Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC

Facility

$29,600.81

Service Code	MSDRG 240
Min. Negotiated Rate	$29,171.80
Max. Negotiated Rate	$29,600.81
Rate for Payer: Amerigroup Medicaid	$29,457.80
Rate for Payer: Iowa Total Care Managed Medicaid	$29,171.80
Rate for Payer: Molina Healthcare Managed Medicaid	$29,600.81

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC

Facility

$50,623.93

Service Code	MSDRG 239
Min. Negotiated Rate	$49,890.22
Max. Negotiated Rate	$50,623.93
Rate for Payer: Amerigroup Medicaid	$50,379.34
Rate for Payer: Iowa Total Care Managed Medicaid	$49,890.22
Rate for Payer: Molina Healthcare Managed Medicaid	$50,623.93

AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC

Facility

$17,923.30

Service Code	MSDRG 241
Min. Negotiated Rate	$17,663.54
Max. Negotiated Rate	$17,923.30
Rate for Payer: Amerigroup Medicaid	$17,836.71
Rate for Payer: Iowa Total Care Managed Medicaid	$17,663.54
Rate for Payer: Molina Healthcare Managed Medicaid	$17,923.30

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$23,735.60

Service Code	MSDRG 475
Min. Negotiated Rate	$23,391.59
Max. Negotiated Rate	$23,735.60
Rate for Payer: Amerigroup Medicaid	$23,620.92
Rate for Payer: Iowa Total Care Managed Medicaid	$23,391.59
Rate for Payer: Molina Healthcare Managed Medicaid	$23,735.60

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$27,781.23

Service Code	MSDRG 474
Min. Negotiated Rate	$27,378.59
Max. Negotiated Rate	$27,781.23
Rate for Payer: Amerigroup Medicaid	$27,647.01
Rate for Payer: Iowa Total Care Managed Medicaid	$27,378.59
Rate for Payer: Molina Healthcare Managed Medicaid	$27,781.23

AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$10,650.62

Service Code	MSDRG 476
Min. Negotiated Rate	$10,496.26
Max. Negotiated Rate	$10,650.62
Rate for Payer: Amerigroup Medicaid	$10,599.16
Rate for Payer: Iowa Total Care Managed Medicaid	$10,496.26
Rate for Payer: Molina Healthcare Managed Medicaid	$10,650.62

AMPUTATION OF FINGER/THUMB

Facility

$2,907.00

Service Code	CPT 26952
Hospital Charge Code	4863429
Hospital Revenue Code	450
Min. Negotiated Rate	$1,308.15
Max. Negotiated Rate	$6,713.48
Rate for Payer: Aetna of IA Commercial	$2,616.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,616.30
Rate for Payer: Aetna of IA Medicare	$1,656.99
Rate for Payer: Amerigroup Medicaid	$1,676.76
Rate for Payer: Amerigroup Medicare	$1,321.23
Rate for Payer: Cash Price	$2,325.60
Rate for Payer: Cash Price	$2,325.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,180.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,308.15
Rate for Payer: Iowa Total Care Managed Medicaid	$1,660.48
Rate for Payer: Medical Associates Commercial	$2,180.25
Rate for Payer: Medical Associates Managed Medicare	$1,308.15
Rate for Payer: Midlands Choice Commercial	$2,034.90
Rate for Payer: Molina Healthcare Managed Medicaid	$1,684.90
Rate for Payer: Partners Health Alliance Commercial	$1,504.37
Rate for Payer: United Healthcare Commercial	$2,616.30
Rate for Payer: United Healthcare Managed Medicare	$1,715.13
Rate for Payer: Wellmark IA HMO WHPI	$6,094.56
Rate for Payer: Wellmark IA PPO	$6,713.48

AMPUTATION OF FINGER/THUMB

Facility

$2,907.00

Service Code	CPT 26952
Hospital Charge Code	4863429
Hospital Revenue Code	450
Min. Negotiated Rate	$2,034.90
Max. Negotiated Rate	$2,616.30
Rate for Payer: Aetna of IA Commercial	$2,616.30
Rate for Payer: Aetna of IA Medical Rental Products	$2,616.30
Rate for Payer: Cash Price	$2,325.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,180.25
Rate for Payer: Medical Associates Commercial	$2,180.25
Rate for Payer: Midlands Choice Commercial	$2,034.90
Rate for Payer: United Healthcare Commercial	$2,616.30

AMPUTATION OF FINGER/THUMB

Facility

$1,943.00

Service Code	CPT 26951
Hospital Charge Code	4863423
Hospital Revenue Code	450
Min. Negotiated Rate	$1,360.10
Max. Negotiated Rate	$1,748.70
Rate for Payer: Aetna of IA Commercial	$1,748.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,748.70
Rate for Payer: Cash Price	$1,554.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,457.25
Rate for Payer: Medical Associates Commercial	$1,457.25
Rate for Payer: Midlands Choice Commercial	$1,360.10
Rate for Payer: United Healthcare Commercial	$1,748.70

AMPUTATION OF FINGER/THUMB

Facility

$1,943.00

Service Code	CPT 26951
Hospital Charge Code	4863423
Hospital Revenue Code	450
Min. Negotiated Rate	$874.35
Max. Negotiated Rate	$3,486.38
Rate for Payer: Aetna of IA Commercial	$1,748.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,748.70
Rate for Payer: Aetna of IA Medicare	$1,107.51
Rate for Payer: Amerigroup Medicaid	$1,120.72
Rate for Payer: Amerigroup Medicare	$883.09
Rate for Payer: Cash Price	$1,554.40
Rate for Payer: Cash Price	$1,554.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,457.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$874.35
Rate for Payer: Iowa Total Care Managed Medicaid	$1,109.84
Rate for Payer: Medical Associates Commercial	$1,457.25
Rate for Payer: Medical Associates Managed Medicare	$874.35
Rate for Payer: Midlands Choice Commercial	$1,360.10
Rate for Payer: Molina Healthcare Managed Medicaid	$1,126.16
Rate for Payer: Partners Health Alliance Commercial	$1,005.50
Rate for Payer: United Healthcare Commercial	$1,748.70
Rate for Payer: United Healthcare Managed Medicare	$1,146.37
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH CC

Facility

$17,749.90

Service Code	MSDRG 617
Min. Negotiated Rate	$17,492.65
Max. Negotiated Rate	$17,749.90
Rate for Payer: Amerigroup Medicaid	$17,664.15
Rate for Payer: Iowa Total Care Managed Medicaid	$17,492.65
Rate for Payer: Molina Healthcare Managed Medicaid	$17,749.90

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITH MCC

Facility

$23,404.56

Service Code	MSDRG 616
Min. Negotiated Rate	$23,065.35
Max. Negotiated Rate	$23,404.56
Rate for Payer: Amerigroup Medicaid	$23,291.48
Rate for Payer: Iowa Total Care Managed Medicaid	$23,065.35
Rate for Payer: Molina Healthcare Managed Medicaid	$23,404.56

AMPUTATION OF LOWER LIMB FOR ENDOCRINE, NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC

Facility

$8,511.26

Service Code	MSDRG 618
Min. Negotiated Rate	$8,387.90
Max. Negotiated Rate	$8,511.26
Rate for Payer: Amerigroup Medicaid	$8,470.14
Rate for Payer: Iowa Total Care Managed Medicaid	$8,387.90
Rate for Payer: Molina Healthcare Managed Medicaid	$8,511.26

AMYLASE

Facility

$64.00

Service Code	CPT 82150
Hospital Charge Code	631567
Hospital Revenue Code	301
Min. Negotiated Rate	$28.80
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: Aetna of IA Medicare	$36.48
Rate for Payer: Amerigroup Medicaid	$36.92
Rate for Payer: Amerigroup Medicare	$29.09
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	$28.80
Rate for Payer: Iowa Total Care Managed Medicaid	$36.56
Rate for Payer: Medical Associates Commercial	$48.00
Rate for Payer: Medical Associates Managed Medicare	$28.80
Rate for Payer: Midlands Choice Commercial	$44.80
Rate for Payer: Molina Healthcare Managed Medicaid	$37.09
Rate for Payer: Partners Health Alliance Commercial	$33.12
Rate for Payer: United Healthcare Commercial	$57.60
Rate for Payer: United Healthcare Managed Medicare	$37.76
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

AMYLASE

Facility

$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

$12,650.35

Service Code	MSDRG 348
Min. Negotiated Rate	$12,467.01
Max. Negotiated Rate	$12,650.35
Rate for Payer: Amerigroup Medicaid	$12,589.23
Rate for Payer: Iowa Total Care Managed Medicaid	$12,467.01
Rate for Payer: Molina Healthcare Managed Medicaid	$12,650.35

ANAL AND STOMAL PROCEDURES WITH MCC

Facility

$27,723.81

Service Code	MSDRG 347
Min. Negotiated Rate	$27,322.00
Max. Negotiated Rate	$27,723.81
Rate for Payer: Amerigroup Medicaid	$27,589.86
Rate for Payer: Iowa Total Care Managed Medicaid	$27,322.00
Rate for Payer: Molina Healthcare Managed Medicaid	$27,723.81

ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC

Facility

$10,928.73

Service Code	MSDRG 349
Min. Negotiated Rate	$10,770.34
Max. Negotiated Rate	$10,928.73
Rate for Payer: Amerigroup Medicaid	$10,875.93
Rate for Payer: Iowa Total Care Managed Medicaid	$10,770.34
Rate for Payer: Molina Healthcare Managed Medicaid	$10,928.73

ANCA Screen DMCL

Facility

$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

ANCA Screen DMCL

Facility

$115.00

Service Code	CPT 86255
Hospital Charge Code	8037494
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
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	$66.33
Rate for Payer: Amerigroup Medicare	$52.27
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	$51.75
Rate for Payer: Iowa Total Care Managed Medicaid	$65.69
Rate for Payer: Medical Associates Commercial	$86.25
Rate for Payer: Medical Associates Managed Medicare	$51.75
Rate for Payer: Midlands Choice Commercial	$80.50
Rate for Payer: Molina Healthcare Managed Medicaid	$66.65
Rate for Payer: Partners Health Alliance Commercial	$59.51
Rate for Payer: United Healthcare Commercial	$103.50
Rate for Payer: United Healthcare Managed Medicare	$67.85
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

ANCHOR SUTURE 2.5MM

Facility

$788.40

Service Code	HCPCS C1713
Hospital Charge Code	8871630
Hospital Revenue Code	278
Min. Negotiated Rate	$354.78
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	$454.75
Rate for Payer: Amerigroup Medicare	$358.33
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	$354.78
Rate for Payer: Iowa Total Care Managed Medicaid	$450.33
Rate for Payer: Medical Associates Commercial	$591.30
Rate for Payer: Medical Associates Managed Medicare	$354.78
Rate for Payer: Midlands Choice Commercial	$551.88
Rate for Payer: Molina Healthcare Managed Medicaid	$456.96
Rate for Payer: Partners Health Alliance Commercial	$408.00
Rate for Payer: United Healthcare Commercial	$709.56
Rate for Payer: United Healthcare Managed Medicare	$465.16

ANCHOR SUTURE 2.5MM

Facility

$788.40

Service Code	HCPCS 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

ANESTH-BASE UNIT VALUE

Facility

$86.00

Hospital Charge Code	8059593
Hospital Revenue Code	964
Min. Negotiated Rate	$38.70
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	$49.60
Rate for Payer: Amerigroup Medicare	$39.09
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	$38.70
Rate for Payer: Iowa Total Care Managed Medicaid	$49.12
Rate for Payer: Medical Associates Commercial	$64.50
Rate for Payer: Medical Associates Managed Medicare	$38.70
Rate for Payer: Midlands Choice Commercial	$60.20
Rate for Payer: Molina Healthcare Managed Medicaid	$49.85
Rate for Payer: Partners Health Alliance Commercial	$44.50
Rate for Payer: United Healthcare Commercial	$77.40

ANESTH-BASE UNIT VALUE

Facility

$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

$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

Know your out-of-pocket cost for care.

All Charges