Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

Professional

Both

$1,033.00

Service Code	CPT 12034
Hospital Charge Code	7982832
Hospital Revenue Code	981
Min. Negotiated Rate	$185.54
Max. Negotiated Rate	$774.75
Rate for Payer: Amerigroup Medicaid	$187.36
Rate for Payer: Cash Price	$826.40
Rate for Payer: Cash Price	$826.40
Rate for Payer: Iowa Total Care Managed Medicaid	$185.54
Rate for Payer: Medical Associates Commercial	$774.75
Rate for Payer: Midlands Choice Commercial	$723.10
Rate for Payer: Molina Healthcare Managed Medicaid	$186.45
Rate for Payer: Partners Health Alliance Commercial	$774.75
Rate for Payer: United Healthcare Commercial	$488.45
Rate for Payer: Wellmark IA HMO WHPI	$612.00
Rate for Payer: Wellmark IA PPO	$720.00

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS

Facility

$11,504.11

Service Code	MSDRG 065
Min. Negotiated Rate	$11,337.38
Max. Negotiated Rate	$11,504.11
Rate for Payer: Amerigroup Medicaid	$11,448.53
Rate for Payer: Iowa Total Care Managed Medicaid	$11,337.38
Rate for Payer: Molina Healthcare Managed Medicaid	$11,504.11

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC

Facility

$19,407.34

Service Code	MSDRG 064
Min. Negotiated Rate	$19,126.07
Max. Negotiated Rate	$19,407.34
Rate for Payer: Amerigroup Medicaid	$19,313.58
Rate for Payer: Iowa Total Care Managed Medicaid	$19,126.07
Rate for Payer: Molina Healthcare Managed Medicaid	$19,407.34

INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC

Facility

$7,403.30

Service Code	MSDRG 066
Min. Negotiated Rate	$7,296.00
Max. Negotiated Rate	$7,403.30
Rate for Payer: Amerigroup Medicaid	$7,367.53
Rate for Payer: Iowa Total Care Managed Medicaid	$7,296.00
Rate for Payer: Molina Healthcare Managed Medicaid	$7,403.30

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC

Facility

$75,642.01

Service Code	MSDRG 021
Min. Negotiated Rate	$74,545.71
Max. Negotiated Rate	$75,642.01
Rate for Payer: Amerigroup Medicaid	$75,276.56
Rate for Payer: Iowa Total Care Managed Medicaid	$74,545.71
Rate for Payer: Molina Healthcare Managed Medicaid	$75,642.01

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC

Facility

$96,051.47

Service Code	MSDRG 020
Min. Negotiated Rate	$94,659.38
Max. Negotiated Rate	$96,051.47
Rate for Payer: Amerigroup Medicaid	$95,587.41
Rate for Payer: Iowa Total Care Managed Medicaid	$94,659.38
Rate for Payer: Molina Healthcare Managed Medicaid	$96,051.47

INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC

Facility

$54,732.62

Service Code	MSDRG 022
Min. Negotiated Rate	$53,939.37
Max. Negotiated Rate	$54,732.62
Rate for Payer: Amerigroup Medicaid	$54,468.18
Rate for Payer: Iowa Total Care Managed Medicaid	$53,939.37
Rate for Payer: Molina Healthcare Managed Medicaid	$54,732.62

Intraocular Lens Procedure

Facility

$4,747.70

Service Code	CPT 66982
Min. Negotiated Rate	$4,310.01
Max. Negotiated Rate	$4,747.70
Rate for Payer: Wellmark IA HMO WHPI	$4,310.01
Rate for Payer: Wellmark IA PPO	$4,747.70

INTRAOCULAR PROCEDURES WITH CC/MCC

Facility

$14,499.21

Service Code	MSDRG 116
Min. Negotiated Rate	$14,289.07
Max. Negotiated Rate	$14,499.21
Rate for Payer: Amerigroup Medicaid	$14,429.15
Rate for Payer: Iowa Total Care Managed Medicaid	$14,289.07
Rate for Payer: Molina Healthcare Managed Medicaid	$14,499.21

INTRAOCULAR PROCEDURES WITHOUT CC/MCC

Facility

$14,499.21

Service Code	MSDRG 117
Min. Negotiated Rate	$14,289.07
Max. Negotiated Rate	$14,499.21
Rate for Payer: Amerigroup Medicaid	$14,429.15
Rate for Payer: Iowa Total Care Managed Medicaid	$14,289.07
Rate for Payer: Molina Healthcare Managed Medicaid	$14,499.21

INTRAPLEURAL INSERTION CHARGE

Facility

$213.00

Hospital Charge Code	8059077
Hospital Revenue Code	360
Min. Negotiated Rate	$95.85
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	$122.86
Rate for Payer: Amerigroup Medicare	$96.81
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	$95.85
Rate for Payer: Iowa Total Care Managed Medicaid	$121.67
Rate for Payer: Medical Associates Commercial	$159.75
Rate for Payer: Medical Associates Managed Medicare	$95.85
Rate for Payer: Midlands Choice Commercial	$149.10
Rate for Payer: Molina Healthcare Managed Medicaid	$123.45
Rate for Payer: Partners Health Alliance Commercial	$110.23
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

INVASIVE BUNION PLATE LEFT

Facility

$2,592.00

Service Code	HCPCS C1713
Hospital Charge Code	8788813
Hospital Revenue Code	278
Min. Negotiated Rate	$1,166.40
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: Aetna of IA Medicare	$1,477.44
Rate for Payer: Amerigroup Medicaid	$1,495.07
Rate for Payer: Amerigroup Medicare	$1,178.06
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	$1,166.40
Rate for Payer: Iowa Total Care Managed Medicaid	$1,480.55
Rate for Payer: Medical Associates Commercial	$1,944.00
Rate for Payer: Medical Associates Managed Medicare	$1,166.40
Rate for Payer: Midlands Choice Commercial	$1,814.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1,502.32
Rate for Payer: Partners Health Alliance Commercial	$1,341.36
Rate for Payer: United Healthcare Commercial	$2,332.80
Rate for Payer: United Healthcare Managed Medicare	$1,529.28

INVASIVE BUNION PLATE LEFT

Facility

$2,592.00

Service Code	HCPCS 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

iohexol 300 mg/mL Sol[VDMC]

Facility

$172.38

Service Code	HCPCS Q9967
Hospital Charge Code	23686528
Hospital Revenue Code	259
Min. Negotiated Rate	$77.57
Max. Negotiated Rate	$155.14
Rate for Payer: Aetna of IA Commercial	$155.14
Rate for Payer: Aetna of IA Medical Rental Products	$155.14
Rate for Payer: Aetna of IA Medicare	$98.26
Rate for Payer: Amerigroup Medicaid	$99.43
Rate for Payer: Amerigroup Medicare	$78.35
Rate for Payer: Cash Price	$137.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$77.57
Rate for Payer: Iowa Total Care Managed Medicaid	$98.46
Rate for Payer: Medical Associates Commercial	$129.28
Rate for Payer: Medical Associates Managed Medicare	$77.57
Rate for Payer: Midlands Choice Commercial	$120.67
Rate for Payer: Molina Healthcare Managed Medicaid	$99.91
Rate for Payer: Partners Health Alliance Commercial	$89.21
Rate for Payer: United Healthcare Commercial	$155.14
Rate for Payer: United Healthcare Managed Medicare	$101.70

iohexol 300 mg/mL Sol[VDMC]

Facility

$172.38

Service Code	HCPCS Q9967
Hospital Charge Code	23686528
Hospital Revenue Code	259
Min. Negotiated Rate	$120.67
Max. Negotiated Rate	$155.14
Rate for Payer: Aetna of IA Commercial	$155.14
Rate for Payer: Aetna of IA Medical Rental Products	$155.14
Rate for Payer: Cash Price	$137.90
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$129.28
Rate for Payer: Medical Associates Commercial	$129.28
Rate for Payer: Midlands Choice Commercial	$120.67
Rate for Payer: United Healthcare Commercial	$155.14

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	$60.30
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	$77.29
Rate for Payer: Amerigroup Medicare	$60.90
Rate for Payer: Cash Price	$107.20
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	$60.30
Rate for Payer: Iowa Total Care Managed Medicaid	$76.54
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Medical Associates Managed Medicare	$60.30
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: Molina Healthcare Managed Medicaid	$77.67
Rate for Payer: Partners Health Alliance Commercial	$69.34
Rate for Payer: United Healthcare Commercial	$120.60
Rate for Payer: United Healthcare Managed Medicare	$79.06
Rate for Payer: Wellmark IA HMO WHPI	$73.74
Rate for Payer: Wellmark IA PPO	$81.22

IONTOPHORESIS APPLICATION PER 15 MIN

Facility

$134.00

Service Code	CPT 97033 GO
Hospital Charge Code	1373443
Hospital Revenue Code	430
Min. Negotiated Rate	$60.30
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	$77.29
Rate for Payer: Amerigroup Medicare	$60.90
Rate for Payer: Cash Price	$107.20
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	$60.30
Rate for Payer: Iowa Total Care Managed Medicaid	$76.54
Rate for Payer: Medical Associates Commercial	$100.50
Rate for Payer: Medical Associates Managed Medicare	$60.30
Rate for Payer: Midlands Choice Commercial	$93.80
Rate for Payer: Molina Healthcare Managed Medicaid	$77.67
Rate for Payer: Partners Health Alliance Commercial	$69.34
Rate for Payer: United Healthcare Commercial	$120.60
Rate for Payer: United Healthcare Managed Medicare	$79.06
Rate for Payer: Wellmark IA HMO WHPI	$73.74
Rate for Payer: Wellmark IA PPO	$81.22

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

IOP Activity Therapy

Facility

$221.00

Service Code	HCPCS G0176
Hospital Charge Code	8300867
Hospital Revenue Code	904
Min. Negotiated Rate	$99.45
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Aetna of IA Medicare	$125.97
Rate for Payer: Amerigroup Medicaid	$127.47
Rate for Payer: Amerigroup Medicare	$100.44
Rate for Payer: Cash Price	$176.80
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.45
Rate for Payer: Iowa Total Care Managed Medicaid	$126.24
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Medical Associates Managed Medicare	$99.45
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: Molina Healthcare Managed Medicaid	$128.09
Rate for Payer: Partners Health Alliance Commercial	$114.37
Rate for Payer: United Healthcare Commercial	$198.90
Rate for Payer: Wellmark IA HMO WHPI	$124.78
Rate for Payer: Wellmark IA PPO	$137.46

IOP Activity Therapy

Facility

$221.00

Service Code	HCPCS G0176
Hospital Charge Code	8300867
Hospital Revenue Code	904
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: United Healthcare Commercial	$198.90

iopamidol 41% Sol[VDMC]

Facility

$57.58

Service Code	HCPCS Q9966
Hospital Charge Code	12697970
Hospital Revenue Code	259
Min. Negotiated Rate	$25.91
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	$33.21
Rate for Payer: Amerigroup Medicare	$26.17
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	$25.91
Rate for Payer: Iowa Total Care Managed Medicaid	$32.89
Rate for Payer: Medical Associates Commercial	$43.18
Rate for Payer: Medical Associates Managed Medicare	$25.91
Rate for Payer: Midlands Choice Commercial	$40.31
Rate for Payer: Molina Healthcare Managed Medicaid	$33.37
Rate for Payer: Partners Health Alliance Commercial	$29.80
Rate for Payer: United Healthcare Commercial	$51.82
Rate for Payer: United Healthcare Managed Medicare	$33.97

iopamidol 41% Sol[VDMC]

Facility

$57.58

Service Code	HCPCS Q9966
Hospital Charge Code	12697970
Hospital Revenue Code	259
Min. Negotiated Rate	$40.31
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: Cash Price	$46.06
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.18
Rate for Payer: Medical Associates Commercial	$43.18
Rate for Payer: Midlands Choice Commercial	$40.31
Rate for Payer: United Healthcare Commercial	$51.82

Know your out-of-pocket cost for care.

All Charges