Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

REAMER SHAFT 8.0X448MM

Facility

$355.00

Hospital Charge Code	8025851
Hospital Revenue Code	278
Min. Negotiated Rate	$159.75
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	$204.76
Rate for Payer: Amerigroup Medicare	$161.35
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	$159.75
Rate for Payer: Iowa Total Care Managed Medicaid	$202.78
Rate for Payer: Medical Associates Commercial	$266.25
Rate for Payer: Medical Associates Managed Medicare	$159.75
Rate for Payer: Midlands Choice Commercial	$248.50
Rate for Payer: Molina Healthcare Managed Medicaid	$205.76
Rate for Payer: Partners Health Alliance Commercial	$183.71
Rate for Payer: United Healthcare Commercial	$319.50
Rate for Payer: United Healthcare Managed Medicare	$209.45

RECHARGER FOR INTELLIS ADAPTIVESTIM

Facility

$2,700.00

Service Code	HCPCS 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	HCPCS C1778
Hospital Charge Code	8558056
Hospital Revenue Code	278
Min. Negotiated Rate	$1,215.00
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: Aetna of IA Medicare	$1,539.00
Rate for Payer: Amerigroup Medicaid	$1,557.36
Rate for Payer: Amerigroup Medicare	$1,227.15
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	$1,215.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,542.24
Rate for Payer: Medical Associates Commercial	$2,025.00
Rate for Payer: Medical Associates Managed Medicare	$1,215.00
Rate for Payer: Midlands Choice Commercial	$1,890.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,564.92
Rate for Payer: Partners Health Alliance Commercial	$1,397.25
Rate for Payer: United Healthcare Commercial	$2,430.00
Rate for Payer: United Healthcare Managed Medicare	$1,593.00

RECOVERY PHASE 1: Per Interval (1 Minute)

Facility

$16.00

Hospital Charge Code	8025193
Hospital Revenue Code	710
Min. Negotiated Rate	$11.20
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of IA Commercial	$14.40
Rate for Payer: Aetna of IA Medical Rental Products	$14.40
Rate for Payer: Cash Price	$12.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.00
Rate for Payer: Medical Associates Commercial	$12.00
Rate for Payer: Midlands Choice Commercial	$11.20
Rate for Payer: United Healthcare Commercial	$14.40

RECOVERY PHASE 1: Per Interval (1 Minute)

Facility

$16.00

Hospital Charge Code	8025193
Hospital Revenue Code	710
Min. Negotiated Rate	$7.20
Max. Negotiated Rate	$14.40
Rate for Payer: Aetna of IA Commercial	$14.40
Rate for Payer: Aetna of IA Medical Rental Products	$14.40
Rate for Payer: Aetna of IA Medicare	$9.12
Rate for Payer: Amerigroup Medicaid	$9.23
Rate for Payer: Amerigroup Medicare	$7.27
Rate for Payer: Cash Price	$12.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$12.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$7.20
Rate for Payer: Iowa Total Care Managed Medicaid	$9.14
Rate for Payer: Medical Associates Commercial	$12.00
Rate for Payer: Medical Associates Managed Medicare	$7.20
Rate for Payer: Midlands Choice Commercial	$11.20
Rate for Payer: Molina Healthcare Managed Medicaid	$9.27
Rate for Payer: Partners Health Alliance Commercial	$8.28
Rate for Payer: United Healthcare Commercial	$14.40
Rate for Payer: United Healthcare Managed Medicare	$9.44

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	$0.90
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	$1.15
Rate for Payer: Amerigroup Medicare	$0.91
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	$0.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1.14
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Medical Associates Managed Medicare	$0.90
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.16
Rate for Payer: Partners Health Alliance Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Managed Medicare	$1.18

RECOVERY PHASE 2: Per Interval (1 Qty)

Facility

$2.00

Hospital Charge Code	8397988
Hospital Revenue Code	710
Min. Negotiated Rate	$0.90
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	$1.15
Rate for Payer: Amerigroup Medicare	$0.91
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	$0.90
Rate for Payer: Iowa Total Care Managed Medicaid	$1.14
Rate for Payer: Medical Associates Commercial	$1.50
Rate for Payer: Medical Associates Managed Medicare	$0.90
Rate for Payer: Midlands Choice Commercial	$1.40
Rate for Payer: Molina Healthcare Managed Medicaid	$1.16
Rate for Payer: Partners Health Alliance Commercial	$1.04
Rate for Payer: United Healthcare Commercial	$1.80
Rate for Payer: United Healthcare Managed Medicare	$1.18

RECOVERY PHASE 2: Per Interval (1 Qty)

Facility

$2.00

Hospital Charge Code	8397988
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

RECTAL RESECTION WITH CC

Facility

$23,961.92

Service Code	MSDRG 333
Min. Negotiated Rate	$23,614.63
Max. Negotiated Rate	$23,961.92
Rate for Payer: Amerigroup Medicaid	$23,846.15
Rate for Payer: Iowa Total Care Managed Medicaid	$23,614.63
Rate for Payer: Molina Healthcare Managed Medicaid	$23,961.92

RECTAL RESECTION WITH MCC

Facility

$46,849.65

Service Code	MSDRG 332
Min. Negotiated Rate	$46,170.65
Max. Negotiated Rate	$46,849.65
Rate for Payer: Amerigroup Medicaid	$46,623.30
Rate for Payer: Iowa Total Care Managed Medicaid	$46,170.65
Rate for Payer: Molina Healthcare Managed Medicaid	$46,849.65

RECTAL RESECTION WITHOUT CC/MCC

Facility

$15,790.70

Service Code	MSDRG 334
Min. Negotiated Rate	$15,561.84
Max. Negotiated Rate	$15,790.70
Rate for Payer: Amerigroup Medicaid	$15,714.41
Rate for Payer: Iowa Total Care Managed Medicaid	$15,561.84
Rate for Payer: Molina Healthcare Managed Medicaid	$15,790.70

RECTUM SURGERY PROCEDURE

Facility

$2,480.00

Service Code	CPT 45999
Hospital Charge Code	7982909
Hospital Revenue Code	450
Min. Negotiated Rate	$1,116.00
Max. Negotiated Rate	$4,161.95
Rate for Payer: Aetna of IA Commercial	$2,232.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,232.00
Rate for Payer: Aetna of IA Medicare	$1,413.60
Rate for Payer: Amerigroup Medicaid	$1,430.46
Rate for Payer: Amerigroup Medicare	$1,127.16
Rate for Payer: Cash Price	$1,984.00
Rate for Payer: Cash Price	$1,984.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,860.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,116.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,416.58
Rate for Payer: Medical Associates Commercial	$1,860.00
Rate for Payer: Medical Associates Managed Medicare	$1,116.00
Rate for Payer: Midlands Choice Commercial	$1,736.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,437.41
Rate for Payer: Partners Health Alliance Commercial	$1,283.40
Rate for Payer: United Healthcare Commercial	$2,232.00
Rate for Payer: United Healthcare Managed Medicare	$1,463.20
Rate for Payer: Wellmark IA HMO WHPI	$3,778.26
Rate for Payer: Wellmark IA PPO	$4,161.95

RECTUM SURGERY PROCEDURE

Facility

$2,480.00

Service Code	CPT 45999
Hospital Charge Code	7982909
Hospital Revenue Code	450
Min. Negotiated Rate	$1,736.00
Max. Negotiated Rate	$2,232.00
Rate for Payer: Aetna of IA Commercial	$2,232.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,232.00
Rate for Payer: Cash Price	$1,984.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,860.00
Rate for Payer: Medical Associates Commercial	$1,860.00
Rate for Payer: Midlands Choice Commercial	$1,736.00
Rate for Payer: United Healthcare Commercial	$2,232.00

RED BLOOD CELL DISORDERS WITH MCC

Facility

$14,128.76

Service Code	MSDRG 811
Min. Negotiated Rate	$13,923.99
Max. Negotiated Rate	$14,128.76
Rate for Payer: Amerigroup Medicaid	$14,060.50
Rate for Payer: Iowa Total Care Managed Medicaid	$13,923.99
Rate for Payer: Molina Healthcare Managed Medicaid	$14,128.76

RED BLOOD CELL DISORDERS WITHOUT MCC

Facility

$8,689.16

Service Code	MSDRG 812
Min. Negotiated Rate	$8,563.23
Max. Negotiated Rate	$8,689.16
Rate for Payer: Amerigroup Medicaid	$8,647.18
Rate for Payer: Iowa Total Care Managed Medicaid	$8,563.23
Rate for Payer: Molina Healthcare Managed Medicaid	$8,689.16

RE-EVALUATION OCC THERAPY

Facility

$156.00

Service Code	CPT 97168 GO
Hospital Charge Code	5520782
Hospital Revenue Code	434
Min. Negotiated Rate	$70.20
Max. Negotiated Rate	$218.68
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$198.52
Rate for Payer: Wellmark IA PPO	$218.68

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

regadenoson 0.4 mg/5 mL SD syringe [VDMC]

Facility

$86.24

Service Code	HCPCS J2785
Hospital Charge Code	10418813
Hospital Revenue Code	259
Min. Negotiated Rate	$60.37
Max. Negotiated Rate	$77.62
Rate for Payer: Aetna of IA Commercial	$77.62
Rate for Payer: Aetna of IA Medical Rental Products	$77.62
Rate for Payer: Cash Price	$68.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.68
Rate for Payer: Medical Associates Commercial	$64.68
Rate for Payer: Midlands Choice Commercial	$60.37
Rate for Payer: United Healthcare Commercial	$77.62

regadenoson 0.4 mg/5 mL SD syringe [VDMC]

Facility

$86.24

Service Code	HCPCS J2785
Hospital Charge Code	10418813
Hospital Revenue Code	259
Min. Negotiated Rate	$38.81
Max. Negotiated Rate	$77.62
Rate for Payer: Aetna of IA Commercial	$77.62
Rate for Payer: Aetna of IA Medical Rental Products	$77.62
Rate for Payer: Aetna of IA Medicare	$49.16
Rate for Payer: Amerigroup Medicaid	$49.74
Rate for Payer: Amerigroup Medicare	$39.20
Rate for Payer: Cash Price	$68.99
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$38.81
Rate for Payer: Iowa Total Care Managed Medicaid	$49.26
Rate for Payer: Medical Associates Commercial	$64.68
Rate for Payer: Medical Associates Managed Medicare	$38.81
Rate for Payer: Midlands Choice Commercial	$60.37
Rate for Payer: Molina Healthcare Managed Medicaid	$49.98
Rate for Payer: Partners Health Alliance Commercial	$44.63
Rate for Payer: United Healthcare Commercial	$77.62
Rate for Payer: United Healthcare Managed Medicare	$50.88

REHABILITATION WITH CC/MCC

Facility

$25,215.13

Service Code	MSDRG 945
Min. Negotiated Rate	$24,849.68
Max. Negotiated Rate	$25,215.13
Rate for Payer: Amerigroup Medicaid	$25,093.31
Rate for Payer: Iowa Total Care Managed Medicaid	$24,849.68
Rate for Payer: Molina Healthcare Managed Medicaid	$25,215.13

REHABILITATION WITHOUT CC/MCC

Facility

$12,006.29

Service Code	MSDRG 946
Min. Negotiated Rate	$11,832.28
Max. Negotiated Rate	$12,006.29
Rate for Payer: Amerigroup Medicaid	$11,948.29
Rate for Payer: Iowa Total Care Managed Medicaid	$11,832.28
Rate for Payer: Molina Healthcare Managed Medicaid	$12,006.29

remdesivir 100 mg SDV Pow [VDMC]

Facility

$1,369.70

Service Code	HCPCS J0248
Hospital Charge Code	21102628
Hospital Revenue Code	250
Min. Negotiated Rate	$616.36
Max. Negotiated Rate	$1,232.73
Rate for Payer: Aetna of IA Commercial	$1,232.73
Rate for Payer: Aetna of IA Medical Rental Products	$1,232.73
Rate for Payer: Aetna of IA Medicare	$780.73
Rate for Payer: Amerigroup Medicaid	$790.04
Rate for Payer: Amerigroup Medicare	$622.53
Rate for Payer: Cash Price	$1,095.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,027.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$616.36
Rate for Payer: Iowa Total Care Managed Medicaid	$782.37
Rate for Payer: Medical Associates Commercial	$1,027.28
Rate for Payer: Medical Associates Managed Medicare	$616.36
Rate for Payer: Midlands Choice Commercial	$958.79
Rate for Payer: Molina Healthcare Managed Medicaid	$793.88
Rate for Payer: Partners Health Alliance Commercial	$708.82
Rate for Payer: United Healthcare Commercial	$1,232.73
Rate for Payer: United Healthcare Managed Medicare	$808.12

remdesivir 100 mg SDV Pow [VDMC]

Facility

$1,369.70

Service Code	HCPCS J0248
Hospital Charge Code	21102628
Hospital Revenue Code	250
Min. Negotiated Rate	$958.79
Max. Negotiated Rate	$1,232.73
Rate for Payer: Aetna of IA Commercial	$1,232.73
Rate for Payer: Aetna of IA Medical Rental Products	$1,232.73
Rate for Payer: Cash Price	$1,095.76
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,027.28
Rate for Payer: Medical Associates Commercial	$1,027.28
Rate for Payer: Midlands Choice Commercial	$958.79
Rate for Payer: United Healthcare Commercial	$1,232.73

Remote Group Therapy

Facility

$221.00

Service Code	HCPCS C7903
Hospital Charge Code	8300866
Hospital Revenue Code	915
Min. Negotiated Rate	$154.70
Max. Negotiated Rate	$198.90
Rate for Payer: Aetna of IA Commercial	$198.90
Rate for Payer: Aetna of IA Medical Rental Products	$198.90
Rate for Payer: Cash Price	$176.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$165.75
Rate for Payer: Medical Associates Commercial	$165.75
Rate for Payer: Midlands Choice Commercial	$154.70
Rate for Payer: United Healthcare Commercial	$198.90

Know your out-of-pocket cost for care.

All Charges