Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

BIER BLOCK ANESTHESIA

Facility

$422.00

Hospital Charge Code	8059080
Hospital Revenue Code	370
Min. Negotiated Rate	$295.40
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of IA Commercial	$379.80
Rate for Payer: Aetna of IA Medical Rental Products	$379.80
Rate for Payer: Cash Price	$337.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$316.50
Rate for Payer: Medical Associates Commercial	$316.50
Rate for Payer: Midlands Choice Commercial	$295.40
Rate for Payer: United Healthcare Commercial	$379.80

BIER BLOCK ANESTHESIA

Facility

$422.00

Hospital Charge Code	8059080
Hospital Revenue Code	370
Min. Negotiated Rate	$189.90
Max. Negotiated Rate	$379.80
Rate for Payer: Aetna of IA Commercial	$379.80
Rate for Payer: Aetna of IA Medical Rental Products	$379.80
Rate for Payer: Aetna of IA Medicare	$240.54
Rate for Payer: Amerigroup Medicaid	$243.41
Rate for Payer: Amerigroup Medicare	$191.80
Rate for Payer: Cash Price	$337.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$316.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$189.90
Rate for Payer: Iowa Total Care Managed Medicaid	$241.05
Rate for Payer: Medical Associates Commercial	$316.50
Rate for Payer: Medical Associates Managed Medicare	$189.90
Rate for Payer: Midlands Choice Commercial	$295.40
Rate for Payer: Molina Healthcare Managed Medicaid	$244.59
Rate for Payer: Partners Health Alliance Commercial	$218.38
Rate for Payer: United Healthcare Commercial	$379.80
Rate for Payer: United Healthcare Managed Medicare	$248.98

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC

Facility

$68,416.61

Service Code	MSDRG 461
Min. Negotiated Rate	$67,425.04
Max. Negotiated Rate	$68,416.61
Rate for Payer: Amerigroup Medicaid	$68,086.07
Rate for Payer: Iowa Total Care Managed Medicaid	$67,425.04
Rate for Payer: Molina Healthcare Managed Medicaid	$68,416.61

BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC

Facility

$37,145.98

Service Code	MSDRG 462
Min. Negotiated Rate	$36,607.62
Max. Negotiated Rate	$37,145.98
Rate for Payer: Amerigroup Medicaid	$36,966.52
Rate for Payer: Iowa Total Care Managed Medicaid	$36,607.62
Rate for Payer: Molina Healthcare Managed Medicaid	$37,145.98

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC

Facility

$31,876.41

Service Code	MSDRG 409
Min. Negotiated Rate	$31,414.42
Max. Negotiated Rate	$31,876.41
Rate for Payer: Amerigroup Medicaid	$31,722.40
Rate for Payer: Iowa Total Care Managed Medicaid	$31,414.42
Rate for Payer: Molina Healthcare Managed Medicaid	$31,876.41

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC

Facility

$31,876.41

Service Code	MSDRG 408
Min. Negotiated Rate	$31,414.42
Max. Negotiated Rate	$31,876.41
Rate for Payer: Amerigroup Medicaid	$31,722.40
Rate for Payer: Iowa Total Care Managed Medicaid	$31,414.42
Rate for Payer: Molina Healthcare Managed Medicaid	$31,876.41

BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC

Facility

$18,765.53

Service Code	MSDRG 410
Min. Negotiated Rate	$18,493.56
Max. Negotiated Rate	$18,765.53
Rate for Payer: Amerigroup Medicaid	$18,674.87
Rate for Payer: Iowa Total Care Managed Medicaid	$18,493.56
Rate for Payer: Molina Healthcare Managed Medicaid	$18,765.53

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	6312793
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	6312793
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	633670
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

BILIRUBIN DIRECT

Facility

$61.00

Service Code	CPT 82248
Hospital Charge Code	633670
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

BILIRUBIN TOTAL

Facility

$61.00

Service Code	CPT 82247
Hospital Charge Code	633672
Hospital Revenue Code	301
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

BILIRUBIN TOTAL

Facility

$61.00

Service Code	CPT 82247
Hospital Charge Code	633672
Hospital Revenue Code	301
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

BILL ABO

Facility

$52.00

Service Code	CPT 86900
Hospital Charge Code	8015152
Hospital Revenue Code	302
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$46.80
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: United Healthcare Commercial	$46.80

BILL ABO

Facility

$52.00

Service Code	CPT 86900
Hospital Charge Code	8015152
Hospital Revenue Code	302
Min. Negotiated Rate	$23.40
Max. Negotiated Rate	$55.45
Rate for Payer: Aetna of IA Commercial	$46.80
Rate for Payer: Aetna of IA Medical Rental Products	$46.80
Rate for Payer: Aetna of IA Medicare	$29.64
Rate for Payer: Amerigroup Medicaid	$29.99
Rate for Payer: Amerigroup Medicare	$23.63
Rate for Payer: Cash Price	$41.60
Rate for Payer: Cash Price	$41.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.40
Rate for Payer: Iowa Total Care Managed Medicaid	$29.70
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Medical Associates Managed Medicare	$23.40
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: Molina Healthcare Managed Medicaid	$30.14
Rate for Payer: Partners Health Alliance Commercial	$26.91
Rate for Payer: United Healthcare Commercial	$46.80
Rate for Payer: United Healthcare Managed Medicare	$30.68
Rate for Payer: Wellmark IA HMO WHPI	$50.34
Rate for Payer: Wellmark IA PPO	$55.45

Bill Alcohol Saliva 82055

Facility

$61.00

Service Code	CPT 80320
Hospital Charge Code	8100912
Hospital Revenue Code	300
Min. Negotiated Rate	$27.45
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Aetna of IA Medicare	$34.77
Rate for Payer: Amerigroup Medicaid	$35.18
Rate for Payer: Amerigroup Medicare	$27.72
Rate for Payer: Cash Price	$48.80
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$27.45
Rate for Payer: Iowa Total Care Managed Medicaid	$34.84
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Medical Associates Managed Medicare	$27.45
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: Molina Healthcare Managed Medicaid	$35.36
Rate for Payer: Partners Health Alliance Commercial	$31.57
Rate for Payer: United Healthcare Commercial	$54.90
Rate for Payer: United Healthcare Managed Medicare	$35.99
Rate for Payer: Wellmark IA HMO WHPI	$43.25
Rate for Payer: Wellmark IA PPO	$47.64

Bill Alcohol Saliva 82055

Facility

$61.00

Service Code	CPT 80320
Hospital Charge Code	8100912
Hospital Revenue Code	300
Min. Negotiated Rate	$42.70
Max. Negotiated Rate	$54.90
Rate for Payer: Aetna of IA Commercial	$54.90
Rate for Payer: Aetna of IA Medical Rental Products	$54.90
Rate for Payer: Cash Price	$48.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$45.75
Rate for Payer: Medical Associates Commercial	$45.75
Rate for Payer: Midlands Choice Commercial	$42.70
Rate for Payer: United Healthcare Commercial	$54.90

BILL ANTIBODY ELUTION

Facility

$125.00

Service Code	CPT 86860
Hospital Charge Code	7829178
Hospital Revenue Code	302
Min. Negotiated Rate	$56.25
Max. Negotiated Rate	$153.86
Rate for Payer: Aetna of IA Commercial	$112.50
Rate for Payer: Aetna of IA Medical Rental Products	$112.50
Rate for Payer: Aetna of IA Medicare	$71.25
Rate for Payer: Amerigroup Medicaid	$72.10
Rate for Payer: Amerigroup Medicare	$56.81
Rate for Payer: Cash Price	$100.00
Rate for Payer: Cash Price	$100.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$56.25
Rate for Payer: Iowa Total Care Managed Medicaid	$71.40
Rate for Payer: Medical Associates Commercial	$93.75
Rate for Payer: Medical Associates Managed Medicare	$56.25
Rate for Payer: Midlands Choice Commercial	$87.50
Rate for Payer: Molina Healthcare Managed Medicaid	$72.45
Rate for Payer: Partners Health Alliance Commercial	$64.69
Rate for Payer: United Healthcare Commercial	$112.50
Rate for Payer: United Healthcare Managed Medicare	$73.75
Rate for Payer: Wellmark IA HMO WHPI	$139.67
Rate for Payer: Wellmark IA PPO	$153.86

BILL ANTIBODY ELUTION

Facility

$125.00

Service Code	CPT 86860
Hospital Charge Code	7829178
Hospital Revenue Code	302
Min. Negotiated Rate	$87.50
Max. Negotiated Rate	$112.50
Rate for Payer: Aetna of IA Commercial	$112.50
Rate for Payer: Aetna of IA Medical Rental Products	$112.50
Rate for Payer: Cash Price	$100.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$93.75
Rate for Payer: Medical Associates Commercial	$93.75
Rate for Payer: Midlands Choice Commercial	$87.50
Rate for Payer: United Healthcare Commercial	$112.50

BILL ANTIBODY ID

Facility

$141.00

Service Code	CPT 86870
Hospital Charge Code	7829179
Hospital Revenue Code	302
Min. Negotiated Rate	$98.70
Max. Negotiated Rate	$126.90
Rate for Payer: Aetna of IA Commercial	$126.90
Rate for Payer: Aetna of IA Medical Rental Products	$126.90
Rate for Payer: Cash Price	$112.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.75
Rate for Payer: Medical Associates Commercial	$105.75
Rate for Payer: Midlands Choice Commercial	$98.70
Rate for Payer: United Healthcare Commercial	$126.90

BILL ANTIBODY ID

Facility

$141.00

Service Code	CPT 86870
Hospital Charge Code	7829179
Hospital Revenue Code	302
Min. Negotiated Rate	$63.45
Max. Negotiated Rate	$153.86
Rate for Payer: Aetna of IA Commercial	$126.90
Rate for Payer: Aetna of IA Medical Rental Products	$126.90
Rate for Payer: Aetna of IA Medicare	$80.37
Rate for Payer: Amerigroup Medicaid	$81.33
Rate for Payer: Amerigroup Medicare	$64.08
Rate for Payer: Cash Price	$112.80
Rate for Payer: Cash Price	$112.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$105.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$63.45
Rate for Payer: Iowa Total Care Managed Medicaid	$80.54
Rate for Payer: Medical Associates Commercial	$105.75
Rate for Payer: Medical Associates Managed Medicare	$63.45
Rate for Payer: Midlands Choice Commercial	$98.70
Rate for Payer: Molina Healthcare Managed Medicaid	$81.72
Rate for Payer: Partners Health Alliance Commercial	$72.97
Rate for Payer: United Healthcare Commercial	$126.90
Rate for Payer: United Healthcare Managed Medicare	$83.19
Rate for Payer: Wellmark IA HMO WHPI	$139.67
Rate for Payer: Wellmark IA PPO	$153.86

BILL ANTIBODY SCREEN

Facility

$73.00

Service Code	CPT 86850
Hospital Charge Code	7862116
Hospital Revenue Code	302
Min. Negotiated Rate	$32.85
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Aetna of IA Medicare	$41.61
Rate for Payer: Amerigroup Medicaid	$42.11
Rate for Payer: Amerigroup Medicare	$33.18
Rate for Payer: Cash Price	$58.40
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.85
Rate for Payer: Iowa Total Care Managed Medicaid	$41.70
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Medical Associates Managed Medicare	$32.85
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: Molina Healthcare Managed Medicaid	$42.31
Rate for Payer: Partners Health Alliance Commercial	$37.78
Rate for Payer: United Healthcare Commercial	$65.70
Rate for Payer: United Healthcare Managed Medicare	$43.07
Rate for Payer: Wellmark IA HMO WHPI	$50.34
Rate for Payer: Wellmark IA PPO	$55.45

BILL ANTIBODY SCREEN

Facility

$73.00

Service Code	CPT 86850
Hospital Charge Code	7862116
Hospital Revenue Code	302
Min. Negotiated Rate	$51.10
Max. Negotiated Rate	$65.70
Rate for Payer: Aetna of IA Commercial	$65.70
Rate for Payer: Aetna of IA Medical Rental Products	$65.70
Rate for Payer: Cash Price	$58.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$54.75
Rate for Payer: Medical Associates Commercial	$54.75
Rate for Payer: Midlands Choice Commercial	$51.10
Rate for Payer: United Healthcare Commercial	$65.70

BILL ANTIBODY TITER

Facility

$78.00

Service Code	CPT 86886
Hospital Charge Code	7829181
Hospital Revenue Code	302
Min. Negotiated Rate	$54.60
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of IA Commercial	$70.20
Rate for Payer: Aetna of IA Medical Rental Products	$70.20
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.50
Rate for Payer: Medical Associates Commercial	$58.50
Rate for Payer: Midlands Choice Commercial	$54.60
Rate for Payer: United Healthcare Commercial	$70.20

BILL ANTIBODY TITER

Facility

$78.00

Service Code	CPT 86886
Hospital Charge Code	7829181
Hospital Revenue Code	302
Min. Negotiated Rate	$35.10
Max. Negotiated Rate	$70.20
Rate for Payer: Aetna of IA Commercial	$70.20
Rate for Payer: Aetna of IA Medical Rental Products	$70.20
Rate for Payer: Aetna of IA Medicare	$44.46
Rate for Payer: Amerigroup Medicaid	$44.99
Rate for Payer: Amerigroup Medicare	$35.45
Rate for Payer: Cash Price	$62.40
Rate for Payer: Cash Price	$62.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$58.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.10
Rate for Payer: Iowa Total Care Managed Medicaid	$44.55
Rate for Payer: Medical Associates Commercial	$58.50
Rate for Payer: Medical Associates Managed Medicare	$35.10
Rate for Payer: Midlands Choice Commercial	$54.60
Rate for Payer: Molina Healthcare Managed Medicaid	$45.21
Rate for Payer: Partners Health Alliance Commercial	$40.36
Rate for Payer: United Healthcare Commercial	$70.20
Rate for Payer: United Healthcare Managed Medicare	$46.02
Rate for Payer: Wellmark IA HMO WHPI	$50.34
Rate for Payer: Wellmark IA PPO	$55.45

Know your out-of-pocket cost for care.

All Charges