

Both

$809.00

Hospital Charge Code	8069046
Hospital Revenue Code	981
Min. Negotiated Rate	$566.30
Max. Negotiated Rate	$606.75
Rate for Payer: Cash Price	$647.20
Rate for Payer: Medical Associates Commercial	$606.75
Rate for Payer: Midlands Choice Commercial	$566.30

EXC MAL LESION TRUNK ARMS LEGS 3.1-4.0 CM

Professional

Both

$1,529.00

Service Code	CPT 11604
Hospital Charge Code	8825542
Hospital Revenue Code	975
Min. Negotiated Rate	$192.60
Max. Negotiated Rate	$1,070.30
Rate for Payer: Aetna of IA Medicare	$192.60
Rate for Payer: Amerigroup Medicaid	$199.15
Rate for Payer: Cash Price	$1,223.20
Rate for Payer: Cash Price	$1,223.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$231.12
Rate for Payer: Iowa Total Care Managed Medicaid	$196.45
Rate for Payer: Medical Associates Commercial	$365.94
Rate for Payer: Medical Associates Managed Medicare	$192.60
Rate for Payer: Midlands Choice Commercial	$1,070.30
Rate for Payer: Oscar Health of IA Commercial	$333.20
Rate for Payer: Partners Health Alliance Commercial	$288.90

EXC TR-EXT B9+MARG 0.6-1 CM

Professional

Both

$493.00

Service Code	CPT 11401
Hospital Charge Code	7982851
Hospital Revenue Code	981
Min. Negotiated Rate	$96.62
Max. Negotiated Rate	$223.56
Rate for Payer: Aetna of IA Medicare	$96.62
Rate for Payer: Amerigroup Medicaid	$99.91
Rate for Payer: Cash Price	$394.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$115.94
Rate for Payer: Iowa Total Care Managed Medicaid	$98.55
Rate for Payer: Medical Associates Commercial	$173.92
Rate for Payer: Medical Associates Managed Medicare	$96.62
Rate for Payer: Midlands Choice Commercial	$223.56
Rate for Payer: Oscar Health of IA Commercial	$167.15
Rate for Payer: Partners Health Alliance Commercial	$144.93

EXC TR-EXT B9+MARG 2.1-3CM/<

Facility

$750.00

Service Code	CPT 11403
Hospital Charge Code	7982982
Hospital Revenue Code	510
Min. Negotiated Rate	$374.85
Max. Negotiated Rate	$1,451.30
Rate for Payer: Aetna of IA Commercial	$675.00
Rate for Payer: Aetna of IA Medical Rental Products	$675.00
Rate for Payer: Aetna of IA Medicare	$427.50
Rate for Payer: Amerigroup Medicaid	$378.52
Rate for Payer: Amerigroup Medicare	$378.75
Rate for Payer: Cash Price	$600.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$562.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$375.00
Rate for Payer: Iowa Total Care Managed Medicaid	$374.85
Rate for Payer: Medical Associates Commercial	$562.50
Rate for Payer: Medical Associates Managed Medicare	$375.00
Rate for Payer: Midlands Choice Commercial	$525.00
Rate for Payer: Molina Healthcare Managed Medicaid	$380.62
Rate for Payer: Molina Healthcare Managed Medicare	$380.40
Rate for Payer: Oscar Health of IA Commercial	$562.50
Rate for Payer: Partners Health Alliance Commercial	$562.50
Rate for Payer: United Healthcare Commercial	$675.00
Rate for Payer: United Healthcare Managed Medicare	$442.50
Rate for Payer: Wellmark IA HMO	$1,319.36
Rate for Payer: Wellmark IA PPO	$1,451.30

EXC TR-EXT B9+MARG 2.1-3CM/<

Facility

$750.00

Service Code	CPT 11403
Hospital Charge Code	7982982
Hospital Revenue Code	510
Min. Negotiated Rate	$525.00
Max. Negotiated Rate	$675.00
Rate for Payer: Aetna of IA Commercial	$675.00
Rate for Payer: Aetna of IA Medical Rental Products	$675.00
Rate for Payer: Cash Price	$600.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$562.50
Rate for Payer: Medical Associates Commercial	$562.50
Rate for Payer: Midlands Choice Commercial	$525.00
Rate for Payer: United Healthcare Commercial	$675.00

EXC TR-EXT MAL+MARG > 4 CM

Professional

Both

$1,494.00

Service Code	CPT 11606
Hospital Charge Code	8069148
Hospital Revenue Code	975
Min. Negotiated Rate	$284.12
Max. Negotiated Rate	$1,045.80
Rate for Payer: Aetna of IA Medicare	$284.12
Rate for Payer: Amerigroup Medicaid	$293.78
Rate for Payer: Cash Price	$1,195.20
Rate for Payer: Cash Price	$1,195.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$340.94
Rate for Payer: Iowa Total Care Managed Medicaid	$289.80
Rate for Payer: Medical Associates Commercial	$539.83
Rate for Payer: Medical Associates Managed Medicare	$284.12
Rate for Payer: Midlands Choice Commercial	$1,045.80
Rate for Payer: Oscar Health of IA Commercial	$491.53
Rate for Payer: Partners Health Alliance Commercial	$426.18

exenatide 10 mcg/0.04 mL SC Sol [VDMC]

Facility

$1,406.50

Service Code	HCPCS J3490
Hospital Charge Code	10387741
Hospital Revenue Code	259
Min. Negotiated Rate	$984.55
Max. Negotiated Rate	$1,265.85
Rate for Payer: Aetna of IA Commercial	$1,265.85
Rate for Payer: Aetna of IA Medical Rental Products	$1,265.85
Rate for Payer: Cash Price	$1,125.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,054.88
Rate for Payer: Medical Associates Commercial	$1,054.88
Rate for Payer: Midlands Choice Commercial	$984.55
Rate for Payer: United Healthcare Commercial	$1,265.85

exenatide 10 mcg/0.04 mL SC Sol [VDMC]

Facility

$1,406.50

Service Code	HCPCS J3490
Hospital Charge Code	10387741
Hospital Revenue Code	259
Min. Negotiated Rate	$702.97
Max. Negotiated Rate	$1,265.85
Rate for Payer: Aetna of IA Commercial	$1,265.85
Rate for Payer: Aetna of IA Medical Rental Products	$1,265.85
Rate for Payer: Aetna of IA Medicare	$801.70
Rate for Payer: Amerigroup Medicaid	$709.86
Rate for Payer: Amerigroup Medicare	$710.28
Rate for Payer: Cash Price	$1,125.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,054.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$703.25
Rate for Payer: Iowa Total Care Managed Medicaid	$702.97
Rate for Payer: Medical Associates Commercial	$1,054.88
Rate for Payer: Medical Associates Managed Medicare	$703.25
Rate for Payer: Midlands Choice Commercial	$984.55
Rate for Payer: Molina Healthcare Managed Medicaid	$713.80
Rate for Payer: Molina Healthcare Managed Medicare	$713.38
Rate for Payer: Oscar Health of IA Commercial	$1,054.88
Rate for Payer: Partners Health Alliance Commercial	$1,054.88
Rate for Payer: United Healthcare Commercial	$1,265.85
Rate for Payer: United Healthcare Managed Medicare	$829.84

exenatide 2 mg Pow[VDMC]

Facility

$516.54

Service Code	NDC 66780-0219-04
Hospital Charge Code	11346878
Hospital Revenue Code	259
Min. Negotiated Rate	$258.17
Max. Negotiated Rate	$464.89
Rate for Payer: Aetna of IA Commercial	$464.89
Rate for Payer: Aetna of IA Medical Rental Products	$464.89
Rate for Payer: Aetna of IA Medicare	$294.43
Rate for Payer: Amerigroup Medicaid	$260.70
Rate for Payer: Amerigroup Medicare	$260.85
Rate for Payer: Cash Price	$413.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$387.40
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$258.27
Rate for Payer: Iowa Total Care Managed Medicaid	$258.17
Rate for Payer: Medical Associates Commercial	$387.40
Rate for Payer: Medical Associates Managed Medicare	$258.27
Rate for Payer: Midlands Choice Commercial	$361.58
Rate for Payer: Molina Healthcare Managed Medicaid	$262.14
Rate for Payer: Molina Healthcare Managed Medicare	$261.99
Rate for Payer: Oscar Health of IA Commercial	$387.40
Rate for Payer: Partners Health Alliance Commercial	$387.40
Rate for Payer: United Healthcare Commercial	$464.89
Rate for Payer: United Healthcare Managed Medicare	$304.76

exenatide 2 mg Pow[VDMC]

Facility

$516.54

Service Code	NDC 66780-0219-04
Hospital Charge Code	11346878
Hospital Revenue Code	259
Min. Negotiated Rate	$361.58
Max. Negotiated Rate	$464.89
Rate for Payer: Aetna of IA Commercial	$464.89
Rate for Payer: Aetna of IA Medical Rental Products	$464.89
Rate for Payer: Cash Price	$413.23
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$387.40
Rate for Payer: Medical Associates Commercial	$387.40
Rate for Payer: Midlands Choice Commercial	$361.58
Rate for Payer: United Healthcare Commercial	$464.89

exenatide 5 mcg/0.02 mL SC Sol [VDMC]

Facility

$1,774.62

Service Code	HCPCS J3490
Hospital Charge Code	10387810
Hospital Revenue Code	259
Min. Negotiated Rate	$1,242.23
Max. Negotiated Rate	$1,597.16
Rate for Payer: Aetna of IA Commercial	$1,597.16
Rate for Payer: Aetna of IA Medical Rental Products	$1,597.16
Rate for Payer: Cash Price	$1,419.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,330.96
Rate for Payer: Medical Associates Commercial	$1,330.96
Rate for Payer: Midlands Choice Commercial	$1,242.23
Rate for Payer: United Healthcare Commercial	$1,597.16

exenatide 5 mcg/0.02 mL SC Sol [VDMC]

Facility

$1,774.62

Service Code	HCPCS J3490
Hospital Charge Code	10387810
Hospital Revenue Code	259
Min. Negotiated Rate	$886.96
Max. Negotiated Rate	$1,597.16
Rate for Payer: Aetna of IA Commercial	$1,597.16
Rate for Payer: Aetna of IA Medical Rental Products	$1,597.16
Rate for Payer: Aetna of IA Medicare	$1,011.53
Rate for Payer: Amerigroup Medicaid	$895.65
Rate for Payer: Amerigroup Medicare	$896.18
Rate for Payer: Cash Price	$1,419.70
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,330.96
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$887.31
Rate for Payer: Iowa Total Care Managed Medicaid	$886.96
Rate for Payer: Medical Associates Commercial	$1,330.96
Rate for Payer: Medical Associates Managed Medicare	$887.31
Rate for Payer: Midlands Choice Commercial	$1,242.23
Rate for Payer: Molina Healthcare Managed Medicaid	$900.62
Rate for Payer: Molina Healthcare Managed Medicare	$900.09
Rate for Payer: Oscar Health of IA Commercial	$1,330.96
Rate for Payer: Partners Health Alliance Commercial	$1,330.96
Rate for Payer: United Healthcare Commercial	$1,597.16
Rate for Payer: United Healthcare Managed Medicare	$1,047.03

Extensive Burns or Full Thickness Burns With MV >96 Hours Without Skin Graft

Facility

$22,226.14

Service Code	MS-DRG 933
Hospital Charge Code	645
Min. Negotiated Rate	$21,904.02
Max. Negotiated Rate	$22,226.14
Rate for Payer: Amerigroup Medicaid	$22,118.77
Rate for Payer: Iowa Total Care Managed Medicaid	$21,904.02
Rate for Payer: Molina Healthcare Managed Medicaid	$22,226.14

Extensive Burns or Full Thickness Burns With MV >96 Hours With Skin Graft

Facility

$207,048.00

Service Code	MS-DRG 927
Hospital Charge Code	642
Min. Negotiated Rate	$204,047.31
Max. Negotiated Rate	$207,048.00
Rate for Payer: Amerigroup Medicaid	$206,047.77
Rate for Payer: Iowa Total Care Managed Medicaid	$204,047.31
Rate for Payer: Molina Healthcare Managed Medicaid	$207,048.00

Extensive O.R. Procedures Unrelated to Principal Diagnosis With CC

Facility

$15,682.90

Service Code	MS-DRG 982
Hospital Charge Code	673
Min. Negotiated Rate	$15,455.61
Max. Negotiated Rate	$15,682.90
Rate for Payer: Amerigroup Medicaid	$15,607.14
Rate for Payer: Iowa Total Care Managed Medicaid	$15,455.61
Rate for Payer: Molina Healthcare Managed Medicaid	$15,682.90

Extensive O.R. Procedures Unrelated to Principal Diagnosis With MCC

Facility

$40,819.45

Service Code	MS-DRG 981
Hospital Charge Code	672
Min. Negotiated Rate	$40,227.86
Max. Negotiated Rate	$40,819.45
Rate for Payer: Amerigroup Medicaid	$40,622.25
Rate for Payer: Iowa Total Care Managed Medicaid	$40,227.86
Rate for Payer: Molina Healthcare Managed Medicaid	$40,819.45

Extensive O.R. Procedures Unrelated to Principal Diagnosis Without CC/MCC

Facility

$11,898.49

Service Code	MS-DRG 983
Hospital Charge Code	674
Min. Negotiated Rate	$11,726.05
Max. Negotiated Rate	$11,898.49
Rate for Payer: Amerigroup Medicaid	$11,841.01
Rate for Payer: Iowa Total Care Managed Medicaid	$11,726.05
Rate for Payer: Molina Healthcare Managed Medicaid	$11,898.49

EXTERNAL CEPHALIC VERSION

Facility

$3,594.00

Service Code	CPT 59412
Hospital Charge Code	7984752
Hospital Revenue Code	721
Min. Negotiated Rate	$1,796.28
Max. Negotiated Rate	$3,234.60
Rate for Payer: Aetna of IA Commercial	$3,234.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,234.60
Rate for Payer: Aetna of IA Medicare	$2,048.58
Rate for Payer: Amerigroup Medicaid	$1,813.89
Rate for Payer: Amerigroup Medicare	$1,814.97
Rate for Payer: Cash Price	$2,875.20
Rate for Payer: Cash Price	$2,875.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,695.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,797.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,796.28
Rate for Payer: Medical Associates Commercial	$2,695.50
Rate for Payer: Medical Associates Managed Medicare	$1,797.00
Rate for Payer: Midlands Choice Commercial	$2,515.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,823.96
Rate for Payer: Molina Healthcare Managed Medicare	$1,822.88
Rate for Payer: Oscar Health of IA Commercial	$2,695.50
Rate for Payer: Partners Health Alliance Commercial	$2,695.50
Rate for Payer: United Healthcare Commercial	$3,234.60
Rate for Payer: United Healthcare Managed Medicare	$2,120.46
Rate for Payer: Wellmark IA HMO	$2,127.22
Rate for Payer: Wellmark IA PPO	$2,339.94

EXTERNAL CEPHALIC VERSION

Facility

$3,594.00

Service Code	CPT 59412
Hospital Charge Code	7984752
Hospital Revenue Code	721
Min. Negotiated Rate	$2,515.80
Max. Negotiated Rate	$3,234.60
Rate for Payer: Aetna of IA Commercial	$3,234.60
Rate for Payer: Aetna of IA Medical Rental Products	$3,234.60
Rate for Payer: Cash Price	$2,875.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,695.50
Rate for Payer: Medical Associates Commercial	$2,695.50
Rate for Payer: Midlands Choice Commercial	$2,515.80
Rate for Payer: United Healthcare Commercial	$3,234.60

EXTRA ATTENDANT- SAFETY REASONS

Facility

$84.00

Service Code	CPT A0424 QN
Hospital Charge Code	7932764
Hospital Revenue Code	540
Min. Negotiated Rate	$58.80
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of IA Commercial	$75.60
Rate for Payer: Aetna of IA Medical Rental Products	$75.60
Rate for Payer: Cash Price	$67.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.00
Rate for Payer: Medical Associates Commercial	$63.00
Rate for Payer: Midlands Choice Commercial	$58.80
Rate for Payer: United Healthcare Commercial	$75.60

EXTRA ATTENDANT- SAFETY REASONS

Facility

$84.00

Service Code	CPT A0424 QN
Hospital Charge Code	7932764
Hospital Revenue Code	540
Min. Negotiated Rate	$41.98
Max. Negotiated Rate	$75.60
Rate for Payer: Aetna of IA Commercial	$75.60
Rate for Payer: Aetna of IA Medical Rental Products	$75.60
Rate for Payer: Aetna of IA Medicare	$47.88
Rate for Payer: Amerigroup Medicaid	$42.39
Rate for Payer: Amerigroup Medicare	$42.42
Rate for Payer: Cash Price	$67.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$42.00
Rate for Payer: Iowa Total Care Managed Medicaid	$41.98
Rate for Payer: Medical Associates Commercial	$63.00
Rate for Payer: Medical Associates Managed Medicare	$42.00
Rate for Payer: Midlands Choice Commercial	$58.80
Rate for Payer: Molina Healthcare Managed Medicaid	$42.63
Rate for Payer: Molina Healthcare Managed Medicare	$42.60
Rate for Payer: Oscar Health of IA Commercial	$63.00
Rate for Payer: Partners Health Alliance Commercial	$63.00
Rate for Payer: United Healthcare Commercial	$75.60
Rate for Payer: United Healthcare Managed Medicare	$71.40

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1-stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification), complex, requiring devices or techniques not generally used in routine cataract surgery (eg, iris expansion device, suture support for intraocular lens, or primary posterior capsulorrhexis) or performed on patients in the amblyogenic developmental stage; without endoscopic cyclophotocoagulation

Facility

$4,535.30

Service Code	CPT 66982
Hospital Revenue Code	360
Min. Negotiated Rate	$4,123.00
Max. Negotiated Rate	$4,535.30
Rate for Payer: Wellmark IA HMO	$4,123.00
Rate for Payer: Wellmark IA PPO	$4,535.30

Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation

Facility

$4,535.30

Service Code	CPT 66984
Hospital Revenue Code	360
Min. Negotiated Rate	$4,123.00
Max. Negotiated Rate	$4,535.30
Rate for Payer: Wellmark IA HMO	$4,123.00
Rate for Payer: Wellmark IA PPO	$4,535.30

Know your out-of-pocket cost for care.

All Charges