Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Concussion With CC

Facility

$8,835.54

Service Code	MS-DRG 089
Hospital Charge Code	769
Min. Negotiated Rate	$8,707.48
Max. Negotiated Rate	$8,835.54
Rate for Payer: Amerigroup Medicaid	$8,792.85
Rate for Payer: Iowa Total Care Managed Medicaid	$8,707.48
Rate for Payer: Molina Healthcare Managed Medicaid	$8,835.54

Concussion With MCC

Facility

$14,366.97

Service Code	MS-DRG 088
Hospital Charge Code	768
Min. Negotiated Rate	$14,158.75
Max. Negotiated Rate	$14,366.97
Rate for Payer: Amerigroup Medicaid	$14,297.56
Rate for Payer: Iowa Total Care Managed Medicaid	$14,158.75
Rate for Payer: Molina Healthcare Managed Medicaid	$14,366.97

Concussion Without CC/MCC

Facility

$5,034.40

Service Code	MS-DRG 090
Hospital Charge Code	770
Min. Negotiated Rate	$4,961.43
Max. Negotiated Rate	$5,034.40
Rate for Payer: Amerigroup Medicaid	$5,010.07
Rate for Payer: Iowa Total Care Managed Medicaid	$4,961.43
Rate for Payer: Molina Healthcare Managed Medicaid	$5,034.40

conivaptan 20 mg/100 mL-D5% Sol SDV [VDMC]

Facility

$2,252.16

Service Code	HCPCS C9488
Hospital Charge Code	10379711
Hospital Revenue Code	259
Min. Negotiated Rate	$1,125.63
Max. Negotiated Rate	$2,026.94
Rate for Payer: Aetna of IA Commercial	$2,026.94
Rate for Payer: Aetna of IA Medical Rental Products	$2,026.94
Rate for Payer: Aetna of IA Medicare	$1,283.73
Rate for Payer: Amerigroup Medicaid	$1,136.67
Rate for Payer: Amerigroup Medicare	$1,137.34
Rate for Payer: Cash Price	$1,801.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,689.12
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,126.08
Rate for Payer: Iowa Total Care Managed Medicaid	$1,125.63
Rate for Payer: Medical Associates Commercial	$1,689.12
Rate for Payer: Medical Associates Managed Medicare	$1,126.08
Rate for Payer: Midlands Choice Commercial	$1,576.51
Rate for Payer: Molina Healthcare Managed Medicaid	$1,142.97
Rate for Payer: Molina Healthcare Managed Medicare	$1,142.30
Rate for Payer: Oscar Health of IA Commercial	$1,689.12
Rate for Payer: Partners Health Alliance Commercial	$1,689.12
Rate for Payer: United Healthcare Commercial	$2,026.94
Rate for Payer: United Healthcare Managed Medicare	$1,328.77

conivaptan 20 mg/100 mL-D5% Sol SDV [VDMC]

Facility

$2,252.16

Service Code	HCPCS C9488
Hospital Charge Code	10379711
Hospital Revenue Code	259
Min. Negotiated Rate	$1,576.51
Max. Negotiated Rate	$2,026.94
Rate for Payer: Aetna of IA Commercial	$2,026.94
Rate for Payer: Aetna of IA Medical Rental Products	$2,026.94
Rate for Payer: Cash Price	$1,801.73
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,689.12
Rate for Payer: Medical Associates Commercial	$1,689.12
Rate for Payer: Midlands Choice Commercial	$1,576.51
Rate for Payer: United Healthcare Commercial	$2,026.94

conjugated estrogens topical 0.625 mg/g Cre [VDMC]

Facility

$1,531.04

Service Code	HCPCS A9270
Hospital Charge Code	11222513
Hospital Revenue Code	259
Min. Negotiated Rate	$765.21
Max. Negotiated Rate	$1,377.94
Rate for Payer: Aetna of IA Commercial	$1,377.94
Rate for Payer: Aetna of IA Medical Rental Products	$1,377.94
Rate for Payer: Aetna of IA Medicare	$872.69
Rate for Payer: Amerigroup Medicaid	$772.72
Rate for Payer: Amerigroup Medicare	$773.18
Rate for Payer: Cash Price	$1,224.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,148.28
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$765.52
Rate for Payer: Iowa Total Care Managed Medicaid	$765.21
Rate for Payer: Medical Associates Commercial	$1,148.28
Rate for Payer: Medical Associates Managed Medicare	$765.52
Rate for Payer: Midlands Choice Commercial	$1,071.73
Rate for Payer: Molina Healthcare Managed Medicaid	$777.00
Rate for Payer: Molina Healthcare Managed Medicare	$776.54
Rate for Payer: Oscar Health of IA Commercial	$1,148.28
Rate for Payer: Partners Health Alliance Commercial	$1,148.28
Rate for Payer: United Healthcare Commercial	$1,377.94
Rate for Payer: United Healthcare Managed Medicare	$903.31

conjugated estrogens topical 0.625 mg/g Cre [VDMC]

Facility

$1,531.04

Service Code	HCPCS A9270
Hospital Charge Code	11222513
Hospital Revenue Code	259
Min. Negotiated Rate	$1,071.73
Max. Negotiated Rate	$1,377.94
Rate for Payer: Aetna of IA Commercial	$1,377.94
Rate for Payer: Aetna of IA Medical Rental Products	$1,377.94
Rate for Payer: Cash Price	$1,224.83
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,148.28
Rate for Payer: Medical Associates Commercial	$1,148.28
Rate for Payer: Midlands Choice Commercial	$1,071.73
Rate for Payer: United Healthcare Commercial	$1,377.94

Connective Tissue Disorders With CC

Facility

$11,948.69

Service Code	MS-DRG 546
Hospital Charge Code	353
Min. Negotiated Rate	$11,775.52
Max. Negotiated Rate	$11,948.69
Rate for Payer: Amerigroup Medicaid	$11,890.97
Rate for Payer: Iowa Total Care Managed Medicaid	$11,775.52
Rate for Payer: Molina Healthcare Managed Medicaid	$11,948.69

Connective Tissue Disorders With MCC

Facility

$16,780.33

Service Code	MS-DRG 545
Hospital Charge Code	352
Min. Negotiated Rate	$16,537.14
Max. Negotiated Rate	$16,780.33
Rate for Payer: Amerigroup Medicaid	$16,699.27
Rate for Payer: Iowa Total Care Managed Medicaid	$16,537.14
Rate for Payer: Molina Healthcare Managed Medicaid	$16,780.33

Connective Tissue Disorders Without CC/MCC

Facility

$7,882.79

Service Code	MS-DRG 547
Hospital Charge Code	354
Min. Negotiated Rate	$7,768.54
Max. Negotiated Rate	$7,882.79
Rate for Payer: Amerigroup Medicaid	$7,844.71
Rate for Payer: Iowa Total Care Managed Medicaid	$7,768.54
Rate for Payer: Molina Healthcare Managed Medicaid	$7,882.79

CONSCIOUS SED SCHD >5 1ST 30 M

Facility

$235.00

Hospital Charge Code	8012943
Hospital Revenue Code	761
Min. Negotiated Rate	$164.50
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of IA Commercial	$211.50
Rate for Payer: Aetna of IA Medical Rental Products	$211.50
Rate for Payer: Cash Price	$188.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$176.25
Rate for Payer: Medical Associates Commercial	$176.25
Rate for Payer: Midlands Choice Commercial	$164.50
Rate for Payer: United Healthcare Commercial	$211.50

CONSCIOUS SED SCHD >5 1ST 30 M

Facility

$235.00

Hospital Charge Code	8012943
Hospital Revenue Code	761
Min. Negotiated Rate	$117.45
Max. Negotiated Rate	$211.50
Rate for Payer: Aetna of IA Commercial	$211.50
Rate for Payer: Aetna of IA Medical Rental Products	$211.50
Rate for Payer: Aetna of IA Medicare	$133.95
Rate for Payer: Amerigroup Medicaid	$118.60
Rate for Payer: Amerigroup Medicare	$118.68
Rate for Payer: Cash Price	$188.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$176.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$117.50
Rate for Payer: Iowa Total Care Managed Medicaid	$117.45
Rate for Payer: Medical Associates Commercial	$176.25
Rate for Payer: Medical Associates Managed Medicare	$117.50
Rate for Payer: Midlands Choice Commercial	$164.50
Rate for Payer: Molina Healthcare Managed Medicaid	$119.26
Rate for Payer: Molina Healthcare Managed Medicare	$119.19
Rate for Payer: Oscar Health of IA Commercial	$176.25
Rate for Payer: Partners Health Alliance Commercial	$176.25
Rate for Payer: United Healthcare Commercial	$211.50
Rate for Payer: United Healthcare Managed Medicare	$138.65

CONTINUOUS CARDIAC MONITORING 1-3 LEADS TRACING ONLY

Facility

$104.00

Service Code	CPT 93041
Hospital Charge Code	7982922
Hospital Revenue Code	730
Min. Negotiated Rate	$72.80
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: United Healthcare Commercial	$93.60

CONTINUOUS CARDIAC MONITORING 1-3 LEADS TRACING ONLY

Facility

$104.00

Service Code	CPT 93041
Hospital Charge Code	7982922
Hospital Revenue Code	730
Min. Negotiated Rate	$51.98
Max. Negotiated Rate	$93.60
Rate for Payer: Aetna of IA Commercial	$93.60
Rate for Payer: Aetna of IA Medical Rental Products	$93.60
Rate for Payer: Aetna of IA Medicare	$59.28
Rate for Payer: Amerigroup Medicaid	$52.49
Rate for Payer: Amerigroup Medicare	$52.52
Rate for Payer: Cash Price	$83.20
Rate for Payer: Cash Price	$83.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$78.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$52.00
Rate for Payer: Iowa Total Care Managed Medicaid	$51.98
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Medical Associates Managed Medicare	$52.00
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: Molina Healthcare Managed Medicaid	$52.78
Rate for Payer: Molina Healthcare Managed Medicare	$52.75
Rate for Payer: Oscar Health of IA Commercial	$78.00
Rate for Payer: Partners Health Alliance Commercial	$78.00
Rate for Payer: United Healthcare Commercial	$93.60
Rate for Payer: United Healthcare Managed Medicare	$61.36
Rate for Payer: Wellmark IA HMO	$83.08
Rate for Payer: Wellmark IA PPO	$91.39

CONTRACEPTIVE CAPS INSERTION CHARGE

Professional

Both

$345.00

Service Code	CPT 11981
Hospital Charge Code	8068935
Hospital Revenue Code	975
Min. Negotiated Rate	$56.02
Max. Negotiated Rate	$132.36
Rate for Payer: Aetna of IA Medicare	$56.02
Rate for Payer: Amerigroup Medicaid	$57.92
Rate for Payer: Cash Price	$276.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$67.22
Rate for Payer: Iowa Total Care Managed Medicaid	$57.14
Rate for Payer: Medical Associates Commercial	$106.44
Rate for Payer: Medical Associates Managed Medicare	$56.02
Rate for Payer: Midlands Choice Commercial	$132.36
Rate for Payer: Oscar Health of IA Commercial	$96.91
Rate for Payer: Partners Health Alliance Commercial	$84.03

CONTRACEPTIVE CAPS REMOVAL CHARGE

Professional

Both

$484.00

Service Code	CPT 11976
Hospital Charge Code	8068933
Hospital Revenue Code	975
Min. Negotiated Rate	$83.40
Max. Negotiated Rate	$338.80
Rate for Payer: Aetna of IA Medicare	$83.40
Rate for Payer: Amerigroup Medicaid	$86.24
Rate for Payer: Cash Price	$387.20
Rate for Payer: Cash Price	$387.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$100.08
Rate for Payer: Iowa Total Care Managed Medicaid	$85.07
Rate for Payer: Medical Associates Commercial	$158.46
Rate for Payer: Medical Associates Managed Medicare	$83.40
Rate for Payer: Midlands Choice Commercial	$338.80
Rate for Payer: Oscar Health of IA Commercial	$144.28
Rate for Payer: Partners Health Alliance Commercial	$125.10

CONTRAST BATH / 15 MIN APPLICATION

Facility

$82.00

Service Code	CPT 97034 GP
Hospital Charge Code	1374011
Hospital Revenue Code	420
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

CONTRAST BATH / 15 MIN APPLICATION

Facility

$82.00

Service Code	CPT 97034 GP
Hospital Charge Code	1374011
Hospital Revenue Code	420
Min. Negotiated Rate	$40.98
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$41.39
Rate for Payer: Amerigroup Medicare	$41.41
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.00
Rate for Payer: Iowa Total Care Managed Medicaid	$40.98
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$41.00
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$41.62
Rate for Payer: Molina Healthcare Managed Medicare	$41.59
Rate for Payer: Oscar Health of IA Commercial	$61.50
Rate for Payer: Partners Health Alliance Commercial	$61.50
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38

CONTRAST BATH/PER 15 MIN

Facility

$82.00

Service Code	CPT 97034 GO
Hospital Charge Code	1373567
Hospital Revenue Code	430
Min. Negotiated Rate	$40.98
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Aetna of IA Medicare	$46.74
Rate for Payer: Amerigroup Medicaid	$41.39
Rate for Payer: Amerigroup Medicare	$41.41
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$41.00
Rate for Payer: Iowa Total Care Managed Medicaid	$40.98
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$41.00
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$41.62
Rate for Payer: Molina Healthcare Managed Medicare	$41.59
Rate for Payer: Oscar Health of IA Commercial	$61.50
Rate for Payer: Partners Health Alliance Commercial	$61.50
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38

CONTRAST BATH/PER 15 MIN

Facility

$82.00

Service Code	CPT 97034 GO
Hospital Charge Code	1373567
Hospital Revenue Code	430
Min. Negotiated Rate	$57.40
Max. Negotiated Rate	$73.80
Rate for Payer: Aetna of IA Commercial	$73.80
Rate for Payer: Aetna of IA Medical Rental Products	$73.80
Rate for Payer: Cash Price	$65.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$61.50
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: United Healthcare Commercial	$73.80

CONTROLLER FOR INTELLIS ADAPTIVESTIM

Facility

$1,971.00

Service Code	CPT C1778
Hospital Charge Code	8557560
Hospital Revenue Code	278
Min. Negotiated Rate	$985.11
Max. Negotiated Rate	$1,773.90
Rate for Payer: Aetna of IA Commercial	$1,773.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,773.90
Rate for Payer: Aetna of IA Medicare	$1,123.47
Rate for Payer: Amerigroup Medicaid	$994.76
Rate for Payer: Amerigroup Medicare	$995.36
Rate for Payer: Cash Price	$1,576.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,478.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$985.50
Rate for Payer: Iowa Total Care Managed Medicaid	$985.11
Rate for Payer: Medical Associates Commercial	$1,478.25
Rate for Payer: Medical Associates Managed Medicare	$985.50
Rate for Payer: Midlands Choice Commercial	$1,379.70
Rate for Payer: Molina Healthcare Managed Medicaid	$1,000.28
Rate for Payer: Molina Healthcare Managed Medicare	$999.69
Rate for Payer: Oscar Health of IA Commercial	$1,478.25
Rate for Payer: Partners Health Alliance Commercial	$1,478.25
Rate for Payer: United Healthcare Commercial	$1,773.90
Rate for Payer: United Healthcare Managed Medicare	$1,162.89

CONTROLLER FOR INTELLIS ADAPTIVESTIM

Facility

$1,971.00

Service Code	CPT C1778
Hospital Charge Code	8557560
Hospital Revenue Code	278
Min. Negotiated Rate	$1,379.70
Max. Negotiated Rate	$1,773.90
Rate for Payer: Aetna of IA Commercial	$1,773.90
Rate for Payer: Aetna of IA Medical Rental Products	$1,773.90
Rate for Payer: Cash Price	$1,576.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,478.25
Rate for Payer: Medical Associates Commercial	$1,478.25
Rate for Payer: Midlands Choice Commercial	$1,379.70
Rate for Payer: United Healthcare Commercial	$1,773.90

Control nasal hemorrhage, anterior, simple (limited cautery and/or packing) any method

Facility

$362.82

Service Code	CPT 30901
Hospital Revenue Code	490
Min. Negotiated Rate	$329.84
Max. Negotiated Rate	$362.82
Rate for Payer: Wellmark IA HMO	$329.84
Rate for Payer: Wellmark IA PPO	$362.82

CONTROL OF NOSEBLEED

Professional

Both

$730.00

Service Code	CPT 30903
Hospital Charge Code	7982781
Hospital Revenue Code	981
Min. Negotiated Rate	$69.26
Max. Negotiated Rate	$511.00
Rate for Payer: Aetna of IA Medicare	$69.26
Rate for Payer: Amerigroup Medicaid	$71.61
Rate for Payer: Cash Price	$584.00
Rate for Payer: Cash Price	$584.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.11
Rate for Payer: Iowa Total Care Managed Medicaid	$70.65
Rate for Payer: Medical Associates Commercial	$124.67
Rate for Payer: Medical Associates Managed Medicare	$69.26
Rate for Payer: Midlands Choice Commercial	$511.00
Rate for Payer: Oscar Health of IA Commercial	$119.82
Rate for Payer: Partners Health Alliance Commercial	$103.89

CONTROL OF NOSEBLEED

Professional

Both

$897.00

Service Code	CPT 30905
Hospital Charge Code	7982780
Hospital Revenue Code	981
Min. Negotiated Rate	$94.86
Max. Negotiated Rate	$627.90
Rate for Payer: Aetna of IA Medicare	$94.86
Rate for Payer: Amerigroup Medicaid	$98.09
Rate for Payer: Cash Price	$717.60
Rate for Payer: Cash Price	$717.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$113.83
Rate for Payer: Iowa Total Care Managed Medicaid	$96.76
Rate for Payer: Medical Associates Commercial	$170.75
Rate for Payer: Medical Associates Managed Medicare	$94.86
Rate for Payer: Midlands Choice Commercial	$627.90
Rate for Payer: Oscar Health of IA Commercial	$164.11
Rate for Payer: Partners Health Alliance Commercial	$142.29

Know your out-of-pocket cost for care.

All Charges