Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

Major Skin Disorders Without MCC

Facility

$5,557.03

Service Code	MS-DRG 596
Hospital Charge Code	394
Min. Negotiated Rate	$5,476.49
Max. Negotiated Rate	$5,557.03
Rate for Payer: Amerigroup Medicaid	$5,530.18
Rate for Payer: Iowa Total Care Managed Medicaid	$5,476.49
Rate for Payer: Molina Healthcare Managed Medicaid	$5,557.03

Major Small and Large Bowel Procedures With CC

Facility

$20,253.72

Service Code	MS-DRG 330
Hospital Charge Code	180
Min. Negotiated Rate	$19,960.19
Max. Negotiated Rate	$20,253.72
Rate for Payer: Amerigroup Medicaid	$20,155.87
Rate for Payer: Iowa Total Care Managed Medicaid	$19,960.19
Rate for Payer: Molina Healthcare Managed Medicaid	$20,253.72

Major Small and Large Bowel Procedures With MCC

Facility

$33,213.23

Service Code	MS-DRG 329
Hospital Charge Code	179
Min. Negotiated Rate	$32,731.88
Max. Negotiated Rate	$33,213.23
Rate for Payer: Amerigroup Medicaid	$33,052.78
Rate for Payer: Iowa Total Care Managed Medicaid	$32,731.88
Rate for Payer: Molina Healthcare Managed Medicaid	$33,213.23

Major Small and Large Bowel Procedures Without CC/MCC

Facility

$14,926.02

Service Code	MS-DRG 331
Hospital Charge Code	181
Min. Negotiated Rate	$14,709.71
Max. Negotiated Rate	$14,926.02
Rate for Payer: Amerigroup Medicaid	$14,853.92
Rate for Payer: Iowa Total Care Managed Medicaid	$14,709.71
Rate for Payer: Molina Healthcare Managed Medicaid	$14,926.02

Major Thumb or Joint Procedures

Facility

$10,886.70

Service Code	MS-DRG 506
Hospital Charge Code	323
Min. Negotiated Rate	$10,728.92
Max. Negotiated Rate	$10,886.70
Rate for Payer: Amerigroup Medicaid	$10,834.11
Rate for Payer: Iowa Total Care Managed Medicaid	$10,728.92
Rate for Payer: Molina Healthcare Managed Medicaid	$10,886.70

Malignancy, Female Reproductive System With CC

Facility

$8,622.94

Service Code	MS-DRG 755
Hospital Charge Code	513
Min. Negotiated Rate	$8,497.97
Max. Negotiated Rate	$8,622.94
Rate for Payer: Amerigroup Medicaid	$8,581.28
Rate for Payer: Iowa Total Care Managed Medicaid	$8,497.97
Rate for Payer: Molina Healthcare Managed Medicaid	$8,622.94

Malignancy, Female Reproductive System With MCC

Facility

$12,882.74

Service Code	MS-DRG 754
Hospital Charge Code	512
Min. Negotiated Rate	$12,696.03
Max. Negotiated Rate	$12,882.74
Rate for Payer: Amerigroup Medicaid	$12,820.50
Rate for Payer: Iowa Total Care Managed Medicaid	$12,696.03
Rate for Payer: Molina Healthcare Managed Medicaid	$12,882.74

Malignancy, Female Reproductive System Without CC/MCC

Facility

$8,622.94

Service Code	MS-DRG 756
Hospital Charge Code	514
Min. Negotiated Rate	$8,497.97
Max. Negotiated Rate	$8,622.94
Rate for Payer: Amerigroup Medicaid	$8,581.28
Rate for Payer: Iowa Total Care Managed Medicaid	$8,497.97
Rate for Payer: Molina Healthcare Managed Medicaid	$8,622.94

Malignancy, Male Reproductive System With CC

Facility

$10,722.33

Service Code	MS-DRG 723
Hospital Charge Code	487
Min. Negotiated Rate	$10,566.93
Max. Negotiated Rate	$10,722.33
Rate for Payer: Amerigroup Medicaid	$10,670.53
Rate for Payer: Iowa Total Care Managed Medicaid	$10,566.93
Rate for Payer: Molina Healthcare Managed Medicaid	$10,722.33

Malignancy, Male Reproductive System With MCC

Facility

$16,824.63

Service Code	MS-DRG 722
Hospital Charge Code	486
Min. Negotiated Rate	$16,580.79
Max. Negotiated Rate	$16,824.63
Rate for Payer: Amerigroup Medicaid	$16,743.35
Rate for Payer: Iowa Total Care Managed Medicaid	$16,580.79
Rate for Payer: Molina Healthcare Managed Medicaid	$16,824.63

Malignancy, Male Reproductive System Without CC/MCC

Facility

$6,393.63

Service Code	MS-DRG 724
Hospital Charge Code	488
Min. Negotiated Rate	$6,300.97
Max. Negotiated Rate	$6,393.63
Rate for Payer: Amerigroup Medicaid	$6,362.74
Rate for Payer: Iowa Total Care Managed Medicaid	$6,300.97
Rate for Payer: Molina Healthcare Managed Medicaid	$6,393.63

Malignancy of Hepatobiliary System or Pancreas With CC

Facility

$13,896.51

Service Code	MS-DRG 436
Hospital Charge Code	262
Min. Negotiated Rate	$13,695.11
Max. Negotiated Rate	$13,896.51
Rate for Payer: Amerigroup Medicaid	$13,829.38
Rate for Payer: Iowa Total Care Managed Medicaid	$13,695.11
Rate for Payer: Molina Healthcare Managed Medicaid	$13,896.51

Malignancy of Hepatobiliary System or Pancreas With MCC

Facility

$13,896.51

Service Code	MS-DRG 435
Hospital Charge Code	261
Min. Negotiated Rate	$13,695.11
Max. Negotiated Rate	$13,896.51
Rate for Payer: Amerigroup Medicaid	$13,829.38
Rate for Payer: Iowa Total Care Managed Medicaid	$13,695.11
Rate for Payer: Molina Healthcare Managed Medicaid	$13,896.51

Malignancy of Hepatobiliary System or Pancreas Without CC/MCC

Facility

$8,806.01

Service Code	MS-DRG 437
Hospital Charge Code	263
Min. Negotiated Rate	$8,678.38
Max. Negotiated Rate	$8,806.01
Rate for Payer: Amerigroup Medicaid	$8,763.47
Rate for Payer: Iowa Total Care Managed Medicaid	$8,678.38
Rate for Payer: Molina Healthcare Managed Medicaid	$8,806.01

Malignant Breast Disorders With CC

Facility

$6,127.88

Service Code	MS-DRG 598
Hospital Charge Code	396
Min. Negotiated Rate	$6,039.07
Max. Negotiated Rate	$6,127.88
Rate for Payer: Amerigroup Medicaid	$6,098.28
Rate for Payer: Iowa Total Care Managed Medicaid	$6,039.07
Rate for Payer: Molina Healthcare Managed Medicaid	$6,127.88

Malignant Breast Disorders With MCC

Facility

$16,113.01

Service Code	MS-DRG 597
Hospital Charge Code	395
Min. Negotiated Rate	$15,879.49
Max. Negotiated Rate	$16,113.01
Rate for Payer: Amerigroup Medicaid	$16,035.17
Rate for Payer: Iowa Total Care Managed Medicaid	$15,879.49
Rate for Payer: Molina Healthcare Managed Medicaid	$16,113.01

Malignant Breast Disorders Without CC/MCC

Facility

$6,127.88

Service Code	MS-DRG 599
Hospital Charge Code	397
Min. Negotiated Rate	$6,039.07
Max. Negotiated Rate	$6,127.88
Rate for Payer: Amerigroup Medicaid	$6,098.28
Rate for Payer: Iowa Total Care Managed Medicaid	$6,039.07
Rate for Payer: Molina Healthcare Managed Medicaid	$6,127.88

MALLEOLUS IMPLANT 4.5MM X 65MM

Facility

$4,095.00

Service Code	CPT C1713
Hospital Charge Code	8924289
Hospital Revenue Code	278
Min. Negotiated Rate	$2,866.50
Max. Negotiated Rate	$3,685.50
Rate for Payer: Aetna of IA Commercial	$3,685.50
Rate for Payer: Aetna of IA Medical Rental Products	$3,685.50
Rate for Payer: Cash Price	$3,276.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,071.25
Rate for Payer: Medical Associates Commercial	$3,071.25
Rate for Payer: Midlands Choice Commercial	$2,866.50
Rate for Payer: United Healthcare Commercial	$3,685.50

MALLEOLUS IMPLANT 4.5MM X 65MM

Facility

$4,095.00

Service Code	CPT C1713
Hospital Charge Code	8924289
Hospital Revenue Code	278
Min. Negotiated Rate	$2,046.68
Max. Negotiated Rate	$3,685.50
Rate for Payer: Aetna of IA Commercial	$3,685.50
Rate for Payer: Aetna of IA Medical Rental Products	$3,685.50
Rate for Payer: Aetna of IA Medicare	$2,334.15
Rate for Payer: Amerigroup Medicaid	$2,066.75
Rate for Payer: Amerigroup Medicare	$2,067.98
Rate for Payer: Cash Price	$3,276.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,071.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,047.50
Rate for Payer: Iowa Total Care Managed Medicaid	$2,046.68
Rate for Payer: Medical Associates Commercial	$3,071.25
Rate for Payer: Medical Associates Managed Medicare	$2,047.50
Rate for Payer: Midlands Choice Commercial	$2,866.50
Rate for Payer: Molina Healthcare Managed Medicaid	$2,078.21
Rate for Payer: Molina Healthcare Managed Medicare	$2,076.98
Rate for Payer: Oscar Health of IA Commercial	$3,071.25
Rate for Payer: Partners Health Alliance Commercial	$3,071.25
Rate for Payer: United Healthcare Commercial	$3,685.50
Rate for Payer: United Healthcare Managed Medicare	$2,416.05

mannitol 20% IV Sol 500 ml[VDMC]

Facility

$70.56

Service Code	HCPCS J7799
Hospital Charge Code	13192394
Hospital Revenue Code	259
Min. Negotiated Rate	$35.27
Max. Negotiated Rate	$63.50
Rate for Payer: Aetna of IA Commercial	$63.50
Rate for Payer: Aetna of IA Medical Rental Products	$63.50
Rate for Payer: Aetna of IA Medicare	$40.22
Rate for Payer: Amerigroup Medicaid	$35.61
Rate for Payer: Amerigroup Medicare	$35.63
Rate for Payer: Cash Price	$56.45
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$35.28
Rate for Payer: Iowa Total Care Managed Medicaid	$35.27
Rate for Payer: Medical Associates Commercial	$52.92
Rate for Payer: Medical Associates Managed Medicare	$35.28
Rate for Payer: Midlands Choice Commercial	$49.39
Rate for Payer: Molina Healthcare Managed Medicaid	$35.81
Rate for Payer: Molina Healthcare Managed Medicare	$35.79
Rate for Payer: Oscar Health of IA Commercial	$52.92
Rate for Payer: Partners Health Alliance Commercial	$52.92
Rate for Payer: United Healthcare Commercial	$63.50
Rate for Payer: United Healthcare Managed Medicare	$41.63

mannitol 20% IV Sol 500 ml[VDMC]

Facility

$70.56

Service Code	HCPCS J7799
Hospital Charge Code	13192394
Hospital Revenue Code	259
Min. Negotiated Rate	$49.39
Max. Negotiated Rate	$63.50
Rate for Payer: Aetna of IA Commercial	$63.50
Rate for Payer: Aetna of IA Medical Rental Products	$63.50
Rate for Payer: Cash Price	$56.45
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.92
Rate for Payer: Medical Associates Commercial	$52.92
Rate for Payer: Midlands Choice Commercial	$49.39
Rate for Payer: United Healthcare Commercial	$63.50

MANUAL THERAPY PER 15 MINUTES

Facility

$111.00

Service Code	CPT 97140 GO
Hospital Charge Code	750909
Hospital Revenue Code	430
Min. Negotiated Rate	$55.48
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Aetna of IA Medicare	$63.27
Rate for Payer: Amerigroup Medicaid	$56.02
Rate for Payer: Amerigroup Medicare	$56.06
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.50
Rate for Payer: Iowa Total Care Managed Medicaid	$55.48
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Medical Associates Managed Medicare	$55.50
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: Molina Healthcare Managed Medicaid	$56.33
Rate for Payer: Molina Healthcare Managed Medicare	$56.30
Rate for Payer: Oscar Health of IA Commercial	$83.25
Rate for Payer: Partners Health Alliance Commercial	$83.25
Rate for Payer: United Healthcare Commercial	$99.90
Rate for Payer: United Healthcare Managed Medicare	$65.49

MANUAL THERAPY PER 15 MINUTES

Facility

$111.00

Service Code	CPT 97140 GO
Hospital Charge Code	750909
Hospital Revenue Code	430
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: United Healthcare Commercial	$99.90

MANUAL THERAPY PER 15 MINUTES

Facility

$111.00

Service Code	CPT 97140 GP
Hospital Charge Code	1373910
Hospital Revenue Code	420
Min. Negotiated Rate	$77.70
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: United Healthcare Commercial	$99.90

MANUAL THERAPY PER 15 MINUTES

Facility

$111.00

Service Code	CPT 97140 GP
Hospital Charge Code	1373910
Hospital Revenue Code	420
Min. Negotiated Rate	$55.48
Max. Negotiated Rate	$99.90
Rate for Payer: Aetna of IA Commercial	$99.90
Rate for Payer: Aetna of IA Medical Rental Products	$99.90
Rate for Payer: Aetna of IA Medicare	$63.27
Rate for Payer: Amerigroup Medicaid	$56.02
Rate for Payer: Amerigroup Medicare	$56.06
Rate for Payer: Cash Price	$88.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$83.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$55.50
Rate for Payer: Iowa Total Care Managed Medicaid	$55.48
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Medical Associates Managed Medicare	$55.50
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: Molina Healthcare Managed Medicaid	$56.33
Rate for Payer: Molina Healthcare Managed Medicare	$56.30
Rate for Payer: Oscar Health of IA Commercial	$83.25
Rate for Payer: Partners Health Alliance Commercial	$83.25
Rate for Payer: United Healthcare Commercial	$99.90
Rate for Payer: United Healthcare Managed Medicare	$65.49

Know your out-of-pocket cost for care.

All Charges