Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

Facility

$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

Both

$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	$815.17
Rate for Payer: Medical Associates Managed Medicare	$452.87
Rate for Payer: Midlands Choice Commercial	$1,144.50
Rate for Payer: Oscar Health of IA Commercial	$783.47
Rate for Payer: Partners Health Alliance Commercial	$679.30

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

Facility

$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

$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

$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

Both

$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	$517.16
Rate for Payer: Medical Associates Managed Medicare	$287.31
Rate for Payer: Midlands Choice Commercial	$1,026.90
Rate for Payer: Oscar Health of IA Commercial	$497.05
Rate for Payer: Partners Health Alliance Commercial	$430.96

REPAIR OF NAIL BED SIMPLE

Professional

Both

$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	$180.29
Rate for Payer: Medical Associates Managed Medicare	$100.16
Rate for Payer: Midlands Choice Commercial	$436.80
Rate for Payer: Oscar Health of IA Commercial	$173.28
Rate for Payer: Partners Health Alliance Commercial	$150.24

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

Facility

$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

$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

$12,953.60

Service Code	MS-DRG 178
Hospital Charge Code	49
Min. Negotiated Rate	$12,765.87
Max. Negotiated Rate	$12,953.60
Rate for Payer: Amerigroup Medicaid	$12,891.03
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

$14,795.12

Service Code	MS-DRG 177
Hospital Charge Code	48
Min. Negotiated Rate	$14,580.70
Max. Negotiated Rate	$14,795.12
Rate for Payer: Amerigroup Medicaid	$14,723.64
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

$11,941.80

Service Code	MS-DRG 179
Hospital Charge Code	50
Min. Negotiated Rate	$11,768.73
Max. Negotiated Rate	$11,941.80
Rate for Payer: Amerigroup Medicaid	$11,884.11
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

$8,715.46

Service Code	MS-DRG 181
Hospital Charge Code	52
Min. Negotiated Rate	$8,589.14
Max. Negotiated Rate	$8,715.46
Rate for Payer: Amerigroup Medicaid	$8,673.35
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

$14,264.61

Service Code	MS-DRG 180
Hospital Charge Code	51
Min. Negotiated Rate	$14,057.87
Max. Negotiated Rate	$14,264.61
Rate for Payer: Amerigroup Medicaid	$14,195.70
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

$7,752.87

Service Code	MS-DRG 182
Hospital Charge Code	53
Min. Negotiated Rate	$7,640.51
Max. Negotiated Rate	$7,752.87
Rate for Payer: Amerigroup Medicaid	$7,715.42
Rate for Payer: Iowa Total Care Managed Medicaid	$7,640.51
Rate for Payer: Molina Healthcare Managed Medicaid	$7,752.87

Respiratory Panel 2.1 (BioFire)

Facility

$661.00

Service Code	CPT 87633
Hospital Charge Code	8789842
Hospital Revenue Code	306
Min. Negotiated Rate	$314.34
Max. Negotiated Rate	$594.90
Rate for Payer: Aetna of IA Commercial	$594.90
Rate for Payer: Aetna of IA Medical Rental Products	$594.90
Rate for Payer: Aetna of IA Medicare	$376.77
Rate for Payer: Amerigroup Medicaid	$333.61
Rate for Payer: Amerigroup Medicare	$333.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$495.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$330.50
Rate for Payer: Iowa Total Care Managed Medicaid	$330.37
Rate for Payer: Medical Associates Commercial	$495.75
Rate for Payer: Medical Associates Managed Medicare	$330.50
Rate for Payer: Midlands Choice Commercial	$462.70
Rate for Payer: Molina Healthcare Managed Medicaid	$335.46
Rate for Payer: Molina Healthcare Managed Medicare	$335.26
Rate for Payer: Oscar Health of IA Commercial	$495.75
Rate for Payer: Partners Health Alliance Commercial	$495.75
Rate for Payer: United Healthcare Commercial	$594.90
Rate for Payer: United Healthcare Managed Medicare	$389.99
Rate for Payer: Wellmark IA HMO	$314.34
Rate for Payer: Wellmark IA PPO	$345.77

Respiratory Panel 2.1 (BioFire)

Facility

$661.00

Service Code	CPT 87633
Hospital Charge Code	8789842
Hospital Revenue Code	306
Min. Negotiated Rate	$462.70
Max. Negotiated Rate	$594.90
Rate for Payer: Aetna of IA Commercial	$594.90
Rate for Payer: Aetna of IA Medical Rental Products	$594.90
Rate for Payer: Cash Price	$528.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$495.75
Rate for Payer: Medical Associates Commercial	$495.75
Rate for Payer: Midlands Choice Commercial	$462.70
Rate for Payer: United Healthcare Commercial	$594.90

Respiratory Panel by PCR

Facility

$661.00

Service Code	CPT 87633
Hospital Charge Code	8757579
Hospital Revenue Code	306
Min. Negotiated Rate	$462.70
Max. Negotiated Rate	$594.90
Rate for Payer: Aetna of IA Commercial	$594.90
Rate for Payer: Aetna of IA Medical Rental Products	$594.90
Rate for Payer: Cash Price	$528.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$495.75
Rate for Payer: Medical Associates Commercial	$495.75
Rate for Payer: Midlands Choice Commercial	$462.70
Rate for Payer: United Healthcare Commercial	$594.90

Respiratory Panel by PCR

Facility

$661.00

Service Code	CPT 87633
Hospital Charge Code	8757579
Hospital Revenue Code	306
Min. Negotiated Rate	$314.34
Max. Negotiated Rate	$594.90
Rate for Payer: Aetna of IA Commercial	$594.90
Rate for Payer: Aetna of IA Medical Rental Products	$594.90
Rate for Payer: Aetna of IA Medicare	$376.77
Rate for Payer: Amerigroup Medicaid	$333.61
Rate for Payer: Amerigroup Medicare	$333.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Cash Price	$528.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$495.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$330.50
Rate for Payer: Iowa Total Care Managed Medicaid	$330.37
Rate for Payer: Medical Associates Commercial	$495.75
Rate for Payer: Medical Associates Managed Medicare	$330.50
Rate for Payer: Midlands Choice Commercial	$462.70
Rate for Payer: Molina Healthcare Managed Medicaid	$335.46
Rate for Payer: Molina Healthcare Managed Medicare	$335.26
Rate for Payer: Oscar Health of IA Commercial	$495.75
Rate for Payer: Partners Health Alliance Commercial	$495.75
Rate for Payer: United Healthcare Commercial	$594.90
Rate for Payer: United Healthcare Managed Medicare	$389.99
Rate for Payer: Wellmark IA HMO	$314.34
Rate for Payer: Wellmark IA PPO	$345.77

Respiratory Signs and Symptoms

Facility

$5,582.61

Service Code	MS-DRG 204
Hospital Charge Code	75
Min. Negotiated Rate	$5,501.71
Max. Negotiated Rate	$5,582.61
Rate for Payer: Amerigroup Medicaid	$5,555.64
Rate for Payer: Iowa Total Care Managed Medicaid	$5,501.71
Rate for Payer: Molina Healthcare Managed Medicaid	$5,582.61

Respiratory System Diagnosis With Ventilator Support <=96 Hours

Facility

$18,396.46

Service Code	MS-DRG 208
Hospital Charge Code	79
Min. Negotiated Rate	$18,129.85
Max. Negotiated Rate	$18,396.46
Rate for Payer: Amerigroup Medicaid	$18,307.59
Rate for Payer: Iowa Total Care Managed Medicaid	$18,129.85
Rate for Payer: Molina Healthcare Managed Medicaid	$18,396.46

Respiratory System Diagnosis With Ventilator Support >96 Hours

Facility

$54,005.34

Service Code	MS-DRG 207
Hospital Charge Code	78
Min. Negotiated Rate	$53,222.65
Max. Negotiated Rate	$54,005.34
Rate for Payer: Amerigroup Medicaid	$53,744.44
Rate for Payer: Iowa Total Care Managed Medicaid	$53,222.65
Rate for Payer: Molina Healthcare Managed Medicaid	$54,005.34

RESTRATA 1X1 SOFT TISSUE REPAIR

Facility

$1,599.00

Service Code	CPT C1713
Hospital Charge Code	8885369
Hospital Revenue Code	278
Min. Negotiated Rate	$1,119.30
Max. Negotiated Rate	$1,439.10
Rate for Payer: Aetna of IA Commercial	$1,439.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,439.10
Rate for Payer: Cash Price	$1,279.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,199.25
Rate for Payer: Medical Associates Commercial	$1,199.25
Rate for Payer: Midlands Choice Commercial	$1,119.30
Rate for Payer: United Healthcare Commercial	$1,439.10

RESTRATA 1X1 SOFT TISSUE REPAIR

Facility

$1,599.00

Service Code	CPT C1713
Hospital Charge Code	8885369
Hospital Revenue Code	278
Min. Negotiated Rate	$799.18
Max. Negotiated Rate	$1,439.10
Rate for Payer: Aetna of IA Commercial	$1,439.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,439.10
Rate for Payer: Aetna of IA Medicare	$911.43
Rate for Payer: Amerigroup Medicaid	$807.02
Rate for Payer: Amerigroup Medicare	$807.50
Rate for Payer: Cash Price	$1,279.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,199.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$799.50
Rate for Payer: Iowa Total Care Managed Medicaid	$799.18
Rate for Payer: Medical Associates Commercial	$1,199.25
Rate for Payer: Medical Associates Managed Medicare	$799.50
Rate for Payer: Midlands Choice Commercial	$1,119.30
Rate for Payer: Molina Healthcare Managed Medicaid	$811.49
Rate for Payer: Molina Healthcare Managed Medicare	$811.01
Rate for Payer: Oscar Health of IA Commercial	$1,199.25
Rate for Payer: Partners Health Alliance Commercial	$1,199.25
Rate for Payer: United Healthcare Commercial	$1,439.10
Rate for Payer: United Healthcare Managed Medicare	$943.41

Restrata 1x2 soft tissue repair

Facility

$2,925.00

Service Code	CPT c1713
Hospital Charge Code	8874155
Hospital Revenue Code	278
Min. Negotiated Rate	$2,047.50
Max. Negotiated Rate	$2,632.50
Rate for Payer: Aetna of IA Commercial	$2,632.50
Rate for Payer: Aetna of IA Medical Rental Products	$2,632.50
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,193.75
Rate for Payer: Medical Associates Commercial	$2,193.75
Rate for Payer: Midlands Choice Commercial	$2,047.50
Rate for Payer: United Healthcare Commercial	$2,632.50

Know your out-of-pocket cost for care.

All Charges