Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Histoplasmosis Immunodiffusion DMCL

Facility

$114.00

Service Code	CPT 86698
Hospital Charge Code	8037874
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
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	$57.54
Rate for Payer: Amerigroup Medicare	$57.57
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	$57.00
Rate for Payer: Iowa Total Care Managed Medicaid	$56.98
Rate for Payer: Medical Associates Commercial	$85.50
Rate for Payer: Medical Associates Managed Medicare	$57.00
Rate for Payer: Midlands Choice Commercial	$79.80
Rate for Payer: Molina Healthcare Managed Medicaid	$57.86
Rate for Payer: Molina Healthcare Managed Medicare	$57.82
Rate for Payer: Oscar Health of IA Commercial	$85.50
Rate for Payer: Partners Health Alliance Commercial	$85.50
Rate for Payer: United Healthcare Commercial	$102.60
Rate for Payer: United Healthcare Managed Medicare	$67.26
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Histoplasmosis Immunodiffusion DMCL

Facility

$114.00

Service Code	CPT 86698
Hospital Charge Code	8037874
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

HIV 1 2 DMCL

Facility

$91.00

Service Code	CPT 87389
Hospital Charge Code	8037875
Hospital Revenue Code	302
Min. Negotiated Rate	$63.70
Max. Negotiated Rate	$81.90
Rate for Payer: Aetna of IA Commercial	$81.90
Rate for Payer: Aetna of IA Medical Rental Products	$81.90
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$68.25
Rate for Payer: Medical Associates Commercial	$68.25
Rate for Payer: Midlands Choice Commercial	$63.70
Rate for Payer: United Healthcare Commercial	$81.90

HIV 1 2 DMCL

Facility

$91.00

Service Code	CPT 87389
Hospital Charge Code	8037875
Hospital Revenue Code	302
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$81.90
Rate for Payer: Aetna of IA Commercial	$81.90
Rate for Payer: Aetna of IA Medical Rental Products	$81.90
Rate for Payer: Aetna of IA Medicare	$51.87
Rate for Payer: Amerigroup Medicaid	$45.93
Rate for Payer: Amerigroup Medicare	$45.96
Rate for Payer: Cash Price	$72.80
Rate for Payer: Cash Price	$72.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$68.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$45.50
Rate for Payer: Iowa Total Care Managed Medicaid	$45.48
Rate for Payer: Medical Associates Commercial	$68.25
Rate for Payer: Medical Associates Managed Medicare	$45.50
Rate for Payer: Midlands Choice Commercial	$63.70
Rate for Payer: Molina Healthcare Managed Medicaid	$46.18
Rate for Payer: Molina Healthcare Managed Medicare	$46.16
Rate for Payer: Oscar Health of IA Commercial	$68.25
Rate for Payer: Partners Health Alliance Commercial	$68.25
Rate for Payer: United Healthcare Commercial	$81.90
Rate for Payer: United Healthcare Managed Medicare	$53.69
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

HIV IN HOUSE

Facility

$76.00

Service Code	CPT G0433
Hospital Charge Code	4017669
Hospital Revenue Code	302
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of IA Commercial	$68.40
Rate for Payer: Aetna of IA Medical Rental Products	$68.40
Rate for Payer: Aetna of IA Medicare	$43.32
Rate for Payer: Amerigroup Medicaid	$38.36
Rate for Payer: Amerigroup Medicare	$38.38
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cash Price	$60.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.00
Rate for Payer: Iowa Total Care Managed Medicaid	$37.98
Rate for Payer: Medical Associates Commercial	$57.00
Rate for Payer: Medical Associates Managed Medicare	$38.00
Rate for Payer: Midlands Choice Commercial	$53.20
Rate for Payer: Molina Healthcare Managed Medicaid	$38.57
Rate for Payer: Molina Healthcare Managed Medicare	$38.55
Rate for Payer: Oscar Health of IA Commercial	$57.00
Rate for Payer: Partners Health Alliance Commercial	$57.00
Rate for Payer: United Healthcare Commercial	$68.40
Rate for Payer: United Healthcare Managed Medicare	$44.84
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

HIV IN HOUSE

Facility

$76.00

Service Code	CPT G0433
Hospital Charge Code	4017669
Hospital Revenue Code	302
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of IA Commercial	$68.40
Rate for Payer: Aetna of IA Medical Rental Products	$68.40
Rate for Payer: Cash Price	$60.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.00
Rate for Payer: Medical Associates Commercial	$57.00
Rate for Payer: Midlands Choice Commercial	$53.20
Rate for Payer: United Healthcare Commercial	$68.40

HIV IN HOUSE

Facility

$76.00

Service Code	CPT G0433
Hospital Charge Code	633757
Hospital Revenue Code	302
Min. Negotiated Rate	$53.20
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of IA Commercial	$68.40
Rate for Payer: Aetna of IA Medical Rental Products	$68.40
Rate for Payer: Cash Price	$60.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.00
Rate for Payer: Medical Associates Commercial	$57.00
Rate for Payer: Midlands Choice Commercial	$53.20
Rate for Payer: United Healthcare Commercial	$68.40

HIV IN HOUSE

Facility

$76.00

Service Code	CPT G0433
Hospital Charge Code	633757
Hospital Revenue Code	302
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$68.40
Rate for Payer: Aetna of IA Commercial	$68.40
Rate for Payer: Aetna of IA Medical Rental Products	$68.40
Rate for Payer: Aetna of IA Medicare	$43.32
Rate for Payer: Amerigroup Medicaid	$38.36
Rate for Payer: Amerigroup Medicare	$38.38
Rate for Payer: Cash Price	$60.80
Rate for Payer: Cash Price	$60.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.00
Rate for Payer: Iowa Total Care Managed Medicaid	$37.98
Rate for Payer: Medical Associates Commercial	$57.00
Rate for Payer: Medical Associates Managed Medicare	$38.00
Rate for Payer: Midlands Choice Commercial	$53.20
Rate for Payer: Molina Healthcare Managed Medicaid	$38.57
Rate for Payer: Molina Healthcare Managed Medicare	$38.55
Rate for Payer: Oscar Health of IA Commercial	$57.00
Rate for Payer: Partners Health Alliance Commercial	$57.00
Rate for Payer: United Healthcare Commercial	$68.40
Rate for Payer: United Healthcare Managed Medicare	$44.84
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

HIV With Extensive O.R. Procedures With MCC

Facility

$56,976.76

Service Code	MS-DRG 969
Hospital Charge Code	666
Min. Negotiated Rate	$56,151.01
Max. Negotiated Rate	$56,976.76
Rate for Payer: Amerigroup Medicaid	$56,701.51
Rate for Payer: Iowa Total Care Managed Medicaid	$56,151.01
Rate for Payer: Molina Healthcare Managed Medicaid	$56,976.76

HIV With Extensive O.R. Procedures Without MCC

Facility

$28,986.89

Service Code	MS-DRG 970
Hospital Charge Code	667
Min. Negotiated Rate	$28,566.79
Max. Negotiated Rate	$28,986.89
Rate for Payer: Amerigroup Medicaid	$28,846.86
Rate for Payer: Iowa Total Care Managed Medicaid	$28,566.79
Rate for Payer: Molina Healthcare Managed Medicaid	$28,986.89

HIV With Major Related Condition With CC

Facility

$8,633.76

Service Code	MS-DRG 975
Hospital Charge Code	669
Min. Negotiated Rate	$8,508.64
Max. Negotiated Rate	$8,633.76
Rate for Payer: Amerigroup Medicaid	$8,592.05
Rate for Payer: Iowa Total Care Managed Medicaid	$8,508.64
Rate for Payer: Molina Healthcare Managed Medicaid	$8,633.76

HIV With Major Related Condition With MCC

Facility

$19,834.44

Service Code	MS-DRG 974
Hospital Charge Code	668
Min. Negotiated Rate	$19,546.98
Max. Negotiated Rate	$19,834.44
Rate for Payer: Amerigroup Medicaid	$19,738.62
Rate for Payer: Iowa Total Care Managed Medicaid	$19,546.98
Rate for Payer: Molina Healthcare Managed Medicaid	$19,834.44

HIV With Major Related Condition Without CC/MCC

Facility

$8,633.76

Service Code	MS-DRG 976
Hospital Charge Code	670
Min. Negotiated Rate	$8,508.64
Max. Negotiated Rate	$8,633.76
Rate for Payer: Amerigroup Medicaid	$8,592.05
Rate for Payer: Iowa Total Care Managed Medicaid	$8,508.64
Rate for Payer: Molina Healthcare Managed Medicaid	$8,633.76

HIV With or Without Other Related Condition

Facility

$9,940.84

Service Code	MS-DRG 977
Hospital Charge Code	671
Min. Negotiated Rate	$9,796.77
Max. Negotiated Rate	$9,940.84
Rate for Payer: Amerigroup Medicaid	$9,892.82
Rate for Payer: Iowa Total Care Managed Medicaid	$9,796.77
Rate for Payer: Molina Healthcare Managed Medicaid	$9,940.84

HLA B27 Blood DMCL

Facility

$152.00

Service Code	CPT 86812
Hospital Charge Code	8519282
Hospital Revenue Code	301
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Aetna of IA Medicare	$86.64
Rate for Payer: Amerigroup Medicaid	$76.71
Rate for Payer: Amerigroup Medicare	$76.76
Rate for Payer: Cash Price	$121.60
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.00
Rate for Payer: Iowa Total Care Managed Medicaid	$75.97
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Medical Associates Managed Medicare	$76.00
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: Molina Healthcare Managed Medicaid	$77.14
Rate for Payer: Molina Healthcare Managed Medicare	$77.09
Rate for Payer: Oscar Health of IA Commercial	$114.00
Rate for Payer: Partners Health Alliance Commercial	$114.00
Rate for Payer: United Healthcare Commercial	$136.80
Rate for Payer: United Healthcare Managed Medicare	$89.68
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

HLA B27 Blood DMCL

Facility

$152.00

Service Code	CPT 86812
Hospital Charge Code	8519282
Hospital Revenue Code	301
Min. Negotiated Rate	$106.40
Max. Negotiated Rate	$136.80
Rate for Payer: Aetna of IA Commercial	$136.80
Rate for Payer: Aetna of IA Medical Rental Products	$136.80
Rate for Payer: Cash Price	$121.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.00
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: United Healthcare Commercial	$136.80

Holter Monitor 24 Hour RT

Facility

$380.00

Service Code	CPT 93224
Hospital Charge Code	7068790
Hospital Revenue Code	731
Min. Negotiated Rate	$189.92
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna of IA Commercial	$342.00
Rate for Payer: Aetna of IA Medical Rental Products	$342.00
Rate for Payer: Aetna of IA Medicare	$216.60
Rate for Payer: Amerigroup Medicaid	$191.79
Rate for Payer: Amerigroup Medicare	$191.90
Rate for Payer: Cash Price	$304.00
Rate for Payer: Cash Price	$304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$285.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$190.00
Rate for Payer: Iowa Total Care Managed Medicaid	$189.92
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Medical Associates Managed Medicare	$190.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: Molina Healthcare Managed Medicaid	$192.85
Rate for Payer: Molina Healthcare Managed Medicare	$192.74
Rate for Payer: Oscar Health of IA Commercial	$285.00
Rate for Payer: Partners Health Alliance Commercial	$285.00
Rate for Payer: United Healthcare Commercial	$342.00
Rate for Payer: United Healthcare Managed Medicare	$224.20
Rate for Payer: Wellmark IA HMO	$281.48
Rate for Payer: Wellmark IA PPO	$309.63

Holter Monitor 24 Hour RT

Facility

$380.00

Service Code	CPT 93224
Hospital Charge Code	7068790
Hospital Revenue Code	731
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna of IA Commercial	$342.00
Rate for Payer: Aetna of IA Medical Rental Products	$342.00
Rate for Payer: Cash Price	$304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$285.00
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: United Healthcare Commercial	$342.00

Holter Monitor 48 Hour RT

Facility

$380.00

Service Code	CPT 93224
Hospital Charge Code	7068791
Hospital Revenue Code	731
Min. Negotiated Rate	$189.92
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna of IA Commercial	$342.00
Rate for Payer: Aetna of IA Medical Rental Products	$342.00
Rate for Payer: Aetna of IA Medicare	$216.60
Rate for Payer: Amerigroup Medicaid	$191.79
Rate for Payer: Amerigroup Medicare	$191.90
Rate for Payer: Cash Price	$304.00
Rate for Payer: Cash Price	$304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$285.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$190.00
Rate for Payer: Iowa Total Care Managed Medicaid	$189.92
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Medical Associates Managed Medicare	$190.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: Molina Healthcare Managed Medicaid	$192.85
Rate for Payer: Molina Healthcare Managed Medicare	$192.74
Rate for Payer: Oscar Health of IA Commercial	$285.00
Rate for Payer: Partners Health Alliance Commercial	$285.00
Rate for Payer: United Healthcare Commercial	$342.00
Rate for Payer: United Healthcare Managed Medicare	$224.20
Rate for Payer: Wellmark IA HMO	$281.48
Rate for Payer: Wellmark IA PPO	$309.63

Holter Monitor 48 Hour RT

Facility

$380.00

Service Code	CPT 93224
Hospital Charge Code	7068791
Hospital Revenue Code	731
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$342.00
Rate for Payer: Aetna of IA Commercial	$342.00
Rate for Payer: Aetna of IA Medical Rental Products	$342.00
Rate for Payer: Cash Price	$304.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$285.00
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: United Healthcare Commercial	$342.00

HOME SLEEP TEST - TYPE 3

Facility

$350.00

Service Code	CPT G0399
Hospital Charge Code	6174794
Hospital Revenue Code	920
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna of IA Commercial	$315.00
Rate for Payer: Aetna of IA Medical Rental Products	$315.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$262.50
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: United Healthcare Commercial	$315.00

HOME SLEEP TEST - TYPE 3

Facility

$350.00

Service Code	CPT G0399
Hospital Charge Code	6174794
Hospital Revenue Code	920
Min. Negotiated Rate	$174.93
Max. Negotiated Rate	$403.74
Rate for Payer: Aetna of IA Commercial	$315.00
Rate for Payer: Aetna of IA Medical Rental Products	$315.00
Rate for Payer: Aetna of IA Medicare	$199.50
Rate for Payer: Amerigroup Medicaid	$176.64
Rate for Payer: Amerigroup Medicare	$176.75
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$262.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$175.00
Rate for Payer: Iowa Total Care Managed Medicaid	$174.93
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Medical Associates Managed Medicare	$175.00
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: Molina Healthcare Managed Medicaid	$177.62
Rate for Payer: Molina Healthcare Managed Medicare	$177.52
Rate for Payer: Oscar Health of IA Commercial	$262.50
Rate for Payer: Partners Health Alliance Commercial	$262.50
Rate for Payer: United Healthcare Commercial	$315.00
Rate for Payer: United Healthcare Managed Medicare	$206.50
Rate for Payer: Wellmark IA HMO	$367.04
Rate for Payer: Wellmark IA PPO	$403.74

HOME SLEEP TEST - TYPE 3 PORTA

Facility

$350.00

Service Code	CPT G0399
Hospital Charge Code	6658835
Hospital Revenue Code	920
Min. Negotiated Rate	$174.93
Max. Negotiated Rate	$403.74
Rate for Payer: Aetna of IA Commercial	$315.00
Rate for Payer: Aetna of IA Medical Rental Products	$315.00
Rate for Payer: Aetna of IA Medicare	$199.50
Rate for Payer: Amerigroup Medicaid	$176.64
Rate for Payer: Amerigroup Medicare	$176.75
Rate for Payer: Cash Price	$280.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$262.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$175.00
Rate for Payer: Iowa Total Care Managed Medicaid	$174.93
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Medical Associates Managed Medicare	$175.00
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: Molina Healthcare Managed Medicaid	$177.62
Rate for Payer: Molina Healthcare Managed Medicare	$177.52
Rate for Payer: Oscar Health of IA Commercial	$262.50
Rate for Payer: Partners Health Alliance Commercial	$262.50
Rate for Payer: United Healthcare Commercial	$315.00
Rate for Payer: United Healthcare Managed Medicare	$206.50
Rate for Payer: Wellmark IA HMO	$367.04
Rate for Payer: Wellmark IA PPO	$403.74

HOME SLEEP TEST - TYPE 3 PORTA

Facility

$350.00

Service Code	CPT G0399
Hospital Charge Code	6658835
Hospital Revenue Code	920
Min. Negotiated Rate	$245.00
Max. Negotiated Rate	$315.00
Rate for Payer: Aetna of IA Commercial	$315.00
Rate for Payer: Aetna of IA Medical Rental Products	$315.00
Rate for Payer: Cash Price	$280.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$262.50
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: United Healthcare Commercial	$315.00

Homocysteine DMCL

Facility

$161.00

Service Code	CPT 83090
Hospital Charge Code	8037876
Hospital Revenue Code	301
Min. Negotiated Rate	$112.70
Max. Negotiated Rate	$144.90
Rate for Payer: Aetna of IA Commercial	$144.90
Rate for Payer: Aetna of IA Medical Rental Products	$144.90
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: United Healthcare Commercial	$144.90

Know your out-of-pocket cost for care.

All Charges