Van Diest Medical Center

All Charges

Charge

Type

Price

magnesium sulfate 50% 5gm/10ml SDV

Facility IP

$24.21

Service Code	CPT J3475
Hospital Charge Code	43700538
Hospital Revenue Code	636
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$21.79
Rate for Payer: Aetna of IA Commercial	$21.79
Rate for Payer: Aetna of IA Medical Rental Products	$21.79
Rate for Payer: Cash Price	$19.37
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.16
Rate for Payer: Medical Associates Commercial	$18.16
Rate for Payer: Midlands Choice Commercial	$16.95
Rate for Payer: United Healthcare Commercial	$21.79

magnesium sulfate 50% Inj Sol 2 mL SDV

Facility IP

$24.23

Service Code	CPT J3475
Hospital Charge Code	43702745
Hospital Revenue Code	636
Min. Negotiated Rate	$16.96
Max. Negotiated Rate	$21.81
Rate for Payer: Aetna of IA Commercial	$21.81
Rate for Payer: Aetna of IA Medical Rental Products	$21.81
Rate for Payer: Cash Price	$19.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.17
Rate for Payer: Medical Associates Commercial	$18.17
Rate for Payer: Midlands Choice Commercial	$16.96
Rate for Payer: United Healthcare Commercial	$21.81

magnesium sulfate 50% Inj Sol 2 mL SDV

Facility OP

$24.23

Service Code	CPT J3475
Hospital Charge Code	43702745
Hospital Revenue Code	636
Min. Negotiated Rate	$12.11
Max. Negotiated Rate	$21.81
Rate for Payer: Aetna of IA Commercial	$21.81
Rate for Payer: Aetna of IA Medical Rental Products	$21.81
Rate for Payer: Aetna of IA Medicare	$13.81
Rate for Payer: Amerigroup Medicaid	$12.23
Rate for Payer: Amerigroup Medicare	$12.24
Rate for Payer: Cash Price	$19.39
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$18.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.12
Rate for Payer: Iowa Total Care Managed Medicaid	$12.11
Rate for Payer: Medical Associates Commercial	$18.17
Rate for Payer: Medical Associates Managed Medicare	$12.12
Rate for Payer: Midlands Choice Commercial	$16.96
Rate for Payer: Molina Healthcare Managed Medicaid	$12.30
Rate for Payer: Partners Health Alliance Commercial	$18.17
Rate for Payer: United Healthcare Commercial	$21.81
Rate for Payer: United Healthcare Managed Medicare	$14.30

Major Bladder Procedures With CC

Facility IP

$20,862.97

Service Code	MS-DRG 654
Hospital Charge Code	436
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$20,862.97
Rate for Payer: Amerigroup Medicaid	$20,762.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$20,560.61
Rate for Payer: Molina Healthcare Managed Medicaid	$20,862.97

Major Bladder Procedures With MCC

Facility IP

$33,097.09

Service Code	MS-DRG 653
Hospital Charge Code	435
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$33,097.09
Rate for Payer: Amerigroup Medicaid	$32,937.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$32,617.42
Rate for Payer: Molina Healthcare Managed Medicaid	$33,097.09

Major Bladder Procedures Without CC/MCC

Facility IP

$20,862.97

Service Code	MS-DRG 655
Hospital Charge Code	437
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$20,862.97
Rate for Payer: Amerigroup Medicaid	$20,762.18
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$20,560.61
Rate for Payer: Molina Healthcare Managed Medicaid	$20,862.97

Major Chest Procedures With CC

Facility IP

$22,081.46

Service Code	MS-DRG 164
Hospital Charge Code	41
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$22,081.46
Rate for Payer: Amerigroup Medicaid	$21,974.78
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$21,761.43
Rate for Payer: Molina Healthcare Managed Medicaid	$22,081.46

Major Chest Procedures With MCC

Facility IP

$40,115.72

Service Code	MS-DRG 163
Hospital Charge Code	40
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$40,115.72
Rate for Payer: Amerigroup Medicaid	$39,921.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$39,534.33
Rate for Payer: Molina Healthcare Managed Medicaid	$40,115.72

Major Chest Procedures Without CC/MCC

Facility IP

$15,899.44

Service Code	MS-DRG 165
Hospital Charge Code	42
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$15,899.44
Rate for Payer: Amerigroup Medicaid	$15,822.63
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$15,669.02
Rate for Payer: Molina Healthcare Managed Medicaid	$15,899.44

Major Chest Trauma With CC

Facility IP

$7,139.69

Service Code	MS-DRG 184
Hospital Charge Code	55
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$7,139.69
Rate for Payer: Amerigroup Medicaid	$7,105.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7,036.22
Rate for Payer: Molina Healthcare Managed Medicaid	$7,139.69

Major Chest Trauma With MCC

Facility IP

$9,703.63

Service Code	MS-DRG 183
Hospital Charge Code	54
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,703.63
Rate for Payer: Amerigroup Medicaid	$9,656.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$9,563.00
Rate for Payer: Molina Healthcare Managed Medicaid	$9,703.63

Major Chest Trauma Without CC/MCC

Facility IP

$4,201.73

Service Code	MS-DRG 185
Hospital Charge Code	56
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$4,201.73
Rate for Payer: Amerigroup Medicaid	$4,181.43
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$4,140.83
Rate for Payer: Molina Healthcare Managed Medicaid	$4,201.73

Major Esophageal Disorders With CC

Facility IP

$9,620.96

Service Code	MS-DRG 369
Hospital Charge Code	210
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,620.96
Rate for Payer: Amerigroup Medicaid	$9,574.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$9,481.52
Rate for Payer: Molina Healthcare Managed Medicaid	$9,620.96

Major Esophageal Disorders With MCC

Facility IP

$16,666.16

Service Code	MS-DRG 368
Hospital Charge Code	209
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$16,666.16
Rate for Payer: Amerigroup Medicaid	$16,585.65
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$16,424.62
Rate for Payer: Molina Healthcare Managed Medicaid	$16,666.16

Major Esophageal Disorders Without CC/MCC

Facility IP

$5,174.16

Service Code	MS-DRG 370
Hospital Charge Code	211
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$5,174.16
Rate for Payer: Amerigroup Medicaid	$5,149.17
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$5,099.17
Rate for Payer: Molina Healthcare Managed Medicaid	$5,174.16

Major Gastrointestinal Disorders and Peritoneal Infections With CC

Facility IP

$8,369.01

Service Code	MS-DRG 372
Hospital Charge Code	213
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,369.01
Rate for Payer: Amerigroup Medicaid	$8,328.58
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$8,247.72
Rate for Payer: Molina Healthcare Managed Medicaid	$8,369.01

Major Gastrointestinal Disorders and Peritoneal Infections With MCC

Facility IP

$14,053.00

Service Code	MS-DRG 371
Hospital Charge Code	212
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,053.00
Rate for Payer: Amerigroup Medicaid	$13,985.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$13,849.34
Rate for Payer: Molina Healthcare Managed Medicaid	$14,053.00

Major Gastrointestinal Disorders and Peritoneal Infections Without CC/MCC

Facility IP

$7,807.00

Service Code	MS-DRG 373
Hospital Charge Code	214
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$7,807.00
Rate for Payer: Amerigroup Medicaid	$7,769.29
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7,693.86
Rate for Payer: Molina Healthcare Managed Medicaid	$7,807.00

Major Head and Neck Procedures With CC

Facility IP

$15,697.67

Service Code	MS-DRG 141
Hospital Charge Code	21
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$15,697.67
Rate for Payer: Amerigroup Medicaid	$15,621.83
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$15,470.17
Rate for Payer: Molina Healthcare Managed Medicaid	$15,697.67

Major Head and Neck Procedures With MCC

Facility IP

$31,442.58

Service Code	MS-DRG 140
Hospital Charge Code	20
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$31,442.58
Rate for Payer: Amerigroup Medicaid	$31,290.68
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$30,986.89
Rate for Payer: Molina Healthcare Managed Medicaid	$31,442.58

Major Head and Neck Procedures Without CC/MCC

Facility IP

$11,016.61

Service Code	MS-DRG 142
Hospital Charge Code	22
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,016.61
Rate for Payer: Amerigroup Medicaid	$10,963.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$10,856.95
Rate for Payer: Molina Healthcare Managed Medicaid	$11,016.61

Major Hematological and Immunological Diagnoses Except Sickle Cell Crisis and Coagulation Disorders With CC

Facility IP

$9,137.69

Service Code	MS-DRG 809
Hospital Charge Code	551
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,137.69
Rate for Payer: Amerigroup Medicaid	$9,093.55
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$9,005.26
Rate for Payer: Molina Healthcare Managed Medicaid	$9,137.69

Major Hematological and Immunological Diagnoses Except Sickle Cell Crisis and Coagulation Disorders With MCC

Facility IP

$15,671.09

Service Code	MS-DRG 808
Hospital Charge Code	550
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$15,671.09
Rate for Payer: Amerigroup Medicaid	$15,595.38
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$15,443.97
Rate for Payer: Molina Healthcare Managed Medicaid	$15,671.09

Major Hematological and Immunological Diagnoses Except Sickle Cell Crisis and Coagulation Disorders Without CC/MCC

Facility IP

$7,528.47

Service Code	MS-DRG 810
Hospital Charge Code	552
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$7,528.47
Rate for Payer: Amerigroup Medicaid	$7,492.10
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$7,419.36
Rate for Payer: Molina Healthcare Managed Medicaid	$7,528.47

Major Hip and Knee Joint Replacement or Reattachment of Lower Extremity With MCC or Total Ankle Replacement

Facility IP

$25,554.84

Service Code	MS-DRG 469
Hospital Charge Code	289
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$25,554.84
Rate for Payer: Amerigroup Medicaid	$25,431.39
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$25,184.48
Rate for Payer: Molina Healthcare Managed Medicaid	$25,554.84

Price Transparency.

All Charges