Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

OT EVAL

Facility

$158.00

Hospital Charge Code	4812784
Hospital Revenue Code	434
Min. Negotiated Rate	$78.97
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Aetna of IA Medicare	$90.06
Rate for Payer: Amerigroup Medicaid	$79.74
Rate for Payer: Amerigroup Medicare	$79.79
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.00
Rate for Payer: Iowa Total Care Managed Medicaid	$78.97
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Medical Associates Managed Medicare	$79.00
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: Molina Healthcare Managed Medicaid	$80.18
Rate for Payer: Molina Healthcare Managed Medicare	$80.14
Rate for Payer: Oscar Health of IA Commercial	$118.50
Rate for Payer: Partners Health Alliance Commercial	$118.50
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22

OT EVAL HIGH COMPLEX 60 MIN

Facility

$158.00

Service Code	CPT 97167 GO
Hospital Charge Code	8397275
Hospital Revenue Code	434
Min. Negotiated Rate	$78.97
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Aetna of IA Medicare	$90.06
Rate for Payer: Amerigroup Medicaid	$79.74
Rate for Payer: Amerigroup Medicare	$79.79
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.00
Rate for Payer: Iowa Total Care Managed Medicaid	$78.97
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Medical Associates Managed Medicare	$79.00
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: Molina Healthcare Managed Medicaid	$80.18
Rate for Payer: Molina Healthcare Managed Medicare	$80.14
Rate for Payer: Oscar Health of IA Commercial	$118.50
Rate for Payer: Partners Health Alliance Commercial	$118.50
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22

OT EVAL HIGH COMPLEX 60 MIN

Facility

$158.00

Service Code	CPT 97167 GO
Hospital Charge Code	8397275
Hospital Revenue Code	434
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: United Healthcare Commercial	$142.20

OT EVAL LOW COMPLEX 30 MIN

Facility

$158.00

Service Code	CPT 97165 GO
Hospital Charge Code	8397258
Hospital Revenue Code	434
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: United Healthcare Commercial	$142.20

OT EVAL LOW COMPLEX 30 MIN

Facility

$158.00

Service Code	CPT 97165 GO
Hospital Charge Code	8397258
Hospital Revenue Code	434
Min. Negotiated Rate	$78.97
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Aetna of IA Medicare	$90.06
Rate for Payer: Amerigroup Medicaid	$79.74
Rate for Payer: Amerigroup Medicare	$79.79
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.00
Rate for Payer: Iowa Total Care Managed Medicaid	$78.97
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Medical Associates Managed Medicare	$79.00
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: Molina Healthcare Managed Medicaid	$80.18
Rate for Payer: Molina Healthcare Managed Medicare	$80.14
Rate for Payer: Oscar Health of IA Commercial	$118.50
Rate for Payer: Partners Health Alliance Commercial	$118.50
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22

OT EVAL MOD COMPLEX 45 MIN

Facility

$158.00

Service Code	CPT 97166 GO
Hospital Charge Code	8397267
Hospital Revenue Code	434
Min. Negotiated Rate	$110.60
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: United Healthcare Commercial	$142.20

OT EVAL MOD COMPLEX 45 MIN

Facility

$158.00

Service Code	CPT 97166 GO
Hospital Charge Code	8397267
Hospital Revenue Code	434
Min. Negotiated Rate	$78.97
Max. Negotiated Rate	$142.20
Rate for Payer: Aetna of IA Commercial	$142.20
Rate for Payer: Aetna of IA Medical Rental Products	$142.20
Rate for Payer: Aetna of IA Medicare	$90.06
Rate for Payer: Amerigroup Medicaid	$79.74
Rate for Payer: Amerigroup Medicare	$79.79
Rate for Payer: Cash Price	$126.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$118.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$79.00
Rate for Payer: Iowa Total Care Managed Medicaid	$78.97
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Medical Associates Managed Medicare	$79.00
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: Molina Healthcare Managed Medicaid	$80.18
Rate for Payer: Molina Healthcare Managed Medicare	$80.14
Rate for Payer: Oscar Health of IA Commercial	$118.50
Rate for Payer: Partners Health Alliance Commercial	$118.50
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22

Other Antepartum Diagnoses With O.R. Procedures With CC

Facility

$7,885.75

Service Code	MS-DRG 818
Hospital Charge Code	560
Min. Negotiated Rate	$7,771.46
Max. Negotiated Rate	$7,885.75
Rate for Payer: Amerigroup Medicaid	$7,847.65
Rate for Payer: Iowa Total Care Managed Medicaid	$7,771.46
Rate for Payer: Molina Healthcare Managed Medicaid	$7,885.75

Other Antepartum Diagnoses With O.R. Procedures With MCC

Facility

$10,904.41

Service Code	MS-DRG 817
Hospital Charge Code	559
Min. Negotiated Rate	$10,746.37
Max. Negotiated Rate	$10,904.41
Rate for Payer: Amerigroup Medicaid	$10,851.73
Rate for Payer: Iowa Total Care Managed Medicaid	$10,746.37
Rate for Payer: Molina Healthcare Managed Medicaid	$10,904.41

Other Antepartum Diagnoses With O.R. Procedures Without CC/MCC

Facility

$7,015.68

Service Code	MS-DRG 819
Hospital Charge Code	561
Min. Negotiated Rate	$6,914.00
Max. Negotiated Rate	$7,015.68
Rate for Payer: Amerigroup Medicaid	$6,981.78
Rate for Payer: Iowa Total Care Managed Medicaid	$6,914.00
Rate for Payer: Molina Healthcare Managed Medicaid	$7,015.68

Other Antepartum Diagnoses Without O.R. Procedures With CC

Facility

$5,121.00

Service Code	MS-DRG 832
Hospital Charge Code	574
Min. Negotiated Rate	$5,046.79
Max. Negotiated Rate	$5,121.00
Rate for Payer: Amerigroup Medicaid	$5,096.26
Rate for Payer: Iowa Total Care Managed Medicaid	$5,046.79
Rate for Payer: Molina Healthcare Managed Medicaid	$5,121.00

Other Antepartum Diagnoses Without O.R. Procedures With MCC

Facility

$6,979.25

Service Code	MS-DRG 831
Hospital Charge Code	573
Min. Negotiated Rate	$6,878.10
Max. Negotiated Rate	$6,979.25
Rate for Payer: Amerigroup Medicaid	$6,945.54
Rate for Payer: Iowa Total Care Managed Medicaid	$6,878.10
Rate for Payer: Molina Healthcare Managed Medicaid	$6,979.25

Other Antepartum Diagnoses Without O.R. Procedures Without CC/MCC

Facility

$3,925.15

Service Code	MS-DRG 833
Hospital Charge Code	575
Min. Negotiated Rate	$3,868.27
Max. Negotiated Rate	$3,925.15
Rate for Payer: Amerigroup Medicaid	$3,906.19
Rate for Payer: Iowa Total Care Managed Medicaid	$3,868.27
Rate for Payer: Molina Healthcare Managed Medicaid	$3,925.15

Other Cardiothoracic Procedures With MCC

Facility

$52,023.07

Service Code	MS-DRG 228
Hospital Charge Code	93
Min. Negotiated Rate	$51,269.12
Max. Negotiated Rate	$52,023.07
Rate for Payer: Amerigroup Medicaid	$51,771.76
Rate for Payer: Iowa Total Care Managed Medicaid	$51,269.12
Rate for Payer: Molina Healthcare Managed Medicaid	$52,023.07

Other Cardiothoracic Procedures Without MCC

Facility

$30,339.24

Service Code	MS-DRG 229
Hospital Charge Code	94
Min. Negotiated Rate	$29,899.55
Max. Negotiated Rate	$30,339.24
Rate for Payer: Amerigroup Medicaid	$30,192.68
Rate for Payer: Iowa Total Care Managed Medicaid	$29,899.55
Rate for Payer: Molina Healthcare Managed Medicaid	$30,339.24

Other Circulatory System Diagnoses With CC

Facility

$9,138.69

Service Code	MS-DRG 315
Hospital Charge Code	172
Min. Negotiated Rate	$9,006.24
Max. Negotiated Rate	$9,138.69
Rate for Payer: Amerigroup Medicaid	$9,094.54
Rate for Payer: Iowa Total Care Managed Medicaid	$9,006.24
Rate for Payer: Molina Healthcare Managed Medicaid	$9,138.69

Other Circulatory System Diagnoses With MCC

Facility

$17,263.59

Service Code	MS-DRG 314
Hospital Charge Code	171
Min. Negotiated Rate	$17,013.40
Max. Negotiated Rate	$17,263.59
Rate for Payer: Amerigroup Medicaid	$17,180.19
Rate for Payer: Iowa Total Care Managed Medicaid	$17,013.40
Rate for Payer: Molina Healthcare Managed Medicaid	$17,263.59

Other Circulatory System Diagnoses Without CC/MCC

Facility

$5,521.59

Service Code	MS-DRG 316
Hospital Charge Code	173
Min. Negotiated Rate	$5,441.57
Max. Negotiated Rate	$5,521.59
Rate for Payer: Amerigroup Medicaid	$5,494.92
Rate for Payer: Iowa Total Care Managed Medicaid	$5,441.57
Rate for Payer: Molina Healthcare Managed Medicaid	$5,521.59

Other Circulatory System O.R. Procedures

Facility

$24,007.62

Service Code	MS-DRG 264
Hospital Charge Code	126
Min. Negotiated Rate	$23,659.69
Max. Negotiated Rate	$24,007.62
Rate for Payer: Amerigroup Medicaid	$23,891.64
Rate for Payer: Iowa Total Care Managed Medicaid	$23,659.69
Rate for Payer: Molina Healthcare Managed Medicaid	$24,007.62

Other Digestive System Diagnoses With CC

Facility

$7,475.32

Service Code	MS-DRG 394
Hospital Charge Code	235
Min. Negotiated Rate	$7,366.98
Max. Negotiated Rate	$7,475.32
Rate for Payer: Amerigroup Medicaid	$7,439.21
Rate for Payer: Iowa Total Care Managed Medicaid	$7,366.98
Rate for Payer: Molina Healthcare Managed Medicaid	$7,475.32

Other Digestive System Diagnoses With MCC

Facility

$14,346.30

Service Code	MS-DRG 393
Hospital Charge Code	234
Min. Negotiated Rate	$14,138.38
Max. Negotiated Rate	$14,346.30
Rate for Payer: Amerigroup Medicaid	$14,276.99
Rate for Payer: Iowa Total Care Managed Medicaid	$14,138.38
Rate for Payer: Molina Healthcare Managed Medicaid	$14,346.30

Other Digestive System Diagnoses Without CC/MCC

Facility

$6,923.16

Service Code	MS-DRG 395
Hospital Charge Code	236
Min. Negotiated Rate	$6,822.82
Max. Negotiated Rate	$6,923.16
Rate for Payer: Amerigroup Medicaid	$6,889.71
Rate for Payer: Iowa Total Care Managed Medicaid	$6,822.82
Rate for Payer: Molina Healthcare Managed Medicaid	$6,923.16

Other Digestive System O.R. Procedures With CC

Facility

$20,508.64

Service Code	MS-DRG 357
Hospital Charge Code	207
Min. Negotiated Rate	$20,211.41
Max. Negotiated Rate	$20,508.64
Rate for Payer: Amerigroup Medicaid	$20,409.56
Rate for Payer: Iowa Total Care Managed Medicaid	$20,211.41
Rate for Payer: Molina Healthcare Managed Medicaid	$20,508.64

Other Digestive System O.R. Procedures With MCC

Facility

$31,450.45

Service Code	MS-DRG 356
Hospital Charge Code	206
Min. Negotiated Rate	$30,994.65
Max. Negotiated Rate	$31,450.45
Rate for Payer: Amerigroup Medicaid	$31,298.52
Rate for Payer: Iowa Total Care Managed Medicaid	$30,994.65
Rate for Payer: Molina Healthcare Managed Medicaid	$31,450.45

Other Digestive System O.R. Procedures Without CC/MCC

Facility

$11,196.73

Service Code	MS-DRG 358
Hospital Charge Code	208
Min. Negotiated Rate	$11,034.46
Max. Negotiated Rate	$11,196.73
Rate for Payer: Amerigroup Medicaid	$11,142.64
Rate for Payer: Iowa Total Care Managed Medicaid	$11,034.46
Rate for Payer: Molina Healthcare Managed Medicaid	$11,196.73

Know your out-of-pocket cost for care.

All Charges