Van Diest Medical Center

All Charges

Charge

Type

Price

insulin lispro-insulin lispro protamine 25 units-75 units/mL

Facility OP

$92.93

Service Code	CPT J1815
Hospital Charge Code	43700083
Hospital Revenue Code	636
Min. Negotiated Rate	$46.45
Max. Negotiated Rate	$83.64
Rate for Payer: Aetna of IA Commercial	$83.64
Rate for Payer: Aetna of IA Medical Rental Products	$83.64
Rate for Payer: Aetna of IA Medicare	$52.97
Rate for Payer: Amerigroup Medicaid	$46.90
Rate for Payer: Amerigroup Medicare	$46.93
Rate for Payer: Cash Price	$74.34
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.70
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$46.46
Rate for Payer: Iowa Total Care Managed Medicaid	$46.45
Rate for Payer: Medical Associates Commercial	$69.70
Rate for Payer: Medical Associates Managed Medicare	$46.46
Rate for Payer: Midlands Choice Commercial	$65.05
Rate for Payer: Molina Healthcare Managed Medicaid	$47.16
Rate for Payer: Partners Health Alliance Commercial	$69.70
Rate for Payer: United Healthcare Commercial	$83.64
Rate for Payer: United Healthcare Managed Medicare	$54.83

insulin regular human recombinant 100 units/mL 3 ML Inj Sol

Facility IP

$32.80

Service Code	CPT J1815
Hospital Charge Code	43706016
Hospital Revenue Code	636
Min. Negotiated Rate	$22.96
Max. Negotiated Rate	$29.52
Rate for Payer: Aetna of IA Commercial	$29.52
Rate for Payer: Aetna of IA Medical Rental Products	$29.52
Rate for Payer: Cash Price	$26.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.60
Rate for Payer: Medical Associates Commercial	$24.60
Rate for Payer: Midlands Choice Commercial	$22.96
Rate for Payer: United Healthcare Commercial	$29.52

insulin regular human recombinant 100 units/mL 3 ML Inj Sol

Facility OP

$32.80

Service Code	CPT J1815
Hospital Charge Code	43706016
Hospital Revenue Code	636
Min. Negotiated Rate	$16.39
Max. Negotiated Rate	$29.52
Rate for Payer: Aetna of IA Commercial	$29.52
Rate for Payer: Aetna of IA Medical Rental Products	$29.52
Rate for Payer: Aetna of IA Medicare	$18.70
Rate for Payer: Amerigroup Medicaid	$16.55
Rate for Payer: Amerigroup Medicare	$16.56
Rate for Payer: Cash Price	$26.24
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$24.60
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$16.40
Rate for Payer: Iowa Total Care Managed Medicaid	$16.39
Rate for Payer: Medical Associates Commercial	$24.60
Rate for Payer: Medical Associates Managed Medicare	$16.40
Rate for Payer: Midlands Choice Commercial	$22.96
Rate for Payer: Molina Healthcare Managed Medicaid	$16.65
Rate for Payer: Partners Health Alliance Commercial	$24.60
Rate for Payer: United Healthcare Commercial	$29.52
Rate for Payer: United Healthcare Managed Medicare	$19.35

INTEGRATIVE MEDICINE 30 MINUTES

Professional

$75.00

Service Code	CPT 99999
Hospital Charge Code	8431964
Hospital Revenue Code	983
Min. Negotiated Rate	$52.50
Max. Negotiated Rate	$82.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Cash Price	$60.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$52.50
Rate for Payer: Wellmark IA HMO	$82.00
Rate for Payer: Wellmark IA PPO	$82.00

INTEGRATIVE MEDICINE 60 MINUTES

Professional

$150.00

Service Code	CPT 99999
Hospital Charge Code	8431965
Hospital Revenue Code	983
Min. Negotiated Rate	$75.00
Max. Negotiated Rate	$105.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: Wellmark IA HMO	$82.00
Rate for Payer: Wellmark IA PPO	$82.00

INTELLIS ADAPTIVESTIM

Facility IP

$27,720.00

Service Code	CPT C1778
Hospital Charge Code	8557558
Hospital Revenue Code	278
Min. Negotiated Rate	$19,404.00
Max. Negotiated Rate	$24,948.00
Rate for Payer: Aetna of IA Commercial	$24,948.00
Rate for Payer: Aetna of IA Medical Rental Products	$24,948.00
Rate for Payer: Cash Price	$22,176.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20,790.00
Rate for Payer: Medical Associates Commercial	$20,790.00
Rate for Payer: Midlands Choice Commercial	$19,404.00
Rate for Payer: United Healthcare Commercial	$24,948.00

INTELLIS ADAPTIVESTIM

Facility OP

$27,720.00

Service Code	CPT C1778
Hospital Charge Code	8557558
Hospital Revenue Code	278
Min. Negotiated Rate	$13,854.46
Max. Negotiated Rate	$24,948.00
Rate for Payer: Aetna of IA Commercial	$24,948.00
Rate for Payer: Aetna of IA Medical Rental Products	$24,948.00
Rate for Payer: Aetna of IA Medicare	$15,800.40
Rate for Payer: Amerigroup Medicaid	$13,990.28
Rate for Payer: Amerigroup Medicare	$13,998.60
Rate for Payer: Cash Price	$22,176.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20,790.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13,860.00
Rate for Payer: Iowa Total Care Managed Medicaid	$13,854.46
Rate for Payer: Medical Associates Commercial	$20,790.00
Rate for Payer: Medical Associates Managed Medicare	$13,860.00
Rate for Payer: Midlands Choice Commercial	$19,404.00
Rate for Payer: Molina Healthcare Managed Medicaid	$14,067.90
Rate for Payer: Partners Health Alliance Commercial	$20,790.00
Rate for Payer: United Healthcare Commercial	$24,948.00
Rate for Payer: United Healthcare Managed Medicare	$16,354.80

INTERPRETATION

Professional

$15.00

Service Code	CPT T1013
Hospital Charge Code	8300878
Hospital Revenue Code	983
Min. Negotiated Rate	$10.50
Max. Negotiated Rate	$75.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Medical Associates Commercial	$75.00
Rate for Payer: Midlands Choice Commercial	$10.50
Rate for Payer: Wellmark IA HMO	$14.50
Rate for Payer: Wellmark IA PPO	$14.50

INTERSCALENE BLOCK CHARGE

Facility OP

$300.00

Service Code	CPT 64415
Hospital Charge Code	8059064
Hospital Revenue Code	964
Min. Negotiated Rate	$149.94
Max. Negotiated Rate	$1,560.42
Rate for Payer: Aetna of IA Commercial	$270.00
Rate for Payer: Aetna of IA Medical Rental Products	$270.00
Rate for Payer: Aetna of IA Medicare	$171.00
Rate for Payer: Amerigroup Medicaid	$151.41
Rate for Payer: Amerigroup Medicare	$151.50
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$150.00
Rate for Payer: Iowa Total Care Managed Medicaid	$149.94
Rate for Payer: Medical Associates Commercial	$225.00
Rate for Payer: Medical Associates Managed Medicare	$150.00
Rate for Payer: Midlands Choice Commercial	$210.00
Rate for Payer: Molina Healthcare Managed Medicaid	$152.25
Rate for Payer: Partners Health Alliance Commercial	$225.00
Rate for Payer: United Healthcare Commercial	$270.00
Rate for Payer: United Healthcare Managed Medicare	$177.00
Rate for Payer: Wellmark IA HMO	$1,418.56
Rate for Payer: Wellmark IA PPO	$1,560.42

INTERSCALENE BLOCK CHARGE

Facility IP

$300.00

Service Code	CPT 64415
Hospital Charge Code	8059064
Hospital Revenue Code	964
Min. Negotiated Rate	$210.00
Max. Negotiated Rate	$270.00
Rate for Payer: Aetna of IA Commercial	$270.00
Rate for Payer: Aetna of IA Medical Rental Products	$270.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$225.00
Rate for Payer: Medical Associates Commercial	$225.00
Rate for Payer: Midlands Choice Commercial	$210.00
Rate for Payer: United Healthcare Commercial	$270.00

INTERSTIM II NEUROSTIMULATOR

Facility OP

$18,684.00

Service Code	CPT C1778
Hospital Charge Code	8026098
Hospital Revenue Code	278
Min. Negotiated Rate	$9,338.26
Max. Negotiated Rate	$16,815.60
Rate for Payer: Aetna of IA Commercial	$16,815.60
Rate for Payer: Aetna of IA Medical Rental Products	$16,815.60
Rate for Payer: Aetna of IA Medicare	$10,649.88
Rate for Payer: Amerigroup Medicaid	$9,429.81
Rate for Payer: Amerigroup Medicare	$9,435.42
Rate for Payer: Cash Price	$14,947.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$14,013.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$9,342.00
Rate for Payer: Iowa Total Care Managed Medicaid	$9,338.26
Rate for Payer: Medical Associates Commercial	$14,013.00
Rate for Payer: Medical Associates Managed Medicare	$9,342.00
Rate for Payer: Midlands Choice Commercial	$13,078.80
Rate for Payer: Molina Healthcare Managed Medicaid	$9,482.13
Rate for Payer: Partners Health Alliance Commercial	$14,013.00
Rate for Payer: United Healthcare Commercial	$16,815.60
Rate for Payer: United Healthcare Managed Medicare	$11,023.56

INTERSTIM II NEUROSTIMULATOR

Facility IP

$18,684.00

Service Code	CPT C1778
Hospital Charge Code	8026098
Hospital Revenue Code	278
Min. Negotiated Rate	$13,078.80
Max. Negotiated Rate	$16,815.60
Rate for Payer: Aetna of IA Commercial	$16,815.60
Rate for Payer: Aetna of IA Medical Rental Products	$16,815.60
Rate for Payer: Cash Price	$14,947.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$14,013.00
Rate for Payer: Medical Associates Commercial	$14,013.00
Rate for Payer: Midlands Choice Commercial	$13,078.80
Rate for Payer: United Healthcare Commercial	$16,815.60

Interstitial Lung Disease With CC

Facility IP

$8,688.89

Service Code	MS-DRG 197
Hospital Charge Code	68
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,688.89
Rate for Payer: Amerigroup Medicaid	$8,646.91
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	$8,562.96
Rate for Payer: Molina Healthcare Managed Medicaid	$8,688.89

Interstitial Lung Disease With MCC

Facility IP

$13,728.20

Service Code	MS-DRG 196
Hospital Charge Code	67
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$13,728.20
Rate for Payer: Amerigroup Medicaid	$13,661.88
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	$13,529.24
Rate for Payer: Molina Healthcare Managed Medicaid	$13,728.20

Interstitial Lung Disease Without CC/MCC

Facility IP

$7,307.99

Service Code	MS-DRG 198
Hospital Charge Code	69
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$7,307.99
Rate for Payer: Amerigroup Medicaid	$7,272.69
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	$7,202.08
Rate for Payer: Molina Healthcare Managed Medicaid	$7,307.99

INTMD RPR FACE/MM 2.5 CM/<

Professional

$854.00

Service Code	CPT 12051
Hospital Charge Code	7982825
Hospital Revenue Code	981
Min. Negotiated Rate	$153.88
Max. Negotiated Rate	$597.80
Rate for Payer: Aetna of IA Medicare	$153.88
Rate for Payer: Amerigroup Medicaid	$159.11
Rate for Payer: Cash Price	$683.20
Rate for Payer: Cash Price	$683.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$184.66
Rate for Payer: Iowa Total Care Managed Medicaid	$156.96
Rate for Payer: Medical Associates Commercial	$292.37
Rate for Payer: Medical Associates Managed Medicare	$153.88
Rate for Payer: Midlands Choice Commercial	$597.80
Rate for Payer: Partners Health Alliance Commercial	$230.82
Rate for Payer: Wellmark IA HMO	$321.00
Rate for Payer: Wellmark IA PPO	$377.00

INTMD RPR FACE/MM 2.6-5.0 CM

Professional

$640.00

Service Code	CPT 12052
Hospital Charge Code	7982824
Hospital Revenue Code	981
Min. Negotiated Rate	$181.43
Max. Negotiated Rate	$448.00
Rate for Payer: Aetna of IA Medicare	$181.43
Rate for Payer: Amerigroup Medicaid	$187.60
Rate for Payer: Cash Price	$512.00
Rate for Payer: Cash Price	$512.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$217.72
Rate for Payer: Iowa Total Care Managed Medicaid	$185.06
Rate for Payer: Medical Associates Commercial	$344.72
Rate for Payer: Medical Associates Managed Medicare	$181.43
Rate for Payer: Midlands Choice Commercial	$448.00
Rate for Payer: Partners Health Alliance Commercial	$272.14
Rate for Payer: Wellmark IA HMO	$378.00
Rate for Payer: Wellmark IA PPO	$443.00

INTMD RPR FACE/MM 5.1-7.5 CM

Professional

$1,143.00

Service Code	CPT 12053
Hospital Charge Code	7982823
Hospital Revenue Code	981
Min. Negotiated Rate	$195.58
Max. Negotiated Rate	$800.10
Rate for Payer: Aetna of IA Medicare	$195.58
Rate for Payer: Amerigroup Medicaid	$202.23
Rate for Payer: Cash Price	$914.40
Rate for Payer: Cash Price	$914.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$234.70
Rate for Payer: Iowa Total Care Managed Medicaid	$199.49
Rate for Payer: Medical Associates Commercial	$371.60
Rate for Payer: Medical Associates Managed Medicare	$195.58
Rate for Payer: Midlands Choice Commercial	$800.10
Rate for Payer: Partners Health Alliance Commercial	$293.37
Rate for Payer: Wellmark IA HMO	$408.00
Rate for Payer: Wellmark IA PPO	$479.00

INTMD RPR FACE/MM 7.6-12.5CM

Professional

$1,192.00

Service Code	CPT 12054
Hospital Charge Code	7982822
Hospital Revenue Code	981
Min. Negotiated Rate	$199.22
Max. Negotiated Rate	$834.40
Rate for Payer: Aetna of IA Medicare	$199.22
Rate for Payer: Amerigroup Medicaid	$205.99
Rate for Payer: Cash Price	$953.60
Rate for Payer: Cash Price	$953.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$239.06
Rate for Payer: Iowa Total Care Managed Medicaid	$203.20
Rate for Payer: Medical Associates Commercial	$378.52
Rate for Payer: Medical Associates Managed Medicare	$199.22
Rate for Payer: Midlands Choice Commercial	$834.40
Rate for Payer: Partners Health Alliance Commercial	$298.83
Rate for Payer: Wellmark IA HMO	$417.00
Rate for Payer: Wellmark IA PPO	$489.00

INTMD RPR N-HF/GENIT12.6-20

Professional

$1,326.00

Service Code	CPT 12045
Hospital Charge Code	7982826
Hospital Revenue Code	981
Min. Negotiated Rate	$246.12
Max. Negotiated Rate	$928.20
Rate for Payer: Aetna of IA Medicare	$246.12
Rate for Payer: Amerigroup Medicaid	$254.49
Rate for Payer: Cash Price	$1,060.80
Rate for Payer: Cash Price	$1,060.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$295.34
Rate for Payer: Iowa Total Care Managed Medicaid	$251.04
Rate for Payer: Medical Associates Commercial	$467.63
Rate for Payer: Medical Associates Managed Medicare	$246.12
Rate for Payer: Midlands Choice Commercial	$928.20
Rate for Payer: Partners Health Alliance Commercial	$369.18
Rate for Payer: Wellmark IA HMO	$522.00
Rate for Payer: Wellmark IA PPO	$612.00

INTMD RPR N-HF/GENIT 2.5CM/<

Professional

$785.00

Service Code	CPT 12041
Hospital Charge Code	7982829
Hospital Revenue Code	981
Min. Negotiated Rate	$132.15
Max. Negotiated Rate	$549.50
Rate for Payer: Aetna of IA Medicare	$132.15
Rate for Payer: Amerigroup Medicaid	$136.64
Rate for Payer: Cash Price	$628.00
Rate for Payer: Cash Price	$628.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$158.58
Rate for Payer: Iowa Total Care Managed Medicaid	$134.79
Rate for Payer: Medical Associates Commercial	$251.08
Rate for Payer: Medical Associates Managed Medicare	$132.15
Rate for Payer: Midlands Choice Commercial	$549.50
Rate for Payer: Partners Health Alliance Commercial	$198.22
Rate for Payer: Wellmark IA HMO	$275.00
Rate for Payer: Wellmark IA PPO	$322.00

INTMD RPR N-HF/GENIT2.6-7.5

Professional

$958.00

Service Code	CPT 12042
Hospital Charge Code	7982828
Hospital Revenue Code	981
Min. Negotiated Rate	$178.21
Max. Negotiated Rate	$670.60
Rate for Payer: Aetna of IA Medicare	$178.21
Rate for Payer: Amerigroup Medicaid	$184.27
Rate for Payer: Cash Price	$766.40
Rate for Payer: Cash Price	$766.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$213.85
Rate for Payer: Iowa Total Care Managed Medicaid	$181.77
Rate for Payer: Medical Associates Commercial	$338.60
Rate for Payer: Medical Associates Managed Medicare	$178.21
Rate for Payer: Midlands Choice Commercial	$670.60
Rate for Payer: Partners Health Alliance Commercial	$267.32
Rate for Payer: Wellmark IA HMO	$370.00
Rate for Payer: Wellmark IA PPO	$434.00

INTMD RPR N-HF/GENIT7.6-12.5

Professional

$1,188.00

Service Code	CPT 12044
Hospital Charge Code	7982827
Hospital Revenue Code	981
Min. Negotiated Rate	$194.30
Max. Negotiated Rate	$831.60
Rate for Payer: Aetna of IA Medicare	$194.30
Rate for Payer: Amerigroup Medicaid	$200.91
Rate for Payer: Cash Price	$950.40
Rate for Payer: Cash Price	$950.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$233.16
Rate for Payer: Iowa Total Care Managed Medicaid	$198.19
Rate for Payer: Medical Associates Commercial	$369.17
Rate for Payer: Medical Associates Managed Medicare	$194.30
Rate for Payer: Midlands Choice Commercial	$831.60
Rate for Payer: Partners Health Alliance Commercial	$291.45
Rate for Payer: Wellmark IA HMO	$405.00
Rate for Payer: Wellmark IA PPO	$475.00

INTMD RPR S/A/T/EXT 12.6-20

Professional

$1,261.00

Service Code	CPT 12035
Hospital Charge Code	7982831
Hospital Revenue Code	981
Min. Negotiated Rate	$217.01
Max. Negotiated Rate	$882.70
Rate for Payer: Aetna of IA Medicare	$217.01
Rate for Payer: Amerigroup Medicaid	$224.39
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$260.41
Rate for Payer: Iowa Total Care Managed Medicaid	$221.35
Rate for Payer: Medical Associates Commercial	$412.32
Rate for Payer: Medical Associates Managed Medicare	$217.01
Rate for Payer: Midlands Choice Commercial	$882.70
Rate for Payer: Partners Health Alliance Commercial	$325.52
Rate for Payer: Wellmark IA HMO	$457.00
Rate for Payer: Wellmark IA PPO	$537.00

INTMD RPR S/A/T/EXT 20.1-30

Professional

$1,395.00

Service Code	CPT 12036
Hospital Charge Code	7982830
Hospital Revenue Code	981
Min. Negotiated Rate	$252.13
Max. Negotiated Rate	$976.50
Rate for Payer: Aetna of IA Medicare	$252.13
Rate for Payer: Amerigroup Medicaid	$260.70
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$302.56
Rate for Payer: Iowa Total Care Managed Medicaid	$257.17
Rate for Payer: Medical Associates Commercial	$479.05
Rate for Payer: Medical Associates Managed Medicare	$252.13
Rate for Payer: Midlands Choice Commercial	$976.50
Rate for Payer: Partners Health Alliance Commercial	$378.20
Rate for Payer: Wellmark IA HMO	$534.00
Rate for Payer: Wellmark IA PPO	$627.00

Price Transparency.

All Charges