Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Level 1

Facility

$890.00

Hospital Charge Code	1378485
Hospital Revenue Code	360
Min. Negotiated Rate	$400.50
Max. Negotiated Rate	$801.00
Rate for Payer: Aetna of IA Commercial	$801.00
Rate for Payer: Aetna of IA Medical Rental Products	$801.00
Rate for Payer: Aetna of IA Medicare	$507.30
Rate for Payer: Amerigroup Medicaid	$513.35
Rate for Payer: Amerigroup Medicare	$404.50
Rate for Payer: Cash Price	$712.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$667.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$400.50
Rate for Payer: Iowa Total Care Managed Medicaid	$508.37
Rate for Payer: Medical Associates Commercial	$667.50
Rate for Payer: Medical Associates Managed Medicare	$400.50
Rate for Payer: Midlands Choice Commercial	$623.00
Rate for Payer: Molina Healthcare Managed Medicaid	$515.84
Rate for Payer: Partners Health Alliance Commercial	$460.57
Rate for Payer: United Healthcare Commercial	$801.00
Rate for Payer: United Healthcare Managed Medicare	$525.10

LEVEL 1

Facility

$179.00

Service Code	CPT 99281 25
Hospital Charge Code	6922784
Hospital Revenue Code	450
Min. Negotiated Rate	$80.55
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Aetna of IA Medicare	$102.03
Rate for Payer: Amerigroup Medicaid	$103.25
Rate for Payer: Amerigroup Medicare	$81.36
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$80.55
Rate for Payer: Iowa Total Care Managed Medicaid	$102.24
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Medical Associates Managed Medicare	$80.55
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: Molina Healthcare Managed Medicaid	$103.75
Rate for Payer: Partners Health Alliance Commercial	$92.63
Rate for Payer: United Healthcare Commercial	$161.10
Rate for Payer: United Healthcare Managed Medicare	$105.61

LEVEL 1

Professional

Both

$70.00

Service Code	CPT 99281
Hospital Charge Code	7982755
Hospital Revenue Code	981
Min. Negotiated Rate	$24.94
Max. Negotiated Rate	$52.50
Rate for Payer: Cash Price	$56.00
Rate for Payer: Cash Price	$56.00
Rate for Payer: Medical Associates Commercial	$52.50
Rate for Payer: Midlands Choice Commercial	$49.00
Rate for Payer: Partners Health Alliance Commercial	$52.50
Rate for Payer: United Healthcare Commercial	$24.94

LEVEL 1

Facility

$179.00

Service Code	CPT 99281 25
Hospital Charge Code	6922784
Hospital Revenue Code	450
Min. Negotiated Rate	$125.30
Max. Negotiated Rate	$161.10
Rate for Payer: Aetna of IA Commercial	$161.10
Rate for Payer: Aetna of IA Medical Rental Products	$161.10
Rate for Payer: Cash Price	$143.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$134.25
Rate for Payer: Medical Associates Commercial	$134.25
Rate for Payer: Midlands Choice Commercial	$125.30
Rate for Payer: United Healthcare Commercial	$161.10

Level 1: Per Additional Intervals (30 Min)

Facility

$89.00

Hospital Charge Code	1378485
Hospital Revenue Code	360
Min. Negotiated Rate	$62.30
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of IA Commercial	$80.10
Rate for Payer: Aetna of IA Medical Rental Products	$80.10
Rate for Payer: Cash Price	$71.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.75
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: United Healthcare Commercial	$80.10

Level 1: Per Additional Intervals (30 Min)

Facility

$89.00

Hospital Charge Code	1378485
Hospital Revenue Code	360
Min. Negotiated Rate	$40.05
Max. Negotiated Rate	$80.10
Rate for Payer: Aetna of IA Commercial	$80.10
Rate for Payer: Aetna of IA Medical Rental Products	$80.10
Rate for Payer: Aetna of IA Medicare	$50.73
Rate for Payer: Amerigroup Medicaid	$51.34
Rate for Payer: Amerigroup Medicare	$40.45
Rate for Payer: Cash Price	$71.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$66.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$40.05
Rate for Payer: Iowa Total Care Managed Medicaid	$50.84
Rate for Payer: Medical Associates Commercial	$66.75
Rate for Payer: Medical Associates Managed Medicare	$40.05
Rate for Payer: Midlands Choice Commercial	$62.30
Rate for Payer: Molina Healthcare Managed Medicaid	$51.58
Rate for Payer: Partners Health Alliance Commercial	$46.06
Rate for Payer: United Healthcare Commercial	$80.10
Rate for Payer: United Healthcare Managed Medicare	$52.51

Level 2

Facility

$2,300.00

Hospital Charge Code	1378486
Hospital Revenue Code	360
Min. Negotiated Rate	$1,035.00
Max. Negotiated Rate	$2,070.00
Rate for Payer: Aetna of IA Commercial	$2,070.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,070.00
Rate for Payer: Aetna of IA Medicare	$1,311.00
Rate for Payer: Amerigroup Medicaid	$1,326.64
Rate for Payer: Amerigroup Medicare	$1,045.35
Rate for Payer: Cash Price	$1,840.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,725.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,035.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,313.76
Rate for Payer: Medical Associates Commercial	$1,725.00
Rate for Payer: Medical Associates Managed Medicare	$1,035.00
Rate for Payer: Midlands Choice Commercial	$1,610.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,333.08
Rate for Payer: Partners Health Alliance Commercial	$1,190.25
Rate for Payer: United Healthcare Commercial	$2,070.00
Rate for Payer: United Healthcare Managed Medicare	$1,357.00

Level 2

Facility

$2,300.00

Hospital Charge Code	1378486
Hospital Revenue Code	360
Min. Negotiated Rate	$1,610.00
Max. Negotiated Rate	$2,070.00
Rate for Payer: Aetna of IA Commercial	$2,070.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,070.00
Rate for Payer: Cash Price	$1,840.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,725.00
Rate for Payer: Medical Associates Commercial	$1,725.00
Rate for Payer: Midlands Choice Commercial	$1,610.00
Rate for Payer: United Healthcare Commercial	$2,070.00

LEVEL 2

Professional

Both

$126.00

Service Code	CPT 99282
Hospital Charge Code	7982754
Hospital Revenue Code	981
Min. Negotiated Rate	$48.08
Max. Negotiated Rate	$94.50
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Medical Associates Commercial	$94.50
Rate for Payer: Midlands Choice Commercial	$88.20
Rate for Payer: Partners Health Alliance Commercial	$94.50
Rate for Payer: United Healthcare Commercial	$48.08

LEVEL 2

Facility

$249.00

Service Code	CPT 99282 25
Hospital Charge Code	6922786
Hospital Revenue Code	450
Min. Negotiated Rate	$174.30
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of IA Commercial	$224.10
Rate for Payer: Aetna of IA Medical Rental Products	$224.10
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$186.75
Rate for Payer: Medical Associates Commercial	$186.75
Rate for Payer: Midlands Choice Commercial	$174.30
Rate for Payer: United Healthcare Commercial	$224.10

LEVEL 2

Facility

$249.00

Service Code	CPT 99282 25
Hospital Charge Code	6922786
Hospital Revenue Code	450
Min. Negotiated Rate	$112.05
Max. Negotiated Rate	$224.10
Rate for Payer: Aetna of IA Commercial	$224.10
Rate for Payer: Aetna of IA Medical Rental Products	$224.10
Rate for Payer: Aetna of IA Medicare	$141.93
Rate for Payer: Amerigroup Medicaid	$143.62
Rate for Payer: Amerigroup Medicare	$113.17
Rate for Payer: Cash Price	$199.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$186.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$112.05
Rate for Payer: Iowa Total Care Managed Medicaid	$142.23
Rate for Payer: Medical Associates Commercial	$186.75
Rate for Payer: Medical Associates Managed Medicare	$112.05
Rate for Payer: Midlands Choice Commercial	$174.30
Rate for Payer: Molina Healthcare Managed Medicaid	$144.32
Rate for Payer: Partners Health Alliance Commercial	$128.86
Rate for Payer: United Healthcare Commercial	$224.10
Rate for Payer: United Healthcare Managed Medicare	$146.91

Level 2: Per Additional Intervals (30 Min)

Facility

$230.00

Hospital Charge Code	1378486
Hospital Revenue Code	360
Min. Negotiated Rate	$103.50
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: Aetna of IA Medicare	$131.10
Rate for Payer: Amerigroup Medicaid	$132.66
Rate for Payer: Amerigroup Medicare	$104.53
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	$119.03
Rate for Payer: United Healthcare Commercial	$207.00
Rate for Payer: United Healthcare Managed Medicare	$135.70

Level 2: Per Additional Intervals (30 Min)

Facility

$230.00

Hospital Charge Code	1378486
Hospital Revenue Code	360
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

Level 3

Facility

$3,850.00

Hospital Charge Code	1378487
Hospital Revenue Code	360
Min. Negotiated Rate	$2,695.00
Max. Negotiated Rate	$3,465.00
Rate for Payer: Aetna of IA Commercial	$3,465.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,465.00
Rate for Payer: Cash Price	$3,080.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,887.50
Rate for Payer: Medical Associates Commercial	$2,887.50
Rate for Payer: Midlands Choice Commercial	$2,695.00
Rate for Payer: United Healthcare Commercial	$3,465.00

Level 3

Facility

$3,850.00

Hospital Charge Code	1378487
Hospital Revenue Code	360
Min. Negotiated Rate	$1,732.50
Max. Negotiated Rate	$3,465.00
Rate for Payer: Aetna of IA Commercial	$3,465.00
Rate for Payer: Aetna of IA Medical Rental Products	$3,465.00
Rate for Payer: Aetna of IA Medicare	$2,194.50
Rate for Payer: Amerigroup Medicaid	$2,220.68
Rate for Payer: Amerigroup Medicare	$1,749.83
Rate for Payer: Cash Price	$3,080.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,887.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,732.50
Rate for Payer: Iowa Total Care Managed Medicaid	$2,199.12
Rate for Payer: Medical Associates Commercial	$2,887.50
Rate for Payer: Medical Associates Managed Medicare	$1,732.50
Rate for Payer: Midlands Choice Commercial	$2,695.00
Rate for Payer: Molina Healthcare Managed Medicaid	$2,231.46
Rate for Payer: Partners Health Alliance Commercial	$1,992.38
Rate for Payer: United Healthcare Commercial	$3,465.00
Rate for Payer: United Healthcare Managed Medicare	$2,271.50

LEVEL 3

Facility

$438.00

Service Code	CPT 99283 25
Hospital Charge Code	6922787
Hospital Revenue Code	450
Min. Negotiated Rate	$306.60
Max. Negotiated Rate	$394.20
Rate for Payer: Aetna of IA Commercial	$394.20
Rate for Payer: Aetna of IA Medical Rental Products	$394.20
Rate for Payer: Cash Price	$350.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$328.50
Rate for Payer: Medical Associates Commercial	$328.50
Rate for Payer: Midlands Choice Commercial	$306.60
Rate for Payer: United Healthcare Commercial	$394.20

LEVEL 3

Professional

Both

$189.00

Service Code	CPT 99283
Hospital Charge Code	7982753
Hospital Revenue Code	981
Min. Negotiated Rate	$72.14
Max. Negotiated Rate	$141.75
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Medical Associates Commercial	$141.75
Rate for Payer: Midlands Choice Commercial	$132.30
Rate for Payer: Partners Health Alliance Commercial	$141.75
Rate for Payer: United Healthcare Commercial	$72.14

LEVEL 3

Facility

$438.00

Service Code	CPT 99283 25
Hospital Charge Code	6922787
Hospital Revenue Code	450
Min. Negotiated Rate	$197.10
Max. Negotiated Rate	$394.20
Rate for Payer: Aetna of IA Commercial	$394.20
Rate for Payer: Aetna of IA Medical Rental Products	$394.20
Rate for Payer: Aetna of IA Medicare	$249.66
Rate for Payer: Amerigroup Medicaid	$252.64
Rate for Payer: Amerigroup Medicare	$199.07
Rate for Payer: Cash Price	$350.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$328.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$197.10
Rate for Payer: Iowa Total Care Managed Medicaid	$250.19
Rate for Payer: Medical Associates Commercial	$328.50
Rate for Payer: Medical Associates Managed Medicare	$197.10
Rate for Payer: Midlands Choice Commercial	$306.60
Rate for Payer: Molina Healthcare Managed Medicaid	$253.86
Rate for Payer: Partners Health Alliance Commercial	$226.66
Rate for Payer: United Healthcare Commercial	$394.20
Rate for Payer: United Healthcare Managed Medicare	$258.42

Level 3: Per Additional Intervals (30 Min)

Facility

$385.00

Hospital Charge Code	1378487
Hospital Revenue Code	360
Min. Negotiated Rate	$269.50
Max. Negotiated Rate	$346.50
Rate for Payer: Aetna of IA Commercial	$346.50
Rate for Payer: Aetna of IA Medical Rental Products	$346.50
Rate for Payer: Cash Price	$308.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$288.75
Rate for Payer: Medical Associates Commercial	$288.75
Rate for Payer: Midlands Choice Commercial	$269.50
Rate for Payer: United Healthcare Commercial	$346.50

Level 3: Per Additional Intervals (30 Min)

Facility

$385.00

Hospital Charge Code	1378487
Hospital Revenue Code	360
Min. Negotiated Rate	$173.25
Max. Negotiated Rate	$346.50
Rate for Payer: Aetna of IA Commercial	$346.50
Rate for Payer: Aetna of IA Medical Rental Products	$346.50
Rate for Payer: Aetna of IA Medicare	$219.45
Rate for Payer: Amerigroup Medicaid	$222.07
Rate for Payer: Amerigroup Medicare	$174.98
Rate for Payer: Cash Price	$308.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$288.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$173.25
Rate for Payer: Iowa Total Care Managed Medicaid	$219.91
Rate for Payer: Medical Associates Commercial	$288.75
Rate for Payer: Medical Associates Managed Medicare	$173.25
Rate for Payer: Midlands Choice Commercial	$269.50
Rate for Payer: Molina Healthcare Managed Medicaid	$223.15
Rate for Payer: Partners Health Alliance Commercial	$199.24
Rate for Payer: United Healthcare Commercial	$346.50
Rate for Payer: United Healthcare Managed Medicare	$227.15

Level 4

Facility

$5,700.00

Hospital Charge Code	1378484
Hospital Revenue Code	360
Min. Negotiated Rate	$3,990.00
Max. Negotiated Rate	$5,130.00
Rate for Payer: Aetna of IA Commercial	$5,130.00
Rate for Payer: Aetna of IA Medical Rental Products	$5,130.00
Rate for Payer: Cash Price	$4,560.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,275.00
Rate for Payer: Medical Associates Commercial	$4,275.00
Rate for Payer: Midlands Choice Commercial	$3,990.00
Rate for Payer: United Healthcare Commercial	$5,130.00

Level 4

Facility

$5,700.00

Hospital Charge Code	1378484
Hospital Revenue Code	360
Min. Negotiated Rate	$2,565.00
Max. Negotiated Rate	$5,130.00
Rate for Payer: Aetna of IA Commercial	$5,130.00
Rate for Payer: Aetna of IA Medical Rental Products	$5,130.00
Rate for Payer: Aetna of IA Medicare	$3,249.00
Rate for Payer: Amerigroup Medicaid	$3,287.76
Rate for Payer: Amerigroup Medicare	$2,590.65
Rate for Payer: Cash Price	$4,560.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,275.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,565.00
Rate for Payer: Iowa Total Care Managed Medicaid	$3,255.84
Rate for Payer: Medical Associates Commercial	$4,275.00
Rate for Payer: Medical Associates Managed Medicare	$2,565.00
Rate for Payer: Midlands Choice Commercial	$3,990.00
Rate for Payer: Molina Healthcare Managed Medicaid	$3,303.72
Rate for Payer: Partners Health Alliance Commercial	$2,949.75
Rate for Payer: United Healthcare Commercial	$5,130.00
Rate for Payer: United Healthcare Managed Medicare	$3,363.00

LEVEL 4

Facility

$711.00

Service Code	CPT 99284 25
Hospital Charge Code	6922788
Hospital Revenue Code	450
Min. Negotiated Rate	$319.95
Max. Negotiated Rate	$639.90
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Aetna of IA Medicare	$405.27
Rate for Payer: Amerigroup Medicaid	$410.10
Rate for Payer: Amerigroup Medicare	$323.15
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$319.95
Rate for Payer: Iowa Total Care Managed Medicaid	$406.12
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Medical Associates Managed Medicare	$319.95
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: Molina Healthcare Managed Medicaid	$412.10
Rate for Payer: Partners Health Alliance Commercial	$367.94
Rate for Payer: United Healthcare Commercial	$639.90
Rate for Payer: United Healthcare Managed Medicare	$419.49

LEVEL 4

Facility

$711.00

Service Code	CPT 99284 25
Hospital Charge Code	6922788
Hospital Revenue Code	450
Min. Negotiated Rate	$497.70
Max. Negotiated Rate	$639.90
Rate for Payer: Aetna of IA Commercial	$639.90
Rate for Payer: Aetna of IA Medical Rental Products	$639.90
Rate for Payer: Cash Price	$568.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$533.25
Rate for Payer: Medical Associates Commercial	$533.25
Rate for Payer: Midlands Choice Commercial	$497.70
Rate for Payer: United Healthcare Commercial	$639.90

LEVEL 4

Professional

Both

$359.00

Service Code	CPT 99284
Hospital Charge Code	7982752
Hospital Revenue Code	981
Min. Negotiated Rate	$131.86
Max. Negotiated Rate	$269.25
Rate for Payer: Cash Price	$287.20
Rate for Payer: Cash Price	$287.20
Rate for Payer: Medical Associates Commercial	$269.25
Rate for Payer: Midlands Choice Commercial	$251.30
Rate for Payer: Partners Health Alliance Commercial	$269.25
Rate for Payer: United Healthcare Commercial	$131.86

Know your out-of-pocket cost for care.

All Charges