Van Diest Medical Center

All Charges

Charge

Type

Price

Inguinal and Femoral Hernia Procedures With CC

Facility IP

$11,546.14

Service Code	MS-DRG 351
Hospital Charge Code	201
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,546.14
Rate for Payer: Amerigroup Medicaid	$11,490.36
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$11,378.80
Rate for Payer: Molina Healthcare Managed Medicaid	$11,546.14

Inguinal and Femoral Hernia Procedures With MCC

Facility IP

$17,359.07

Service Code	MS-DRG 350
Hospital Charge Code	200
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$17,359.07
Rate for Payer: Amerigroup Medicaid	$17,275.21
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$17,107.49
Rate for Payer: Molina Healthcare Managed Medicaid	$17,359.07

Inguinal and Femoral Hernia Procedures Without CC/MCC

Facility IP

$7,914.28

Service Code	MS-DRG 352
Hospital Charge Code	202
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$7,914.28
Rate for Payer: Amerigroup Medicaid	$7,876.05
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7,799.58
Rate for Payer: Molina Healthcare Managed Medicaid	$7,914.28

INHIBIN A

Facility OP

$106.00

Service Code	CPT 86336
Hospital Charge Code	8086834
Hospital Revenue Code	302
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of IA Commercial	$95.40
Rate for Payer: Aetna of IA Medical Rental Products	$95.40
Rate for Payer: Aetna of IA Medicare	$60.42
Rate for Payer: Amerigroup Medicaid	$53.50
Rate for Payer: Amerigroup Medicare	$53.53
Rate for Payer: Cash Price	$84.80
Rate for Payer: Cash Price	$84.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$79.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$53.00
Rate for Payer: Iowa Total Care Managed Medicaid	$52.98
Rate for Payer: Medical Associates Commercial	$79.50
Rate for Payer: Medical Associates Managed Medicare	$53.00
Rate for Payer: Midlands Choice Commercial	$74.20
Rate for Payer: Molina Healthcare Managed Medicaid	$53.80
Rate for Payer: Partners Health Alliance Commercial	$79.50
Rate for Payer: United Healthcare Commercial	$95.40
Rate for Payer: United Healthcare Managed Medicare	$62.54
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

INHIBIN A

Facility IP

$106.00

Service Code	CPT 86336
Hospital Charge Code	8086834
Hospital Revenue Code	302
Min. Negotiated Rate	$74.20
Max. Negotiated Rate	$95.40
Rate for Payer: Aetna of IA Commercial	$95.40
Rate for Payer: Aetna of IA Medical Rental Products	$95.40
Rate for Payer: Cash Price	$84.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$79.50
Rate for Payer: Medical Associates Commercial	$79.50
Rate for Payer: Midlands Choice Commercial	$74.20
Rate for Payer: United Healthcare Commercial	$95.40

Initial

Facility IP

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663519
Hospital Revenue Code	943
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$128.70

Initial

Facility OP

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663519
Hospital Revenue Code	943
Min. Negotiated Rate	$71.47
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$72.17
Rate for Payer: Amerigroup Medicare	$72.22
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$71.50
Rate for Payer: Iowa Total Care Managed Medicaid	$71.47
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$71.50
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$72.57
Rate for Payer: Partners Health Alliance Commercial	$107.25
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37

Initial - KX

Facility IP

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663518
Hospital Revenue Code	943
Min. Negotiated Rate	$100.10
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: United Healthcare Commercial	$128.70

Initial - KX

Facility OP

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663518
Hospital Revenue Code	943
Min. Negotiated Rate	$71.47
Max. Negotiated Rate	$128.70
Rate for Payer: Aetna of IA Commercial	$128.70
Rate for Payer: Aetna of IA Medical Rental Products	$128.70
Rate for Payer: Aetna of IA Medicare	$81.51
Rate for Payer: Amerigroup Medicaid	$72.17
Rate for Payer: Amerigroup Medicare	$72.22
Rate for Payer: Cash Price	$114.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$107.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$71.50
Rate for Payer: Iowa Total Care Managed Medicaid	$71.47
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$71.50
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$72.57
Rate for Payer: Partners Health Alliance Commercial	$107.25
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37

INJECT EPIDURAL PATCH

Facility IP

$1,120.00

Service Code	CPT 62273
Hospital Charge Code	4866803
Hospital Revenue Code	761
Min. Negotiated Rate	$784.00
Max. Negotiated Rate	$1,008.00
Rate for Payer: Aetna of IA Commercial	$1,008.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.00
Rate for Payer: Cash Price	$896.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.00
Rate for Payer: Medical Associates Commercial	$840.00
Rate for Payer: Midlands Choice Commercial	$784.00
Rate for Payer: United Healthcare Commercial	$1,008.00

INJECT EPIDURAL PATCH

Facility OP

$1,120.00

Service Code	CPT 62273
Hospital Charge Code	4866803
Hospital Revenue Code	761
Min. Negotiated Rate	$559.78
Max. Negotiated Rate	$1,487.44
Rate for Payer: Aetna of IA Commercial	$1,008.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,008.00
Rate for Payer: Aetna of IA Medicare	$638.40
Rate for Payer: Amerigroup Medicaid	$565.26
Rate for Payer: Amerigroup Medicare	$565.60
Rate for Payer: Cash Price	$896.00
Rate for Payer: Cash Price	$896.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$840.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$560.00
Rate for Payer: Iowa Total Care Managed Medicaid	$559.78
Rate for Payer: Medical Associates Commercial	$840.00
Rate for Payer: Medical Associates Managed Medicare	$560.00
Rate for Payer: Midlands Choice Commercial	$784.00
Rate for Payer: Molina Healthcare Managed Medicaid	$568.40
Rate for Payer: Partners Health Alliance Commercial	$840.00
Rate for Payer: United Healthcare Commercial	$1,008.00
Rate for Payer: United Healthcare Managed Medicare	$660.80
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

INJECT FOR SPINE DISK X-RAY LUMBAR

Professional

$1,176.00

Service Code	CPT 62290
Hospital Charge Code	8101308
Hospital Revenue Code	975
Min. Negotiated Rate	$142.93
Max. Negotiated Rate	$823.20
Rate for Payer: Aetna of IA Medicare	$142.93
Rate for Payer: Amerigroup Medicaid	$147.79
Rate for Payer: Cash Price	$940.80
Rate for Payer: Cash Price	$940.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$171.52
Rate for Payer: Iowa Total Care Managed Medicaid	$145.79
Rate for Payer: Medical Associates Commercial	$271.57
Rate for Payer: Medical Associates Managed Medicare	$142.93
Rate for Payer: Midlands Choice Commercial	$823.20
Rate for Payer: Partners Health Alliance Commercial	$214.40
Rate for Payer: Wellmark IA HMO	$292.00
Rate for Payer: Wellmark IA PPO	$342.00

Injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance (fluoroscopy or CT) including arthrography when performed

Facility OP

$1,151.90

Service Code	CPT 27096
Hospital Revenue Code	360
Min. Negotiated Rate	$1,047.18
Max. Negotiated Rate	$1,151.90
Rate for Payer: Wellmark IA HMO	$1,047.18
Rate for Payer: Wellmark IA PPO	$1,151.90

Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed

Facility OP

$703.14

Service Code	CPT 64454
Hospital Revenue Code	360
Min. Negotiated Rate	$639.22
Max. Negotiated Rate	$703.14
Rate for Payer: Wellmark IA HMO	$639.22
Rate for Payer: Wellmark IA PPO	$703.14

Injection(s), anesthetic agent(s) and/or steroid; other peripheral nerve or branch

Facility OP

$703.14

Service Code	CPT 64450
Hospital Revenue Code	360
Min. Negotiated Rate	$639.22
Max. Negotiated Rate	$703.14
Rate for Payer: Wellmark IA HMO	$639.22
Rate for Payer: Wellmark IA PPO	$703.14

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, each additional level (List separately in addition to code for primary procedure)

Facility OP

$1,487.44

Service Code	CPT 64484
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), anesthetic agent(s) and/or steroid; transforaminal epidural, with imaging guidance (fluoroscopy or CT), lumbar or sacral, single level

Facility OP

$1,487.44

Service Code	CPT 64483
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; second level (List separately in addition to code for primary procedure)

Facility OP

$1,487.44

Service Code	CPT 64491
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level

Facility OP

$1,487.44

Service Code	CPT 64490
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; third and any additional level(s) (List separately in addition to code for primary procedure)

Facility OP

$1,487.44

Service Code	CPT 64492
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; second level (List separately in addition to code for primary procedure)

Facility OP

$1,487.44

Service Code	CPT 64494
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level

Facility OP

$1,487.44

Service Code	CPT 64493
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure)

Facility OP

$1,487.44

Service Code	CPT 64495
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; with imaging guidance (ie, fluoroscopy or CT)

Facility OP

$1,487.44

Service Code	CPT 62321
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

Injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT)

Facility OP

$1,487.44

Service Code	CPT 62323
Hospital Revenue Code	360
Min. Negotiated Rate	$1,352.22
Max. Negotiated Rate	$1,487.44
Rate for Payer: Wellmark IA HMO	$1,352.22
Rate for Payer: Wellmark IA PPO	$1,487.44

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