Van Diest Medical Center

All Charges

Charge

Type

Price

Renal Failure With CC

Facility IP

$6,979.25

Service Code	MS-DRG 683
Hospital Charge Code	459
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$6,979.25
Rate for Payer: Amerigroup Medicaid	$6,945.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$6,878.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,979.25

Renal Failure With MCC

Facility IP

$11,483.15

Service Code	MS-DRG 682
Hospital Charge Code	458
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,483.15
Rate for Payer: Amerigroup Medicaid	$11,427.67
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$11,316.73
Rate for Payer: Molina Healthcare Managed Medicaid	$11,483.15

Renal Failure Without CC/MCC

Facility IP

$4,719.43

Service Code	MS-DRG 684
Hospital Charge Code	460
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$4,719.43
Rate for Payer: Amerigroup Medicaid	$4,696.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$4,651.04
Rate for Payer: Molina Healthcare Managed Medicaid	$4,719.43

RENAL PROFILE

Facility OP

$162.00

Service Code	CPT 80069
Hospital Charge Code	1634883
Hospital Revenue Code	301
Min. Negotiated Rate	$52.08
Max. Negotiated Rate	$145.80
Rate for Payer: Cash Price	$129.60
Rate for Payer: Aetna of IA Commercial	$145.80
Rate for Payer: Aetna of IA Medical Rental Products	$145.80
Rate for Payer: Aetna of IA Medicare	$92.34
Rate for Payer: Amerigroup Medicaid	$81.76
Rate for Payer: Amerigroup Medicare	$81.81
Rate for Payer: Cash Price	$129.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$121.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$81.00
Rate for Payer: Iowa Total Care Managed Medicaid	$80.97
Rate for Payer: Medical Associates Commercial	$121.50
Rate for Payer: Medical Associates Managed Medicare	$81.00
Rate for Payer: Midlands Choice Commercial	$113.40
Rate for Payer: Molina Healthcare Managed Medicaid	$82.22
Rate for Payer: Partners Health Alliance Commercial	$121.50
Rate for Payer: United Healthcare Commercial	$145.80
Rate for Payer: United Healthcare Managed Medicare	$95.58
Rate for Payer: Wellmark IA HMO	$52.08
Rate for Payer: Wellmark IA PPO	$57.29

RENAL PROFILE

Facility IP

$162.00

Service Code	CPT 80069
Hospital Charge Code	1634883
Hospital Revenue Code	301
Min. Negotiated Rate	$113.40
Max. Negotiated Rate	$145.80
Rate for Payer: Aetna of IA Commercial	$145.80
Rate for Payer: Aetna of IA Medical Rental Products	$145.80
Rate for Payer: Cash Price	$129.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$121.50
Rate for Payer: Medical Associates Commercial	$121.50
Rate for Payer: Midlands Choice Commercial	$113.40
Rate for Payer: United Healthcare Commercial	$145.80

Renin Direct DMCL

Facility OP

$180.00

Service Code	CPT 84244
Hospital Charge Code	8037795
Hospital Revenue Code	301
Min. Negotiated Rate	$47.12
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: 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: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Renin Direct DMCL

Facility IP

$180.00

Service Code	CPT 84244
Hospital Charge Code	8037795
Hospital Revenue Code	301
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

repaglinide 1 mg Tab

Facility IP

$1.52

Service Code	CPT A9270
Hospital Charge Code	43700349
Hospital Revenue Code	637
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of IA Commercial	$1.37
Rate for Payer: Aetna of IA Medical Rental Products	$1.37
Rate for Payer: Cash Price	$1.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.14
Rate for Payer: Medical Associates Commercial	$1.14
Rate for Payer: Midlands Choice Commercial	$1.06
Rate for Payer: United Healthcare Commercial	$1.37

repaglinide 1 mg Tab

Facility OP

$1.52

Service Code	CPT A9270
Hospital Charge Code	43700349
Hospital Revenue Code	637
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.37
Rate for Payer: Aetna of IA Commercial	$1.37
Rate for Payer: Aetna of IA Medical Rental Products	$1.37
Rate for Payer: Aetna of IA Medicare	$0.87
Rate for Payer: Amerigroup Medicaid	$0.77
Rate for Payer: Amerigroup Medicare	$0.77
Rate for Payer: Cash Price	$1.21
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.14
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.76
Rate for Payer: Iowa Total Care Managed Medicaid	$0.76
Rate for Payer: Medical Associates Commercial	$1.14
Rate for Payer: Medical Associates Managed Medicare	$0.76
Rate for Payer: Midlands Choice Commercial	$1.06
Rate for Payer: Molina Healthcare Managed Medicaid	$0.77
Rate for Payer: Partners Health Alliance Commercial	$1.14
Rate for Payer: United Healthcare Commercial	$1.37
Rate for Payer: United Healthcare Managed Medicare	$0.90

Repair, complex, trunk; 2.6 cm to 7.5 cm

Facility OP

$1,060.51

Service Code	CPT 13101
Hospital Revenue Code	360
Min. Negotiated Rate	$964.10
Max. Negotiated Rate	$1,060.51
Rate for Payer: Wellmark IA HMO	$964.10
Rate for Payer: Wellmark IA PPO	$1,060.51

Repair, complex, trunk; each additional 5 cm or less (List separately in addition to code for primary procedure)

Facility OP

$1,060.51

Service Code	CPT 13102
Hospital Revenue Code	360
Min. Negotiated Rate	$964.10
Max. Negotiated Rate	$1,060.51
Rate for Payer: Wellmark IA HMO	$964.10
Rate for Payer: Wellmark IA PPO	$1,060.51

REPAIR FOREARM TENDON/MUSCLE

Professional

$1,635.00

Service Code	CPT 25270
Hospital Charge Code	7982870
Hospital Revenue Code	981
Min. Negotiated Rate	$452.87
Max. Negotiated Rate	$1,144.50
Rate for Payer: Aetna of IA Medicare	$452.87
Rate for Payer: Amerigroup Medicaid	$468.27
Rate for Payer: Cash Price	$1,308.00
Rate for Payer: Cash Price	$1,308.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$543.44
Rate for Payer: Iowa Total Care Managed Medicaid	$461.93
Rate for Payer: Medical Associates Commercial	$860.45
Rate for Payer: Medical Associates Managed Medicare	$452.87
Rate for Payer: Midlands Choice Commercial	$1,144.50
Rate for Payer: Partners Health Alliance Commercial	$679.30
Rate for Payer: Wellmark IA HMO	$956.00
Rate for Payer: Wellmark IA PPO	$1,122.00

Repair initial inguinal hernia, age 5 years or older; reducible

Facility OP

$6,191.88

Service Code	CPT 49505
Hospital Revenue Code	360
Min. Negotiated Rate	$5,628.98
Max. Negotiated Rate	$6,191.88
Rate for Payer: Wellmark IA HMO	$5,628.98
Rate for Payer: Wellmark IA PPO	$6,191.88

Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 12.6 cm to 20.0 cm

Facility OP

$1,060.51

Service Code	CPT 12035
Hospital Revenue Code	490
Min. Negotiated Rate	$964.10
Max. Negotiated Rate	$1,060.51
Rate for Payer: Wellmark IA HMO	$964.10
Rate for Payer: Wellmark IA PPO	$1,060.51

Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities (excluding hands and feet); 7.6 cm to 12.5 cm

Facility OP

$1,060.51

Service Code	CPT 12034
Hospital Revenue Code	360
Min. Negotiated Rate	$964.10
Max. Negotiated Rate	$1,060.51
Rate for Payer: Wellmark IA HMO	$964.10
Rate for Payer: Wellmark IA PPO	$1,060.51

REPAIR LIP

Professional

$1,467.00

Service Code	CPT 40650
Hospital Charge Code	7982775
Hospital Revenue Code	981
Min. Negotiated Rate	$287.31
Max. Negotiated Rate	$1,026.90
Rate for Payer: Aetna of IA Medicare	$287.31
Rate for Payer: Amerigroup Medicaid	$297.08
Rate for Payer: Cash Price	$1,173.60
Rate for Payer: Cash Price	$1,173.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.77
Rate for Payer: Iowa Total Care Managed Medicaid	$293.06
Rate for Payer: Medical Associates Commercial	$545.89
Rate for Payer: Medical Associates Managed Medicare	$287.31
Rate for Payer: Midlands Choice Commercial	$1,026.90
Rate for Payer: Partners Health Alliance Commercial	$430.96
Rate for Payer: Wellmark IA HMO	$602.00
Rate for Payer: Wellmark IA PPO	$707.00

REPAIR OF NAIL BED SIMPLE

Professional

$624.00

Service Code	CPT 11760
Hospital Charge Code	7982846
Hospital Revenue Code	981
Min. Negotiated Rate	$100.16
Max. Negotiated Rate	$436.80
Rate for Payer: Aetna of IA Medicare	$100.16
Rate for Payer: Amerigroup Medicaid	$103.57
Rate for Payer: Cash Price	$499.20
Rate for Payer: Cash Price	$499.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$120.19
Rate for Payer: Iowa Total Care Managed Medicaid	$102.16
Rate for Payer: Medical Associates Commercial	$190.30
Rate for Payer: Medical Associates Managed Medicare	$100.16
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Partners Health Alliance Commercial	$150.24
Rate for Payer: Wellmark IA HMO	$210.00
Rate for Payer: Wellmark IA PPO	$246.00

Repair, secondary, disrupted ligament, ankle, collateral (eg, Watson-Jones procedure)

Facility OP

$9,723.96

Service Code	CPT 27698
Hospital Revenue Code	360
Min. Negotiated Rate	$8,839.96
Max. Negotiated Rate	$9,723.96
Rate for Payer: Wellmark IA HMO	$8,839.96
Rate for Payer: Wellmark IA PPO	$9,723.96

Repair, tendon, flexor, foot; primary or secondary, without free graft, each tendon

Facility OP

$4,658.74

Service Code	CPT 28200
Hospital Revenue Code	360
Min. Negotiated Rate	$4,235.22
Max. Negotiated Rate	$4,658.74
Rate for Payer: Wellmark IA HMO	$4,235.22
Rate for Payer: Wellmark IA PPO	$4,658.74

Respiratory Infections and Inflammations With CC

Facility IP

$12,953.60

Service Code	MS-DRG 178
Hospital Charge Code	49
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$12,953.60
Rate for Payer: Amerigroup Medicaid	$12,891.03
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$12,765.87
Rate for Payer: Molina Healthcare Managed Medicaid	$12,953.60

Respiratory Infections and Inflammations With MCC

Facility IP

$14,795.12

Service Code	MS-DRG 177
Hospital Charge Code	48
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,795.12
Rate for Payer: Amerigroup Medicaid	$14,723.64
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$14,580.70
Rate for Payer: Molina Healthcare Managed Medicaid	$14,795.12

Respiratory Infections and Inflammations Without CC/MCC

Facility IP

$11,941.80

Service Code	MS-DRG 179
Hospital Charge Code	50
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,941.80
Rate for Payer: Amerigroup Medicaid	$11,884.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$11,768.73
Rate for Payer: Molina Healthcare Managed Medicaid	$11,941.80

Respiratory Neoplasms With CC

Facility IP

$8,715.46

Service Code	MS-DRG 181
Hospital Charge Code	52
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,715.46
Rate for Payer: Amerigroup Medicaid	$8,673.35
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$8,589.14
Rate for Payer: Molina Healthcare Managed Medicaid	$8,715.46

Respiratory Neoplasms With MCC

Facility IP

$14,264.61

Service Code	MS-DRG 180
Hospital Charge Code	51
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,264.61
Rate for Payer: Amerigroup Medicaid	$14,195.70
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$14,057.87
Rate for Payer: Molina Healthcare Managed Medicaid	$14,264.61

Respiratory Neoplasms Without CC/MCC

Facility IP

$7,752.87

Service Code	MS-DRG 182
Hospital Charge Code	53
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$7,752.87
Rate for Payer: Amerigroup Medicaid	$7,715.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7,640.51
Rate for Payer: Molina Healthcare Managed Medicaid	$7,752.87

Price Transparency.

All Charges