Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

OSTEOTOMY, WITH OR WITHOUT LENGTHENING, SHORTENING OR ANGULAR CORRECTION, METATARSAL; OTHER THAN FIRST METATARSAL, EACH

Facility

$5,392.02

Service Code	CPT 28308
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

OT Cog Ther Intervent, Addl 15 Min Units

Facility

$85.00

Service Code	CPT 97130
Hospital Charge Code	8774214
Hospital Revenue Code	430
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$165.57
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$150.31
Rate for Payer: Wellmark IA PPO	$165.57

OT Cog Ther Intervent, Addl 15 Min Units

Facility

$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,First 15 Min Units

Facility

$85.00

Service Code	CPT 97129
Hospital Charge Code	8774208
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,First 15 Min Units

Facility

$85.00

Service Code	CPT 97129
Hospital Charge Code	8774208
Hospital Revenue Code	430
Min. Negotiated Rate	$38.25
Max. Negotiated Rate	$165.57
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: 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
Rate for Payer: Wellmark IA HMO WHPI	$150.31
Rate for Payer: Wellmark IA PPO	$165.57

OT EVAL

Facility

$158.00

Hospital Charge Code	4812784
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	$81.76
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22

OT EVAL

Facility

$158.00

Hospital Charge Code	4812784
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 HIGH COMPLEX 60 MIN

Facility

$158.00

Service Code	CPT 97167 GO
Hospital Charge Code	8397275
Hospital Revenue Code	434
Min. Negotiated Rate	$71.10
Max. Negotiated Rate	$218.68
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: 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	$81.76
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22
Rate for Payer: Wellmark IA HMO WHPI	$198.52
Rate for Payer: Wellmark IA PPO	$218.68

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	$71.10
Max. Negotiated Rate	$218.68
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: 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	$81.76
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22
Rate for Payer: Wellmark IA HMO WHPI	$198.52
Rate for Payer: Wellmark IA PPO	$218.68

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 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	$71.10
Max. Negotiated Rate	$218.68
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: 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	$81.76
Rate for Payer: United Healthcare Commercial	$142.20
Rate for Payer: United Healthcare Managed Medicare	$93.22
Rate for Payer: Wellmark IA HMO WHPI	$198.52
Rate for Payer: Wellmark IA PPO	$218.68

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC

Facility

$9,021.33

Service Code	MSDRG 818
Min. Negotiated Rate	$8,890.58
Max. Negotiated Rate	$9,021.33
Rate for Payer: Amerigroup Medicaid	$8,977.74
Rate for Payer: Iowa Total Care Managed Medicaid	$8,890.58
Rate for Payer: Molina Healthcare Managed Medicaid	$9,021.33

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC

Facility

$12,474.70

Service Code	MSDRG 817
Min. Negotiated Rate	$12,293.90
Max. Negotiated Rate	$12,474.70
Rate for Payer: Amerigroup Medicaid	$12,414.43
Rate for Payer: Iowa Total Care Managed Medicaid	$12,293.90
Rate for Payer: Molina Healthcare Managed Medicaid	$12,474.70

OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC

Facility

$8,025.96

Service Code	MSDRG 819
Min. Negotiated Rate	$7,909.64
Max. Negotiated Rate	$8,025.96
Rate for Payer: Amerigroup Medicaid	$7,987.19
Rate for Payer: Iowa Total Care Managed Medicaid	$7,909.64
Rate for Payer: Molina Healthcare Managed Medicaid	$8,025.96

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC

Facility

$5,858.46

Service Code	MSDRG 832
Min. Negotiated Rate	$5,773.55
Max. Negotiated Rate	$5,858.46
Rate for Payer: Amerigroup Medicaid	$5,830.15
Rate for Payer: Iowa Total Care Managed Medicaid	$5,773.55
Rate for Payer: Molina Healthcare Managed Medicaid	$5,858.46

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC

Facility

$7,984.30

Service Code	MSDRG 831
Min. Negotiated Rate	$7,868.58
Max. Negotiated Rate	$7,984.30
Rate for Payer: Amerigroup Medicaid	$7,945.73
Rate for Payer: Iowa Total Care Managed Medicaid	$7,868.58
Rate for Payer: Molina Healthcare Managed Medicaid	$7,984.30

OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC

Facility

$4,490.40

Service Code	MSDRG 833
Min. Negotiated Rate	$4,425.32
Max. Negotiated Rate	$4,490.40
Rate for Payer: Amerigroup Medicaid	$4,468.70
Rate for Payer: Iowa Total Care Managed Medicaid	$4,425.32
Rate for Payer: Molina Healthcare Managed Medicaid	$4,490.40

OTHER CARDIOTHORACIC PROCEDURES WITH MCC

Facility

$59,514.64

Service Code	MSDRG 228
Min. Negotiated Rate	$58,652.08
Max. Negotiated Rate	$59,514.64
Rate for Payer: Amerigroup Medicaid	$59,227.10
Rate for Payer: Iowa Total Care Managed Medicaid	$58,652.08
Rate for Payer: Molina Healthcare Managed Medicaid	$59,514.64

OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC

Facility

$34,708.24

Service Code	MSDRG 229
Min. Negotiated Rate	$34,205.21
Max. Negotiated Rate	$34,708.24
Rate for Payer: Amerigroup Medicaid	$34,540.55
Rate for Payer: Iowa Total Care Managed Medicaid	$34,205.21
Rate for Payer: Molina Healthcare Managed Medicaid	$34,708.24

OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC

Facility

$10,454.70

Service Code	MSDRG 315
Min. Negotiated Rate	$10,303.17
Max. Negotiated Rate	$10,454.70
Rate for Payer: Amerigroup Medicaid	$10,404.19
Rate for Payer: Iowa Total Care Managed Medicaid	$10,303.17
Rate for Payer: Molina Healthcare Managed Medicaid	$10,454.70

OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC

Facility

$19,749.64

Service Code	MSDRG 314
Min. Negotiated Rate	$19,463.40
Max. Negotiated Rate	$19,749.64
Rate for Payer: Amerigroup Medicaid	$19,654.22
Rate for Payer: Iowa Total Care Managed Medicaid	$19,463.40
Rate for Payer: Molina Healthcare Managed Medicaid	$19,749.64

OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC

Facility

$6,316.73

Service Code	MSDRG 316
Min. Negotiated Rate	$6,225.18
Max. Negotiated Rate	$6,316.73
Rate for Payer: Amerigroup Medicaid	$6,286.21
Rate for Payer: Iowa Total Care Managed Medicaid	$6,225.18
Rate for Payer: Molina Healthcare Managed Medicaid	$6,316.73

OTHER CIRCULATORY SYSTEM O.R. PROCEDURES

Facility

$27,464.83

Service Code	MSDRG 264
Min. Negotiated Rate	$27,066.78
Max. Negotiated Rate	$27,464.83
Rate for Payer: Amerigroup Medicaid	$27,332.14
Rate for Payer: Iowa Total Care Managed Medicaid	$27,066.78
Rate for Payer: Molina Healthcare Managed Medicaid	$27,464.83

Know your out-of-pocket cost for care.

All Charges