Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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

COMPREHENSIVE METABOLIC PANEL

Facility

$198.00

Service Code	CPT 80053
Hospital Charge Code	633709
Hospital Revenue Code	301
Min. Negotiated Rate	$60.97
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82
Rate for Payer: Wellmark IA HMO WHPI	$60.97
Rate for Payer: Wellmark IA PPO	$67.17

COMPREHENSIVE METABOLIC PANEL

Facility

$198.00

Service Code	CPT 80053
Hospital Charge Code	633709
Hospital Revenue Code	301
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

COMPUTER XM OK

Facility

$73.00

Service Code	CPT 86920
Hospital Charge Code	6306782
Hospital Revenue Code	302
Min. Negotiated Rate	$32.85
Max. Negotiated Rate	$153.86
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	$139.67
Rate for Payer: Wellmark IA PPO	$153.86

COMPUTER XM OK

Facility

$73.00

Service Code	CPT 86920
Hospital Charge Code	6306782
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

CONCELLTRATE 100 2.5CC JAR

Facility

$2,205.00

Service Code	HCPCS C1713
Hospital Charge Code	8463706
Hospital Revenue Code	278
Min. Negotiated Rate	$992.25
Max. Negotiated Rate	$1,984.50
Rate for Payer: Aetna of IA Commercial	$1,984.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,984.50
Rate for Payer: Aetna of IA Medicare	$1,256.85
Rate for Payer: Amerigroup Medicaid	$1,271.84
Rate for Payer: Amerigroup Medicare	$1,002.17
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,653.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$992.25
Rate for Payer: Iowa Total Care Managed Medicaid	$1,259.50
Rate for Payer: Medical Associates Commercial	$1,653.75
Rate for Payer: Medical Associates Managed Medicare	$992.25
Rate for Payer: Midlands Choice Commercial	$1,543.50
Rate for Payer: Molina Healthcare Managed Medicaid	$1,278.02
Rate for Payer: Partners Health Alliance Commercial	$1,141.09
Rate for Payer: United Healthcare Commercial	$1,984.50
Rate for Payer: United Healthcare Managed Medicare	$1,300.95

CONCELLTRATE 100 2.5CC JAR

Facility

$2,205.00

Service Code	HCPCS C1713
Hospital Charge Code	8463706
Hospital Revenue Code	278
Min. Negotiated Rate	$1,543.50
Max. Negotiated Rate	$1,984.50
Rate for Payer: Aetna of IA Commercial	$1,984.50
Rate for Payer: Aetna of IA Medical Rental Products	$1,984.50
Rate for Payer: Cash Price	$1,764.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,653.75
Rate for Payer: Medical Associates Commercial	$1,653.75
Rate for Payer: Midlands Choice Commercial	$1,543.50
Rate for Payer: United Healthcare Commercial	$1,984.50

CONCUSSION WITH CC

Facility

$10,107.90

Service Code	MSDRG 089
Min. Negotiated Rate	$9,961.40
Max. Negotiated Rate	$10,107.90
Rate for Payer: Amerigroup Medicaid	$10,059.06
Rate for Payer: Iowa Total Care Managed Medicaid	$9,961.40
Rate for Payer: Molina Healthcare Managed Medicaid	$10,107.90

CONCUSSION WITH MCC

Facility

$16,435.89

Service Code	MSDRG 088
Min. Negotiated Rate	$16,197.68
Max. Negotiated Rate	$16,435.89
Rate for Payer: Amerigroup Medicaid	$16,356.48
Rate for Payer: Iowa Total Care Managed Medicaid	$16,197.68
Rate for Payer: Molina Healthcare Managed Medicaid	$16,435.89

CONCUSSION WITHOUT CC/MCC

Facility

$5,759.37

Service Code	MSDRG 090
Min. Negotiated Rate	$5,675.90
Max. Negotiated Rate	$5,759.37
Rate for Payer: Amerigroup Medicaid	$5,731.55
Rate for Payer: Iowa Total Care Managed Medicaid	$5,675.90
Rate for Payer: Molina Healthcare Managed Medicaid	$5,759.37

CONNECTIVE TISSUE DISORDERS WITH CC

Facility

$13,669.36

Service Code	MSDRG 546
Min. Negotiated Rate	$13,471.25
Max. Negotiated Rate	$13,669.36
Rate for Payer: Amerigroup Medicaid	$13,603.32
Rate for Payer: Iowa Total Care Managed Medicaid	$13,471.25
Rate for Payer: Molina Healthcare Managed Medicaid	$13,669.36

CONNECTIVE TISSUE DISORDERS WITH MCC

Facility

$19,196.78

Service Code	MSDRG 545
Min. Negotiated Rate	$18,918.56
Max. Negotiated Rate	$19,196.78
Rate for Payer: Amerigroup Medicaid	$19,104.04
Rate for Payer: Iowa Total Care Managed Medicaid	$18,918.56
Rate for Payer: Molina Healthcare Managed Medicaid	$19,196.78

CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC

Facility

$9,017.95

Service Code	MSDRG 547
Min. Negotiated Rate	$8,887.25
Max. Negotiated Rate	$9,017.95
Rate for Payer: Amerigroup Medicaid	$8,974.38
Rate for Payer: Iowa Total Care Managed Medicaid	$8,887.25
Rate for Payer: Molina Healthcare Managed Medicaid	$9,017.95

CONSCIOUS SED-ER >5 1ST 30 MIN

Facility

$195.00

Hospital Charge Code	4866823
Hospital Revenue Code	450
Min. Negotiated Rate	$87.75
Max. Negotiated Rate	$175.50
Rate for Payer: Aetna of IA Commercial	$175.50
Rate for Payer: Aetna of IA Medical Rental Products	$175.50
Rate for Payer: Aetna of IA Medicare	$111.15
Rate for Payer: Amerigroup Medicaid	$112.48
Rate for Payer: Amerigroup Medicare	$88.63
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$146.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$87.75
Rate for Payer: Iowa Total Care Managed Medicaid	$111.38
Rate for Payer: Medical Associates Commercial	$146.25
Rate for Payer: Medical Associates Managed Medicare	$87.75
Rate for Payer: Midlands Choice Commercial	$136.50
Rate for Payer: Molina Healthcare Managed Medicaid	$113.02
Rate for Payer: Partners Health Alliance Commercial	$100.91
Rate for Payer: United Healthcare Commercial	$175.50
Rate for Payer: United Healthcare Managed Medicare	$115.05

CONSCIOUS SED-ER >5 1ST 30 MIN

Facility

$195.00

Hospital Charge Code	4866823
Hospital Revenue Code	450
Min. Negotiated Rate	$136.50
Max. Negotiated Rate	$175.50
Rate for Payer: Aetna of IA Commercial	$175.50
Rate for Payer: Aetna of IA Medical Rental Products	$175.50
Rate for Payer: Cash Price	$156.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$146.25
Rate for Payer: Medical Associates Commercial	$146.25
Rate for Payer: Midlands Choice Commercial	$136.50
Rate for Payer: United Healthcare Commercial	$175.50

CONSCIOUS SED-ER EA ADDL 15MIN

Facility

$25.00

Service Code	CPT 99153
Hospital Charge Code	4866821
Hospital Revenue Code	450
Min. Negotiated Rate	$11.25
Max. Negotiated Rate	$57.79
Rate for Payer: Aetna of IA Commercial	$22.50
Rate for Payer: Aetna of IA Medical Rental Products	$22.50
Rate for Payer: Aetna of IA Medicare	$14.25
Rate for Payer: Amerigroup Medicaid	$14.42
Rate for Payer: Amerigroup Medicare	$11.36
Rate for Payer: Cash Price	$20.00
Rate for Payer: Cash Price	$20.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$11.25
Rate for Payer: Iowa Total Care Managed Medicaid	$14.28
Rate for Payer: Medical Associates Commercial	$18.75
Rate for Payer: Medical Associates Managed Medicare	$11.25
Rate for Payer: Midlands Choice Commercial	$17.50
Rate for Payer: Molina Healthcare Managed Medicaid	$14.49
Rate for Payer: Partners Health Alliance Commercial	$12.94
Rate for Payer: United Healthcare Commercial	$22.50
Rate for Payer: United Healthcare Managed Medicare	$14.75
Rate for Payer: Wellmark IA HMO WHPI	$52.47
Rate for Payer: Wellmark IA PPO	$57.79

CONSCIOUS SED-ER EA ADDL 15MIN

Facility

$25.00

Service Code	CPT 99153
Hospital Charge Code	4866821
Hospital Revenue Code	450
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$22.50
Rate for Payer: Aetna of IA Commercial	$22.50
Rate for Payer: Aetna of IA Medical Rental Products	$22.50
Rate for Payer: Cash Price	$20.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.75
Rate for Payer: Medical Associates Commercial	$18.75
Rate for Payer: Midlands Choice Commercial	$17.50
Rate for Payer: United Healthcare Commercial	$22.50

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	$105.75
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	$135.55
Rate for Payer: Amerigroup Medicare	$106.81
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	$105.75
Rate for Payer: Iowa Total Care Managed Medicaid	$134.23
Rate for Payer: Medical Associates Commercial	$176.25
Rate for Payer: Medical Associates Managed Medicare	$105.75
Rate for Payer: Midlands Choice Commercial	$164.50
Rate for Payer: Molina Healthcare Managed Medicaid	$136.21
Rate for Payer: Partners Health Alliance Commercial	$121.61
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	$46.80
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: Aetna of IA Medicare	$59.28
Rate for Payer: Amerigroup Medicaid	$59.99
Rate for Payer: Amerigroup Medicare	$47.27
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	$46.80
Rate for Payer: Iowa Total Care Managed Medicaid	$59.40
Rate for Payer: Medical Associates Commercial	$78.00
Rate for Payer: Medical Associates Managed Medicare	$46.80
Rate for Payer: Midlands Choice Commercial	$72.80
Rate for Payer: Molina Healthcare Managed Medicaid	$60.28
Rate for Payer: Partners Health Alliance Commercial	$53.82
Rate for Payer: United Healthcare Commercial	$93.60
Rate for Payer: United Healthcare Managed Medicare	$61.36
Rate for Payer: Wellmark IA HMO WHPI	$75.15
Rate for Payer: Wellmark IA PPO	$82.79

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

CONTRACEPTIVE CAPS INSERTION CHARGE

Professional

Both

$345.00

Service Code	CPT 11981
Hospital Charge Code	8068935
Hospital Revenue Code	975
Min. Negotiated Rate	$109.59
Max. Negotiated Rate	$258.75
Rate for Payer: Amerigroup Medicaid	$110.66
Rate for Payer: Cash Price	$276.00
Rate for Payer: Cash Price	$276.00
Rate for Payer: Iowa Total Care Managed Medicaid	$109.59
Rate for Payer: Medical Associates Commercial	$258.75
Rate for Payer: Midlands Choice Commercial	$241.50
Rate for Payer: Molina Healthcare Managed Medicaid	$110.13
Rate for Payer: Partners Health Alliance Commercial	$258.75
Rate for Payer: United Healthcare Commercial	$155.01
Rate for Payer: Wellmark IA HMO WHPI	$184.10
Rate for Payer: Wellmark IA PPO	$216.60

CONTRACEPTIVE CAPS REMOVAL CHARGE

Professional

Both

$484.00

Service Code	CPT 11976
Hospital Charge Code	8068933
Hospital Revenue Code	975
Min. Negotiated Rate	$114.61
Max. Negotiated Rate	$363.00
Rate for Payer: Amerigroup Medicaid	$115.73
Rate for Payer: Cash Price	$387.20
Rate for Payer: Cash Price	$387.20
Rate for Payer: Iowa Total Care Managed Medicaid	$114.61
Rate for Payer: Medical Associates Commercial	$363.00
Rate for Payer: Midlands Choice Commercial	$338.80
Rate for Payer: Molina Healthcare Managed Medicaid	$115.17
Rate for Payer: Partners Health Alliance Commercial	$363.00
Rate for Payer: United Healthcare Commercial	$219.10
Rate for Payer: Wellmark IA HMO WHPI	$265.60
Rate for Payer: Wellmark IA PPO	$312.50

CONTRAST BATH / 15 MIN APPLICATION

Facility

$82.00

Service Code	CPT 97034 GP
Hospital Charge Code	1374011
Hospital Revenue Code	420
Min. Negotiated Rate	$36.90
Max. Negotiated Rate	$81.22
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	$47.30
Rate for Payer: Amerigroup Medicare	$37.27
Rate for Payer: Cash Price	$65.60
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	$36.90
Rate for Payer: Iowa Total Care Managed Medicaid	$46.84
Rate for Payer: Medical Associates Commercial	$61.50
Rate for Payer: Medical Associates Managed Medicare	$36.90
Rate for Payer: Midlands Choice Commercial	$57.40
Rate for Payer: Molina Healthcare Managed Medicaid	$47.53
Rate for Payer: Partners Health Alliance Commercial	$42.44
Rate for Payer: United Healthcare Commercial	$73.80
Rate for Payer: United Healthcare Managed Medicare	$48.38
Rate for Payer: Wellmark IA HMO WHPI	$73.74
Rate for Payer: Wellmark IA PPO	$81.22

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

Know your out-of-pocket cost for care.

All Charges