Van Diest Medical Center

All Charges

Charge

Type

Price

SINGLE PULSE OXIMETRY

Facility IP

$10.00

Service Code	CPT 94760
Hospital Charge Code	5338940
Hospital Revenue Code	410
Min. Negotiated Rate	$7.00
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of IA Commercial	$9.00
Rate for Payer: Aetna of IA Medical Rental Products	$9.00
Rate for Payer: Cash Price	$8.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.50
Rate for Payer: Medical Associates Commercial	$7.50
Rate for Payer: Midlands Choice Commercial	$7.00
Rate for Payer: United Healthcare Commercial	$9.00

SINGLE PULSE OXIMETRY

Facility OP

$10.00

Service Code	CPT 94760
Hospital Charge Code	5338940
Hospital Revenue Code	410
Min. Negotiated Rate	$5.00
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of IA Commercial	$9.00
Rate for Payer: Aetna of IA Medical Rental Products	$9.00
Rate for Payer: Aetna of IA Medicare	$5.70
Rate for Payer: Amerigroup Medicaid	$5.05
Rate for Payer: Amerigroup Medicare	$5.05
Rate for Payer: Cash Price	$8.00
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$5.00
Rate for Payer: Iowa Total Care Managed Medicaid	$5.00
Rate for Payer: Medical Associates Commercial	$7.50
Rate for Payer: Medical Associates Managed Medicare	$5.00
Rate for Payer: Midlands Choice Commercial	$7.00
Rate for Payer: Molina Healthcare Managed Medicaid	$5.08
Rate for Payer: Partners Health Alliance Commercial	$7.50
Rate for Payer: United Healthcare Commercial	$9.00
Rate for Payer: United Healthcare Managed Medicare	$5.90

Sinus and Mastoid Procedures With CC/MCC

Facility IP

$21,074.58

Service Code	MS-DRG 135
Hospital Charge Code	15
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$21,074.58
Rate for Payer: Amerigroup Medicaid	$20,972.77
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	$20,769.15
Rate for Payer: Molina Healthcare Managed Medicaid	$21,074.58

Sinus and Mastoid Procedures Without CC/MCC

Facility IP

$12,360.10

Service Code	MS-DRG 136
Hospital Charge Code	16
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$12,360.10
Rate for Payer: Amerigroup Medicaid	$12,300.39
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	$12,180.97
Rate for Payer: Molina Healthcare Managed Medicaid	$12,360.10

sitaGLIPtin 50 mg oral tablet

Facility IP

$58.53

Service Code	CPT A9270
Hospital Charge Code	43722188
Hospital Revenue Code	637
Min. Negotiated Rate	$40.97
Max. Negotiated Rate	$52.68
Rate for Payer: Aetna of IA Commercial	$52.68
Rate for Payer: Aetna of IA Medical Rental Products	$52.68
Rate for Payer: Cash Price	$46.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.90
Rate for Payer: Medical Associates Commercial	$43.90
Rate for Payer: Midlands Choice Commercial	$40.97
Rate for Payer: United Healthcare Commercial	$52.68

sitaGLIPtin 50 mg oral tablet

Facility OP

$58.53

Service Code	CPT A9270
Hospital Charge Code	43722188
Hospital Revenue Code	637
Min. Negotiated Rate	$29.25
Max. Negotiated Rate	$52.68
Rate for Payer: Aetna of IA Commercial	$52.68
Rate for Payer: Aetna of IA Medical Rental Products	$52.68
Rate for Payer: Aetna of IA Medicare	$33.36
Rate for Payer: Amerigroup Medicaid	$29.54
Rate for Payer: Amerigroup Medicare	$29.56
Rate for Payer: Cash Price	$46.82
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$43.90
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.26
Rate for Payer: Iowa Total Care Managed Medicaid	$29.25
Rate for Payer: Medical Associates Commercial	$43.90
Rate for Payer: Medical Associates Managed Medicare	$29.26
Rate for Payer: Midlands Choice Commercial	$40.97
Rate for Payer: Molina Healthcare Managed Medicaid	$29.70
Rate for Payer: Partners Health Alliance Commercial	$43.90
Rate for Payer: United Healthcare Commercial	$52.68
Rate for Payer: United Healthcare Managed Medicare	$34.53

Sjogren's A Antibody DMCL

Facility IP

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037800
Hospital Revenue Code	302
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: United Healthcare Commercial	$122.40

Sjogren's A Antibody DMCL

Facility OP

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037800
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Aetna of IA Medicare	$77.52
Rate for Payer: Amerigroup Medicaid	$68.64
Rate for Payer: Amerigroup Medicare	$68.68
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$68.00
Rate for Payer: Iowa Total Care Managed Medicaid	$67.97
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Medical Associates Managed Medicare	$68.00
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: Molina Healthcare Managed Medicaid	$69.02
Rate for Payer: Partners Health Alliance Commercial	$102.00
Rate for Payer: United Healthcare Commercial	$122.40
Rate for Payer: United Healthcare Managed Medicare	$80.24
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Sjogren's B Antibody DMCL

Facility IP

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037801
Hospital Revenue Code	302
Min. Negotiated Rate	$95.20
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: United Healthcare Commercial	$122.40

Sjogren's B Antibody DMCL

Facility OP

$136.00

Service Code	CPT 86235
Hospital Charge Code	8037801
Hospital Revenue Code	302
Min. Negotiated Rate	$47.12
Max. Negotiated Rate	$122.40
Rate for Payer: Aetna of IA Commercial	$122.40
Rate for Payer: Aetna of IA Medical Rental Products	$122.40
Rate for Payer: Aetna of IA Medicare	$77.52
Rate for Payer: Amerigroup Medicaid	$68.64
Rate for Payer: Amerigroup Medicare	$68.68
Rate for Payer: Cash Price	$108.80
Rate for Payer: Cash Price	$108.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$102.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$68.00
Rate for Payer: Iowa Total Care Managed Medicaid	$67.97
Rate for Payer: Medical Associates Commercial	$102.00
Rate for Payer: Medical Associates Managed Medicare	$68.00
Rate for Payer: Midlands Choice Commercial	$95.20
Rate for Payer: Molina Healthcare Managed Medicaid	$69.02
Rate for Payer: Partners Health Alliance Commercial	$102.00
Rate for Payer: United Healthcare Commercial	$122.40
Rate for Payer: United Healthcare Managed Medicare	$80.24
Rate for Payer: Wellmark IA HMO	$47.12
Rate for Payer: Wellmark IA PPO	$51.83

Skin Debridement With CC

Facility IP

$11,955.59

Service Code	MS-DRG 571
Hospital Charge Code	375
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,955.59
Rate for Payer: Amerigroup Medicaid	$11,897.83
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	$11,782.32
Rate for Payer: Molina Healthcare Managed Medicaid	$11,955.59

Skin Debridement With MCC

Facility IP

$14,700.63

Service Code	MS-DRG 570
Hospital Charge Code	374
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,700.63
Rate for Payer: Amerigroup Medicaid	$14,629.62
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	$14,487.58
Rate for Payer: Molina Healthcare Managed Medicaid	$14,700.63

Skin Debridement Without CC/MCC

Facility IP

$9,053.05

Service Code	MS-DRG 572
Hospital Charge Code	376
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$9,053.05
Rate for Payer: Amerigroup Medicaid	$9,009.32
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	$8,921.85
Rate for Payer: Molina Healthcare Managed Medicaid	$9,053.05

Skin Graft Except for Skin Ulcer or Cellulitis With CC

Facility IP

$17,881.70

Service Code	MS-DRG 577
Hospital Charge Code	381
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$17,881.70
Rate for Payer: Amerigroup Medicaid	$17,795.31
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	$17,622.54
Rate for Payer: Molina Healthcare Managed Medicaid	$17,881.70

Skin Graft Except for Skin Ulcer or Cellulitis With MCC

Facility IP

$49,816.40

Service Code	MS-DRG 576
Hospital Charge Code	380
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$49,816.40
Rate for Payer: Amerigroup Medicaid	$49,575.74
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	$49,094.43
Rate for Payer: Molina Healthcare Managed Medicaid	$49,816.40

Skin Graft Except for Skin Ulcer or Cellulitis Without CC/MCC

Facility IP

$11,804.01

Service Code	MS-DRG 578
Hospital Charge Code	382
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$11,804.01
Rate for Payer: Amerigroup Medicaid	$11,746.99
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	$11,632.94
Rate for Payer: Molina Healthcare Managed Medicaid	$11,804.01

Skin Graft for Skin Ulcer or Cellulitis With CC

Facility IP

$20,721.24

Service Code	MS-DRG 574
Hospital Charge Code	378
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$20,721.24
Rate for Payer: Amerigroup Medicaid	$20,621.14
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	$20,420.93
Rate for Payer: Molina Healthcare Managed Medicaid	$20,721.24

Skin Graft for Skin Ulcer or Cellulitis With MCC

Facility IP

$54,514.18

Service Code	MS-DRG 573
Hospital Charge Code	377
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$54,514.18
Rate for Payer: Amerigroup Medicaid	$54,250.83
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	$53,724.12
Rate for Payer: Molina Healthcare Managed Medicaid	$54,514.18

Skin Graft for Skin Ulcer or Cellulitis Without CC/MCC

Facility IP

$17,337.42

Service Code	MS-DRG 575
Hospital Charge Code	379
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$17,337.42
Rate for Payer: Amerigroup Medicaid	$17,253.66
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	$17,086.15
Rate for Payer: Molina Healthcare Managed Medicaid	$17,337.42

Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders With CC

Facility IP

$14,145.52

Service Code	MS-DRG 623
Hospital Charge Code	415
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$14,145.52
Rate for Payer: Amerigroup Medicaid	$14,077.19
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	$13,940.51
Rate for Payer: Molina Healthcare Managed Medicaid	$14,145.52

Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders With MCC

Facility IP

$35,567.54

Service Code	MS-DRG 622
Hospital Charge Code	414
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$35,567.54
Rate for Payer: Amerigroup Medicaid	$35,395.71
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	$35,052.07
Rate for Payer: Molina Healthcare Managed Medicaid	$35,567.54

Skin Grafts and Wound Debridement for Endocrine, Nutritional and Metabolic Disorders Without CC/MCC

Facility IP

$10,773.51

Service Code	MS-DRG 624
Hospital Charge Code	416
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$10,773.51
Rate for Payer: Amerigroup Medicaid	$10,721.47
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	$10,617.37
Rate for Payer: Molina Healthcare Managed Medicaid	$10,773.51

Skin Grafts for Injuries With CC/MCC

Facility IP

$27,045.97

Service Code	MS-DRG 904
Hospital Charge Code	625
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$27,045.97
Rate for Payer: Amerigroup Medicaid	$26,915.31
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	$26,654.00
Rate for Payer: Molina Healthcare Managed Medicaid	$27,045.97

Skin Grafts for Injuries Without CC/MCC

Facility IP

$16,112.03

Service Code	MS-DRG 905
Hospital Charge Code	626
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$16,112.03
Rate for Payer: Amerigroup Medicaid	$16,034.20
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	$15,878.52
Rate for Payer: Molina Healthcare Managed Medicaid	$16,112.03

Skin Ulcers With CC

Facility IP

$6,734.18

Service Code	MS-DRG 593
Hospital Charge Code	391
Min. Negotiated Rate	$2,034.00
Max. Negotiated Rate	$6,734.18
Rate for Payer: Amerigroup Medicaid	$6,701.64
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	$6,636.58
Rate for Payer: Molina Healthcare Managed Medicaid	$6,734.18

Price Transparency.

All Charges