Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

INTMD RPR N-HF/GENIT 2.5CM/<

Professional

Both

$785.00

Service Code	CPT 12041
Hospital Charge Code	7982829
Hospital Revenue Code	981
Min. Negotiated Rate	$380.30
Max. Negotiated Rate	$588.75
Rate for Payer: Cash Price	$628.00
Rate for Payer: Cash Price	$628.00
Rate for Payer: Medical Associates Commercial	$588.75
Rate for Payer: Midlands Choice Commercial	$549.50
Rate for Payer: Partners Health Alliance Commercial	$588.75
Rate for Payer: United Healthcare Commercial	$380.30

INTMD RPR N-HF/GENIT 2.5CM/<

Facility

$418.00

Service Code	CPT 12041
Hospital Charge Code	4863374
Hospital Revenue Code	450
Min. Negotiated Rate	$292.60
Max. Negotiated Rate	$376.20
Rate for Payer: Aetna of IA Commercial	$376.20
Rate for Payer: Aetna of IA Medical Rental Products	$376.20
Rate for Payer: Cash Price	$334.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$313.50
Rate for Payer: Medical Associates Commercial	$313.50
Rate for Payer: Midlands Choice Commercial	$292.60
Rate for Payer: United Healthcare Commercial	$376.20

INTMD RPR N-HF/GENIT 2.5CM/<

Facility

$418.00

Service Code	CPT 12041
Hospital Charge Code	4863374
Hospital Revenue Code	450
Min. Negotiated Rate	$188.10
Max. Negotiated Rate	$376.20
Rate for Payer: Aetna of IA Commercial	$376.20
Rate for Payer: Aetna of IA Medical Rental Products	$376.20
Rate for Payer: Aetna of IA Medicare	$238.26
Rate for Payer: Amerigroup Medicaid	$241.10
Rate for Payer: Amerigroup Medicare	$189.98
Rate for Payer: Cash Price	$334.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$313.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$188.10
Rate for Payer: Iowa Total Care Managed Medicaid	$238.76
Rate for Payer: Medical Associates Commercial	$313.50
Rate for Payer: Medical Associates Managed Medicare	$188.10
Rate for Payer: Midlands Choice Commercial	$292.60
Rate for Payer: Molina Healthcare Managed Medicaid	$242.27
Rate for Payer: Partners Health Alliance Commercial	$216.31
Rate for Payer: United Healthcare Commercial	$376.20
Rate for Payer: United Healthcare Managed Medicare	$246.62

INTMD RPR N-HF/GENIT2.6-7.5

Facility

$363.00

Service Code	CPT 12042
Hospital Charge Code	4863375
Hospital Revenue Code	450
Min. Negotiated Rate	$254.10
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of IA Commercial	$326.70
Rate for Payer: Aetna of IA Medical Rental Products	$326.70
Rate for Payer: Cash Price	$290.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$272.25
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: United Healthcare Commercial	$326.70

INTMD RPR N-HF/GENIT2.6-7.5

Facility

$363.00

Service Code	CPT 12042
Hospital Charge Code	4863375
Hospital Revenue Code	450
Min. Negotiated Rate	$163.35
Max. Negotiated Rate	$326.70
Rate for Payer: Aetna of IA Commercial	$326.70
Rate for Payer: Aetna of IA Medical Rental Products	$326.70
Rate for Payer: Aetna of IA Medicare	$206.91
Rate for Payer: Amerigroup Medicaid	$209.38
Rate for Payer: Amerigroup Medicare	$164.98
Rate for Payer: Cash Price	$290.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$272.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$163.35
Rate for Payer: Iowa Total Care Managed Medicaid	$207.35
Rate for Payer: Medical Associates Commercial	$272.25
Rate for Payer: Medical Associates Managed Medicare	$163.35
Rate for Payer: Midlands Choice Commercial	$254.10
Rate for Payer: Molina Healthcare Managed Medicaid	$210.39
Rate for Payer: Partners Health Alliance Commercial	$187.85
Rate for Payer: United Healthcare Commercial	$326.70
Rate for Payer: United Healthcare Managed Medicare	$214.17

INTMD RPR N-HF/GENIT2.6-7.5

Professional

Both

$958.00

Service Code	CPT 12042
Hospital Charge Code	7982828
Hospital Revenue Code	981
Min. Negotiated Rate	$453.60
Max. Negotiated Rate	$718.50
Rate for Payer: Cash Price	$766.40
Rate for Payer: Cash Price	$766.40
Rate for Payer: Medical Associates Commercial	$718.50
Rate for Payer: Midlands Choice Commercial	$670.60
Rate for Payer: Partners Health Alliance Commercial	$718.50
Rate for Payer: United Healthcare Commercial	$453.60

INTMD RPR N-HF/GENIT7.6-12.5

Facility

$304.00

Service Code	CPT 12044
Hospital Charge Code	4863380
Hospital Revenue Code	450
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna of IA Commercial	$273.60
Rate for Payer: Aetna of IA Medical Rental Products	$273.60
Rate for Payer: Cash Price	$243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$228.00
Rate for Payer: Medical Associates Commercial	$228.00
Rate for Payer: Midlands Choice Commercial	$212.80
Rate for Payer: United Healthcare Commercial	$273.60

INTMD RPR N-HF/GENIT7.6-12.5

Facility

$304.00

Service Code	CPT 12044
Hospital Charge Code	4863380
Hospital Revenue Code	450
Min. Negotiated Rate	$136.80
Max. Negotiated Rate	$273.60
Rate for Payer: Aetna of IA Commercial	$273.60
Rate for Payer: Aetna of IA Medical Rental Products	$273.60
Rate for Payer: Aetna of IA Medicare	$173.28
Rate for Payer: Amerigroup Medicaid	$175.35
Rate for Payer: Amerigroup Medicare	$138.17
Rate for Payer: Cash Price	$243.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$228.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$136.80
Rate for Payer: Iowa Total Care Managed Medicaid	$173.64
Rate for Payer: Medical Associates Commercial	$228.00
Rate for Payer: Medical Associates Managed Medicare	$136.80
Rate for Payer: Midlands Choice Commercial	$212.80
Rate for Payer: Molina Healthcare Managed Medicaid	$176.20
Rate for Payer: Partners Health Alliance Commercial	$157.32
Rate for Payer: United Healthcare Commercial	$273.60
Rate for Payer: United Healthcare Managed Medicare	$179.36

INTMD RPR N-HF/GENIT7.6-12.5

Professional

Both

$1,188.00

Service Code	CPT 12044
Hospital Charge Code	7982827
Hospital Revenue Code	981
Min. Negotiated Rate	$559.46
Max. Negotiated Rate	$891.00
Rate for Payer: Cash Price	$950.40
Rate for Payer: Cash Price	$950.40
Rate for Payer: Medical Associates Commercial	$891.00
Rate for Payer: Midlands Choice Commercial	$831.60
Rate for Payer: Partners Health Alliance Commercial	$891.00
Rate for Payer: United Healthcare Commercial	$559.46

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

Professional

Both

$1,261.00

Service Code	CPT 12035
Hospital Charge Code	7982831
Hospital Revenue Code	981
Min. Negotiated Rate	$579.18
Max. Negotiated Rate	$945.75
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Cash Price	$1,008.80
Rate for Payer: Medical Associates Commercial	$945.75
Rate for Payer: Midlands Choice Commercial	$882.70
Rate for Payer: Partners Health Alliance Commercial	$945.75
Rate for Payer: United Healthcare Commercial	$579.18

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

Facility

$724.00

Service Code	CPT 12035
Hospital Charge Code	4863363
Hospital Revenue Code	450
Min. Negotiated Rate	$325.80
Max. Negotiated Rate	$651.60
Rate for Payer: Aetna of IA Commercial	$651.60
Rate for Payer: Aetna of IA Medical Rental Products	$651.60
Rate for Payer: Aetna of IA Medicare	$412.68
Rate for Payer: Amerigroup Medicaid	$417.60
Rate for Payer: Amerigroup Medicare	$329.06
Rate for Payer: Cash Price	$579.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$543.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$325.80
Rate for Payer: Iowa Total Care Managed Medicaid	$413.55
Rate for Payer: Medical Associates Commercial	$543.00
Rate for Payer: Medical Associates Managed Medicare	$325.80
Rate for Payer: Midlands Choice Commercial	$506.80
Rate for Payer: Molina Healthcare Managed Medicaid	$419.63
Rate for Payer: Partners Health Alliance Commercial	$374.67
Rate for Payer: United Healthcare Commercial	$651.60
Rate for Payer: United Healthcare Managed Medicare	$427.16

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

Facility

$724.00

Service Code	CPT 12035
Hospital Charge Code	4863363
Hospital Revenue Code	450
Min. Negotiated Rate	$506.80
Max. Negotiated Rate	$651.60
Rate for Payer: Aetna of IA Commercial	$651.60
Rate for Payer: Aetna of IA Medical Rental Products	$651.60
Rate for Payer: Cash Price	$579.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$543.00
Rate for Payer: Medical Associates Commercial	$543.00
Rate for Payer: Midlands Choice Commercial	$506.80
Rate for Payer: United Healthcare Commercial	$651.60

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

Facility

$579.00

Service Code	CPT 12036
Hospital Charge Code	4863365
Hospital Revenue Code	450
Min. Negotiated Rate	$260.55
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Aetna of IA Medicare	$330.03
Rate for Payer: Amerigroup Medicaid	$333.97
Rate for Payer: Amerigroup Medicare	$263.16
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$260.55
Rate for Payer: Iowa Total Care Managed Medicaid	$330.72
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Medical Associates Managed Medicare	$260.55
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: Molina Healthcare Managed Medicaid	$335.59
Rate for Payer: Partners Health Alliance Commercial	$299.63
Rate for Payer: United Healthcare Commercial	$521.10
Rate for Payer: United Healthcare Managed Medicare	$341.61

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

Facility

$579.00

Service Code	CPT 12036
Hospital Charge Code	4863365
Hospital Revenue Code	450
Min. Negotiated Rate	$405.30
Max. Negotiated Rate	$521.10
Rate for Payer: Aetna of IA Commercial	$521.10
Rate for Payer: Aetna of IA Medical Rental Products	$521.10
Rate for Payer: Cash Price	$463.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$434.25
Rate for Payer: Medical Associates Commercial	$434.25
Rate for Payer: Midlands Choice Commercial	$405.30
Rate for Payer: United Healthcare Commercial	$521.10

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	$645.57
Max. Negotiated Rate	$1,046.25
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Cash Price	$1,116.00
Rate for Payer: Medical Associates Commercial	$1,046.25
Rate for Payer: Midlands Choice Commercial	$976.50
Rate for Payer: Partners Health Alliance Commercial	$1,046.25
Rate for Payer: United Healthcare Commercial	$645.57

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	$371.00
Max. Negotiated Rate	$397.50
Rate for Payer: Cash Price	$424.00
Rate for Payer: Cash Price	$424.00
Rate for Payer: Medical Associates Commercial	$397.50
Rate for Payer: Midlands Choice Commercial	$371.00
Rate for Payer: Partners Health Alliance Commercial	$397.50
Rate for Payer: United Healthcare Commercial	$379.01

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

Facility

$380.00

Service Code	CPT 12031
Hospital Charge Code	4863354
Hospital Revenue Code	450
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

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

Facility

$380.00

Service Code	CPT 12031
Hospital Charge Code	4863354
Hospital Revenue Code	450
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: 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

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

Facility

$380.00

Service Code	CPT 12032
Hospital Charge Code	4863355
Hospital Revenue Code	450
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: 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

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	$455.89
Max. Negotiated Rate	$600.00
Rate for Payer: Cash Price	$640.00
Rate for Payer: Cash Price	$640.00
Rate for Payer: Medical Associates Commercial	$600.00
Rate for Payer: Midlands Choice Commercial	$560.00
Rate for Payer: Partners Health Alliance Commercial	$600.00
Rate for Payer: United Healthcare Commercial	$455.89

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

Facility

$380.00

Service Code	CPT 12032
Hospital Charge Code	4863355
Hospital Revenue Code	450
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

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	$488.45
Max. Negotiated Rate	$774.75
Rate for Payer: Cash Price	$826.40
Rate for Payer: Cash Price	$826.40
Rate for Payer: Medical Associates Commercial	$774.75
Rate for Payer: Midlands Choice Commercial	$723.10
Rate for Payer: Partners Health Alliance Commercial	$774.75
Rate for Payer: United Healthcare Commercial	$488.45

INTMD RPR S/TR/EXT 7.6-12.5

Facility

$724.00

Service Code	CPT 12034
Hospital Charge Code	4863356
Hospital Revenue Code	450
Min. Negotiated Rate	$506.80
Max. Negotiated Rate	$651.60
Rate for Payer: Aetna of IA Commercial	$651.60
Rate for Payer: Aetna of IA Medical Rental Products	$651.60
Rate for Payer: Cash Price	$579.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$543.00
Rate for Payer: Medical Associates Commercial	$543.00
Rate for Payer: Midlands Choice Commercial	$506.80
Rate for Payer: United Healthcare Commercial	$651.60

INTMD RPR S/TR/EXT 7.6-12.5

Facility

$724.00

Service Code	CPT 12034
Hospital Charge Code	4863356
Hospital Revenue Code	450
Min. Negotiated Rate	$325.80
Max. Negotiated Rate	$651.60
Rate for Payer: Aetna of IA Commercial	$651.60
Rate for Payer: Aetna of IA Medical Rental Products	$651.60
Rate for Payer: Aetna of IA Medicare	$412.68
Rate for Payer: Amerigroup Medicaid	$417.60
Rate for Payer: Amerigroup Medicare	$329.06
Rate for Payer: Cash Price	$579.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$543.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$325.80
Rate for Payer: Iowa Total Care Managed Medicaid	$413.55
Rate for Payer: Medical Associates Commercial	$543.00
Rate for Payer: Medical Associates Managed Medicare	$325.80
Rate for Payer: Midlands Choice Commercial	$506.80
Rate for Payer: Molina Healthcare Managed Medicaid	$419.63
Rate for Payer: Partners Health Alliance Commercial	$374.67
Rate for Payer: United Healthcare Commercial	$651.60
Rate for Payer: United Healthcare Managed Medicare	$427.16

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

Know your out-of-pocket cost for care.

All Charges