Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

INFUSION TX SEQENTIAL

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	6922797
Hospital Revenue Code	260
Min. Negotiated Rate	$103.50
Max. Negotiated Rate	$598.25
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Aetna of IA Medicare	$131.10
Rate for Payer: Amerigroup Medicaid	$132.66
Rate for Payer: Amerigroup Medicare	$104.54
Rate for Payer: Cash Price	$184.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$103.50
Rate for Payer: Iowa Total Care Managed Medicaid	$131.38
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Medical Associates Managed Medicare	$103.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: Molina Healthcare Managed Medicaid	$133.31
Rate for Payer: Partners Health Alliance Commercial	$119.02
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70
Rate for Payer: Wellmark IA HMO WHPI	$543.09
Rate for Payer: Wellmark IA PPO	$598.25

INFUSION TX SEQENTIAL

Facility

$230.00

Service Code	CPT 96367
Hospital Charge Code	6922797
Hospital Revenue Code	260
Min. Negotiated Rate	$161.00
Max. Negotiated Rate	$207.00
Rate for Payer: Aetna of IA Commercial	$207.00
Rate for Payer: Aetna of IA Medical Rental Products	$207.00
Rate for Payer: Cash Price	$184.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$172.50
Rate for Payer: Medical Associates Commercial	$172.50
Rate for Payer: Midlands Choice Commercial	$161.00
Rate for Payer: United Healthcare Commercial	$207.00

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC

Facility

$13,208.84

Service Code	MSDRG 351
Min. Negotiated Rate	$13,017.40
Max. Negotiated Rate	$13,208.84
Rate for Payer: Amerigroup Medicaid	$13,145.02
Rate for Payer: Iowa Total Care Managed Medicaid	$13,017.40
Rate for Payer: Molina Healthcare Managed Medicaid	$13,208.84

INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC

Facility

$19,858.86

Service Code	MSDRG 350
Min. Negotiated Rate	$19,571.04
Max. Negotiated Rate	$19,858.86
Rate for Payer: Amerigroup Medicaid	$19,762.91
Rate for Payer: Iowa Total Care Managed Medicaid	$19,571.04
Rate for Payer: Molina Healthcare Managed Medicaid	$19,858.86

INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC

Facility

$9,053.98

Service Code	MSDRG 352
Min. Negotiated Rate	$8,922.76
Max. Negotiated Rate	$9,053.98
Rate for Payer: Amerigroup Medicaid	$9,010.24
Rate for Payer: Iowa Total Care Managed Medicaid	$8,922.76
Rate for Payer: Molina Healthcare Managed Medicaid	$9,053.98

Inhalation Pediatric Spacing Device [VDMC]

Facility

$56.64

Service Code	NDC 08373-9823-00
Hospital Charge Code	11676962
Hospital Revenue Code	259
Min. Negotiated Rate	$25.49
Max. Negotiated Rate	$50.98
Rate for Payer: Aetna of IA Commercial	$50.98
Rate for Payer: Aetna of IA Medical Rental Products	$50.98
Rate for Payer: Aetna of IA Medicare	$32.28
Rate for Payer: Amerigroup Medicaid	$32.67
Rate for Payer: Amerigroup Medicare	$25.74
Rate for Payer: Cash Price	$45.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$25.49
Rate for Payer: Iowa Total Care Managed Medicaid	$32.35
Rate for Payer: Medical Associates Commercial	$42.48
Rate for Payer: Medical Associates Managed Medicare	$25.49
Rate for Payer: Midlands Choice Commercial	$39.65
Rate for Payer: Molina Healthcare Managed Medicaid	$32.83
Rate for Payer: Partners Health Alliance Commercial	$29.31
Rate for Payer: United Healthcare Commercial	$50.98
Rate for Payer: United Healthcare Managed Medicare	$33.42

Inhalation Pediatric Spacing Device [VDMC]

Facility

$56.64

Service Code	NDC 08373-9823-00
Hospital Charge Code	11676962
Hospital Revenue Code	259
Min. Negotiated Rate	$39.65
Max. Negotiated Rate	$50.98
Rate for Payer: Aetna of IA Commercial	$50.98
Rate for Payer: Aetna of IA Medical Rental Products	$50.98
Rate for Payer: Cash Price	$45.31
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$42.48
Rate for Payer: Medical Associates Commercial	$42.48
Rate for Payer: Midlands Choice Commercial	$39.65
Rate for Payer: United Healthcare Commercial	$50.98

Inhalation Spacing Device Adult [VDMC]

Facility

$31.44

Service Code	NDC 08373-7478-00
Hospital Charge Code	11676913
Hospital Revenue Code	259
Min. Negotiated Rate	$22.01
Max. Negotiated Rate	$28.30
Rate for Payer: Aetna of IA Commercial	$28.30
Rate for Payer: Aetna of IA Medical Rental Products	$28.30
Rate for Payer: Cash Price	$25.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.58
Rate for Payer: Medical Associates Commercial	$23.58
Rate for Payer: Midlands Choice Commercial	$22.01
Rate for Payer: United Healthcare Commercial	$28.30

Inhalation Spacing Device Adult [VDMC]

Facility

$31.44

Service Code	NDC 08373-7478-00
Hospital Charge Code	11676913
Hospital Revenue Code	259
Min. Negotiated Rate	$14.15
Max. Negotiated Rate	$28.30
Rate for Payer: Aetna of IA Commercial	$28.30
Rate for Payer: Aetna of IA Medical Rental Products	$28.30
Rate for Payer: Aetna of IA Medicare	$17.92
Rate for Payer: Amerigroup Medicaid	$18.13
Rate for Payer: Amerigroup Medicare	$14.29
Rate for Payer: Cash Price	$25.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$23.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$14.15
Rate for Payer: Iowa Total Care Managed Medicaid	$17.96
Rate for Payer: Medical Associates Commercial	$23.58
Rate for Payer: Medical Associates Managed Medicare	$14.15
Rate for Payer: Midlands Choice Commercial	$22.01
Rate for Payer: Molina Healthcare Managed Medicaid	$18.22
Rate for Payer: Partners Health Alliance Commercial	$16.27
Rate for Payer: United Healthcare Commercial	$28.30
Rate for Payer: United Healthcare Managed Medicare	$18.55

INHIBIN A

Facility

$106.00

Service Code	CPT 86336
Hospital Charge Code	8086834
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
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	$61.14
Rate for Payer: Amerigroup Medicare	$48.18
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	$47.70
Rate for Payer: Iowa Total Care Managed Medicaid	$60.55
Rate for Payer: Medical Associates Commercial	$79.50
Rate for Payer: Medical Associates Managed Medicare	$47.70
Rate for Payer: Midlands Choice Commercial	$74.20
Rate for Payer: Molina Healthcare Managed Medicaid	$61.44
Rate for Payer: Partners Health Alliance Commercial	$54.86
Rate for Payer: United Healthcare Commercial	$95.40
Rate for Payer: United Healthcare Managed Medicare	$62.54
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

INHIBIN A

Facility

$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

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663519
Hospital Revenue Code	943
Min. Negotiated Rate	$64.35
Max. Negotiated Rate	$406.12
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	$82.48
Rate for Payer: Amerigroup Medicare	$64.99
Rate for Payer: Cash Price	$114.40
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	$64.35
Rate for Payer: Iowa Total Care Managed Medicaid	$81.68
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$64.35
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$82.88
Rate for Payer: Partners Health Alliance Commercial	$74.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37
Rate for Payer: Wellmark IA HMO WHPI	$368.68
Rate for Payer: Wellmark IA PPO	$406.12

Initial

Facility

$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 - KX

Facility

$143.00

Service Code	CPT 93668 KX
Hospital Charge Code	8663518
Hospital Revenue Code	943
Min. Negotiated Rate	$64.35
Max. Negotiated Rate	$406.12
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	$82.48
Rate for Payer: Amerigroup Medicare	$64.99
Rate for Payer: Cash Price	$114.40
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	$64.35
Rate for Payer: Iowa Total Care Managed Medicaid	$81.68
Rate for Payer: Medical Associates Commercial	$107.25
Rate for Payer: Medical Associates Managed Medicare	$64.35
Rate for Payer: Midlands Choice Commercial	$100.10
Rate for Payer: Molina Healthcare Managed Medicaid	$82.88
Rate for Payer: Partners Health Alliance Commercial	$74.00
Rate for Payer: United Healthcare Commercial	$128.70
Rate for Payer: United Healthcare Managed Medicare	$84.37
Rate for Payer: Wellmark IA HMO WHPI	$368.68
Rate for Payer: Wellmark IA PPO	$406.12

Initial - KX

Facility

$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 OBSERVATION HIGH COMPLEXITY

Professional

Both

$305.00

Service Code	CPT 99220
Hospital Charge Code	5140803
Hospital Revenue Code	983
Min. Negotiated Rate	$213.50
Max. Negotiated Rate	$291.00
Rate for Payer: Cash Price	$244.00
Rate for Payer: Cash Price	$244.00
Rate for Payer: Medical Associates Commercial	$228.75
Rate for Payer: Midlands Choice Commercial	$213.50
Rate for Payer: Partners Health Alliance Commercial	$228.75
Rate for Payer: Wellmark IA HMO WHPI	$291.00
Rate for Payer: Wellmark IA PPO	$291.00

INJECT EPIDURAL PATCH

Facility

$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

$1,120.00

Service Code	CPT 62273
Hospital Charge Code	4866803
Hospital Revenue Code	761
Min. Negotiated Rate	$504.00
Max. Negotiated Rate	$1,679.15
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	$646.02
Rate for Payer: Amerigroup Medicare	$509.04
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	$504.00
Rate for Payer: Iowa Total Care Managed Medicaid	$639.74
Rate for Payer: Medical Associates Commercial	$840.00
Rate for Payer: Medical Associates Managed Medicare	$504.00
Rate for Payer: Midlands Choice Commercial	$784.00
Rate for Payer: Molina Healthcare Managed Medicaid	$649.15
Rate for Payer: Partners Health Alliance Commercial	$579.60
Rate for Payer: United Healthcare Commercial	$1,008.00
Rate for Payer: United Healthcare Managed Medicare	$660.80
Rate for Payer: Wellmark IA HMO WHPI	$1,524.35
Rate for Payer: Wellmark IA PPO	$1,679.15

INJECT FOR SPINE DISK X-RAY LUMBAR

Professional

Both

$1,176.00

Service Code	CPT 62290
Hospital Charge Code	8101308
Hospital Revenue Code	975
Min. Negotiated Rate	$215.24
Max. Negotiated Rate	$882.00
Rate for Payer: Amerigroup Medicaid	$217.35
Rate for Payer: Cash Price	$940.80
Rate for Payer: Cash Price	$940.80
Rate for Payer: Iowa Total Care Managed Medicaid	$215.24
Rate for Payer: Medical Associates Commercial	$882.00
Rate for Payer: Midlands Choice Commercial	$823.20
Rate for Payer: Molina Healthcare Managed Medicaid	$216.30
Rate for Payer: Partners Health Alliance Commercial	$882.00
Rate for Payer: United Healthcare Commercial	$536.22
Rate for Payer: Wellmark IA HMO WHPI	$644.00
Rate for Payer: Wellmark IA PPO	$757.60

INJECTION PROCEDURE FOR SACROILIAC JOINT; PROVISION OF ANESTHETIC, STEROID AND/OR OTHER THERAPEUTIC AGENT, WITH OR WITHOUT ARTHROGRAPHY

Facility

$1,236.32

Service Code	CPT G0260
Hospital Revenue Code	360
Min. Negotiated Rate	$1,122.35
Max. Negotiated Rate	$1,236.32
Rate for Payer: Wellmark IA HMO WHPI	$1,122.35
Rate for Payer: Wellmark IA PPO	$1,236.32

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; AXILLARY NERVE, INCLUDING IMAGING GUIDANCE, WHEN PERFORMED

Facility

$839.58

Service Code	CPT 64417
Hospital Revenue Code	360
Min. Negotiated Rate	$762.18
Max. Negotiated Rate	$839.58
Rate for Payer: Wellmark IA HMO WHPI	$762.18
Rate for Payer: Wellmark IA PPO	$839.58

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; ILIOINGUINAL, ILIOHYPOGASTRIC NERVES

Facility

$839.58

Service Code	CPT 64425
Hospital Revenue Code	360
Min. Negotiated Rate	$762.18
Max. Negotiated Rate	$839.58
Rate for Payer: Wellmark IA HMO WHPI	$762.18
Rate for Payer: Wellmark IA PPO	$839.58

INJECTION(S), ANESTHETIC AGENT(S) AND/OR STEROID; OTHER PERIPHERAL NERVE OR BRANCH

Facility

$839.58

Service Code	CPT 64450
Hospital Revenue Code	490
Min. Negotiated Rate	$762.18
Max. Negotiated Rate	$839.58
Rate for Payer: Wellmark IA HMO WHPI	$762.18
Rate for Payer: Wellmark IA PPO	$839.58

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

$1,679.15

Service Code	CPT 64493
Hospital Revenue Code	490
Min. Negotiated Rate	$1,524.35
Max. Negotiated Rate	$1,679.15
Rate for Payer: Wellmark IA HMO WHPI	$1,524.35
Rate for Payer: Wellmark IA PPO	$1,679.15

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

$1,679.15

Service Code	CPT 62323
Hospital Revenue Code	490
Min. Negotiated Rate	$1,524.35
Max. Negotiated Rate	$1,679.15
Rate for Payer: Wellmark IA HMO WHPI	$1,524.35
Rate for Payer: Wellmark IA PPO	$1,679.15

Know your out-of-pocket cost for care.

All Charges