Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

Professional

Both

$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	$453.83
Rate for Payer: Medical Associates Managed Medicare	$252.13
Rate for Payer: Midlands Choice Commercial	$976.50
Rate for Payer: Oscar Health of IA Commercial	$436.18
Rate for Payer: Partners Health Alliance Commercial	$378.20

INTMD RPR S/A/T/EXT 2.5 CM/<

Professional

Both

$530.00

Service Code	CPT 12031
Hospital Charge Code	7982834
Hospital Revenue Code	981
Min. Negotiated Rate	$137.69
Max. Negotiated Rate	$371.00
Rate for Payer: Aetna of IA Medicare	$137.69
Rate for Payer: Amerigroup Medicaid	$142.37
Rate for Payer: Cash Price	$424.00
Rate for Payer: Cash Price	$424.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.23
Rate for Payer: Iowa Total Care Managed Medicaid	$140.44
Rate for Payer: Medical Associates Commercial	$247.84
Rate for Payer: Medical Associates Managed Medicare	$137.69
Rate for Payer: Midlands Choice Commercial	$371.00
Rate for Payer: Oscar Health of IA Commercial	$238.20
Rate for Payer: Partners Health Alliance Commercial	$206.54

INTMD RPR S/A/T/EXT 2.6-7.5

Professional

Both

$800.00

Service Code	CPT 12032
Hospital Charge Code	7982833
Hospital Revenue Code	981
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$401.35
Rate for Payer: Aetna of IA Medicare	$173.25
Rate for Payer: Amerigroup Medicaid	$179.14
Rate for Payer: Cash Price	$640.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$207.90
Rate for Payer: Iowa Total Care Managed Medicaid	$176.72
Rate for Payer: Medical Associates Commercial	$311.85
Rate for Payer: Medical Associates Managed Medicare	$173.25
Rate for Payer: Midlands Choice Commercial	$401.35
Rate for Payer: Oscar Health of IA Commercial	$299.72
Rate for Payer: Partners Health Alliance Commercial	$259.88

INTMD RPR S/TR/EXT 7.6-12.5

Professional

Both

$1,033.00

Service Code	CPT 12034
Hospital Charge Code	7982832
Hospital Revenue Code	981
Min. Negotiated Rate	$186.35
Max. Negotiated Rate	$723.10
Rate for Payer: Aetna of IA Medicare	$186.35
Rate for Payer: Amerigroup Medicaid	$192.69
Rate for Payer: Cash Price	$826.40
Rate for Payer: Cash Price	$826.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$223.62
Rate for Payer: Iowa Total Care Managed Medicaid	$190.08
Rate for Payer: Medical Associates Commercial	$335.43
Rate for Payer: Medical Associates Managed Medicare	$186.35
Rate for Payer: Midlands Choice Commercial	$723.10
Rate for Payer: Oscar Health of IA Commercial	$322.39
Rate for Payer: Partners Health Alliance Commercial	$279.52

Intracranial Hemorrhage or Cerebral Infarction With CC or TPA in 24 Hours

Facility

$10,056.00

Service Code	MS-DRG 065
Hospital Charge Code	745
Min. Negotiated Rate	$9,910.26
Max. Negotiated Rate	$10,056.00
Rate for Payer: Amerigroup Medicaid	$10,007.42
Rate for Payer: Iowa Total Care Managed Medicaid	$9,910.26
Rate for Payer: Molina Healthcare Managed Medicaid	$10,056.00

Intracranial Hemorrhage or Cerebral Infarction With MCC

Facility

$16,964.38

Service Code	MS-DRG 064
Hospital Charge Code	744
Min. Negotiated Rate	$16,718.52
Max. Negotiated Rate	$16,964.38
Rate for Payer: Amerigroup Medicaid	$16,882.43
Rate for Payer: Iowa Total Care Managed Medicaid	$16,718.52
Rate for Payer: Molina Healthcare Managed Medicaid	$16,964.38

Intracranial Hemorrhage or Cerebral Infarction Without CC/MCC

Facility

$6,471.39

Service Code	MS-DRG 066
Hospital Charge Code	746
Min. Negotiated Rate	$6,377.60
Max. Negotiated Rate	$6,471.39
Rate for Payer: Amerigroup Medicaid	$6,440.13
Rate for Payer: Iowa Total Care Managed Medicaid	$6,377.60
Rate for Payer: Molina Healthcare Managed Medicaid	$6,471.39

Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With CC

Facility

$66,120.36

Service Code	MS-DRG 021
Hospital Charge Code	710
Min. Negotiated Rate	$65,162.10
Max. Negotiated Rate	$66,120.36
Rate for Payer: Amerigroup Medicaid	$65,800.94
Rate for Payer: Iowa Total Care Managed Medicaid	$65,162.10
Rate for Payer: Molina Healthcare Managed Medicaid	$66,120.36

Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With MCC

Facility

$83,960.72

Service Code	MS-DRG 020
Hospital Charge Code	709
Min. Negotiated Rate	$82,743.90
Max. Negotiated Rate	$83,960.72
Rate for Payer: Amerigroup Medicaid	$83,555.11
Rate for Payer: Iowa Total Care Managed Medicaid	$82,743.90
Rate for Payer: Molina Healthcare Managed Medicaid	$83,960.72

Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without CC/MCC

Facility

$47,843.00

Service Code	MS-DRG 022
Hospital Charge Code	711
Min. Negotiated Rate	$47,149.62
Max. Negotiated Rate	$47,843.00
Rate for Payer: Amerigroup Medicaid	$47,611.87
Rate for Payer: Iowa Total Care Managed Medicaid	$47,149.62
Rate for Payer: Molina Healthcare Managed Medicaid	$47,843.00

Intraocular Lens Procedure

Facility

$4,535.30

Service Code	CPT 66982
Min. Negotiated Rate	$4,123.00
Max. Negotiated Rate	$4,535.30
Rate for Payer: Wellmark IA HMO	$4,123.00
Rate for Payer: Wellmark IA PPO	$4,535.30

Intraocular Procedures With CC/MCC

Facility

$12,674.08

Service Code	MS-DRG 116
Hospital Charge Code	8
Min. Negotiated Rate	$12,490.40
Max. Negotiated Rate	$12,674.08
Rate for Payer: Amerigroup Medicaid	$12,612.85
Rate for Payer: Iowa Total Care Managed Medicaid	$12,490.40
Rate for Payer: Molina Healthcare Managed Medicaid	$12,674.08

Intraocular Procedures Without CC/MCC

Facility

$12,674.08

Service Code	MS-DRG 117
Hospital Charge Code	9
Min. Negotiated Rate	$12,490.40
Max. Negotiated Rate	$12,674.08
Rate for Payer: Amerigroup Medicaid	$12,612.85
Rate for Payer: Iowa Total Care Managed Medicaid	$12,490.40
Rate for Payer: Molina Healthcare Managed Medicaid	$12,674.08

INTRAPLEURAL INSERTION CHARGE

Facility

$213.00

Hospital Charge Code	8059077
Hospital Revenue Code	360
Min. Negotiated Rate	$106.46
Max. Negotiated Rate	$191.70
Rate for Payer: Aetna of IA Commercial	$191.70
Rate for Payer: Aetna of IA Medical Rental Products	$191.70
Rate for Payer: Aetna of IA Medicare	$121.41
Rate for Payer: Amerigroup Medicaid	$107.50
Rate for Payer: Amerigroup Medicare	$107.56
Rate for Payer: Cash Price	$170.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$159.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$106.50
Rate for Payer: Iowa Total Care Managed Medicaid	$106.46
Rate for Payer: Medical Associates Commercial	$159.75
Rate for Payer: Medical Associates Managed Medicare	$106.50
Rate for Payer: Midlands Choice Commercial	$149.10
Rate for Payer: Molina Healthcare Managed Medicaid	$108.10
Rate for Payer: Molina Healthcare Managed Medicare	$108.03
Rate for Payer: Oscar Health of IA Commercial	$159.75
Rate for Payer: Partners Health Alliance Commercial	$159.75
Rate for Payer: United Healthcare Commercial	$191.70
Rate for Payer: United Healthcare Managed Medicare	$125.67

INTRAPLEURAL INSERTION CHARGE

Facility

$213.00

Hospital Charge Code	8059077
Hospital Revenue Code	360
Min. Negotiated Rate	$149.10
Max. Negotiated Rate	$191.70
Rate for Payer: Aetna of IA Commercial	$191.70
Rate for Payer: Aetna of IA Medical Rental Products	$191.70
Rate for Payer: Cash Price	$170.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$159.75
Rate for Payer: Medical Associates Commercial	$159.75
Rate for Payer: Midlands Choice Commercial	$149.10
Rate for Payer: United Healthcare Commercial	$191.70

Intubation, endotracheal, emergency procedure

Facility

$1,815.48

Service Code	CPT 31500
Hospital Revenue Code	490
Min. Negotiated Rate	$1,650.44
Max. Negotiated Rate	$1,815.48
Rate for Payer: Wellmark IA HMO	$1,650.44
Rate for Payer: Wellmark IA PPO	$1,815.48

INVASIVE BUNION PLATE LEFT

Facility

$2,592.00

Service Code	CPT C1713
Hospital Charge Code	8788813
Hospital Revenue Code	278
Min. Negotiated Rate	$1,814.40
Max. Negotiated Rate	$2,332.80
Rate for Payer: Aetna of IA Commercial	$2,332.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,332.80
Rate for Payer: Cash Price	$2,073.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,944.00
Rate for Payer: Medical Associates Commercial	$1,944.00
Rate for Payer: Midlands Choice Commercial	$1,814.40
Rate for Payer: United Healthcare Commercial	$2,332.80

INVASIVE BUNION PLATE LEFT

Facility

$2,592.00

Service Code	CPT C1713
Hospital Charge Code	8788813
Hospital Revenue Code	278
Min. Negotiated Rate	$1,295.48
Max. Negotiated Rate	$2,332.80
Rate for Payer: Aetna of IA Commercial	$2,332.80
Rate for Payer: Aetna of IA Medical Rental Products	$2,332.80
Rate for Payer: Aetna of IA Medicare	$1,477.44
Rate for Payer: Amerigroup Medicaid	$1,308.18
Rate for Payer: Amerigroup Medicare	$1,308.96
Rate for Payer: Cash Price	$2,073.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,944.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,296.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,295.48
Rate for Payer: Medical Associates Commercial	$1,944.00
Rate for Payer: Medical Associates Managed Medicare	$1,296.00
Rate for Payer: Midlands Choice Commercial	$1,814.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,315.44
Rate for Payer: Molina Healthcare Managed Medicare	$1,314.66
Rate for Payer: Oscar Health of IA Commercial	$1,944.00
Rate for Payer: Partners Health Alliance Commercial	$1,944.00
Rate for Payer: United Healthcare Commercial	$2,332.80
Rate for Payer: United Healthcare Managed Medicare	$1,529.28

iohexol 300 mg/mL Sol[VDMC]

Facility

$172.76

Service Code	HCPCS Q9967
Hospital Charge Code	23686528
Hospital Revenue Code	259
Min. Negotiated Rate	$86.35
Max. Negotiated Rate	$155.48
Rate for Payer: Aetna of IA Commercial	$155.48
Rate for Payer: Aetna of IA Medical Rental Products	$155.48
Rate for Payer: Aetna of IA Medicare	$98.47
Rate for Payer: Amerigroup Medicaid	$87.19
Rate for Payer: Amerigroup Medicare	$87.24
Rate for Payer: Cash Price	$138.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$86.38
Rate for Payer: Iowa Total Care Managed Medicaid	$86.35
Rate for Payer: Medical Associates Commercial	$129.57
Rate for Payer: Medical Associates Managed Medicare	$86.38
Rate for Payer: Midlands Choice Commercial	$120.93
Rate for Payer: Molina Healthcare Managed Medicaid	$87.68
Rate for Payer: Molina Healthcare Managed Medicare	$87.62
Rate for Payer: Oscar Health of IA Commercial	$129.57
Rate for Payer: Partners Health Alliance Commercial	$129.57
Rate for Payer: United Healthcare Commercial	$155.48
Rate for Payer: United Healthcare Managed Medicare	$101.93

iohexol 300 mg/mL Sol[VDMC]

Facility

$172.76

Service Code	HCPCS Q9967
Hospital Charge Code	23686528
Hospital Revenue Code	259
Min. Negotiated Rate	$120.93
Max. Negotiated Rate	$155.48
Rate for Payer: Aetna of IA Commercial	$155.48
Rate for Payer: Aetna of IA Medical Rental Products	$155.48
Rate for Payer: Cash Price	$138.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.57
Rate for Payer: Medical Associates Commercial	$129.57
Rate for Payer: Midlands Choice Commercial	$120.93
Rate for Payer: United Healthcare Commercial	$155.48

IONTOPHORESIS APPLICATION PER 15 MIN

Facility

$134.00

Service Code	CPT 97033 GP
Hospital Charge Code	1373909
Hospital Revenue Code	420
Min. Negotiated Rate	$93.80
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: United Healthcare Commercial	$120.60

IONTOPHORESIS APPLICATION PER 15 MIN

Facility

$134.00

Service Code	CPT 97033 GO
Hospital Charge Code	1373443
Hospital Revenue Code	430
Min. Negotiated Rate	$66.97
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Aetna of IA Medicare	$76.38
Rate for Payer: Amerigroup Medicaid	$67.63
Rate for Payer: Amerigroup Medicare	$67.67
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.00
Rate for Payer: Iowa Total Care Managed Medicaid	$66.97
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Medical Associates Managed Medicare	$67.00
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: Molina Healthcare Managed Medicaid	$68.00
Rate for Payer: Molina Healthcare Managed Medicare	$67.96
Rate for Payer: Oscar Health of IA Commercial	$100.50
Rate for Payer: Partners Health Alliance Commercial	$100.50
Rate for Payer: United Healthcare Commercial	$120.60
Rate for Payer: United Healthcare Managed Medicare	$79.06

IONTOPHORESIS APPLICATION PER 15 MIN

Facility

$134.00

Service Code	CPT 97033 GO
Hospital Charge Code	1373443
Hospital Revenue Code	430
Min. Negotiated Rate	$93.80
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: United Healthcare Commercial	$120.60

IONTOPHORESIS APPLICATION PER 15 MIN

Facility

$134.00

Service Code	CPT 97033 GP
Hospital Charge Code	1373909
Hospital Revenue Code	420
Min. Negotiated Rate	$66.97
Max. Negotiated Rate	$120.60
Rate for Payer: Aetna of IA Commercial	$120.60
Rate for Payer: Aetna of IA Medical Rental Products	$120.60
Rate for Payer: Aetna of IA Medicare	$76.38
Rate for Payer: Amerigroup Medicaid	$67.63
Rate for Payer: Amerigroup Medicare	$67.67
Rate for Payer: Cash Price	$107.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$67.00
Rate for Payer: Iowa Total Care Managed Medicaid	$66.97
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Medical Associates Managed Medicare	$67.00
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: Molina Healthcare Managed Medicaid	$68.00
Rate for Payer: Molina Healthcare Managed Medicare	$67.96
Rate for Payer: Oscar Health of IA Commercial	$100.50
Rate for Payer: Partners Health Alliance Commercial	$100.50
Rate for Payer: United Healthcare Commercial	$120.60
Rate for Payer: United Healthcare Managed Medicare	$79.06

iopamidol 41% Sol[VDMC]

Facility

$57.58

Service Code	HCPCS Q9966
Hospital Charge Code	12697970
Hospital Revenue Code	259
Min. Negotiated Rate	$28.78
Max. Negotiated Rate	$51.82
Rate for Payer: Aetna of IA Commercial	$51.82
Rate for Payer: Aetna of IA Medical Rental Products	$51.82
Rate for Payer: Aetna of IA Medicare	$32.82
Rate for Payer: Amerigroup Medicaid	$29.06
Rate for Payer: Amerigroup Medicare	$29.08
Rate for Payer: Cash Price	$46.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.79
Rate for Payer: Iowa Total Care Managed Medicaid	$28.78
Rate for Payer: Medical Associates Commercial	$43.18
Rate for Payer: Medical Associates Managed Medicare	$28.79
Rate for Payer: Midlands Choice Commercial	$40.31
Rate for Payer: Molina Healthcare Managed Medicaid	$29.22
Rate for Payer: Molina Healthcare Managed Medicare	$29.20
Rate for Payer: Oscar Health of IA Commercial	$43.18
Rate for Payer: Partners Health Alliance Commercial	$43.18
Rate for Payer: United Healthcare Commercial	$51.82
Rate for Payer: United Healthcare Managed Medicare	$33.97

Know your out-of-pocket cost for care.

All Charges