Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC

Facility

$15,943.83

Service Code	MSDRG 418
Min. Negotiated Rate	$15,712.76
Max. Negotiated Rate	$15,943.83
Rate for Payer: Amerigroup Medicaid	$15,866.80
Rate for Payer: Iowa Total Care Managed Medicaid	$15,712.76
Rate for Payer: Molina Healthcare Managed Medicaid	$15,943.83

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC

Facility

$18,649.56

Service Code	MSDRG 417
Min. Negotiated Rate	$18,379.27
Max. Negotiated Rate	$18,649.56
Rate for Payer: Amerigroup Medicaid	$18,559.45
Rate for Payer: Iowa Total Care Managed Medicaid	$18,379.27
Rate for Payer: Molina Healthcare Managed Medicaid	$18,649.56

LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$12,674.00

Service Code	MSDRG 419
Min. Negotiated Rate	$12,490.31
Max. Negotiated Rate	$12,674.00
Rate for Payer: Amerigroup Medicaid	$12,612.76
Rate for Payer: Iowa Total Care Managed Medicaid	$12,490.31
Rate for Payer: Molina Healthcare Managed Medicaid	$12,674.00

Laparoscopic colectomy partial with anastomosis

Professional

Both

$5,204.00

Service Code	CPT 44204
Hospital Charge Code	8068987
Hospital Revenue Code	975
Min. Negotiated Rate	$1,302.26
Max. Negotiated Rate	$3,903.00
Rate for Payer: Amerigroup Medicaid	$1,315.03
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Cash Price	$4,163.20
Rate for Payer: Iowa Total Care Managed Medicaid	$1,302.26
Rate for Payer: Medical Associates Commercial	$3,903.00
Rate for Payer: Midlands Choice Commercial	$3,642.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,308.65
Rate for Payer: Partners Health Alliance Commercial	$3,903.00
Rate for Payer: United Healthcare Commercial	$2,328.74
Rate for Payer: Wellmark IA HMO WHPI	$2,935.30
Rate for Payer: Wellmark IA PPO	$3,453.30

Laparoscopic urethral sling for stress incontinence

Professional

Both

$2,826.00

Service Code	CPT 51992
Hospital Charge Code	8069155
Hospital Revenue Code	975
Min. Negotiated Rate	$722.64
Max. Negotiated Rate	$2,119.50
Rate for Payer: Amerigroup Medicaid	$729.72
Rate for Payer: Cash Price	$2,260.80
Rate for Payer: Cash Price	$2,260.80
Rate for Payer: Iowa Total Care Managed Medicaid	$722.64
Rate for Payer: Medical Associates Commercial	$2,119.50
Rate for Payer: Midlands Choice Commercial	$1,978.20
Rate for Payer: Molina Healthcare Managed Medicaid	$726.18
Rate for Payer: Partners Health Alliance Commercial	$2,119.50
Rate for Payer: United Healthcare Commercial	$1,293.39
Rate for Payer: Wellmark IA HMO WHPI	$1,569.90
Rate for Payer: Wellmark IA PPO	$1,846.90

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY

Facility

$9,362.63

Service Code	CPT 47562
Hospital Revenue Code	490
Min. Negotiated Rate	$8,499.49
Max. Negotiated Rate	$9,362.63
Rate for Payer: Wellmark IA HMO WHPI	$8,499.49
Rate for Payer: Wellmark IA PPO	$9,362.63

Laparoscopy; surgical; enterolysis (separate procedure)

Professional

Both

$3,106.00

Service Code	CPT 44180
Hospital Charge Code	8069049
Hospital Revenue Code	975
Min. Negotiated Rate	$783.42
Max. Negotiated Rate	$2,329.50
Rate for Payer: Amerigroup Medicaid	$791.10
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Cash Price	$2,484.80
Rate for Payer: Iowa Total Care Managed Medicaid	$783.42
Rate for Payer: Medical Associates Commercial	$2,329.50
Rate for Payer: Midlands Choice Commercial	$2,174.20
Rate for Payer: Molina Healthcare Managed Medicaid	$787.26
Rate for Payer: Partners Health Alliance Commercial	$2,329.50
Rate for Payer: United Healthcare Commercial	$1,386.91
Rate for Payer: Wellmark IA HMO WHPI	$1,770.20
Rate for Payer: Wellmark IA PPO	$2,082.50

LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA

Facility

$8,567.57

Service Code	CPT 49651
Hospital Revenue Code	360
Min. Negotiated Rate	$7,777.73
Max. Negotiated Rate	$8,567.57
Rate for Payer: Wellmark IA HMO WHPI	$7,777.73
Rate for Payer: Wellmark IA PPO	$8,567.57

Laparoscopy; surgical; with aspiration of cavity or cyst (single or multiple)

Professional

Both

$1,245.00

Service Code	CPT 49322
Hospital Charge Code	8378860
Hospital Revenue Code	975
Min. Negotiated Rate	$340.15
Max. Negotiated Rate	$933.75
Rate for Payer: Amerigroup Medicaid	$343.48
Rate for Payer: Cash Price	$996.00
Rate for Payer: Cash Price	$996.00
Rate for Payer: Iowa Total Care Managed Medicaid	$340.15
Rate for Payer: Medical Associates Commercial	$933.75
Rate for Payer: Midlands Choice Commercial	$871.50
Rate for Payer: Molina Healthcare Managed Medicaid	$341.82
Rate for Payer: Partners Health Alliance Commercial	$933.75
Rate for Payer: United Healthcare Commercial	$564.54
Rate for Payer: Wellmark IA HMO WHPI	$724.20
Rate for Payer: Wellmark IA PPO	$852.00

LAPIDUS VLC GRIDLOCK PLATE NEUTRAL

Facility

$2,592.00

Service Code	HCPCS C1713
Hospital Charge Code	8463688
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

LAPIDUS VLC GRIDLOCK PLATE NEUTRAL

Facility

$2,592.00

Service Code	HCPCS C1713
Hospital Charge Code	8463688
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

latanoprost Ophth 0.005% 2.5 ml Sol [VDMC]

Facility

$29.24

Service Code	HCPCS A9270
Hospital Charge Code	10435379
Hospital Revenue Code	259
Min. Negotiated Rate	$13.16
Max. Negotiated Rate	$26.32
Rate for Payer: Aetna of IA Commercial	$26.32
Rate for Payer: Aetna of IA Medical Rental Products	$26.32
Rate for Payer: Aetna of IA Medicare	$16.67
Rate for Payer: Amerigroup Medicaid	$16.87
Rate for Payer: Amerigroup Medicare	$13.29
Rate for Payer: Cash Price	$23.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.93
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$13.16
Rate for Payer: Iowa Total Care Managed Medicaid	$16.70
Rate for Payer: Medical Associates Commercial	$21.93
Rate for Payer: Medical Associates Managed Medicare	$13.16
Rate for Payer: Midlands Choice Commercial	$20.47
Rate for Payer: Molina Healthcare Managed Medicaid	$16.95
Rate for Payer: Partners Health Alliance Commercial	$15.13
Rate for Payer: United Healthcare Commercial	$26.32
Rate for Payer: United Healthcare Managed Medicare	$17.25

latanoprost Ophth 0.005% 2.5 ml Sol [VDMC]

Facility

$29.24

Service Code	HCPCS A9270
Hospital Charge Code	10435379
Hospital Revenue Code	259
Min. Negotiated Rate	$20.47
Max. Negotiated Rate	$26.32
Rate for Payer: Aetna of IA Commercial	$26.32
Rate for Payer: Aetna of IA Medical Rental Products	$26.32
Rate for Payer: Cash Price	$23.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$21.93
Rate for Payer: Medical Associates Commercial	$21.93
Rate for Payer: Midlands Choice Commercial	$20.47
Rate for Payer: United Healthcare Commercial	$26.32

L-carnitine 500mg Tab [VDMC]

Facility

$2.22

Service Code	HCPCS A9270
Hospital Charge Code	11521770
Hospital Revenue Code	259
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna of IA Commercial	$2.00
Rate for Payer: Aetna of IA Medical Rental Products	$2.00
Rate for Payer: Aetna of IA Medicare	$1.27
Rate for Payer: Amerigroup Medicaid	$1.28
Rate for Payer: Amerigroup Medicare	$1.01
Rate for Payer: Cash Price	$1.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.67
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1.27
Rate for Payer: Medical Associates Commercial	$1.67
Rate for Payer: Medical Associates Managed Medicare	$1.00
Rate for Payer: Midlands Choice Commercial	$1.55
Rate for Payer: Molina Healthcare Managed Medicaid	$1.29
Rate for Payer: Partners Health Alliance Commercial	$1.15
Rate for Payer: United Healthcare Commercial	$2.00
Rate for Payer: United Healthcare Managed Medicare	$1.31

L-carnitine 500mg Tab [VDMC]

Facility

$2.22

Service Code	HCPCS A9270
Hospital Charge Code	11521770
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna of IA Commercial	$2.00
Rate for Payer: Aetna of IA Medical Rental Products	$2.00
Rate for Payer: Cash Price	$1.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.67
Rate for Payer: Medical Associates Commercial	$1.67
Rate for Payer: Midlands Choice Commercial	$1.55
Rate for Payer: United Healthcare Commercial	$2.00

L-Carnitine 500mg [VDMC]

Facility

$2.62

Service Code	HCPCS A9720
Hospital Charge Code	23410802
Hospital Revenue Code	259
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.36
Rate for Payer: Aetna of IA Commercial	$2.36
Rate for Payer: Aetna of IA Medical Rental Products	$2.36
Rate for Payer: Cash Price	$2.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.97
Rate for Payer: Medical Associates Commercial	$1.97
Rate for Payer: Midlands Choice Commercial	$1.84
Rate for Payer: United Healthcare Commercial	$2.36

L-Carnitine 500mg [VDMC]

Facility

$2.62

Service Code	HCPCS A9720
Hospital Charge Code	23410802
Hospital Revenue Code	259
Min. Negotiated Rate	$1.18
Max. Negotiated Rate	$2.36
Rate for Payer: Aetna of IA Commercial	$2.36
Rate for Payer: Aetna of IA Medical Rental Products	$2.36
Rate for Payer: Aetna of IA Medicare	$1.50
Rate for Payer: Amerigroup Medicaid	$1.51
Rate for Payer: Amerigroup Medicare	$1.19
Rate for Payer: Cash Price	$2.10
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.97
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.18
Rate for Payer: Iowa Total Care Managed Medicaid	$1.50
Rate for Payer: Medical Associates Commercial	$1.97
Rate for Payer: Medical Associates Managed Medicare	$1.18
Rate for Payer: Midlands Choice Commercial	$1.84
Rate for Payer: Molina Healthcare Managed Medicaid	$1.52
Rate for Payer: Partners Health Alliance Commercial	$1.36
Rate for Payer: United Healthcare Commercial	$2.36
Rate for Payer: United Healthcare Managed Medicare	$1.55

LD COMP W/FORC/VAC/3RD-4TH DEG LAC EPIS

Facility

$2,505.00

Service Code	CPT 59409
Hospital Charge Code	7984736
Hospital Revenue Code	720
Min. Negotiated Rate	$1,127.25
Max. Negotiated Rate	$5,499.80
Rate for Payer: Aetna of IA Commercial	$2,254.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,254.50
Rate for Payer: Aetna of IA Medicare	$1,427.85
Rate for Payer: Amerigroup Medicaid	$1,444.88
Rate for Payer: Amerigroup Medicare	$1,138.52
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,878.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,127.25
Rate for Payer: Iowa Total Care Managed Medicaid	$1,430.86
Rate for Payer: Medical Associates Commercial	$1,878.75
Rate for Payer: Medical Associates Managed Medicare	$1,127.25
Rate for Payer: Midlands Choice Commercial	$1,753.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,451.90
Rate for Payer: Partners Health Alliance Commercial	$1,296.34
Rate for Payer: United Healthcare Commercial	$2,254.50
Rate for Payer: United Healthcare Managed Medicare	$1,477.95
Rate for Payer: Wellmark IA HMO WHPI	$4,992.78
Rate for Payer: Wellmark IA PPO	$5,499.80

LD COMP W/FORC/VAC/3RD-4TH DEG LAC EPIS

Facility

$2,505.00

Service Code	CPT 59409
Hospital Charge Code	7984736
Hospital Revenue Code	720
Min. Negotiated Rate	$1,753.50
Max. Negotiated Rate	$2,254.50
Rate for Payer: Aetna of IA Commercial	$2,254.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,254.50
Rate for Payer: Cash Price	$2,004.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,878.75
Rate for Payer: Medical Associates Commercial	$1,878.75
Rate for Payer: Midlands Choice Commercial	$1,753.50
Rate for Payer: United Healthcare Commercial	$2,254.50

LDH

Facility

$58.00

Service Code	CPT 83615
Hospital Charge Code	4022826
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

LDH

Facility

$58.00

Service Code	CPT 83615
Hospital Charge Code	4022826
Hospital Revenue Code	301
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$33.45
Rate for Payer: Amerigroup Medicare	$26.36
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.10
Rate for Payer: Iowa Total Care Managed Medicaid	$33.13
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$26.10
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$33.62
Rate for Payer: Partners Health Alliance Commercial	$30.02
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

LDH

Facility

$58.00

Service Code	CPT 83615
Hospital Charge Code	633770
Hospital Revenue Code	301
Min. Negotiated Rate	$26.10
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Aetna of IA Medicare	$33.06
Rate for Payer: Amerigroup Medicaid	$33.45
Rate for Payer: Amerigroup Medicare	$26.36
Rate for Payer: Cash Price	$46.40
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.10
Rate for Payer: Iowa Total Care Managed Medicaid	$33.13
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$26.10
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$33.62
Rate for Payer: Partners Health Alliance Commercial	$30.02
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

LDH

Facility

$58.00

Service Code	CPT 83615
Hospital Charge Code	633770
Hospital Revenue Code	301
Min. Negotiated Rate	$40.60
Max. Negotiated Rate	$52.20
Rate for Payer: Aetna of IA Commercial	$52.20
Rate for Payer: Aetna of IA Medical Rental Products	$52.20
Rate for Payer: Cash Price	$46.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.50
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: United Healthcare Commercial	$52.20

LD W/O COMPLICATIONS 1ST-2ND DEG LAC

Facility

$1,490.00

Service Code	CPT 59409
Hospital Charge Code	7984737
Hospital Revenue Code	722
Min. Negotiated Rate	$670.50
Max. Negotiated Rate	$5,499.80
Rate for Payer: Aetna of IA Commercial	$1,341.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,341.00
Rate for Payer: Aetna of IA Medicare	$849.30
Rate for Payer: Amerigroup Medicaid	$859.43
Rate for Payer: Amerigroup Medicare	$677.20
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,117.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$670.50
Rate for Payer: Iowa Total Care Managed Medicaid	$851.09
Rate for Payer: Medical Associates Commercial	$1,117.50
Rate for Payer: Medical Associates Managed Medicare	$670.50
Rate for Payer: Midlands Choice Commercial	$1,043.00
Rate for Payer: Molina Healthcare Managed Medicaid	$863.60
Rate for Payer: Partners Health Alliance Commercial	$771.08
Rate for Payer: United Healthcare Commercial	$1,341.00
Rate for Payer: United Healthcare Managed Medicare	$879.10
Rate for Payer: Wellmark IA HMO WHPI	$4,992.78
Rate for Payer: Wellmark IA PPO	$5,499.80

LD W/O COMPLICATIONS 1ST-2ND DEG LAC

Facility

$1,490.00

Service Code	CPT 59409
Hospital Charge Code	7984737
Hospital Revenue Code	722
Min. Negotiated Rate	$1,043.00
Max. Negotiated Rate	$1,341.00
Rate for Payer: Aetna of IA Commercial	$1,341.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,341.00
Rate for Payer: Cash Price	$1,192.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,117.50
Rate for Payer: Medical Associates Commercial	$1,117.50
Rate for Payer: Midlands Choice Commercial	$1,043.00
Rate for Payer: United Healthcare Commercial	$1,341.00

Know your out-of-pocket cost for care.

All Charges