Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

CORD ABO/RH

Facility

$52.00

Service Code	CPT 86900
Hospital Charge Code	4022838
Hospital Revenue Code	302
Min. Negotiated Rate	$25.99
Max. Negotiated Rate	$107.07
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	$26.24
Rate for Payer: Amerigroup Medicare	$26.26
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	$26.00
Rate for Payer: Iowa Total Care Managed Medicaid	$25.99
Rate for Payer: Medical Associates Commercial	$39.00
Rate for Payer: Medical Associates Managed Medicare	$26.00
Rate for Payer: Midlands Choice Commercial	$36.40
Rate for Payer: Molina Healthcare Managed Medicaid	$26.39
Rate for Payer: Molina Healthcare Managed Medicare	$26.37
Rate for Payer: Oscar Health of IA Commercial	$39.00
Rate for Payer: Partners Health Alliance Commercial	$39.00
Rate for Payer: United Healthcare Commercial	$46.80
Rate for Payer: United Healthcare Managed Medicare	$30.68
Rate for Payer: Wellmark IA HMO	$97.34
Rate for Payer: Wellmark IA PPO	$107.07

CORD ABO/RH

Facility

$52.00

Service Code	CPT 86900
Hospital Charge Code	4022838
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

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80307
Hospital Charge Code	8558202
Hospital Revenue Code	301
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: United Healthcare Commercial	$258.30

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80301
Hospital Charge Code	7811988
Hospital Revenue Code	301
Min. Negotiated Rate	$143.44
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Aetna of IA Medicare	$163.59
Rate for Payer: Amerigroup Medicaid	$144.85
Rate for Payer: Amerigroup Medicare	$144.94
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$143.50
Rate for Payer: Iowa Total Care Managed Medicaid	$143.44
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Medical Associates Managed Medicare	$143.50
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: Molina Healthcare Managed Medicaid	$145.65
Rate for Payer: Molina Healthcare Managed Medicare	$145.57
Rate for Payer: Oscar Health of IA Commercial	$215.25
Rate for Payer: Partners Health Alliance Commercial	$215.25
Rate for Payer: United Healthcare Commercial	$258.30
Rate for Payer: United Healthcare Managed Medicare	$169.33

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80301
Hospital Charge Code	7811988
Hospital Revenue Code	301
Min. Negotiated Rate	$200.90
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: United Healthcare Commercial	$258.30

Cord Drug Screen Ref

Facility

$287.00

Service Code	CPT 80307
Hospital Charge Code	8558202
Hospital Revenue Code	301
Min. Negotiated Rate	$102.92
Max. Negotiated Rate	$258.30
Rate for Payer: Aetna of IA Commercial	$258.30
Rate for Payer: Aetna of IA Medical Rental Products	$258.30
Rate for Payer: Aetna of IA Medicare	$163.59
Rate for Payer: Amerigroup Medicaid	$144.85
Rate for Payer: Amerigroup Medicare	$144.94
Rate for Payer: Cash Price	$229.60
Rate for Payer: Cash Price	$229.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$215.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$143.50
Rate for Payer: Iowa Total Care Managed Medicaid	$143.44
Rate for Payer: Medical Associates Commercial	$215.25
Rate for Payer: Medical Associates Managed Medicare	$143.50
Rate for Payer: Midlands Choice Commercial	$200.90
Rate for Payer: Molina Healthcare Managed Medicaid	$145.65
Rate for Payer: Molina Healthcare Managed Medicare	$145.57
Rate for Payer: Oscar Health of IA Commercial	$215.25
Rate for Payer: Partners Health Alliance Commercial	$215.25
Rate for Payer: United Healthcare Commercial	$258.30
Rate for Payer: United Healthcare Managed Medicare	$169.33
Rate for Payer: Wellmark IA HMO	$102.92
Rate for Payer: Wellmark IA PPO	$113.21

CORKSCREW BIO 3.7MM X 17.9

Facility

$621.00

Service Code	CPT C1713
Hospital Charge Code	8046879
Hospital Revenue Code	278
Min. Negotiated Rate	$310.38
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Aetna of IA Medicare	$353.97
Rate for Payer: Amerigroup Medicaid	$313.42
Rate for Payer: Amerigroup Medicare	$313.60
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$310.50
Rate for Payer: Iowa Total Care Managed Medicaid	$310.38
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Medical Associates Managed Medicare	$310.50
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: Molina Healthcare Managed Medicaid	$315.16
Rate for Payer: Molina Healthcare Managed Medicare	$314.97
Rate for Payer: Oscar Health of IA Commercial	$465.75
Rate for Payer: Partners Health Alliance Commercial	$465.75
Rate for Payer: United Healthcare Commercial	$558.90
Rate for Payer: United Healthcare Managed Medicare	$366.39

CORKSCREW BIO 3.7MM X 17.9

Facility

$621.00

Service Code	CPT C1713
Hospital Charge Code	8046879
Hospital Revenue Code	278
Min. Negotiated Rate	$434.70
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: United Healthcare Commercial	$558.90

CORKSCREW BIO 4.5

Facility

$591.00

Service Code	CPT C1713
Hospital Charge Code	8026413
Hospital Revenue Code	278
Min. Negotiated Rate	$413.70
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of IA Commercial	$531.90
Rate for Payer: Aetna of IA Medical Rental Products	$531.90
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$443.25
Rate for Payer: Medical Associates Commercial	$443.25
Rate for Payer: Midlands Choice Commercial	$413.70
Rate for Payer: United Healthcare Commercial	$531.90

CORKSCREW BIO 4.5

Facility

$591.00

Service Code	CPT C1713
Hospital Charge Code	8026413
Hospital Revenue Code	278
Min. Negotiated Rate	$295.38
Max. Negotiated Rate	$531.90
Rate for Payer: Aetna of IA Commercial	$531.90
Rate for Payer: Aetna of IA Medical Rental Products	$531.90
Rate for Payer: Aetna of IA Medicare	$336.87
Rate for Payer: Amerigroup Medicaid	$298.28
Rate for Payer: Amerigroup Medicare	$298.46
Rate for Payer: Cash Price	$472.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$443.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$295.50
Rate for Payer: Iowa Total Care Managed Medicaid	$295.38
Rate for Payer: Medical Associates Commercial	$443.25
Rate for Payer: Medical Associates Managed Medicare	$295.50
Rate for Payer: Midlands Choice Commercial	$413.70
Rate for Payer: Molina Healthcare Managed Medicaid	$299.93
Rate for Payer: Molina Healthcare Managed Medicare	$299.76
Rate for Payer: Oscar Health of IA Commercial	$443.25
Rate for Payer: Partners Health Alliance Commercial	$443.25
Rate for Payer: United Healthcare Commercial	$531.90
Rate for Payer: United Healthcare Managed Medicare	$348.69

CORKSCREW BIO 5.5

Facility

$621.00

Service Code	CPT C1713
Hospital Charge Code	8026415
Hospital Revenue Code	278
Min. Negotiated Rate	$434.70
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: United Healthcare Commercial	$558.90

CORKSCREW BIO 5.5

Facility

$621.00

Service Code	CPT C1713
Hospital Charge Code	8026415
Hospital Revenue Code	278
Min. Negotiated Rate	$310.38
Max. Negotiated Rate	$558.90
Rate for Payer: Aetna of IA Commercial	$558.90
Rate for Payer: Aetna of IA Medical Rental Products	$558.90
Rate for Payer: Aetna of IA Medicare	$353.97
Rate for Payer: Amerigroup Medicaid	$313.42
Rate for Payer: Amerigroup Medicare	$313.60
Rate for Payer: Cash Price	$496.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$465.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$310.50
Rate for Payer: Iowa Total Care Managed Medicaid	$310.38
Rate for Payer: Medical Associates Commercial	$465.75
Rate for Payer: Medical Associates Managed Medicare	$310.50
Rate for Payer: Midlands Choice Commercial	$434.70
Rate for Payer: Molina Healthcare Managed Medicaid	$315.16
Rate for Payer: Molina Healthcare Managed Medicare	$314.97
Rate for Payer: Oscar Health of IA Commercial	$465.75
Rate for Payer: Partners Health Alliance Commercial	$465.75
Rate for Payer: United Healthcare Commercial	$558.90
Rate for Payer: United Healthcare Managed Medicare	$366.39

CORKSCREW BIO 6.5

Facility

$609.00

Service Code	CPT C1713
Hospital Charge Code	8026414
Hospital Revenue Code	278
Min. Negotiated Rate	$426.30
Max. Negotiated Rate	$548.10
Rate for Payer: Aetna of IA Commercial	$548.10
Rate for Payer: Aetna of IA Medical Rental Products	$548.10
Rate for Payer: Cash Price	$487.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$456.75
Rate for Payer: Medical Associates Commercial	$456.75
Rate for Payer: Midlands Choice Commercial	$426.30
Rate for Payer: United Healthcare Commercial	$548.10

CORKSCREW BIO 6.5

Facility

$609.00

Service Code	CPT C1713
Hospital Charge Code	8026414
Hospital Revenue Code	278
Min. Negotiated Rate	$304.38
Max. Negotiated Rate	$548.10
Rate for Payer: Aetna of IA Commercial	$548.10
Rate for Payer: Aetna of IA Medical Rental Products	$548.10
Rate for Payer: Aetna of IA Medicare	$347.13
Rate for Payer: Amerigroup Medicaid	$307.36
Rate for Payer: Amerigroup Medicare	$307.54
Rate for Payer: Cash Price	$487.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$456.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$304.50
Rate for Payer: Iowa Total Care Managed Medicaid	$304.38
Rate for Payer: Medical Associates Commercial	$456.75
Rate for Payer: Medical Associates Managed Medicare	$304.50
Rate for Payer: Midlands Choice Commercial	$426.30
Rate for Payer: Molina Healthcare Managed Medicaid	$309.07
Rate for Payer: Molina Healthcare Managed Medicare	$308.88
Rate for Payer: Oscar Health of IA Commercial	$456.75
Rate for Payer: Partners Health Alliance Commercial	$456.75
Rate for Payer: United Healthcare Commercial	$548.10
Rate for Payer: United Healthcare Managed Medicare	$359.31

Coronary Bypass With Cardiac Catheterization With MCC

Facility

$53,256.33

Service Code	MS-DRG 233
Hospital Charge Code	97
Min. Negotiated Rate	$52,484.50
Max. Negotiated Rate	$53,256.33
Rate for Payer: Amerigroup Medicaid	$52,999.05
Rate for Payer: Iowa Total Care Managed Medicaid	$52,484.50
Rate for Payer: Molina Healthcare Managed Medicaid	$53,256.33

Coronary Bypass With Cardiac Catheterization Without MCC

Facility

$46,882.37

Service Code	MS-DRG 234
Hospital Charge Code	98
Min. Negotiated Rate	$46,202.92
Max. Negotiated Rate	$46,882.37
Rate for Payer: Amerigroup Medicaid	$46,655.89
Rate for Payer: Iowa Total Care Managed Medicaid	$46,202.92
Rate for Payer: Molina Healthcare Managed Medicaid	$46,882.37

Coronary Bypass Without Cardiac Catheterization With MCC

Facility

$44,024.14

Service Code	MS-DRG 235
Hospital Charge Code	99
Min. Negotiated Rate	$43,386.11
Max. Negotiated Rate	$44,024.14
Rate for Payer: Amerigroup Medicaid	$43,811.46
Rate for Payer: Iowa Total Care Managed Medicaid	$43,386.11
Rate for Payer: Molina Healthcare Managed Medicaid	$44,024.14

Coronary Bypass Without Cardiac Catheterization Without MCC

Facility

$36,385.45

Service Code	MS-DRG 236
Hospital Charge Code	100
Min. Negotiated Rate	$35,858.12
Max. Negotiated Rate	$36,385.45
Rate for Payer: Amerigroup Medicaid	$36,209.67
Rate for Payer: Iowa Total Care Managed Medicaid	$35,858.12
Rate for Payer: Molina Healthcare Managed Medicaid	$36,385.45

Coronary Bypass With PTCA With MCC

Facility

$62,610.56

Service Code	MS-DRG 231
Hospital Charge Code	95
Min. Negotiated Rate	$61,703.16
Max. Negotiated Rate	$62,610.56
Rate for Payer: Amerigroup Medicaid	$62,308.09
Rate for Payer: Iowa Total Care Managed Medicaid	$61,703.16
Rate for Payer: Molina Healthcare Managed Medicaid	$62,610.56

Coronary Bypass With PTCA Without MCC

Facility

$61,019.04

Service Code	MS-DRG 232
Hospital Charge Code	96
Min. Negotiated Rate	$60,134.70
Max. Negotiated Rate	$61,019.04
Rate for Payer: Amerigroup Medicaid	$60,724.26
Rate for Payer: Iowa Total Care Managed Medicaid	$60,134.70
Rate for Payer: Molina Healthcare Managed Medicaid	$61,019.04

Coronavirus 2019 Novel (SARS-CoV-2) DMCL

Facility

$338.00

Service Code	CPT U0002
Hospital Charge Code	8944439
Hospital Revenue Code	300
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: United Healthcare Commercial	$304.20

Coronavirus 2019 Novel (SARS-CoV-2) DMCL

Facility

$338.00

Service Code	CPT U0002
Hospital Charge Code	8944439
Hospital Revenue Code	300
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Aetna of IA Medicare	$192.66
Rate for Payer: Amerigroup Medicaid	$170.59
Rate for Payer: Amerigroup Medicare	$170.69
Rate for Payer: Cash Price	$270.40
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$169.00
Rate for Payer: Iowa Total Care Managed Medicaid	$168.93
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Medical Associates Managed Medicare	$169.00
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: Molina Healthcare Managed Medicaid	$171.54
Rate for Payer: Molina Healthcare Managed Medicare	$171.43
Rate for Payer: Oscar Health of IA Commercial	$253.50
Rate for Payer: Partners Health Alliance Commercial	$253.50
Rate for Payer: United Healthcare Commercial	$304.20
Rate for Payer: United Healthcare Managed Medicare	$199.42
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

Coronavirus 2019 Novel (SARS-CoV-2) IgG Ab DMCL

Facility

$150.00

Service Code	CPT 86769
Hospital Charge Code	8788720
Hospital Revenue Code	302
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

Coronavirus 2019 Novel (SARS-CoV-2) IgG Ab DMCL

Facility

$150.00

Service Code	CPT 86769
Hospital Charge Code	8788720
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
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: Molina Healthcare Managed Medicare	$76.08
Rate for Payer: Oscar Health of IA Commercial	$112.50
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	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Coronavirus 2019 Novel Screening PCR

Facility

$338.00

Service Code	CPT 87635 CS
Hospital Charge Code	8783451
Hospital Revenue Code	306
Min. Negotiated Rate	$236.60
Max. Negotiated Rate	$304.20
Rate for Payer: Aetna of IA Commercial	$304.20
Rate for Payer: Aetna of IA Medical Rental Products	$304.20
Rate for Payer: Cash Price	$270.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$253.50
Rate for Payer: Medical Associates Commercial	$253.50
Rate for Payer: Midlands Choice Commercial	$236.60
Rate for Payer: United Healthcare Commercial	$304.20

Know your out-of-pocket cost for care.

All Charges