Van Diest Medical Center

All Charges

Charge

Type

Price

O.R. Procedures for Obesity Without CC/MCC

Facility IP

$14,051.04

Service Code	MS-DRG 621
Hospital Charge Code	413
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,051.04
Rate for Payer: Amerigroup Medicaid	$13,983.16
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	$13,847.40
Rate for Payer: Molina Healthcare Managed Medicaid	$14,051.04

O.R. Procedures With Diagnoses of Other Contact With Health Services With CC

Facility IP

$10,476.27

Service Code	MS-DRG 940
Hospital Charge Code	649
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$10,476.27
Rate for Payer: Amerigroup Medicaid	$10,425.66
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	$10,324.44
Rate for Payer: Molina Healthcare Managed Medicaid	$10,476.27

O.R. Procedures With Diagnoses of Other Contact With Health Services With MCC

Facility IP

$33,337.25

Service Code	MS-DRG 939
Hospital Charge Code	648
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$33,337.25
Rate for Payer: Amerigroup Medicaid	$33,176.20
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	$32,854.10
Rate for Payer: Molina Healthcare Managed Medicaid	$33,337.25

O.R. Procedures With Diagnoses of Other Contact With Health Services Without CC/MCC

Facility IP

$8,869.98

Service Code	MS-DRG 941
Hospital Charge Code	650
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$8,869.98
Rate for Payer: Amerigroup Medicaid	$8,827.13
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	$8,741.43
Rate for Payer: Molina Healthcare Managed Medicaid	$8,869.98

O.R. Procedures With Principal Diagnosis of Mental Illness

Facility IP

$11,869.95

Service Code	MS-DRG 876
Hospital Charge Code	609
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,869.95
Rate for Payer: Amerigroup Medicaid	$11,812.61
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	$11,697.92
Rate for Payer: Molina Healthcare Managed Medicaid	$11,869.95

ORTHO DYNBRAC PER 15 MIN

Facility OP

$131.00

Service Code	CPT 97760 GO
Hospital Charge Code	1373573
Hospital Revenue Code	430
Min. Negotiated Rate	$65.47
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of IA Commercial	$117.90
Rate for Payer: Aetna of IA Medical Rental Products	$117.90
Rate for Payer: Aetna of IA Medicare	$74.67
Rate for Payer: Amerigroup Medicaid	$66.12
Rate for Payer: Amerigroup Medicare	$66.16
Rate for Payer: Cash Price	$104.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.50
Rate for Payer: Iowa Total Care Managed Medicaid	$65.47
Rate for Payer: Medical Associates Commercial	$98.25
Rate for Payer: Medical Associates Managed Medicare	$65.50
Rate for Payer: Midlands Choice Commercial	$91.70
Rate for Payer: Molina Healthcare Managed Medicaid	$66.48
Rate for Payer: Partners Health Alliance Commercial	$98.25
Rate for Payer: United Healthcare Commercial	$117.90
Rate for Payer: United Healthcare Managed Medicare	$77.29

ORTHO DYNBRAC PER 15 MIN

Facility IP

$131.00

Service Code	CPT 97760 GO
Hospital Charge Code	1373573
Hospital Revenue Code	430
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of IA Commercial	$117.90
Rate for Payer: Aetna of IA Medical Rental Products	$117.90
Rate for Payer: Cash Price	$104.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.25
Rate for Payer: Medical Associates Commercial	$98.25
Rate for Payer: Midlands Choice Commercial	$91.70
Rate for Payer: United Healthcare Commercial	$117.90

ORTHOTICS TRAINING MGMT/BRACE 15 MIN

Facility IP

$131.00

Service Code	CPT 97760 GP
Hospital Charge Code	1374120
Hospital Revenue Code	420
Min. Negotiated Rate	$91.70
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of IA Commercial	$117.90
Rate for Payer: Aetna of IA Medical Rental Products	$117.90
Rate for Payer: Cash Price	$104.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.25
Rate for Payer: Medical Associates Commercial	$98.25
Rate for Payer: Midlands Choice Commercial	$91.70
Rate for Payer: United Healthcare Commercial	$117.90

ORTHOTICS TRAINING MGMT/BRACE 15 MIN

Facility OP

$131.00

Service Code	CPT 97760 GP
Hospital Charge Code	1374120
Hospital Revenue Code	420
Min. Negotiated Rate	$65.47
Max. Negotiated Rate	$117.90
Rate for Payer: Aetna of IA Commercial	$117.90
Rate for Payer: Aetna of IA Medical Rental Products	$117.90
Rate for Payer: Aetna of IA Medicare	$74.67
Rate for Payer: Amerigroup Medicaid	$66.12
Rate for Payer: Amerigroup Medicare	$66.16
Rate for Payer: Cash Price	$104.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$98.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$65.50
Rate for Payer: Iowa Total Care Managed Medicaid	$65.47
Rate for Payer: Medical Associates Commercial	$98.25
Rate for Payer: Medical Associates Managed Medicare	$65.50
Rate for Payer: Midlands Choice Commercial	$91.70
Rate for Payer: Molina Healthcare Managed Medicaid	$66.48
Rate for Payer: Partners Health Alliance Commercial	$98.25
Rate for Payer: United Healthcare Commercial	$117.90
Rate for Payer: United Healthcare Managed Medicare	$77.29

oseltamivir 30 mg Cap

Facility OP

$3.90

Service Code	CPT A9270
Hospital Charge Code	43700141
Hospital Revenue Code	637
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of IA Commercial	$3.51
Rate for Payer: Aetna of IA Medical Rental Products	$3.51
Rate for Payer: Aetna of IA Medicare	$2.22
Rate for Payer: Amerigroup Medicaid	$1.97
Rate for Payer: Amerigroup Medicare	$1.97
Rate for Payer: Cash Price	$3.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.92
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1.95
Rate for Payer: Iowa Total Care Managed Medicaid	$1.95
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Medical Associates Managed Medicare	$1.95
Rate for Payer: Midlands Choice Commercial	$2.73
Rate for Payer: Molina Healthcare Managed Medicaid	$1.98
Rate for Payer: Partners Health Alliance Commercial	$2.92
Rate for Payer: United Healthcare Commercial	$3.51
Rate for Payer: United Healthcare Managed Medicare	$2.30

oseltamivir 30 mg Cap

Facility IP

$3.90

Service Code	CPT A9270
Hospital Charge Code	43700141
Hospital Revenue Code	637
Min. Negotiated Rate	$2.73
Max. Negotiated Rate	$3.51
Rate for Payer: Aetna of IA Commercial	$3.51
Rate for Payer: Aetna of IA Medical Rental Products	$3.51
Rate for Payer: Cash Price	$3.12
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2.92
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Midlands Choice Commercial	$2.73
Rate for Payer: United Healthcare Commercial	$3.51

oseltamivir 6 mg/mL Pow 60ml

Facility OP

$116.84

Service Code	CPT A9270
Hospital Charge Code	43705961
Hospital Revenue Code	637
Min. Negotiated Rate	$58.40
Max. Negotiated Rate	$105.16
Rate for Payer: Aetna of IA Commercial	$105.16
Rate for Payer: Aetna of IA Medical Rental Products	$105.16
Rate for Payer: Aetna of IA Medicare	$66.60
Rate for Payer: Amerigroup Medicaid	$58.97
Rate for Payer: Amerigroup Medicare	$59.00
Rate for Payer: Cash Price	$93.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$87.63
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$58.42
Rate for Payer: Iowa Total Care Managed Medicaid	$58.40
Rate for Payer: Medical Associates Commercial	$87.63
Rate for Payer: Medical Associates Managed Medicare	$58.42
Rate for Payer: Midlands Choice Commercial	$81.79
Rate for Payer: Molina Healthcare Managed Medicaid	$59.30
Rate for Payer: Partners Health Alliance Commercial	$87.63
Rate for Payer: United Healthcare Commercial	$105.16
Rate for Payer: United Healthcare Managed Medicare	$68.94

oseltamivir 6 mg/mL Pow 60ml

Facility IP

$116.84

Service Code	CPT A9270
Hospital Charge Code	43705961
Hospital Revenue Code	637
Min. Negotiated Rate	$81.79
Max. Negotiated Rate	$105.16
Rate for Payer: Aetna of IA Commercial	$105.16
Rate for Payer: Aetna of IA Medical Rental Products	$105.16
Rate for Payer: Cash Price	$93.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$87.63
Rate for Payer: Medical Associates Commercial	$87.63
Rate for Payer: Midlands Choice Commercial	$81.79
Rate for Payer: United Healthcare Commercial	$105.16

oseltamivir 75 mg Cap

Facility IP

$4.76

Service Code	CPT A9270
Hospital Charge Code	43761678
Hospital Revenue Code	637
Min. Negotiated Rate	$3.33
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna of IA Commercial	$4.28
Rate for Payer: Aetna of IA Medical Rental Products	$4.28
Rate for Payer: Cash Price	$3.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.57
Rate for Payer: Medical Associates Commercial	$3.57
Rate for Payer: Midlands Choice Commercial	$3.33
Rate for Payer: United Healthcare Commercial	$4.28

oseltamivir 75 mg Cap

Facility OP

$4.76

Service Code	CPT A9270
Hospital Charge Code	43761678
Hospital Revenue Code	637
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna of IA Commercial	$4.28
Rate for Payer: Aetna of IA Medical Rental Products	$4.28
Rate for Payer: Aetna of IA Medicare	$2.71
Rate for Payer: Amerigroup Medicaid	$2.40
Rate for Payer: Amerigroup Medicare	$2.40
Rate for Payer: Cash Price	$3.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3.57
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.38
Rate for Payer: Iowa Total Care Managed Medicaid	$2.38
Rate for Payer: Medical Associates Commercial	$3.57
Rate for Payer: Medical Associates Managed Medicare	$2.38
Rate for Payer: Midlands Choice Commercial	$3.33
Rate for Payer: Molina Healthcare Managed Medicaid	$2.42
Rate for Payer: Partners Health Alliance Commercial	$3.57
Rate for Payer: United Healthcare Commercial	$4.28
Rate for Payer: United Healthcare Managed Medicare	$2.81

Osmolality DMCL

Facility IP

$63.00

Service Code	CPT 83930
Hospital Charge Code	8037745
Hospital Revenue Code	301
Min. Negotiated Rate	$44.10
Max. Negotiated Rate	$56.70
Rate for Payer: Aetna of IA Commercial	$56.70
Rate for Payer: Aetna of IA Medical Rental Products	$56.70
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.25
Rate for Payer: Medical Associates Commercial	$47.25
Rate for Payer: Midlands Choice Commercial	$44.10
Rate for Payer: United Healthcare Commercial	$56.70

Osmolality DMCL

Facility OP

$63.00

Service Code	CPT 83930
Hospital Charge Code	8037745
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$56.70
Rate for Payer: United Healthcare Commercial	$56.70
Rate for Payer: Aetna of IA Commercial	$56.70
Rate for Payer: Aetna of IA Medical Rental Products	$56.70
Rate for Payer: Aetna of IA Medicare	$35.91
Rate for Payer: Amerigroup Medicaid	$31.80
Rate for Payer: Amerigroup Medicare	$31.82
Rate for Payer: Cash Price	$50.40
Rate for Payer: Cash Price	$50.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$47.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.50
Rate for Payer: Iowa Total Care Managed Medicaid	$31.49
Rate for Payer: Medical Associates Commercial	$47.25
Rate for Payer: Medical Associates Managed Medicare	$31.50
Rate for Payer: Midlands Choice Commercial	$44.10
Rate for Payer: Molina Healthcare Managed Medicaid	$31.97
Rate for Payer: Partners Health Alliance Commercial	$47.25
Rate for Payer: United Healthcare Managed Medicare	$37.17
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

Osmolality Urine DMCL

Facility IP

$65.00

Service Code	CPT 83935
Hospital Charge Code	8037735
Hospital Revenue Code	301
Min. Negotiated Rate	$45.50
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of IA Commercial	$58.50
Rate for Payer: Aetna of IA Medical Rental Products	$58.50
Rate for Payer: Cash Price	$52.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.75
Rate for Payer: Medical Associates Commercial	$48.75
Rate for Payer: Midlands Choice Commercial	$45.50
Rate for Payer: United Healthcare Commercial	$58.50

Osmolality Urine DMCL

Facility OP

$65.00

Service Code	CPT 83935
Hospital Charge Code	8037735
Hospital Revenue Code	301
Min. Negotiated Rate	$20.46
Max. Negotiated Rate	$58.50
Rate for Payer: Aetna of IA Commercial	$58.50
Rate for Payer: Aetna of IA Medical Rental Products	$58.50
Rate for Payer: Aetna of IA Medicare	$37.05
Rate for Payer: Amerigroup Medicaid	$32.81
Rate for Payer: Amerigroup Medicare	$32.82
Rate for Payer: Cash Price	$52.00
Rate for Payer: Cash Price	$52.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$48.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$32.50
Rate for Payer: Iowa Total Care Managed Medicaid	$32.49
Rate for Payer: Medical Associates Commercial	$48.75
Rate for Payer: Medical Associates Managed Medicare	$32.50
Rate for Payer: Midlands Choice Commercial	$45.50
Rate for Payer: Molina Healthcare Managed Medicaid	$32.99
Rate for Payer: Partners Health Alliance Commercial	$48.75
Rate for Payer: United Healthcare Commercial	$58.50
Rate for Payer: United Healthcare Managed Medicare	$38.35
Rate for Payer: Wellmark IA HMO	$20.46
Rate for Payer: Wellmark IA PPO	$22.51

Ostectomy, partial excision, fifth metatarsal head (bunionette) (separate procedure)

Facility OP

$9,738.28

Service Code	CPT 28110
Hospital Revenue Code	360
Min. Negotiated Rate	$8,852.98
Max. Negotiated Rate	$9,738.28
Rate for Payer: Wellmark IA HMO	$8,852.98
Rate for Payer: Wellmark IA PPO	$9,738.28

Osteomyelitis With CC

Facility IP

$10,277.45

Service Code	MS-DRG 540
Hospital Charge Code	347
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$10,277.45
Rate for Payer: Amerigroup Medicaid	$10,227.80
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	$10,128.50
Rate for Payer: Molina Healthcare Managed Medicaid	$10,277.45

Osteomyelitis With MCC

Facility IP

$14,537.25

Service Code	MS-DRG 539
Hospital Charge Code	346
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,537.25
Rate for Payer: Amerigroup Medicaid	$14,467.02
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	$14,326.56
Rate for Payer: Molina Healthcare Managed Medicaid	$14,537.25

Osteomyelitis Without CC/MCC

Facility IP

$6,093.44

Service Code	MS-DRG 541
Hospital Charge Code	348
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$6,093.44
Rate for Payer: Amerigroup Medicaid	$6,064.00
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	$6,005.13
Rate for Payer: Molina Healthcare Managed Medicaid	$6,093.44

OT Cog Ther Intervent, Addl 15 Min Units

Facility IP

$85.00

Service Code	CPT 97130
Hospital Charge Code	8774214
Hospital Revenue Code	430
Min. Negotiated Rate	$59.50
Max. Negotiated Rate	$76.50
Rate for Payer: Aetna of IA Commercial	$76.50
Rate for Payer: Aetna of IA Medical Rental Products	$76.50
Rate for Payer: Cash Price	$68.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.75
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: United Healthcare Commercial	$76.50

OT Cog Ther Intervent, Addl 15 Min Units

Facility OP

$85.00

Service Code	CPT 97130
Hospital Charge Code	8774214
Hospital Revenue Code	430
Min. Negotiated Rate	$42.48
Max. Negotiated Rate	$122.08
Rate for Payer: Aetna of IA Commercial	$76.50
Rate for Payer: Aetna of IA Medical Rental Products	$76.50
Rate for Payer: Aetna of IA Medicare	$48.45
Rate for Payer: Amerigroup Medicaid	$42.90
Rate for Payer: Amerigroup Medicare	$42.92
Rate for Payer: Cash Price	$68.00
Rate for Payer: Cash Price	$68.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$63.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$42.50
Rate for Payer: Iowa Total Care Managed Medicaid	$42.48
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Medical Associates Managed Medicare	$42.50
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: Molina Healthcare Managed Medicaid	$43.14
Rate for Payer: Partners Health Alliance Commercial	$63.75
Rate for Payer: United Healthcare Commercial	$76.50
Rate for Payer: United Healthcare Managed Medicare	$50.15
Rate for Payer: Wellmark IA HMO	$110.98
Rate for Payer: Wellmark IA PPO	$122.08

Price Transparency.

All Charges