Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

RESPIRATORY NEOPLASMS WITH MCC

Facility

$16,318.78

Service Code	MSDRG 180
Min. Negotiated Rate	$16,082.27
Max. Negotiated Rate	$16,318.78
Rate for Payer: Amerigroup Medicaid	$16,239.94
Rate for Payer: Iowa Total Care Managed Medicaid	$16,082.27
Rate for Payer: Molina Healthcare Managed Medicaid	$16,318.78

RESPIRATORY NEOPLASMS WITHOUT CC/MCC

Facility

$8,869.32

Service Code	MSDRG 182
Min. Negotiated Rate	$8,740.78
Max. Negotiated Rate	$8,869.32
Rate for Payer: Amerigroup Medicaid	$8,826.47
Rate for Payer: Iowa Total Care Managed Medicaid	$8,740.78
Rate for Payer: Molina Healthcare Managed Medicaid	$8,869.32

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 2.1 (BioFire)

Facility

$661.00

Service Code	CPT 87633
Hospital Charge Code	8789842
Hospital Revenue Code	306
Min. Negotiated Rate	$287.85
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	$381.26
Rate for Payer: Amerigroup Medicare	$300.42
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	$297.45
Rate for Payer: Iowa Total Care Managed Medicaid	$377.56
Rate for Payer: Medical Associates Commercial	$495.75
Rate for Payer: Medical Associates Managed Medicare	$297.45
Rate for Payer: Midlands Choice Commercial	$462.70
Rate for Payer: Molina Healthcare Managed Medicaid	$383.12
Rate for Payer: Partners Health Alliance Commercial	$342.07
Rate for Payer: United Healthcare Commercial	$594.90
Rate for Payer: United Healthcare Managed Medicare	$389.99
Rate for Payer: Wellmark IA HMO WHPI	$287.85
Rate for Payer: Wellmark IA PPO	$317.09

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	$287.85
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	$381.26
Rate for Payer: Amerigroup Medicare	$300.42
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	$297.45
Rate for Payer: Iowa Total Care Managed Medicaid	$377.56
Rate for Payer: Medical Associates Commercial	$495.75
Rate for Payer: Medical Associates Managed Medicare	$297.45
Rate for Payer: Midlands Choice Commercial	$462.70
Rate for Payer: Molina Healthcare Managed Medicaid	$383.12
Rate for Payer: Partners Health Alliance Commercial	$342.07
Rate for Payer: United Healthcare Commercial	$594.90
Rate for Payer: United Healthcare Managed Medicare	$389.99
Rate for Payer: Wellmark IA HMO WHPI	$287.85
Rate for Payer: Wellmark IA PPO	$317.09

RESPIRATORY SIGNS AND SYMPTOMS

Facility

$6,386.54

Service Code	MSDRG 204
Min. Negotiated Rate	$6,293.98
Max. Negotiated Rate	$6,386.54
Rate for Payer: Amerigroup Medicaid	$6,355.69
Rate for Payer: Iowa Total Care Managed Medicaid	$6,293.98
Rate for Payer: Molina Healthcare Managed Medicaid	$6,386.54

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS

Facility

$21,045.64

Service Code	MSDRG 208
Min. Negotiated Rate	$20,740.62
Max. Negotiated Rate	$21,045.64
Rate for Payer: Amerigroup Medicaid	$20,943.96
Rate for Payer: Iowa Total Care Managed Medicaid	$20,740.62
Rate for Payer: Molina Healthcare Managed Medicaid	$21,045.64

RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS

Facility

$61,782.36

Service Code	MSDRG 207
Min. Negotiated Rate	$60,886.93
Max. Negotiated Rate	$61,782.36
Rate for Payer: Amerigroup Medicaid	$61,483.87
Rate for Payer: Iowa Total Care Managed Medicaid	$60,886.93
Rate for Payer: Molina Healthcare Managed Medicaid	$61,782.36

Restrata 1x2 soft tissue repair

Facility

$2,925.00

Service Code	HCPCS 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

Restrata 1x2 soft tissue repair

Facility

$2,925.00

Service Code	HCPCS c1713
Hospital Charge Code	8874155
Hospital Revenue Code	278
Min. Negotiated Rate	$1,316.25
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: Aetna of IA Medicare	$1,667.25
Rate for Payer: Amerigroup Medicaid	$1,687.14
Rate for Payer: Amerigroup Medicare	$1,329.41
Rate for Payer: Cash Price	$2,340.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,193.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,316.25
Rate for Payer: Iowa Total Care Managed Medicaid	$1,670.76
Rate for Payer: Medical Associates Commercial	$2,193.75
Rate for Payer: Medical Associates Managed Medicare	$1,316.25
Rate for Payer: Midlands Choice Commercial	$2,047.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,695.33
Rate for Payer: Partners Health Alliance Commercial	$1,513.69
Rate for Payer: United Healthcare Commercial	$2,632.50
Rate for Payer: United Healthcare Managed Medicare	$1,725.75

Restrata 3x3 RMW1

Facility

$6,075.00

Service Code	HCPCS C1713
Hospital Charge Code	8942331
Hospital Revenue Code	278
Min. Negotiated Rate	$2,733.75
Max. Negotiated Rate	$5,467.50
Rate for Payer: Aetna of IA Commercial	$5,467.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,467.50
Rate for Payer: Aetna of IA Medicare	$3,462.75
Rate for Payer: Amerigroup Medicaid	$3,504.06
Rate for Payer: Amerigroup Medicare	$2,761.09
Rate for Payer: Cash Price	$4,860.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,556.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,733.75
Rate for Payer: Iowa Total Care Managed Medicaid	$3,470.04
Rate for Payer: Medical Associates Commercial	$4,556.25
Rate for Payer: Medical Associates Managed Medicare	$2,733.75
Rate for Payer: Midlands Choice Commercial	$4,252.50
Rate for Payer: Molina Healthcare Managed Medicaid	$3,521.07
Rate for Payer: Partners Health Alliance Commercial	$3,143.81
Rate for Payer: United Healthcare Commercial	$5,467.50
Rate for Payer: United Healthcare Managed Medicare	$3,584.25

Restrata 3x3 RMW1

Facility

$6,075.00

Service Code	HCPCS C1713
Hospital Charge Code	8942331
Hospital Revenue Code	278
Min. Negotiated Rate	$4,252.50
Max. Negotiated Rate	$5,467.50
Rate for Payer: Aetna of IA Commercial	$5,467.50
Rate for Payer: Aetna of IA Medical Rental Products	$5,467.50
Rate for Payer: Cash Price	$4,860.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4,556.25
Rate for Payer: Medical Associates Commercial	$4,556.25
Rate for Payer: Midlands Choice Commercial	$4,252.50
Rate for Payer: United Healthcare Commercial	$5,467.50

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

RESTRATA 5PK 1X1 5PK 1X2

Facility

$18,497.00

Service Code	HCPCS C1713
Hospital Charge Code	8943983
Hospital Revenue Code	278
Min. Negotiated Rate	$8,323.65
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: Aetna of IA Medicare	$10,543.29
Rate for Payer: Amerigroup Medicaid	$10,669.07
Rate for Payer: Amerigroup Medicare	$8,406.89
Rate for Payer: Cash Price	$14,797.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$13,872.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$8,323.65
Rate for Payer: Iowa Total Care Managed Medicaid	$10,565.49
Rate for Payer: Medical Associates Commercial	$13,872.75
Rate for Payer: Medical Associates Managed Medicare	$8,323.65
Rate for Payer: Midlands Choice Commercial	$12,947.90
Rate for Payer: Molina Healthcare Managed Medicaid	$10,720.86
Rate for Payer: Partners Health Alliance Commercial	$9,572.20
Rate for Payer: United Healthcare Commercial	$16,647.30
Rate for Payer: United Healthcare Managed Medicare	$10,913.23

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

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: 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
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC

Facility

$9,155.32

Service Code	MSDRG 815
Min. Negotiated Rate	$9,022.63
Max. Negotiated Rate	$9,155.32
Rate for Payer: Amerigroup Medicaid	$9,111.09
Rate for Payer: Iowa Total Care Managed Medicaid	$9,022.63
Rate for Payer: Molina Healthcare Managed Medicaid	$9,155.32

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC

Facility

$21,294.48

Service Code	MSDRG 814
Min. Negotiated Rate	$20,985.85
Max. Negotiated Rate	$21,294.48
Rate for Payer: Amerigroup Medicaid	$21,191.60
Rate for Payer: Iowa Total Care Managed Medicaid	$20,985.85
Rate for Payer: Molina Healthcare Managed Medicaid	$21,294.48

RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC

Facility

$7,766.99

Service Code	MSDRG 816
Min. Negotiated Rate	$7,654.42
Max. Negotiated Rate	$7,766.99
Rate for Payer: Amerigroup Medicaid	$7,729.46
Rate for Payer: Iowa Total Care Managed Medicaid	$7,654.42
Rate for Payer: Molina Healthcare Managed Medicaid	$7,766.99

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	$688.54
Max. Negotiated Rate	$2,001.00
Rate for Payer: Amerigroup Medicaid	$695.29
Rate for Payer: Cash Price	$2,081.60
Rate for Payer: Cash Price	$2,081.60
Rate for Payer: Iowa Total Care Managed Medicaid	$688.54
Rate for Payer: Medical Associates Commercial	$1,951.50
Rate for Payer: Midlands Choice Commercial	$1,821.40
Rate for Payer: Molina Healthcare Managed Medicaid	$691.92
Rate for Payer: Partners Health Alliance Commercial	$1,951.50
Rate for Payer: United Healthcare Commercial	$1,289.47
Rate for Payer: Wellmark IA HMO WHPI	$1,700.80
Rate for Payer: Wellmark IA PPO	$2,001.00

REVISE SPINE ELTRD PLATE

Professional

Both

$2,930.00

Service Code	CPT 63664
Hospital Charge Code	8015888
Hospital Revenue Code	975
Min. Negotiated Rate	$629.90
Max. Negotiated Rate	$2,197.50
Rate for Payer: Amerigroup Medicaid	$636.08
Rate for Payer: Cash Price	$2,344.00
Rate for Payer: Cash Price	$2,344.00
Rate for Payer: Iowa Total Care Managed Medicaid	$629.90
Rate for Payer: Medical Associates Commercial	$2,197.50
Rate for Payer: Midlands Choice Commercial	$2,051.00
Rate for Payer: Molina Healthcare Managed Medicaid	$632.99
Rate for Payer: Partners Health Alliance Commercial	$2,197.50
Rate for Payer: United Healthcare Commercial	$1,282.35
Rate for Payer: Wellmark IA HMO WHPI	$1,694.50
Rate for Payer: Wellmark IA PPO	$1,993.60

REVISION OF HIP OR KNEE REPLACEMENT WITH CC

Facility

$38,220.16

Service Code	MSDRG 467
Min. Negotiated Rate	$37,666.23
Max. Negotiated Rate	$38,220.16
Rate for Payer: Amerigroup Medicaid	$38,035.51
Rate for Payer: Iowa Total Care Managed Medicaid	$37,666.23
Rate for Payer: Molina Healthcare Managed Medicaid	$38,220.16

REVISION OF HIP OR KNEE REPLACEMENT WITH MCC

Facility

$39,036.50

Service Code	MSDRG 466
Min. Negotiated Rate	$38,470.73
Max. Negotiated Rate	$39,036.50
Rate for Payer: Amerigroup Medicaid	$38,847.90
Rate for Payer: Iowa Total Care Managed Medicaid	$38,470.73
Rate for Payer: Molina Healthcare Managed Medicaid	$39,036.50

REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC

Facility

$31,092.73

Service Code	MSDRG 468
Min. Negotiated Rate	$30,642.10
Max. Negotiated Rate	$31,092.73
Rate for Payer: Amerigroup Medicaid	$30,942.51
Rate for Payer: Iowa Total Care Managed Medicaid	$30,642.10
Rate for Payer: Molina Healthcare Managed Medicaid	$31,092.73

Know your out-of-pocket cost for care.

All Charges