Van Diest Medical Center

All Charges

Charge

Type

Price

sertraline 50 mg Tab

Facility OP

$1.90

Service Code	CPT A9270
Hospital Charge Code	43701418
Hospital Revenue Code	637
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.71
Rate for Payer: Aetna of IA Commercial	$1.71
Rate for Payer: Aetna of IA Medical Rental Products	$1.71
Rate for Payer: Aetna of IA Medicare	$1.08
Rate for Payer: Amerigroup Medicaid	$0.96
Rate for Payer: Amerigroup Medicare	$0.96
Rate for Payer: Cash Price	$1.52
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.42
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.95
Rate for Payer: Iowa Total Care Managed Medicaid	$0.95
Rate for Payer: Medical Associates Commercial	$1.42
Rate for Payer: Medical Associates Managed Medicare	$0.95
Rate for Payer: Midlands Choice Commercial	$1.33
Rate for Payer: Molina Healthcare Managed Medicaid	$0.96
Rate for Payer: Partners Health Alliance Commercial	$1.42
Rate for Payer: United Healthcare Commercial	$1.71
Rate for Payer: United Healthcare Managed Medicare	$1.12

SESAMOIDECTOMY FIRST TOE CHARGE .

Professional

$1,671.00

Service Code	CPT 28315
Hospital Charge Code	8825536
Hospital Revenue Code	975
Min. Negotiated Rate	$301.70
Max. Negotiated Rate	$1,169.70
Rate for Payer: Aetna of IA Medicare	$301.70
Rate for Payer: Amerigroup Medicaid	$311.96
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Cash Price	$1,336.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$362.04
Rate for Payer: Iowa Total Care Managed Medicaid	$307.73
Rate for Payer: Medical Associates Commercial	$573.23
Rate for Payer: Medical Associates Managed Medicare	$301.70
Rate for Payer: Midlands Choice Commercial	$1,169.70
Rate for Payer: Partners Health Alliance Commercial	$452.55
Rate for Payer: Wellmark IA HMO	$621.00
Rate for Payer: Wellmark IA PPO	$729.00

sevelamer carbonate 800 mg Tab

Facility OP

$1.78

Service Code	CPT A9270
Hospital Charge Code	43700108
Hospital Revenue Code	637
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of IA Commercial	$1.60
Rate for Payer: Aetna of IA Medical Rental Products	$1.60
Rate for Payer: Aetna of IA Medicare	$1.01
Rate for Payer: Amerigroup Medicaid	$0.90
Rate for Payer: Amerigroup Medicare	$0.90
Rate for Payer: Cash Price	$1.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.89
Rate for Payer: Iowa Total Care Managed Medicaid	$0.89
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Medical Associates Managed Medicare	$0.89
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: Molina Healthcare Managed Medicaid	$0.90
Rate for Payer: Partners Health Alliance Commercial	$1.34
Rate for Payer: United Healthcare Commercial	$1.60
Rate for Payer: United Healthcare Managed Medicare	$1.05

sevelamer carbonate 800 mg Tab

Facility IP

$1.78

Service Code	CPT A9270
Hospital Charge Code	43700108
Hospital Revenue Code	637
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna of IA Commercial	$1.60
Rate for Payer: Aetna of IA Medical Rental Products	$1.60
Rate for Payer: Cash Price	$1.43
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.34
Rate for Payer: Medical Associates Commercial	$1.34
Rate for Payer: Midlands Choice Commercial	$1.25
Rate for Payer: United Healthcare Commercial	$1.60

SHIGA TOXINS

Facility IP

$98.00

Service Code	CPT 87427
Hospital Charge Code	7780541
Hospital Revenue Code	306
Min. Negotiated Rate	$68.60
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: United Healthcare Commercial	$88.20

SHIGA TOXINS

Facility OP

$98.00

Service Code	CPT 87427
Hospital Charge Code	7780541
Hospital Revenue Code	306
Min. Negotiated Rate	$31.00
Max. Negotiated Rate	$88.20
Rate for Payer: Aetna of IA Commercial	$88.20
Rate for Payer: Aetna of IA Medical Rental Products	$88.20
Rate for Payer: Aetna of IA Medicare	$55.86
Rate for Payer: Amerigroup Medicaid	$49.46
Rate for Payer: Amerigroup Medicare	$49.49
Rate for Payer: Cash Price	$78.40
Rate for Payer: Cash Price	$78.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$73.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$49.00
Rate for Payer: Iowa Total Care Managed Medicaid	$48.98
Rate for Payer: Medical Associates Commercial	$73.50
Rate for Payer: Medical Associates Managed Medicare	$49.00
Rate for Payer: Midlands Choice Commercial	$68.60
Rate for Payer: Molina Healthcare Managed Medicaid	$49.74
Rate for Payer: Partners Health Alliance Commercial	$73.50
Rate for Payer: United Healthcare Commercial	$88.20
Rate for Payer: United Healthcare Managed Medicare	$57.82
Rate for Payer: Wellmark IA HMO	$31.00
Rate for Payer: Wellmark IA PPO	$34.10

SHORT CONDYLAR PLATE

Facility IP

$171.00

Service Code	CPT C1713
Hospital Charge Code	8814828
Hospital Revenue Code	278
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of IA Commercial	$153.90
Rate for Payer: Aetna of IA Medical Rental Products	$153.90
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$128.25
Rate for Payer: Medical Associates Commercial	$128.25
Rate for Payer: Midlands Choice Commercial	$119.70
Rate for Payer: United Healthcare Commercial	$153.90

SHORT CONDYLAR PLATE

Facility OP

$171.00

Service Code	CPT C1713
Hospital Charge Code	8814828
Hospital Revenue Code	278
Min. Negotiated Rate	$85.47
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of IA Commercial	$153.90
Rate for Payer: Aetna of IA Medical Rental Products	$153.90
Rate for Payer: Aetna of IA Medicare	$97.47
Rate for Payer: Amerigroup Medicaid	$86.30
Rate for Payer: Amerigroup Medicare	$86.36
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$128.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$85.50
Rate for Payer: Iowa Total Care Managed Medicaid	$85.47
Rate for Payer: Medical Associates Commercial	$128.25
Rate for Payer: Medical Associates Managed Medicare	$85.50
Rate for Payer: Midlands Choice Commercial	$119.70
Rate for Payer: Molina Healthcare Managed Medicaid	$86.78
Rate for Payer: Partners Health Alliance Commercial	$128.25
Rate for Payer: United Healthcare Commercial	$153.90
Rate for Payer: United Healthcare Managed Medicare	$100.89

SHORT LESSER METZ-PLATE

Facility IP

$1,602.00

Service Code	CPT C1713
Hospital Charge Code	8807701
Hospital Revenue Code	278
Min. Negotiated Rate	$1,121.40
Max. Negotiated Rate	$1,441.80
Rate for Payer: Aetna of IA Commercial	$1,441.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,441.80
Rate for Payer: Cash Price	$1,281.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,201.50
Rate for Payer: Medical Associates Commercial	$1,201.50
Rate for Payer: Midlands Choice Commercial	$1,121.40
Rate for Payer: United Healthcare Commercial	$1,441.80

SHORT LESSER METZ-PLATE

Facility OP

$1,602.00

Service Code	CPT C1713
Hospital Charge Code	8807701
Hospital Revenue Code	278
Min. Negotiated Rate	$800.68
Max. Negotiated Rate	$1,441.80
Rate for Payer: Aetna of IA Commercial	$1,441.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,441.80
Rate for Payer: Aetna of IA Medicare	$913.14
Rate for Payer: Amerigroup Medicaid	$808.53
Rate for Payer: Amerigroup Medicare	$809.01
Rate for Payer: Cash Price	$1,281.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,201.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$801.00
Rate for Payer: Iowa Total Care Managed Medicaid	$800.68
Rate for Payer: Medical Associates Commercial	$1,201.50
Rate for Payer: Medical Associates Managed Medicare	$801.00
Rate for Payer: Midlands Choice Commercial	$1,121.40
Rate for Payer: Molina Healthcare Managed Medicaid	$813.02
Rate for Payer: Partners Health Alliance Commercial	$1,201.50
Rate for Payer: United Healthcare Commercial	$1,441.80
Rate for Payer: United Healthcare Managed Medicare	$945.18

Shoulder, Elbow or Forearm Procedures, Except Major Joint Procedures With CC

Facility IP

$20,045.06

Service Code	MS-DRG 511
Hospital Charge Code	328
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$20,045.06
Rate for Payer: Amerigroup Medicaid	$19,948.23
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$19,754.55
Rate for Payer: Molina Healthcare Managed Medicaid	$20,045.06

Shoulder, Elbow or Forearm Procedures, Except Major Joint Procedures With MCC

Facility IP

$22,676.92

Service Code	MS-DRG 510
Hospital Charge Code	327
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$22,676.92
Rate for Payer: Amerigroup Medicaid	$22,567.37
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$22,348.27
Rate for Payer: Molina Healthcare Managed Medicaid	$22,676.92

Shoulder, Elbow or Forearm Procedures, Except Major Joint Procedures Without CC/MCC

Facility IP

$9,977.26

Service Code	MS-DRG 512
Hospital Charge Code	329
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,977.26
Rate for Payer: Amerigroup Medicaid	$9,929.06
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$9,832.66
Rate for Payer: Molina Healthcare Managed Medicaid	$9,977.26

Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Facility OP

$1,638.16

Service Code	CPT 45330
Hospital Revenue Code	360
Min. Negotiated Rate	$1,489.24
Max. Negotiated Rate	$1,638.16
Rate for Payer: Wellmark IA HMO	$1,489.24
Rate for Payer: Wellmark IA PPO	$1,638.16

Sigmoidoscopy, flexible; with biopsy, single or multiple

Facility OP

$1,745.24

Service Code	CPT 45331
Hospital Revenue Code	360
Min. Negotiated Rate	$1,586.58
Max. Negotiated Rate	$1,745.24
Rate for Payer: Wellmark IA HMO	$1,586.58
Rate for Payer: Wellmark IA PPO	$1,745.24

Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

Facility OP

$1,745.24

Service Code	CPT 45338
Hospital Revenue Code	750
Min. Negotiated Rate	$1,586.58
Max. Negotiated Rate	$1,745.24
Rate for Payer: Wellmark IA HMO	$1,586.58
Rate for Payer: Wellmark IA PPO	$1,745.24

SIGMOIDOSCOPY W TATTOOING

Professional

$1,025.00

Service Code	CPT 45335
Hospital Charge Code	8825541
Hospital Revenue Code	975
Min. Negotiated Rate	$60.36
Max. Negotiated Rate	$717.50
Rate for Payer: Aetna of IA Medicare	$60.36
Rate for Payer: Amerigroup Medicaid	$62.41
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$72.43
Rate for Payer: Iowa Total Care Managed Medicaid	$61.57
Rate for Payer: Medical Associates Commercial	$114.68
Rate for Payer: Medical Associates Managed Medicare	$60.36
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Partners Health Alliance Commercial	$90.54
Rate for Payer: Wellmark IA HMO	$126.00
Rate for Payer: Wellmark IA PPO	$147.00

Signs and Symptoms of Musculoskeletal System and Connective Tissue With MCC

Facility IP

$9,174.12

Service Code	MS-DRG 555
Hospital Charge Code	362
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,174.12
Rate for Payer: Amerigroup Medicaid	$9,129.80
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$9,041.16
Rate for Payer: Molina Healthcare Managed Medicaid	$9,174.12

Signs and Symptoms of Musculoskeletal System and Connective Tissue Without MCC

Facility IP

$4,897.59

Service Code	MS-DRG 556
Hospital Charge Code	363
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$4,897.59
Rate for Payer: Amerigroup Medicaid	$4,873.93
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$4,826.61
Rate for Payer: Molina Healthcare Managed Medicaid	$4,897.59

Signs and Symptoms With MCC

Facility IP

$11,201.65

Service Code	MS-DRG 947
Hospital Charge Code	653
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,201.65
Rate for Payer: Amerigroup Medicaid	$11,147.54
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$11,039.31
Rate for Payer: Molina Healthcare Managed Medicaid	$11,201.65

Signs and Symptoms Without MCC

Facility IP

$6,406.43

Service Code	MS-DRG 948
Hospital Charge Code	654
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$6,406.43
Rate for Payer: Amerigroup Medicaid	$6,375.48
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$2,034.00
Rate for Payer: Iowa Total Care Managed Medicaid	$6,313.59
Rate for Payer: Molina Healthcare Managed Medicaid	$6,406.43

SI JOINT INJECT W FLUOROSCOPY

Professional

$413.00

Service Code	CPT 27096
Hospital Charge Code	8059059
Hospital Revenue Code	964
Min. Negotiated Rate	$75.97
Max. Negotiated Rate	$289.10
Rate for Payer: Aetna of IA Medicare	$75.97
Rate for Payer: Amerigroup Medicaid	$78.55
Rate for Payer: Cash Price	$330.40
Rate for Payer: Cash Price	$330.40
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$91.16
Rate for Payer: Iowa Total Care Managed Medicaid	$77.49
Rate for Payer: Medical Associates Commercial	$144.34
Rate for Payer: Medical Associates Managed Medicare	$75.97
Rate for Payer: Midlands Choice Commercial	$289.10
Rate for Payer: Partners Health Alliance Commercial	$113.96
Rate for Payer: Wellmark IA HMO	$147.00
Rate for Payer: Wellmark IA PPO	$172.00

SI JOINT INJ W FLUOROSCOPY

Professional

$532.00

Service Code	CPT 27096
Hospital Charge Code	8015252
Hospital Revenue Code	975
Min. Negotiated Rate	$75.97
Max. Negotiated Rate	$372.40
Rate for Payer: Aetna of IA Medicare	$75.97
Rate for Payer: Amerigroup Medicaid	$78.55
Rate for Payer: Cash Price	$425.60
Rate for Payer: Cash Price	$425.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$91.16
Rate for Payer: Iowa Total Care Managed Medicaid	$77.49
Rate for Payer: Medical Associates Commercial	$144.34
Rate for Payer: Medical Associates Managed Medicare	$75.97
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Partners Health Alliance Commercial	$113.96
Rate for Payer: Wellmark IA HMO	$147.00
Rate for Payer: Wellmark IA PPO	$172.00

silver sulfADIAZINE Top 1% Crm 400 gm

Facility OP

$209.76

Service Code	CPT A9270
Hospital Charge Code	43701408
Hospital Revenue Code	637
Min. Negotiated Rate	$104.84
Max. Negotiated Rate	$188.78
Rate for Payer: Aetna of IA Commercial	$188.78
Rate for Payer: Aetna of IA Medical Rental Products	$188.78
Rate for Payer: Aetna of IA Medicare	$119.56
Rate for Payer: Amerigroup Medicaid	$105.87
Rate for Payer: Amerigroup Medicare	$105.93
Rate for Payer: Cash Price	$167.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$104.88
Rate for Payer: Iowa Total Care Managed Medicaid	$104.84
Rate for Payer: Medical Associates Commercial	$157.32
Rate for Payer: Medical Associates Managed Medicare	$104.88
Rate for Payer: Midlands Choice Commercial	$146.83
Rate for Payer: Molina Healthcare Managed Medicaid	$106.45
Rate for Payer: Partners Health Alliance Commercial	$157.32
Rate for Payer: United Healthcare Commercial	$188.78
Rate for Payer: United Healthcare Managed Medicare	$123.76

silver sulfADIAZINE Top 1% Crm 400 gm

Facility IP

$209.76

Service Code	CPT A9270
Hospital Charge Code	43701408
Hospital Revenue Code	637
Min. Negotiated Rate	$146.83
Max. Negotiated Rate	$188.78
Rate for Payer: Aetna of IA Commercial	$188.78
Rate for Payer: Aetna of IA Medical Rental Products	$188.78
Rate for Payer: Cash Price	$167.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.32
Rate for Payer: Medical Associates Commercial	$157.32
Rate for Payer: Midlands Choice Commercial	$146.83
Rate for Payer: United Healthcare Commercial	$188.78

Price Transparency.

All Charges