Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC

Facility

$23,170.35

Service Code	MSDRG 330
Min. Negotiated Rate	$22,834.54
Max. Negotiated Rate	$23,170.35
Rate for Payer: Amerigroup Medicaid	$23,058.41
Rate for Payer: Iowa Total Care Managed Medicaid	$22,834.54
Rate for Payer: Molina Healthcare Managed Medicaid	$23,170.35

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC

Facility

$37,996.09

Service Code	MSDRG 329
Min. Negotiated Rate	$37,445.41
Max. Negotiated Rate	$37,996.09
Rate for Payer: Amerigroup Medicaid	$37,812.52
Rate for Payer: Iowa Total Care Managed Medicaid	$37,445.41
Rate for Payer: Molina Healthcare Managed Medicaid	$37,996.09

MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC

Facility

$17,075.44

Service Code	MSDRG 331
Min. Negotiated Rate	$16,827.96
Max. Negotiated Rate	$17,075.44
Rate for Payer: Amerigroup Medicaid	$16,992.94
Rate for Payer: Iowa Total Care Managed Medicaid	$16,827.96
Rate for Payer: Molina Healthcare Managed Medicaid	$17,075.44

MAJOR THUMB OR JOINT PROCEDURES

Facility

$12,454.43

Service Code	MSDRG 506
Min. Negotiated Rate	$12,273.93
Max. Negotiated Rate	$12,454.43
Rate for Payer: Amerigroup Medicaid	$12,394.26
Rate for Payer: Iowa Total Care Managed Medicaid	$12,273.93
Rate for Payer: Molina Healthcare Managed Medicaid	$12,454.43

MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH CC

Facility

$9,864.68

Service Code	MSDRG 755
Min. Negotiated Rate	$9,721.71
Max. Negotiated Rate	$9,864.68
Rate for Payer: Amerigroup Medicaid	$9,817.02
Rate for Payer: Iowa Total Care Managed Medicaid	$9,721.71
Rate for Payer: Molina Healthcare Managed Medicaid	$9,864.68

MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$14,737.91

Service Code	MSDRG 754
Min. Negotiated Rate	$14,524.31
Max. Negotiated Rate	$14,737.91
Rate for Payer: Amerigroup Medicaid	$14,666.71
Rate for Payer: Iowa Total Care Managed Medicaid	$14,524.31
Rate for Payer: Molina Healthcare Managed Medicaid	$14,737.91

MALIGNANCY, FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$9,864.68

Service Code	MSDRG 756
Min. Negotiated Rate	$9,721.71
Max. Negotiated Rate	$9,864.68
Rate for Payer: Amerigroup Medicaid	$9,817.02
Rate for Payer: Iowa Total Care Managed Medicaid	$9,721.71
Rate for Payer: Molina Healthcare Managed Medicaid	$9,864.68

MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH CC

Facility

$12,266.39

Service Code	MSDRG 723
Min. Negotiated Rate	$12,088.61
Max. Negotiated Rate	$12,266.39
Rate for Payer: Amerigroup Medicaid	$12,207.13
Rate for Payer: Iowa Total Care Managed Medicaid	$12,088.61
Rate for Payer: Molina Healthcare Managed Medicaid	$12,266.39

MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITH MCC

Facility

$19,247.45

Service Code	MSDRG 722
Min. Negotiated Rate	$18,968.49
Max. Negotiated Rate	$19,247.45
Rate for Payer: Amerigroup Medicaid	$19,154.46
Rate for Payer: Iowa Total Care Managed Medicaid	$18,968.49
Rate for Payer: Molina Healthcare Managed Medicaid	$19,247.45

MALIGNANCY, MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC

Facility

$7,314.35

Service Code	MSDRG 724
Min. Negotiated Rate	$7,208.34
Max. Negotiated Rate	$7,314.35
Rate for Payer: Amerigroup Medicaid	$7,279.01
Rate for Payer: Iowa Total Care Managed Medicaid	$7,208.34
Rate for Payer: Molina Healthcare Managed Medicaid	$7,314.35

MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC

Facility

$15,897.67

Service Code	MSDRG 436
Min. Negotiated Rate	$15,667.26
Max. Negotiated Rate	$15,897.67
Rate for Payer: Amerigroup Medicaid	$15,820.86
Rate for Payer: Iowa Total Care Managed Medicaid	$15,667.26
Rate for Payer: Molina Healthcare Managed Medicaid	$15,897.67

MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC

Facility

$15,897.67

Service Code	MSDRG 435
Min. Negotiated Rate	$15,667.26
Max. Negotiated Rate	$15,897.67
Rate for Payer: Amerigroup Medicaid	$15,820.86
Rate for Payer: Iowa Total Care Managed Medicaid	$15,667.26
Rate for Payer: Molina Healthcare Managed Medicaid	$15,897.67

MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC

Facility

$10,074.12

Service Code	MSDRG 437
Min. Negotiated Rate	$9,928.11
Max. Negotiated Rate	$10,074.12
Rate for Payer: Amerigroup Medicaid	$10,025.44
Rate for Payer: Iowa Total Care Managed Medicaid	$9,928.11
Rate for Payer: Molina Healthcare Managed Medicaid	$10,074.12

MALIGNANT BREAST DISORDERS WITH CC

Facility

$7,010.33

Service Code	MSDRG 598
Min. Negotiated Rate	$6,908.73
Max. Negotiated Rate	$7,010.33
Rate for Payer: Amerigroup Medicaid	$6,976.46
Rate for Payer: Iowa Total Care Managed Medicaid	$6,908.73
Rate for Payer: Molina Healthcare Managed Medicaid	$7,010.33

MALIGNANT BREAST DISORDERS WITH MCC

Facility

$18,433.37

Service Code	MSDRG 597
Min. Negotiated Rate	$18,166.21
Max. Negotiated Rate	$18,433.37
Rate for Payer: Amerigroup Medicaid	$18,344.31
Rate for Payer: Iowa Total Care Managed Medicaid	$18,166.21
Rate for Payer: Molina Healthcare Managed Medicaid	$18,433.37

MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$7,010.33

Service Code	MSDRG 599
Min. Negotiated Rate	$6,908.73
Max. Negotiated Rate	$7,010.33
Rate for Payer: Amerigroup Medicaid	$6,976.46
Rate for Payer: Iowa Total Care Managed Medicaid	$6,908.73
Rate for Payer: Molina Healthcare Managed Medicaid	$7,010.33

MALLEOLUS IMPLANT 4.5MM X 65MM

Facility

$4,095.00

Service Code	HCPCS 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	HCPCS C1713
Hospital Charge Code	8924289
Hospital Revenue Code	278
Min. Negotiated Rate	$1,842.75
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	$2,362.00
Rate for Payer: Amerigroup Medicare	$1,861.18
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	$1,842.75
Rate for Payer: Iowa Total Care Managed Medicaid	$2,339.06
Rate for Payer: Medical Associates Commercial	$3,071.25
Rate for Payer: Medical Associates Managed Medicare	$1,842.75
Rate for Payer: Midlands Choice Commercial	$2,866.50
Rate for Payer: Molina Healthcare Managed Medicaid	$2,373.46
Rate for Payer: Partners Health Alliance Commercial	$2,119.16
Rate for Payer: United Healthcare Commercial	$3,685.50
Rate for Payer: United Healthcare Managed Medicare	$2,416.05

MANIPULATION OF KNEE JOINT UNDER GENERAL ANESTHESIA (INCLUDES APPLICATION OF TRACTION OR OTHER FIXATION DEVICES)

Facility

$2,696.01

Service Code	CPT 27570
Hospital Revenue Code	360
Min. Negotiated Rate	$2,447.47
Max. Negotiated Rate	$2,696.01
Rate for Payer: Wellmark IA HMO WHPI	$2,447.47
Rate for Payer: Wellmark IA PPO	$2,696.01

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	$31.75
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	$40.70
Rate for Payer: Amerigroup Medicare	$32.07
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	$31.75
Rate for Payer: Iowa Total Care Managed Medicaid	$40.30
Rate for Payer: Medical Associates Commercial	$52.92
Rate for Payer: Medical Associates Managed Medicare	$31.75
Rate for Payer: Midlands Choice Commercial	$49.39
Rate for Payer: Molina Healthcare Managed Medicaid	$40.90
Rate for Payer: Partners Health Alliance Commercial	$36.51
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 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 GO
Hospital Charge Code	750909
Hospital Revenue Code	430
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$165.57
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	$64.02
Rate for Payer: Amerigroup Medicare	$50.45
Rate for Payer: Cash Price	$88.80
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	$49.95
Rate for Payer: Iowa Total Care Managed Medicaid	$63.40
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Medical Associates Managed Medicare	$49.95
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: Molina Healthcare Managed Medicaid	$64.34
Rate for Payer: Partners Health Alliance Commercial	$57.44
Rate for Payer: United Healthcare Commercial	$99.90
Rate for Payer: United Healthcare Managed Medicare	$65.49
Rate for Payer: Wellmark IA HMO WHPI	$150.31
Rate for Payer: Wellmark IA PPO	$165.57

MANUAL THERAPY PER 15 MINUTES

Facility

$111.00

Service Code	CPT 97140 GP
Hospital Charge Code	1373910
Hospital Revenue Code	420
Min. Negotiated Rate	$49.95
Max. Negotiated Rate	$165.57
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	$64.02
Rate for Payer: Amerigroup Medicare	$50.45
Rate for Payer: Cash Price	$88.80
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	$49.95
Rate for Payer: Iowa Total Care Managed Medicaid	$63.40
Rate for Payer: Medical Associates Commercial	$83.25
Rate for Payer: Medical Associates Managed Medicare	$49.95
Rate for Payer: Midlands Choice Commercial	$77.70
Rate for Payer: Molina Healthcare Managed Medicaid	$64.34
Rate for Payer: Partners Health Alliance Commercial	$57.44
Rate for Payer: United Healthcare Commercial	$99.90
Rate for Payer: United Healthcare Managed Medicare	$65.49
Rate for Payer: Wellmark IA HMO WHPI	$150.31
Rate for Payer: Wellmark IA PPO	$165.57

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

Know your out-of-pocket cost for care.

All Charges