Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC

Facility

$26,707.05

Service Code	MSDRG 987
Min. Negotiated Rate	$26,319.98
Max. Negotiated Rate	$26,707.05
Rate for Payer: Amerigroup Medicaid	$26,578.02
Rate for Payer: Iowa Total Care Managed Medicaid	$26,319.98
Rate for Payer: Molina Healthcare Managed Medicaid	$26,707.05

NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC

Facility

$8,407.67

Service Code	MSDRG 989
Min. Negotiated Rate	$8,285.82
Max. Negotiated Rate	$8,407.67
Rate for Payer: Amerigroup Medicaid	$8,367.05
Rate for Payer: Iowa Total Care Managed Medicaid	$8,285.82
Rate for Payer: Molina Healthcare Managed Medicaid	$8,407.67

NON-LOCKING SCREW 2.7MMX14MM

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8759894
Hospital Revenue Code	278
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Aetna of IA Medicare	$123.12
Rate for Payer: Amerigroup Medicaid	$124.59
Rate for Payer: Amerigroup Medicare	$98.17
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.20
Rate for Payer: Iowa Total Care Managed Medicaid	$123.38
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Medical Associates Managed Medicare	$97.20
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: Molina Healthcare Managed Medicaid	$125.19
Rate for Payer: Partners Health Alliance Commercial	$111.78
Rate for Payer: United Healthcare Commercial	$194.40
Rate for Payer: United Healthcare Managed Medicare	$127.44

NON-LOCKING SCREW 2.7MMX14MM

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8759894
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: United Healthcare Commercial	$194.40

NON-LOCKING SCREW 2.7MMx16MM

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8967554
Hospital Revenue Code	278
Min. Negotiated Rate	$151.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: United Healthcare Commercial	$194.40

NON-LOCKING SCREW 2.7MMx16MM

Facility

$216.00

Service Code	HCPCS C1713
Hospital Charge Code	8967554
Hospital Revenue Code	278
Min. Negotiated Rate	$97.20
Max. Negotiated Rate	$194.40
Rate for Payer: Aetna of IA Commercial	$194.40
Rate for Payer: Aetna of IA Medical Rental Products	$194.40
Rate for Payer: Aetna of IA Medicare	$123.12
Rate for Payer: Amerigroup Medicaid	$124.59
Rate for Payer: Amerigroup Medicare	$98.17
Rate for Payer: Cash Price	$172.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$162.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$97.20
Rate for Payer: Iowa Total Care Managed Medicaid	$123.38
Rate for Payer: Medical Associates Commercial	$162.00
Rate for Payer: Medical Associates Managed Medicare	$97.20
Rate for Payer: Midlands Choice Commercial	$151.20
Rate for Payer: Molina Healthcare Managed Medicaid	$125.19
Rate for Payer: Partners Health Alliance Commercial	$111.78
Rate for Payer: United Healthcare Commercial	$194.40
Rate for Payer: United Healthcare Managed Medicare	$127.44

NON-LOCKING SCREW 3.5MMX12MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8793251
Hospital Revenue Code	278
Min. Negotiated Rate	$89.10
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Aetna of IA Medicare	$112.86
Rate for Payer: Amerigroup Medicaid	$114.21
Rate for Payer: Amerigroup Medicare	$89.99
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$89.10
Rate for Payer: Iowa Total Care Managed Medicaid	$113.10
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Medical Associates Managed Medicare	$89.10
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: Molina Healthcare Managed Medicaid	$114.76
Rate for Payer: Partners Health Alliance Commercial	$102.46
Rate for Payer: United Healthcare Commercial	$178.20
Rate for Payer: United Healthcare Managed Medicare	$116.82

NON-LOCKING SCREW 3.5MMX12MM

Facility

$198.00

Service Code	HCPCS C1713
Hospital Charge Code	8793251
Hospital Revenue Code	278
Min. Negotiated Rate	$138.60
Max. Negotiated Rate	$178.20
Rate for Payer: Aetna of IA Commercial	$178.20
Rate for Payer: Aetna of IA Medical Rental Products	$178.20
Rate for Payer: Cash Price	$158.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$148.50
Rate for Payer: Medical Associates Commercial	$148.50
Rate for Payer: Midlands Choice Commercial	$138.60
Rate for Payer: United Healthcare Commercial	$178.20

NON-LOCKING SCREW 4.0MMX16MM

Facility

$333.00

Service Code	HCPCS C1713
Hospital Charge Code	8986279
Hospital Revenue Code	278
Min. Negotiated Rate	$149.85
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Aetna of IA Medicare	$189.81
Rate for Payer: Amerigroup Medicaid	$192.07
Rate for Payer: Amerigroup Medicare	$151.35
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$149.85
Rate for Payer: Iowa Total Care Managed Medicaid	$190.21
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Medical Associates Managed Medicare	$149.85
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: Molina Healthcare Managed Medicaid	$193.01
Rate for Payer: Partners Health Alliance Commercial	$172.33
Rate for Payer: United Healthcare Commercial	$299.70
Rate for Payer: United Healthcare Managed Medicare	$196.47

NON-LOCKING SCREW 4.0MMX16MM

Facility

$333.00

Service Code	HCPCS C1713
Hospital Charge Code	8986279
Hospital Revenue Code	278
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: United Healthcare Commercial	$299.70

NON-LOCKING SCREW 4.0MMX50MM

Facility

$333.00

Service Code	HCPCS C1713
Hospital Charge Code	8986281
Hospital Revenue Code	278
Min. Negotiated Rate	$149.85
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Aetna of IA Medicare	$189.81
Rate for Payer: Amerigroup Medicaid	$192.07
Rate for Payer: Amerigroup Medicare	$151.35
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$149.85
Rate for Payer: Iowa Total Care Managed Medicaid	$190.21
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Medical Associates Managed Medicare	$149.85
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: Molina Healthcare Managed Medicaid	$193.01
Rate for Payer: Partners Health Alliance Commercial	$172.33
Rate for Payer: United Healthcare Commercial	$299.70
Rate for Payer: United Healthcare Managed Medicare	$196.47

NON-LOCKING SCREW 4.0MMX50MM

Facility

$333.00

Service Code	HCPCS C1713
Hospital Charge Code	8986281
Hospital Revenue Code	278
Min. Negotiated Rate	$233.10
Max. Negotiated Rate	$299.70
Rate for Payer: Aetna of IA Commercial	$299.70
Rate for Payer: Aetna of IA Medical Rental Products	$299.70
Rate for Payer: Cash Price	$266.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$249.75
Rate for Payer: Medical Associates Commercial	$249.75
Rate for Payer: Midlands Choice Commercial	$233.10
Rate for Payer: United Healthcare Commercial	$299.70

NON-MALIGNANT BREAST DISORDERS WITH CC/MCC

Facility

$11,214.73

Service Code	MSDRG 600
Min. Negotiated Rate	$11,052.19
Max. Negotiated Rate	$11,214.73
Rate for Payer: Amerigroup Medicaid	$11,160.55
Rate for Payer: Iowa Total Care Managed Medicaid	$11,052.19
Rate for Payer: Molina Healthcare Managed Medicaid	$11,214.73

NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC

Facility

$4,347.40

Service Code	MSDRG 601
Min. Negotiated Rate	$4,284.39
Max. Negotiated Rate	$4,347.40
Rate for Payer: Amerigroup Medicaid	$4,326.39
Rate for Payer: Iowa Total Care Managed Medicaid	$4,284.39
Rate for Payer: Molina Healthcare Managed Medicaid	$4,347.40

NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC

Facility

$9,171.08

Service Code	MSDRG 071
Min. Negotiated Rate	$9,038.16
Max. Negotiated Rate	$9,171.08
Rate for Payer: Amerigroup Medicaid	$9,126.77
Rate for Payer: Iowa Total Care Managed Medicaid	$9,038.16
Rate for Payer: Molina Healthcare Managed Medicaid	$9,171.08

NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC

Facility

$17,622.67

Service Code	MSDRG 070
Min. Negotiated Rate	$17,367.26
Max. Negotiated Rate	$17,622.67
Rate for Payer: Amerigroup Medicaid	$17,537.52
Rate for Payer: Iowa Total Care Managed Medicaid	$17,367.26
Rate for Payer: Molina Healthcare Managed Medicaid	$17,622.67

NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC

Facility

$7,438.20

Service Code	MSDRG 072
Min. Negotiated Rate	$7,330.40
Max. Negotiated Rate	$7,438.20
Rate for Payer: Amerigroup Medicaid	$7,402.27
Rate for Payer: Iowa Total Care Managed Medicaid	$7,330.40
Rate for Payer: Molina Healthcare Managed Medicaid	$7,438.20

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC

Facility

$16,040.67

Service Code	MSDRG 067
Min. Negotiated Rate	$15,808.19
Max. Negotiated Rate	$16,040.67
Rate for Payer: Amerigroup Medicaid	$15,963.17
Rate for Payer: Iowa Total Care Managed Medicaid	$15,808.19
Rate for Payer: Molina Healthcare Managed Medicaid	$16,040.67

NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC

Facility

$10,954.63

Service Code	MSDRG 068
Min. Negotiated Rate	$10,795.86
Max. Negotiated Rate	$10,954.63
Rate for Payer: Amerigroup Medicaid	$10,901.70
Rate for Payer: Iowa Total Care Managed Medicaid	$10,795.86
Rate for Payer: Molina Healthcare Managed Medicaid	$10,954.63

NON-STERILE SNIPER STAPLE IMPLANTS 20X20X20

Facility

$1,629.00

Service Code	HCPCS C1713
Hospital Charge Code	8837859
Hospital Revenue Code	278
Min. Negotiated Rate	$1,140.30
Max. Negotiated Rate	$1,466.10
Rate for Payer: Aetna of IA Commercial	$1,466.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,466.10
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,221.75
Rate for Payer: Medical Associates Commercial	$1,221.75
Rate for Payer: Midlands Choice Commercial	$1,140.30
Rate for Payer: United Healthcare Commercial	$1,466.10

NON-STERILE SNIPER STAPLE IMPLANTS 20X20X20

Facility

$1,629.00

Service Code	HCPCS C1713
Hospital Charge Code	8837859
Hospital Revenue Code	278
Min. Negotiated Rate	$733.05
Max. Negotiated Rate	$1,466.10
Rate for Payer: Aetna of IA Commercial	$1,466.10
Rate for Payer: Aetna of IA Medical Rental Products	$1,466.10
Rate for Payer: Aetna of IA Medicare	$928.53
Rate for Payer: Amerigroup Medicaid	$939.61
Rate for Payer: Amerigroup Medicare	$740.38
Rate for Payer: Cash Price	$1,303.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,221.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$733.05
Rate for Payer: Iowa Total Care Managed Medicaid	$930.48
Rate for Payer: Medical Associates Commercial	$1,221.75
Rate for Payer: Medical Associates Managed Medicare	$733.05
Rate for Payer: Midlands Choice Commercial	$1,140.30
Rate for Payer: Molina Healthcare Managed Medicaid	$944.17
Rate for Payer: Partners Health Alliance Commercial	$843.01
Rate for Payer: United Healthcare Commercial	$1,466.10
Rate for Payer: United Healthcare Managed Medicare	$961.11

NON-STERILE SNIPER STAPLE IMPLANTS 8X8X8

Facility

$1,368.00

Service Code	HCPCS C1713
Hospital Charge Code	8830151
Hospital Revenue Code	278
Min. Negotiated Rate	$615.60
Max. Negotiated Rate	$1,231.20
Rate for Payer: Aetna of IA Commercial	$1,231.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,231.20
Rate for Payer: Aetna of IA Medicare	$779.76
Rate for Payer: Amerigroup Medicaid	$789.06
Rate for Payer: Amerigroup Medicare	$621.76
Rate for Payer: Cash Price	$1,094.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,026.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$615.60
Rate for Payer: Iowa Total Care Managed Medicaid	$781.40
Rate for Payer: Medical Associates Commercial	$1,026.00
Rate for Payer: Medical Associates Managed Medicare	$615.60
Rate for Payer: Midlands Choice Commercial	$957.60
Rate for Payer: Molina Healthcare Managed Medicaid	$792.89
Rate for Payer: Partners Health Alliance Commercial	$707.94
Rate for Payer: United Healthcare Commercial	$1,231.20
Rate for Payer: United Healthcare Managed Medicare	$807.12

NON-STERILE SNIPER STAPLE IMPLANTS 8X8X8

Facility

$1,368.00

Service Code	HCPCS C1713
Hospital Charge Code	8830151
Hospital Revenue Code	278
Min. Negotiated Rate	$957.60
Max. Negotiated Rate	$1,231.20
Rate for Payer: Aetna of IA Commercial	$1,231.20
Rate for Payer: Aetna of IA Medical Rental Products	$1,231.20
Rate for Payer: Cash Price	$1,094.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,026.00
Rate for Payer: Medical Associates Commercial	$1,026.00
Rate for Payer: Midlands Choice Commercial	$957.60
Rate for Payer: United Healthcare Commercial	$1,231.20

NON-STRES TEST (COB)

Facility

$461.00

Service Code	CPT 59025
Hospital Charge Code	4126788
Hospital Revenue Code	720
Min. Negotiated Rate	$207.45
Max. Negotiated Rate	$494.37
Rate for Payer: Aetna of IA Commercial	$414.90
Rate for Payer: Aetna of IA Medical Rental Products	$414.90
Rate for Payer: Aetna of IA Medicare	$262.77
Rate for Payer: Amerigroup Medicaid	$265.90
Rate for Payer: Amerigroup Medicare	$209.52
Rate for Payer: Cash Price	$368.80
Rate for Payer: Cash Price	$368.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$345.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$207.45
Rate for Payer: Iowa Total Care Managed Medicaid	$263.32
Rate for Payer: Medical Associates Commercial	$345.75
Rate for Payer: Medical Associates Managed Medicare	$207.45
Rate for Payer: Midlands Choice Commercial	$322.70
Rate for Payer: Molina Healthcare Managed Medicaid	$267.20
Rate for Payer: Partners Health Alliance Commercial	$238.57
Rate for Payer: United Healthcare Commercial	$414.90
Rate for Payer: United Healthcare Managed Medicare	$271.99
Rate for Payer: Wellmark IA HMO WHPI	$448.80
Rate for Payer: Wellmark IA PPO	$494.37

NON-STRES TEST (COB)

Facility

$461.00

Service Code	CPT 59025
Hospital Charge Code	4126788
Hospital Revenue Code	720
Min. Negotiated Rate	$322.70
Max. Negotiated Rate	$414.90
Rate for Payer: Aetna of IA Commercial	$414.90
Rate for Payer: Aetna of IA Medical Rental Products	$414.90
Rate for Payer: Cash Price	$368.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$345.75
Rate for Payer: Medical Associates Commercial	$345.75
Rate for Payer: Midlands Choice Commercial	$322.70
Rate for Payer: United Healthcare Commercial	$414.90

Know your out-of-pocket cost for care.

All Charges