Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

NM Thyroid Imaging w/ Uptake Single

Facility

$1,439.00

Service Code	CPT 78014
Hospital Charge Code	1169394
Hospital Revenue Code	341
Min. Negotiated Rate	$1,007.30
Max. Negotiated Rate	$1,295.10
Rate for Payer: Aetna of IA Commercial	$1,295.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,295.10
Rate for Payer: Cash Price	$1,151.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,079.25
Rate for Payer: Medical Associates Commercial	$1,079.25
Rate for Payer: Midlands Choice Commercial	$1,007.30
Rate for Payer: United Healthcare Commercial	$1,295.10

NM Thyroid Imaging w/ Uptake Single

Facility

$1,439.00

Service Code	CPT 78014
Hospital Charge Code	1169394
Hospital Revenue Code	341
Min. Negotiated Rate	$719.21
Max. Negotiated Rate	$1,295.10
Rate for Payer: Aetna of IA Commercial	$1,295.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,295.10
Rate for Payer: Aetna of IA Medicare	$820.23
Rate for Payer: Amerigroup Medicaid	$726.26
Rate for Payer: Amerigroup Medicare	$726.70
Rate for Payer: Cash Price	$1,151.20
Rate for Payer: Cash Price	$1,151.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,079.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$719.50
Rate for Payer: Iowa Total Care Managed Medicaid	$719.21
Rate for Payer: Medical Associates Commercial	$1,079.25
Rate for Payer: Medical Associates Managed Medicare	$719.50
Rate for Payer: Midlands Choice Commercial	$1,007.30
Rate for Payer: Molina Healthcare Managed Medicaid	$730.29
Rate for Payer: Molina Healthcare Managed Medicare	$729.86
Rate for Payer: Oscar Health of IA Commercial	$1,079.25
Rate for Payer: Partners Health Alliance Commercial	$1,079.25
Rate for Payer: United Healthcare Commercial	$1,295.10
Rate for Payer: United Healthcare Managed Medicare	$849.01
Rate for Payer: Wellmark IA HMO	$879.16
Rate for Payer: Wellmark IA PPO	$967.08

NM Thyroid Uptake Single Determination

Facility

$1,190.00

Service Code	CPT 78012
Hospital Charge Code	1169400
Hospital Revenue Code	341
Min. Negotiated Rate	$594.76
Max. Negotiated Rate	$1,071.00
Rate for Payer: Aetna of IA Commercial	$1,071.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,071.00
Rate for Payer: Aetna of IA Medicare	$678.30
Rate for Payer: Amerigroup Medicaid	$600.59
Rate for Payer: Amerigroup Medicare	$600.95
Rate for Payer: Cash Price	$952.00
Rate for Payer: Cash Price	$952.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$892.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$595.00
Rate for Payer: Iowa Total Care Managed Medicaid	$594.76
Rate for Payer: Medical Associates Commercial	$892.50
Rate for Payer: Medical Associates Managed Medicare	$595.00
Rate for Payer: Midlands Choice Commercial	$833.00
Rate for Payer: Molina Healthcare Managed Medicaid	$603.92
Rate for Payer: Molina Healthcare Managed Medicare	$603.57
Rate for Payer: Oscar Health of IA Commercial	$892.50
Rate for Payer: Partners Health Alliance Commercial	$892.50
Rate for Payer: United Healthcare Commercial	$1,071.00
Rate for Payer: United Healthcare Managed Medicare	$702.10
Rate for Payer: Wellmark IA HMO	$879.16
Rate for Payer: Wellmark IA PPO	$967.08

NM Thyroid Uptake Single Determination

Facility

$1,190.00

Service Code	CPT 78012
Hospital Charge Code	1169400
Hospital Revenue Code	341
Min. Negotiated Rate	$833.00
Max. Negotiated Rate	$1,071.00
Rate for Payer: Aetna of IA Commercial	$1,071.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,071.00
Rate for Payer: Cash Price	$952.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$892.50
Rate for Payer: Medical Associates Commercial	$892.50
Rate for Payer: Midlands Choice Commercial	$833.00
Rate for Payer: United Healthcare Commercial	$1,071.00

Non-bacterial Infection of Nervous System Except Viral Meningitis With CC

Facility

$12,511.68

Service Code	MS-DRG 098
Hospital Charge Code	778
Min. Negotiated Rate	$12,330.35
Max. Negotiated Rate	$12,511.68
Rate for Payer: Amerigroup Medicaid	$12,451.24
Rate for Payer: Iowa Total Care Managed Medicaid	$12,330.35
Rate for Payer: Molina Healthcare Managed Medicaid	$12,511.68

Non-bacterial Infection of Nervous System Except Viral Meningitis With MCC

Facility

$20,606.08

Service Code	MS-DRG 097
Hospital Charge Code	777
Min. Negotiated Rate	$20,307.45
Max. Negotiated Rate	$20,606.08
Rate for Payer: Amerigroup Medicaid	$20,506.54
Rate for Payer: Iowa Total Care Managed Medicaid	$20,307.45
Rate for Payer: Molina Healthcare Managed Medicaid	$20,606.08

Non-bacterial Infection of Nervous System Except Viral Meningitis Without CC/MCC

Facility

$8,734.16

Service Code	MS-DRG 099
Hospital Charge Code	779
Min. Negotiated Rate	$8,607.58
Max. Negotiated Rate	$8,734.16
Rate for Payer: Amerigroup Medicaid	$8,691.96
Rate for Payer: Iowa Total Care Managed Medicaid	$8,607.58
Rate for Payer: Molina Healthcare Managed Medicaid	$8,734.16

NON COVERED MILEAGE PER 10TH OF A MILE

Facility

$2.00

Service Code	CPT A0888
Hospital Charge Code	5966786
Hospital Revenue Code	540
Min. Negotiated Rate	$1.40
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: United Healthcare Commercial	$1.80

NON COVERED MILEAGE PER 10TH OF A MILE

Facility

$2.00

Service Code	CPT A0888
Hospital Charge Code	5966786
Hospital Revenue Code	540
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.80
Rate for Payer: Aetna of IA Commercial	$1.80
Rate for Payer: Aetna of IA Medical Rental Products	$1.80
Rate for Payer: Aetna of IA Medicare	$1.14
Rate for Payer: Amerigroup Medicaid	$1.01
Rate for Payer: Amerigroup Medicare	$1.01
Rate for Payer: Cash Price	$1.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.50
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	$1.00
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Medical Associates Managed Medicare	$1.00
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.02
Rate for Payer: Molina Healthcare Managed Medicare	$1.01
Rate for Payer: Oscar Health of IA Commercial	$1.50
Rate for Payer: Partners Health Alliance Commercial	$1.50
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Managed Medicare	$1.70

Non-extensive Burns

Facility

$5,548.17

Service Code	MS-DRG 935
Hospital Charge Code	647
Min. Negotiated Rate	$5,467.76
Max. Negotiated Rate	$5,548.17
Rate for Payer: Amerigroup Medicaid	$5,521.37
Rate for Payer: Iowa Total Care Managed Medicaid	$5,467.76
Rate for Payer: Molina Healthcare Managed Medicaid	$5,548.17

Non-extensive O.R. Procedures Unrelated to Principal Diagnosis With CC

Facility

$16,968.33

Service Code	MS-DRG 988
Hospital Charge Code	676
Min. Negotiated Rate	$16,722.41
Max. Negotiated Rate	$16,968.33
Rate for Payer: Amerigroup Medicaid	$16,886.36
Rate for Payer: Iowa Total Care Managed Medicaid	$16,722.41
Rate for Payer: Molina Healthcare Managed Medicaid	$16,968.33

Non-extensive O.R. Procedures Unrelated to Principal Diagnosis With MCC

Facility

$23,345.22

Service Code	MS-DRG 987
Hospital Charge Code	675
Min. Negotiated Rate	$23,006.89
Max. Negotiated Rate	$23,345.22
Rate for Payer: Amerigroup Medicaid	$23,232.44
Rate for Payer: Iowa Total Care Managed Medicaid	$23,006.89
Rate for Payer: Molina Healthcare Managed Medicaid	$23,345.22

Non-extensive O.R. Procedures Unrelated to Principal Diagnosis Without CC/MCC

Facility

$7,349.33

Service Code	MS-DRG 989
Hospital Charge Code	677
Min. Negotiated Rate	$7,242.82
Max. Negotiated Rate	$7,349.33
Rate for Payer: Amerigroup Medicaid	$7,313.82
Rate for Payer: Iowa Total Care Managed Medicaid	$7,242.82
Rate for Payer: Molina Healthcare Managed Medicaid	$7,349.33

NON-LOCKING SCREW 2.7MMX14MM

Facility

$216.00

Service Code	CPT C1713
Hospital Charge Code	8759894
Hospital Revenue Code	278
Min. Negotiated Rate	$107.96
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Aetna of IA Medicare	$123.12
Rate for Payer: Amerigroup Medicaid	$109.02
Rate for Payer: Amerigroup Medicare	$109.08
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$108.00
Rate for Payer: Iowa Total Care Managed Medicaid	$107.96
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Medical Associates Managed Medicare	$108.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: Molina Healthcare Managed Medicaid	$109.62
Rate for Payer: Molina Healthcare Managed Medicare	$109.56
Rate for Payer: Oscar Health of IA Commercial	$162.00
Rate for Payer: Partners Health Alliance Commercial	$162.00
Rate for Payer: United Healthcare Commercial	$194.40
Rate for Payer: United Healthcare Managed Medicare	$127.44

NON-LOCKING SCREW 2.7MMX14MM

Facility

$216.00

Service Code	CPT C1713
Hospital Charge Code	8759894
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: United Healthcare Commercial	$194.40

NON-LOCKING SCREW 3.5MMX12MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8793251
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

NON-LOCKING SCREW 3.5MMX12MM

Facility

$198.00

Service Code	CPT C1713
Hospital Charge Code	8793251
Hospital Revenue Code	278
Min. Negotiated Rate	$98.96
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$99.93
Rate for Payer: Amerigroup Medicare	$99.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$99.00
Rate for Payer: Iowa Total Care Managed Medicaid	$98.96
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$99.00
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$100.48
Rate for Payer: Molina Healthcare Managed Medicare	$100.43
Rate for Payer: Oscar Health of IA Commercial	$148.50
Rate for Payer: Partners Health Alliance Commercial	$148.50
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

NON-LOCKING SCREW 3.5MMX16MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8884277
Hospital Revenue Code	278
Min. Negotiated Rate	$89.96
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Molina Healthcare Managed Medicare	$91.30
Rate for Payer: Oscar Health of IA Commercial	$135.00
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20

NON-LOCKING SCREW 3.5MMX16MM

Facility

$180.00

Service Code	CPT C1713
Hospital Charge Code	8884277
Hospital Revenue Code	278
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

Non-malignant Breast Disorders With CC/MCC

Facility

$9,803.04

Service Code	MS-DRG 600
Hospital Charge Code	398
Min. Negotiated Rate	$9,660.97
Max. Negotiated Rate	$9,803.04
Rate for Payer: Amerigroup Medicaid	$9,755.69
Rate for Payer: Iowa Total Care Managed Medicaid	$9,660.97
Rate for Payer: Molina Healthcare Managed Medicaid	$9,803.04

Non-malignant Breast Disorders Without CC/MCC

Facility

$3,800.16

Service Code	MS-DRG 601
Hospital Charge Code	399
Min. Negotiated Rate	$3,745.08
Max. Negotiated Rate	$3,800.16
Rate for Payer: Amerigroup Medicaid	$3,781.80
Rate for Payer: Iowa Total Care Managed Medicaid	$3,745.08
Rate for Payer: Molina Healthcare Managed Medicaid	$3,800.16

Nonspecific Cerebrovascular Disorders With CC

Facility

$8,016.64

Service Code	MS-DRG 071
Hospital Charge Code	751
Min. Negotiated Rate	$7,900.46
Max. Negotiated Rate	$8,016.64
Rate for Payer: Amerigroup Medicaid	$7,977.92
Rate for Payer: Iowa Total Care Managed Medicaid	$7,900.46
Rate for Payer: Molina Healthcare Managed Medicaid	$8,016.64

Nonspecific Cerebrovascular Disorders With MCC

Facility

$15,404.36

Service Code	MS-DRG 070
Hospital Charge Code	750
Min. Negotiated Rate	$15,181.11
Max. Negotiated Rate	$15,404.36
Rate for Payer: Amerigroup Medicaid	$15,329.94
Rate for Payer: Iowa Total Care Managed Medicaid	$15,181.11
Rate for Payer: Molina Healthcare Managed Medicaid	$15,404.36

Nonspecific Cerebrovascular Disorders Without CC/MCC

Facility

$6,501.90

Service Code	MS-DRG 072
Hospital Charge Code	752
Min. Negotiated Rate	$6,407.67
Max. Negotiated Rate	$6,501.90
Rate for Payer: Amerigroup Medicaid	$6,470.49
Rate for Payer: Iowa Total Care Managed Medicaid	$6,407.67
Rate for Payer: Molina Healthcare Managed Medicaid	$6,501.90

Nonspecific CVA and Precerebral Occlusion Without Infarction With MCC

Facility

$14,021.51

Service Code	MS-DRG 067
Hospital Charge Code	747
Min. Negotiated Rate	$13,818.30
Max. Negotiated Rate	$14,021.51
Rate for Payer: Amerigroup Medicaid	$13,953.77
Rate for Payer: Iowa Total Care Managed Medicaid	$13,818.30
Rate for Payer: Molina Healthcare Managed Medicaid	$14,021.51

Know your out-of-pocket cost for care.

All Charges