Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

COLORECTAL CANCER SCREENING; COLONOSCOPY ON INDIVIDUAL NOT MEETING CRITERIA FOR HIGH RISK

Facility

$2,844.40

Service Code	CPT G0121
Hospital Revenue Code	750
Min. Negotiated Rate	$2,582.18
Max. Negotiated Rate	$2,844.40
Rate for Payer: Wellmark IA HMO WHPI	$2,582.18
Rate for Payer: Wellmark IA PPO	$2,844.40

COLORECTAL CANCER SCREENING; FLEXIBLE SIGMOIDOSCOPY

Facility

$2,844.40

Service Code	CPT G0104
Hospital Revenue Code	750
Min. Negotiated Rate	$2,582.18
Max. Negotiated Rate	$2,844.40
Rate for Payer: Wellmark IA HMO WHPI	$2,582.18
Rate for Payer: Wellmark IA PPO	$2,844.40

Colposcopy of cervix w/loop electrode bx of cervix

Professional

Both

$1,024.00

Service Code	CPT 57460
Hospital Charge Code	8068975
Hospital Revenue Code	975
Min. Negotiated Rate	$257.33
Max. Negotiated Rate	$768.00
Rate for Payer: Amerigroup Medicaid	$259.85
Rate for Payer: Cash Price	$819.20
Rate for Payer: Cash Price	$819.20
Rate for Payer: Iowa Total Care Managed Medicaid	$257.33
Rate for Payer: Medical Associates Commercial	$768.00
Rate for Payer: Midlands Choice Commercial	$716.80
Rate for Payer: Molina Healthcare Managed Medicaid	$258.59
Rate for Payer: Partners Health Alliance Commercial	$768.00
Rate for Payer: United Healthcare Commercial	$462.77
Rate for Payer: Wellmark IA HMO WHPI	$594.40
Rate for Payer: Wellmark IA PPO	$699.30

COLPOSCOPY W/BIOPSIES ECC

Professional

Both

$506.00

Service Code	CPT 57454
Hospital Charge Code	8378889
Hospital Revenue Code	975
Min. Negotiated Rate	$141.34
Max. Negotiated Rate	$379.50
Rate for Payer: Amerigroup Medicaid	$142.73
Rate for Payer: Cash Price	$404.80
Rate for Payer: Cash Price	$404.80
Rate for Payer: Iowa Total Care Managed Medicaid	$141.34
Rate for Payer: Medical Associates Commercial	$379.50
Rate for Payer: Midlands Choice Commercial	$354.20
Rate for Payer: Molina Healthcare Managed Medicaid	$142.03
Rate for Payer: Partners Health Alliance Commercial	$379.50
Rate for Payer: United Healthcare Commercial	$248.86
Rate for Payer: Wellmark IA HMO WHPI	$320.80
Rate for Payer: Wellmark IA PPO	$377.40

COMPATIBLE

Facility

$81.00

Service Code	CPT 86922
Hospital Charge Code	5850785
Hospital Revenue Code	302
Min. Negotiated Rate	$36.45
Max. Negotiated Rate	$153.86
Rate for Payer: Aetna of IA Commercial	$72.90
Rate for Payer: Aetna of IA Medical Rental Products	$72.90
Rate for Payer: Aetna of IA Medicare	$46.17
Rate for Payer: Amerigroup Medicaid	$46.72
Rate for Payer: Amerigroup Medicare	$36.81
Rate for Payer: Cash Price	$64.80
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$60.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$36.45
Rate for Payer: Iowa Total Care Managed Medicaid	$46.27
Rate for Payer: Medical Associates Commercial	$60.75
Rate for Payer: Medical Associates Managed Medicare	$36.45
Rate for Payer: Midlands Choice Commercial	$56.70
Rate for Payer: Molina Healthcare Managed Medicaid	$46.95
Rate for Payer: Partners Health Alliance Commercial	$41.92
Rate for Payer: United Healthcare Commercial	$72.90
Rate for Payer: United Healthcare Managed Medicare	$47.79
Rate for Payer: Wellmark IA HMO WHPI	$139.67
Rate for Payer: Wellmark IA PPO	$153.86

COMPATIBLE

Facility

$81.00

Service Code	CPT 86922
Hospital Charge Code	5850785
Hospital Revenue Code	302
Min. Negotiated Rate	$56.70
Max. Negotiated Rate	$72.90
Rate for Payer: Aetna of IA Commercial	$72.90
Rate for Payer: Aetna of IA Medical Rental Products	$72.90
Rate for Payer: Cash Price	$64.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$60.75
Rate for Payer: Medical Associates Commercial	$60.75
Rate for Payer: Midlands Choice Commercial	$56.70
Rate for Payer: United Healthcare Commercial	$72.90

Complement C3 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037514
Hospital Revenue Code	302
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

Complement C3 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037514
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$56.53
Rate for Payer: Amerigroup Medicare	$44.54
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.10
Rate for Payer: Iowa Total Care Managed Medicaid	$55.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$44.10
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$56.80
Rate for Payer: Partners Health Alliance Commercial	$50.72
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

Complement C4 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037515
Hospital Revenue Code	302
Min. Negotiated Rate	$41.83
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$56.53
Rate for Payer: Amerigroup Medicare	$44.54
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$44.10
Rate for Payer: Iowa Total Care Managed Medicaid	$55.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$44.10
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$56.80
Rate for Payer: Partners Health Alliance Commercial	$50.72
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82
Rate for Payer: Wellmark IA HMO WHPI	$41.83
Rate for Payer: Wellmark IA PPO	$46.08

Complement C4 DMCL

Facility

$98.00

Service Code	CPT 86160
Hospital Charge Code	8037515
Hospital Revenue Code	302
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

Complete Blood Count w Man Diff DMCL

Facility

$66.00

Service Code	CPT 85027
Hospital Charge Code	8037516
Hospital Revenue Code	305
Min. Negotiated Rate	$29.07
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Aetna of IA Medicare	$37.62
Rate for Payer: Amerigroup Medicaid	$38.07
Rate for Payer: Amerigroup Medicare	$30.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.70
Rate for Payer: Iowa Total Care Managed Medicaid	$37.70
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Medical Associates Managed Medicare	$29.70
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: Molina Healthcare Managed Medicaid	$38.25
Rate for Payer: Partners Health Alliance Commercial	$34.16
Rate for Payer: United Healthcare Commercial	$59.40
Rate for Payer: United Healthcare Managed Medicare	$38.94
Rate for Payer: Wellmark IA HMO WHPI	$29.07
Rate for Payer: Wellmark IA PPO	$32.02

Complete Blood Count w Man Diff DMCL

Facility

$66.00

Service Code	CPT 85027
Hospital Charge Code	8037516
Hospital Revenue Code	305
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: United Healthcare Commercial	$59.40

COMPLEX DRAINAGE WOUND

Facility

$2,100.00

Service Code	CPT 10180
Hospital Charge Code	4862803
Hospital Revenue Code	450
Min. Negotiated Rate	$945.00
Max. Negotiated Rate	$4,090.88
Rate for Payer: Aetna of IA Commercial	$1,890.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,890.00
Rate for Payer: Aetna of IA Medicare	$1,197.00
Rate for Payer: Amerigroup Medicaid	$1,211.28
Rate for Payer: Amerigroup Medicare	$954.45
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,575.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$945.00
Rate for Payer: Iowa Total Care Managed Medicaid	$1,199.52
Rate for Payer: Medical Associates Commercial	$1,575.00
Rate for Payer: Medical Associates Managed Medicare	$945.00
Rate for Payer: Midlands Choice Commercial	$1,470.00
Rate for Payer: Molina Healthcare Managed Medicaid	$1,217.16
Rate for Payer: Partners Health Alliance Commercial	$1,086.75
Rate for Payer: United Healthcare Commercial	$1,890.00
Rate for Payer: United Healthcare Managed Medicare	$1,239.00
Rate for Payer: Wellmark IA HMO WHPI	$3,713.74
Rate for Payer: Wellmark IA PPO	$4,090.88

COMPLEX DRAINAGE WOUND

Facility

$2,100.00

Service Code	CPT 10180
Hospital Charge Code	4862803
Hospital Revenue Code	450
Min. Negotiated Rate	$1,470.00
Max. Negotiated Rate	$1,890.00
Rate for Payer: Aetna of IA Commercial	$1,890.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,890.00
Rate for Payer: Cash Price	$1,680.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,575.00
Rate for Payer: Medical Associates Commercial	$1,575.00
Rate for Payer: Midlands Choice Commercial	$1,470.00
Rate for Payer: United Healthcare Commercial	$1,890.00

COMPLICATED PEPTIC ULCER WITH CC

Facility

$8,934.63

Service Code	MSDRG 381
Min. Negotiated Rate	$8,805.14
Max. Negotiated Rate	$8,934.63
Rate for Payer: Amerigroup Medicaid	$8,891.46
Rate for Payer: Iowa Total Care Managed Medicaid	$8,805.14
Rate for Payer: Molina Healthcare Managed Medicaid	$8,934.63

COMPLICATED PEPTIC ULCER WITH MCC

Facility

$16,272.62

Service Code	MSDRG 380
Min. Negotiated Rate	$16,036.78
Max. Negotiated Rate	$16,272.62
Rate for Payer: Amerigroup Medicaid	$16,194.00
Rate for Payer: Iowa Total Care Managed Medicaid	$16,036.78
Rate for Payer: Molina Healthcare Managed Medicaid	$16,272.62

COMPLICATED PEPTIC ULCER WITHOUT CC/MCC

Facility

$8,098.03

Service Code	MSDRG 382
Min. Negotiated Rate	$7,980.66
Max. Negotiated Rate	$8,098.03
Rate for Payer: Amerigroup Medicaid	$8,058.90
Rate for Payer: Iowa Total Care Managed Medicaid	$7,980.66
Rate for Payer: Molina Healthcare Managed Medicaid	$8,098.03

COMPLICATIONS OF TREATMENT WITH CC

Facility

$11,066.10

Service Code	MSDRG 920
Min. Negotiated Rate	$10,905.72
Max. Negotiated Rate	$11,066.10
Rate for Payer: Amerigroup Medicaid	$11,012.64
Rate for Payer: Iowa Total Care Managed Medicaid	$10,905.72
Rate for Payer: Molina Healthcare Managed Medicaid	$11,066.10

COMPLICATIONS OF TREATMENT WITH MCC

Facility

$14,265.00

Service Code	MSDRG 919
Min. Negotiated Rate	$14,058.26
Max. Negotiated Rate	$14,265.00
Rate for Payer: Amerigroup Medicaid	$14,196.08
Rate for Payer: Iowa Total Care Managed Medicaid	$14,058.26
Rate for Payer: Molina Healthcare Managed Medicaid	$14,265.00

COMPLICATIONS OF TREATMENT WITHOUT CC/MCC

Facility

$5,355.15

Service Code	MSDRG 921
Min. Negotiated Rate	$5,277.53
Max. Negotiated Rate	$5,355.15
Rate for Payer: Amerigroup Medicaid	$5,329.27
Rate for Payer: Iowa Total Care Managed Medicaid	$5,277.53
Rate for Payer: Molina Healthcare Managed Medicaid	$5,355.15

COMPOSITE CORKSCREW 5.5 SUTURE ANCHOR

Facility

$549.00

Service Code	HCPCS C1713
Hospital Charge Code	8026044
Hospital Revenue Code	278
Min. Negotiated Rate	$384.30
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of IA Commercial	$494.10
Rate for Payer: Aetna of IA Medical Rental Products	$494.10
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$411.75
Rate for Payer: Medical Associates Commercial	$411.75
Rate for Payer: Midlands Choice Commercial	$384.30
Rate for Payer: United Healthcare Commercial	$494.10

COMPOSITE CORKSCREW 5.5 SUTURE ANCHOR

Facility

$549.00

Service Code	HCPCS C1713
Hospital Charge Code	8026044
Hospital Revenue Code	278
Min. Negotiated Rate	$247.05
Max. Negotiated Rate	$494.10
Rate for Payer: Aetna of IA Commercial	$494.10
Rate for Payer: Aetna of IA Medical Rental Products	$494.10
Rate for Payer: Aetna of IA Medicare	$312.93
Rate for Payer: Amerigroup Medicaid	$316.66
Rate for Payer: Amerigroup Medicare	$249.52
Rate for Payer: Cash Price	$439.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$411.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$247.05
Rate for Payer: Iowa Total Care Managed Medicaid	$313.59
Rate for Payer: Medical Associates Commercial	$411.75
Rate for Payer: Medical Associates Managed Medicare	$247.05
Rate for Payer: Midlands Choice Commercial	$384.30
Rate for Payer: Molina Healthcare Managed Medicaid	$318.20
Rate for Payer: Partners Health Alliance Commercial	$284.11
Rate for Payer: United Healthcare Commercial	$494.10
Rate for Payer: United Healthcare Managed Medicare	$323.91

COMPOSITE MESH 15CM SYMBOTEX

Facility

$1,320.00

Service Code	HCPCS C1781
Hospital Charge Code	9004789
Hospital Revenue Code	278
Min. Negotiated Rate	$924.00
Max. Negotiated Rate	$1,188.00
Rate for Payer: Aetna of IA Commercial	$1,188.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,188.00
Rate for Payer: Cash Price	$1,056.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$990.00
Rate for Payer: Medical Associates Commercial	$990.00
Rate for Payer: Midlands Choice Commercial	$924.00
Rate for Payer: United Healthcare Commercial	$1,188.00

COMPOSITE MESH 15CM SYMBOTEX

Facility

$1,320.00

Service Code	HCPCS C1781
Hospital Charge Code	9004789
Hospital Revenue Code	278
Min. Negotiated Rate	$594.00
Max. Negotiated Rate	$1,188.00
Rate for Payer: Aetna of IA Commercial	$1,188.00
Rate for Payer: Aetna of IA Medical Rental Products	$1,188.00
Rate for Payer: Aetna of IA Medicare	$752.40
Rate for Payer: Amerigroup Medicaid	$761.38
Rate for Payer: Amerigroup Medicare	$599.94
Rate for Payer: Cash Price	$1,056.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$990.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$594.00
Rate for Payer: Iowa Total Care Managed Medicaid	$753.98
Rate for Payer: Medical Associates Commercial	$990.00
Rate for Payer: Medical Associates Managed Medicare	$594.00
Rate for Payer: Midlands Choice Commercial	$924.00
Rate for Payer: Molina Healthcare Managed Medicaid	$765.07
Rate for Payer: Partners Health Alliance Commercial	$683.10
Rate for Payer: United Healthcare Commercial	$1,188.00
Rate for Payer: United Healthcare Managed Medicare	$778.80

COMPOSITE SKIN GRAFT

Facility

$1,823.00

Service Code	CPT 15760
Hospital Charge Code	7982945
Hospital Revenue Code	450
Min. Negotiated Rate	$1,276.10
Max. Negotiated Rate	$1,640.70
Rate for Payer: Aetna of IA Commercial	$1,640.70
Rate for Payer: Aetna of IA Medical Rental Products	$1,640.70
Rate for Payer: Cash Price	$1,458.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,367.25
Rate for Payer: Medical Associates Commercial	$1,367.25
Rate for Payer: Midlands Choice Commercial	$1,276.10
Rate for Payer: United Healthcare Commercial	$1,640.70

Know your out-of-pocket cost for care.

All Charges