Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Hep B Sur Ab Quant DMCL

Facility

$88.00

Service Code	CPT 86706
Hospital Charge Code	8037862
Hospital Revenue Code	302
Min. Negotiated Rate	$39.60
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of IA Commercial	$79.20
Rate for Payer: Aetna of IA Medical Rental Products	$79.20
Rate for Payer: Aetna of IA Medicare	$50.16
Rate for Payer: Amerigroup Medicaid	$50.76
Rate for Payer: Amerigroup Medicare	$40.00
Rate for Payer: Cash Price	$70.40
Rate for Payer: Cash Price	$70.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$39.60
Rate for Payer: Iowa Total Care Managed Medicaid	$50.27
Rate for Payer: Medical Associates Commercial	$66.00
Rate for Payer: Medical Associates Managed Medicare	$39.60
Rate for Payer: Midlands Choice Commercial	$61.60
Rate for Payer: Molina Healthcare Managed Medicaid	$51.00
Rate for Payer: Partners Health Alliance Commercial	$45.54
Rate for Payer: United Healthcare Commercial	$79.20
Rate for Payer: United Healthcare Managed Medicare	$51.92
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

Hep B Sur Ab Quant DMCL

Facility

$88.00

Service Code	CPT 86706
Hospital Charge Code	8037862
Hospital Revenue Code	302
Min. Negotiated Rate	$61.60
Max. Negotiated Rate	$79.20
Rate for Payer: Aetna of IA Commercial	$79.20
Rate for Payer: Aetna of IA Medical Rental Products	$79.20
Rate for Payer: Cash Price	$70.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.00
Rate for Payer: Medical Associates Commercial	$66.00
Rate for Payer: Midlands Choice Commercial	$61.60
Rate for Payer: United Healthcare Commercial	$79.20

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC

Facility

$17,055.17

Service Code	MSDRG 354
Min. Negotiated Rate	$16,807.99
Max. Negotiated Rate	$17,055.17
Rate for Payer: Amerigroup Medicaid	$16,972.77
Rate for Payer: Iowa Total Care Managed Medicaid	$16,807.99
Rate for Payer: Molina Healthcare Managed Medicaid	$17,055.17

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC

Facility

$22,679.43

Service Code	MSDRG 353
Min. Negotiated Rate	$22,350.73
Max. Negotiated Rate	$22,679.43
Rate for Payer: Amerigroup Medicaid	$22,569.86
Rate for Payer: Iowa Total Care Managed Medicaid	$22,350.73
Rate for Payer: Molina Healthcare Managed Medicaid	$22,679.43

HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC

Facility

$15,193.93

Service Code	MSDRG 355
Min. Negotiated Rate	$14,973.73
Max. Negotiated Rate	$15,193.93
Rate for Payer: Amerigroup Medicaid	$15,120.53
Rate for Payer: Iowa Total Care Managed Medicaid	$14,973.73
Rate for Payer: Molina Healthcare Managed Medicaid	$15,193.93

Herpes Simplex PCR Qual DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037869
Hospital Revenue Code	306
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82
Rate for Payer: Wellmark IA HMO WHPI	$86.50
Rate for Payer: Wellmark IA PPO	$95.28

Herpes Simplex PCR Qual DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037869
Hospital Revenue Code	306
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

Herpes Simplex PCR Qual Stat DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037870
Hospital Revenue Code	306
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82
Rate for Payer: Wellmark IA HMO WHPI	$86.50
Rate for Payer: Wellmark IA PPO	$95.28

Herpes Simplex PCR Qual Stat DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037870
Hospital Revenue Code	306
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

Herpes Simplex Virus by PCR DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037872
Hospital Revenue Code	306
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82
Rate for Payer: Wellmark IA HMO WHPI	$86.50
Rate for Payer: Wellmark IA PPO	$95.28

Herpes Simplex Virus by PCR DMCL

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8037872
Hospital Revenue Code	306
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

Herpes Simplex Virus IgM Antibody DMCL

Facility

$118.00

Service Code	CPT 86694
Hospital Charge Code	8037873
Hospital Revenue Code	302
Min. Negotiated Rate	$82.60
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna of IA Commercial	$106.20
Rate for Payer: Aetna of IA Medical Rental Products	$106.20
Rate for Payer: Cash Price	$94.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$88.50
Rate for Payer: Medical Associates Commercial	$88.50
Rate for Payer: Midlands Choice Commercial	$82.60
Rate for Payer: United Healthcare Commercial	$106.20

Herpes Simplex Virus IgM Antibody DMCL

Facility

$118.00

Service Code	CPT 86694
Hospital Charge Code	8037873
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$106.20
Rate for Payer: Aetna of IA Commercial	$106.20
Rate for Payer: Aetna of IA Medical Rental Products	$106.20
Rate for Payer: Aetna of IA Medicare	$67.26
Rate for Payer: Amerigroup Medicaid	$68.06
Rate for Payer: Amerigroup Medicare	$53.63
Rate for Payer: Cash Price	$94.40
Rate for Payer: Cash Price	$94.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$88.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$53.10
Rate for Payer: Iowa Total Care Managed Medicaid	$67.40
Rate for Payer: Medical Associates Commercial	$88.50
Rate for Payer: Medical Associates Managed Medicare	$53.10
Rate for Payer: Midlands Choice Commercial	$82.60
Rate for Payer: Molina Healthcare Managed Medicaid	$68.39
Rate for Payer: Partners Health Alliance Commercial	$61.06
Rate for Payer: United Healthcare Commercial	$106.20
Rate for Payer: United Healthcare Managed Medicare	$69.62
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

HERPES SIMPLEX VIRUS PCR

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8093935
Hospital Revenue Code	306
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

HERPES SIMPLEX VIRUS PCR

Facility

$198.00

Service Code	CPT 87529
Hospital Charge Code	8093935
Hospital Revenue Code	306
Min. Negotiated Rate	$86.50
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82
Rate for Payer: Wellmark IA HMO WHPI	$86.50
Rate for Payer: Wellmark IA PPO	$95.28

hetastarch 60 mg/mL-NS IV Sol [VDMC]

Facility

$112.26

Service Code	HCPCS J3490
Hospital Charge Code	10393629
Hospital Revenue Code	259
Min. Negotiated Rate	$50.52
Max. Negotiated Rate	$101.03
Rate for Payer: Aetna of IA Commercial	$101.03
Rate for Payer: Aetna of IA Medical Rental Products	$101.03
Rate for Payer: Aetna of IA Medicare	$63.99
Rate for Payer: Amerigroup Medicaid	$64.75
Rate for Payer: Amerigroup Medicare	$51.02
Rate for Payer: Cash Price	$89.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$84.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$50.52
Rate for Payer: Iowa Total Care Managed Medicaid	$64.12
Rate for Payer: Medical Associates Commercial	$84.20
Rate for Payer: Medical Associates Managed Medicare	$50.52
Rate for Payer: Midlands Choice Commercial	$78.58
Rate for Payer: Molina Healthcare Managed Medicaid	$65.07
Rate for Payer: Partners Health Alliance Commercial	$58.09
Rate for Payer: United Healthcare Commercial	$101.03
Rate for Payer: United Healthcare Managed Medicare	$66.23

hetastarch 60 mg/mL-NS IV Sol [VDMC]

Facility

$112.26

Service Code	HCPCS J3490
Hospital Charge Code	10393629
Hospital Revenue Code	259
Min. Negotiated Rate	$78.58
Max. Negotiated Rate	$101.03
Rate for Payer: Aetna of IA Commercial	$101.03
Rate for Payer: Aetna of IA Medical Rental Products	$101.03
Rate for Payer: Cash Price	$89.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$84.20
Rate for Payer: Medical Associates Commercial	$84.20
Rate for Payer: Midlands Choice Commercial	$78.58
Rate for Payer: United Healthcare Commercial	$101.03

Hgb A1C

Facility

$77.00

Service Code	CPT 83036
Hospital Charge Code	1383763
Hospital Revenue Code	301
Min. Negotiated Rate	$30.49
Max. Negotiated Rate	$69.30
Rate for Payer: Aetna of IA Commercial	$69.30
Rate for Payer: Aetna of IA Medical Rental Products	$69.30
Rate for Payer: Aetna of IA Medicare	$43.89
Rate for Payer: Amerigroup Medicaid	$44.41
Rate for Payer: Amerigroup Medicare	$35.00
Rate for Payer: Cash Price	$61.60
Rate for Payer: Cash Price	$61.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$34.65
Rate for Payer: Iowa Total Care Managed Medicaid	$43.98
Rate for Payer: Medical Associates Commercial	$57.75
Rate for Payer: Medical Associates Managed Medicare	$34.65
Rate for Payer: Midlands Choice Commercial	$53.90
Rate for Payer: Molina Healthcare Managed Medicaid	$44.63
Rate for Payer: Partners Health Alliance Commercial	$39.85
Rate for Payer: United Healthcare Commercial	$69.30
Rate for Payer: United Healthcare Managed Medicare	$45.43
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

Hgb A1C

Facility

$77.00

Service Code	CPT 83036
Hospital Charge Code	1383763
Hospital Revenue Code	301
Min. Negotiated Rate	$53.90
Max. Negotiated Rate	$69.30
Rate for Payer: Aetna of IA Commercial	$69.30
Rate for Payer: Aetna of IA Medical Rental Products	$69.30
Rate for Payer: Cash Price	$61.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$57.75
Rate for Payer: Medical Associates Commercial	$57.75
Rate for Payer: Midlands Choice Commercial	$53.90
Rate for Payer: United Healthcare Commercial	$69.30

HHN/MDI DEMONSTRATE AND/OR EVAL

Facility

$165.00

Service Code	CPT 94664
Hospital Charge Code	5338934
Hospital Revenue Code	412
Min. Negotiated Rate	$74.25
Max. Negotiated Rate	$203.84
Rate for Payer: Aetna of IA Commercial	$148.50
Rate for Payer: Aetna of IA Medical Rental Products	$148.50
Rate for Payer: Aetna of IA Medicare	$94.05
Rate for Payer: Amerigroup Medicaid	$95.17
Rate for Payer: Amerigroup Medicare	$74.99
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$123.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$74.25
Rate for Payer: Iowa Total Care Managed Medicaid	$94.25
Rate for Payer: Medical Associates Commercial	$123.75
Rate for Payer: Medical Associates Managed Medicare	$74.25
Rate for Payer: Midlands Choice Commercial	$115.50
Rate for Payer: Molina Healthcare Managed Medicaid	$95.63
Rate for Payer: Partners Health Alliance Commercial	$85.39
Rate for Payer: United Healthcare Commercial	$148.50
Rate for Payer: United Healthcare Managed Medicare	$97.35
Rate for Payer: Wellmark IA HMO WHPI	$185.05
Rate for Payer: Wellmark IA PPO	$203.84

HHN/MDI DEMONSTRATE AND/OR EVAL

Facility

$165.00

Service Code	CPT 94664
Hospital Charge Code	5338934
Hospital Revenue Code	412
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of IA Commercial	$148.50
Rate for Payer: Aetna of IA Medical Rental Products	$148.50
Rate for Payer: Cash Price	$132.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$123.75
Rate for Payer: Medical Associates Commercial	$123.75
Rate for Payer: Midlands Choice Commercial	$115.50
Rate for Payer: United Healthcare Commercial	$148.50

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC

Facility

$22,999.21

Service Code	MSDRG 481
Min. Negotiated Rate	$22,665.87
Max. Negotiated Rate	$22,999.21
Rate for Payer: Amerigroup Medicaid	$22,888.09
Rate for Payer: Iowa Total Care Managed Medicaid	$22,665.87
Rate for Payer: Molina Healthcare Managed Medicaid	$22,999.21

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC

Facility

$31,420.39

Service Code	MSDRG 480
Min. Negotiated Rate	$30,965.01
Max. Negotiated Rate	$31,420.39
Rate for Payer: Amerigroup Medicaid	$31,268.58
Rate for Payer: Iowa Total Care Managed Medicaid	$30,965.01
Rate for Payer: Molina Healthcare Managed Medicaid	$31,420.39

HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC

Facility

$16,206.19

Service Code	MSDRG 482
Min. Negotiated Rate	$15,971.31
Max. Negotiated Rate	$16,206.19
Rate for Payer: Amerigroup Medicaid	$16,127.89
Rate for Payer: Iowa Total Care Managed Medicaid	$15,971.31
Rate for Payer: Molina Healthcare Managed Medicaid	$16,206.19

HIP FEMORAL HEAD 32MM

Facility

$1,510.00

Service Code	HCPCS C1776
Hospital Charge Code	8025900
Hospital Revenue Code	278
Min. Negotiated Rate	$1,057.00
Max. Negotiated Rate	$1,359.00
Rate for Payer: Aetna of IA Commercial	$1,359.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,359.00
Rate for Payer: Cash Price	$1,208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,132.50
Rate for Payer: Medical Associates Commercial	$1,132.50
Rate for Payer: Midlands Choice Commercial	$1,057.00
Rate for Payer: United Healthcare Commercial	$1,359.00

Know your out-of-pocket cost for care.

All Charges