Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Rapid Plasma Reagin DMCL

Facility

$58.00

Service Code	CPT 86592
Hospital Charge Code	8037793
Hospital Revenue Code	302
Min. Negotiated Rate	$28.99
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	$29.27
Rate for Payer: Amerigroup Medicare	$29.29
Rate for Payer: Cash Price	$46.40
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	$29.00
Rate for Payer: Iowa Total Care Managed Medicaid	$28.99
Rate for Payer: Medical Associates Commercial	$43.50
Rate for Payer: Medical Associates Managed Medicare	$29.00
Rate for Payer: Midlands Choice Commercial	$40.60
Rate for Payer: Molina Healthcare Managed Medicaid	$29.44
Rate for Payer: Molina Healthcare Managed Medicare	$29.42
Rate for Payer: Oscar Health of IA Commercial	$43.50
Rate for Payer: Partners Health Alliance Commercial	$43.50
Rate for Payer: United Healthcare Commercial	$52.20
Rate for Payer: United Healthcare Managed Medicare	$34.22
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Rapid Plasma Reagin DMCL

Facility

$58.00

Service Code	CPT 86592
Hospital Charge Code	8037793
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

rasagiline 1 mg oral tablet [VDMC]

Facility

$11.60

Service Code	HCPCS A9270
Hospital Charge Code	10418744
Hospital Revenue Code	259
Min. Negotiated Rate	$8.12
Max. Negotiated Rate	$10.44
Rate for Payer: Aetna of IA Commercial	$10.44
Rate for Payer: Aetna of IA Medical Rental Products	$10.44
Rate for Payer: Cash Price	$9.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.70
Rate for Payer: Medical Associates Commercial	$8.70
Rate for Payer: Midlands Choice Commercial	$8.12
Rate for Payer: United Healthcare Commercial	$10.44

rasagiline 1 mg oral tablet [VDMC]

Facility

$11.60

Service Code	HCPCS A9270
Hospital Charge Code	10418744
Hospital Revenue Code	259
Min. Negotiated Rate	$5.80
Max. Negotiated Rate	$10.44
Rate for Payer: Aetna of IA Commercial	$10.44
Rate for Payer: Aetna of IA Medical Rental Products	$10.44
Rate for Payer: Aetna of IA Medicare	$6.61
Rate for Payer: Amerigroup Medicaid	$5.85
Rate for Payer: Amerigroup Medicare	$5.86
Rate for Payer: Cash Price	$9.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$8.70
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.80
Rate for Payer: Iowa Total Care Managed Medicaid	$5.80
Rate for Payer: Medical Associates Commercial	$8.70
Rate for Payer: Medical Associates Managed Medicare	$5.80
Rate for Payer: Midlands Choice Commercial	$8.12
Rate for Payer: Molina Healthcare Managed Medicaid	$5.89
Rate for Payer: Molina Healthcare Managed Medicare	$5.88
Rate for Payer: Oscar Health of IA Commercial	$8.70
Rate for Payer: Partners Health Alliance Commercial	$8.70
Rate for Payer: United Healthcare Commercial	$10.44
Rate for Payer: United Healthcare Managed Medicare	$6.84

RBC AUTOMATED CELL COUNT

Facility

$34.00

Service Code	CPT 85041
Hospital Charge Code	4006787
Hospital Revenue Code	305
Min. Negotiated Rate	$16.99
Max. Negotiated Rate	$36.15
Rate for Payer: Aetna of IA Commercial	$30.60
Rate for Payer: Aetna of IA Medical Rental Products	$30.60
Rate for Payer: Aetna of IA Medicare	$19.38
Rate for Payer: Amerigroup Medicaid	$17.16
Rate for Payer: Amerigroup Medicare	$17.17
Rate for Payer: Cash Price	$27.20
Rate for Payer: Cash Price	$27.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$25.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$17.00
Rate for Payer: Iowa Total Care Managed Medicaid	$16.99
Rate for Payer: Medical Associates Commercial	$25.50
Rate for Payer: Medical Associates Managed Medicare	$17.00
Rate for Payer: Midlands Choice Commercial	$23.80
Rate for Payer: Molina Healthcare Managed Medicaid	$17.26
Rate for Payer: Molina Healthcare Managed Medicare	$17.24
Rate for Payer: Oscar Health of IA Commercial	$25.50
Rate for Payer: Partners Health Alliance Commercial	$25.50
Rate for Payer: United Healthcare Commercial	$30.60
Rate for Payer: United Healthcare Managed Medicare	$20.06
Rate for Payer: Wellmark IA HMO	$32.86
Rate for Payer: Wellmark IA PPO	$36.15

RBC AUTOMATED CELL COUNT

Facility

$34.00

Service Code	CPT 85041
Hospital Charge Code	4006787
Hospital Revenue Code	305
Min. Negotiated Rate	$23.80
Max. Negotiated Rate	$30.60
Rate for Payer: Aetna of IA Commercial	$30.60
Rate for Payer: Aetna of IA Medical Rental Products	$30.60
Rate for Payer: Cash Price	$27.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$25.50
Rate for Payer: Medical Associates Commercial	$25.50
Rate for Payer: Midlands Choice Commercial	$23.80
Rate for Payer: United Healthcare Commercial	$30.60

RBC Folate DMCL

Facility

$165.00

Service Code	CPT 82747
Hospital Charge Code	8037794
Hospital Revenue Code	301
Min. Negotiated Rate	$68.82
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of IA Commercial	$148.50
Rate for Payer: Aetna of IA Medical Rental Products	$148.50
Rate for Payer: Aetna of IA Medicare	$94.05
Rate for Payer: Amerigroup Medicaid	$83.28
Rate for Payer: Amerigroup Medicare	$83.32
Rate for Payer: Cash Price	$132.00
Rate for Payer: Cash Price	$132.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$123.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$82.50
Rate for Payer: Iowa Total Care Managed Medicaid	$82.47
Rate for Payer: Medical Associates Commercial	$123.75
Rate for Payer: Medical Associates Managed Medicare	$82.50
Rate for Payer: Midlands Choice Commercial	$115.50
Rate for Payer: Molina Healthcare Managed Medicaid	$83.74
Rate for Payer: Molina Healthcare Managed Medicare	$83.69
Rate for Payer: Oscar Health of IA Commercial	$123.75
Rate for Payer: Partners Health Alliance Commercial	$123.75
Rate for Payer: United Healthcare Commercial	$148.50
Rate for Payer: United Healthcare Managed Medicare	$97.35
Rate for Payer: Wellmark IA HMO	$68.82
Rate for Payer: Wellmark IA PPO	$75.70

RBC Folate DMCL

Facility

$165.00

Service Code	CPT 82747
Hospital Charge Code	8037794
Hospital Revenue Code	301
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$148.50
Rate for Payer: Aetna of IA Commercial	$148.50
Rate for Payer: Aetna of IA Medical Rental Products	$148.50
Rate for Payer: Cash Price	$132.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$123.75
Rate for Payer: Medical Associates Commercial	$123.75
Rate for Payer: Midlands Choice Commercial	$115.50
Rate for Payer: United Healthcare Commercial	$148.50

REAMER, LOW PROFILE

Facility

$351.00

Hospital Charge Code	8047061
Hospital Revenue Code	278
Min. Negotiated Rate	$245.70
Max. Negotiated Rate	$315.90
Rate for Payer: Aetna of IA Commercial	$315.90
Rate for Payer: Aetna of IA Medical Rental Products	$315.90
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$263.25
Rate for Payer: Medical Associates Commercial	$263.25
Rate for Payer: Midlands Choice Commercial	$245.70
Rate for Payer: United Healthcare Commercial	$315.90

REAMER, LOW PROFILE

Facility

$351.00

Hospital Charge Code	8047061
Hospital Revenue Code	278
Min. Negotiated Rate	$175.43
Max. Negotiated Rate	$315.90
Rate for Payer: Aetna of IA Commercial	$315.90
Rate for Payer: Aetna of IA Medical Rental Products	$315.90
Rate for Payer: Aetna of IA Medicare	$200.07
Rate for Payer: Amerigroup Medicaid	$177.15
Rate for Payer: Amerigroup Medicare	$177.26
Rate for Payer: Cash Price	$280.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$263.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$175.50
Rate for Payer: Iowa Total Care Managed Medicaid	$175.43
Rate for Payer: Medical Associates Commercial	$263.25
Rate for Payer: Medical Associates Managed Medicare	$175.50
Rate for Payer: Midlands Choice Commercial	$245.70
Rate for Payer: Molina Healthcare Managed Medicaid	$178.13
Rate for Payer: Molina Healthcare Managed Medicare	$178.03
Rate for Payer: Oscar Health of IA Commercial	$263.25
Rate for Payer: Partners Health Alliance Commercial	$263.25
Rate for Payer: United Healthcare Commercial	$315.90
Rate for Payer: United Healthcare Managed Medicare	$207.09

REAMER SHAFT 8.0X448MM

Facility

$355.00

Hospital Charge Code	8025851
Hospital Revenue Code	278
Min. Negotiated Rate	$177.43
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of IA Commercial	$319.50
Rate for Payer: Aetna of IA Medical Rental Products	$319.50
Rate for Payer: Aetna of IA Medicare	$202.35
Rate for Payer: Amerigroup Medicaid	$179.17
Rate for Payer: Amerigroup Medicare	$179.28
Rate for Payer: Cash Price	$284.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$266.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$177.50
Rate for Payer: Iowa Total Care Managed Medicaid	$177.43
Rate for Payer: Medical Associates Commercial	$266.25
Rate for Payer: Medical Associates Managed Medicare	$177.50
Rate for Payer: Midlands Choice Commercial	$248.50
Rate for Payer: Molina Healthcare Managed Medicaid	$180.16
Rate for Payer: Molina Healthcare Managed Medicare	$180.06
Rate for Payer: Oscar Health of IA Commercial	$266.25
Rate for Payer: Partners Health Alliance Commercial	$266.25
Rate for Payer: United Healthcare Commercial	$319.50
Rate for Payer: United Healthcare Managed Medicare	$209.45

REAMER SHAFT 8.0X448MM

Facility

$355.00

Hospital Charge Code	8025851
Hospital Revenue Code	278
Min. Negotiated Rate	$248.50
Max. Negotiated Rate	$319.50
Rate for Payer: Aetna of IA Commercial	$319.50
Rate for Payer: Aetna of IA Medical Rental Products	$319.50
Rate for Payer: Cash Price	$284.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$266.25
Rate for Payer: Medical Associates Commercial	$266.25
Rate for Payer: Midlands Choice Commercial	$248.50
Rate for Payer: United Healthcare Commercial	$319.50

RECHARGER FOR INTELLIS ADAPTIVESTIM

Facility

$2,700.00

Service Code	CPT C1778
Hospital Charge Code	8558056
Hospital Revenue Code	278
Min. Negotiated Rate	$1,890.00
Max. Negotiated Rate	$2,430.00
Rate for Payer: Aetna of IA Commercial	$2,430.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,430.00
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,025.00
Rate for Payer: Medical Associates Commercial	$2,025.00
Rate for Payer: Midlands Choice Commercial	$1,890.00
Rate for Payer: United Healthcare Commercial	$2,430.00

RECHARGER FOR INTELLIS ADAPTIVESTIM

Facility

$2,700.00

Service Code	CPT C1778
Hospital Charge Code	8558056
Hospital Revenue Code	278
Min. Negotiated Rate	$1,349.46
Max. Negotiated Rate	$2,430.00
Rate for Payer: Aetna of IA Commercial	$2,430.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,430.00
Rate for Payer: Aetna of IA Medicare	$1,539.00
Rate for Payer: Amerigroup Medicaid	$1,362.69
Rate for Payer: Amerigroup Medicare	$1,363.50
Rate for Payer: Cash Price	$2,160.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,025.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,350.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,349.46
Rate for Payer: Medical Associates Commercial	$2,025.00
Rate for Payer: Medical Associates Managed Medicare	$1,350.00
Rate for Payer: Midlands Choice Commercial	$1,890.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,370.25
Rate for Payer: Molina Healthcare Managed Medicare	$1,369.44
Rate for Payer: Oscar Health of IA Commercial	$2,025.00
Rate for Payer: Partners Health Alliance Commercial	$2,025.00
Rate for Payer: United Healthcare Commercial	$2,430.00
Rate for Payer: United Healthcare Managed Medicare	$1,593.00

RECOVERY PHASE 2

Facility

$2.00

Hospital Charge Code	8025190
Hospital Revenue Code	710
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

RECOVERY PHASE 2

Facility

$2.00

Hospital Charge Code	8025190
Hospital Revenue Code	710
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	$1.18

Rectal Resection With CC

Facility

$20,945.65

Service Code	MS-DRG 333
Hospital Charge Code	183
Min. Negotiated Rate	$20,642.09
Max. Negotiated Rate	$20,945.65
Rate for Payer: Amerigroup Medicaid	$20,844.46
Rate for Payer: Iowa Total Care Managed Medicaid	$20,642.09
Rate for Payer: Molina Healthcare Managed Medicaid	$20,945.65

Rectal Resection With MCC

Facility

$40,952.32

Service Code	MS-DRG 332
Hospital Charge Code	182
Min. Negotiated Rate	$40,358.81
Max. Negotiated Rate	$40,952.32
Rate for Payer: Amerigroup Medicaid	$40,754.48
Rate for Payer: Iowa Total Care Managed Medicaid	$40,358.81
Rate for Payer: Molina Healthcare Managed Medicaid	$40,952.32

Rectal Resection Without CC/MCC

Facility

$13,803.00

Service Code	MS-DRG 334
Hospital Charge Code	184
Min. Negotiated Rate	$13,602.95
Max. Negotiated Rate	$13,803.00
Rate for Payer: Amerigroup Medicaid	$13,736.32
Rate for Payer: Iowa Total Care Managed Medicaid	$13,602.95
Rate for Payer: Molina Healthcare Managed Medicaid	$13,803.00

Red Blood Cell Disorders With MCC

Facility

$12,350.26

Service Code	MS-DRG 811
Hospital Charge Code	553
Min. Negotiated Rate	$12,171.27
Max. Negotiated Rate	$12,350.26
Rate for Payer: Amerigroup Medicaid	$12,290.60
Rate for Payer: Iowa Total Care Managed Medicaid	$12,171.27
Rate for Payer: Molina Healthcare Managed Medicaid	$12,350.26

Red Blood Cell Disorders Without MCC

Facility

$7,595.39

Service Code	MS-DRG 812
Hospital Charge Code	554
Min. Negotiated Rate	$7,485.31
Max. Negotiated Rate	$7,595.39
Rate for Payer: Amerigroup Medicaid	$7,558.70
Rate for Payer: Iowa Total Care Managed Medicaid	$7,485.31
Rate for Payer: Molina Healthcare Managed Medicaid	$7,595.39

RE-EVALUATION OCC THERAPY

Facility

$156.00

Service Code	CPT 97168 GO
Hospital Charge Code	5520782
Hospital Revenue Code	434
Min. Negotiated Rate	$77.97
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	$78.73
Rate for Payer: Amerigroup Medicare	$78.78
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	$78.00
Rate for Payer: Iowa Total Care Managed Medicaid	$77.97
Rate for Payer: Medical Associates Commercial	$117.00
Rate for Payer: Medical Associates Managed Medicare	$78.00
Rate for Payer: Midlands Choice Commercial	$109.20
Rate for Payer: Molina Healthcare Managed Medicaid	$79.17
Rate for Payer: Molina Healthcare Managed Medicare	$79.12
Rate for Payer: Oscar Health of IA Commercial	$117.00
Rate for Payer: Partners Health Alliance Commercial	$117.00
Rate for Payer: United Healthcare Commercial	$140.40
Rate for Payer: United Healthcare Managed Medicare	$92.04

RE-EVALUATION OCC THERAPY

Facility

$156.00

Service Code	CPT 97168 GO
Hospital Charge Code	5520782
Hospital Revenue Code	434
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

Rehabilitation With CC/MCC

Facility

$22,041.10

Service Code	MS-DRG 945
Hospital Charge Code	651
Min. Negotiated Rate	$21,721.66
Max. Negotiated Rate	$22,041.10
Rate for Payer: Amerigroup Medicaid	$21,934.62
Rate for Payer: Iowa Total Care Managed Medicaid	$21,721.66
Rate for Payer: Molina Healthcare Managed Medicaid	$22,041.10

Rehabilitation Without CC/MCC

Facility

$10,494.97

Service Code	MS-DRG 946
Hospital Charge Code	652
Min. Negotiated Rate	$10,342.87
Max. Negotiated Rate	$10,494.97
Rate for Payer: Amerigroup Medicaid	$10,444.27
Rate for Payer: Iowa Total Care Managed Medicaid	$10,342.87
Rate for Payer: Molina Healthcare Managed Medicaid	$10,494.97

Know your out-of-pocket cost for care.

All Charges