Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

RESTRATA 5PK 1X1 5PK 1X2

Facility

$18,497.00

Service Code	HCPCS C1713
Hospital Charge Code	8943983
Hospital Revenue Code	278
Min. Negotiated Rate	$12,947.90
Max. Negotiated Rate	$16,647.30
Rate for Payer: Aetna of IA Commercial	$16,647.30
Rate for Payer: Aetna of IA Medical Rental Products	$16,647.30
Rate for Payer: Cash Price	$14,797.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13,872.75
Rate for Payer: Medical Associates Commercial	$13,872.75
Rate for Payer: Midlands Choice Commercial	$12,947.90
Rate for Payer: United Healthcare Commercial	$16,647.30

Reticulocyte Count DMCL

Facility

$59.00

Service Code	CPT 85045
Hospital Charge Code	8037796
Hospital Revenue Code	305
Min. Negotiated Rate	$26.55
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Aetna of IA Medicare	$33.63
Rate for Payer: Amerigroup Medicaid	$34.03
Rate for Payer: Amerigroup Medicare	$26.82
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$26.55
Rate for Payer: Iowa Total Care Managed Medicaid	$33.70
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Medical Associates Managed Medicare	$26.55
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: Molina Healthcare Managed Medicaid	$34.20
Rate for Payer: Partners Health Alliance Commercial	$30.53
Rate for Payer: United Healthcare Commercial	$53.10
Rate for Payer: United Healthcare Managed Medicare	$34.81

Reticulocyte Count DMCL

Facility

$59.00

Service Code	CPT 85045
Hospital Charge Code	8037796
Hospital Revenue Code	305
Min. Negotiated Rate	$41.30
Max. Negotiated Rate	$53.10
Rate for Payer: Aetna of IA Commercial	$53.10
Rate for Payer: Aetna of IA Medical Rental Products	$53.10
Rate for Payer: Cash Price	$47.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$44.25
Rate for Payer: Medical Associates Commercial	$44.25
Rate for Payer: Midlands Choice Commercial	$41.30
Rate for Payer: United Healthcare Commercial	$53.10

REVISE SPINE ELTRD PERQ ARAY

Professional

Both

$2,602.00

Service Code	CPT 63663
Hospital Charge Code	8015893
Hospital Revenue Code	975
Min. Negotiated Rate	$1,289.47
Max. Negotiated Rate	$1,951.50
Rate for Payer: Cash Price	$2,081.60
Rate for Payer: Cash Price	$2,081.60
Rate for Payer: Medical Associates Commercial	$1,951.50
Rate for Payer: Midlands Choice Commercial	$1,821.40
Rate for Payer: Partners Health Alliance Commercial	$1,951.50
Rate for Payer: United Healthcare Commercial	$1,289.47

REVISE SPINE ELTRD PLATE

Professional

Both

$2,930.00

Service Code	CPT 63664
Hospital Charge Code	8015888
Hospital Revenue Code	975
Min. Negotiated Rate	$1,282.35
Max. Negotiated Rate	$2,197.50
Rate for Payer: Cash Price	$2,344.00
Rate for Payer: Cash Price	$2,344.00
Rate for Payer: Medical Associates Commercial	$2,197.50
Rate for Payer: Midlands Choice Commercial	$2,051.00
Rate for Payer: Partners Health Alliance Commercial	$2,197.50
Rate for Payer: United Healthcare Commercial	$1,282.35

REV OR REM IMPL SPINAL NS PG OR RECEIVER

Professional

Both

$1,249.00

Service Code	CPT 63688
Hospital Charge Code	8015878
Hospital Revenue Code	975
Min. Negotiated Rate	$557.62
Max. Negotiated Rate	$936.75
Rate for Payer: Cash Price	$999.20
Rate for Payer: Cash Price	$999.20
Rate for Payer: Medical Associates Commercial	$936.75
Rate for Payer: Midlands Choice Commercial	$874.30
Rate for Payer: Partners Health Alliance Commercial	$936.75
Rate for Payer: United Healthcare Commercial	$557.62

Rheumatoid Factor DMCL

Facility

$58.00

Service Code	CPT 86431
Hospital Charge Code	8037797
Hospital Revenue Code	302
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

Rheumatoid Factor DMCL

Facility

$58.00

Service Code	CPT 86431
Hospital Charge Code	8037797
Hospital Revenue Code	302
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: 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

RHIG

Facility

$133.00

Service Code	CPT 90384
Hospital Charge Code	1378504
Hospital Revenue Code	636
Min. Negotiated Rate	$59.85
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Aetna of IA Medicare	$75.81
Rate for Payer: Amerigroup Medicaid	$76.71
Rate for Payer: Amerigroup Medicare	$60.45
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$59.85
Rate for Payer: Iowa Total Care Managed Medicaid	$75.97
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Medical Associates Managed Medicare	$59.85
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: Molina Healthcare Managed Medicaid	$77.09
Rate for Payer: Partners Health Alliance Commercial	$68.83
Rate for Payer: United Healthcare Commercial	$119.70
Rate for Payer: United Healthcare Managed Medicare	$78.47

RHIG

Facility

$133.00

Service Code	CPT 90384
Hospital Charge Code	1378504
Hospital Revenue Code	636
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: United Healthcare Commercial	$119.70

RH TYPING

Facility

$52.00

Service Code	CPT 86901
Hospital Charge Code	8015194
Hospital Revenue Code	302
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: United Healthcare Commercial	$46.80

RH TYPING

Facility

$52.00

Service Code	CPT 86901
Hospital Charge Code	8015194
Hospital Revenue Code	302
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Aetna of IA Medicare	$29.64
Rate for Payer: Amerigroup Medicaid	$29.99
Rate for Payer: Amerigroup Medicare	$23.63
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.40
Rate for Payer: Iowa Total Care Managed Medicaid	$29.70
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Medical Associates Managed Medicare	$23.40
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: Molina Healthcare Managed Medicaid	$30.14
Rate for Payer: Partners Health Alliance Commercial	$26.91
Rate for Payer: United Healthcare Commercial	$46.80
Rate for Payer: United Healthcare Managed Medicare	$30.68

Rhythm Strip

Facility

$104.00

Service Code	CPT 93041
Hospital Charge Code	7068798
Hospital Revenue Code	730
Min. Negotiated Rate	$46.80
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Aetna of IA Medicare	$59.28
Rate for Payer: Amerigroup Medicaid	$59.99
Rate for Payer: Amerigroup Medicare	$47.27
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$46.80
Rate for Payer: Iowa Total Care Managed Medicaid	$59.40
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Medical Associates Managed Medicare	$46.80
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: Molina Healthcare Managed Medicaid	$60.28
Rate for Payer: Partners Health Alliance Commercial	$53.82
Rate for Payer: United Healthcare Commercial	$93.60
Rate for Payer: United Healthcare Managed Medicare	$61.36

Rhythm Strip

Facility

$104.00

Service Code	CPT 93041
Hospital Charge Code	7068798
Hospital Revenue Code	730
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: United Healthcare Commercial	$93.60

riboflavin 100 mg Tab [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	10418882
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Aetna of IA Medicare	$0.69
Rate for Payer: Amerigroup Medicaid	$0.70
Rate for Payer: Amerigroup Medicare	$0.55
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.91
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.55
Rate for Payer: Iowa Total Care Managed Medicaid	$0.70
Rate for Payer: Medical Associates Commercial	$0.91
Rate for Payer: Medical Associates Managed Medicare	$0.55
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: Molina Healthcare Managed Medicaid	$0.71
Rate for Payer: Partners Health Alliance Commercial	$0.63
Rate for Payer: United Healthcare Commercial	$1.10
Rate for Payer: United Healthcare Managed Medicare	$0.72

riboflavin 100 mg Tab [VDMC]

Facility

$1.22

Service Code	HCPCS A9270
Hospital Charge Code	10418882
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.10
Rate for Payer: Aetna of IA Commercial	$1.10
Rate for Payer: Aetna of IA Medical Rental Products	$1.10
Rate for Payer: Cash Price	$0.97
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$0.91
Rate for Payer: Medical Associates Commercial	$0.91
Rate for Payer: Midlands Choice Commercial	$0.85
Rate for Payer: United Healthcare Commercial	$1.10

rifampin 300mg cap [VDMC]

Facility

$3.39

Service Code	HCPCS A9270
Hospital Charge Code	10419087
Hospital Revenue Code	259
Min. Negotiated Rate	$1.53
Max. Negotiated Rate	$3.05
Rate for Payer: Aetna of IA Commercial	$3.05
Rate for Payer: Aetna of IA Medical Rental Products	$3.05
Rate for Payer: Aetna of IA Medicare	$1.93
Rate for Payer: Amerigroup Medicaid	$1.96
Rate for Payer: Amerigroup Medicare	$1.54
Rate for Payer: Cash Price	$2.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.53
Rate for Payer: Iowa Total Care Managed Medicaid	$1.94
Rate for Payer: Medical Associates Commercial	$2.54
Rate for Payer: Medical Associates Managed Medicare	$1.53
Rate for Payer: Midlands Choice Commercial	$2.37
Rate for Payer: Molina Healthcare Managed Medicaid	$1.97
Rate for Payer: Partners Health Alliance Commercial	$1.76
Rate for Payer: United Healthcare Commercial	$3.05
Rate for Payer: United Healthcare Managed Medicare	$2.00

rifampin 300mg cap [VDMC]

Facility

$3.39

Service Code	HCPCS A9270
Hospital Charge Code	10419087
Hospital Revenue Code	259
Min. Negotiated Rate	$2.37
Max. Negotiated Rate	$3.05
Rate for Payer: Aetna of IA Commercial	$3.05
Rate for Payer: Aetna of IA Medical Rental Products	$3.05
Rate for Payer: Cash Price	$2.71
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.54
Rate for Payer: Medical Associates Commercial	$2.54
Rate for Payer: Midlands Choice Commercial	$2.37
Rate for Payer: United Healthcare Commercial	$3.05

rifampin 600 mg IV Inj [VDMC]

Facility

$236.56

Service Code	HCPCS J3490
Hospital Charge Code	10418951
Hospital Revenue Code	259
Min. Negotiated Rate	$165.59
Max. Negotiated Rate	$212.90
Rate for Payer: Aetna of IA Commercial	$212.90
Rate for Payer: Aetna of IA Medical Rental Products	$212.90
Rate for Payer: Cash Price	$189.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$177.42
Rate for Payer: Medical Associates Commercial	$177.42
Rate for Payer: Midlands Choice Commercial	$165.59
Rate for Payer: United Healthcare Commercial	$212.90

rifampin 600 mg IV Inj [VDMC]

Facility

$236.56

Service Code	HCPCS J3490
Hospital Charge Code	10418951
Hospital Revenue Code	259
Min. Negotiated Rate	$106.45
Max. Negotiated Rate	$212.90
Rate for Payer: Aetna of IA Commercial	$212.90
Rate for Payer: Aetna of IA Medical Rental Products	$212.90
Rate for Payer: Aetna of IA Medicare	$134.84
Rate for Payer: Amerigroup Medicaid	$136.45
Rate for Payer: Amerigroup Medicare	$107.52
Rate for Payer: Cash Price	$189.25
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$177.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$106.45
Rate for Payer: Iowa Total Care Managed Medicaid	$135.12
Rate for Payer: Medical Associates Commercial	$177.42
Rate for Payer: Medical Associates Managed Medicare	$106.45
Rate for Payer: Midlands Choice Commercial	$165.59
Rate for Payer: Molina Healthcare Managed Medicaid	$137.11
Rate for Payer: Partners Health Alliance Commercial	$122.42
Rate for Payer: United Healthcare Commercial	$212.90
Rate for Payer: United Healthcare Managed Medicare	$139.57

RING CAPSULAR TENSION 12MM

Facility

$128.00

Service Code	HCPCS C1713
Hospital Charge Code	8047043
Hospital Revenue Code	278
Min. Negotiated Rate	$89.60
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: United Healthcare Commercial	$115.20

RING CAPSULAR TENSION 12MM

Facility

$128.00

Service Code	HCPCS C1713
Hospital Charge Code	8047043
Hospital Revenue Code	278
Min. Negotiated Rate	$57.60
Max. Negotiated Rate	$115.20
Rate for Payer: Aetna of IA Commercial	$115.20
Rate for Payer: Aetna of IA Medical Rental Products	$115.20
Rate for Payer: Aetna of IA Medicare	$72.96
Rate for Payer: Amerigroup Medicaid	$73.83
Rate for Payer: Amerigroup Medicare	$58.18
Rate for Payer: Cash Price	$102.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$96.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.60
Rate for Payer: Iowa Total Care Managed Medicaid	$73.11
Rate for Payer: Medical Associates Commercial	$96.00
Rate for Payer: Medical Associates Managed Medicare	$57.60
Rate for Payer: Midlands Choice Commercial	$89.60
Rate for Payer: Molina Healthcare Managed Medicaid	$74.19
Rate for Payer: Partners Health Alliance Commercial	$66.24
Rate for Payer: United Healthcare Commercial	$115.20
Rate for Payer: United Healthcare Managed Medicare	$75.52

RING, CAPSULAR, TENSION TYPE 14

Facility

$396.00

Service Code	HCPCS V2632
Hospital Charge Code	8988548
Hospital Revenue Code	276
Min. Negotiated Rate	$277.20
Max. Negotiated Rate	$356.40
Rate for Payer: Aetna of IA Commercial	$356.40
Rate for Payer: Aetna of IA Medical Rental Products	$356.40
Rate for Payer: Cash Price	$316.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$297.00
Rate for Payer: Medical Associates Commercial	$297.00
Rate for Payer: Midlands Choice Commercial	$277.20
Rate for Payer: United Healthcare Commercial	$356.40

RING, CAPSULAR, TENSION TYPE 14

Facility

$396.00

Service Code	HCPCS V2632
Hospital Charge Code	8988548
Hospital Revenue Code	276
Min. Negotiated Rate	$178.20
Max. Negotiated Rate	$356.40
Rate for Payer: Aetna of IA Commercial	$356.40
Rate for Payer: Aetna of IA Medical Rental Products	$356.40
Rate for Payer: Aetna of IA Medicare	$225.72
Rate for Payer: Amerigroup Medicaid	$228.41
Rate for Payer: Amerigroup Medicare	$179.98
Rate for Payer: Cash Price	$316.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$297.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$178.20
Rate for Payer: Iowa Total Care Managed Medicaid	$226.20
Rate for Payer: Medical Associates Commercial	$297.00
Rate for Payer: Medical Associates Managed Medicare	$178.20
Rate for Payer: Midlands Choice Commercial	$277.20
Rate for Payer: Molina Healthcare Managed Medicaid	$229.52
Rate for Payer: Partners Health Alliance Commercial	$204.93
Rate for Payer: United Healthcare Commercial	$356.40
Rate for Payer: United Healthcare Managed Medicare	$233.64

risperiDONE 0.25 mg Tab [VDMC]

Facility

$1.43

Service Code	HCPCS A9270
Hospital Charge Code	10419221
Hospital Revenue Code	259
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Aetna of IA Medicare	$0.81
Rate for Payer: Amerigroup Medicaid	$0.82
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.14
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.07
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.64
Rate for Payer: Iowa Total Care Managed Medicaid	$0.82
Rate for Payer: Medical Associates Commercial	$1.07
Rate for Payer: Medical Associates Managed Medicare	$0.64
Rate for Payer: Midlands Choice Commercial	$1.00
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Managed Medicare	$0.84

Know your out-of-pocket cost for care.

All Charges