Van Diest Medical Center

All Charges

Charge

Type

Price

Wound Debridement and Skin Graft Except Hand for Musculoskeletal and Connective Tissue Disorders With CC

Facility IP

$24,431.83

Service Code	MS-DRG 464
Hospital Charge Code	284
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$24,431.83
Rate for Payer: Amerigroup Medicaid	$24,313.80
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	$24,077.74
Rate for Payer: Molina Healthcare Managed Medicaid	$24,431.83

Wound Debridement and Skin Graft Except Hand for Musculoskeletal and Connective Tissue Disorders With MCC

Facility IP

$32,978.00

Service Code	MS-DRG 463
Hospital Charge Code	283
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$32,978.00
Rate for Payer: Amerigroup Medicaid	$32,818.68
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	$32,500.06
Rate for Payer: Molina Healthcare Managed Medicaid	$32,978.00

Wound Debridement and Skin Graft Except Hand for Musculoskeletal and Connective Tissue Disorders Without CC/MCC

Facility IP

$13,176.04

Service Code	MS-DRG 465
Hospital Charge Code	285
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$13,176.04
Rate for Payer: Amerigroup Medicaid	$13,112.38
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	$12,985.08
Rate for Payer: Molina Healthcare Managed Medicaid	$13,176.04

Wound Debridements for Injuries With CC

Facility IP

$16,528.37

Service Code	MS-DRG 902
Hospital Charge Code	623
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$16,528.37
Rate for Payer: Amerigroup Medicaid	$16,448.52
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	$16,288.83
Rate for Payer: Molina Healthcare Managed Medicaid	$16,528.37

Wound Debridements for Injuries With MCC

Facility IP

$41,961.17

Service Code	MS-DRG 901
Hospital Charge Code	622
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$41,961.17
Rate for Payer: Amerigroup Medicaid	$41,758.46
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	$41,353.03
Rate for Payer: Molina Healthcare Managed Medicaid	$41,961.17

Wound Debridements for Injuries Without CC/MCC

Facility IP

$10,527.45

Service Code	MS-DRG 903
Hospital Charge Code	624
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$10,527.45
Rate for Payer: Amerigroup Medicaid	$10,476.59
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	$10,374.88
Rate for Payer: Molina Healthcare Managed Medicaid	$10,527.45

XENFORM TISSUE REPAIR 8MMX12MM

Facility OP

$2,530.00

Hospital Charge Code	8026509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,264.49
Max. Negotiated Rate	$2,277.00
Rate for Payer: Aetna of IA Commercial	$2,277.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,277.00
Rate for Payer: Aetna of IA Medicare	$1,442.10
Rate for Payer: Amerigroup Medicaid	$1,276.89
Rate for Payer: Amerigroup Medicare	$1,277.65
Rate for Payer: Cash Price	$2,024.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,897.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,265.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,264.49
Rate for Payer: Medical Associates Commercial	$1,897.50
Rate for Payer: Medical Associates Managed Medicare	$1,265.00
Rate for Payer: Midlands Choice Commercial	$1,771.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,283.98
Rate for Payer: Partners Health Alliance Commercial	$1,897.50
Rate for Payer: United Healthcare Commercial	$2,277.00
Rate for Payer: United Healthcare Managed Medicare	$1,492.70

XENFORM TISSUE REPAIR 8MMX12MM

Facility IP

$2,530.00

Hospital Charge Code	8026509
Hospital Revenue Code	278
Min. Negotiated Rate	$1,771.00
Max. Negotiated Rate	$2,277.00
Rate for Payer: Aetna of IA Commercial	$2,277.00
Rate for Payer: Aetna of IA Medical Rental Products	$2,277.00
Rate for Payer: Cash Price	$2,024.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,897.50
Rate for Payer: Medical Associates Commercial	$1,897.50
Rate for Payer: Midlands Choice Commercial	$1,771.00
Rate for Payer: United Healthcare Commercial	$2,277.00

X-LARGE PLUGS

Facility OP

$324.00

Service Code	CPT C1781
Hospital Charge Code	8417556
Hospital Revenue Code	278
Min. Negotiated Rate	$161.94
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Aetna of IA Medicare	$184.68
Rate for Payer: Amerigroup Medicaid	$163.52
Rate for Payer: Amerigroup Medicare	$163.62
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$162.00
Rate for Payer: Iowa Total Care Managed Medicaid	$161.94
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Medical Associates Managed Medicare	$162.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: Molina Healthcare Managed Medicaid	$164.43
Rate for Payer: Partners Health Alliance Commercial	$243.00
Rate for Payer: United Healthcare Commercial	$291.60
Rate for Payer: United Healthcare Managed Medicare	$191.16

X-LARGE PLUGS

Facility IP

$324.00

Service Code	CPT C1781
Hospital Charge Code	8417556
Hospital Revenue Code	278
Min. Negotiated Rate	$226.80
Max. Negotiated Rate	$291.60
Rate for Payer: Aetna of IA Commercial	$291.60
Rate for Payer: Aetna of IA Medical Rental Products	$291.60
Rate for Payer: Cash Price	$259.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$243.00
Rate for Payer: Medical Associates Commercial	$243.00
Rate for Payer: Midlands Choice Commercial	$226.80
Rate for Payer: United Healthcare Commercial	$291.60

XR Abdomen 2 View

Facility OP

$180.00

Service Code	CPT 74019
Hospital Charge Code	2408784
Hospital Revenue Code	320
Min. Negotiated Rate	$59.52
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20
Rate for Payer: Wellmark IA HMO	$59.52
Rate for Payer: Wellmark IA PPO	$65.47

XR Abdomen 2 View

Facility IP

$180.00

Service Code	CPT 74019
Hospital Charge Code	2408784
Hospital Revenue Code	320
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

XR ABDOMEN AP

Facility IP

$150.00

Service Code	CPT 74018
Hospital Charge Code	1169926
Hospital Revenue Code	320
Min. Negotiated Rate	$105.00
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: United Healthcare Commercial	$135.00

XR ABDOMEN AP

Facility OP

$150.00

Service Code	CPT 74018
Hospital Charge Code	1169926
Hospital Revenue Code	320
Min. Negotiated Rate	$59.52
Max. Negotiated Rate	$135.00
Rate for Payer: Aetna of IA Commercial	$135.00
Rate for Payer: Aetna of IA Medical Rental Products	$135.00
Rate for Payer: Aetna of IA Medicare	$85.50
Rate for Payer: Amerigroup Medicaid	$75.70
Rate for Payer: Amerigroup Medicare	$75.75
Rate for Payer: Cash Price	$120.00
Rate for Payer: Cash Price	$120.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$112.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$75.00
Rate for Payer: Iowa Total Care Managed Medicaid	$74.97
Rate for Payer: Medical Associates Commercial	$112.50
Rate for Payer: Medical Associates Managed Medicare	$75.00
Rate for Payer: Midlands Choice Commercial	$105.00
Rate for Payer: Molina Healthcare Managed Medicaid	$76.12
Rate for Payer: Partners Health Alliance Commercial	$112.50
Rate for Payer: United Healthcare Commercial	$135.00
Rate for Payer: United Healthcare Managed Medicare	$88.50
Rate for Payer: Wellmark IA HMO	$59.52
Rate for Payer: Wellmark IA PPO	$65.47

XR Abdomen AP Obliques Cone Views

Facility IP

$202.00

Service Code	CPT 74010
Hospital Charge Code	1169928
Hospital Revenue Code	320
Min. Negotiated Rate	$141.40
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of IA Commercial	$181.80
Rate for Payer: Aetna of IA Medical Rental Products	$181.80
Rate for Payer: Cash Price	$161.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$151.50
Rate for Payer: Medical Associates Commercial	$151.50
Rate for Payer: Midlands Choice Commercial	$141.40
Rate for Payer: United Healthcare Commercial	$181.80

XR Abdomen AP Obliques Cone Views

Facility OP

$202.00

Service Code	CPT 74010
Hospital Charge Code	1169928
Hospital Revenue Code	320
Min. Negotiated Rate	$100.96
Max. Negotiated Rate	$181.80
Rate for Payer: Aetna of IA Commercial	$181.80
Rate for Payer: Aetna of IA Medical Rental Products	$181.80
Rate for Payer: Aetna of IA Medicare	$115.14
Rate for Payer: Amerigroup Medicaid	$101.95
Rate for Payer: Amerigroup Medicare	$102.01
Rate for Payer: Cash Price	$161.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$151.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$101.00
Rate for Payer: Iowa Total Care Managed Medicaid	$100.96
Rate for Payer: Medical Associates Commercial	$151.50
Rate for Payer: Medical Associates Managed Medicare	$101.00
Rate for Payer: Midlands Choice Commercial	$141.40
Rate for Payer: Molina Healthcare Managed Medicaid	$102.52
Rate for Payer: Partners Health Alliance Commercial	$151.50
Rate for Payer: United Healthcare Commercial	$181.80
Rate for Payer: United Healthcare Managed Medicare	$119.18

XR Abdomen Complete w/ Decub/Erect

Facility OP

$180.00

Service Code	CPT 74021
Hospital Charge Code	1169930
Hospital Revenue Code	320
Min. Negotiated Rate	$59.52
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20
Rate for Payer: Wellmark IA HMO	$59.52
Rate for Payer: Wellmark IA PPO	$65.47

XR Abdomen Complete w/ Decub/Erect

Facility IP

$180.00

Service Code	CPT 74021
Hospital Charge Code	1169930
Hospital Revenue Code	320
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

XR Abdomen Series w/ Chest 1 View

Facility IP

$180.00

Service Code	CPT 74022
Hospital Charge Code	1169932
Hospital Revenue Code	320
Min. Negotiated Rate	$126.00
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: United Healthcare Commercial	$162.00

XR Abdomen Series w/ Chest 1 View

Facility OP

$180.00

Service Code	CPT 74022
Hospital Charge Code	1169932
Hospital Revenue Code	320
Min. Negotiated Rate	$59.52
Max. Negotiated Rate	$162.00
Rate for Payer: Aetna of IA Commercial	$162.00
Rate for Payer: Aetna of IA Medical Rental Products	$162.00
Rate for Payer: Aetna of IA Medicare	$102.60
Rate for Payer: Amerigroup Medicaid	$90.85
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$144.00
Rate for Payer: Cash Price	$144.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$135.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$89.96
Rate for Payer: Medical Associates Commercial	$135.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$126.00
Rate for Payer: Molina Healthcare Managed Medicaid	$91.35
Rate for Payer: Partners Health Alliance Commercial	$135.00
Rate for Payer: United Healthcare Commercial	$162.00
Rate for Payer: United Healthcare Managed Medicare	$106.20
Rate for Payer: Wellmark IA HMO	$59.52
Rate for Payer: Wellmark IA PPO	$65.47

XR AC Joints Bilateral w/ + w/o wts

Facility OP

$148.00

Service Code	CPT 73050 50
Hospital Charge Code	1169922
Hospital Revenue Code	320
Min. Negotiated Rate	$73.97
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of IA Commercial	$133.20
Rate for Payer: Aetna of IA Medical Rental Products	$133.20
Rate for Payer: Aetna of IA Medicare	$84.36
Rate for Payer: Amerigroup Medicaid	$74.70
Rate for Payer: Amerigroup Medicare	$74.74
Rate for Payer: Cash Price	$118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$74.00
Rate for Payer: Iowa Total Care Managed Medicaid	$73.97
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Medical Associates Managed Medicare	$74.00
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: Molina Healthcare Managed Medicaid	$75.11
Rate for Payer: Partners Health Alliance Commercial	$111.00
Rate for Payer: United Healthcare Commercial	$133.20
Rate for Payer: United Healthcare Managed Medicare	$87.32

XR AC Joints Bilateral w/ + w/o wts

Facility IP

$148.00

Service Code	CPT 73050 50
Hospital Charge Code	1169922
Hospital Revenue Code	320
Min. Negotiated Rate	$103.60
Max. Negotiated Rate	$133.20
Rate for Payer: Aetna of IA Commercial	$133.20
Rate for Payer: Aetna of IA Medical Rental Products	$133.20
Rate for Payer: Cash Price	$118.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$111.00
Rate for Payer: Medical Associates Commercial	$111.00
Rate for Payer: Midlands Choice Commercial	$103.60
Rate for Payer: United Healthcare Commercial	$133.20

XR Ankle 2 Views Left

Facility OP

$133.00

Service Code	CPT 73600 LT
Hospital Charge Code	1169936
Hospital Revenue Code	320
Min. Negotiated Rate	$66.47
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Aetna of IA Medicare	$75.81
Rate for Payer: Amerigroup Medicaid	$67.13
Rate for Payer: Amerigroup Medicare	$67.16
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$66.50
Rate for Payer: Iowa Total Care Managed Medicaid	$66.47
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Medical Associates Managed Medicare	$66.50
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: Molina Healthcare Managed Medicaid	$67.50
Rate for Payer: Partners Health Alliance Commercial	$99.75
Rate for Payer: United Healthcare Commercial	$119.70
Rate for Payer: United Healthcare Managed Medicare	$78.47

XR Ankle 2 Views Left

Facility IP

$133.00

Service Code	CPT 73600 LT
Hospital Charge Code	1169936
Hospital Revenue Code	320
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: United Healthcare Commercial	$119.70

XR Ankle 2 Views Right

Facility IP

$133.00

Service Code	CPT 73600 RT
Hospital Charge Code	1169938
Hospital Revenue Code	320
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$119.70
Rate for Payer: Aetna of IA Commercial	$119.70
Rate for Payer: Aetna of IA Medical Rental Products	$119.70
Rate for Payer: Cash Price	$106.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$99.75
Rate for Payer: Medical Associates Commercial	$99.75
Rate for Payer: Midlands Choice Commercial	$93.10
Rate for Payer: United Healthcare Commercial	$119.70

Price Transparency.

All Charges