Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC

Facility

$16,074.45

Service Code	MSDRG 621
Min. Negotiated Rate	$15,841.48
Max. Negotiated Rate	$16,074.45
Rate for Payer: Amerigroup Medicaid	$15,996.79
Rate for Payer: Iowa Total Care Managed Medicaid	$15,841.48
Rate for Payer: Molina Healthcare Managed Medicaid	$16,074.45

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC

Facility

$11,984.90

Service Code	MSDRG 940
Min. Negotiated Rate	$11,811.20
Max. Negotiated Rate	$11,984.90
Rate for Payer: Amerigroup Medicaid	$11,927.00
Rate for Payer: Iowa Total Care Managed Medicaid	$11,811.20
Rate for Payer: Molina Healthcare Managed Medicaid	$11,984.90

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC

Facility

$38,137.97

Service Code	MSDRG 939
Min. Negotiated Rate	$37,585.23
Max. Negotiated Rate	$38,137.97
Rate for Payer: Amerigroup Medicaid	$37,953.71
Rate for Payer: Iowa Total Care Managed Medicaid	$37,585.23
Rate for Payer: Molina Healthcare Managed Medicaid	$38,137.97

O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC

Facility

$10,147.30

Service Code	MSDRG 941
Min. Negotiated Rate	$10,000.24
Max. Negotiated Rate	$10,147.30
Rate for Payer: Amerigroup Medicaid	$10,098.28
Rate for Payer: Iowa Total Care Managed Medicaid	$10,000.24
Rate for Payer: Molina Healthcare Managed Medicaid	$10,147.30

O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS

Facility

$13,579.28

Service Code	MSDRG 876
Min. Negotiated Rate	$13,382.48
Max. Negotiated Rate	$13,579.28
Rate for Payer: Amerigroup Medicaid	$13,513.68
Rate for Payer: Iowa Total Care Managed Medicaid	$13,382.48
Rate for Payer: Molina Healthcare Managed Medicaid	$13,579.28

ORTHO DYNBRAC PER 15 MIN

Facility

$131.00

Service Code	CPT 97760 GO
Hospital Charge Code	1373573
Hospital Revenue Code	430
Min. Negotiated Rate	$58.95
Max. Negotiated Rate	$165.57
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$150.31
Rate for Payer: Wellmark IA PPO	$165.57

ORTHO DYNBRAC PER 15 MIN

Facility

$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

$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

$131.00

Service Code	CPT 97760 GP
Hospital Charge Code	1374120
Hospital Revenue Code	420
Min. Negotiated Rate	$58.95
Max. Negotiated Rate	$165.57
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$150.31
Rate for Payer: Wellmark IA PPO	$165.57

oseltamivir 30 mg Cap [VDMC]

Facility

$3.90

Service Code	HCPCS A9270
Hospital Charge Code	14563568
Hospital Revenue Code	259
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 30 mg Cap [VDMC]

Facility

$3.90

Service Code	HCPCS A9270
Hospital Charge Code	14563568
Hospital Revenue Code	259
Min. Negotiated Rate	$1.75
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	$2.25
Rate for Payer: Amerigroup Medicare	$1.77
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	$1.75
Rate for Payer: Iowa Total Care Managed Medicaid	$2.23
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Medical Associates Managed Medicare	$1.75
Rate for Payer: Midlands Choice Commercial	$2.73
Rate for Payer: Molina Healthcare Managed Medicaid	$2.26
Rate for Payer: Partners Health Alliance Commercial	$2.02
Rate for Payer: United Healthcare Commercial	$3.51
Rate for Payer: United Healthcare Managed Medicare	$2.30

oseltamivir 6 mg/mL Pow 60ml [VDMC]

Facility

$116.84

Service Code	HCPCS A9270
Hospital Charge Code	10410690
Hospital Revenue Code	259
Min. Negotiated Rate	$52.58
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	$67.39
Rate for Payer: Amerigroup Medicare	$53.10
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	$52.58
Rate for Payer: Iowa Total Care Managed Medicaid	$66.74
Rate for Payer: Medical Associates Commercial	$87.63
Rate for Payer: Medical Associates Managed Medicare	$52.58
Rate for Payer: Midlands Choice Commercial	$81.79
Rate for Payer: Molina Healthcare Managed Medicaid	$67.72
Rate for Payer: Partners Health Alliance Commercial	$60.47
Rate for Payer: United Healthcare Commercial	$105.16
Rate for Payer: United Healthcare Managed Medicare	$68.94

oseltamivir 6 mg/mL Pow 60ml [VDMC]

Facility

$116.84

Service Code	HCPCS A9270
Hospital Charge Code	10410690
Hospital Revenue Code	259
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 [VDMC]

Facility

$3.89

Service Code	HCPCS A9270
Hospital Charge Code	10410755
Hospital Revenue Code	259
Min. Negotiated Rate	$2.72
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna of IA Commercial	$3.50
Rate for Payer: Aetna of IA Medical Rental Products	$3.50
Rate for Payer: Cash Price	$3.11
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	$2.72
Rate for Payer: United Healthcare Commercial	$3.50

oseltamivir 75 mg Cap [VDMC]

Facility

$3.89

Service Code	HCPCS A9270
Hospital Charge Code	10410755
Hospital Revenue Code	259
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna of IA Commercial	$3.50
Rate for Payer: Aetna of IA Medical Rental Products	$3.50
Rate for Payer: Aetna of IA Medicare	$2.22
Rate for Payer: Amerigroup Medicaid	$2.24
Rate for Payer: Amerigroup Medicare	$1.77
Rate for Payer: Cash Price	$3.11
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	$1.75
Rate for Payer: Iowa Total Care Managed Medicaid	$2.22
Rate for Payer: Medical Associates Commercial	$2.92
Rate for Payer: Medical Associates Managed Medicare	$1.75
Rate for Payer: Midlands Choice Commercial	$2.72
Rate for Payer: Molina Healthcare Managed Medicaid	$2.25
Rate for Payer: Partners Health Alliance Commercial	$2.01
Rate for Payer: United Healthcare Commercial	$3.50
Rate for Payer: United Healthcare Managed Medicare	$2.29

Osmolality DMCL

Facility

$63.00

Service Code	CPT 83930
Hospital Charge Code	8037745
Hospital Revenue Code	301
Min. Negotiated Rate	$28.35
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: Aetna of IA Medicare	$35.91
Rate for Payer: Amerigroup Medicaid	$36.34
Rate for Payer: Amerigroup Medicare	$28.63
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	$28.35
Rate for Payer: Iowa Total Care Managed Medicaid	$35.99
Rate for Payer: Medical Associates Commercial	$47.25
Rate for Payer: Medical Associates Managed Medicare	$28.35
Rate for Payer: Midlands Choice Commercial	$44.10
Rate for Payer: Molina Healthcare Managed Medicaid	$36.51
Rate for Payer: Partners Health Alliance Commercial	$32.60
Rate for Payer: United Healthcare Commercial	$56.70
Rate for Payer: United Healthcare Managed Medicare	$37.17
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

Osmolality DMCL

Facility

$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 Urine DMCL

Facility

$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

$65.00

Service Code	CPT 83935
Hospital Charge Code	8037735
Hospital Revenue Code	301
Min. Negotiated Rate	$29.25
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	$37.49
Rate for Payer: Amerigroup Medicare	$29.54
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	$29.25
Rate for Payer: Iowa Total Care Managed Medicaid	$37.13
Rate for Payer: Medical Associates Commercial	$48.75
Rate for Payer: Medical Associates Managed Medicare	$29.25
Rate for Payer: Midlands Choice Commercial	$45.50
Rate for Payer: Molina Healthcare Managed Medicaid	$37.67
Rate for Payer: Partners Health Alliance Commercial	$33.64
Rate for Payer: United Healthcare Commercial	$58.50
Rate for Payer: United Healthcare Managed Medicare	$38.35
Rate for Payer: Wellmark IA HMO WHPI	$30.49
Rate for Payer: Wellmark IA PPO	$33.58

OSSIO FIBER SUTURE ANCHOR SYSTEM

Facility

$3,051.00

Service Code	HCPCS C1713
Hospital Charge Code	8972320
Hospital Revenue Code	278
Min. Negotiated Rate	$2,135.70
Max. Negotiated Rate	$2,745.90
Rate for Payer: Aetna of IA Commercial	$2,745.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,745.90
Rate for Payer: Cash Price	$2,440.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,288.25
Rate for Payer: Medical Associates Commercial	$2,288.25
Rate for Payer: Midlands Choice Commercial	$2,135.70
Rate for Payer: United Healthcare Commercial	$2,745.90

OSSIO FIBER SUTURE ANCHOR SYSTEM

Facility

$3,051.00

Service Code	HCPCS C1713
Hospital Charge Code	8972320
Hospital Revenue Code	278
Min. Negotiated Rate	$1,372.95
Max. Negotiated Rate	$2,745.90
Rate for Payer: Aetna of IA Commercial	$2,745.90
Rate for Payer: Aetna of IA Medical Rental Products	$2,745.90
Rate for Payer: Aetna of IA Medicare	$1,739.07
Rate for Payer: Amerigroup Medicaid	$1,759.82
Rate for Payer: Amerigroup Medicare	$1,386.68
Rate for Payer: Cash Price	$2,440.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$2,288.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,372.95
Rate for Payer: Iowa Total Care Managed Medicaid	$1,742.73
Rate for Payer: Medical Associates Commercial	$2,288.25
Rate for Payer: Medical Associates Managed Medicare	$1,372.95
Rate for Payer: Midlands Choice Commercial	$2,135.70
Rate for Payer: Molina Healthcare Managed Medicaid	$1,768.36
Rate for Payer: Partners Health Alliance Commercial	$1,578.89
Rate for Payer: United Healthcare Commercial	$2,745.90
Rate for Payer: United Healthcare Managed Medicare	$1,800.09

OSTECTOMY, CALCANEUS;

Facility

$5,392.02

Service Code	CPT 28118
Hospital Revenue Code	360
Min. Negotiated Rate	$4,894.94
Max. Negotiated Rate	$5,392.02
Rate for Payer: Wellmark IA HMO WHPI	$4,894.94
Rate for Payer: Wellmark IA PPO	$5,392.02

OSTEOMYELITIS WITH CC

Facility

$11,757.45

Service Code	MSDRG 540
Min. Negotiated Rate	$11,587.05
Max. Negotiated Rate	$11,757.45
Rate for Payer: Amerigroup Medicaid	$11,700.65
Rate for Payer: Iowa Total Care Managed Medicaid	$11,587.05
Rate for Payer: Molina Healthcare Managed Medicaid	$11,757.45

OSTEOMYELITIS WITH MCC

Facility

$16,630.68

Service Code	MSDRG 539
Min. Negotiated Rate	$16,389.65
Max. Negotiated Rate	$16,630.68
Rate for Payer: Amerigroup Medicaid	$16,550.33
Rate for Payer: Iowa Total Care Managed Medicaid	$16,389.65
Rate for Payer: Molina Healthcare Managed Medicaid	$16,630.68

OSTEOMYELITIS WITHOUT CC/MCC

Facility

$6,970.92

Service Code	MSDRG 541
Min. Negotiated Rate	$6,869.89
Max. Negotiated Rate	$6,970.92
Rate for Payer: Amerigroup Medicaid	$6,937.24
Rate for Payer: Iowa Total Care Managed Medicaid	$6,869.89
Rate for Payer: Molina Healthcare Managed Medicaid	$6,970.92

Know your out-of-pocket cost for care.

All Charges