Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

HIV 1 2 DMCL

Facility

$91.00

Service Code	CPT 87389
Hospital Charge Code	8037875
Hospital Revenue Code	302
Min. Negotiated Rate	$34.03
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	$52.49
Rate for Payer: Amerigroup Medicare	$41.36
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	$40.95
Rate for Payer: Iowa Total Care Managed Medicaid	$51.98
Rate for Payer: Medical Associates Commercial	$68.25
Rate for Payer: Medical Associates Managed Medicare	$40.95
Rate for Payer: Midlands Choice Commercial	$63.70
Rate for Payer: Molina Healthcare Managed Medicaid	$52.74
Rate for Payer: Partners Health Alliance Commercial	$47.09
Rate for Payer: United Healthcare Commercial	$81.90
Rate for Payer: United Healthcare Managed Medicare	$53.69
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

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 IN HOUSE

Facility

$76.00

Service Code	HCPCS G0433
Hospital Charge Code	4017669
Hospital Revenue Code	302
Min. Negotiated Rate	$34.03
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	$43.84
Rate for Payer: Amerigroup Medicare	$34.54
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	$34.20
Rate for Payer: Iowa Total Care Managed Medicaid	$43.41
Rate for Payer: Medical Associates Commercial	$57.00
Rate for Payer: Medical Associates Managed Medicare	$34.20
Rate for Payer: Midlands Choice Commercial	$53.20
Rate for Payer: Molina Healthcare Managed Medicaid	$44.05
Rate for Payer: Partners Health Alliance Commercial	$39.33
Rate for Payer: United Healthcare Commercial	$68.40
Rate for Payer: United Healthcare Managed Medicare	$44.84
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

HIV IN HOUSE

Facility

$76.00

Service Code	HCPCS G0433
Hospital Charge Code	633757
Hospital Revenue Code	302
Min. Negotiated Rate	$34.03
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	$43.84
Rate for Payer: Amerigroup Medicare	$34.54
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	$34.20
Rate for Payer: Iowa Total Care Managed Medicaid	$43.41
Rate for Payer: Medical Associates Commercial	$57.00
Rate for Payer: Medical Associates Managed Medicare	$34.20
Rate for Payer: Midlands Choice Commercial	$53.20
Rate for Payer: Molina Healthcare Managed Medicaid	$44.05
Rate for Payer: Partners Health Alliance Commercial	$39.33
Rate for Payer: United Healthcare Commercial	$68.40
Rate for Payer: United Healthcare Managed Medicare	$44.84
Rate for Payer: Wellmark IA HMO WHPI	$34.03
Rate for Payer: Wellmark IA PPO	$37.49

HIV IN HOUSE

Facility

$76.00

Service Code	HCPCS 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	HCPCS 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 WITH EXTENSIVE O.R. PROCEDURES WITH MCC

Facility

$65,181.68

Service Code	MSDRG 969
Min. Negotiated Rate	$64,236.99
Max. Negotiated Rate	$65,181.68
Rate for Payer: Amerigroup Medicaid	$64,866.77
Rate for Payer: Iowa Total Care Managed Medicaid	$64,236.99
Rate for Payer: Molina Healthcare Managed Medicaid	$65,181.68

HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC

Facility

$33,161.15

Service Code	MSDRG 970
Min. Negotiated Rate	$32,680.54
Max. Negotiated Rate	$33,161.15
Rate for Payer: Amerigroup Medicaid	$33,000.94
Rate for Payer: Iowa Total Care Managed Medicaid	$32,680.54
Rate for Payer: Molina Healthcare Managed Medicaid	$33,161.15

HIV WITH MAJOR RELATED CONDITION WITH CC

Facility

$9,877.07

Service Code	MSDRG 975
Min. Negotiated Rate	$9,733.92
Max. Negotiated Rate	$9,877.07
Rate for Payer: Amerigroup Medicaid	$9,829.35
Rate for Payer: Iowa Total Care Managed Medicaid	$9,733.92
Rate for Payer: Molina Healthcare Managed Medicaid	$9,877.07

HIV WITH MAJOR RELATED CONDITION WITH MCC

Facility

$22,690.69

Service Code	MSDRG 974
Min. Negotiated Rate	$22,361.83
Max. Negotiated Rate	$22,690.69
Rate for Payer: Amerigroup Medicaid	$22,581.06
Rate for Payer: Iowa Total Care Managed Medicaid	$22,361.83
Rate for Payer: Molina Healthcare Managed Medicaid	$22,690.69

HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC

Facility

$9,877.07

Service Code	MSDRG 976
Min. Negotiated Rate	$9,733.92
Max. Negotiated Rate	$9,877.07
Rate for Payer: Amerigroup Medicaid	$9,829.35
Rate for Payer: Iowa Total Care Managed Medicaid	$9,733.92
Rate for Payer: Molina Healthcare Managed Medicaid	$9,877.07

HIV WITH OR WITHOUT OTHER RELATED CONDITION

Facility

$11,372.37

Service Code	MSDRG 977
Min. Negotiated Rate	$11,207.55
Max. Negotiated Rate	$11,372.37
Rate for Payer: Amerigroup Medicaid	$11,317.42
Rate for Payer: Iowa Total Care Managed Medicaid	$11,207.55
Rate for Payer: Molina Healthcare Managed Medicaid	$11,372.37

HLA B27 Blood DMCL

Facility

$152.00

Service Code	CPT 86812
Hospital Charge Code	8519282
Hospital Revenue Code	301
Min. Negotiated Rate	$50.34
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	$87.67
Rate for Payer: Amerigroup Medicare	$69.08
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	$68.40
Rate for Payer: Iowa Total Care Managed Medicaid	$86.82
Rate for Payer: Medical Associates Commercial	$114.00
Rate for Payer: Medical Associates Managed Medicare	$68.40
Rate for Payer: Midlands Choice Commercial	$106.40
Rate for Payer: Molina Healthcare Managed Medicaid	$88.10
Rate for Payer: Partners Health Alliance Commercial	$78.66
Rate for Payer: United Healthcare Commercial	$136.80
Rate for Payer: United Healthcare Managed Medicare	$89.68
Rate for Payer: Wellmark IA HMO WHPI	$50.34
Rate for Payer: Wellmark IA PPO	$55.45

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	$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 24 Hour RT

Facility

$380.00

Service Code	CPT 93224
Hospital Charge Code	7068790
Hospital Revenue Code	731
Min. Negotiated Rate	$171.00
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: Aetna of IA Medicare	$216.60
Rate for Payer: Amerigroup Medicaid	$219.18
Rate for Payer: Amerigroup Medicare	$172.71
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	$171.00
Rate for Payer: Iowa Total Care Managed Medicaid	$217.06
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Medical Associates Managed Medicare	$171.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: Molina Healthcare Managed Medicaid	$220.25
Rate for Payer: Partners Health Alliance Commercial	$196.65
Rate for Payer: United Healthcare Commercial	$342.00
Rate for Payer: United Healthcare Managed Medicare	$224.20
Rate for Payer: Wellmark IA HMO WHPI	$183.63
Rate for Payer: Wellmark IA PPO	$202.28

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

Holter Monitor 48 Hour RT

Facility

$380.00

Service Code	CPT 93224
Hospital Charge Code	7068791
Hospital Revenue Code	731
Min. Negotiated Rate	$171.00
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: Aetna of IA Medicare	$216.60
Rate for Payer: Amerigroup Medicaid	$219.18
Rate for Payer: Amerigroup Medicare	$172.71
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	$171.00
Rate for Payer: Iowa Total Care Managed Medicaid	$217.06
Rate for Payer: Medical Associates Commercial	$285.00
Rate for Payer: Medical Associates Managed Medicare	$171.00
Rate for Payer: Midlands Choice Commercial	$266.00
Rate for Payer: Molina Healthcare Managed Medicaid	$220.25
Rate for Payer: Partners Health Alliance Commercial	$196.65
Rate for Payer: United Healthcare Commercial	$342.00
Rate for Payer: United Healthcare Managed Medicare	$224.20
Rate for Payer: Wellmark IA HMO WHPI	$183.63
Rate for Payer: Wellmark IA PPO	$202.28

HOME SLEEP TEST - TYPE 3

Facility

$350.00

Service Code	HCPCS 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	HCPCS G0399
Hospital Charge Code	6658835
Hospital Revenue Code	920
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$618.55
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	$201.88
Rate for Payer: Amerigroup Medicare	$159.08
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	$157.50
Rate for Payer: Iowa Total Care Managed Medicaid	$199.92
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Medical Associates Managed Medicare	$157.50
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: Molina Healthcare Managed Medicaid	$202.86
Rate for Payer: Partners Health Alliance Commercial	$181.12
Rate for Payer: United Healthcare Commercial	$315.00
Rate for Payer: United Healthcare Managed Medicare	$206.50
Rate for Payer: Wellmark IA HMO WHPI	$561.53
Rate for Payer: Wellmark IA PPO	$618.55

HOME SLEEP TEST - TYPE 3

Facility

$350.00

Service Code	HCPCS 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

HOME SLEEP TEST - TYPE 3

Facility

$350.00

Service Code	HCPCS G0399
Hospital Charge Code	6174794
Hospital Revenue Code	920
Min. Negotiated Rate	$157.50
Max. Negotiated Rate	$618.55
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	$201.88
Rate for Payer: Amerigroup Medicare	$159.08
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	$157.50
Rate for Payer: Iowa Total Care Managed Medicaid	$199.92
Rate for Payer: Medical Associates Commercial	$262.50
Rate for Payer: Medical Associates Managed Medicare	$157.50
Rate for Payer: Midlands Choice Commercial	$245.00
Rate for Payer: Molina Healthcare Managed Medicaid	$202.86
Rate for Payer: Partners Health Alliance Commercial	$181.12
Rate for Payer: United Healthcare Commercial	$315.00
Rate for Payer: United Healthcare Managed Medicare	$206.50
Rate for Payer: Wellmark IA HMO WHPI	$561.53
Rate for Payer: Wellmark IA PPO	$618.55

Homocysteine DMCL

Facility

$161.00

Service Code	CPT 83090
Hospital Charge Code	8037876
Hospital Revenue Code	301
Min. Negotiated Rate	$49.63
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: Aetna of IA Medicare	$91.77
Rate for Payer: Amerigroup Medicaid	$92.86
Rate for Payer: Amerigroup Medicare	$73.17
Rate for Payer: Cash Price	$128.80
Rate for Payer: Cash Price	$128.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$72.45
Rate for Payer: Iowa Total Care Managed Medicaid	$91.96
Rate for Payer: Medical Associates Commercial	$120.75
Rate for Payer: Medical Associates Managed Medicare	$72.45
Rate for Payer: Midlands Choice Commercial	$112.70
Rate for Payer: Molina Healthcare Managed Medicaid	$93.32
Rate for Payer: Partners Health Alliance Commercial	$83.32
Rate for Payer: United Healthcare Commercial	$144.90
Rate for Payer: United Healthcare Managed Medicare	$94.99
Rate for Payer: Wellmark IA HMO WHPI	$49.63
Rate for Payer: Wellmark IA PPO	$54.67

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

HORMONE BINDING GLOBULIN

Facility

$177.00

Service Code	CPT 84270
Hospital Charge Code	8093936
Hospital Revenue Code	301
Min. Negotiated Rate	$123.90
Max. Negotiated Rate	$159.30
Rate for Payer: Aetna of IA Commercial	$159.30
Rate for Payer: Aetna of IA Medical Rental Products	$159.30
Rate for Payer: Cash Price	$141.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$132.75
Rate for Payer: Medical Associates Commercial	$132.75
Rate for Payer: Midlands Choice Commercial	$123.90
Rate for Payer: United Healthcare Commercial	$159.30

Know your out-of-pocket cost for care.

All Charges