Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

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	$71.10
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	$91.13
Rate for Payer: Amerigroup Medicare	$71.81
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	$71.10
Rate for Payer: Iowa Total Care Managed Medicaid	$90.25
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Medical Associates Managed Medicare	$71.10
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: Molina Healthcare Managed Medicaid	$91.58
Rate for Payer: Partners Health Alliance Commercial	$81.77
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	$71.10
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	$91.13
Rate for Payer: Amerigroup Medicare	$71.81
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	$71.10
Rate for Payer: Iowa Total Care Managed Medicaid	$90.25
Rate for Payer: Medical Associates Commercial	$118.50
Rate for Payer: Medical Associates Managed Medicare	$71.10
Rate for Payer: Midlands Choice Commercial	$110.60
Rate for Payer: Molina Healthcare Managed Medicaid	$91.58
Rate for Payer: Partners Health Alliance Commercial	$81.77
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 RE-EVAL EST PLAN CARE

Facility

$153.00

Service Code	CPT 97168 GO
Hospital Charge Code	8397283
Hospital Revenue Code	434
Min. Negotiated Rate	$107.10
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: United Healthcare Commercial	$137.70

OT RE-EVAL EST PLAN CARE

Facility

$153.00

Service Code	CPT 97168 GO
Hospital Charge Code	8397283
Hospital Revenue Code	434
Min. Negotiated Rate	$68.85
Max. Negotiated Rate	$137.70
Rate for Payer: Aetna of IA Commercial	$137.70
Rate for Payer: Aetna of IA Medical Rental Products	$137.70
Rate for Payer: Aetna of IA Medicare	$87.21
Rate for Payer: Amerigroup Medicaid	$88.25
Rate for Payer: Amerigroup Medicare	$69.54
Rate for Payer: Cash Price	$122.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$114.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$68.85
Rate for Payer: Iowa Total Care Managed Medicaid	$87.39
Rate for Payer: Medical Associates Commercial	$114.75
Rate for Payer: Medical Associates Managed Medicare	$68.85
Rate for Payer: Midlands Choice Commercial	$107.10
Rate for Payer: Molina Healthcare Managed Medicaid	$88.68
Rate for Payer: Partners Health Alliance Commercial	$79.18
Rate for Payer: United Healthcare Commercial	$137.70
Rate for Payer: United Healthcare Managed Medicare	$90.27

OT Wheelchair Training Charges

Facility

$85.00

Service Code	CPT 97542
Hospital Charge Code	1041810
Hospital Revenue Code	430
Min. Negotiated Rate	$38.25
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: Aetna of IA Medicare	$48.45
Rate for Payer: Amerigroup Medicaid	$49.03
Rate for Payer: Amerigroup Medicare	$38.63
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	$38.25
Rate for Payer: Iowa Total Care Managed Medicaid	$48.55
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Medical Associates Managed Medicare	$38.25
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: Molina Healthcare Managed Medicaid	$49.27
Rate for Payer: Partners Health Alliance Commercial	$43.99
Rate for Payer: United Healthcare Commercial	$76.50
Rate for Payer: United Healthcare Managed Medicare	$50.15

OT Wheelchair Training Charges

Facility

$85.00

Service Code	CPT 97542
Hospital Charge Code	1041810
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 Wound Care Selective Debridement Addl Charge

Facility

$85.00

Service Code	CPT 97598
Hospital Charge Code	7395136
Hospital Revenue Code	430
Min. Negotiated Rate	$38.25
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: Aetna of IA Medicare	$48.45
Rate for Payer: Amerigroup Medicaid	$49.03
Rate for Payer: Amerigroup Medicare	$38.63
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	$38.25
Rate for Payer: Iowa Total Care Managed Medicaid	$48.55
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Medical Associates Managed Medicare	$38.25
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: Molina Healthcare Managed Medicaid	$49.27
Rate for Payer: Partners Health Alliance Commercial	$43.99
Rate for Payer: United Healthcare Commercial	$76.50
Rate for Payer: United Healthcare Managed Medicare	$50.15

OT Wound Care Selective Debridement Addl Charge

Facility

$85.00

Service Code	CPT 97598
Hospital Charge Code	7395136
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 Wound Care Selective Debridement Charge

Facility

$85.00

Service Code	CPT 97597
Hospital Charge Code	7395135
Hospital Revenue Code	430
Min. Negotiated Rate	$38.25
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: Aetna of IA Medicare	$48.45
Rate for Payer: Amerigroup Medicaid	$49.03
Rate for Payer: Amerigroup Medicare	$38.63
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	$38.25
Rate for Payer: Iowa Total Care Managed Medicaid	$48.55
Rate for Payer: Medical Associates Commercial	$63.75
Rate for Payer: Medical Associates Managed Medicare	$38.25
Rate for Payer: Midlands Choice Commercial	$59.50
Rate for Payer: Molina Healthcare Managed Medicaid	$49.27
Rate for Payer: Partners Health Alliance Commercial	$43.99
Rate for Payer: United Healthcare Commercial	$76.50
Rate for Payer: United Healthcare Managed Medicare	$50.15

OT Wound Care Selective Debridement Charge

Facility

$85.00

Service Code	CPT 97597
Hospital Charge Code	7395135
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

OUTPATIENT IN ED ADD ON CODE

Professional

Both

$154.00

Service Code	CPT 99355 AJ\|HO
Hospital Charge Code	4759858
Hospital Revenue Code	450
Min. Negotiated Rate	$107.80
Max. Negotiated Rate	$115.50
Rate for Payer: Cash Price	$123.20
Rate for Payer: Medical Associates Commercial	$115.50
Rate for Payer: Midlands Choice Commercial	$107.80
Rate for Payer: Partners Health Alliance Commercial	$115.50

OUTPATIENT LEVEL 1 CHARGE (10 pts/<)

Facility

$200.00

Service Code	HCPCS G0463
Hospital Charge Code	8027048
Hospital Revenue Code	761
Min. Negotiated Rate	$90.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of IA Commercial	$180.00
Rate for Payer: Aetna of IA Medical Rental Products	$180.00
Rate for Payer: Aetna of IA Medicare	$114.00
Rate for Payer: Amerigroup Medicaid	$115.36
Rate for Payer: Amerigroup Medicare	$90.90
Rate for Payer: Cash Price	$160.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$90.00
Rate for Payer: Iowa Total Care Managed Medicaid	$114.24
Rate for Payer: Medical Associates Commercial	$150.00
Rate for Payer: Medical Associates Managed Medicare	$90.00
Rate for Payer: Midlands Choice Commercial	$140.00
Rate for Payer: Molina Healthcare Managed Medicaid	$115.92
Rate for Payer: Partners Health Alliance Commercial	$103.50
Rate for Payer: United Healthcare Commercial	$180.00
Rate for Payer: United Healthcare Managed Medicare	$118.00

OUTPATIENT LEVEL 1 CHARGE (10 pts/<)

Facility

$200.00

Service Code	HCPCS G0463
Hospital Charge Code	8027048
Hospital Revenue Code	761
Min. Negotiated Rate	$140.00
Max. Negotiated Rate	$180.00
Rate for Payer: Aetna of IA Commercial	$180.00
Rate for Payer: Aetna of IA Medical Rental Products	$180.00
Rate for Payer: Cash Price	$160.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$150.00
Rate for Payer: Medical Associates Commercial	$150.00
Rate for Payer: Midlands Choice Commercial	$140.00
Rate for Payer: United Healthcare Commercial	$180.00

oxaliplatin 5 mg/mL 20ml [VDMC]

Facility

$93.48

Service Code	HCPCS J9263
Hospital Charge Code	14142147
Hospital Revenue Code	259
Min. Negotiated Rate	$42.07
Max. Negotiated Rate	$84.13
Rate for Payer: Aetna of IA Commercial	$84.13
Rate for Payer: Aetna of IA Medical Rental Products	$84.13
Rate for Payer: Aetna of IA Medicare	$53.28
Rate for Payer: Amerigroup Medicaid	$53.92
Rate for Payer: Amerigroup Medicare	$42.49
Rate for Payer: Cash Price	$74.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.11
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$42.07
Rate for Payer: Iowa Total Care Managed Medicaid	$53.40
Rate for Payer: Medical Associates Commercial	$70.11
Rate for Payer: Medical Associates Managed Medicare	$42.07
Rate for Payer: Midlands Choice Commercial	$65.44
Rate for Payer: Molina Healthcare Managed Medicaid	$54.18
Rate for Payer: Partners Health Alliance Commercial	$48.38
Rate for Payer: United Healthcare Commercial	$84.13
Rate for Payer: United Healthcare Managed Medicare	$55.15

oxaliplatin 5 mg/mL 20ml [VDMC]

Facility

$93.48

Service Code	HCPCS J9263
Hospital Charge Code	14142147
Hospital Revenue Code	259
Min. Negotiated Rate	$65.44
Max. Negotiated Rate	$84.13
Rate for Payer: Aetna of IA Commercial	$84.13
Rate for Payer: Aetna of IA Medical Rental Products	$84.13
Rate for Payer: Cash Price	$74.78
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$70.11
Rate for Payer: Medical Associates Commercial	$70.11
Rate for Payer: Midlands Choice Commercial	$65.44
Rate for Payer: United Healthcare Commercial	$84.13

oxazepam 15 mg Cap [VDMC]

Facility

$6.29

Service Code	HCPCS A9270
Hospital Charge Code	10410824
Hospital Revenue Code	259
Min. Negotiated Rate	$4.41
Max. Negotiated Rate	$5.67
Rate for Payer: Aetna of IA Commercial	$5.67
Rate for Payer: Aetna of IA Medical Rental Products	$5.67
Rate for Payer: Cash Price	$5.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.72
Rate for Payer: Medical Associates Commercial	$4.72
Rate for Payer: Midlands Choice Commercial	$4.41
Rate for Payer: United Healthcare Commercial	$5.67

oxazepam 15 mg Cap [VDMC]

Facility

$6.29

Service Code	HCPCS A9270
Hospital Charge Code	10410824
Hospital Revenue Code	259
Min. Negotiated Rate	$2.83
Max. Negotiated Rate	$5.67
Rate for Payer: Aetna of IA Commercial	$5.67
Rate for Payer: Aetna of IA Medical Rental Products	$5.67
Rate for Payer: Aetna of IA Medicare	$3.59
Rate for Payer: Amerigroup Medicaid	$3.63
Rate for Payer: Amerigroup Medicare	$2.86
Rate for Payer: Cash Price	$5.04
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$4.72
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2.83
Rate for Payer: Iowa Total Care Managed Medicaid	$3.60
Rate for Payer: Medical Associates Commercial	$4.72
Rate for Payer: Medical Associates Managed Medicare	$2.83
Rate for Payer: Midlands Choice Commercial	$4.41
Rate for Payer: Molina Healthcare Managed Medicaid	$3.65
Rate for Payer: Partners Health Alliance Commercial	$3.26
Rate for Payer: United Healthcare Commercial	$5.67
Rate for Payer: United Healthcare Managed Medicare	$3.71

oxcarbazepine 600mg Tab [VDMC]

Facility

$2.08

Service Code	HCPCS A9270
Hospital Charge Code	10609857
Hospital Revenue Code	259
Min. Negotiated Rate	$0.94
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of IA Commercial	$1.87
Rate for Payer: Aetna of IA Medical Rental Products	$1.87
Rate for Payer: Aetna of IA Medicare	$1.19
Rate for Payer: Amerigroup Medicaid	$1.20
Rate for Payer: Amerigroup Medicare	$0.95
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.56
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.94
Rate for Payer: Iowa Total Care Managed Medicaid	$1.19
Rate for Payer: Medical Associates Commercial	$1.56
Rate for Payer: Medical Associates Managed Medicare	$0.94
Rate for Payer: Midlands Choice Commercial	$1.46
Rate for Payer: Molina Healthcare Managed Medicaid	$1.21
Rate for Payer: Partners Health Alliance Commercial	$1.08
Rate for Payer: United Healthcare Commercial	$1.87
Rate for Payer: United Healthcare Managed Medicare	$1.23

oxcarbazepine 600mg Tab [VDMC]

Facility

$2.08

Service Code	HCPCS A9270
Hospital Charge Code	10609857
Hospital Revenue Code	259
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.87
Rate for Payer: Aetna of IA Commercial	$1.87
Rate for Payer: Aetna of IA Medical Rental Products	$1.87
Rate for Payer: Cash Price	$1.67
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.56
Rate for Payer: Medical Associates Commercial	$1.56
Rate for Payer: Midlands Choice Commercial	$1.46
Rate for Payer: United Healthcare Commercial	$1.87

Oxcarbazepine Trileptal DMCL

Facility

$131.00

Service Code	CPT 80183
Hospital Charge Code	8037746
Hospital Revenue Code	301
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

Oxcarbazepine Trileptal DMCL

Facility

$131.00

Service Code	CPT 80183
Hospital Charge Code	8037746
Hospital Revenue Code	301
Min. Negotiated Rate	$58.95
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	$75.56
Rate for Payer: Amerigroup Medicare	$59.54
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	$58.95
Rate for Payer: Iowa Total Care Managed Medicaid	$74.83
Rate for Payer: Medical Associates Commercial	$98.25
Rate for Payer: Medical Associates Managed Medicare	$58.95
Rate for Payer: Midlands Choice Commercial	$91.70
Rate for Payer: Molina Healthcare Managed Medicaid	$75.93
Rate for Payer: Partners Health Alliance Commercial	$67.79
Rate for Payer: United Healthcare Commercial	$117.90
Rate for Payer: United Healthcare Managed Medicare	$77.29

OXIMETRY, PULSE CONTINUOUS OVERNIGHT

Facility

$260.00

Service Code	CPT 94762
Hospital Charge Code	6658828
Hospital Revenue Code	460
Min. Negotiated Rate	$182.00
Max. Negotiated Rate	$234.00
Rate for Payer: Aetna of IA Commercial	$234.00
Rate for Payer: Aetna of IA Medical Rental Products	$234.00
Rate for Payer: Cash Price	$208.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$195.00
Rate for Payer: Medical Associates Commercial	$195.00
Rate for Payer: Midlands Choice Commercial	$182.00
Rate for Payer: United Healthcare Commercial	$234.00

Know your out-of-pocket cost for care.

All Charges