Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

LEVEL 2

Professional

Both

$126.00

Service Code	CPT 99282
Hospital Charge Code	7982754
Hospital Revenue Code	981
Min. Negotiated Rate	$29.55
Max. Negotiated Rate	$94.50
Rate for Payer: Amerigroup Medicaid	$29.84
Rate for Payer: Cash Price	$100.80
Rate for Payer: Cash Price	$100.80
Rate for Payer: Iowa Total Care Managed Medicaid	$29.55
Rate for Payer: Medical Associates Commercial	$94.50
Rate for Payer: Midlands Choice Commercial	$88.20
Rate for Payer: Molina Healthcare Managed Medicaid	$29.69
Rate for Payer: Partners Health Alliance Commercial	$94.50
Rate for Payer: United Healthcare Commercial	$48.08
Rate for Payer: Wellmark IA HMO WHPI	$65.00
Rate for Payer: Wellmark IA PPO	$65.00

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: 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	$104.54
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

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	$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	$1,749.82
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

$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

$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	$60.30
Max. Negotiated Rate	$141.75
Rate for Payer: Amerigroup Medicaid	$60.89
Rate for Payer: Cash Price	$151.20
Rate for Payer: Cash Price	$151.20
Rate for Payer: Iowa Total Care Managed Medicaid	$60.30
Rate for Payer: Medical Associates Commercial	$141.75
Rate for Payer: Midlands Choice Commercial	$132.30
Rate for Payer: Molina Healthcare Managed Medicaid	$60.60
Rate for Payer: Partners Health Alliance Commercial	$141.75
Rate for Payer: United Healthcare Commercial	$72.14
Rate for Payer: Wellmark IA HMO WHPI	$110.60
Rate for Payer: Wellmark IA PPO	$110.60

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	$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 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 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

Professional

Both

$359.00

Service Code	CPT 99284
Hospital Charge Code	7982752
Hospital Revenue Code	981
Min. Negotiated Rate	$92.85
Max. Negotiated Rate	$269.25
Rate for Payer: Amerigroup Medicaid	$93.76
Rate for Payer: Cash Price	$287.20
Rate for Payer: Cash Price	$287.20
Rate for Payer: Iowa Total Care Managed Medicaid	$92.85
Rate for Payer: Medical Associates Commercial	$269.25
Rate for Payer: Midlands Choice Commercial	$251.30
Rate for Payer: Molina Healthcare Managed Medicaid	$93.31
Rate for Payer: Partners Health Alliance Commercial	$269.25
Rate for Payer: United Healthcare Commercial	$131.86
Rate for Payer: Wellmark IA HMO WHPI	$188.20
Rate for Payer: Wellmark IA PPO	$188.20

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

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: Per Additional Intervals (30 Min)

Facility

$570.00

Hospital Charge Code	1378484
Hospital Revenue Code	360
Min. Negotiated Rate	$399.00
Max. Negotiated Rate	$513.00
Rate for Payer: Aetna of IA Commercial	$513.00
Rate for Payer: Aetna of IA Medical Rental Products	$513.00
Rate for Payer: Cash Price	$456.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$427.50
Rate for Payer: Medical Associates Commercial	$427.50
Rate for Payer: Midlands Choice Commercial	$399.00
Rate for Payer: United Healthcare Commercial	$513.00

Level 4: Per Additional Intervals (30 Min)

Facility

$570.00

Hospital Charge Code	1378484
Hospital Revenue Code	360
Min. Negotiated Rate	$256.50
Max. Negotiated Rate	$513.00
Rate for Payer: Aetna of IA Commercial	$513.00
Rate for Payer: Aetna of IA Medical Rental Products	$513.00
Rate for Payer: Aetna of IA Medicare	$324.90
Rate for Payer: Amerigroup Medicaid	$328.78
Rate for Payer: Amerigroup Medicare	$259.06
Rate for Payer: Cash Price	$456.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$427.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$256.50
Rate for Payer: Iowa Total Care Managed Medicaid	$325.58
Rate for Payer: Medical Associates Commercial	$427.50
Rate for Payer: Medical Associates Managed Medicare	$256.50
Rate for Payer: Midlands Choice Commercial	$399.00
Rate for Payer: Molina Healthcare Managed Medicaid	$330.37
Rate for Payer: Partners Health Alliance Commercial	$294.98
Rate for Payer: United Healthcare Commercial	$513.00
Rate for Payer: United Healthcare Managed Medicare	$336.30

Level 5

Facility

$7,300.00

Hospital Charge Code	1378488
Hospital Revenue Code	360
Min. Negotiated Rate	$3,285.00
Max. Negotiated Rate	$6,570.00
Rate for Payer: Aetna of IA Commercial	$6,570.00
Rate for Payer: Aetna of IA Medical Rental Products	$6,570.00
Rate for Payer: Aetna of IA Medicare	$4,161.00
Rate for Payer: Amerigroup Medicaid	$4,210.64
Rate for Payer: Amerigroup Medicare	$3,317.85
Rate for Payer: Cash Price	$5,840.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,475.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$3,285.00
Rate for Payer: Iowa Total Care Managed Medicaid	$4,169.76
Rate for Payer: Medical Associates Commercial	$5,475.00
Rate for Payer: Medical Associates Managed Medicare	$3,285.00
Rate for Payer: Midlands Choice Commercial	$5,110.00
Rate for Payer: Molina Healthcare Managed Medicaid	$4,231.08
Rate for Payer: Partners Health Alliance Commercial	$3,777.75
Rate for Payer: United Healthcare Commercial	$6,570.00
Rate for Payer: United Healthcare Managed Medicare	$4,307.00

Level 5

Facility

$7,300.00

Hospital Charge Code	1378488
Hospital Revenue Code	360
Min. Negotiated Rate	$5,110.00
Max. Negotiated Rate	$6,570.00
Rate for Payer: Aetna of IA Commercial	$6,570.00
Rate for Payer: Aetna of IA Medical Rental Products	$6,570.00
Rate for Payer: Cash Price	$5,840.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$5,475.00
Rate for Payer: Medical Associates Commercial	$5,475.00
Rate for Payer: Midlands Choice Commercial	$5,110.00
Rate for Payer: United Healthcare Commercial	$6,570.00

LEVEL 5

Professional

Both

$529.00

Service Code	CPT 99285
Hospital Charge Code	7982751
Hospital Revenue Code	981
Min. Negotiated Rate	$145.96
Max. Negotiated Rate	$396.75
Rate for Payer: Amerigroup Medicaid	$147.39
Rate for Payer: Cash Price	$423.20
Rate for Payer: Cash Price	$423.20
Rate for Payer: Iowa Total Care Managed Medicaid	$145.96
Rate for Payer: Medical Associates Commercial	$396.75
Rate for Payer: Midlands Choice Commercial	$370.30
Rate for Payer: Molina Healthcare Managed Medicaid	$146.68
Rate for Payer: Partners Health Alliance Commercial	$396.75
Rate for Payer: United Healthcare Commercial	$191.48
Rate for Payer: Wellmark IA HMO WHPI	$272.60
Rate for Payer: Wellmark IA PPO	$272.60

LEVEL 5

Facility

$1,042.00

Service Code	CPT 99285 25
Hospital Charge Code	6922790
Hospital Revenue Code	450
Min. Negotiated Rate	$468.90
Max. Negotiated Rate	$937.80
Rate for Payer: Aetna of IA Commercial	$937.80
Rate for Payer: Aetna of IA Medical Rental Products	$937.80
Rate for Payer: Aetna of IA Medicare	$593.94
Rate for Payer: Amerigroup Medicaid	$601.03
Rate for Payer: Amerigroup Medicare	$473.59
Rate for Payer: Cash Price	$833.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$781.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$468.90
Rate for Payer: Iowa Total Care Managed Medicaid	$595.19
Rate for Payer: Medical Associates Commercial	$781.50
Rate for Payer: Medical Associates Managed Medicare	$468.90
Rate for Payer: Midlands Choice Commercial	$729.40
Rate for Payer: Molina Healthcare Managed Medicaid	$603.94
Rate for Payer: Partners Health Alliance Commercial	$539.24
Rate for Payer: United Healthcare Commercial	$937.80
Rate for Payer: United Healthcare Managed Medicare	$614.78

LEVEL 5

Facility

$1,042.00

Service Code	CPT 99285 25
Hospital Charge Code	6922790
Hospital Revenue Code	450
Min. Negotiated Rate	$729.40
Max. Negotiated Rate	$937.80
Rate for Payer: Aetna of IA Commercial	$937.80
Rate for Payer: Aetna of IA Medical Rental Products	$937.80
Rate for Payer: Cash Price	$833.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$781.50
Rate for Payer: Medical Associates Commercial	$781.50
Rate for Payer: Midlands Choice Commercial	$729.40
Rate for Payer: United Healthcare Commercial	$937.80

Level 5: Per Additional Intervals (30 Min)

Facility

$365.00

Hospital Charge Code	1378488
Hospital Revenue Code	360
Min. Negotiated Rate	$255.50
Max. Negotiated Rate	$328.50
Rate for Payer: Aetna of IA Commercial	$328.50
Rate for Payer: Aetna of IA Medical Rental Products	$328.50
Rate for Payer: Cash Price	$292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$273.75
Rate for Payer: Medical Associates Commercial	$273.75
Rate for Payer: Midlands Choice Commercial	$255.50
Rate for Payer: United Healthcare Commercial	$328.50

Level 5: Per Additional Intervals (30 Min)

Facility

$365.00

Hospital Charge Code	1378488
Hospital Revenue Code	360
Min. Negotiated Rate	$164.25
Max. Negotiated Rate	$328.50
Rate for Payer: Aetna of IA Commercial	$328.50
Rate for Payer: Aetna of IA Medical Rental Products	$328.50
Rate for Payer: Aetna of IA Medicare	$208.05
Rate for Payer: Amerigroup Medicaid	$210.53
Rate for Payer: Amerigroup Medicare	$165.89
Rate for Payer: Cash Price	$292.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$273.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$164.25
Rate for Payer: Iowa Total Care Managed Medicaid	$208.49
Rate for Payer: Medical Associates Commercial	$273.75
Rate for Payer: Medical Associates Managed Medicare	$164.25
Rate for Payer: Midlands Choice Commercial	$255.50
Rate for Payer: Molina Healthcare Managed Medicaid	$211.55
Rate for Payer: Partners Health Alliance Commercial	$188.89
Rate for Payer: United Healthcare Commercial	$328.50
Rate for Payer: United Healthcare Managed Medicare	$215.35

Know your out-of-pocket cost for care.

All Charges