Van Diest Medical Center

All Charges

Charge

Type

Price

Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders With MCC

Facility IP

$20,458.44

Service Code	MS-DRG 616
Hospital Charge Code	408
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$20,458.44
Rate for Payer: Amerigroup Medicaid	$20,359.61
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	$20,161.94
Rate for Payer: Molina Healthcare Managed Medicaid	$20,458.44

Amputation of Lower Limb for Endocrine, Nutritional and Metabolic Disorders Without CC/MCC

Facility IP

$7,439.88

Service Code	MS-DRG 618
Hospital Charge Code	410
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$7,439.88
Rate for Payer: Amerigroup Medicaid	$7,403.94
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	$7,332.06
Rate for Payer: Molina Healthcare Managed Medicaid	$7,439.88

Amputation, toe; interphalangeal joint

Facility OP

$4,658.74

Service Code	CPT 28825
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

Amputation, toe; metatarsophalangeal joint

Facility OP

$4,658.74

Service Code	CPT 28820
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

AMYLASE

Facility OP

$64.00

Service Code	CPT 82150
Hospital Charge Code	631567
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$32.30
Rate for Payer: Amerigroup Medicare	$32.32
Rate for Payer: Cash Price	$51.20
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.00
Rate for Payer: Iowa Total Care Managed Medicaid	$31.99
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$32.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$32.48
Rate for Payer: Partners Health Alliance Commercial	$48.00
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

AMYLASE

Facility IP

$64.00

Service Code	CPT 82150
Hospital Charge Code	631567
Hospital Revenue Code	301
Min. Negotiated Rate	$44.80
Max. Negotiated Rate	$57.60
Rate for Payer: Aetna of IA Commercial	$57.60
Rate for Payer: Aetna of IA Medical Rental Products	$57.60
Rate for Payer: Cash Price	$51.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.00
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: United Healthcare Commercial	$57.60

Anal and Stomal Procedures With CC

Facility IP

$11,057.95

Service Code	MS-DRG 348
Hospital Charge Code	198
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,057.95
Rate for Payer: Amerigroup Medicaid	$11,004.53
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	$10,897.69
Rate for Payer: Molina Healthcare Managed Medicaid	$11,057.95

Anal and Stomal Procedures With MCC

Facility IP

$24,234.00

Service Code	MS-DRG 347
Hospital Charge Code	197
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$24,234.00
Rate for Payer: Amerigroup Medicaid	$24,116.92
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	$23,882.78
Rate for Payer: Molina Healthcare Managed Medicaid	$24,234.00

Anal and Stomal Procedures Without CC/MCC

Facility IP

$9,553.05

Service Code	MS-DRG 349
Hospital Charge Code	199
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,553.05
Rate for Payer: Amerigroup Medicaid	$9,506.90
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	$9,414.60
Rate for Payer: Molina Healthcare Managed Medicaid	$9,553.05

ANCA Screen DMCL

Facility OP

$115.00

Service Code	CPT 86255
Hospital Charge Code	8037494
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Aetna of IA Medicare	$65.55
Rate for Payer: Amerigroup Medicaid	$58.04
Rate for Payer: Amerigroup Medicare	$58.08
Rate for Payer: Cash Price	$92.00
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$57.50
Rate for Payer: Iowa Total Care Managed Medicaid	$57.48
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Medical Associates Managed Medicare	$57.50
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: Molina Healthcare Managed Medicaid	$58.36
Rate for Payer: Partners Health Alliance Commercial	$86.25
Rate for Payer: United Healthcare Commercial	$103.50
Rate for Payer: United Healthcare Managed Medicare	$67.85
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

ANCA Screen DMCL

Facility IP

$115.00

Service Code	CPT 86255
Hospital Charge Code	8037494
Hospital Revenue Code	302
Min. Negotiated Rate	$80.50
Max. Negotiated Rate	$103.50
Rate for Payer: Aetna of IA Commercial	$103.50
Rate for Payer: Aetna of IA Medical Rental Products	$103.50
Rate for Payer: Cash Price	$92.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$86.25
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: United Healthcare Commercial	$103.50

ANCHOR SUTURE 2.5MM

Facility IP

$788.40

Service Code	CPT C1713
Hospital Charge Code	8871630
Hospital Revenue Code	278
Min. Negotiated Rate	$551.88
Max. Negotiated Rate	$709.56
Rate for Payer: Aetna of IA Commercial	$709.56
Rate for Payer: Aetna of IA Medical Rental Products	$709.56
Rate for Payer: Cash Price	$630.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$591.30
Rate for Payer: Medical Associates Commercial	$591.30
Rate for Payer: Midlands Choice Commercial	$551.88
Rate for Payer: United Healthcare Commercial	$709.56

ANCHOR SUTURE 2.5MM

Facility OP

$788.40

Service Code	CPT C1713
Hospital Charge Code	8871630
Hospital Revenue Code	278
Min. Negotiated Rate	$394.04
Max. Negotiated Rate	$709.56
Rate for Payer: Aetna of IA Commercial	$709.56
Rate for Payer: Aetna of IA Medical Rental Products	$709.56
Rate for Payer: Aetna of IA Medicare	$449.39
Rate for Payer: Amerigroup Medicaid	$397.91
Rate for Payer: Amerigroup Medicare	$398.14
Rate for Payer: Cash Price	$630.72
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$591.30
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$394.20
Rate for Payer: Iowa Total Care Managed Medicaid	$394.04
Rate for Payer: Medical Associates Commercial	$591.30
Rate for Payer: Medical Associates Managed Medicare	$394.20
Rate for Payer: Midlands Choice Commercial	$551.88
Rate for Payer: Molina Healthcare Managed Medicaid	$400.11
Rate for Payer: Partners Health Alliance Commercial	$591.30
Rate for Payer: United Healthcare Commercial	$709.56
Rate for Payer: United Healthcare Managed Medicare	$465.16

ANESTH-BASE UNIT VALUE

Facility OP

$86.00

Hospital Charge Code	8059593
Hospital Revenue Code	964
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Aetna of IA Medicare	$49.02
Rate for Payer: Amerigroup Medicaid	$43.40
Rate for Payer: Amerigroup Medicare	$43.43
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$43.00
Rate for Payer: Iowa Total Care Managed Medicaid	$42.98
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Medical Associates Managed Medicare	$43.00
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: Molina Healthcare Managed Medicaid	$43.64
Rate for Payer: Partners Health Alliance Commercial	$64.50
Rate for Payer: United Healthcare Commercial	$77.40
Rate for Payer: United Healthcare Managed Medicare	$50.74

ANESTH-BASE UNIT VALUE

Facility IP

$86.00

Hospital Charge Code	8059593
Hospital Revenue Code	964
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: United Healthcare Commercial	$77.40

ANESTHESIA MAC I

Facility IP

$383.00

Hospital Charge Code	8084816
Hospital Revenue Code	370
Min. Negotiated Rate	$268.10
Max. Negotiated Rate	$344.70
Rate for Payer: Aetna of IA Commercial	$344.70
Rate for Payer: Aetna of IA Medical Rental Products	$344.70
Rate for Payer: Cash Price	$306.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$287.25
Rate for Payer: Medical Associates Commercial	$287.25
Rate for Payer: Midlands Choice Commercial	$268.10
Rate for Payer: United Healthcare Commercial	$344.70

ANESTHESIA MAC I

Facility OP

$383.00

Hospital Charge Code	8084816
Hospital Revenue Code	370
Min. Negotiated Rate	$191.42
Max. Negotiated Rate	$344.70
Rate for Payer: Aetna of IA Commercial	$344.70
Rate for Payer: Aetna of IA Medical Rental Products	$344.70
Rate for Payer: Aetna of IA Medicare	$218.31
Rate for Payer: Amerigroup Medicaid	$193.30
Rate for Payer: Amerigroup Medicare	$193.42
Rate for Payer: Cash Price	$306.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$287.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$191.50
Rate for Payer: Iowa Total Care Managed Medicaid	$191.42
Rate for Payer: Medical Associates Commercial	$287.25
Rate for Payer: Medical Associates Managed Medicare	$191.50
Rate for Payer: Midlands Choice Commercial	$268.10
Rate for Payer: Molina Healthcare Managed Medicaid	$194.37
Rate for Payer: Partners Health Alliance Commercial	$287.25
Rate for Payer: United Healthcare Commercial	$344.70
Rate for Payer: United Healthcare Managed Medicare	$225.97

ANESTHESIA-MAC I

Facility IP

$383.00

Hospital Charge Code	8059071
Hospital Revenue Code	370
Min. Negotiated Rate	$268.10
Max. Negotiated Rate	$344.70
Rate for Payer: Aetna of IA Commercial	$344.70
Rate for Payer: Aetna of IA Medical Rental Products	$344.70
Rate for Payer: Cash Price	$306.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$287.25
Rate for Payer: Medical Associates Commercial	$287.25
Rate for Payer: Midlands Choice Commercial	$268.10
Rate for Payer: United Healthcare Commercial	$344.70

ANESTHESIA-MAC I

Facility OP

$383.00

Hospital Charge Code	8059071
Hospital Revenue Code	370
Min. Negotiated Rate	$191.42
Max. Negotiated Rate	$344.70
Rate for Payer: Aetna of IA Commercial	$344.70
Rate for Payer: Aetna of IA Medical Rental Products	$344.70
Rate for Payer: Aetna of IA Medicare	$218.31
Rate for Payer: Amerigroup Medicaid	$193.30
Rate for Payer: Amerigroup Medicare	$193.42
Rate for Payer: Cash Price	$306.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$287.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$191.50
Rate for Payer: Iowa Total Care Managed Medicaid	$191.42
Rate for Payer: Medical Associates Commercial	$287.25
Rate for Payer: Medical Associates Managed Medicare	$191.50
Rate for Payer: Midlands Choice Commercial	$268.10
Rate for Payer: Molina Healthcare Managed Medicaid	$194.37
Rate for Payer: Partners Health Alliance Commercial	$287.25
Rate for Payer: United Healthcare Commercial	$344.70
Rate for Payer: United Healthcare Managed Medicare	$225.97

ANESTHESIA MAC II

Facility IP

$514.00

Hospital Charge Code	8059072
Hospital Revenue Code	370
Min. Negotiated Rate	$359.80
Max. Negotiated Rate	$462.60
Rate for Payer: Aetna of IA Commercial	$462.60
Rate for Payer: Aetna of IA Medical Rental Products	$462.60
Rate for Payer: Cash Price	$411.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$385.50
Rate for Payer: Medical Associates Commercial	$385.50
Rate for Payer: Midlands Choice Commercial	$359.80
Rate for Payer: United Healthcare Commercial	$462.60

ANESTHESIA MAC II

Facility OP

$514.00

Hospital Charge Code	8059072
Hospital Revenue Code	370
Min. Negotiated Rate	$256.90
Max. Negotiated Rate	$462.60
Rate for Payer: Aetna of IA Commercial	$462.60
Rate for Payer: Aetna of IA Medical Rental Products	$462.60
Rate for Payer: Aetna of IA Medicare	$292.98
Rate for Payer: Amerigroup Medicaid	$259.42
Rate for Payer: Amerigroup Medicare	$259.57
Rate for Payer: Cash Price	$411.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$385.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$257.00
Rate for Payer: Iowa Total Care Managed Medicaid	$256.90
Rate for Payer: Medical Associates Commercial	$385.50
Rate for Payer: Medical Associates Managed Medicare	$257.00
Rate for Payer: Midlands Choice Commercial	$359.80
Rate for Payer: Molina Healthcare Managed Medicaid	$260.86
Rate for Payer: Partners Health Alliance Commercial	$385.50
Rate for Payer: United Healthcare Commercial	$462.60
Rate for Payer: United Healthcare Managed Medicare	$303.26

ANESTH-SPECIAL CIRCUMSTANCES

Facility IP

$86.00

Hospital Charge Code	8059068
Hospital Revenue Code	964
Min. Negotiated Rate	$60.20
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: United Healthcare Commercial	$77.40

ANESTH-SPECIAL CIRCUMSTANCES

Facility OP

$86.00

Hospital Charge Code	8059068
Hospital Revenue Code	964
Min. Negotiated Rate	$42.98
Max. Negotiated Rate	$77.40
Rate for Payer: Aetna of IA Commercial	$77.40
Rate for Payer: Aetna of IA Medical Rental Products	$77.40
Rate for Payer: Aetna of IA Medicare	$49.02
Rate for Payer: Amerigroup Medicaid	$43.40
Rate for Payer: Amerigroup Medicare	$43.43
Rate for Payer: Cash Price	$68.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$64.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$43.00
Rate for Payer: Iowa Total Care Managed Medicaid	$42.98
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Medical Associates Managed Medicare	$43.00
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: Molina Healthcare Managed Medicaid	$43.64
Rate for Payer: Partners Health Alliance Commercial	$64.50
Rate for Payer: United Healthcare Commercial	$77.40
Rate for Payer: United Healthcare Managed Medicare	$50.74

Angina Pectoris

Facility IP

$4,296.21

Service Code	MS-DRG 311
Hospital Charge Code	168
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$4,296.21
Rate for Payer: Amerigroup Medicaid	$4,275.46
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	$4,233.95
Rate for Payer: Molina Healthcare Managed Medicaid	$4,296.21

Angiotensin Converting Enzyme DMCL

Facility OP

$139.00

Service Code	CPT 82164
Hospital Charge Code	8037493
Hospital Revenue Code	301
Min. Negotiated Rate	$45.88
Max. Negotiated Rate	$125.10
Rate for Payer: Aetna of IA Commercial	$125.10
Rate for Payer: Aetna of IA Medical Rental Products	$125.10
Rate for Payer: Aetna of IA Medicare	$79.23
Rate for Payer: Amerigroup Medicaid	$70.15
Rate for Payer: Amerigroup Medicare	$70.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Cash Price	$111.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$104.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$69.50
Rate for Payer: Iowa Total Care Managed Medicaid	$69.47
Rate for Payer: Medical Associates Commercial	$104.25
Rate for Payer: Medical Associates Managed Medicare	$69.50
Rate for Payer: Midlands Choice Commercial	$97.30
Rate for Payer: Molina Healthcare Managed Medicaid	$70.54
Rate for Payer: Partners Health Alliance Commercial	$104.25
Rate for Payer: United Healthcare Commercial	$125.10
Rate for Payer: United Healthcare Managed Medicare	$82.01
Rate for Payer: Wellmark IA HMO	$45.88
Rate for Payer: Wellmark IA PPO	$50.47

Price Transparency.

All Charges