Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

EXTERNAL CEPHALIC VERSION

Facility

$3,594.00

Service Code	CPT 59412
Hospital Charge Code	7984752
Hospital Revenue Code	721
Min. Negotiated Rate	$1,617.30
Max. Negotiated Rate	$3,366.11
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	$2,073.02
Rate for Payer: Amerigroup Medicare	$1,633.47
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	$1,617.30
Rate for Payer: Iowa Total Care Managed Medicaid	$2,052.89
Rate for Payer: Medical Associates Commercial	$2,695.50
Rate for Payer: Medical Associates Managed Medicare	$1,617.30
Rate for Payer: Midlands Choice Commercial	$2,515.80
Rate for Payer: Molina Healthcare Managed Medicaid	$2,083.08
Rate for Payer: Partners Health Alliance Commercial	$1,859.90
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 WHPI	$3,055.79
Rate for Payer: Wellmark IA PPO	$3,366.11

EXTRA ATTENDANT- SAFETY REASONS

Facility

$84.00

Service Code	HCPCS A0424 QN
Hospital Charge Code	7932764
Hospital Revenue Code	540
Min. Negotiated Rate	$37.80
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: Aetna of IA Medicare	$47.88
Rate for Payer: Amerigroup Medicaid	$48.45
Rate for Payer: Amerigroup Medicare	$38.18
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	$37.80
Rate for Payer: Iowa Total Care Managed Medicaid	$47.98
Rate for Payer: Medical Associates Commercial	$63.00
Rate for Payer: Medical Associates Managed Medicare	$37.80
Rate for Payer: Midlands Choice Commercial	$58.80
Rate for Payer: Molina Healthcare Managed Medicaid	$48.69
Rate for Payer: Partners Health Alliance Commercial	$43.47
Rate for Payer: United Healthcare Commercial	$75.60
Rate for Payer: United Healthcare Managed Medicare	$71.40

EXTRA ATTENDANT- SAFETY REASONS

Facility

$84.00

Service Code	HCPCS 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

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

$4,747.70

Service Code	CPT 66984
Hospital Revenue Code	490
Min. Negotiated Rate	$4,310.01
Max. Negotiated Rate	$4,747.70
Rate for Payer: Wellmark IA HMO WHPI	$4,310.01
Rate for Payer: Wellmark IA PPO	$4,747.70

Facility

$4,747.70

Service Code	CPT 66984
Min. Negotiated Rate	$4,310.01
Max. Negotiated Rate	$4,747.70
Rate for Payer: Wellmark IA HMO WHPI	$4,310.01
Rate for Payer: Wellmark IA PPO	$4,747.70

EXTRACRANIAL PROCEDURES WITH CC

Facility

$13,776.33

Service Code	MSDRG 038
Min. Negotiated Rate	$13,576.67
Max. Negotiated Rate	$13,776.33
Rate for Payer: Amerigroup Medicaid	$13,709.77
Rate for Payer: Iowa Total Care Managed Medicaid	$13,576.67
Rate for Payer: Molina Healthcare Managed Medicaid	$13,776.33

EXTRACRANIAL PROCEDURES WITH MCC

Facility

$23,451.85

Service Code	MSDRG 037
Min. Negotiated Rate	$23,111.96
Max. Negotiated Rate	$23,451.85
Rate for Payer: Amerigroup Medicaid	$23,338.54
Rate for Payer: Iowa Total Care Managed Medicaid	$23,111.96
Rate for Payer: Molina Healthcare Managed Medicaid	$23,451.85

EXTRACRANIAL PROCEDURES WITHOUT CC/MCC

Facility

$9,168.83

Service Code	MSDRG 039
Min. Negotiated Rate	$9,035.95
Max. Negotiated Rate	$9,168.83
Rate for Payer: Amerigroup Medicaid	$9,124.53
Rate for Payer: Iowa Total Care Managed Medicaid	$9,035.95
Rate for Payer: Molina Healthcare Managed Medicaid	$9,168.83

Extractable Nuclear Antigen Ab DMCL

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8037843
Hospital Revenue Code	302
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

Extractable Nuclear Antigen Ab DMCL

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8037843
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$59.00
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

EXTRACTABLE NUCLEAR ANTIGEN OR ANTIBODY

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8093932
Hospital Revenue Code	302
Min. Negotiated Rate	$79.80
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: United Healthcare Commercial	$102.60

EXTRACTABLE NUCLEAR ANTIGEN OR ANTIBODY

Facility

$114.00

Service Code	CPT 86235
Hospital Charge Code	8093932
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$102.60
Rate for Payer: Aetna of IA Commercial	$102.60
Rate for Payer: Aetna of IA Medical Rental Products	$102.60
Rate for Payer: Aetna of IA Medicare	$64.98
Rate for Payer: Amerigroup Medicaid	$65.76
Rate for Payer: Amerigroup Medicare	$51.81
Rate for Payer: Cash Price	$91.20
Rate for Payer: Cash Price	$91.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$85.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$51.30
Rate for Payer: Iowa Total Care Managed Medicaid	$65.12
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$51.30
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$66.07
Rate for Payer: Partners Health Alliance Commercial	$59.00
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

EXTRAOCULAR PROCEDURES EXCEPT ORBIT

Facility

$13,269.64

Service Code	MSDRG 115
Min. Negotiated Rate	$13,077.32
Max. Negotiated Rate	$13,269.64
Rate for Payer: Amerigroup Medicaid	$13,205.53
Rate for Payer: Iowa Total Care Managed Medicaid	$13,077.32
Rate for Payer: Molina Healthcare Managed Medicaid	$13,269.64

EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE

Facility

$43,296.07

Service Code	MSDRG 790
Min. Negotiated Rate	$42,668.57
Max. Negotiated Rate	$43,296.07
Rate for Payer: Amerigroup Medicaid	$43,086.89
Rate for Payer: Iowa Total Care Managed Medicaid	$42,668.57
Rate for Payer: Molina Healthcare Managed Medicaid	$43,296.07

ezetimibe 10 mg Tab [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10387879
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Aetna of IA Medicare	$0.85
Rate for Payer: Amerigroup Medicaid	$0.86
Rate for Payer: Amerigroup Medicare	$0.68
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.67
Rate for Payer: Iowa Total Care Managed Medicaid	$0.85
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Medical Associates Managed Medicare	$0.67
Rate for Payer: Midlands Choice Commercial	$1.05
Rate for Payer: Molina Healthcare Managed Medicaid	$0.87
Rate for Payer: Partners Health Alliance Commercial	$0.77
Rate for Payer: United Healthcare Commercial	$1.34
Rate for Payer: United Healthcare Managed Medicare	$0.88

ezetimibe 10 mg Tab [VDMC]

Facility

$1.49

Service Code	HCPCS A9270
Hospital Charge Code	10387879
Hospital Revenue Code	259
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of IA Commercial	$1.34
Rate for Payer: Aetna of IA Medical Rental Products	$1.34
Rate for Payer: Cash Price	$1.19
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.12
Rate for Payer: Medical Associates Commercial	$1.12
Rate for Payer: Midlands Choice Commercial	$1.05
Rate for Payer: United Healthcare Commercial	$1.34

Factor V Leiden DMCL

Facility

$220.00

Service Code	CPT 81241
Hospital Charge Code	8037844
Hospital Revenue Code	301
Min. Negotiated Rate	$99.00
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna of IA Commercial	$198.00
Rate for Payer: Aetna of IA Medical Rental Products	$198.00
Rate for Payer: Aetna of IA Medicare	$125.40
Rate for Payer: Amerigroup Medicaid	$126.90
Rate for Payer: Amerigroup Medicare	$99.99
Rate for Payer: Cash Price	$176.00
Rate for Payer: Cash Price	$176.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.00
Rate for Payer: Iowa Total Care Managed Medicaid	$125.66
Rate for Payer: Medical Associates Commercial	$165.00
Rate for Payer: Medical Associates Managed Medicare	$99.00
Rate for Payer: Midlands Choice Commercial	$154.00
Rate for Payer: Molina Healthcare Managed Medicaid	$127.51
Rate for Payer: Partners Health Alliance Commercial	$113.85
Rate for Payer: United Healthcare Commercial	$198.00
Rate for Payer: United Healthcare Managed Medicare	$129.80
Rate for Payer: Wellmark IA HMO WHPI	$100.68
Rate for Payer: Wellmark IA PPO	$110.90

Factor V Leiden DMCL

Facility

$220.00

Service Code	CPT 81241
Hospital Charge Code	8037844
Hospital Revenue Code	301
Min. Negotiated Rate	$154.00
Max. Negotiated Rate	$198.00
Rate for Payer: Aetna of IA Commercial	$198.00
Rate for Payer: Aetna of IA Medical Rental Products	$198.00
Rate for Payer: Cash Price	$176.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.00
Rate for Payer: Medical Associates Commercial	$165.00
Rate for Payer: Midlands Choice Commercial	$154.00
Rate for Payer: United Healthcare Commercial	$198.00

Factor X Assay DMCL

Facility

$129.00

Service Code	CPT 85260
Hospital Charge Code	8037845
Hospital Revenue Code	305
Min. Negotiated Rate	$29.07
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of IA Commercial	$116.10
Rate for Payer: Aetna of IA Medical Rental Products	$116.10
Rate for Payer: Aetna of IA Medicare	$73.53
Rate for Payer: Amerigroup Medicaid	$74.41
Rate for Payer: Amerigroup Medicare	$58.63
Rate for Payer: Cash Price	$103.20
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$58.05
Rate for Payer: Iowa Total Care Managed Medicaid	$73.68
Rate for Payer: Medical Associates Commercial	$96.75
Rate for Payer: Medical Associates Managed Medicare	$58.05
Rate for Payer: Midlands Choice Commercial	$90.30
Rate for Payer: Molina Healthcare Managed Medicaid	$74.77
Rate for Payer: Partners Health Alliance Commercial	$66.76
Rate for Payer: United Healthcare Commercial	$116.10
Rate for Payer: United Healthcare Managed Medicare	$76.11
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

Factor X Assay DMCL

Facility

$129.00

Service Code	CPT 85260
Hospital Charge Code	8037845
Hospital Revenue Code	305
Min. Negotiated Rate	$90.30
Max. Negotiated Rate	$116.10
Rate for Payer: Aetna of IA Commercial	$116.10
Rate for Payer: Aetna of IA Medical Rental Products	$116.10
Rate for Payer: Cash Price	$103.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.75
Rate for Payer: Medical Associates Commercial	$96.75
Rate for Payer: Midlands Choice Commercial	$90.30
Rate for Payer: United Healthcare Commercial	$116.10

FAMILY THERAPY 60 MIN

Professional

Both

$177.00

Service Code	CPT 90847 AJ\|HO
Hospital Charge Code	4849292
Hospital Revenue Code	916
Min. Negotiated Rate	$19.03
Max. Negotiated Rate	$166.46
Rate for Payer: Amerigroup Medicaid	$19.22
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Iowa Total Care Managed Medicaid	$19.03
Rate for Payer: Medical Associates Commercial	$132.75
Rate for Payer: Midlands Choice Commercial	$123.90
Rate for Payer: Molina Healthcare Managed Medicaid	$19.13
Rate for Payer: Optum Behavioral Health	$116.25
Rate for Payer: Partners Health Alliance Commercial	$132.75
Rate for Payer: United Healthcare Commercial	$166.46
Rate for Payer: Wellmark IA HMO WHPI	$138.10
Rate for Payer: Wellmark IA PPO	$138.10

FAMILY THERAPY W/O PATIENT

Professional

Both

$177.00

Service Code	CPT 90846 AJ\|HO
Hospital Charge Code	4849291
Hospital Revenue Code	916
Min. Negotiated Rate	$19.03
Max. Negotiated Rate	$160.69
Rate for Payer: Amerigroup Medicaid	$19.22
Rate for Payer: Cash Price	$141.60
Rate for Payer: Cash Price	$141.60
Rate for Payer: Iowa Total Care Managed Medicaid	$19.03
Rate for Payer: Medical Associates Commercial	$132.75
Rate for Payer: Midlands Choice Commercial	$123.90
Rate for Payer: Molina Healthcare Managed Medicaid	$19.13
Rate for Payer: Optum Behavioral Health	$111.73
Rate for Payer: Partners Health Alliance Commercial	$132.75
Rate for Payer: United Healthcare Commercial	$160.69
Rate for Payer: Wellmark IA HMO WHPI	$131.80
Rate for Payer: Wellmark IA PPO	$131.80

famotidine 10 mg/mL 2 ml IV Sol [VDMC]

Facility

$22.50

Service Code	HCPCS J3490
Hospital Charge Code	10387948
Hospital Revenue Code	259
Min. Negotiated Rate	$10.13
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna of IA Commercial	$20.25
Rate for Payer: Aetna of IA Medical Rental Products	$20.25
Rate for Payer: Aetna of IA Medicare	$12.83
Rate for Payer: Amerigroup Medicaid	$12.98
Rate for Payer: Amerigroup Medicare	$10.23
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.88
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$10.13
Rate for Payer: Iowa Total Care Managed Medicaid	$12.85
Rate for Payer: Medical Associates Commercial	$16.88
Rate for Payer: Medical Associates Managed Medicare	$10.13
Rate for Payer: Midlands Choice Commercial	$15.75
Rate for Payer: Molina Healthcare Managed Medicaid	$13.04
Rate for Payer: Partners Health Alliance Commercial	$11.64
Rate for Payer: United Healthcare Commercial	$20.25
Rate for Payer: United Healthcare Managed Medicare	$13.28

famotidine 10 mg/mL 2 ml IV Sol [VDMC]

Facility

$22.50

Service Code	HCPCS J3490
Hospital Charge Code	10387948
Hospital Revenue Code	259
Min. Negotiated Rate	$15.75
Max. Negotiated Rate	$20.25
Rate for Payer: Aetna of IA Commercial	$20.25
Rate for Payer: Aetna of IA Medical Rental Products	$20.25
Rate for Payer: Cash Price	$18.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$16.88
Rate for Payer: Medical Associates Commercial	$16.88
Rate for Payer: Midlands Choice Commercial	$15.75
Rate for Payer: United Healthcare Commercial	$20.25

Know your out-of-pocket cost for care.

All Charges