Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Sjogren's B Antibody DMCL

Facility

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037801
Hospital Revenue Code	302
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: United Healthcare Commercial	$122.40

Sjogren's B Antibody DMCL

Facility

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037801
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Aetna of IA Medicare	$77.52
Rate for Payer: Amerigroup Medicaid	$78.44
Rate for Payer: Amerigroup Medicare	$61.81
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$61.20
Rate for Payer: Iowa Total Care Managed Medicaid	$77.68
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Medical Associates Managed Medicare	$61.20
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: Molina Healthcare Managed Medicaid	$78.83
Rate for Payer: Partners Health Alliance Commercial	$70.38
Rate for Payer: United Healthcare Commercial	$122.40
Rate for Payer: United Healthcare Managed Medicare	$80.24
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

SKIN DEBRIDEMENT WITH CC

Facility

$13,677.24

Service Code	MSDRG 571
Min. Negotiated Rate	$13,479.02
Max. Negotiated Rate	$13,677.24
Rate for Payer: Amerigroup Medicaid	$13,611.16
Rate for Payer: Iowa Total Care Managed Medicaid	$13,479.02
Rate for Payer: Molina Healthcare Managed Medicaid	$13,677.24

SKIN DEBRIDEMENT WITH MCC

Facility

$16,817.59

Service Code	MSDRG 570
Min. Negotiated Rate	$16,573.85
Max. Negotiated Rate	$16,817.59
Rate for Payer: Amerigroup Medicaid	$16,736.34
Rate for Payer: Iowa Total Care Managed Medicaid	$16,573.85
Rate for Payer: Molina Healthcare Managed Medicaid	$16,817.59

SKIN DEBRIDEMENT WITHOUT CC/MCC

Facility

$10,356.74

Service Code	MSDRG 572
Min. Negotiated Rate	$10,206.63
Max. Negotiated Rate	$10,356.74
Rate for Payer: Amerigroup Medicaid	$10,306.70
Rate for Payer: Iowa Total Care Managed Medicaid	$10,206.63
Rate for Payer: Molina Healthcare Managed Medicaid	$10,356.74

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$20,456.75

Service Code	MSDRG 577
Min. Negotiated Rate	$20,160.27
Max. Negotiated Rate	$20,456.75
Rate for Payer: Amerigroup Medicaid	$20,357.92
Rate for Payer: Iowa Total Care Managed Medicaid	$20,160.27
Rate for Payer: Molina Healthcare Managed Medicaid	$20,456.75

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$56,990.20

Service Code	MSDRG 576
Min. Negotiated Rate	$56,164.23
Max. Negotiated Rate	$56,990.20
Rate for Payer: Amerigroup Medicaid	$56,714.86
Rate for Payer: Iowa Total Care Managed Medicaid	$56,164.23
Rate for Payer: Molina Healthcare Managed Medicaid	$56,990.20

SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$13,503.84

Service Code	MSDRG 578
Min. Negotiated Rate	$13,308.13
Max. Negotiated Rate	$13,503.84
Rate for Payer: Amerigroup Medicaid	$13,438.60
Rate for Payer: Iowa Total Care Managed Medicaid	$13,308.13
Rate for Payer: Molina Healthcare Managed Medicaid	$13,503.84

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC

Facility

$23,705.19

Service Code	MSDRG 574
Min. Negotiated Rate	$23,361.63
Max. Negotiated Rate	$23,705.19
Rate for Payer: Amerigroup Medicaid	$23,590.67
Rate for Payer: Iowa Total Care Managed Medicaid	$23,361.63
Rate for Payer: Molina Healthcare Managed Medicaid	$23,705.19

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC

Facility

$62,364.49

Service Code	MSDRG 573
Min. Negotiated Rate	$61,460.63
Max. Negotiated Rate	$62,364.49
Rate for Payer: Amerigroup Medicaid	$62,063.18
Rate for Payer: Iowa Total Care Managed Medicaid	$61,460.63
Rate for Payer: Molina Healthcare Managed Medicaid	$62,364.49

SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC

Facility

$19,834.08

Service Code	MSDRG 575
Min. Negotiated Rate	$19,546.63
Max. Negotiated Rate	$19,834.08
Rate for Payer: Amerigroup Medicaid	$19,738.26
Rate for Payer: Iowa Total Care Managed Medicaid	$19,546.63
Rate for Payer: Molina Healthcare Managed Medicaid	$19,834.08

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$16,182.54

Service Code	MSDRG 623
Min. Negotiated Rate	$15,948.00
Max. Negotiated Rate	$16,182.54
Rate for Payer: Amerigroup Medicaid	$16,104.36
Rate for Payer: Iowa Total Care Managed Medicaid	$15,948.00
Rate for Payer: Molina Healthcare Managed Medicaid	$16,182.54

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$40,689.43

Service Code	MSDRG 622
Min. Negotiated Rate	$40,099.71
Max. Negotiated Rate	$40,689.43
Rate for Payer: Amerigroup Medicaid	$40,492.85
Rate for Payer: Iowa Total Care Managed Medicaid	$40,099.71
Rate for Payer: Molina Healthcare Managed Medicaid	$40,689.43

SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$12,324.94

Service Code	MSDRG 624
Min. Negotiated Rate	$12,146.32
Max. Negotiated Rate	$12,324.94
Rate for Payer: Amerigroup Medicaid	$12,265.40
Rate for Payer: Iowa Total Care Managed Medicaid	$12,146.32
Rate for Payer: Molina Healthcare Managed Medicaid	$12,324.94

SKIN GRAFTS FOR INJURIES WITH CC/MCC

Facility

$30,940.72

Service Code	MSDRG 904
Min. Negotiated Rate	$30,492.29
Max. Negotiated Rate	$30,940.72
Rate for Payer: Amerigroup Medicaid	$30,791.24
Rate for Payer: Iowa Total Care Managed Medicaid	$30,492.29
Rate for Payer: Molina Healthcare Managed Medicaid	$30,940.72

SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC

Facility

$18,432.24

Service Code	MSDRG 905
Min. Negotiated Rate	$18,165.10
Max. Negotiated Rate	$18,432.24
Rate for Payer: Amerigroup Medicaid	$18,343.19
Rate for Payer: Iowa Total Care Managed Medicaid	$18,165.10
Rate for Payer: Molina Healthcare Managed Medicaid	$18,432.24

SKIN ULCERS WITH CC

Facility

$7,703.93

Service Code	MSDRG 593
Min. Negotiated Rate	$7,592.28
Max. Negotiated Rate	$7,703.93
Rate for Payer: Amerigroup Medicaid	$7,666.71
Rate for Payer: Iowa Total Care Managed Medicaid	$7,592.28
Rate for Payer: Molina Healthcare Managed Medicaid	$7,703.93

SKIN ULCERS WITH MCC

Facility

$11,264.27

Service Code	MSDRG 592
Min. Negotiated Rate	$11,101.02
Max. Negotiated Rate	$11,264.27
Rate for Payer: Amerigroup Medicaid	$11,209.85
Rate for Payer: Iowa Total Care Managed Medicaid	$11,101.02
Rate for Payer: Molina Healthcare Managed Medicaid	$11,264.27

SKIN ULCERS WITHOUT CC/MCC

Facility

$7,703.93

Service Code	MSDRG 594
Min. Negotiated Rate	$7,592.28
Max. Negotiated Rate	$7,703.93
Rate for Payer: Amerigroup Medicaid	$7,666.71
Rate for Payer: Iowa Total Care Managed Medicaid	$7,592.28
Rate for Payer: Molina Healthcare Managed Medicaid	$7,703.93

SLEEP STUDY ATTENDED

Facility

$3,126.00

Service Code	CPT 95810
Hospital Charge Code	5338942
Hospital Revenue Code	920
Min. Negotiated Rate	$1,406.70
Max. Negotiated Rate	$2,900.63
Rate for Payer: Aetna of IA Commercial	$2,813.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,813.40
Rate for Payer: Aetna of IA Medicare	$1,781.82
Rate for Payer: Amerigroup Medicaid	$1,803.08
Rate for Payer: Amerigroup Medicare	$1,420.77
Rate for Payer: Cash Price	$2,500.80
Rate for Payer: Cash Price	$2,500.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,344.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,406.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,785.57
Rate for Payer: Medical Associates Commercial	$2,344.50
Rate for Payer: Medical Associates Managed Medicare	$1,406.70
Rate for Payer: Midlands Choice Commercial	$2,188.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,811.83
Rate for Payer: Partners Health Alliance Commercial	$1,617.70
Rate for Payer: United Healthcare Commercial	$2,813.40
Rate for Payer: United Healthcare Managed Medicare	$1,844.34
Rate for Payer: Wellmark IA HMO WHPI	$2,633.23
Rate for Payer: Wellmark IA PPO	$2,900.63

SLEEP STUDY ATTENDED

Facility

$3,126.00

Service Code	CPT 95810
Hospital Charge Code	5338942
Hospital Revenue Code	920
Min. Negotiated Rate	$2,188.20
Max. Negotiated Rate	$2,813.40
Rate for Payer: Aetna of IA Commercial	$2,813.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,813.40
Rate for Payer: Cash Price	$2,500.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,344.50
Rate for Payer: Medical Associates Commercial	$2,344.50
Rate for Payer: Midlands Choice Commercial	$2,188.20
Rate for Payer: United Healthcare Commercial	$2,813.40

SLEEP STUDY/CPAP TRIAL

Facility

$3,376.00

Service Code	CPT 95811
Hospital Charge Code	5338943
Hospital Revenue Code	920
Min. Negotiated Rate	$2,363.20
Max. Negotiated Rate	$3,038.40
Rate for Payer: Aetna of IA Commercial	$3,038.40
Rate for Payer: Aetna of IA Medical Rental Products	$3,038.40
Rate for Payer: Cash Price	$2,700.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,532.00
Rate for Payer: Medical Associates Commercial	$2,532.00
Rate for Payer: Midlands Choice Commercial	$2,363.20
Rate for Payer: United Healthcare Commercial	$3,038.40

SLEEP STUDY/CPAP TRIAL

Facility

$3,376.00

Service Code	CPT 95811
Hospital Charge Code	5338943
Hospital Revenue Code	920
Min. Negotiated Rate	$1,519.20
Max. Negotiated Rate	$3,038.40
Rate for Payer: Aetna of IA Commercial	$3,038.40
Rate for Payer: Aetna of IA Medical Rental Products	$3,038.40
Rate for Payer: Aetna of IA Medicare	$1,924.32
Rate for Payer: Amerigroup Medicaid	$1,947.28
Rate for Payer: Amerigroup Medicare	$1,534.39
Rate for Payer: Cash Price	$2,700.80
Rate for Payer: Cash Price	$2,700.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,532.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,519.20
Rate for Payer: Iowa Total Care Managed Medicaid	$1,928.37
Rate for Payer: Medical Associates Commercial	$2,532.00
Rate for Payer: Medical Associates Managed Medicare	$1,519.20
Rate for Payer: Midlands Choice Commercial	$2,363.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,956.73
Rate for Payer: Partners Health Alliance Commercial	$1,747.08
Rate for Payer: United Healthcare Commercial	$3,038.40
Rate for Payer: United Healthcare Managed Medicare	$1,991.84
Rate for Payer: Wellmark IA HMO WHPI	$2,633.23
Rate for Payer: Wellmark IA PPO	$2,900.63

SLEEP STUDY MSLT

Facility

$3,126.00

Service Code	CPT 95805
Hospital Charge Code	6608799
Hospital Revenue Code	920
Min. Negotiated Rate	$1,406.70
Max. Negotiated Rate	$2,900.63
Rate for Payer: Aetna of IA Commercial	$2,813.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,813.40
Rate for Payer: Aetna of IA Medicare	$1,781.82
Rate for Payer: Amerigroup Medicaid	$1,803.08
Rate for Payer: Amerigroup Medicare	$1,420.77
Rate for Payer: Cash Price	$2,500.80
Rate for Payer: Cash Price	$2,500.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,344.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,406.70
Rate for Payer: Iowa Total Care Managed Medicaid	$1,785.57
Rate for Payer: Medical Associates Commercial	$2,344.50
Rate for Payer: Medical Associates Managed Medicare	$1,406.70
Rate for Payer: Midlands Choice Commercial	$2,188.20
Rate for Payer: Molina Healthcare Managed Medicaid	$1,811.83
Rate for Payer: Partners Health Alliance Commercial	$1,617.70
Rate for Payer: United Healthcare Commercial	$2,813.40
Rate for Payer: United Healthcare Managed Medicare	$1,844.34
Rate for Payer: Wellmark IA HMO WHPI	$2,633.23
Rate for Payer: Wellmark IA PPO	$2,900.63

SLEEP STUDY MSLT

Facility

$3,126.00

Service Code	CPT 95805
Hospital Charge Code	6608799
Hospital Revenue Code	920
Min. Negotiated Rate	$2,188.20
Max. Negotiated Rate	$2,813.40
Rate for Payer: Aetna of IA Commercial	$2,813.40
Rate for Payer: Aetna of IA Medical Rental Products	$2,813.40
Rate for Payer: Cash Price	$2,500.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,344.50
Rate for Payer: Medical Associates Commercial	$2,344.50
Rate for Payer: Midlands Choice Commercial	$2,188.20
Rate for Payer: United Healthcare Commercial	$2,813.40

Know your out-of-pocket cost for care.

All Charges