Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SPINAL ANESTHESIA III

Facility

$459.00

Hospital Charge Code	8059079
Hospital Revenue Code	370
Min. Negotiated Rate	$321.30
Max. Negotiated Rate	$413.10
Rate for Payer: Aetna of IA Commercial	$413.10
Rate for Payer: Aetna of IA Medical Rental Products	$413.10
Rate for Payer: Cash Price	$367.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$344.25
Rate for Payer: Medical Associates Commercial	$344.25
Rate for Payer: Midlands Choice Commercial	$321.30
Rate for Payer: United Healthcare Commercial	$413.10

SPINAL FLUID TAP DIAGNOSTI C

Professional

Both

$262.00

Service Code	CPT 62270
Hospital Charge Code	4662901
Hospital Revenue Code	983
Min. Negotiated Rate	$183.40
Max. Negotiated Rate	$210.02
Rate for Payer: Cash Price	$209.60
Rate for Payer: Cash Price	$209.60
Rate for Payer: Medical Associates Commercial	$196.50
Rate for Payer: Midlands Choice Commercial	$183.40
Rate for Payer: Partners Health Alliance Commercial	$196.50
Rate for Payer: United Healthcare Commercial	$210.02

SPINAL FLUID TAP DIAGNOSTIC

Professional

Both

$526.00

Service Code	CPT 62270
Hospital Charge Code	7982766
Hospital Revenue Code	981
Min. Negotiated Rate	$210.02
Max. Negotiated Rate	$394.50
Rate for Payer: Cash Price	$420.80
Rate for Payer: Cash Price	$420.80
Rate for Payer: Medical Associates Commercial	$394.50
Rate for Payer: Midlands Choice Commercial	$368.20
Rate for Payer: Partners Health Alliance Commercial	$394.50
Rate for Payer: United Healthcare Commercial	$210.02

SPINAL FLUID TAP DIAGNOSTIC

Facility

$509.00

Service Code	CPT 62270
Hospital Charge Code	4866799
Hospital Revenue Code	450
Min. Negotiated Rate	$356.30
Max. Negotiated Rate	$458.10
Rate for Payer: Aetna of IA Commercial	$458.10
Rate for Payer: Aetna of IA Medical Rental Products	$458.10
Rate for Payer: Cash Price	$407.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$381.75
Rate for Payer: Medical Associates Commercial	$381.75
Rate for Payer: Midlands Choice Commercial	$356.30
Rate for Payer: United Healthcare Commercial	$458.10

SPINAL FLUID TAP DIAGNOSTIC

Facility

$509.00

Service Code	CPT 62270
Hospital Charge Code	4866799
Hospital Revenue Code	450
Min. Negotiated Rate	$229.05
Max. Negotiated Rate	$458.10
Rate for Payer: Aetna of IA Commercial	$458.10
Rate for Payer: Aetna of IA Medical Rental Products	$458.10
Rate for Payer: Aetna of IA Medicare	$290.13
Rate for Payer: Amerigroup Medicaid	$293.59
Rate for Payer: Amerigroup Medicare	$231.34
Rate for Payer: Cash Price	$407.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$381.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$229.05
Rate for Payer: Iowa Total Care Managed Medicaid	$290.74
Rate for Payer: Medical Associates Commercial	$381.75
Rate for Payer: Medical Associates Managed Medicare	$229.05
Rate for Payer: Midlands Choice Commercial	$356.30
Rate for Payer: Molina Healthcare Managed Medicaid	$295.02
Rate for Payer: Partners Health Alliance Commercial	$263.41
Rate for Payer: United Healthcare Commercial	$458.10
Rate for Payer: United Healthcare Managed Medicare	$300.31

Spinal injection- lumbar w/o imaging

Professional

Both

$517.00

Service Code	CPT 62322
Hospital Charge Code	8037762
Hospital Revenue Code	975
Min. Negotiated Rate	$227.78
Max. Negotiated Rate	$387.75
Rate for Payer: Cash Price	$413.60
Rate for Payer: Cash Price	$413.60
Rate for Payer: Medical Associates Commercial	$387.75
Rate for Payer: Midlands Choice Commercial	$361.90
Rate for Payer: Partners Health Alliance Commercial	$387.75
Rate for Payer: United Healthcare Commercial	$227.78

SPINAL PUNCTURE LUMBAR

Facility

$406.00

Service Code	CPT 62270
Hospital Charge Code	8059050
Hospital Revenue Code	964
Min. Negotiated Rate	$284.20
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: United Healthcare Commercial	$365.40

SPINAL PUNCTURE LUMBAR

Professional

Both

$463.00

Service Code	CPT 62270
Hospital Charge Code	8059050
Hospital Revenue Code	975
Min. Negotiated Rate	$210.02
Max. Negotiated Rate	$347.25
Rate for Payer: Cash Price	$370.40
Rate for Payer: Cash Price	$370.40
Rate for Payer: Medical Associates Commercial	$347.25
Rate for Payer: Midlands Choice Commercial	$324.10
Rate for Payer: Partners Health Alliance Commercial	$347.25
Rate for Payer: United Healthcare Commercial	$210.02

SPINAL PUNCTURE LUMBAR

Facility

$406.00

Service Code	CPT 62270
Hospital Charge Code	8059050
Hospital Revenue Code	964
Min. Negotiated Rate	$182.70
Max. Negotiated Rate	$365.40
Rate for Payer: Aetna of IA Commercial	$365.40
Rate for Payer: Aetna of IA Medical Rental Products	$365.40
Rate for Payer: Aetna of IA Medicare	$231.42
Rate for Payer: Amerigroup Medicaid	$234.18
Rate for Payer: Amerigroup Medicare	$184.53
Rate for Payer: Cash Price	$324.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$304.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$182.70
Rate for Payer: Iowa Total Care Managed Medicaid	$231.91
Rate for Payer: Medical Associates Commercial	$304.50
Rate for Payer: Medical Associates Managed Medicare	$182.70
Rate for Payer: Midlands Choice Commercial	$284.20
Rate for Payer: Molina Healthcare Managed Medicaid	$235.32
Rate for Payer: Partners Health Alliance Commercial	$210.10
Rate for Payer: United Healthcare Commercial	$365.40

Spinal Tap Procedure

Facility

$602.00

Service Code	CPT 62270
Hospital Charge Code	8060782
Hospital Revenue Code	761
Min. Negotiated Rate	$421.40
Max. Negotiated Rate	$541.80
Rate for Payer: Aetna of IA Commercial	$541.80
Rate for Payer: Aetna of IA Medical Rental Products	$541.80
Rate for Payer: Cash Price	$481.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$451.50
Rate for Payer: Medical Associates Commercial	$451.50
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: United Healthcare Commercial	$541.80

Spinal Tap Procedure

Facility

$602.00

Service Code	CPT 62270
Hospital Charge Code	8060782
Hospital Revenue Code	761
Min. Negotiated Rate	$270.90
Max. Negotiated Rate	$541.80
Rate for Payer: Aetna of IA Commercial	$541.80
Rate for Payer: Aetna of IA Medical Rental Products	$541.80
Rate for Payer: Aetna of IA Medicare	$343.14
Rate for Payer: Amerigroup Medicaid	$347.23
Rate for Payer: Amerigroup Medicare	$273.61
Rate for Payer: Cash Price	$481.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$451.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$270.90
Rate for Payer: Iowa Total Care Managed Medicaid	$343.86
Rate for Payer: Medical Associates Commercial	$451.50
Rate for Payer: Medical Associates Managed Medicare	$270.90
Rate for Payer: Midlands Choice Commercial	$421.40
Rate for Payer: Molina Healthcare Managed Medicaid	$348.92
Rate for Payer: Partners Health Alliance Commercial	$311.54
Rate for Payer: United Healthcare Commercial	$541.80
Rate for Payer: United Healthcare Managed Medicare	$355.18

spironolactone 100 mg Tab [VDMC]

Facility

$1.60

Service Code	HCPCS A9270
Hospital Charge Code	10422027
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of IA Commercial	$1.44
Rate for Payer: Aetna of IA Medical Rental Products	$1.44
Rate for Payer: Aetna of IA Medicare	$0.91
Rate for Payer: Amerigroup Medicaid	$0.92
Rate for Payer: Amerigroup Medicare	$0.73
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.72
Rate for Payer: Iowa Total Care Managed Medicaid	$0.91
Rate for Payer: Medical Associates Commercial	$1.20
Rate for Payer: Medical Associates Managed Medicare	$0.72
Rate for Payer: Midlands Choice Commercial	$1.12
Rate for Payer: Molina Healthcare Managed Medicaid	$0.93
Rate for Payer: Partners Health Alliance Commercial	$0.83
Rate for Payer: United Healthcare Commercial	$1.44
Rate for Payer: United Healthcare Managed Medicare	$0.94

spironolactone 100 mg Tab [VDMC]

Facility

$1.60

Service Code	HCPCS A9270
Hospital Charge Code	10422027
Hospital Revenue Code	259
Min. Negotiated Rate	$1.12
Max. Negotiated Rate	$1.44
Rate for Payer: Aetna of IA Commercial	$1.44
Rate for Payer: Aetna of IA Medical Rental Products	$1.44
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.20
Rate for Payer: Medical Associates Commercial	$1.20
Rate for Payer: Midlands Choice Commercial	$1.12
Rate for Payer: United Healthcare Commercial	$1.44

spironolactone 25 mg Tab [VDMC]

Facility

$1.44

Service Code	HCPCS A9270
Hospital Charge Code	10422096
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.08
Rate for Payer: Medical Associates Commercial	$1.08
Rate for Payer: Midlands Choice Commercial	$1.01
Rate for Payer: United Healthcare Commercial	$1.29

spironolactone 25 mg Tab [VDMC]

Facility

$1.44

Service Code	HCPCS A9270
Hospital Charge Code	10422096
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$1.29
Rate for Payer: Aetna of IA Commercial	$1.29
Rate for Payer: Aetna of IA Medical Rental Products	$1.29
Rate for Payer: Aetna of IA Medicare	$0.82
Rate for Payer: Amerigroup Medicaid	$0.83
Rate for Payer: Amerigroup Medicare	$0.65
Rate for Payer: Cash Price	$1.15
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1.08
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$0.65
Rate for Payer: Iowa Total Care Managed Medicaid	$0.82
Rate for Payer: Medical Associates Commercial	$1.08
Rate for Payer: Medical Associates Managed Medicare	$0.65
Rate for Payer: Midlands Choice Commercial	$1.01
Rate for Payer: Molina Healthcare Managed Medicaid	$0.83
Rate for Payer: Partners Health Alliance Commercial	$0.74
Rate for Payer: United Healthcare Commercial	$1.29
Rate for Payer: United Healthcare Managed Medicare	$0.85

SPRAVATO OBSERVATION

Professional

Both

$500.00

Service Code	CPT 99213
Hospital Charge Code	8829628
Hospital Revenue Code	983
Min. Negotiated Rate	$81.57
Max. Negotiated Rate	$375.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Cash Price	$400.00
Rate for Payer: Medical Associates Commercial	$375.00
Rate for Payer: Midlands Choice Commercial	$350.00
Rate for Payer: Partners Health Alliance Commercial	$375.00
Rate for Payer: United Healthcare Commercial	$81.57

SQ/IM INJECTIONS ADMIN

Facility

$66.00

Service Code	CPT 96372
Hospital Charge Code	7984745
Hospital Revenue Code	761
Min. Negotiated Rate	$46.20
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: United Healthcare Commercial	$59.40

SQ/IM INJECTIONS ADMIN

Facility

$66.00

Service Code	CPT 96372
Hospital Charge Code	7984745
Hospital Revenue Code	761
Min. Negotiated Rate	$29.70
Max. Negotiated Rate	$59.40
Rate for Payer: Aetna of IA Commercial	$59.40
Rate for Payer: Aetna of IA Medical Rental Products	$59.40
Rate for Payer: Aetna of IA Medicare	$37.62
Rate for Payer: Amerigroup Medicaid	$38.07
Rate for Payer: Amerigroup Medicare	$30.00
Rate for Payer: Cash Price	$52.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$49.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$29.70
Rate for Payer: Iowa Total Care Managed Medicaid	$37.70
Rate for Payer: Medical Associates Commercial	$49.50
Rate for Payer: Medical Associates Managed Medicare	$29.70
Rate for Payer: Midlands Choice Commercial	$46.20
Rate for Payer: Molina Healthcare Managed Medicaid	$38.25
Rate for Payer: Partners Health Alliance Commercial	$34.16
Rate for Payer: United Healthcare Commercial	$59.40
Rate for Payer: United Healthcare Managed Medicare	$38.94

STANDARD MPJ PLATE, RIGHT

Facility

$1,914.00

Service Code	HCPCS C1713
Hospital Charge Code	8948786
Hospital Revenue Code	278
Min. Negotiated Rate	$1,339.80
Max. Negotiated Rate	$1,722.60
Rate for Payer: Aetna of IA Commercial	$1,722.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,722.60
Rate for Payer: Cash Price	$1,531.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,435.50
Rate for Payer: Medical Associates Commercial	$1,435.50
Rate for Payer: Midlands Choice Commercial	$1,339.80
Rate for Payer: United Healthcare Commercial	$1,722.60

STANDARD MPJ PLATE, RIGHT

Facility

$1,914.00

Service Code	HCPCS C1713
Hospital Charge Code	8948786
Hospital Revenue Code	278
Min. Negotiated Rate	$861.30
Max. Negotiated Rate	$1,722.60
Rate for Payer: Aetna of IA Commercial	$1,722.60
Rate for Payer: Aetna of IA Medical Rental Products	$1,722.60
Rate for Payer: Aetna of IA Medicare	$1,090.98
Rate for Payer: Amerigroup Medicaid	$1,104.00
Rate for Payer: Amerigroup Medicare	$869.91
Rate for Payer: Cash Price	$1,531.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,435.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$861.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1,093.28
Rate for Payer: Medical Associates Commercial	$1,435.50
Rate for Payer: Medical Associates Managed Medicare	$861.30
Rate for Payer: Midlands Choice Commercial	$1,339.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,109.35
Rate for Payer: Partners Health Alliance Commercial	$990.50
Rate for Payer: United Healthcare Commercial	$1,722.60
Rate for Payer: United Healthcare Managed Medicare	$1,129.26

STAPLER GIA 60 2.5 MULTIFIRE DISPOSABLE

Facility

$484.00

Hospital Charge Code	8046475
Hospital Revenue Code	272
Min. Negotiated Rate	$217.80
Max. Negotiated Rate	$435.60
Rate for Payer: Aetna of IA Commercial	$435.60
Rate for Payer: Aetna of IA Medical Rental Products	$435.60
Rate for Payer: Aetna of IA Medicare	$275.88
Rate for Payer: Amerigroup Medicaid	$279.17
Rate for Payer: Amerigroup Medicare	$219.98
Rate for Payer: Cash Price	$387.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$363.00
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$217.80
Rate for Payer: Iowa Total Care Managed Medicaid	$276.46
Rate for Payer: Medical Associates Commercial	$363.00
Rate for Payer: Medical Associates Managed Medicare	$217.80
Rate for Payer: Midlands Choice Commercial	$338.80
Rate for Payer: Molina Healthcare Managed Medicaid	$280.53
Rate for Payer: Partners Health Alliance Commercial	$250.47
Rate for Payer: United Healthcare Commercial	$435.60
Rate for Payer: United Healthcare Managed Medicare	$285.56

STAPLER GIA 60 2.5 MULTIFIRE DISPOSABLE

Facility

$484.00

Hospital Charge Code	8046475
Hospital Revenue Code	272
Min. Negotiated Rate	$338.80
Max. Negotiated Rate	$435.60
Rate for Payer: Aetna of IA Commercial	$435.60
Rate for Payer: Aetna of IA Medical Rental Products	$435.60
Rate for Payer: Cash Price	$387.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$363.00
Rate for Payer: Medical Associates Commercial	$363.00
Rate for Payer: Midlands Choice Commercial	$338.80
Rate for Payer: United Healthcare Commercial	$435.60

Sterile Water Injection 1000ml bag [VDMC]

Facility

$69.60

Service Code	HCPCS A4217
Hospital Charge Code	17516196
Hospital Revenue Code	259
Min. Negotiated Rate	$48.72
Max. Negotiated Rate	$62.64
Rate for Payer: Aetna of IA Commercial	$62.64
Rate for Payer: Aetna of IA Medical Rental Products	$62.64
Rate for Payer: Cash Price	$55.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.20
Rate for Payer: Medical Associates Commercial	$52.20
Rate for Payer: Midlands Choice Commercial	$48.72
Rate for Payer: United Healthcare Commercial	$62.64

Sterile Water Injection 1000ml bag [VDMC]

Facility

$69.60

Service Code	HCPCS A4217
Hospital Charge Code	17516196
Hospital Revenue Code	259
Min. Negotiated Rate	$31.32
Max. Negotiated Rate	$62.64
Rate for Payer: Aetna of IA Commercial	$62.64
Rate for Payer: Aetna of IA Medical Rental Products	$62.64
Rate for Payer: Aetna of IA Medicare	$39.67
Rate for Payer: Amerigroup Medicaid	$40.15
Rate for Payer: Amerigroup Medicare	$31.63
Rate for Payer: Cash Price	$55.68
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$52.20
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$31.32
Rate for Payer: Iowa Total Care Managed Medicaid	$39.76
Rate for Payer: Medical Associates Commercial	$52.20
Rate for Payer: Medical Associates Managed Medicare	$31.32
Rate for Payer: Midlands Choice Commercial	$48.72
Rate for Payer: Molina Healthcare Managed Medicaid	$40.34
Rate for Payer: Partners Health Alliance Commercial	$36.02
Rate for Payer: United Healthcare Commercial	$62.64
Rate for Payer: United Healthcare Managed Medicare	$41.06

STERISHIELD II DUAL LAYER AMNION PATCH 4X4

Facility

$4,131.00

Service Code	HCPCS C1781
Hospital Charge Code	8578902
Hospital Revenue Code	278
Min. Negotiated Rate	$2,891.70
Max. Negotiated Rate	$3,717.90
Rate for Payer: Aetna of IA Commercial	$3,717.90
Rate for Payer: Aetna of IA Medical Rental Products	$3,717.90
Rate for Payer: Cash Price	$3,304.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$3,098.25
Rate for Payer: Medical Associates Commercial	$3,098.25
Rate for Payer: Midlands Choice Commercial	$2,891.70
Rate for Payer: United Healthcare Commercial	$3,717.90

Know your out-of-pocket cost for care.

All Charges