Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

PT/INR

Facility

$43.00

Service Code	CPT 85610
Hospital Charge Code	1635510
Hospital Revenue Code	305
Min. Negotiated Rate	$30.10
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna of IA Commercial	$38.70
Rate for Payer: Aetna of IA Medical Rental Products	$38.70
Rate for Payer: Cash Price	$34.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$32.25
Rate for Payer: Medical Associates Commercial	$32.25
Rate for Payer: Midlands Choice Commercial	$30.10
Rate for Payer: United Healthcare Commercial	$38.70

PTNM NEUROELTRD STIM POST TIBIAL

Facility

$659.00

Service Code	CPT 64566
Hospital Charge Code	8588846
Hospital Revenue Code	761
Min. Negotiated Rate	$461.30
Max. Negotiated Rate	$593.10
Rate for Payer: Aetna of IA Commercial	$593.10
Rate for Payer: Aetna of IA Medical Rental Products	$593.10
Rate for Payer: Cash Price	$527.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$494.25
Rate for Payer: Medical Associates Commercial	$494.25
Rate for Payer: Midlands Choice Commercial	$461.30
Rate for Payer: United Healthcare Commercial	$593.10

PTNM NEUROELTRD STIM POST TIBIAL

Facility

$659.00

Service Code	CPT 64566
Hospital Charge Code	8588846
Hospital Revenue Code	761
Min. Negotiated Rate	$296.55
Max. Negotiated Rate	$593.10
Rate for Payer: Aetna of IA Commercial	$593.10
Rate for Payer: Aetna of IA Medical Rental Products	$593.10
Rate for Payer: Aetna of IA Medicare	$375.63
Rate for Payer: Amerigroup Medicaid	$380.11
Rate for Payer: Amerigroup Medicare	$299.52
Rate for Payer: Cash Price	$527.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$494.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$296.55
Rate for Payer: Iowa Total Care Managed Medicaid	$376.42
Rate for Payer: Medical Associates Commercial	$494.25
Rate for Payer: Medical Associates Managed Medicare	$296.55
Rate for Payer: Midlands Choice Commercial	$461.30
Rate for Payer: Molina Healthcare Managed Medicaid	$381.96
Rate for Payer: Partners Health Alliance Commercial	$341.03
Rate for Payer: United Healthcare Commercial	$593.10
Rate for Payer: United Healthcare Managed Medicare	$388.81

PT RE-EVAL EST PLAN CARE

Facility

$137.00

Service Code	CPT 97164 GP
Hospital Charge Code	8397249
Hospital Revenue Code	424
Min. Negotiated Rate	$61.65
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of IA Commercial	$123.30
Rate for Payer: Aetna of IA Medical Rental Products	$123.30
Rate for Payer: Aetna of IA Medicare	$78.09
Rate for Payer: Amerigroup Medicaid	$79.02
Rate for Payer: Amerigroup Medicare	$62.27
Rate for Payer: Cash Price	$109.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$61.65
Rate for Payer: Iowa Total Care Managed Medicaid	$78.25
Rate for Payer: Medical Associates Commercial	$102.75
Rate for Payer: Medical Associates Managed Medicare	$61.65
Rate for Payer: Midlands Choice Commercial	$95.90
Rate for Payer: Molina Healthcare Managed Medicaid	$79.41
Rate for Payer: Partners Health Alliance Commercial	$70.90
Rate for Payer: United Healthcare Commercial	$123.30
Rate for Payer: United Healthcare Managed Medicare	$80.83

PT RE-EVAL EST PLAN CARE

Facility

$137.00

Service Code	CPT 97164 GP
Hospital Charge Code	8397249
Hospital Revenue Code	424
Min. Negotiated Rate	$95.90
Max. Negotiated Rate	$123.30
Rate for Payer: Aetna of IA Commercial	$123.30
Rate for Payer: Aetna of IA Medical Rental Products	$123.30
Rate for Payer: Cash Price	$109.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.75
Rate for Payer: Medical Associates Commercial	$102.75
Rate for Payer: Midlands Choice Commercial	$95.90
Rate for Payer: United Healthcare Commercial	$123.30

PT RE-EVALUATION

Facility

$92.00

Hospital Charge Code	5520784
Hospital Revenue Code	424
Min. Negotiated Rate	$41.40
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of IA Commercial	$82.80
Rate for Payer: Aetna of IA Medical Rental Products	$82.80
Rate for Payer: Aetna of IA Medicare	$52.44
Rate for Payer: Amerigroup Medicaid	$53.07
Rate for Payer: Amerigroup Medicare	$41.81
Rate for Payer: Cash Price	$73.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.40
Rate for Payer: Iowa Total Care Managed Medicaid	$52.55
Rate for Payer: Medical Associates Commercial	$69.00
Rate for Payer: Medical Associates Managed Medicare	$41.40
Rate for Payer: Midlands Choice Commercial	$64.40
Rate for Payer: Molina Healthcare Managed Medicaid	$53.32
Rate for Payer: Partners Health Alliance Commercial	$47.61
Rate for Payer: United Healthcare Commercial	$82.80
Rate for Payer: United Healthcare Managed Medicare	$54.28

PT RE-EVALUATION

Facility

$92.00

Hospital Charge Code	5520784
Hospital Revenue Code	424
Min. Negotiated Rate	$64.40
Max. Negotiated Rate	$82.80
Rate for Payer: Aetna of IA Commercial	$82.80
Rate for Payer: Aetna of IA Medical Rental Products	$82.80
Rate for Payer: Cash Price	$73.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$69.00
Rate for Payer: Medical Associates Commercial	$69.00
Rate for Payer: Midlands Choice Commercial	$64.40
Rate for Payer: United Healthcare Commercial	$82.80

PTT

Facility

$64.00

Service Code	CPT 85730
Hospital Charge Code	633794
Hospital Revenue Code	305
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

PTT

Facility

$64.00

Service Code	CPT 85730
Hospital Charge Code	633794
Hospital Revenue Code	305
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76

PTT SUBSTITUTION, PLASMA FRACTIONS

Facility

$64.00

Service Code	CPT 85732
Hospital Charge Code	8093944
Hospital Revenue Code	305
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

PTT SUBSTITUTION, PLASMA FRACTIONS

Facility

$64.00

Service Code	CPT 85732
Hospital Charge Code	8093944
Hospital Revenue Code	305
Min. Negotiated Rate	$28.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76

PT Unattended E-Stim Units

Facility

$85.00

Service Code	HCPCS G0283 GP
Hospital Charge Code	1374022
Hospital Revenue Code	420
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of IA Commercial	$76.50
Rate for Payer: Aetna of IA Medical Rental Products	$76.50
Rate for Payer: Cash Price	$68.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.75
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: United Healthcare Commercial	$76.50

PT Unattended E-Stim Units

Facility

$85.00

Service Code	HCPCS G0283 GP
Hospital Charge Code	1374022
Hospital Revenue Code	420
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of IA Commercial	$76.50
Rate for Payer: Aetna of IA Medical Rental Products	$76.50
Rate for Payer: Aetna of IA Medicare	$48.45
Rate for Payer: Amerigroup Medicaid	$49.03
Rate for Payer: Amerigroup Medicare	$38.63
Rate for Payer: Cash Price	$68.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.25
Rate for Payer: Iowa Total Care Managed Medicaid	$48.55
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Medical Associates Managed Medicare	$38.25
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: Molina Healthcare Managed Medicaid	$49.27
Rate for Payer: Partners Health Alliance Commercial	$43.99
Rate for Payer: United Healthcare Commercial	$76.50
Rate for Payer: United Healthcare Managed Medicare	$50.15

PULM FUNCTION TEST VOLUMES BY GAS

Facility

$260.00

Service Code	CPT 94727
Hospital Charge Code	5338938
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

PULM FUNCTION TEST VOLUMES BY GAS

Facility

$260.00

Service Code	CPT 94727
Hospital Charge Code	5338938
Hospital Revenue Code	460
Min. Negotiated Rate	$117.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Aetna of IA Medicare	$148.20
Rate for Payer: Amerigroup Medicaid	$149.97
Rate for Payer: Amerigroup Medicare	$118.17
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$117.00
Rate for Payer: Iowa Total Care Managed Medicaid	$148.51
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Medical Associates Managed Medicare	$117.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: Molina Healthcare Managed Medicaid	$150.70
Rate for Payer: Partners Health Alliance Commercial	$134.55
Rate for Payer: United Healthcare Commercial	$234.00
Rate for Payer: United Healthcare Managed Medicare	$153.40

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	8059082
Hospital Revenue Code	948
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: United Healthcare Commercial	$140.40

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	8059082
Hospital Revenue Code	948
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Aetna of IA Medicare	$88.92
Rate for Payer: Amerigroup Medicaid	$89.98
Rate for Payer: Amerigroup Medicare	$70.90
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$70.20
Rate for Payer: Iowa Total Care Managed Medicaid	$89.11
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Medical Associates Managed Medicare	$70.20
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: Molina Healthcare Managed Medicaid	$90.42
Rate for Payer: Partners Health Alliance Commercial	$80.73
Rate for Payer: United Healthcare Commercial	$140.40
Rate for Payer: United Healthcare Managed Medicare	$92.04

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	8059084
Hospital Revenue Code	948
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Aetna of IA Medicare	$88.92
Rate for Payer: Amerigroup Medicaid	$89.98
Rate for Payer: Amerigroup Medicare	$70.90
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$70.20
Rate for Payer: Iowa Total Care Managed Medicaid	$89.11
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Medical Associates Managed Medicare	$70.20
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: Molina Healthcare Managed Medicaid	$90.42
Rate for Payer: Partners Health Alliance Commercial	$80.73
Rate for Payer: United Healthcare Commercial	$140.40
Rate for Payer: United Healthcare Managed Medicare	$92.04

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239 KX
Hospital Charge Code	8059083
Hospital Revenue Code	948
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Aetna of IA Medicare	$88.92
Rate for Payer: Amerigroup Medicaid	$89.98
Rate for Payer: Amerigroup Medicare	$70.90
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$70.20
Rate for Payer: Iowa Total Care Managed Medicaid	$89.11
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Medical Associates Managed Medicare	$70.20
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: Molina Healthcare Managed Medicaid	$90.42
Rate for Payer: Partners Health Alliance Commercial	$80.73
Rate for Payer: United Healthcare Commercial	$140.40
Rate for Payer: United Healthcare Managed Medicare	$92.04

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	8059081
Hospital Revenue Code	948
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Aetna of IA Medicare	$88.92
Rate for Payer: Amerigroup Medicaid	$89.98
Rate for Payer: Amerigroup Medicare	$70.90
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$70.20
Rate for Payer: Iowa Total Care Managed Medicaid	$89.11
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Medical Associates Managed Medicare	$70.20
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: Molina Healthcare Managed Medicaid	$90.42
Rate for Payer: Partners Health Alliance Commercial	$80.73
Rate for Payer: United Healthcare Commercial	$140.40
Rate for Payer: United Healthcare Managed Medicare	$92.04

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	8059084
Hospital Revenue Code	948
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: United Healthcare Commercial	$140.40

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239
Hospital Charge Code	8059081
Hospital Revenue Code	948
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: United Healthcare Commercial	$140.40

Pulmonary Rehab Non COPD Charge

Facility

$156.00

Service Code	HCPCS G0239 KX
Hospital Charge Code	8059083
Hospital Revenue Code	948
Min. Negotiated Rate	$109.20
Max. Negotiated Rate	$140.40
Rate for Payer: Aetna of IA Commercial	$140.40
Rate for Payer: Aetna of IA Medical Rental Products	$140.40
Rate for Payer: Cash Price	$124.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$117.00
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: United Healthcare Commercial	$140.40

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625
Hospital Charge Code	7702165
Hospital Revenue Code	948
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: United Healthcare Commercial	$215.10

PULMONARY REHAB PHASE II

Facility

$239.00

Service Code	CPT 94625 KX
Hospital Charge Code	7827005
Hospital Revenue Code	948
Min. Negotiated Rate	$167.30
Max. Negotiated Rate	$215.10
Rate for Payer: Aetna of IA Commercial	$215.10
Rate for Payer: Aetna of IA Medical Rental Products	$215.10
Rate for Payer: Cash Price	$191.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$179.25
Rate for Payer: Medical Associates Commercial	$179.25
Rate for Payer: Midlands Choice Commercial	$167.30
Rate for Payer: United Healthcare Commercial	$215.10

Know your out-of-pocket cost for care.

All Charges