Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

INTELLIS ADAPTIVESTIM

Facility

$27,720.00

Service Code	HCPCS C1778
Hospital Charge Code	8557558
Hospital Revenue Code	278
Min. Negotiated Rate	$12,474.00
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: Aetna of IA Medicare	$15,800.40
Rate for Payer: Amerigroup Medicaid	$15,988.90
Rate for Payer: Amerigroup Medicare	$12,598.74
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	$12,474.00
Rate for Payer: Iowa Total Care Managed Medicaid	$15,833.66
Rate for Payer: Medical Associates Commercial	$20,790.00
Rate for Payer: Medical Associates Managed Medicare	$12,474.00
Rate for Payer: Midlands Choice Commercial	$19,404.00
Rate for Payer: Molina Healthcare Managed Medicaid	$16,066.51
Rate for Payer: Partners Health Alliance Commercial	$14,345.10
Rate for Payer: United Healthcare Commercial	$24,948.00
Rate for Payer: United Healthcare Managed Medicare	$16,354.80

INTELLIS ADAPTIVESTIM

Facility

$27,720.00

Service Code	HCPCS 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

INTERPRETATION

Professional

Both

$15.00

Service Code	HCPCS T1013
Hospital Charge Code	8300878
Hospital Revenue Code	983
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$14.50
Rate for Payer: Amerigroup Medicaid	$1.68
Rate for Payer: Cash Price	$12.00
Rate for Payer: Cash Price	$12.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1.66
Rate for Payer: Medical Associates Commercial	$11.25
Rate for Payer: Midlands Choice Commercial	$10.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1.67
Rate for Payer: Partners Health Alliance Commercial	$11.25
Rate for Payer: Wellmark IA HMO WHPI	$14.50
Rate for Payer: Wellmark IA PPO	$14.50

INTERSCALENE BLOCK CHARGE

Professional

Both

$300.00

Service Code	CPT 64415
Hospital Charge Code	8059064
Hospital Revenue Code	975
Min. Negotiated Rate	$103.09
Max. Negotiated Rate	$296.30
Rate for Payer: Amerigroup Medicaid	$104.10
Rate for Payer: Cash Price	$240.00
Rate for Payer: Cash Price	$240.00
Rate for Payer: Iowa Total Care Managed Medicaid	$103.09
Rate for Payer: Medical Associates Commercial	$225.00
Rate for Payer: Midlands Choice Commercial	$210.00
Rate for Payer: Molina Healthcare Managed Medicaid	$103.60
Rate for Payer: Partners Health Alliance Commercial	$225.00
Rate for Payer: United Healthcare Commercial	$172.82
Rate for Payer: Wellmark IA HMO WHPI	$251.80
Rate for Payer: Wellmark IA PPO	$296.30

INTERSCALENE BLOCK CHARGE

Facility

$300.00

Service Code	CPT 64415
Hospital Charge Code	8059064
Hospital Revenue Code	964
Min. Negotiated Rate	$135.00
Max. Negotiated Rate	$2,560.12
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	$173.04
Rate for Payer: Amerigroup Medicare	$136.35
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	$135.00
Rate for Payer: Iowa Total Care Managed Medicaid	$171.36
Rate for Payer: Medical Associates Commercial	$225.00
Rate for Payer: Medical Associates Managed Medicare	$135.00
Rate for Payer: Midlands Choice Commercial	$210.00
Rate for Payer: Molina Healthcare Managed Medicaid	$173.88
Rate for Payer: Partners Health Alliance Commercial	$155.25
Rate for Payer: United Healthcare Commercial	$270.00
Rate for Payer: Wellmark IA HMO WHPI	$2,324.10
Rate for Payer: Wellmark IA PPO	$2,560.12

INTERSCALENE BLOCK CHARGE

Facility

$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

$18,684.00

Service Code	HCPCS 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

INTERSTIM II NEUROSTIMULATOR

Facility

$18,684.00

Service Code	HCPCS C1778
Hospital Charge Code	8026098
Hospital Revenue Code	278
Min. Negotiated Rate	$8,407.80
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: Aetna of IA Medicare	$10,649.88
Rate for Payer: Amerigroup Medicaid	$10,776.93
Rate for Payer: Amerigroup Medicare	$8,491.88
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	$8,407.80
Rate for Payer: Iowa Total Care Managed Medicaid	$10,672.30
Rate for Payer: Medical Associates Commercial	$14,013.00
Rate for Payer: Medical Associates Managed Medicare	$8,407.80
Rate for Payer: Midlands Choice Commercial	$13,078.80
Rate for Payer: Molina Healthcare Managed Medicaid	$10,829.25
Rate for Payer: Partners Health Alliance Commercial	$9,668.97
Rate for Payer: United Healthcare Commercial	$16,815.60
Rate for Payer: United Healthcare Managed Medicare	$11,023.56

INTERSTITIAL LUNG DISEASE WITH CC

Facility

$9,940.12

Service Code	MSDRG 197
Min. Negotiated Rate	$9,796.06
Max. Negotiated Rate	$9,940.12
Rate for Payer: Amerigroup Medicaid	$9,892.10
Rate for Payer: Iowa Total Care Managed Medicaid	$9,796.06
Rate for Payer: Molina Healthcare Managed Medicaid	$9,940.12

INTERSTITIAL LUNG DISEASE WITH MCC

Facility

$15,705.13

Service Code	MSDRG 196
Min. Negotiated Rate	$15,477.51
Max. Negotiated Rate	$15,705.13
Rate for Payer: Amerigroup Medicaid	$15,629.25
Rate for Payer: Iowa Total Care Managed Medicaid	$15,477.51
Rate for Payer: Molina Healthcare Managed Medicaid	$15,705.13

INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC

Facility

$8,360.38

Service Code	MSDRG 198
Min. Negotiated Rate	$8,239.21
Max. Negotiated Rate	$8,360.38
Rate for Payer: Amerigroup Medicaid	$8,319.99
Rate for Payer: Iowa Total Care Managed Medicaid	$8,239.21
Rate for Payer: Molina Healthcare Managed Medicaid	$8,360.38

INTMD RPR FACE/MM 20.1-30.0

Facility

$579.00

Service Code	CPT 12056
Hospital Charge Code	4863405
Hospital Revenue Code	450
Min. Negotiated Rate	$260.55
Max. Negotiated Rate	$1,127.76
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

INTMD RPR FACE/MM 20.1-30.0

Facility

$579.00

Service Code	CPT 12056
Hospital Charge Code	4863405
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 FACE/MM 2.5 CM/<

Facility

$380.00

Service Code	CPT 12051
Hospital Charge Code	4863393
Hospital Revenue Code	450
Min. Negotiated Rate	$171.00
Max. Negotiated Rate	$1,127.76
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

INTMD RPR FACE/MM 2.5 CM/<

Facility

$380.00

Service Code	CPT 12051
Hospital Charge Code	4863393
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 FACE/MM 2.5 CM/<

Professional

Both

$854.00

Service Code	CPT 12051
Hospital Charge Code	7982825
Hospital Revenue Code	981
Min. Negotiated Rate	$157.93
Max. Negotiated Rate	$640.50
Rate for Payer: Amerigroup Medicaid	$159.47
Rate for Payer: Cash Price	$683.20
Rate for Payer: Cash Price	$683.20
Rate for Payer: Iowa Total Care Managed Medicaid	$157.93
Rate for Payer: Medical Associates Commercial	$640.50
Rate for Payer: Midlands Choice Commercial	$597.80
Rate for Payer: Molina Healthcare Managed Medicaid	$158.70
Rate for Payer: Partners Health Alliance Commercial	$640.50
Rate for Payer: United Healthcare Commercial	$409.55
Rate for Payer: Wellmark IA HMO WHPI	$518.40
Rate for Payer: Wellmark IA PPO	$609.90

INTMD RPR FACE/MM 2.6-5.0 CM

Facility

$380.00

Service Code	CPT 12052
Hospital Charge Code	4863394
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 FACE/MM 2.6-5.0 CM

Facility

$380.00

Service Code	CPT 12052
Hospital Charge Code	4863394
Hospital Revenue Code	450
Min. Negotiated Rate	$171.00
Max. Negotiated Rate	$1,127.76
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

INTMD RPR FACE/MM 2.6-5.0 CM

Professional

Both

$640.00

Service Code	CPT 12052
Hospital Charge Code	7982824
Hospital Revenue Code	981
Min. Negotiated Rate	$177.16
Max. Negotiated Rate	$678.50
Rate for Payer: Amerigroup Medicaid	$178.90
Rate for Payer: Cash Price	$512.00
Rate for Payer: Cash Price	$512.00
Rate for Payer: Iowa Total Care Managed Medicaid	$177.16
Rate for Payer: Medical Associates Commercial	$480.00
Rate for Payer: Midlands Choice Commercial	$448.00
Rate for Payer: Molina Healthcare Managed Medicaid	$178.03
Rate for Payer: Partners Health Alliance Commercial	$480.00
Rate for Payer: United Healthcare Commercial	$460.56
Rate for Payer: Wellmark IA HMO WHPI	$576.80
Rate for Payer: Wellmark IA PPO	$678.50

INTMD RPR FACE/MM 5.1-7.5 CM

Facility

$386.00

Service Code	CPT 12053
Hospital Charge Code	4863395
Hospital Revenue Code	450
Min. Negotiated Rate	$173.70
Max. Negotiated Rate	$1,127.76
Rate for Payer: Aetna of IA Commercial	$347.40
Rate for Payer: Aetna of IA Medical Rental Products	$347.40
Rate for Payer: Aetna of IA Medicare	$220.02
Rate for Payer: Amerigroup Medicaid	$222.64
Rate for Payer: Amerigroup Medicare	$175.44
Rate for Payer: Cash Price	$308.80
Rate for Payer: Cash Price	$308.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$289.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$173.70
Rate for Payer: Iowa Total Care Managed Medicaid	$220.48
Rate for Payer: Medical Associates Commercial	$289.50
Rate for Payer: Medical Associates Managed Medicare	$173.70
Rate for Payer: Midlands Choice Commercial	$270.20
Rate for Payer: Molina Healthcare Managed Medicaid	$223.73
Rate for Payer: Partners Health Alliance Commercial	$199.76
Rate for Payer: United Healthcare Commercial	$347.40
Rate for Payer: United Healthcare Managed Medicare	$227.74
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

INTMD RPR FACE/MM 5.1-7.5 CM

Professional

Both

$1,143.00

Service Code	CPT 12053
Hospital Charge Code	7982823
Hospital Revenue Code	981
Min. Negotiated Rate	$197.99
Max. Negotiated Rate	$857.25
Rate for Payer: Amerigroup Medicaid	$199.93
Rate for Payer: Cash Price	$914.40
Rate for Payer: Cash Price	$914.40
Rate for Payer: Iowa Total Care Managed Medicaid	$197.99
Rate for Payer: Medical Associates Commercial	$857.25
Rate for Payer: Midlands Choice Commercial	$800.10
Rate for Payer: Molina Healthcare Managed Medicaid	$198.96
Rate for Payer: Partners Health Alliance Commercial	$857.25
Rate for Payer: United Healthcare Commercial	$537.70
Rate for Payer: Wellmark IA HMO WHPI	$664.30
Rate for Payer: Wellmark IA PPO	$781.50

INTMD RPR FACE/MM 5.1-7.5 CM

Facility

$386.00

Service Code	CPT 12053
Hospital Charge Code	4863395
Hospital Revenue Code	450
Min. Negotiated Rate	$270.20
Max. Negotiated Rate	$347.40
Rate for Payer: Aetna of IA Commercial	$347.40
Rate for Payer: Aetna of IA Medical Rental Products	$347.40
Rate for Payer: Cash Price	$308.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$289.50
Rate for Payer: Medical Associates Commercial	$289.50
Rate for Payer: Midlands Choice Commercial	$270.20
Rate for Payer: United Healthcare Commercial	$347.40

INTMD RPR FACE/MM 7.6-12.5CM

Facility

$380.00

Service Code	CPT 12054
Hospital Charge Code	4863397
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 FACE/MM 7.6-12.5CM

Facility

$380.00

Service Code	CPT 12054
Hospital Charge Code	4863397
Hospital Revenue Code	450
Min. Negotiated Rate	$171.00
Max. Negotiated Rate	$1,127.76
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$1,023.80
Rate for Payer: Wellmark IA PPO	$1,127.76

INTMD RPR FACE/MM 7.6-12.5CM

Professional

Both

$1,192.00

Service Code	CPT 12054
Hospital Charge Code	7982822
Hospital Revenue Code	981
Min. Negotiated Rate	$231.63
Max. Negotiated Rate	$894.00
Rate for Payer: Amerigroup Medicaid	$233.90
Rate for Payer: Cash Price	$953.60
Rate for Payer: Cash Price	$953.60
Rate for Payer: Iowa Total Care Managed Medicaid	$231.63
Rate for Payer: Medical Associates Commercial	$894.00
Rate for Payer: Midlands Choice Commercial	$834.40
Rate for Payer: Molina Healthcare Managed Medicaid	$232.77
Rate for Payer: Partners Health Alliance Commercial	$894.00
Rate for Payer: United Healthcare Commercial	$565.17
Rate for Payer: Wellmark IA HMO WHPI	$699.50
Rate for Payer: Wellmark IA PPO	$823.00

Know your out-of-pocket cost for care.

All Charges